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

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

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 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 Objectives 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. Myth Busting Sexual Health Is important to an individuals self-identity and general wellbeing.

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 professiona ls are typically not educated to manage sexual

health issues of older adults. Sexual health is often ignored in the assessment of older adult health.

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. 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

(Lindau, et al., 2007) aged 65 to 74 and 26% of adults aged 75 to 84. 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 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. (Baumgartner et al., 2008) 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

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.

Health Care Provider Barriers to Sexual Health in Older A study of 100 patients aged 39 to Adults 86 and their health care providers revealed that less than 10% of providers asked Providers:

patients about Are subject to myths and attitudes erectile function, although about sexuality and aging. over 90% of May be insensitive to older patients were interested in adults needs. treatment (Chitale, Dont know how to manage sexual issues. ethealth

al., 2007) Experience discomfort in managing sexual issues. (Chitale et al., 2007) 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 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. 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 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) 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 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 Sexual Dysfunction Sexual disorders fall into four categories: 1. Hypoactive sexual desire disorder, Sexual dysfunction 2. Sexual arousal disorder is prevalent

3. Orgasmic disorder worldwide, and the of 4. Sexual pain disorders occurrence sexual dysfunctions (Walsh & Berman, 2004) increases directly with age for both men and women. (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 (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. (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 Diabetes effects sexual health among older adults in a number of ways: impacts sexual function. impacts arousal and pleasurable sensations.

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. (RockliffeFidler & Kiemle, 2003) 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. (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 (Korfage et al., 2009) health scores.

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 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%.

(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(Martin formal education.

et al., 2008) 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. (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 2006)was significantly associated with aged 55 (Tannenbaum to 95,et al.,UI alterations in sexual activity. Other Medical Conditions Impacting Sexual Health Strokes and subsequent aphasias impact sexual

(Lemieux et al., 2001) health via difficulties in desire, function and communication Parkinsons disease (PD) In a study of 444 older adults with PD, sexual et al., 2005), limitations (Mott 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 (Rosen, 2006)

affect erectile function, sexual arousal and ejaculatory dysfunction. 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) Sexual Behaviors Common to

Cognitively Impaired Older Adults Sexual Behaviors 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 (Montejo et al., 2001) 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 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 Case #2

Taken from: McNicoll, L. (2008). Issues of sexuality in the elderly Geriatrics for the Practicing Physician, 91(10), 321-322. 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? What questions do you have about your sexual needs and function? In what ways has your sexual relationship with your partner changed as you have aged?

What interventions or information can I provide to (Wallace, 2000) help you to fulfill your sexuality? 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 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 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. Health Promotion

Whats 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. 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 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. (Freedman et al., 2009) The Many Faces of ED Treatment* (*The speaker does not recommend any particular drug treatment) 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. (Wespes et al., 2007) 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. (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 patients medication is adversely impacting sexual

function and consider change in medications when appropriate and possible. 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 (Klein et al., 2007) of erection, and 6) enjoyment 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. 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 Web Links Hartford Institute for Geriatric Nursing/ Sexuality Issues in Aging. _to_know_more MedlinePlus

American Foundation for Urological Disease, Inc World Health Organization (2004). Sexual Health- A New Focus for WHO. Progress in Reproductive Health Research, 67. 1-8. American Association of Older Persons. Great Sex Well After 50. html References References with Levels of Evidence provided as a handout

Taken from GNEC resources Contact Information: [email protected]; 812-573-9146 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)

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