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Sexuality and the Nursing Home Thomas Magnuson, M.D. Assistant Professor Division of Geriatric Psychiatry UNMC.

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Presentation on theme: "Sexuality and the Nursing Home Thomas Magnuson, M.D. Assistant Professor Division of Geriatric Psychiatry UNMC."— Presentation transcript:

1 Sexuality and the Nursing Home Thomas Magnuson, M.D. Assistant Professor Division of Geriatric Psychiatry UNMC

2 To Get Your Nursing CEUs After this program go to After this program go to Your program ID number for the June 14 th program is 10CE027. Your program ID number for the June 14 th program is 10CE027. Instructions are on the website. Instructions are on the website. **All questions about continuing education credit and payment can be directed towards the College of Nursing at UNMC.** **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 Identify normal changes in sexuality as we age Discuss expressions of normal sexuality in nursing home residents Discuss expressions of normal sexuality in nursing home residents Explore assessment and treatment of hypersexuality Explore assessment and treatment of hypersexuality

4 Sexuality and Aging Human drive Human drive Diminishes with aging Diminishes with aging Other bodily changes Other bodily changes Mechanically less responsive Mechanically less responsive Opportunity Opportunity Partner passes away or is ill Partner passes away or is ill Cultural bias Cultural bias Images of beauty, sexuality Images of beauty, sexuality

5 Sexuality and Dementia Partners must adapt to change Partners must adapt to change Degree of intimacy Degree of intimacy May be less interested May be less interested Patience Patience May be clumsy, poorly coordinated May be clumsy, poorly coordinated See as appropriate See as appropriate Be supportive of their desire for intimacy Be supportive of their desire for intimacy May alter what regarded as intimacy May alter what regarded as intimacy Normal sexual activity may be unrealistic Normal sexual activity may be unrealistic May be uncomfortable, frustrating May be uncomfortable, frustrating Persons views, attitudes on sexuality may change Persons views, attitudes on sexuality may change

6 Case One Elderly male with mild-moderate dementia Elderly male with mild-moderate dementia Wife is a daily visitor Wife is a daily visitor Always pleasant and cooperative with staff Always pleasant and cooperative with staff No roommate No roommate Wife asks that a “Do not disturb” sign be placed on the door for an hour Wife asks that a “Do not disturb” sign be placed on the door for an hour “…or should I lock the door?” “…or should I lock the door?” She clearly conveys that they will be intimate She clearly conveys that they will be intimate What do you do? What do you do?

7 Case Two Two demented residents Two demented residents Found naked in bed together Found naked in bed together Both still married Both still married Both assent to the behavior Both assent to the behavior How do you report this? How do you report this? Serious resident-resident contact Serious resident-resident contact Do they have the capacity to have sex? Do they have the capacity to have sex? One family doesn’t care One family doesn’t care The other family is upset The other family is upset What are you going to do? What are you going to do?

8 Sexuality in the Nursing Home Most still want to be sexually active Most still want to be sexually active Over 60% of elderly residents endorsed a desire for intimacy Over 60% of elderly residents endorsed a desire for intimacy 52% of men report intercourse in the previous 4 weeks 52% of men report intercourse in the previous 4 weeks Barriers to intimacy exist Barriers to intimacy exist Lack of privacy Lack of privacy Staff, family attitudes Staff, family attitudes Informed consent issues Informed consent issues Lack of a partner Lack of a partner

9 Gone With the Wind Up to now in nursing home care Up to now in nursing home care Only an issue when hypersexual Only an issue when hypersexual Normal sexuality not on the radar screen Normal sexuality not on the radar screen Like sexuality doesn’t exist Like sexuality doesn’t exist Baby boomers Baby boomers Expect sexuality to be part of aging Expect sexuality to be part of aging Why do you think Viagra came out now? Why do you think Viagra came out now? Will demand the industry change Will demand the industry change Activity therapy takes on a whole new meaning Activity therapy takes on a whole new meaning It’s not bingo It’s not bingo Accommodate their needs Accommodate their needs Long-term and short-term relationships Long-term and short-term relationships

10 Lack of Privacy Multiple person rooms Multiple person rooms State-of-the-art State-of-the-art New facilities will be more accommodating New facilities will be more accommodating Routine interruptions Routine interruptions Vitals Vitals Medications Medications Housekeeping Housekeeping Wandering residents Wandering residents Surprise! Surprise! Conjugal visit rooms Conjugal visit rooms Wave of the future Wave of the future

11 Staff Responses Variable reports Variable reports Generally positive attitudes Generally positive attitudes Some uneasy about sexual behavior Some uneasy about sexual behavior Seen as cute or disgusting Seen as cute or disgusting Wait until you’re 65 Wait until you’re 65 Leave baggage at the door Leave baggage at the door Study monitoring staff responses Study monitoring staff responses Paid no notice and gave no assist Paid no notice and gave no assist 94 inappropriate sexual behaviors 94 inappropriate sexual behaviors Staff responded to none of them Staff responded to none of them Ignored 10/17 appropriate sexual behaviors Ignored 10/17 appropriate sexual behaviors Kissing, hugging, caressing Kissing, hugging, caressing

12 Informed Consent What is important What is important What form does the behavior take? What form does the behavior take? Is it consistent with previous beliefs or practices? Is it consistent with previous beliefs or practices? Context Context Delusions another is one’s spouse? Delusions another is one’s spouse? Who initiates the behavior? Who initiates the behavior? Problem…to whom? Problem…to whom? Family, staff? Family, staff? Risks…to whom? Risks…to whom? STDs, exercise induced asthma? STDs, exercise induced asthma? Capacity to say no? Capacity to say no?

13 Informed Consent Do they understand the relationship? Do they understand the relationship? Aware of initiator Aware of initiator Not confused thinking of spouse Not confused thinking of spouse Comfortable with level of intimacy Comfortable with level of intimacy Can they avoid exploitation? Can they avoid exploitation? Consistent with beliefs, values Consistent with beliefs, values Say no Say no Do they understand the risks? Do they understand the risks? Time limited nature of the relationship Time limited nature of the relationship How will they act when it ends? How will they act when it ends?

14 Lack of a Partner Many are widowed Many are widowed Lack a significant other upon admission Lack a significant other upon admission A dearth of new partners A dearth of new partners Especially for female residents Especially for female residents The Beach Boys were right… The Beach Boys were right… Family concerns Family concerns Angry, embarrassed Angry, embarrassed Companionship not valued Companionship not valued Few activities to promote relationships Few activities to promote relationships Fearful of exploitation Fearful of exploitation Institutional oversight present Institutional oversight present

15 Case Three 66 year old female with dementia 66 year old female with dementia Mildly impaired Mildly impaired No behavioral or psychiatric problems No behavioral or psychiatric problems Found to be masturbating in her bed Found to be masturbating in her bed Only when roommate is out of the room Only when roommate is out of the room No significant medical complications from the behavior No significant medical complications from the behavior Trauma from use of inappropriate objects, e.g. Trauma from use of inappropriate objects, e.g. What do you do? 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 Definition Exposure Exposure Obscene sexual language Obscene sexual language Inappropriate masturbation Inappropriate masturbation Propositioning of others Propositioning of others Touching breasts and genitalia Touching breasts and genitalia

18 Hypersexuality Behavioral problems Behavioral problems Common in dementia Common in dementia 80% of demented patients at some point 80% of demented patients at some point Aggression, agitation, disruptive vocalizations, etc. Aggression, agitation, disruptive vocalizations, etc. Hypersexuality a rare problem Hypersexuality a rare problem 2-25% 2-25% One equal, most say more in males One equal, most say more in males Nursing home 18% Nursing home 18% Consults 1.8% Consults 1.8% Physical 87.8% Physical 87.8% Verbal 65.7% Verbal 65.7%

19 Hypersexuality Significant issue Significant issue Resident Resident May require medication May require medication May develop aggression, agitation May develop aggression, agitation May have to move May have to move Staff Staff Usually young females Usually young females Open communication with supervisor Open communication with supervisor Educate to recognize, manage Educate to recognize, manage This adds to burden, turnover This adds to burden, turnover

20 Hypersexuality Why does this occur? Why does this occur? Disinhibition Disinhibition Brain areas that control impulsiveness are damaged Brain areas that control impulsiveness are damaged Proposition, touch multiple residents, staff Proposition, touch multiple residents, staff Mania Mania Delusions, hallucinations Delusions, hallucinations Damage to other areas leads to delusions and hallucinations Damage to other areas leads to delusions and hallucinations Mistakes staff for his wife Mistakes staff for his wife Medications Medications Parkinson’s agents Parkinson’s agents Also used in restless leg syndrome Also used in restless leg syndrome Testosterone Testosterone Given sometimes for weakness, depression Given sometimes for weakness, depression Tumor Tumor Great increase in sex drive Great increase in sex drive

21 Hypersexuality Make sure you see what you see Make sure you see what you see Not all sexual acts are hypersexual Not all sexual acts are hypersexual With masturbation it is the context of masturbation With masturbation it is the context of masturbation Standing with their pants down Standing with their pants down May not remember how to get them off for bed May not remember how to get them off for bed Frustrated aphasic patients can swear appropriately Frustrated aphasic patients can swear appropriately Sexual terms blurt out, but not focused Sexual terms blurt out, but not focused Touching your bottom Touching your bottom Wants your attention as you walk by his wheelchair Wants your attention as you walk by his wheelchair

22 Reporting Context varies reporting Context varies reporting What if a female pats your bottom? What if a female pats your bottom? What if the couple is married? What if the couple is married? Staff member’s attitudes and beliefs Staff member’s attitudes and beliefs What is deemed normal varies greatly What is deemed normal varies greatly This is a medical, not moral issue This is a medical, not moral issue Extent of behavior Extent of behavior Holding hands to intercourse Holding hands to intercourse Where is the line drawn? Where is the line drawn?

23 Case Four 76 year old male with severe dementia 76 year old male with severe dementia Grabs caregivers breasts and genitalia Grabs caregivers breasts and genitalia Seen touching residents as well Seen touching residents as well Assessment for medical causes unremarkable Assessment for medical causes unremarkable No quick fix No quick fix Family embarrassed Family embarrassed Other residents’ families are angry Other residents’ families are angry What do you do? What do you do?

24 Treatment What not to do What not to do Ignore the behavior Ignore the behavior Really…it won’t go away Really…it won’t go away Get upset Get upset Your emotional response to the behavior has a great deal to do with making it better or worse Your emotional response to the behavior has a great deal to do with making it better or worse Tell them it is “inappropriate” Tell them it is “inappropriate” If they knew that… If they knew that… Send mixed messages Send mixed messages Kisses, hugs, holding hands Kisses, hugs, holding hands

25 Treatment Nonpharmacologic Nonpharmacologic We must change our behavior to the resident We must change our behavior to the resident They cannot learn They cannot learn Return to room, close the door Return to room, close the door Appropriate except for place Appropriate except for place Separate resident from the target Separate resident from the target Move to another unit, hallway Move to another unit, hallway Use same sex staff members Use same sex staff members Especially bathing, dressing, toileting Especially bathing, dressing, toileting Prevention Prevention Activities Activities Clear identification as a medical professional Clear identification as a medical professional

26 Treatment Pharmacologic Pharmacologic Usually start with an SSRI antidepressant Usually start with an SSRI antidepressant A side effect A side effect Reduces sex drive Reduces sex drive Mechanical problems Mechanical problems Prozac (fluoxetine) Prozac (fluoxetine) Zoloft (sertraline) Zoloft (sertraline) Paxil (paroxetine) Paxil (paroxetine) Luvox (fluvoxamine) Luvox (fluvoxamine) Celexa (citalopram) Celexa (citalopram) Lexapro (escitalopram) Lexapro (escitalopram)

27 Treatment SSRI antidepressants SSRI antidepressants What to watch for What to watch for Nausea and/or diarrhea Nausea and/or diarrhea Jittery Jittery Insomnia/sedation Insomnia/sedation Headache Headache Low sodium Low sodium Rare GI bleed Rare GI bleed

28 Treatment Pharmacolgic Pharmacolgic Hormone treatment Hormone treatment Cyproterone and depo-provera Cyproterone and depo-provera Testosterone and LH levels Testosterone and LH levels Oral and IM Oral and IM Estrogen Estrogen Daily dosing Daily dosing Oral, patch Oral, patch Leuprolide Leuprolide IM monthly IM monthly

29 Treatment Hormone treatment Hormone treatment What to watch for What to watch for Thromboembolism and stroke Thromboembolism and stroke Depression Depression Bone density loss Bone density loss Weight gain Weight gain Hot flashes and gynecomastia Hot flashes and gynecomastia Fatigue Fatigue

30 Treatment Others Others Exelon (rivastigmine) Exelon (rivastigmine) Tagamet (cimetidine) Tagamet (cimetidine) Neurontin (gabapentin) Neurontin (gabapentin) Clomipramine Clomipramine

31 Cases Case One Case One Normal behavior Normal behavior Assure privacy, dignity Assure privacy, dignity Case Two Case Two Assess competency Assess competency Be aware of family concerns Be aware of family concerns Risks and benefits include mood, QOL issues Risks and benefits include mood, QOL issues

32 Cases Case Three Case Three CLOSE THE DOOR! CLOSE THE DOOR! Case Four Case Four Begin nonpharmacologic interventions Begin nonpharmacologic interventions Provide as much information as possible to PCP Provide as much information as possible to PCP Make sure all staff is trained in assessment and interventions Make sure all staff is trained in assessment and interventions Communicate with families Communicate with families Need for education, reassurance Need for education, reassurance

33 Objectives Identify normal changes in sexuality as we age Identify normal changes in sexuality as we age Discuss normal expressions of sexuality in nursing home residents Discuss normal expressions of sexuality in nursing home residents Explore assessment and treatment of hypersexuality Explore assessment and treatment of hypersexuality


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