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 www.aacn.nche.edu/gnec.htm.
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
Myth Busting
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.
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.
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.
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 Adults
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.
Other Barriers to Older Adult Sexual Health
Physical Barriers to Sexual Health
Normal aging changes
Pathological changes
Chronic pain
Cognitive impairment
Environmental restrictions
Body image
Adverse medication effects
Societal discomfort with issues of homosexuality
Older people are homosexual too!
They may have not come out yet
LGBT may fear physical harm for coming out
Require great sensitivity due to years of isolation
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:
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 estrogen after menopause
Normal Aging Changes Male Sexual Response
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 practice.
Sexual Dysfunction
Sexual disorders fall into four categories:
Hypoactive sexual desire disorder,
Sexual arousal disorder
Orgasmic disorder
Sexual pain disorders
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
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.
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.
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.
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.
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
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.
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.
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.
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
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.
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.
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?
PLISSIT MODEL (Annon, 1976)
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.
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.
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
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.
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.
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
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
Contact Information: rdugger@uscb.edu; 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)
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 www.aacn.nche.edu/gnec.htm.
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
Myth Busting
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.
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.
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.
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 Adults
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.
Other Barriers to Older Adult Sexual Health
Physical Barriers to Sexual Health
Normal aging changes
Pathological changes
Chronic pain
Cognitive impairment
Environmental restrictions
Body image
Adverse medication effects
Societal discomfort with issues of homosexuality
Older people are homosexual too!
They may have not come out yet
LGBT may fear physical harm for coming out
Require great sensitivity due to years of isolation
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:
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 estrogen after menopause
Normal Aging Changes Male Sexual Response
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 practice.
Sexual Dysfunction
Sexual disorders fall into four categories:
Hypoactive sexual desire disorder,
Sexual arousal disorder
Orgasmic disorder
Sexual pain disorders
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
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.
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.
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.
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.
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
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.
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.
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.
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
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.
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.
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?
PLISSIT MODEL (Annon, 1976)
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.
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.
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
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.
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.
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
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
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References
Contact Information: rdugger@uscb.edu; 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)