1. Sex in the Nursing Home Satinderpal K. Sandhu, MD Program Director Geriatric Fellowship Summa Care Health System

2. Let’s Talk About Sex-in Older Adults Definitions of Sex and Sexuality Attitudes of Older Adults and By Older Adults about Sex Aging and Sex Barriers and Policies Regarding Sex in the Nursing Home

3. Case-Iowa NH 12/25/09 nurse TG walked into a room where Ben (former college professor) a 78 y.o. resident had just finished having intercourse with Agnes (former school teacher) an 87 y.o. resident-not his wife. Ben was divorced, Agnes was married. Both had dementia. When the staff tried to separate them Agnes began cursing, yelling and trying to hit the staff. Not first time they were found in a “sexual” situation. In Nov 09 they had been found in bed talking, both naked from the waist down. Staff not overly surprised-the two had gravitated to each other, with Agnes calling Ben by her husbands name and being calmed by his presence. At this time families of both residents were notified. Ben’s daughter was worried that he would be kicked out. The DON said the encounter reflected a normal human need, and no plans were being made to dc him. Agnes’ family voiced no concerns. The Dept of Inspections and Appeals was not notified as no abuse was viewed to have occurred on the first occassion. After this recent incident though the facility did try and discourage Ben from being with Agnes..ie 15 minute checks. Gruley: Bloomberg News, July 2013

4. Case con’t (Sex in the Midwest) Back to Xmas 09: TG had not actually witnessed Ben and Agnes having sex. It was reported by her by two other nurses who had seen Ben standing behind Agnes who was naked on all fours on the bed, with Ben as one of the nurses said “going to town.” Agnes was examined-vaginal area appeared red, bruises on lower shins. The DON and administrator were contacted and called the families. Agnes’ son declined having his mother being examined at a hospital saying it seemed like “ a mutual sexual act”. The son did not tell his father. Ben’s daughter was just told that her father had been found naked again. As no evidence of abuse existed, the state again not notified. The NH took steps to avoid more sexual encounters between the two, keeping them apart and having drugs prescribed to Ben to curb his sexual urges. No more sexual episodes were documented. Gruley: Bloomberg News, July 2013

5. What does the word Sex mean Sex: Noun -Male/Female: synonymous with gender -Either the male or female gender of a species esp as differentiated with reference to the reproductive organs Verb -To ascertain the sex of a species -To arouse sexually or increase the appeal of Idiom -To engage in sexual intercourse

6. Sexuality -Closely linked with intimacy (emotional and physical) -Basic human need:not affected by age -Includes: How one feels about oneself as a person How one feels about being male or female How one treats his/her body How one lives/dresses How one relates to members of the same and opposite sex Sexual expression : all of the above +holding hands, kissing, masturbating, touching and sexual intercourse.

7. The “Ick” Factor

8. Society’s Views of Sex in Seniors Ageist Asexual Parents/Grandparents ≠ People Excluded from studies ie HIV/AIDS 2007 NEJM study: 3005 individual between age 57-85 38% men and 22 % reported having discussed sex with a physician since age 50. Only for the Young and Beautiful Surprise, Disgust and Inappropriate vs Cute College students more disgusted by the idea of 70-75 year olds having sex then the idea of 30-35 year olds having sex. NH View: Behavior Problem

9. Sex IQ 1) What percentage of individuals aged 75-85 in the US reported being sexually active? (vaginal/oral) a) 18% b) 23% c) 26% 2) In the above group what percentage of individuals report having sex once a week or more? a) 18% b) 23% c) 26 % Global study revealed that in individuals between 70-80 yrs 53% of men and 21% of women said they engaged in sexual intercourse during the 12 months before being interviewed –(Nicolosi et al)

10. Seniors Gone Wild Dept of Health and Human Services 2013 report - 2011-2012 : 2.2 million beneficiaries received free STD screening and counseling (5% of all those on Medicare- same number as those who received free screening colonoscopies) 66,000 received free HIV tests - 2007-2011: 65+ Chlamydia infections: 31% Syphilis infections: 52%

11. Sex IQ According to the 2010 National Survey of Sexual Health and Behavior, among college-age Americans, condoms are used in 35% of sexual encounters, but in 55% of sexual encounters among those 61 and older. T/F 40% in college kids/ 6% in those 61+

12. They Want It-They Do It Living longer and Living healthier Access to Viagra Retirement communities/Assisted living are the new college campuses Baby Boomers (1946-1964) are joining the ranks Burn the bra-Gimme the pill generation

13. Effects of Aging on Sexual Function Female Loss of estrogen ↓ vaginal lubrication vasomotor symptoms neurologic and psycho-social changes ( ie: irritability, anorgasmaia) Sexual Problems Lack of interest (testosterone) Vaginal dryness Dyspareunia Decrease in clitoral sensitivity Decrease in orgasmic intensity and frequency Male Sign changes in penile structure ↓ in elastic fibers, collagen, smooth muscle, mechanical sensitivity→ ED Most common cause of ED are vascular causes Sexual Problems Difficulty in maintaining or achieving an erection Lack of interest Climaxing too quickly or not able to climax Performance anxiety

14. Where there’s a Will, there’s a Way Aging Changes + Disease OA, DM, CAD, cancer and consequences, prolapses, pain issues, and on and on + Medications + NH = NO SEX

15. Barriers to Sexual Expression in LTC Lack of privacy Double rooms/doors without locks/single beds Lack of a willing partner Loss of interest Negative attitudes of physicians and NH staff Bias of institution /staff Feeling unattractive Embarrassed and lack of understanding of their feelings

16. Policies State and Federal Laws protect the right of NH residents to have consensual sexual relations, to ensure privacy. Only are required to report incidents that potentially cause harm No standard policy on how to do this No current laws how to determine if patient with dementia can consent Ohio Residents’ Rights Privacy for spouse visits, to share room if in same LTC-unless not medically advisable, to upon reasonable request to have room doors closed and not opened without knocking, except in case of emergency or not medically advisable. No mention of policy of sex between non-married residents or those with dementia.

17. AMDA survey 2013 Spurred on by Bryan Gruley’s articles in Bloomberg News 23% had a sexual behavior policy in place 13% provided training 4% said there is no current need for educational resources on sexuality and intimacy in LTC. Sexual habits, preferences and orientation not asked about routinely on admission –not part of MDS.

18. Blurred Lines Dementia Autonomy vs Safety aka Paternalism How to determine consent? Different decisions require different levels of capacity Do you understand the risk of undergoing a lobectomy and chemo for lung cancer? VS Do you like ice cream?

19. Determining Decision Making Capacity Grisso and Appelbaum framework for decision making capacity 1) able to communicate a choice 2) understand the relevant information 3) appreciate the situation and its consequences 4) display reasoning Lichtenberg (1997) Decision Tree (promoted by PEAK) MMSE >14 yes-continue eval no- pt can’t consent Ability to avoid exploitation yes-continue eval no-pt can’t consent Patient’s awareness of the relationship yes-continue eval no-pt can’t consent Patient’s awareness of risk yes-continue eval no-pt can’t consent

20. I Like Ice Cream! Positive Indicators Verbal expressions of pleasure while participating in the activity, eyes crinkled, smiles, laughter, relaxed facial expression and body language, nods positively Negative Indicators Closed Body Language, frown on face, angry verbal outbursts, grimacing, psychomotor agitation, eyes wide open frightened look Decisions about sex involve emotion, can be irrational and even have harmful consequences in cognitively intact individuals Decisions regarding whether or not to have sex are closer to those of ice cream than surgery (Richardson and Lazar) Tarzia et al: J Med Ethics 2012

21. Sex IQ Federal regulations mandate that nursing homes inform families if two consenting adults are engaged in a romantic relationship. T/F

22. Hebrew Home Person Centered Care “My biggest problem is my residents aren’t having enough sex.” Dan Reingold-President &CEO Presumption is that someone with dementia CAN consent to sex. 1995-Adopted a 4 page policy-updated in 2013 “have the right to seek out and engage in sexual expression” www.hebrewhome.org Gruley: Bloomberg News, July 2013, October 2013

23. Sandra Day O’Connor Glen Campbell

24. Back to Agnes and Ben -2010 the Inspection and Appeals board while looking into another incident at the NH, heard about Agnes and Ben. -March 12, 2010-cited the NH for failure to protect Agnes-placing the NH in “immediate jeopardy” for being disqualified for Medicare/Medicaid patients. -March 17, 2010-Ben was discharged. Next closest NH was 2 hours away from his family. -March 24, 2010-Both the administrator and DON fired. -May 2010-I and A board said that Agnes had been “sexually assaulted” and the NH had failed to report it. Home fined $47,000. Ended up paying $14,500 without admitting wrong doing. -September 2010-Agnes died at another facility. Shortly before her death son told father about Xmas 09. Husband said he forgave his wife”there was nothing she could have done.” Of note the family at this time had a lawsuit against the facility saying Agnes had been raped. -December 2010-Ben dies. -No one ever asked either resident at any time what happened, what they felt about what occurred. Gruley: Bloomberg News, July 2013

25. DON and Administrator - DON lost her nursing license-did not even go to a hearing regarding her license due to depression. 2013- runs a child day care out of her home -Administrator landed job at an assisted living facility. Left though in June, 2012 after the Iowa Board of Nursing Home Administrators accused him of professional incompetence. In September of 2012 he was acquitted by the Iowa nursing home board which said “testimony that the sex was consensual was “more persuasive.” He was cited though for not following proper procedures in discharging the man. 2013- the administrator of a pediatric care center in Iowa. Gruley: Bloomberg News, July 2013

26. Summary Sexual relationships are important to the elderly. Senior Sex is happening at home and in the nursing home. Policies regarding sex in the nursing home, especially between residents with dementia are limited and lack consistency. Education is needed for : patients, families, health care staff, ltc administrators, nursing home regulators, judges, lawyers-for all!

27. Sound Track for Sex in the NH Lecture ( not yet available on i-tunes ) Let’s Talk About Sex: Salt-n-Pepa Sexy Back : Justin Timberlake Sexual Healing: Marvin Gaye I’m Too Sexy: Right Said Fred Blurred Lines: Robin Thicke I Want Your Sex: George Michael Let’s Do It (Let’s Fall in Love): Cole Porter sung by Alanis Morissett

28. Shredded Wheat and Sex “80 is the new 18”