Investigating the sexual quality of life and its relationship with general health in older men in Iran
Alireza Najimi1, Yousef Veisani2, Sanaz Azami1, Arman Azadi1
1 Student Research Committee, Department of Nursing, School of Nursing and Midwifery, Ilam University of Medical Sciences, Ilam, Iran
2 Psychosocial Injuries Research Center, Ilam University of Medical Sciences, Ilam, Iran
|Date of Submission||17-Dec-2019|
|Date of Acceptance||24-Feb-2020|
|Date of Web Publication||30-Jun-2020|
Dr. Arman Azadi
Department of Nursing, School of Nursing and Midwifery, Ilam University of Medical Sciences, Ilam
Source of Support: None, Conflict of Interest: None
INTRODUCTION: Sexual problems in elder people are considered as a public health concern and can affect their overall health and quality of life. This study aimed to investigate the sexual quality of life and its relationship with general health in older men in the west of Iran.
METHODS: This was a cross-sectional study among 362 older men aged 60 years or older attending Comprehensive Health Care Centers in Ilam, Iran. Samples selected through Quota sampling method and simple random sampling. Data were collected using the Sexual Quality of Life Questionnaire-Male and General Health Questionnaire-28.
RESULTS: The mean ± standard deviation (SD) of age was 69.9 ± 8.1 years. The mean ± SD score of sexual quality of life and general health of older men was 46.6 ± 14.6 and 19.2 ± 9.7, respectively. A positive and significant association was found between sexual quality of life and general health (P < 0.001, r = −0.41). Moreover, general health, age, sleep problems, and the level of education were the important predictors for sexual quality of life in elder men (P < 0.05).
CONCLUSION: According to the results, the sexual quality of life of participants was at a moderate level. Since only some factors influencing the sexual quality of life were ascertained, further studies are required to investigate all factors influencing older men's sexual quality of life.
Keywords: General health, Iran, older men, sexual function, sexual quality of life
|How to cite this article:|
Najimi A, Veisani Y, Azami S, Azadi A. Investigating the sexual quality of life and its relationship with general health in older men in Iran. J Edu Health Promot 2020;9:150
|How to cite this URL:|
Najimi A, Veisani Y, Azami S, Azadi A. Investigating the sexual quality of life and its relationship with general health in older men in Iran. J Edu Health Promot [serial online] 2020 [cited 2020 Oct 22];9:150. Available from: https://www.jehp.net/text.asp?2020/9/1/150/288351
| Introduction|| |
The elderly population is on the rise worldwide. Iran, like other countries, will face the increase of people aged over 60 years and over in the future. According to statistics, the ratio of the elderly population to the total population increased from 7.22% in 2006 to 8.20% in 2011 and 9.1% in 2017.
Although old age does not mean the earlier onset of disease and disability, the elderly are more likely to expose to diseases, and health complications compared to younger people. In Iran, given the fact that sexual problems are of high prevalence in older men, but this has been less investigated., Some studies showed that this problem is not only among Iranian older adults, but also is of high prevalence in the older men.,,, A survey by Hyde et al. showed that 49.9% of sexual problems in older men was related to erectile dysfunction, 4.7% related to decreased sexual desire in sexual activity, 38.7% related to the inability to reach orgasm, and 20.4% were concern about their ability in sexual activity. In general, 72% reported having at least one problem in sexual functioning. The findings of some related studies in Iran show that sexual problems in older men are a subject that has been more taken into consideration in recent years.,
Sexual quality of life is defined as status that describes the individual's subjective evaluation of the positive and negative aspects of one's sexual relationship, and his/her subsequent affective response to this evaluation. Despite the important role of sexual quality of life in life satisfaction and the elderly's good feeling, there are a few researches due to different reasons such as this misconception that the elderly have no sexual value anymore and change in age-related physiological and cognitive functioning naturally result in impaired sexual function and decreased sexual desire. The elderly desire for reporting sexual issues and participating in studies due to embarrassment in one-to-one interviews and self-reporting biases than the younger is lower.
According to some studies, some factors including a high sexual quality of life in the older people associated with physical and psychological health, age, the level of education, positive attitude toward sexual issues, having happy social connections, spouse's physical and mental health, sleep satisfaction, etc., are the most critical factors contributing to the sexual quality of life., Much of the predictor diseases of sexual functioning are low.,,
One of the most critical issues in old age is general health status, which can affect the function and sexual quality of life of older adults. Most of the psychological and physical health status, such as blood pressure, coronary artery disease, diabetes, insomnia, anxiety, and depression, are associated with sexual dysfunction.,
In general, numerous factors affect the sexual quality of life of older men. However, little studies have been conducted in Iran regarding the role of each of these factors and their effects on older people's sexual functioning and the relationship of the older men's sexual quality of life with general health. In addition, conducting research about sexual issues and examining different dimensions in the older adults considering cultural and social barriers, especially in provinces located in the west of Iran, is not possible. The lack of appropriate studies, the contradiction in the results of some studies, and the absence of valid and reliable tools caused the investigation to face challenges. Hence, the objective of the study was to investigate the quality of sexual life and its relationship with general health in older men residing in Ilam, Iran.
| Methods|| |
This was a cross-sectional study.
The study population was 362 men who met the following criteria: Aged >60 years, residing in Ilam city, being alive of a spouse, having health records in comprehensive health centers, the lack of a severe mental and physical disease, being able to communicate through verbal communication, and willingness to participate in the study.
The exclusion criteria were as follows: having score < 6 in the abbreviated mental test, the lack of willingness to continue the study, and imperfect response to questionnaires.
Selection of study subjects
Sampling carried out using the quota method and simple random sampling. First, a list of comprehensive health-care centers together with the number of households with the elderly was designed. The sample size was characterized based on the ratio of the population covered by comprehensive health-care centers (18 centers) to the overall population. Standard deviation (SD) of sexual quality of life for estimation sample size was 11.67 according to the previous report using mean estimation in population formula Sadat study. Considering a 95% confidence interval the overall sample size in this study was 362 subjects. Second, samples selected using a simple random sampling method and based on the one's national number. Then, participants were contacted and asked to refer to comprehensive health-care centers at a specific time for receiving care services and participating in the study if they wish. When participants attending the center, the interviewer attended the comprehensive health care center and explained the objectives of the study to the elderly. Informed consent was obtained from those willing to participate. After that, questionnaires were given to participants for completion. Interviewers completed the questionnaire for those participants who had not enough literate to complete the questionnaires. Those participants who were not agreed to participate in the study, alternative samples were selected randomly, and this continued until completing samples in each center.
Three questionnaires were used for data collection. The first questionnaire was related to sociodemographic characteristics and problems associated with participants' well-being (such as age, education level, heart disease, and sleep problems). The second questionnaire was related to Sexual Quality of Life Questionnaire-Male. This questionnaire was designed in 2008 by Abraham et al. This questionnaire aimed at assessing the sexual quality of life in older men by focusing on dimensions of sexual confidence, emotional health, and interpersonal relationship in the past 4 weeks. The Persian version of the questionnaire like the original English version contains 11 items, each with a 6-point Likert scale ranging from “completely agree” (score 1) to “completely disagree” (score 6). The total score can range from 11 to 66 points. The higher the score indicates the greater the quality of life. The validity of the Persian version was conducted by Sadat (2017). Besides, the reliability of the questionnaire using the internal consistency assessment method was 0.95.
The third questionnaire was the General Health Questionnaire (GHQ-28). This questionnaire was designed to assess the general health status and comprises various versions. The GHQ-28 scale of the questionnaire was derived based on the original 60-item version by Goldberg and Hillier in 1979. Twenty-eight item version has the highest validity, sensitivity, and specificity compared to other versions. This questionnaire consists of four subscales; somatic symptoms (questions: 1–7), anxiety and insomnia (questions: 8–14), social functioning (questions: 15–21), and depression (questions: 22–28).
There are different methods for scoring the questionnaire. Since, in most studies, the Likert scoring pattern has been used, this pattern was used in this study. In this method, the items are rated on a scale ranging from 0 to 3, with total scores ranging from 0 to 84. In this questionnaire, the lower score represents better general health, and the score of more than 23 represents undesirable general health. The validity and reliability of the questionnaire have been done several times in Iran. The assessment of the reliability of the questionnaire by Nazifi et al. showed Cronbach's alpha coefficient 0.82 for subscales.
The first author was introduced to the research units, and data were collected from April to September 2019. The objectives of the study were explained to participants, and we assured all the participants that their participation in the study is voluntary. Informed consent was obtained from the participants. Further, no cost was imposed on participants and their family members. Participants were assured that all information would remain confidential, and they were free to withdraw from the research at any time. The interview was carried out by a male interviewer at the participants' preferred place. The study proposal was approved by the Ethics committee's Ilam University of Medical Sciences (IR.MEDILUM.REC.1398.051).
Data were coded after collecting and were analyzed using SPSS software version 21 (SPSS Inc., Chicago, IL, USA). Data were analyzed by descriptive statistics (including; frequency, percentage, mean, and SD 95%) and also analytical statistics (including; Independent sample t-test, one-way ANOVA, Pearson correlation coefficient, linear regression, and multivariable linear regression model by forward method). The P < 0.05 was considered as a statistical significance level in this study.
| Results|| |
The sociodemographic characteristics are shown in [Table 1]. The mean age of participants was 69.9 ± 8.1 (range 60–100 years old). About 55.5% of participants were 60–69 years old, and 15.5% were aged 80 years or older. Other sociodemographic characteristics and associated with participants' health problems are represented in [Table 1]. The mean score of sexual quality of life and general health of participants was 46.6 ± 14.6 and 19.2 ± 9.7, respectively. There was a significant and positive association between sexual quality of life and general health (r = −0.41, P < 0.001). Our results showed that sexual quality of life in the elderly decreased with increasing age (P < 0.001), while the employment status (retired/employed) (P < 0.001) and having a higher level of education (P = 0.01) lead to an improvement in sexual quality of life [Table 2].
|Table 1: Frequency and percentage of the socio-demographic characteristics and variables associated with health problems|
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|Table 2: Mean±standard deviation of Sexual Quality of Life Questionnaire-Male and General Health Questionnaire-28 based on demographic characteristics and associated with participants' health problems|
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As shown in [Table 2], a direct and significant association was found between general health and employment status (P < 0.001), as well as education status (P = 0.026). Tukey's post hoc test showed that the elderly aged 60–69 years (P < 0.001) and aged 70–79 years (P = 0.002) were more likely to have a higher sexual quality of life than elderly aged >80 years. Moreover, general health status among elderly aged 70–79 years was more likely to have better general health than elderly aged >80 years (P = 0.002). The correlation between questionnaire dimensions of general health and the total score of sexual quality of life are represented in [Table 3].
|Table 3: Correlation between questionnaire dimensions of General Health Questionnaire-28 and (Sexual Quality of Life Questionnaire-Male)|
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A signification correlation was observed between the total score of GHQ-28 and dimensions of somatic symptoms (r = 0.82), anxiety and insomnia (r = 0.80), social functioning (r = 0.81), and depression (r = 0.75) (P < 0.001). Since a higher score in the GHQ-28 questionnaire represents lower general health, the correlation between the total score of general health and its subscales with sexual quality of life reported in the form of negative sign. Based on this, there was a correlation between the sexual quality of life in older men and the dimensions of GHQ-28.
To determine the most important predictor variables of sexual quality of life, multivariable regression analysis performed given the results of univariate regression. The variables of age, employment status, the level of education, smoking cigarette, the history of prostatic hypertrophy, and sleep problems predicted the sexual quality of life significantly in the older men (F (7,361) = 18.02, P < 0.001, R2 = 0.513).
According to multivariable regression using the forward method, the most important predictors of sexual quality of life in the older adults were general health status, age, education status, and sleep problems, respectively, meaning that with an increase in the score of general health and age per year, the score of sexual quality of life in the older people decreases to 0.49 and 0.35 score, respectively (P < 0.001). Having the level of education more than 12 years led to an increase of 4.69 scores in the sexual quality of life in the elderly (P = 0.003). By contrast, the presence of sleep problems resulted in a decline of 3.50 score in the elderly's the sexual quality of life (P = 0.02). Having prostate hypertrophy had a direct effect on the sexual quality of life in older people, but this was not statistically significant (P = 0.20) [Table 4].
|Table 4: Predictors variables of participants' sexual quality of life with regards to the results of the multivariable regression using the forward method|
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[Figure 1] demonstrates that an increase in the level of education (R2 = 0.02) lead to increased sexual quality of life in participants, while an increase in the total score of general health (R2 = 0.1), age (R2 = 0.04), and sleep problems (R2 = 0.01) result in decreased sexual quality of life.
|Figure 1: The associations of predictor variables of the older adults' sexual quality of life (general health, age, level of education, and sleep problems)|
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| Discussion|| |
The objective of this study was to investigate the sexual quality of life and its relationship with general health in older men in the west of Iran. The results showed that older men had a moderate sexual quality of life and general health. General health, age, education status, and sleep problems were the most important predictor variables in the older men's sexual quality of life. In our study, higher general health and a higher level of education were the predictors of increasing the sexual quality of life, while sleep problems and increased age were the predictors of decreasing the sexual quality of life in older men. Rezaei et al. (2018) showed that increasing age, lower education, having depression, and incontinence were associated with increased symptoms of andropause in older men, which is in line with our results.
A study by Lew-Starowicz and Rola showed that the mean score of sexual function is correlated with the score of sexual quality of life, and poor sexual function affects substantially the sexual quality of life, which was in accordance with our results.
The results of our study showed that the general health status of older adults was at a moderate level. These results were in line with the studies of Barati et al. in Hamedan and Nejati et al. in Qom., Moreover, in this study, one of the most critical predictor factors in older men's sexual quality of life was general health. These results were in agreement with Flynn et al., study that reported participants in excellent health had significantly higher sexual satisfaction than those in fair or poor health. Besides, our findings were in conformity with a study by Rezaei et al., (2018) that found a significant association between the eight aspects of health-related quality of life and the andropause severity in the older men. Smith et al. showed that having realistic physical, psychological expectations, and mutual interactions in sexual intercourse among couples lead to sexual satisfaction. It can be concluded that maintaining and promoting physical and mental health and managing stress and tension in the older men can play an essential role in life satisfaction and an improvement in an emotional relationship and sexual quality of life.
Based on this survey, increased age, especially in the eighth decades and above, had a considerable impact on decreasing sexual quality of life in the older men. This result was in accordance with the study by Forbes et al. that reported sexual quality of life and sexual functioning decrease with increasing age. Since the elderly have a high age, we are expecting that sexual desire, sexual activity, and sexual quality of life gradually decrease. It can be attributed to the physiology of the body, atrophy, and losing the sexual partner.
The results showed that by increasing the level of education, the sexual quality of life in older men is improved, which is in line with the study by Forbes et al. that showed the level of education is useful in sexual activity knowledge, and by increasing level of education, individuals experience lower sexual dysfunction. It can be inferred that sexual activity is training-oriented, and if it is correct principles are observed, high sexual quality of life will be obtained, but it requires more research.
The results showed that sleep problems give rise to decreased sexual quality of life in older people. These results were compatible with the study by Smith et al. that reported a significant association between sleep quality and sexual function in men aged >50 years. Besides, our results were in line with a study by Charandabi et al., that showed sleep dysfunction leads to a decline in five-dimension men's sexual function.
In general, the findings of this study showed that sexual quality of life and general health were two important issues in old age, and there was a mutual connection between the sexual quality of life and general health. In a study by Naeinian et al., people with sexual dysfunction had lower general health in somatic, social, and mental dimensions. A survey by Lee et al. showed that lower health status was associated with lower sexual activity and a higher prevalence of sexual function problems, especially among older men.
Given the study results, it is suggested that country health managers in educational programs pay more attention to the importance of sexual quality of life and its relationship with older adults' general health. Given that sexual issues are among those issues that older people are less likely to talk regarding with health professionals and counselors, these programs should be more embedded in the educational programs of comprehensive health center. In addition, since health-care professionals in health centers in Iran have little education and knowledge concerning sexual health and its importance, this concept should be taught in retraining programs.
Despite the strength of this study, it also has some limitations. First, this was a descriptive study, and the older men's quality of life examined at a specific point in time. Thereby, conducting longitudinal studies would result in more knowledge regarding factors influencing older men's sexual quality of life. Second, this study was done in one of the western cities of Iran, which may not represent the entire population of older men's quality of life. Hence, it is suggested similar studies should be done in other parts of Iran. Owing to collecting data by self-reported method, and feeling of ashamed by men who have sexual problems in the studied city, our findings likely represent an underestimate of the true extent of sexual problems.
Future research would benefit from the use of a larger sample and also other research methodology, not only to verify these findings but also to assess the impact of other demographic and cultural variables that may influence older men's sexual quality of life.
| Conclusion|| |
The results of this study highlighted the critical factors influencing older men's sexual quality of life. The results showed that the sexual quality of life in the older men was at a moderate level. Moreover, this study revealed the predictor factors of men's sexual quality of life, such as general health status, age, the level of education, and sleep problems. However, further studies should be conducted in the future to acknowledge the effect of these factors on men's sexual quality of life and other factors influencing.
This study was performed as a master thesis project titled “Investigating the sexual quality of life and its relationship with general health in Iranian elderly men” which was approved by Ilam University of Medical Sciences. The authors gratefully acknowledge the cooperation of the elderly who participated in the study.
Financial support and sponsorship
This study was funded by the Deputy of Research and Technology of the Ilam University of Medical Sciences.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kanasi E, Ayilavarapu S, Jones J. The aging population: Demographics and the biology of aging. Periodontol 2000 2016;72:13-8.
Noroozian M. The elderly population in Iran: An ever growing concern in the health system. Iran J Psychiatry Behav Sci 2012;6:1-6.
Safarkhanlou H, Rezaei Ghahroodi Z. The evolution of the elderly population in Iran and the world. Statistics J 2017;5(3):8-16. In Persian.
Molavi R, Alavi M, Keshvari M. Relationship between general health of older health service users and their self-esteem in Isfahan in 2014. Iran J Nurs Midwifery Res 2015;20:717-22.
Bozorgmehri S, Fink HA, Parimi N, Canales B, Ensrud KE, Ancoli-Israel S, et al
. Association of sleep disordered breathing with erectile dysfunction in community dwelling older men. J Urol 2017;197:776-82.
Rezaei N, Azadi A, Pakzad R. Prevalence of andropause among Iranian men and its relationship with quality of life. Aging Male 2018:1-8.
Skałacka K, Gerymski R. Sexual activity and life satisfaction in older adults. Psychogeriatrics 2019;19:195-201.
Çayan S, Kendirci M, Yaman Ö, Aşçı R, Orhan İ, Usta MF, et al
. Prevalence of erectile dysfunction in men over 40 years of age in Turkey: Results from the Turkish Society of Andrology Male Sexual Health Study Group. Turk J Urol 2017;43:122-9.
Janik MR, Bielecka I, Kwiatkowski A, Janik PE, Drazba T, Bujok J, et al
. Cross-sectional study of male sexual function in bariatric patients. Wideochir Inne Tech Maloinwazyjne 2016;11:171-7.
Geerkens MJ, Al-Itejawi HH, Nieuwenhuijzen JA, Meuleman EJ, Lissenberg-Witte BI, van Moorselaar RJ, et al
. Sexual dysfunction and bother due to erectile dysfunction in the healthy elderly male population: Prevalence from a systematic review. Eur Urol Focus 2019; pii: S2405-4569(19)30079-3.
Hyde Z, Flicker L, Hankey GJ, Almeida OP, McCaul KA, Chubb SA, et al
. Prevalence and predictors of sexual problems in men aged 75-95 years: A population-based study. J Sex Med 2012;9:442-53.
Ramezani MA, Ahmadi K, Ghaemmaghami A, Marzabadi EA, Pardakhti F. Epidemiology of sexual dysfunction in iran: A systematic review and meta-analysis. Int J Prev Med 2015;6:43.
] [Full text]
Malakouti SK, Salehi M, Nojomi M, Zandi T, Eftekhar M. Sexual functioning among the elderly population in Tehran, Iran. J Sex Marital Ther 2012;38:365-77.
Koh S, Sewell DD. Sexual functions in older adults. Am J Geriatr Psychiatry 2015;23:223-6.
Erens B, Mitchell KR, Gibson L, Datta J, Lewis R, Field N, et al
. Health status, sexual activity and satisfaction among older people in Britain: A mixed methods study. PLoS One 2019;14:e0213835.
Taylor A, Gosney MA. Sexuality in older age: Essential considerations for healthcare professionals. Age Ageing 2011;40:538-43.
Lew-Starowicz M, Rola R. Sexual dysfunctions and sexual quality of life in men with multiple sclerosis. J Sex Med 2014;11:1294-301.
Gareri P, Castagna A, Francomano D, Cerminara G, de Fazio P. Erectile dysfunction in the elderly: An old widespread issue with novel treatment perspectives. Int J Endocrinol 2014;2014:1-14.
Wang V, Depp CA, Ceglowski J, Thompson WK, Rock D, Jeste DV. Sexual health and function in later life: A population-based study of 606 older adults with a partner. Am J Geriatr Psychiatry 2015;23:227-33.
Forbes MK, Eaton NR, Krueger RF. Sexual quality of life and aging: A prospective study of a nationally representative sample. J Sex Res 2017;54:137-48.
Charandabi SM, Rezaei N, Hakimi S, Khatami S, Valizadeh R, Azadi A. Sleep disturbances and sexual function among men aged 45-75 years in an urban area of Iran. Sleep Sci 2016;9:29-34.
Corona G, Rastrelli G, Maseroli E, Forti G, Maggi M. Sexual function of the ageing male. Best Pract Res Clin Endocrinol Metab 2013;27:581-601.
Flynn KE, Lin L, Bruner DW, Cyranowski JM, Hahn EA, Jeffery DD, et al
. Sexual satisfaction and the importance of sexual health to quality of life throughout the life course of U.S. Adults. J Sex Med 2016;13:1642-50.
Smith L, Grabovac I, Veronese N, Soysal P, Isik AT, Stubbs B, et al
. Sleep quality, duration, and associated sexual function at older age: Findings from the english longitudinal study of ageing. J Sex Med 2019;16:427-33.
Sadat Z. Validity and reliability of farsi male sexual quality of life questionnaire. JIIHSR 2017;1:73-80.
Abraham L, Symonds T, Morris MF. Psychometric validation of a sexual quality of life questionnaire for use in men with premature ejaculation or erectile dysfunction. J Sex Med 2008;5:595-601.
Fisher TD. The impact of socially conveyed norms on the reporting of sexual behavior and attitudes by men and women. J Expl Soc Psychol 2009;45:567-72.
Goldberg DP, Hillier VF. A scaled version of the general health questionnaire. Psychol Med 1979;9:139-45.
Shayan Z, Pourmovahed Z, Najafipour F, Abdoli AM, Mohebpour F, Najafipour S. Factor structure of the general health questionnaire-28 (GHQ-28) from infertile women attending the yazd research and clinical center for infertility. Int J Reprod Biomed (Yazd) 2015;13:801-8.
Hjelle EG, Bragstad LK, Zucknick M, Kirkevold M, Thommessen B, Sveen U. The general health questionnaire-28 (GHQ-28) as an outcome measurement in a randomized controlled trial in a Norwegian stroke population. BMC Psychol 2019;7:18.
Ploubidis GB, Abbott RA, Huppert FA, Kuh D, Wadsworth ME, Croudace TJ. Improvements in social functioning reported by a birth cohort in mid-adult life: A person-centred analysis of GHQ-28 social dysfunction items using latent class analysis. Pers Individ Dif 2007;42:305-16.
Zare N, Sharif F, Dehesh T, Moradi F. General health in the elderly and younger adults of rural areas in fars province, Iran. Int J Community Based Nurs Midwifery 2015;3:60-6.
Nazifi M, Mokarami H, Akbaritabar A, Faraji Kujerdi M, Tabrizi R, Rahi A. Reliability, validity and factor structure of the persian translation of general health questionnire (GHQ-28) in hospitals of kerman university of medical science. J Fasa U Med Sci 2014;3:336-42.
Barati M, Fathi Y, Soltanian A, Moeini B. Assessment of mental health status and health promoting behaviors in the elderly living in Iran, Hamadan. Iran J Nurs Midwifery Res 2012;20:12-9.
Nejati V, Izadi-Najafabadi S, Shoja O, Javadi M, Rezaei F. Cognitive and general health status in elderly with and without history of falling. Yektaweb J 2013;8:7-15.
Smith L, Yang L, Veronese N, Soysal P, Stubbs B, Jackson SE. Sexual activity is associated with greater enjoyment of life in older adults. Sex Med 2019;7:11-8.
Naeinian MR, Shaeiri MR, Hosseini FS. General health and quality of life in patients with sexual dysfunctions. Urol J 2011;8:127-31.
Lee DM, Vanhoutte B, Nazroo J, Pendleton N. Sexual health and positive subjective well-being in partnered older men and women. J Gerontol B Psychol Sci Soc Sci 2016;71:698-710.
[Table 1], [Table 2], [Table 3], [Table 4]