Approaches to sexual health in elderly patients
The elderly are far from asexual and doctors can do a lot to ease their problems, argues Professor
The issue of sexuality in older people has generally been ignored by health and social care professionals, partly evidenced by the fact that it is rarely covered in assessments and care plans1. Such omission fuels the perception that older people are asexual, thereby denying them 'permission' to be sexual and the opportunity to seek professional help for sexual difficulties when they occur.
The truth is that a significant proportion of older men and women do wish to continue meaningful sexual expression, either with their partner or on their own.
A large, general practice-based study in the UK among men and women aged 18 to 75 revealed that self-reported sexual satisfaction and respondents' perception of their partners' sexual satisfaction is not influenced by age2.
Elderly men and women enjoy sexual expression for a variety of reasons, with particular emphasis on positivity of self-image, increased comfort levels, reduction of tension and improved ability to sleep3. However, elderly people can suffer all types of sexual difficulties so that their aspiration to be sexual may be thwarted, for example:
lage-related increasing prevalence of organic diseases, especially cardiovascular morbidity
lconcomitant use of therapeutic drugs, which may impair sexual functioning
llack of privacy when elderly couples live with their children or in residential care homes.
Finding a new sexual relationship after divorce or the death of a loved partner can be difficult at any age but is often particularly problematic for the elderly. Not only is there the sexual ageism issue but also the difficulty many people, especially men, have in resuming sexual intercourse after a period of enforced abstinence.
For example, 'widower's syndrome' is a particular presentation of erectile disorder where the man finds it impossible to consummate a new relationship after the death of his former loving partner. Many psychological factors contribute to this, but perhaps the most significant is the feeling of guilt arising from the usually unexpressed feeling that he is being unfaithful.
This situation can be difficult to overcome. Pharmacological treatment is sometimes helpful, but psychological approaches are frequently required to resolve the guilt.
Discovering sexual difficulties
in the elderly
Elderly men and women are less likely than their younger counterparts to present directly with sexual difficulties because of embarrassment and their fear that the health professional will ridicule them for wanting to be sexually active. The health professional may also feel more uncomfortable asking elderly people about their sexual function than they do raising the issue with younger patients.
But if you simply ask the elderly patient in a matter-of-fact manner whether they have any sexual difficulties they would like advice about, most will feel relieved that their desire for sexual expression is accepted and regarded as important and that help with problems is forthcoming. However,
asking about sexual function in the elderly has to be done in such a way as not to imply that it is abnormal for the person to not be sexually active.
It is important to understand the normal age-related changes that occur in sexual functioning. Failure to do so will result in misdiagnosis. For example, elderly men may achieve full erection only just before ejaculation and both elderly men and women generally need prolonged and more genitally intense stimulation to induce arousal, orgasm and ejaculation than younger people.
Management of sexual problems in the elderly is little different from in younger people and should, ideally, involve combined sex and couples therapy and pharmacological or mechanical approaches. Be especially careful to ensure elderly people are referred only to sex and couple therapists who are properly accredited and are experienced in dealing with problems in this age group.
The successful management of sexual difficulties at any age relies very much on taking a good sexual, relationship and medical history. Ideally, the history should also be obtained from the presenting partner's sexual partner as it is important to consider the presenting symptom in the context of the sexual adjustment in the relationship and the partner's sexual functioning. For example, a man may present with loss of erection on attempted penetration when the underlying problem is dyspareunia resulting from urogenital atrophy in the partner. Giving this man erectogenic treatment may aggravate the partner's problem and cause relationship difficulties.
Sexual difficulties in the partner that may cause pain on attempted intromission, such as vaginal dryness, or may prevent intercourse altogether, as in vaginismus, should be treated before a man is given erectogenic therapy if he wishes to resume sexual intercourse.
Vaginal dryness in elderly women can be especially troublesome. If it arises from oestrogen deficiency-induced urogenital atrophy, the specific treatment is oestrogen replacement administered systemically or locally. When oestrogen is contraindicated, Replens effectively moisturises the vagina. Vaginal dryness can also occur from sexual arousal disorder of either organic origin (cardiovascular disease, diabetes, post-pelvic surgery or radiotherapy) or psychological origin.
A frequent chain of events is for the woman to have reduced lubrication, attempt sexual intercourse, experience pain and then find the anticipation of pain inhibits future arousal, which gives rise to dryness and more pain. This chain can often be broken by the use of a lubricating product. It is surprising how many elderly couples continue to use Vaseline for this purpose. There are many better products available for coital lubrication. Most couples find the water or silicon-based products work well as coital lubricants, but a vegetable oil (such as sweet almond oil) is often preferred for external genital lubrication during self or partner stimulation.
Aids to stimulation
It was mentioned above that there is an age-related increase in the amount of stimulation required to induce sexual arousal and ejaculation/orgasm. Elderly people may benefit from advice on means to enhance genital stimulation.
Vibrators can be useful for both men and women. Recently a new clitoral stimulator, Vielle, has been marketed which may prove helpful for women, especially for self-stimulation. If used, it requires the application of copious amounts of an artificial lubricant.
It is surprising how few couples experiment with different coital positions. This does not cause major problems if all is going well but if one partner develops limited mobility that makes intercourse difficult, painful or impossible (for instance arthritis of the hip in a woman preventing adequate access to the vulva), they may not readily experiment with different positions. Advice may therefore be required.
Help for the health professional
Unfortunately, advice and treatment is often denied to patients because health professionals lack training in the management of sexual problems and need to overcome difficulties discussing sexual issues with patients of any age, but especially the elderly.
Whenever possible, patients presenting with sexual difficulties should be referred to someone who can offer reliable advice. There are various courses that provide the information that will help to address sexual problems. Failing this, there are websites that can provide advice, some of which are listed in the box below.
Writing in 1977, Glover stated 'the encouragement of sexual relationships in the elderly is of profound value in maintaining emotional and physical status and loss of sexual function is unnecessary in both men and women'4.
Since then, major advances have been made in the management of sexual problems. It is essential that health professionals change their mindset and accept that elderly people may wish to continue to be sexually active and they deserve to benefit from these advances.
The Lancashire Postgraduate School of Medicine and Health, Preston, runs a five-day course leading to the University Certificate in Basic Sexual and Relationship Therapy. For more information see the website (www.uclan.ac.uk).
1. May K, Riley A. Sexual function after 60. J Brit Menopause Soc 2002;8:112-5
2. Dunn KM et al. Satisfaction in the sex life of a general practice sample.
J Sex Marit Ther 2000;26:141-51
3. Starr B, Weiner M. The Starr-Weiner Report on Sex and Sexuality in the Mature Years. New York, McGraw Hill, 1981
4. Glover BH. Sex counselling in the elderly. Hospital Practice 1977;12:101-13
www.spod-uk.org (for disabled people)
www.womenshealthlondon.org.uk (covers HRT and menopause)
www.menopause.org (North American Menopause Society)