Dr. Kris Case: My First Patient, a Man of 80, and Sex in Later Life

I still remember my first sexual health case well. It wasn't a young man worried about his performance, but a man of about 80 who sat in front of me looking shy but determined. This case changed the way I see sex in older age for good.

Background

He had been referred by another doctor who cared for his chronic conditions. I understand that many doctors may feel awkward talking about sex with older patients, and older people themselves often don't dare raise it, for fear of being seen as "old but still obsessed".

What he told me was that his erections had been declining for several years, he no longer had morning erections as before, and he felt his sense of manhood had gone. He didn't want anything adventurous. He wanted to feel confident, and to be close to his wife in a way that suited their age.

What I found

I made a whole-person assessment, following the principles of family medicine.

• Chronic conditions. He had diabetes and high blood pressure, which can damage the blood vessels and nerves involved in erections (read: testosterone, diabetes, blood pressure and NCDs).
• The heart. I asked about chest pain, breathlessness and exercise capacity to judge whether his heart was ready for sexual activity, and checked that he was not using nitrates.
• Medicines. I reviewed all his medicines, because some blood pressure medicines and some antidepressants affect erections.
• Mood. I assessed for depression and low spirits, which are common in older people and can reduce sexual desire (read: depression or low testosterone?).
• Relationship and family. I asked about his relationship with his wife, whether there was any conflict, and about her health and needs.

Man in his 80s

Existing conditions

• Diabetes
• High blood pressure

Heart

• Chest pain, exercise capacity
• Not on nitrate medicine

Medicines

• Some blood pressure drugs
• Some antidepressants

Mind

• Low mood, discouragement

Relationship

• His relationship with his wife
• His wife's health and wishes

Care

1. Optimising his chronic disease care together with his regular doctor, keeping blood sugar and blood pressure on target, because this is the foundation of vascular health.
2. Starting erection medicine carefully. A PDE5 inhibitor at a low starting dose, because older people are often more sensitive to medicines, with advice on symptoms to watch for, such as dizziness, feeling faint or chest pain (read: tadalafil vs sildenafil).
3. Explaining the key contraindications. Never use it with nitrates, and if there is chest pain during or after sex, go to hospital immediately and tell the doctor which medicine was taken.
4. Widening the meaning of sexual pleasure. Hugging, touch, sleeping close together, or even masturbation are all normal and valuable forms of sexual expression. It doesn't have to end in penetration.
5. Supporting his self-image and confidence, encouraging gentle exercise suited to his age, looking after himself, and looking in the mirror with pride.

At follow-up he said he felt more confident and had become closer to his wife, in a way they were both comfortable with.

1. 1BackgroundErections declining for years; wanted confidence and closeness with his wife
2. 2Control conditionsSugar and blood pressure, with his treating doctor
3. 3Careful medicineLow starting dose as assessed; never with nitrates
4. 4Widen the meaningHugging, touching, sleeping close; it needn't end in penetration
5. 5OutcomeMore confident, close to his wife in a way both are comfortable with

What I learned

• Sexuality is a natural part of being human at every age. Research in older adults has found that many remain sexually active into their 70s and 80s, and that being able to talk about this with a doctor is linked to better quality of life.
• The doctor needs to raise the topic, because many older people don't dare start.
• Safety comes first. Medicines that work well in young men have to be adjusted to an older person's heart, other conditions and current medicines.
• When body and mind are well, sexual health follows. Caring for the whole person is the heart of family medicine (read: what is a family physician?).

If you or a family member are going through the same thing

Read more in Men's health after 50: what to look after and ED: causes and treatment. Don't buy erection medicine for an older person to use on their own, because it may interact with heart medicines. At Dr. Kris Clinic, I care for the sexual health of older adults privately, with a full safety assessment, and can coordinate with their regular doctor. English-speaking consultations are available.