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

Acknowledgement of Resources Utilized *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 9:45am eSlide - P3562 - AACN Hartford-sponsored Faculty Development

GNEC 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 www.aacn.nche.edu/gnec.htm. 12/18/2006 9:45am eSlide - P3562 - AACN Hartford-sponsored Faculty Development

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

Myth Busting 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 Many believe that older adults are asexual There is a general discomfort with sexual issues in the U.S. Health care professionals are typically not educated to manage sexual health issues of older adults. Sexual health is often ignored in the assessment of older adult health. Many older adults have internalized these misconceptions, and believe that sexuality is an inappropriate concern for them.

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.

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. “My father maybe, but my mother, never.” Sexual intercourse is often thought of as a young, healthy person’s activity for the purpose of procreation.

Myth Busting 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. Level IV Lindau, S.T., Schumm, L.P., Laumann, E.O., Levinson, W., O’Muircheartaigh, C.A., & Waite, L.J. (2007). A study of sexuality and health among older adults in the United States, The New England Journal of Medicine, 357, 762-744. (Lindau, et al., 2007)

Older adults continue to be sexual beings. Reality 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.

Why Should We 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.

Older Adult Barriers to Sexual Health 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. The authors concluded that sexuality patient information and education requires more attention. Level IV Baumgartner, M. K., Hermanns, T., Cohen, A., Schmid, D. M., Seifert, B., Sulser, T. et al. (2008). Patients' knowledge about risk factors for erectile dysfunction is poor. J.Sex.Med., 5(10), 2399-2404. (Baumgartner et al., 2008)

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

Case #1 Taken from: McNicoll, L. (2008). Issues of sexuality in the elderly Geriatrics for the Practicing Physician, 91(10), 321-322. Read Case #1 – example/sample issue 12/18/2006 9:45am eSlide - P3562 - AACN Hartford-sponsored Faculty Development

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) 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. Level IV Chitale, S., Collins, R., Hull, S., Smith, E., & Irving, S. (2007). Is the current practice providing an integrated approach to the management of LUTS and ED in primary care? an audit and literature review. J.Sex.Med., 4(6), 1713-1725. (Chitale et al., 2007)

Other Barriers to Older Adult Sexual Health 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 Physical Barriers to Sexual Health Normal aging changes Pathological changes Chronic pain Cognitive impairment Environmental restrictions Body image Adverse medication effects

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

Normal Aging Changes Female Sexual Response After sexual intercourse, women return to the pre-aroused stage faster than they would at an earlier age. Vaginal contractions become fewer and weaker during orgasm.

Normal Aging Changes Female Sexual Response 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 Decreased/delayed vaginal lubrication, which may lead to pain during intercourse

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. Level IV Araujo, A. B., Mohr, B. A., & McKinlay, J. B. (2004). Changes in sexual function in middle-aged and older men: Longitudinal data from the Massachusetts male aging study. Journal of the American Geriatrics Society, 52(9), 1502-1509. (Araujo et al., 2004)

Normal Aging Changes Male Sexual Response 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 the impact on sexual functioning is not as significant as in women

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. Body image issues from aging changes Cultural beliefs about sexual practice. Bodily changes, such as wrinkles and sagging skin may result in self-consciousness that impacts sexual relations.

Sexual Dysfunction Sexual disorders fall into four categories: Hypoactive sexual desire disorder, Sexual arousal disorder Orgasmic disorder Sexual pain disorders Sexual dysfunction is prevalent worldwide, and the occurrence of sexual dysfunctions increases directly with age for both men and women. There is strong support for the increased frequency of symptoms with age. Pathological changes of aging are major risk factors for sexual disorders. Level V Walsh, K. E., & Berman, J. R. (2004). Sexual dysfunction in the older woman: An overview of the current understanding and management. Drugs & Aging, 21(655-67510). Derogatis, L. R., & Burnett, A. L. (2008). The epidemiology of sexual dysfunctions. J.Sex.Med., 5(2), 289-300. (Walsh & Berman, 2004) (Derogatis & Burnett, 2008)

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 Cognitive Impairment/Dementia

Heart Disease and Female 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 Level IV Addis, I. B., Ireland, C. C., Vittinghoff, E., Lin, F., Stuenkel, C. A., & Hulley, S. (2005). Sexual activity and function in postmenopausal women with heart disease. Obstetrics and Gynecology, 106(1), 121-127. (Addis et al., 2005)

Heart Disease & Male 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. Level IV Bohm, M., Baumhakel, M., Probstfield, J. L., Schmieder, R., Yusuf, S., Zhao, F. et al. (2007). Sexual function, satisfaction, and association of erectile dysfunction with cardiovascular disease and risk factors in cardiovascular high-risk patients: Substudy of the ONgoing telmisartan alone and in combination with ramipril global endpoint Trial/Telmisartan randomized AssessmeNT study in ACE-INtolerant subjects with cardiovascular disease (ONTARGET/TRANSCEND). American Heart Journal, 154(1), 94-101. (Bohm et al., 2007)

Diabetes & Sexual Health 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, 2011 http://www.diabetes.org/diabetes-basics/diabetes-statistics/ Diabetes effects sexual health among older adults in a number of ways: impacts sexual function. impacts arousal and pleasurable sensations. Up to 50% of men and 25% of women may experience some kind of sexual problems or a loss of sexual desire as a result of diabetes. Nerves that tell the body to release lubricant into the vaginal area can become damaged if you have diabetes. In addition, vaginal dryness occurs after menopause in many women. Problems with libido and orgasm seem to be more common in women with diabetes. For men, diabetes can cause damage to the nervous system over a sustained period of time, also known as diabetic neuropathy. One aspect of this is the potential for diabetes to damage the erectile tissue leaving it impossible for a man to achieve or maintain an erection. Almost 1 in 3 men with diabetes suffer from erectile dysfunction Erectile dysfunction can be the way in which men discover that they have diabetes. However, through strict management if the disease through diet, exercise, pills and insulin injections, minor sexual problems usually recede and it is possible for the man to achieve and erection For some women with diabetes, vaginitis (inflammation of the vagina) can be recurrent. Bacterial vaginitis occurs due to yeast infections and thrush is the most common of the conditions. This can make sex painful, and is heralded by itching or burning sensations. Cystitis can also be a recurrent problem for women with diabetes. Furthermore, some evidence indicates that, in a similar way to men being unable to maintain an erection, the woman’s clitoris may fail to respond to stimulation Approximately 42% of those with diabetes are aged 65 years or older.

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) Level IV RockliffeFidler, C., & Kiemle, G. (2003). Sexual function in diabetic women: A psychological perspective. Sexual and Relationship Therapy, 18(2), 143-159 Level II Rosen, R. C., Wing, R. R., Schneider, S., Wadden, T. A., Foster, G. D., West, D. S. et al. (2009). Erectile dysfunction in type 2 diabetic men: Relationship to exercise fitness and cardiovascular risk factors in the look AHEAD trial. J.Sex.Med., 6(5), 1414-1422. (Rosen et al., 2009)

Depression & Sexual Health 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 57-78 years revealed that men with ED had significantly lower mental health scores. Depression is under diagnosed in older adults Level IV Korfage, I. J., Pluijm, S., Roobol, M., Dohle, G. R., Schroder, F. H., & Essink-Bot, M. L. (2009). Erectile dysfunction and mental health in a general population of older men. J.Sex.Med., 6(2), 505-512 (Korfage et al., 2009)

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. Quintard, 2008 One hundred women with breast cancer were randomly assigned to a group receiving beauty treatments during hospitalization or a control group. Three months after surgery, patients who had received beauty treatments reported higher body-image scores than the control group, but there was no effect in psychological distress. Level II Quintard, B., & Lakdja, F. (2008). Assessing the effect of beauty treatments on psychological distress, body image, and coping: A longitudinal study of patients undergoing surgical procedures for breast cancer. Psycho-Oncology, 17(10), 1032-1038.

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%. Level II Siegel, T., Moul, J. W., Spevak, M., Alvord, W.G., & Costabile, R.A. (2001). The development of erectile dysfunction in men treated for prostate cancer. Journal of Urology, 165, 430-435. (Siegel et al., 2001)

HIV and Older Adults 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. (Martin et al., 2008) Level V Martin, C. P., Fain, M. J., & Klotz, S. A. (2008). The older HIV-positive adult: A critical review of the medical literature. The American Journal of Medicine, 121(12), 1032-1037. Level IV Magalhaes, M. G., Greenberg, B., Hansen, H., & Glick, M. (2007). Comorbidities in older patients with HIV: A retrospective study. The Journal of the American Dental Association, 138(11), 1468-1475. (Magalhaes et al., 2007)

Urinary Incontinence & Sexual Health 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. Level IV Tannenbaum, C., Corcos, J., & Assalian, P. (2006). The relationship between sexual activity and urinary incontinence in older women. Journal of the American Geriatrics Society, 54(8), 1220-1224. (Tannenbaum et al., 2006)

Other Medical Conditions Impacting Sexual Health 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. (Lemieux et al., 2001) Level IV Lemieux, L., CohenSchneider, R., & Holzapfel, S. (2001). Aphasia and sexuality. Sexuality and Disability, 19(4), 253-266. Level IV Mott, S., Kenrick, M., Dixon, M., & Bird, G. (2005). Sexual limitations in people living with parkinson's disease. Australasian Journal on Ageing, 24(4), 196-201. Level V: Rosen, R. C. (2006). Assessment of sexual dysfunction in patients with benign prostatic hyperplasia. BJU International, 97 Suppl 2, 29-33; discussion 44-5. (Mott et al., 2005), (Rosen, 2006)

Cognitive Impairment & Sexual Health 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) Level IV Nagaratnam, N., & Gayagay, G. (2002). Hypersexuality in nursing care facilities—a descriptive study. Archives of Gerontology and Geriatrics, 35(3), 195-203.

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

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

Effect of Medications and Treatments on Sexual Health 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. Level IV Montejo, A. L., Llorca, G., Izquierdo, J. A., & Rico-Villademoros, F. (2001). Incidence of sexual dysfunction associated with antidepressant agents: A prospective multicenter study of 1022 outpatients. spanish working group for the study of psychotropic-related sexual dysfunction. The Journal of Clinical Psychiatry, 62 Suppl 3, 10-21. (Montejo et al., 2001)

Effect of Medications and Treatments on Sexual Health 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.

Case #2 Taken from: McNicoll, L. (2008). Issues of sexuality in the elderly Geriatrics for the Practicing Physician, 91(10), 321-322. Read 2nd case 12/18/2006 9:45am eSlide - P3562 - AACN Hartford-sponsored Faculty Development

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

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? Level V Wallace, M. (2000). Sexuality and Intimacy. In Textbook of Gerontological Nursing, 2nd Ed. St. Louis: Mosby Year Book, Inc. What questions do you have about your sexual needs and function? (Wallace, 2000)

P LI SS IT PLISSIT MODEL (Annon, 1976) 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 The PLISSIT Model was initiated in the 70s and remains a good model to follow when assessing and planning for sexual health with anyone – including older adults. Level IV Annon, J. (1976). The PLISSIT model: A proposed conceptual scheme for the behavioral treatment for sexual problems. Journal of Sex Education Therapy, 2(2), 1-15. This article originally appeared in the Journal of Sex Education and Therapy, a publication of the American Association of Sexuality Educators, Counselors and Therapists (AASECT). Printed with permission.

Elements of 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

Assessment Essentials 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.

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.

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

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. Remember the info about diabetes and coronary heart disease management

Compensate for Disease & Normal Aging Changes 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 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. Level II Freedman, M., Kaunitz, A. M., Reape, K. Z., Hait, H., & Shu, H. (2009). Twice-weekly synthetic conjugated estrogens vaginal cream for the treatment of vaginal atrophy. Menopause (New York, N.Y.), 16(4), 735-741. (Freedman et al., 2009)

The Many Faces of ED Treatment. ( The Many Faces of ED Treatment* (*The speaker does not recommend any particular drug treatment) 12/18/2006 9:45am eSlide - P3562 - AACN Hartford-sponsored Faculty Development

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

Compensate for Disease & Normal Aging Changes 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. Level II Wespes, E., Moncada, I., Schmitt, H., Jungwirth, A., Chan, M., & Varanese, L. (2007). The influence of age on treatment outcomes in men with erectile dysfunction treated with two regimens of tadalafil: Results of the SURE study. BJU International, 99(1), 121-126. Level II Shah, P. J., Dinsmore, W., Oakes, R. A., & Hackett, G. (2007). Injection therapy for the treatment of erectile dysfunction: A comparison between alprostadil and a combination of vasoactive intestinal polypeptide and phentolamine mesilate. Current Medical Research and Opinion, 23(10), 2577-2583. (Wespes et al., 2007) (Shah et al., 2007)

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 and possible. A study of 22 male hypertensive patients measured the effect of an eight week exercise training program on Erectile function. The results showed that the exercise training program resulted in a significant improvement in erectile function of hypertensive patients . The authors concluded that exercise is a good nonpharmacologic management of ED in male hypertensive patients. Level II Lamina, S., Okoye, C. G., & Dagogo, T. T. (2009). Therapeutic effect of an interval exercise training program in the management of erectile dysfunction in hypertensive patients. Journal of Clinical Hypertension (Greenwich, Conn.), 11(3), 125-129.

Heart Disease Management & Sexual Health 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. Level II Klein, R., Bar-on, E., Klein, J., & Benbenishty, R. (2007). The impact of sexual therapy on patients after cardiac events participating in a cardiac rehabilitation program. Eur.J.Cardiovasc.Prev.Rehabil., 14(5), 672-678. (Klein et al., 2007)

Diabetes & Sexual Health 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.

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. (boo Pro pee on) Level II Seidman, S. N., & Roose, S. P. (2006). The sexual effects of testosterone replacement in depressed men: Randomized, placebo-controlled clinical trial. Journal of Sex & Marital Therapy, 32(3), 267-273. Wellbutrin – no sexual side effect and may have a pro-sexual response effect 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

Cancer and Sexual Health 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.

Environmental Management 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).

Summary 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.

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 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/

References References with Levels of Evidence provided as a handout Taken from GNEC resources www.aacn.nche.edu/gnec.htm Level IV Addis, I. B., Ireland, C. C., Vittinghoff, E., Lin, F., Stuenkel, C. A., & Hulley, S. (2005). Sexual activity and function in postmenopausal women with heart disease. Obstetrics and Gynecology, 106(1), 121-127. Level IV Annon, J. (1976). The PLISSIT model: A proposed conceptual scheme for the behavioral treatment for sexual problems. Journal of Sex Education Therapy, 2(2), 1-15.  Level IV Araujo, A. B., Mohr, B. A., & McKinlay, J. B. (2004). Changes in sexual function in middle-aged and older men: Longitudinal data from the Massachusetts male aging study. Journal of the American Geriatrics Society, 52(9), 1502-1509.  Level II Barton, D. L., Wender, D. B., Sloan, J. A., Dalton, R. J., Balcueva, E. P., Atherton, P. J. et al. (2007). Randomized controlled trial to evaluate transdermal testosterone in female cancer survivors with decreased libido; north central cancer treatment group protocol N02C3. Journal of the National Cancer Institute, 99(9), 672 Level IV Baumgartner, M. K., Hermanns, T., Cohen, A., Schmid, D. M., Seifert, B., Sulser, T. et al. (2008). Patients' knowledge about risk factors for erectile dysfunction is poor. J.Sex.Med., 5(10), 2399-2404. Level V Black, B., Muralee, S., & Tampi, R. T. (2005). Inappropriate sexual behaviors in dementia. Journal of Geriatric Psychiatry & Neurology, 18(3), 155-162. Level IV Bohm, M., Baumhakel, M., Probstfield, J. L., Schmieder, R., Yusuf, S., Zhao, F. et al. (2007). Sexual function, satisfaction, and association of erectile dysfunction with cardiovascular disease and risk factors in cardiovascular high-risk patients: Substudy of the ONgoing telmisartan alone and in combination with ramipril global endpoint Trial/Telmisartan randomized AssessmeNT study in ACE-INtolerant subjects with cardiovascular disease (ONTARGET/TRANSCEND). American Heart Journal, 154(1), 94-101. Level IV Chitale, S., Collins, R., Hull, S., Smith, E., & Irving, S. (2007). Is the current practice providing an integrated approach to the management of LUTS and ED in primary care? an audit and literature review. J.Sex.Med., 4(6), 1713-1725. Level II Freedman, M., Kaunitz, A. M., Reape, K. Z., Hait, H., & Shu, H. (2009). Twice-weekly synthetic conjugated estrogens vaginal cream for the treatment of vaginal atrophy. Menopause (New York, N.Y.), 16(4), 735-741. Level V Johnson, C., Knight, C., & Alderman, N. (2006). Challenges associated with the definition and assessment of inappropriate sexual behavior amongst individuals with an acquired neurological impairment. Brain Injury, 20(7), 687-693. Level II Klein, R., Bar-on, E., Klein, J., & Benbenishty, R. (2007). The impact of sexual therapy on patients after cardiac events participating in a cardiac rehabilitation program. Eur.J.Cardiovasc.Prev.Rehabil., 14(5), 672-678. Level IV Korfage, I. J., Pluijm, S., Roobol, M., Dohle, G. R., Schroder, F. H., & Essink-Bot, M. L. (2009). Erectile dysfunction and mental health in a general population of older men. J.Sex.Med., 6(2), 505-512. Level II Lamina, S., Okoye, C. G., & Dagogo, T. T. (2009). Therapeutic effect of an interval exercise training program in the management of erectile dysfunction in hypertensive patients. Journal of Clinical Hypertension (Greenwich, Conn.), 11(3), 125-129. Level IV Lemieux, L., CohenSchneider, R., & Holzapfel, S. (2001). Aphasia and sexuality. Sexuality and Disability, 19(4), 253-266. Level IV Lindau, S.T., Schumm, L.P., Laumann, E.O., Levinson, W., O’Muircheartaigh, C.A., & Waite, L.J. (2007). A study of sexuality and health among older adults in the United States, The New England Journal of Medicine, 357, 762-744. Level IV Magalhaes, M. G., Greenberg, B., Hansen, H., & Glick, M. (2007). Comorbidities in older patients with HIV: A retrospective study. The Journal of the American Dental Association, 138(11), 1468-1475. Level I Miles CL, Candy B, Jones L, Williams R, Tookman A, King M. Interventions for sexual dysfunction following treatments for cancer. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD005540. DOI: 10.1002/14651858.CD005540.pub2. Level IV Montejo, A. L., Llorca, G., Izquierdo, J. A., & Rico-Villademoros, F. (2001). Incidence of sexual dysfunction associated with antidepressant agents: A prospective multicenter study of 1022 outpatients. spanish working group for the study of psychotropic-related sexual dysfunction. The Journal of Clinical Psychiatry, 62 Suppl 3, 10-21. Level IV Mott, S., Kenrick, M., Dixon, M., & Bird, G. (2005). Sexual limitations in people living with parkinson's disease. Australasian Journal on Ageing, 24(4), 196-201. Level IV Nagaratnam, N., & Gayagay, G. (2002). Hypersexuality in nursing care facilities—a descriptive study. Archives of Gerontology and Geriatrics, 35(3), 195-203. Level II Quintard, B., & Lakdja, F. (2008). Assessing the effect of beauty treatments on psychological distress, body image, and coping: A longitudinal study of patients undergoing surgical procedures for breast cancer. Psycho-Oncology, 17(10), 1032-1038. Level V: Rosen, R. C. (2006). Assessment of sexual dysfunction in patients with benign prostatic hyperplasia. BJU International, 97 Suppl 2, 29-33; discussion 44-5. Level II Rosen, R. C., Wing, R. R., Schneider, S., Wadden, T. A., Foster, G. D., West, D. S. et al. (2009). Erectile dysfunction in type 2 diabetic men: Relationship to exercise fitness and cardiovascular risk factors in the look AHEAD trial. J.Sex.Med., 6(5), 1414-1422. Level II Seidman, S. N., & Roose, S. P. (2006). The sexual effects of testosterone replacement in depressed men: Randomized, placebo-controlled clinical trial. Journal of Sex & Marital Therapy, 32(3), 267-273. Level II Shah, P. J., Dinsmore, W., Oakes, R. A., & Hackett, G. (2007). Injection therapy for the treatment of erectile dysfunction: A comparison between alprostadil and a combination of vasoactive intestinal polypeptide and phentolamine mesilate. Current Medical Research and Opinion, 23(10), 2577-2583. Level IV Sherr, L., Harding, R., Lampe, F., Johnson, M., Anderson, J., Zetler, S. et al. (2009). Clinical and behavioral aspects of aging with HIV infection. Psychology, Health & Medicine, 14(3), 273-279. Level II Siegel, T., Moul, J. W., Spevak, M., Alvord, W.G., & Costabile, R.A. (2001). The development of erectile dysfunction in men treated for prostate cancer. Journal of Urology, 165, 430-435. Level IV Tannenbaum, C., Corcos, J., & Assalian, P. (2006). The relationship between sexual activity and urinary incontinence in older women. Journal of the American Geriatrics Society, 54(8), 1220-1224. Level V Wallace, M. (2000). Sexuality and Intimacy. In Textbook of Gerontological Nursing, 2nd Ed. St. Louis: Mosby Year Book, Inc. Level II Wespes, E., Moncada, I., Schmitt, H., Jungwirth, A., Chan, M., & Varanese, L. (2007). The influence of age on treatment outcomes in men with erectile dysfunction treated with two regimens of tadalafil: Results of the SURE study. BJU International, 99(1), 121-126. Level V Wick, J. Y., & Zanni, G. R. (2005). Disinhibition: Clinical challenges in the long-term care facility. The Consultant Pharmacist, 20(12), 1006-1018. Level V Wiseman, S. V., McAuley, J. W., Freidenberg, G. R., & Freidenberg, D. L. (2000). Hypersexuality in patients with dementia: Possible response to cimetidine. Neurology, May(2), 2024. 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. 12/18/2006 9:45am eSlide - P3562 - AACN Hartford-sponsored Faculty Development

Contact Information: rdugger@uscb.edu; 812-573-9146 12/18/2006 9:45am eSlide - P3562 - AACN Hartford-sponsored Faculty Development

Final Acknowledgement for Resources Utilized in Presentation *Special acknowledgement and thanks to Meredith Wallace PhD, APRN, A/GNP-BC and the Geriatric Nursing Education Consortium (GNEC) 12/18/2006 9:45am eSlide - P3562 - AACN Hartford-sponsored Faculty Development