1. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved Sexuality in Older Adults Author: Meredith Wallace PhD, APRN, A/GNP-BC

2. 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.

3. 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 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.

4. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved Introduction Many believe that older adults are asexual human beings. Sexual health is often ignored in the assessment of older adult health. Most nurses are not educated to manage sexual health issues of older adults. There is a general discomfort with sexual issues in the U.S.

5. 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.

6. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved How Might You Teach This Content? 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.... or use Train-the Trainer Strategies to Incorporate This Content Into Courses?

7. 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.

8. 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)

9. 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.

10. 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.

11. 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 education requires more attention. (Baumgartner et al., 2008)

12. 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

13. 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. Don’t know how to manage sexual health issues. Experience discomfort in managing sexual issues. 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)

14. 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.

15. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved How Might You Teach This Content? 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.... or use Train-the Trainer Strategies to Incorporate This Content Into Courses?

16. 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

17. 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.

18. 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.

19. 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)

20. 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.

21. 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.

22. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved 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. How Might You Teach This Content?... or use Train-the Trainer Strategies to Incorporate This Content Into Courses?

23. 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?

24. 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 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)

25. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved 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

26. 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)

27. 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)

28. 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.

29. 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. 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. (RockliffeFidler & Kiemle, 2003) (Rosen et al., 2009)

30. 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)

31. 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.

32. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved 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)

33. 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. 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. (Martin et al., 2008) (Magalhaes et al., 2007)

34. 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)

35. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved 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)

36. 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.  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 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 dysfunction. (Lemieux et al., 2001) (Mott et al., 2005), (Rosen, 2006)

37. 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.

38. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved Sexual Behaviors Common to Cognitively Impaired Older Adults Cuddling Cuddling Touching of the genitals Touching of the genitals Sexual remarks Sexual remarks Propositioning Propositioning Sexual Behaviors Grabbing & groping Grabbing & groping Use of obscene language Use of obscene language Masturbating without shame Masturbating without shame Aggression and irritability Aggression and irritability

39. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved 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.

40. 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.

41. 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 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. (Montejo et al., 2001)

42. 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.

43. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved 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. How Might You Teach This Content?... or use Train-the Trainer Strategies to Incorporate This Content Into Courses?

44. 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?

45. 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.

46. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved 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? 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 question do you have about your continuing sexual needs and function? (Wallace, 2000)

47. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved ASSESSMENT: How to Try This Older Adult Sexuality: A Continuing Human Need  Click the image to view the How to Try This video

48. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved 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

49. 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

50. 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.

51. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved 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. How Might You Teach This Content?... or use Train-the Trainer Strategies to Incorporate This Content Into Courses?

52. 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.

53. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved NANDA Diagnosis of Sexual Health Problems Sexual Dysfunction Sexuality Pattern, Ineffective

54. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved 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.

55. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved 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.

56. 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.

57. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved 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.

58. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved 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)

59. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved Compensate for Normal Aging Changes Options for normal aging changes to erectile function:  Vacuum pumps  Injection therapy  Implants  Talk therapy  Oral erectile agents.

60. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved 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. 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. (Wespes et al., 2007) (Shah et al., 2007)

61. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved 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.

62. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved 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)

63. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved 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.

64. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved Depression & Sexual Health 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 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. (Siedman & Roose, 2006)

65. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved 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.

66. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved 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. 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. (Miles et al., 2007) (Barton et al., 2007)

67. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved 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.

68. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved Management of Sexual Health Among Cognitively Impaired Older Adults Education/counseling Boundary setting Referrals to psychotherapy Alternative methods of intimacy Approaches to care  Soft spoken, calm  Respectful  Same gender caregivers

69. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved 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.

70. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved 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.

71. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved 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?

72. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved 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).

73. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved 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.

74. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved 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.

75. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved 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 and caregivers.  Persistent, uninhibited sexual behaviors directed at oneself or inappropriately at others (Nagaratnam & Gayagay, 2002) (Black et al., 2005) (Johnson et al., 2006)(Wiseman et al., 2000)(Wick et al., 2005)

76. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved 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 Long- Term 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 3 rd Edition. (E. Capezuti, Zwicker, D., M. Mezey & T. Fulmer, Eds). New York, Springer Publishing Co., pp. 629- 647. 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.

77. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved 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 http://consultgerirn.org/topics/sexuality_issues_in_aging/want_to_know_more MedlinePlus http://www.nlm.nih.gov/medlineplus/sexualhealthissues.html http://www.nlm.nih.gov/medlineplus/sexualhealthissues.html National Institutes on Aging http://www.niapublications.org/engagepages/sexuality.asphttp://www.niapublications.org/engagepages/sexuality.asp American Foundation for Urological Disease, Inc http://www.impotence.orghttp://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/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.htmlGreat 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/http://www.sexscience.org/ Beautiful portraits of older gay couples. http://www.renaldi.com/portfolio/elderly1.htmlhttp://www.renaldi.com/portfolio/elderly1.html

78. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved References 78 12/18/2006 9:45ameSlide - P3562 - AACN Hartford-sponsored Faculty Development References with their Levels of Evidence are found on this slide’s Notes Page.