Presentation on theme: "Sexuality and the Nursing Home"— Presentation transcript:
1 Sexuality and the Nursing Home Thomas Magnuson, M.D.Assistant ProfessorDivision of Geriatric PsychiatryUNMC
2 To Get Your Nursing CEUs After this program go toYour program ID number for the June 14th program is 10CE027.Instructions are on the website.**All questions about continuing education credit and payment can be directed towards the College of Nursing at UNMC.**Heidi Kaschke Program Associate, Continuing Nursing Education
3 Objectives Identify normal changes in sexuality as we age Discuss expressions of normal sexuality in nursing home residentsExplore assessment and treatment of hypersexuality
4 Sexuality and Aging Human drive Other bodily changes Opportunity Diminishes with agingOther bodily changesMechanically less responsiveOpportunityPartner passes away or is illCultural biasImages of beauty, sexuality
5 Sexuality and Dementia Partners must adapt to changeDegree of intimacyMay be less interestedPatienceMay be clumsy, poorly coordinatedSee as appropriateBe supportive of their desire for intimacyMay alter what regarded as intimacyNormal sexual activity may be unrealisticMay be uncomfortable, frustratingPersons views, attitudes on sexuality may change
6 Case One Elderly male with mild-moderate dementia No roommate Wife is a daily visitorAlways pleasant and cooperative with staffNo roommateWife asks that a “Do not disturb” sign be placed on the door for an hour“…or should I lock the door?”She clearly conveys that they will be intimateWhat do you do?
7 Case Two Two demented residents How do you report this? Found naked in bed togetherBoth still marriedBoth assent to the behaviorHow do you report this?Serious resident-resident contactDo they have the capacity to have sex?One family doesn’t careThe other family is upsetWhat are you going to do?
8 Sexuality in the Nursing Home Most still want to be sexually activeOver 60% of elderly residents endorsed a desire for intimacy52% of men report intercourse in the previous 4 weeksBarriers to intimacy existLack of privacyStaff, family attitudesInformed consent issuesLack of a partner
9 Gone With the Wind Up to now in nursing home care Baby boomers Only an issue when hypersexualNormal sexuality not on the radar screenLike sexuality doesn’t existBaby boomersExpect sexuality to be part of agingWhy do you think Viagra came out now?Will demand the industry changeActivity therapy takes on a whole new meaningIt’s not bingoAccommodate their needsLong-term and short-term relationships
10 Lack of Privacy Multiple person rooms Routine interruptions State-of-the-artNew facilities will be more accommodatingRoutine interruptionsVitalsMedicationsHousekeepingWandering residentsSurprise!Conjugal visit roomsWave of the future
11 Staff Responses Variable reports Study monitoring staff responses Generally positive attitudesSome uneasy about sexual behaviorSeen as cute or disgustingWait until you’re 65Leave baggage at the doorStudy monitoring staff responsesPaid no notice and gave no assist94 inappropriate sexual behaviorsStaff responded to none of themIgnored 10/17 appropriate sexual behaviorsKissing, hugging, caressing
12 Informed Consent What is important What form does the behavior take? Is it consistent with previous beliefs or practices?ContextDelusions another is one’s spouse?Who initiates the behavior?Problem…to whom?Family, staff?Risks…to whom?STDs, exercise induced asthma?Capacity to say no?
13 Informed Consent Do they understand the relationship? Aware of initiatorNot confused thinking of spouseComfortable with level of intimacyCan they avoid exploitation?Consistent with beliefs, valuesSay noDo they understand the risks?Time limited nature of the relationshipHow will they act when it ends?
14 Lack of a Partner Many are widowed A dearth of new partners Lack a significant other upon admissionA dearth of new partnersEspecially for female residentsThe Beach Boys were right…Family concernsAngry, embarrassedCompanionship not valuedFew activities to promote relationshipsFearful of exploitationInstitutional oversight present
15 Case Three 66 year old female with dementia Mildly impaired No behavioral or psychiatric problemsFound to be masturbating in her bedOnly when roommate is out of the roomNo significant medical complications from the behaviorTrauma from use of inappropriate objects, e.g.What do you do?
16 “but I know it when I see it.” U.S. Supreme Court Justice Potter Stewart -commenting that pornography is hard to define from a legal standpoint
17 Hypersexuality Definition Exposure Obscene sexual language Inappropriate masturbationPropositioning of othersTouching breasts and genitalia
18 Hypersexuality Behavioral problems Common in dementia 80% of demented patients at some pointAggression, agitation, disruptive vocalizations, etc.Hypersexuality a rare problem2-25%One equal, most say more in malesNursing home 18%Consults 1.8%Physical 87.8%Verbal 65.7%
19 Hypersexuality Significant issue Resident Staff May require medication May develop aggression, agitationMay have to moveStaffUsually young femalesOpen communication with supervisorEducate to recognize, manageThis adds to burden, turnover
20 Hypersexuality Why does this occur? Disinhibition Brain areas that control impulsiveness are damagedProposition, touch multiple residents, staffManiaDelusions, hallucinationsDamage to other areas leads to delusions and hallucinationsMistakes staff for his wifeMedicationsParkinson’s agentsAlso used in restless leg syndromeTestosteroneGiven sometimes for weakness, depressionTumorGreat increase in sex drive
21 Hypersexuality Make sure you see what you see Not all sexual acts are hypersexualWith masturbation it is the context of masturbationStanding with their pants downMay not remember how to get them off for bedFrustrated aphasic patients can swear appropriatelySexual terms blurt out, but not focusedTouching your bottomWants your attention as you walk by his wheelchair
22 Reporting Context varies reporting What if a female pats your bottom?What if the couple is married?Staff member’s attitudes and beliefsWhat is deemed normal varies greatlyThis is a medical, not moral issueExtent of behaviorHolding hands to intercourseWhere is the line drawn?
23 Case Four 76 year old male with severe dementia What do you do? Grabs caregivers breasts and genitaliaSeen touching residents as wellAssessment for medical causes unremarkableNo quick fixFamily embarrassedOther residents’ families are angryWhat do you do?
24 Treatment What not to do Ignore the behavior Get upset Really…it won’t go awayGet upsetYour emotional response to the behavior has a great deal to do with making it better or worseTell them it is “inappropriate”If they knew that…Send mixed messagesKisses, hugs, holding hands
25 Treatment Nonpharmacologic We must change our behavior to the resident They cannot learnReturn to room, close the doorAppropriate except for placeSeparate resident from the targetMove to another unit, hallwayUse same sex staff membersEspecially bathing, dressing, toiletingPreventionActivitiesClear identification as a medical professional
26 Treatment Pharmacologic Usually start with an SSRI antidepressant A side effectReduces sex driveMechanical problemsProzac (fluoxetine)Zoloft (sertraline)Paxil (paroxetine)Luvox (fluvoxamine)Celexa (citalopram)Lexapro (escitalopram)
27 Treatment SSRI antidepressants What to watch for Nausea and/or diarrheaJitteryInsomnia/sedationHeadacheLow sodiumRare GI bleed
28 Treatment Pharmacolgic Hormone treatment Cyproterone and depo-provera Testosterone and LH levelsOral and IMEstrogenDaily dosingOral, patchLeuprolideIM monthly
29 Treatment Hormone treatment What to watch for Thromboembolism and strokeDepressionBone density lossWeight gainHot flashes and gynecomastiaFatigue
31 Cases Case One Case Two Normal behavior Assure privacy, dignity Assess competencyBe aware of family concernsRisks and benefits include mood, QOL issues
32 Cases Case Three Case Four CLOSE THE DOOR! Begin nonpharmacologic interventionsProvide as much information as possible to PCPMake sure all staff is trained in assessment and interventionsCommunicate with familiesNeed for education, reassurance
33 Objectives Identify normal changes in sexuality as we age Discuss normal expressions of sexuality in nursing home residentsExplore assessment and treatment of hypersexuality