Download GNEC - Sexuality in Older Adults

Sexuality in Older
Adults
Author: Meredith Wallace PhD, APRN, A/GNP-BC
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Learner Objectives
1.
Discuss the continuing sexual interests of older
adults.
2.
List barriers and challenges to sexual health in the
aging population.
3.
Identify the impact of normal aging changes, disease
processes, medications and environment on sexual
health of older adults.
4.
Develop a plan of care to promote sexual health of
older adults.
5.
Identify the impact of cultural values and beliefs on
sexual health.
6.
Discuss effective management strategies for
hypersexual behavior among cognitively impaired
older adults.
7.
Plan an effective environment to promote the sexual
health of older adults.
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Introduction
Sexual Health
 Is important to an individual’s
self-identity and general wellbeing.
 Contributes to the satisfaction of
physical needs.
 Fulfills social, emotional, and
psychological components of life.
 Evokes sentiments of joy,
romance, affection, passion, and
intimacy.
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Introduction
Many believe that older adults are
asexual human beings.
There is a
general
discomfort
with sexual
issues in the
U.S.
Most nurses
are not
educated to
manage
sexual health
issues of
older adults.
Sexual health
is often
ignored in the
assessment
of older adult
health.
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Introduction
The beliefs and misconceptions about
older adult sexuality result in the
attitude that older adult sexuality is
not worth considering.
Lack of education, experience and
negative attitudes toward aging
sexuality results in an inability to
meet sexual desires and maintain
sexual health.
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
How Might You Teach This Content?
. . . or use Train-the Trainer Strategies to
Incorporate This Content Into Courses?
1. Begin with sensitivity training with a film about older
adults in love. Suggest: A Rose by Any Other Name
2. Develop a role playing assignment where students
must conduct sexual health assessments on each
other.
3. Use case studies to develop plan of care to manage
sexual health issues of normal functioning and
cognitively impaired older adults.
4. Work with staff development nurses in long-term care
facilities to integrate sexual health knowledge into
clinical practice.
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Myths about Sexuality and Aging
Many people believe that sexual
desires diminish with age.
Others believe that sexual
activity in long-term care
facilities is against the rules.
Older adults are often assumed to be
heterosexual. The presence of
Lesbian, Gay, Bisexual and
Transgender (LGBT) older adults is
not often considered a possibility.
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Reality
Sexuality …
 provides for expressions of affection and passion.
 Enhances avowal of life.
 Enriches communication.
Sexuality is alive and well among older adults:
 Research conducted by Lindau et al (2007) revealed
that in a study of 3005 U.S. older adults current sexual
activity was reported in 73% of adults aged 57 to 64,
53% of adults aged 65 to 74 and 26% of adults aged 75
to 84.
(Lindau, et al., 2007)
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Reality
Older adults continue to be sexual beings. However the
presence of acute and chronic illness requires nursing
assistance to manage sexual health needs by examining:
 Barriers to sexual health.
 Impact of normal, pathological aging changes as well as
medications and environment on sexual health.
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Why Should Nurses Intervene to Promote
the Sexual Health of Older adults?
The expression of sexuality among older adults results in a
higher quality of life achieved by fulfilling a natural desire. It
also may…
 Improve functional status.
 Improve mood.
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Older Adult
Barriers to Sexual Health
Older adults lack knowledge and comfort with sexual health
issues.
 Older adults are not always familiar with safe sex practices.
 Older adults may not be aware of alternative sexual acts and
positions to accommodate health needs.
In a survey study of 81 older community dwelling outpatients,
more than half could not name any risk factors for Erectile
Dysfunction (ED). Patients preferred the internet and general
practitioners as primary sources sexually-related information. The
authors concluded that sexuality patient information and
(Baumgartner et al., 2008)
education requires more attention.
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Older Adult
Barriers to Sexual Health
Old habits
Poor experiences
Fear of discussing sexuality
Victorian Attitudes toward sexuality
Lack of opportunity (no partners or
privacy)
Cultural attitudes toward sexuality
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Health Care Provider
Barriers to Sexual Health in Older Adults
Providers:
 Are subject to myths and attitudes
of sexuality and aging.
 May be insensitive to older
adults needs.
A study of 100 patients
aged 39 to 86 and their
health care providers
revealed that less than
10% of providers asked
patients about erectile
function, although over
90% of patients were
interested in treatment
(Chitale, et al., 2007)
 Don’t know how to manage sexual health issues.
 Experience discomfort in managing sexual issues.
(Chitale et al., 2007)
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Other
Barriers to Sexual Health in Older Adults
Physical Barriers to Sexual
Health
 Normal aging changes
 Pathological aging changes
 Chronic pain
 Cognitive Impairment
 Environmental restrictions
 Body image
 Adverse Medication effects
Societal discomfort with
issues of homosexuality
 Older people are
homosexual too!
 They may have not come
out yet.
 LGBT may fear physical
harm for coming out.
 Require great sensitivity
to years of isolation.
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
How Might You Teach This Content?
. . . or use Train-the Trainer Strategies to
Incorporate This Content Into Courses?
 Ask students to share their experiences and beliefs about older
adult sexual health in order to understand their own attitudes
toward sexuality.
 Identify any formal education students have had with sexual
health in any population.
 Show pictures of elders kissing, caressing, naked. Consider
popular films like “Harold and Maude”
 Encourage students to identify patients or residents who may
need help in promoting their sexual health.
 The more sexual health is discussed, the easier it gets.
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Normal Aging Changes
that Impact Sexual Health
The ‘sexual response cycle’, or the organized
pattern of physical response to sexual stimulation
changes with age. These changes impact sexual
health in both:
 Women
 Men
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Normal Changes of Aging
Female Sexual Response
After menopause, a loss of estrogen in women
results in significant sexual changes, including:
 Thinning of the vaginal walls
 Decreased or delayed vaginal lubrication, which may
lead to pain during intercourse
 Labia atrophy
 The vagina shortens
 The cervix may descend downward into the vagina
 Loss of fat pad over pubic symphysis may lead to pain
from direct pressure over bone.
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Normal Changes of Aging
Female Sexual Response
After sexual intercourse is completed, women
return to the pre-aroused stage faster than they
would at an earlier age.
 Physiological age-related
changes in women have
the potential for significant
alterations in sexual health.
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Normal Changes of Aging
Male Sexual Response
The Massachusetts male aging study
of 1085 older men indicated that age
was identified as an independent risk
factor for decreased sexual function
in older men.
(Araujo et al., 2004)
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Normal Changes of Aging
Male Sexual Response
Men also experience decreased testosterone hormone
levels with aging, but the impact on sexual functioning is not
as significant as in women. In older men:
 More direct stimulation of the penis is required to
experience a somewhat weaker erection.
 Orgasms are fewer and weaker in older men.
 The force and amount of ejaculation is reduced.
 The refractory period after ejaculation is increased.
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Other Age-Related Changes
that Impact Sexual Health
Many individual psychosocial and
cultural factors play a role in how older
adults perceive themselves as sexual
beings, such as:
 Life long beliefs about sexual
health.
 General physical and psychological
well-being.
 Cultural beliefs about sexual
practice.
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
How Might You Teach This Content?
. . . or use Train-the Trainer Strategies to
Incorporate This Content Into Courses?
Use the following case study of normal older adults
and ask students develop a list of potential normal
aging changes that should be considered in the
sexual health of the client. Be sure to ask students
to consider:
 Impact of age and sex on physical function.
 Impact of overall health and psychological function.
 Cultural implications for sexual health functioning.
 Potential for older adult as a LGBT individual.
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Case Study
A 69 year old Hispanic man is admitted to your facility. He is
a veteran who has previously lived alone, but has a partner
who visits often. His medications include: HCTZ 25 mg QD
and Lisinopril 20 mg QD. He denies health problems. He is
very quiet and you have concerns about his sexual health
and safety.
 What is the nurses first action here?
 How would the nurse proceed with an assessment and
management of this resident?
 What other members of the interdisciplinary team should be
involved in the care of the sexuality issues with this
residents?
 Discuss how the nurse would help to meet the
needs of the resident and his partner in this case?
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Sexual Dysfunction
Sexual disorders fall into four categories:
1. Hypoactive sexual desire disorder,
2. Sexual arousal disorder
3. Orgasmic disorder
4. Sexual pain disorders
(Walsh & Berman, 2004)
Sexual dysfunction is
prevalent worldwide,
and the occurrence of
sexual dysfunctions
increases directly with
age for both men and
women.
(Derogatis & Burnett, 2008)
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Pathological Changes
There are a number of medical conditions that cause sexual
dysfunction among older people, including:
 Heart Disease
 Diabetes
 Depression
 Breast and prostate cancers
 HIV/AIDS
 Dementia
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Heart Disease and Sexual Health
In a study of 2,763 postmenopausal women, the
presence of coronary heart disease was significantly
associated with:
 Lack of sexual interest.
 Inability to relax during sexual activity.
 Arousal and orgasmic disorders.
 General discomfort with sex .
(Addis et al., 2005)
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Heart Disease & Sexual Health
In a study of 1,357 men with heart
disease world wide, the
prevalence of ED in the sample
was 50.7% and a significant
decline in sexual activity was
reported after the diagnosis of
cardiovascular disease.
(Bohm et al., 2007)
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Diabetes & Sexual Health
Diabetes is a significant concern among older adults,
effecting approximately 14.7 million individuals in the U.S
each year.
Diabetes effects sexual health among older adults in a number of
ways:
– impacts sexual function.
– impacts arousal and pleasurable sensations.
Approximately 40%
of those with diabetes
are aged 65 years or older.
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Diabetes & Sexual Health
In a study of eight women aged 24 – 83, older
women with diabetes reported lower sexual
function, desire and enjoyment than their younger
counterparts.
(RockliffeFidler & Kiemle, 2003)
In a study of 373 men aged 45-75 with type II
diabetes, 49.8% of the men reported mild or
moderate degrees of ED, and 24.8% had complete
ED.
(Rosen et al., 2009)
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Depression & Sexual Health
The presence of depression among older
adults impacts sexual health, in that
depression often causes a decline in desire
and ability to perform with this disease and
treatment.
A study of 3,810 men aged 57-78 years
revealed that men with ED had significantly
lower mental health scores.
(Korfage et al., 2009)
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Female Reproductive System Cancer
& Sexual Health
Women with breast and other reproductive system cancers
may have difficulty adjusting to disease and treatment due to
their association with bodily changes in self image that
impact sexuality.
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Prostate Cancer
& Sexual Health
Men with prostate
cancer who have
undergone surgical or
radiation treatments
may experience ED
following treatment.
The rate of erectile
dysfunction following
radical prostatectomy
has been reported to
be greater than 80%.
(Siegel et al., 2001)
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
HIV and the Elderly
 HIV cases among older adults in the United
States is increasing, with approximately 25% of
infections occurring in adults over the age of 50
years.
(Martin et al., 2008)
 Older adults with HIV/AIDS and other STDs
must be taught to follow CDC safe sex
practices, as this was not routinely covered in
formal education.
 The use of antiretroviral medications among
older adults may be complicated by multiple
chronic comorbidities and treatments.
 HIV-infected patients need continuous treatment with
antiretroviral agents to suppress viral replication and
maintain immune function.
(Magalhaes et al., 2007)
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
HIV/AIDS
& Sexual Health
In a study of 778 patients in an HIV clinic (86%
response rate) 12% were aged over 50. The
authors reported significantly more males in their
50s (86% vs. 75%), more gay males x(2) = 7, p =
0.04 and fewer females (14% vs. 25%) x(2) = 5; p =
0.03. There were no significant differences in
educational levels, employment or migration status
or physical symptom experience. However, older
patients reported significantly lower psychological
and global burden and were more likely to take
antiretrovirals (88% vs. 79%; p = 0.04).
(Sherr et al., 2009)
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Urinary Incontinence
& Sexual Health
While not well-studied, the presence of urinary incontinence
is theorized to interfere with sexual function among older
adults related to:
 Shame and embarrassment.
 Avoidance of sexual activity for fear of incontinence.
In a study of 2, 361 Community-dwelling women aged 55 to
95, UI was significantly associated with alterations in sexual
activity.
(Tannenbaum et al., 2006)
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Other Diseases Impacting
Sexual Health
Other medical conditions occurring among older adults also
have the potential to impact sexual health, including:
 Strokes and subsequent aphasias impact sexual health
via difficulties in desire, function and communication.
(Lemieux et al., 2001)
 Parkinson’s disease (PD) In a study of 444 older adults
with PD, sexual limitations were reported in 73.5% of
the sample as a product of difficulty in movement.
(Mott et al., 2005),
 Benign Prostatic Hypertrophy (BPH) in older men may
result in altered circulation to the penis effecting erectile
function and sexual arousal. In conjunction with other
predictors of poor sexual health, BPH further impacts
erectile function and may contribute to ejaculatory
(Rosen, 2006)
dysfunction.
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Cognitive Impairment
& Sexual Health
Sexual needs among older adults often manifest in
inappropriate sexual behavior.
In a study of older, cognitively impaired older adults, 1.8%
had sexually inappropriate behavior manifesting in verbal
and physical problems.
In a study that used computed
tomography (CT) of the head to
scan 10 patients with these
problematic sexual behaviors,
cerebral infarction was seen in
six of them, and severe disease
in two others supporting the
organic basis for these symptom.
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Sexual Behaviors Common to
Cognitively Impaired Older Adults
Sexual Behaviors
 Cuddling
 Grabbing & groping
 Touching of the genitals
 Use of obscene language
 Sexual remarks
 Masturbating without
shame
 Propositioning
 Aggression and irritability
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Determining Ability to Give Informed Consent
to Participate in Sexual Relationships
Accurate assessment and documentation of the ability of
cognitively impaired older adults to make informed decisions
regarding sexual relationships with others while in long-term
care, is essential.
It is important to remember that participation in sexual
relationships may still be within the decision-making capacity
of cognitively impaired older adults.
If the resident has been determined to be incapable of
exercising decisional capacity, then the health care staff
must prevent the cognitively-impaired resident from
unsolicited sexual advances.
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Environmental Barriers
Older adults who live in long-term care facilities or
with family members may lack privacy for sexual
relations.
There is an absence of
male partners for older
women - 60% of older
women are partnerless.
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Effect of Medications and
Treatments on Sexual Health
Antidepressants including SSRIs, Tricyclic
Antidepressants, MAOIs impact libido and sexual function,
including:
 Selective serotonin reuptake inhibitors (SSRI). In aa
study of 610 women and 412 men, 59.1% of the
individuals taking SSRI antidepressant medications
(Montejo et al., 2001)
reported sexual dysfunction.
 While the use of MAO inhibitors and tricylic
antidepressants has decreased in favor of the SSRIs
with lower side effect profiles, these medications also
impact sexual function by reducing sexual drive and
causing impotence and erectile and orgasmic
disorders.
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Effect of Medications and
Treatments on Sexual Health
 Antihypertensives including: ACE inhibitors, Alpha
Blockers, Beta Blockers, Calcium Channel Blockers,
Clonidine, Methyldopa and Thiazide Diuretics result
in impotence and ejaculatory disturbances among
older adults.
 Cholesterol lowering medications including statins
and fibrates may impact sexual health.
 Other medications such as antipyschotics
(Phenothiazines & Risperdone) seizure medications
(Carbamazepine) and H2 Blockers (Cimetidine) also
impact sexual health.
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
How Might You Teach This Content?
. . . or use Train-the Trainer Strategies to
Incorporate This Content Into Courses?
Use the following case study of older adults to
identify the impact of pathological aging changes
on sexual health. Ask students to identify the
impact of disease processes on sexual health. Be
sure to ask students to consider:
 The pathophysiological impact of the disease on
sexual function.
 Impact of disease process on self-image.
 The role of culture in assessing and managing sexual
issues among older adults.
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Case Study
Mrs. Austin is a highly functioning 79 year old widow who was recently
admitted to a nursing home with mild cognitive impairment. Mrs. Austin
began a friendship with Mr. Carl, who is wheelchair bound. Mr. Carl is
married to a woman who resides outside the facility. The nursing staff
has noticed more and more intimate touches between Mrs. Austin and
Mr. Carl and is concerned about whether Mrs. Austin is competent to
make the decision to participate in this increasingly intimate relationship.
The staff is also concerned about the moral and ethical issues
surrounding Mr. Carl’s relationship with a woman other than his wife.
 What is the nurses first action here?
 How would the nurse proceed with an assessment and management of
these patients?
 What other members of the interdisciplinary team should be involved in the
care of the sexuality issues with these residents?
 Discuss how the nurse would help to meet the needs of patients and
families in this case?
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Assessment of Sexual Health
Assessment of sexual health is the first step in developing a
plan of care to fulfill sexual needs of older population.
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OPENING THE DOOR:
Sexual Health History Questions
 Can you tell me how you
express your sexuality?
 What concerns do you
have about fulfilling your
continuing sexual needs?
What question do
you have about your
continuing sexual
needs and function?
 In what ways has your sexual
relationship with your partner
changed as you have aged?
 What interventions or
information can I provide to
help you to fulfill your
sexuality?
(Wallace, 2000)
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ASSESSMENT:
How to Try This
Older Adult Sexuality: A Continuing Human Need
 Click the image to view the How to Try This video
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PLISSIT MODEL
P
Obtaining permission from the client to
initiate sexual discussion
LI
Providing the limited information needed to
function sexually
SS
Giving specific suggestions for the individual
to proceed with sexual relations
IT
Providing intensive therapy surrounding the
issues of sexuality for that client
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Assessment
 Health history & review of systems
 Drug review
 Physical assessment
 Assessment for cognitive impairment and impact on sexual
health decision making
 Labs - ? Testosterone levels
 CT/MRI ? For hypersexual behaviors
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Assessment Essentials
 Acquire a quiet, private area in which to talk.
 Assessment should be performed in a respectful manner that
conveys an understanding of the continuing sexual needs of
older adults.
 The more comfortable the healthcare provider is with the
assessment, the more comfortable the client will be.
 Role play assessment / management prior to actual
assessment.
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
How Might You Teach This Content?
. . . or use Train-the Trainer Strategies to
Incorporate This Content Into Courses?
Have students conduct a sexual assessment on
each other or in an older adult clinical site using
the suggested questions or PLISSIT Model. Be
sure to have students identify:
 Normal changes of aging on sexual health.
 The pathophysiological impact of the disease and
medication on sexual function.
 Impact of disease process on self-image.
 The impact of culture and sexual orientation on sexual
health.
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Diagnosis of
Sexual Health Problems
Diagnosis of sexual problems and development of a plan of
care to meet the sexual health needs of older adults is
essential to improved sexual health and quality of life.
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NANDA Diagnosis
of Sexual Health Problems
Sexual Dysfunction
Sexuality Pattern, Ineffective
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Management of
Sexual Health Needs
1) Promote a healthy lifestyle.
2) Compensate for normal age-related changes.
3) Manage pathological diseases that impact
sexual health.
4) Review medications that impact sexual health.
5) Modify environment to facilitate sexual health
functioning.
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Health Promotion
What’s good for the head and heart
is good for the _____.
Eating healthy foods, getting
adequate amounts of sleep,
exercising, decreasing alcohol
intake, stress-management
techniques, and not smoking
are essential to sexual health.
Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Compensate for
Normal Aging Changes
Provide patient teaching on normal aging
changes on sexual function and image.
Discuss need for longer fore-play arousal time to
compensate for normal aging changes.
Consider alternative forms of intimacy when
sexual intercourse is too uncomfortable or not
possible.
Use it or lose it.
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Patient Teaching
Providing teaching regarding normal and
pathological sexual changes with aging.
Introduce to resources for sexual health.
Be sure to include safe sex practices in all patient
teaching encounters.
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Compensate for
Normal Aging Changes
Consider use of artificial water based
lubricants or estrogen gels/patches for
vaginal dryness
In a multicenter, double-blind, randomized,
placebo-controlled study, 305 women with
symptoms of vaginal atrophy were treated
with a low-dose synthetic conjugated
estrogen A (SCE-A) cream twice weekly.
The results indicated that the cream was effective compared with
placebo in treating symptoms of vaginal atrophy, including pain.
(Freedman et al., 2009)
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Compensate for
Normal Aging Changes
Options for normal aging changes to
erectile function:
 Vacuum pumps
 Injection therapy
 Implants
 Talk therapy
 Oral erectile agents.
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Compensate for Normal Aging
Changes
The use of oral erectile
agents such as agents
such as sildenafil Citrate
(Viagra®), vardenafil HCL
(Levitra®), and tadalifil
(Cilalis®) have greatly
aided the onset of ED that
occurs with aging.
(Wespes et al., 2007)
There are a number of
erectile agents available
in the form of injectable
treatments. These are
effective treatments for
ED, however some are
preferred more by
patients than others
related to the extent of
pain from the injections.
(Shah et al., 2007)
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Heart Disease Management &
Sexual Health
Many medications for the treatment of hypertension
and cardiovascular disease impact sexual function
Provide patient teaching about these adverse
medication effects.
Be sure to assess whether patient’s medication
is adversely impacting sexual function and
consider change in medications when
appropriate.
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Heart Disease Management &
Sexual Health
A study of 92 men with a mean age 58 were studied after
myocardial infarction/acute coronary syndromes and/or
coronary artery bypass graft,. The sample was broken into
an intervention group (n=47) and a control group (n=45).
The intervention group had patient education, cognitive
restructuring, emotional support, guided imagery, and
medication (Viagra). Controls participated in cardiac
rehabilitation without these intervention elements. The
intervention group was able to resume sexual activity
within 1 month of their cardiac event (87% vs. 50% in
control). In addition, the intervention group experience
greater improvement in libido, confidence to attain
erection, satisfaction with sexual relationship, frequency of
erection, and enjoyment of sex.
(Klein et al., 2007)
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Diabetes & Sexual Health
Effective management of diabetes will prevent
circulatory and sensory changes that impact sexual
health. Make sure clients:
Test their blood for elevated glucose levels.
Diet and exercise.
Manage blood sugar levels with hypoglycemic
medications and/or insulin.
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Depression & Sexual Health
CATCH 22
• Treatment of depression may help to
improve libido and sexual dysfunctions
such as orgasmic disorders.
• However, medications to treat depression,
often impact sexual function by lowering
libido and causing orgasmic disorders.
A sample of 30 depressed patients with a mean age of 52 was
randomized to receive either T enanthate (testosterone) 200 mg
or sesame-seed oil (placebo). Self-reported sexual functioning
improved in both groups, but no significant differences were
found between groups
(Siedman & Roose, 2006)
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Cancer and Sexual Health
The experience of breast, prostate and other reproductive
system cancers mandates participating in a program of
individual or group support to resolve the bodily changes in
self image that impact sexuality.
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Cancer & Sexual Health
Evidence is beginning to accumulate in favor of oral phosphodiesterase
type 5 (PDE5) inhibitors to manage erectile dysfunction (ED)
immediately following radical prostatectomy (Miles et al., 2007). While
oral erectile agents are widely and becoming more accepted to enhance
erectile function after aggressive prostate cancer treatment, the
effectiveness of these medications is dependent on intake nerve
function.
(Miles et al., 2007)
A study of 150 female cancer survivors were randomized to receive 2%
testosterone in Vanicream for a testosterone dose of 10 mg daily or
placebo Vanicream for 4 weeks and were then crossed over to the
opposite treatment for an additional 4 weeks. The results did not indicate
a significant improvement in libido as a result of the increased
testosterone.
(Barton et al., 2007)
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Cognitive Impairment
The burden of determining ability to give informed consent
for sexual relationships requires:
 Assessment
 Documentation
 Interdisciplinary collaboration – you are not in this
alone.
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Management of Sexual Health Among
Cognitively Impaired Older Adults
 Education/counseling
 Approaches to care
 Boundary setting
 Referrals to psychotherapy
 Soft spoken, calm
 Respectful
 Same gender caregivers
 Alternative methods of intimacy
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Pharmacological Treatment
of Hypersexual Behavior
 Controversial, ethical issues
 Hormonal agents – decrease testosterone
 Anti-androgens
 Side effects include sedation, weigh gain, fatigue, hot and cold
flashes, depression, loss of body hair and mild diabetes.
 Gonadotrophin-releasing hormone
 side effects associated with these medications include hot flashes
decreased erectile function and libido and irritation at injection site.
 Estrogens
 risk of cardiovascular side effects as well and increased fluid retention,
gastrointestinal effects require caution.
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Pharmacological Treatment of
Hypersexual Behavior
 Tricyclic antidepressants & Trazodone
 relatively safe profile
 antilibidinal and anti-obsessive effect.
 Antipsychotics reduce dopamine
 Neuroleptics, mood stabilizers and other agents such as Pinolo
and Cimetidine.
 These later medications have only been tested in small
numbers of patients or supported with anecdotal evidence.
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Case Study
Mr. Carlton has been a resident of New Hills Nursing facility for many
years. He has AD and is wheel chair bound related to deconditioning
post hip fracture. He is well known for his overly flirtatious manner. He
frequently requests the nursing staff to “jump in the sack with me” and
often grabs at staff members as they provide care or pass him in the
halls. Much to the disgust of staff, he has been found masturbating on
several occasions both in his room and in public places. While the
behavior used to happen only occasionally, it is occurring increasingly
more often. The nursing staff can barely provide any care to Mr. Carlton
without being subjected to sexual overtures and harassment.
 What is the nurses first action here?
 How would the nurse proceed with an assessment and management of this
resident?
 What other members of the interdisciplinary team should be involved in the care of
the sexuality issues with this residents?
 Discuss how the nurse would help to meet the needs of the resident and his partner
in this case?
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Environmental Management
 Environmental adaptations are often to ensure privacy and safety among
long-term care and community dwelling residents is essential.
 Arrangements for privacy must be made so the dignity of older adults is
protected during sexual activity.
 Call lights or telephones should be kept within reach during sexual activity and
adaptive equipment such as hospital beds, side rails, or trapezes may need to
be obtained.
 Encourage masturbation for cognitively impaired older adults or those without
partners.
 Develop a sexual “tool kit”
 Individual tubes of lubricants
 Condoms
 Erotic materials (movies, magazines).
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Summary
 Older adults have continuing sexual interests that persist
throughout the lifespan.
 There are many barriers and challenges to sexual health in the
aging population, including normal aging changes, disease
processes, medications and environment.
 It is necessary to conduct a sexual health assessment on ALL
older adults and develop plans of care to manage sexual health
needs.
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Glossary of Terms
 Sexuality
 "a central aspect of being human throughout life and encompasses
sex, gender identities and roles, sexual orientation, eroticism,
pleasure, intimacy and reproduction."
 Sexual Health
 "a state of physical, emotional, mental and social well-being related
to sexuality.“
 Level VI
 World Health Organization (2004). Sexual Health- A New Focus for
WHO. Progress in Reproductive Health Research, 67. 1-8.
Retrieved May 10, 2005.
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Glossary of Terms
Sexually inappropriate behavior and sexual disinhibition, is a
clinically significant level of desire to engage in sexual
behavior.
 Sexual behaviors of severity and/or duration that cause
distress, disturbance or suffering for close relationships
(Nagaratnam & Gayagay, 2002) (Black et al., 2005)
and caregivers.
 Persistent, uninhibited sexual behaviors directed at
oneself or inappropriately at others
(Johnson et al., 2006) (Wiseman et al., 2000) (Wick et al., 2005)
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Resources
 A Rose by any other Name (1976). Post Perfect Productions Backseat
Bingo. Terra Nova Films.
 Freedom of Sexual Expression: Dementia and Resident Rights in LongTerm Care Facilities. Terra Nova Films.
 The Heart Has No Wrinkles. Terra Nova Films
 Arena, J. M. & Wallace, M. (2008). Sexuality. In Geriatric Nursing
Protocols for Best Practice 3rd Edition. (E. Capezuti, Zwicker, D., M.
Mezey & T. Fulmer, Eds). New York, Springer Publishing Co., pp. 629647.
 Wallace, M. & Safer, M. (2009). Hypersexuality in Cognitively Impaired
Older Adults. Geriatric Nursing.
 Wallace, M. (2008). How to Try This; Sexuality Assessment. American
Journal of Nursing, 108(7), 40 - 48.
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Web Links
 Hartford Institute for Geriatric Nursing/ ConsultgeriRN.org. Sexuality Issues in Aging.
http://consultgerirn.org/topics/sexuality_issues_in_aging/want_to_know_more
 MedlinePlus
http://www.nlm.nih.gov/medlineplus/sexualhealthissues.html
 National Institutes on Aging http://www.niapublications.org/engagepages/sexuality.asp
 American Foundation for Urological Disease, Inc http://www.impotence.org
 World Health Organization (2004). Sexual Health- A New Focus for WHO. Progress in
Reproductive Health Research, 67. 1-8. http://www.who.int/reproductivehealth/en/
 American Association of Older Persons. Great Sex Well After 50.
http://www.aarp.org/family/love/articles/berman_sex_after_50.html
 Society for the Scientific Study of Sexuality. http://www.sexscience.org/
 Beautiful portraits of older gay couples. http://www.renaldi.com/portfolio/elderly1.html
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References
References with their Levels of
Evidence are found on this
slide’s Notes Page.
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