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Sexuality in Older Adults B. Renee Dugger, DNP, RN, GCNS-BC*

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1 Sexuality in Older Adults B. Renee Dugger, DNP, RN, GCNS-BC*

2  *Special acknowledgement and thanks to Meredith Wallace PhD, APRN, A/GNP- BC and the Geriatric Nursing Education Consortium (GNEC) for resources utilized for this presentation 12/18/2006 9:45ameSlide - P AACN Hartford-sponsored Faculty Development 2 Acknowledgement of Resources Utilized

3  The Geriatric Nursing Education Consortium (GNEC) is a national initiative of the American Association of Colleges of Nursing (AACN) to enhance geriatric content in senior-level undergraduate nursing courses. This project is generously funded by the John A. Hartford Foundation. Further information about the GNEC program can be found at 12/18/2006 9:45ameSlide - P AACN Hartford-sponsored Faculty Development 3 GNEC

4 1.Identify myths about sexuality in the aging population. 2.Describe changes expected to occur as we age and the barriers/challenges these changes present to sexual health. 3.Discuss the impact of disease processes, medications and environment on the sexual health of older adults. 4.Identify ways to assess and promote the sexual health of older adults. Objectives

5 Sexual Health  Is important to an individual’s self- identity and general well-being.  Contributes to the satisfaction of physical needs.  Fulfills social, emotional, and psychological components of life.  Evokes sentiments of joy, romance, affection, passion, and intimacy. Myth Busting

6 Many believe that older adults are asexual Sexual health is often ignored in the assessment of older adult health. Health care professionals are typically not educated to manage sexual health issues of older adults. There is a general discomfort with sexual issues in the U.S.

7 Myth Busting 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.

8 Myth Busting Many people believe that sexual desires diminish and disappear 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.

9 Sexuality …  provides for expressions of affection and passion.  Enhances the life experience.  Enriches connection and 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. Myth Busting (Lindau, et al., 2007)

10 Older adults continue to be sexual beings. However, older adults may require assistance to manage sexual health needs by examining:  Barriers to sexual health.  Impact of normal aging changes, as well as acute & chronic illnesses, medications and environmental issues on sexual health. Reality

11 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. Why Should We Promote the Sexual Health of Older adults?

12 Older adults may 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 for sexually-related information. Older Adult Barriers to Sexual Health (Baumgartner et al., 2008)

13  Old habits  Negative experiences  Fear of discussing sexuality  Victorian attitudes toward sexuality  Lack of opportunity (no partners or privacy)  Cultural attitudes toward sexuality Older Adult Barriers to Sexual Health

14  Taken from: McNicoll, L. (2008). Issues of sexuality in the elderly Geriatrics for the Practicing Physician, 91(10), /18/2006 9:45ameSlide - P AACN Hartford-sponsored Faculty Development 14 Case #1

15 Providers:  Are subject to myths and attitudes about sexuality and aging.  May be insensitive to older adults needs.  Don’t know how to manage sexual health issues.  Experience discomfort in managing sexual issues. Health Care Provider Barriers to Sexual Health in Older Adults 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) (Chitale et al., 2007)

16 Other Barriers to Older Adult Sexual Health Physical Barriers to Sexual Health  Normal aging changes  Pathological 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 due to years of isolation

17 The ‘sexual response cycle’, or the organized pattern of physical response to sexual stimulation, changes with age. These changes impact sexual health in both: Normal Aging Changes that Impact Sexual Health  Women  Men

18 After sexual intercourse, women return to the pre- aroused stage faster than they would at an earlier age. Normal Aging Changes Female Sexual Response

19  Vaginal wall thinning  Decreased/delayed vaginal lubrication (may lead to pain)  Labia atrophy  Vagina shortens  Cervix may descend downward into the vagina  Loss of fat pad over pubic symphysis may lead to pain from direct pressure over bone  Vaginal contractions become fewer and weaker during orgasm  Many of these changes are a result of loss of estrogen after menopause Normal Aging Changes Female Sexual Response

20 Normal Aging Changes Male Sexual Response The Massachusetts male aging study of 1085 older men indicated that age was an independent risk factor for decreased sexual function in older men. (Araujo et al., 2004)

21  Decreased testosterone hormone levels  Weaker erection to erectile dysfunction (ED)  More direct stimulation of the penis required for erection  Orgasms are fewer and weaker  Reduced force and amount of ejaculation  Increased refractory period after ejaculation Normal Aging Changes Male Sexual Response

22 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.  Body image issues from aging changes  Cultural beliefs about sexual practice. Other Age-Related Changes that Impact Sexual Health

23 Sexual disorders fall into four categories: 1.Hypoactive sexual desire disorder, 2.Sexual arousal disorder 3.Orgasmic disorder 4.Sexual pain disorders Sexual Dysfunction Sexual dysfunction is prevalent worldwide, and the occurrence of sexual dysfunctions increases directly with age for both men and women. (Walsh & Berman, 2004) (Derogatis & Burnett, 2008)

24 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  Cognitive Impairment/Dementia Pathological Changes

25 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 Heart Disease and Female Sexual Health (Addis et al., 2005)

26 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. Heart Disease & Male Sexual Health (Bohm et al., 2007)

27 Diabetes is a significant concern among older adults, effecting approximately 10.9 million, or 26.9% of all people in this age group in the U.S each year. American Diabetes Association, basics/diabetes-statistics/ Diabetes effects sexual health among older adults in a number of ways: – impacts sexual function. – impacts arousal and pleasurable sensations. Diabetes & Sexual Health Approximately 42% of those with diabetes are aged 65 years or older.

28 In a study of eight women aged 24 – 83, older women with diabetes reported lower sexual function, desire and enjoyment than their younger counterparts. In a study of 373 men aged with type II diabetes, 49.8% of the men reported mild or moderate degrees of ED, and 24.8% had complete ED. Diabetes & Sexual Health (RockliffeFidler & Kiemle, 2003) (Rosen et al., 2009)

29 The presence of depression among older adults impacts sexual health  Decline in desire  Decline in ability to perform  Both the disease and treatment can impact sexual health A study of 3,810 men aged years revealed that men with ED had significantly lower mental health scores. Depression & Sexual Health (Korfage et al., 2009)

30 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. Quintard, 2008 Female Reproductive System Cancer & Sexual Health

31 Prostate Cancer & Sexual Health The rate of erectile dysfunction following radical prostatectomy has been reported to be greater than 80%. Men with prostate cancer who have undergone surgical or radiation treatments may experience ED following treatment. (Siegel et al., 2001)

32  HIV cases among older adults in the US is increasing, with ~25% of infections occurring in adults over 50.  Older adults with HIV/AIDS and other STDs should be taught to follow CDC safe sex practices, as this was not routinely covered in formal education.  The use of antiretroviral medications 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. HIV and Older Adults (Martin et al., 2008) (Magalhaes et al., 2007)

33 While not well-studied, the presence of urinary incontinence (UI) 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. Urinary Incontinence & Sexual Health (Tannenbaum et al., 2006)

34  Strokes and subsequent aphasias impact sexual health via difficulties in desire, function and communication  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.  Benign Prostatic Hypertrophy (BPH)  In older men altered circulation to the penis may affect erectile function, sexual arousal and ejaculatory dysfunction. Other Medical Conditions Impacting Sexual Health (Lemieux et al., 2001) (Mott et al., 2005), (Rosen, 2006)

35 Sexual needs among older adults with cognitive impairment may manifest in inappropriate & hypersexual behavior. In a study of older, cognitively impaired older adults, 1.8% had sexually inappropriate behavior manifesting in verbal and physical problems. (Nagaratnam, et al, 2002) Cognitive Impairment & Sexual Health

36 Sexual Behaviors Common to Cognitively Impaired Older Adults Grabbing & groping Grabbing & groping Touching genitals Touching genitals Sexual remarks Sexual remarks Propositioning Propositioning Sexual Behaviors Use of obscene language Use of obscene language Masturbating in public areas Masturbating in public areas Aggression and irritability Aggression and irritability

37 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 Environmental Barriers

38 Antidepressants including Selective serotonin reuptake inhibitors (SSRI), Tricyclic Antidepressants, Monoamine oxidase inhibitors (MAOI) impact libido and sexual function  In a study of 610 women and 412 men, 59.1% of the individuals taking SSRI antidepressant medications reported sexual dysfunction.  MAO inhibitors and Tricyclic Antidepressants have decreased in favor of SSRIs leading to lower side effects, but all can impact sexual function by reducing sexual drive and causing impotence and erectile and orgasmic disorders. Effect of Medications and Treatments on Sexual Health (Montejo et al., 2001)

39  Antihypertensives including: ACE inhibitors, Alpha Blockers, Beta Blockers, Calcium Channel Blockers, Clonidine, Methyldopa and Thiazide Diuretics can result in impotence, decreased libido and ejaculatory disturbances among older adults.  Cholesterol lowering medications, including statins and fibrates, may impact male sexual health via ED.  Other medications such as antipsychotics (Phenothiazine & Risperidone) seizure medications (Carbamazepine) and H2 Blockers (Cimetidine) also impact sexual health due to effecting libido & ejaculation problems. Effect of Medications and Treatments on Sexual Health

40  Taken from: McNicoll, L. (2008). Issues of sexuality in the elderly Geriatrics for the Practicing Physician, 91(10), /18/2006 9:45ameSlide - P AACN Hartford-sponsored Faculty Development 40 Case #2

41 Assessment of sexual health is the first step in developing a plan of care to fulfill the sexual needs of an older population. Assessment of Sexual Health

42 OPENING THE DOOR: Sexual Health History Questions  Can you tell me how you express your sexuality?  What concerns do you have about fulfilling your sexual needs?  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? What questions do you have about your sexual needs and function? (Wallace, 2000)

43 PLISSIT MODEL (Annon, 1976) 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

44  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 Elements of Assessment

45  Find a quiet, private area.  Perform assessment in a respectful manner that conveys 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 planning prior to actual client encounter. Assessment Essentials

46 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. Diagnosis of Sexual Health Problems

47 1)Promote a healthy lifestyle. 2)Compensate for normal age-related changes. 3)Manage diseases that impact sexual health. 4)Review medications that impact sexual health. 5)Modify environment to facilitate sexual health functioning. Management of Sexual Health Needs

48 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. Health Promotion

49  Provide patient teaching about normal aging changes and impact of diseases on sexual function and image.  Discuss need for longer fore-play arousal time to compensate for normal aging changes.  Consider alternative positions or forms of intimacy when sexual intercourse is uncomfortable or not possible.  Understand the principle of: “Use it or lose it.”  Include safe sex practices in all client teaching encounters. Compensate for Disease & Normal Aging Changes

50 Consider use of artificial water based lubricants and estrogen gels/patches/creams 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. Compensate for Disease & Normal Aging Changes (Freedman et al., 2009)

51 12/18/2006 9:45ameSlide - P AACN Hartford-sponsored Faculty Development 51 The Many Faces of ED Treatment* (*The speaker does not recommend any particular drug treatment)

52 Options for normal aging changes to erectile function:  Vacuum pumps  Injection therapy  Implants  Talk therapy  Oral erectile agents Compensate for Disease & Normal Aging Changes

53 The use of oral erectile agents such as sildenafil Citrate (Viagra®), vardenafil HCL (Levitra®), and tadalifil (Cialis®) have greatly aided management of ED. 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 than others due to pain from the injections. (Wespes et al., 2007) (Shah et al., 2007)

54 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 and possible. Heart Disease Management & Sexual Health

55 92 men; mean age 58 were studied after MI/acute coronary syndromes &/or coronary artery bypass graft Intervention group: (n=47) 1) patient education, 2) cognitive restructuring, 3) emotional support, 4) guided imagery, and 5) medication (Viagra) Control group: (n=45) 1) cardiac rehabilitation without other intervention elements Results: Intervention group able to 1) resume sexual activity within 1 month of their cardiac event (87% vs. 50% in control), 2) greater improvement in libido, 3) confidence to attain erection, 4) satisfaction with sexual relationship, 5) frequency of erection, and 6) enjoyment of sex. Heart Disease Management & Sexual Health (Klein et al., 2007)

56 Effective management of diabetes will prevent circulatory and sensory changes that impact sexual health. Make sure clients:  Test blood for elevated glucose levels.  Manage diet and exercise.  Manage blood sugar levels with hypoglycemic medications and/or insulin. Diabetes & Sexual Health

57 bupropion – “found to have no sexual side effect and may have a pro-sexual response effect” (McNicoll, 2008) (brand names: Aplenzin, Budeprion, Buproban, Forfivo XL, Wellbutrin, Zyban)* *Speaker does not recommend any specific medication 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.

58 The experience of breast, prostate and other reproductive system cancers mandates a program of individual &/or group support to resolve self image issues r/t bodily changes that impact sexuality. Cancer and Sexual Health

59  Environmental adaptations to ensure privacy and safety among LTC 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 trapeze bars may need to be obtained.  Privacy and safe environment for masturbation in cognitively impaired older adults or those without partners.  Develop a sexual “tool kit”  Individual tubes of lubricants  Condoms  Erotic materials (movies, magazines). Environmental Management

60  Older adults have continuing sexual needs and interests that persist throughout the lifespan.  There are barriers and challenges to sexual health in the aging population including: 1) normal aging changes, 2) disease processes, 3) medications and 4) environment.  It is necessary to conduct a sexual health assessment on ALL older adults and develop plans of care to manage sexual health needs. Summary

61  Hartford Institute for Geriatric Nursing/ Sexuality Issues in Aging. more more  MedlinePlus  American Foundation for Urological Disease, Inc  World Health Organization (2004). Sexual Health- A New Focus for WHO. Progress in Reproductive Health Research,  American Association of Older Persons. Great Sex Well After 50. Sex Well After 50  Society for the Scientific Study of Sexuality. Web Links

62 12/18/2006 9:45ameSlide - P AACN Hartford-sponsored Faculty Development 62 References References with Levels of Evidence provided as a handout Taken from GNEC resources

63 12/18/2006 9:45ameSlide - P AACN Hartford-sponsored Faculty Development 63 Contact Information:

64  *Special acknowledgement and thanks to Meredith Wallace PhD, APRN, A/GNP- BC and the Geriatric Nursing Education Consortium (GNEC) 12/18/2006 9:45ameSlide - P AACN Hartford-sponsored Faculty Development 64 Final Acknowledgement for Resources Utilized in Presentation

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