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Sexuality in Elder Care:Toward a New ParadigmLois Stewart-Archer RN, MN, CPMHN(C)Regional Clinical Nurse SpecialistWRHA Ge...
SHHHHHH, we’re talking about sex!
Sexuality in Elder                       CareObjectives:• we will ask you to examine, and  maybe change, your attitudes an...
Thoughts on                     Sexuality“In our experiences, old folks stop having    sex for the same reason they stop r...
Thoughts on            Sexuality“Aging … is a metaphor for  asexuality”            H. Davies, et al
Thoughts on             SexualityWhat do the words “sex” and “sexuality” mean to you?What are some common attitudes  and b...
Staff attitudes• residents aren’t interested in sex• sexual behaviours are a problem  not an expression of a need• staff a...
Staff attitudes• concerned about competency of  residents involved• level of comfort with gay and  lesbian relationships• ...
Staff attitudesWhat influences our attitudes and  beliefs on sex and sexuality?• cultural values• personal beliefs• lack o...
Myths about        Sexuality and the            Elderly• “old people don’t have sex”• “old people have stopped  developing...
STATISTICSOf the1604 men and women ages  65-97 who responded to a survey:• 40% reported that they had  sexual activity an ...
STATISTICSA recent study from the New England  Journal of Medicine reported that:• more than half of those surveyed who  w...
STATISTICSAnother study showed that:• 74% of married men and 56% of  married women > 60 continued to  be sexually active• ...
STATISTICSAmong the most seriously cognitively impaired elderly, 7% are reported to exhibit sexually disinhibited behaviour.
Sexuality & Intimacy
SEX & INTIMACY“Sex and intimacy encompass a  kaleidoscope of feelings and activities;  from the deepest longings for mutua...
SEXUALITYSexuality also covers a gamut of behaviours – touching, kissing, caressing and cuddling, genital intercourse with...
Sexuality Defined“Sexuality is a central aspect of being human  throughout life and encompasses sex, gender  identities an...
IntimacyThe need and ability to experience emotional closeness with another human being and to have that emotional closene...
Sexuality: What                  does it mean?•   Close companionship•   Touch and be touched•   Body image•   Synonymous ...
Sexually Dysinhibited                BehaviourIncidence 4% - 7%Occurrence: both males and femalesBoth long term care and a...
Changes secondary to                    DementiaOf Note:Existing relationships →adaptNew relationships → formDesires → flu...
Dementia: Sexuality                           & IntimacyChanged sexual                 Diminishing sexualbehaviours       ...
What Does Not Change?The right to be sexually alive, should adults  wish - regardless of age, ability, or sexual  preferen...
Causes of SDB•   Underlying Medical Problems    Labial Cancer          Vaginitis    Prolapsed uterus       UTI    Colorect...
Causes of SDB•   Aggressive response    to stressor of    institutionalization    •   Threat, fear, loss    •   Structure ...
Causes of SDB•   Dementia/Depression    -   misunderstanding of environmental cues    -   not adhering to social norms    ...
Causes of SDB•   Need for    Intimacy    Desperation    for human    contact
Causes of SDB•   Panic associated    with death    – helps mask
Causes of SDB↓ impulse control              Age-related               Changes
Medication Adverse                                 EffectsA/D (tricyclics - ↓desire, SSRIs - delayed ejaculation, Trazodon...
SDB: Theoretical                             Framework              Habits,            Personality                        ...
General Suggestions for  Basic Intervention
Disturbance in Memory and                   JudgmentReorient to person and place as possibleUse short simple instructions ...
Unmet Need for                      AffectionAssign same caregiver consistentlySpend time with Resident/Pt.Provide tactile...
Death AnxietySpend time with Resident/Pt.Encourage to verbalize feelings  about illness, end of lifeEngage in life-review ...
Age-related changes                          with                    ↓ impulse controlProvide with limits for behaviour, o...
Misinterpreting                      Environmental Cues Behaviour                Possible ExplanationClothing removal     ...
Principles•   Observation•   Assessment of past and present•   Identification of unsatisfied needs•   Adaptation of interv...
Defining Capacity to  Consent to Sexual RelationsAbility to Avoid Exploitation   •   Is the behaviour consistent with form...
Defining Capacity to           Consent to Sexual RelationsAwareness of Potential Risks  •   Does the person realize that s...
Our Approach
Our Approach to                 Sexual Behaviours in                         LTCA Problem-Solving Approach We need to ask ...
Steps in a problem                 solving approach1. Define the problem  • is there a problem?  • whose problem is it?  •...
Steps in a problem                 solving approach2. Assess the person• what is behind the behaviour?
Steps in a problem                  solving approach3. Develop a plan• what is the desired outcome?• as a team, decide on ...
Steps in a problem        solving approach4. Evaluate and monitor
ChallengesMasturbation• video clip• applying the problem solving  approach
ChallengesConsenting Adults• video clip• applying the problem solving  approach
Policy DevelopmentHaving a policy in place provides guidance for looking at a situation in a more objective way.What do yo...
Policy Development• a statement of purpose• definitions of sexuality and intimacy• a definition of sexual expression• a de...
Policy Development•   what individual rights do you want to    include in the policy?     • the resident’s rights     • th...
Policy Development•   resident rights you may want to    consider include:     • the right to seek out and engage       in...
Policy Development•    the right to obtain materials with legal    but sexually explicit content for personal    use•   th...
Policy Development•   the impact on other residents, family, staff     • who is the recipient of the sexual       expressi...
Policy Development• what will you do if there is no consensus  among the resident, other residents, staff  and family?• in...
Ethical ConsiderationsSome thoughts on ethical considerations:• views on sexuality and the elderly are often  not a reflec...
Ethical Considerations• at what point do we, as staff, have the  right to decide what is inappropriate  touching?• how do ...
Ethical Considerations• how do we determine that we are “caring”  for a resident, not “controlling” a resident?• how do we...
Organizational Support of Sexual                 Expression in LTC FacilityArea           InterventionsPolicy         Deve...
Responsibilities of Nursing Home                  Staff Regarding Sexual ExpressionIssues          ResponsibilitiesEnviron...
KEY POINTSPeople with dementia have lived with their sexuality for much longer than they   have lived with Dementia.Not ev...
Video ClipBackseat Bingo    6 min
Questions/Comments
ReferencesArchibald, C. “Sexuality and Dementia: The Role Dementia Plays When Sexual Expression    Becomes a Component of ...
ReferencesLoue, S. “Intimacy and Institutionalized Cognitive Impaired Elderly”, Care Management    Journals Winter 2005Roa...
Reference (Modules)“Intimacy, Sexuality and Sexual Behaviour in Dementia: How to Develop    Practice Guidelines and Policy...
ReferencesVideos:Freedom of Sexual ExpressionBackseat Bingo
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  • What we often forget or overlook is that even if it has been a long time since the older individual has participated in a sexual relationship or even thought about anything sexual, this individual is still a sexual being.
  • Pangman and Seguire define sexuality as “ a fundamental and natural need within everyone’s life, regardless of age and physical state”. A study of care plans revealed the following comments under the heading “sexuality”: “ not applicable” “ keeps jewelry in safe” “ own teeth”
  • Why is the expression of sexuality in the elderly, particularly those in care facilities, rarely seen as positive? Sexual expression can contribute positively to an individual’s life, as long as it does not infringe on the rights of others.
  •  
  • Eg. “To promote the residents’ Bill of Rights as it relates to sexuality and intimacy and ensure each resident’s rights to freedom, privacy, confidentiality and dignity. Residents have the right to make their own choices. If resident is deemed incompetent and actions impact on another, then interventions must occur. If resident is deemed competent, but is putting others at risk or is not respecting rights of others, interventions may be necessary.” “Intimacy and Sexuality Guidelines” from Macassa Lodge, Hamilton. Ontario Sexual expression: “Words, gestures, movements or activities (including reaching, pursuing, touching, or reading) which appear motivated by the desire for sexual gratification”. From the Hebrew Home for the Aged at Riverdale Capacity: the ability to consent to sexual intimacy and/or sexual activity –consent may be indicated by willing participation ie. lack of resistance/objections
  • Staff handbook at New Mercer Commons in Ft. Collins, Colorado stats that “Intimacy is a basic level of respecting humanity, like church services and meals. If you’re serving residents with integrity, you can’t excise it from who they are”. The handbook for this facility address sexuality along with TV services and hairdressing costs.
  • Eg. sexually explicit videos, magazines, books, etc. “ Residents have the following rights, providing in each instance that they do not involve non-consensual acts, acts involving minors, or acts and/or behaviours between persons who are cognitively impaired and/or with impaired judgement, and that they do not impact negatively on the resident community as a whole”. Hebrew Home for the Aged at Riverdale
  • “… where any associated resident is cognitively impaired and/or with impaired judgement, and for whom there is a designated representative (eg. spouse or adult child), this designated representative will be involved in the decision-making process concerning possible course(s) of action to be undertaken with…the resident. Involvement of a designated representative is warranted only in instances where the involved resident is cognitively impaired and/or with impaired judgement”. Hebrew Home for the Aged at Riverdale
  • “… the relevant Interdisciplinary Care Team will make clinical judgements regarding the relative benefits or potential harm associated with the resident’s (s’) sexual expression”. The Hebrew Home for the Aged “ When you see one case, you have only seen one case”. Stephen Post
  • “ I personally would wish to have the integrity of my life journey protected against the waywardness created by dementia.” Stephen Post
  • Transcript of "Sexual dementia behaviors"

    1. 1. Sexuality in Elder Care:Toward a New ParadigmLois Stewart-Archer RN, MN, CPMHN(C)Regional Clinical Nurse SpecialistWRHA Geriatric Mental HealthSusan Bernjak RN, BA, CACE, GNC(c)Regional EducatorWRHA PCH Program
    2. 2. SHHHHHH, we’re talking about sex!
    3. 3. Sexuality in Elder CareObjectives:• we will ask you to examine, and maybe change, your attitudes and beliefs regarding sexuality and the elderly• we will look at some challenging behaviours related to sexuality• we will look at policy development
    4. 4. Thoughts on Sexuality“In our experiences, old folks stop having sex for the same reason they stop riding a bicycle –general infirmity, thinking it looks ridiculous, no bicycle.”    A.  Comfort
    5. 5. Thoughts on Sexuality“Aging … is a metaphor for asexuality” H. Davies, et al
    6. 6. Thoughts on SexualityWhat do the words “sex” and “sexuality” mean to you?What are some common attitudes and beliefs held by staff?Common staff reactions?
    7. 7. Staff attitudes• residents aren’t interested in sex• sexual behaviours are a problem not an expression of a need• staff are uncomfortable with displays of affection/sexual behaviours• staff become paternalistic
    8. 8. Staff attitudes• concerned about competency of residents involved• level of comfort with gay and lesbian relationships• may feel disgusted• uncertain what to do or say
    9. 9. Staff attitudesWhat influences our attitudes and beliefs on sex and sexuality?• cultural values• personal beliefs• lack of understanding• inadequate training
    10. 10. Myths about Sexuality and the Elderly• “old people don’t have sex”• “old people have stopped developing relationships”• “old people aren’t interested in sex”
    11. 11. STATISTICSOf the1604 men and women ages 65-97 who responded to a survey:• 40% reported that they had sexual activity an average of 2.5x/month• 69% of the men and 49% of the women reported that sex was important in their lives
    12. 12. STATISTICSA recent study from the New England Journal of Medicine reported that:• more than half of those surveyed who were between the ages of 57-75 stated that they gave or received oral sex• one third of those between 75 and 85 reported that they gave or received oral sex
    13. 13. STATISTICSAnother study showed that:• 74% of married men and 56% of married women > 60 continued to be sexually active• 31% of unmarried men and 5% of unmarried women > 60 continued to be sexually active
    14. 14. STATISTICSAmong the most seriously cognitively impaired elderly, 7% are reported to exhibit sexually disinhibited behaviour.
    15. 15. Sexuality & Intimacy
    16. 16. SEX & INTIMACY“Sex and intimacy encompass a kaleidoscope of feelings and activities; from the deepest longings for mutual affection to the simple enjoyment of the company of a loved one” (Sherman, 1998).
    17. 17. SEXUALITYSexuality also covers a gamut of behaviours – touching, kissing, caressing and cuddling, genital intercourse with mutual orgasm and feelings of closeness and being wanted and valued as a human being.” (Sherman , 1998).
    18. 18. Sexuality Defined“Sexuality is a central aspect of being human throughout life and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviours, practices, roles, and relationships. While sexuality can include all of these dimensions, not all of them are always experienced or expressed (WHO, 2003).
    19. 19. IntimacyThe need and ability to experience emotional closeness with another human being and to have that emotional closeness predictably reciprocated (Denis Dalley).
    20. 20. Sexuality: What does it mean?• Close companionship• Touch and be touched• Body image• Synonymous with sexual activity and intercourse. (Deacon, Minicheiello, Plummer, 1995)
    21. 21. Sexually Dysinhibited BehaviourIncidence 4% - 7%Occurrence: both males and femalesBoth long term care and acute careParticularly high with those with a dementing illness
    22. 22. Changes secondary to DementiaOf Note:Existing relationships →adaptNew relationships → formDesires → fluctuate
    23. 23. Dementia: Sexuality & IntimacyChanged sexual Diminishing sexualbehaviours interest • Uncharacteristic? • Withdrawn, non-initiate Illness related • Sexual desire – what, when, where Increased sexual demands • Unreasonable, exhaustingLoss of inhibitions • “Objectified” • Advances towards others
    24. 24. What Does Not Change?The right to be sexually alive, should adults wish - regardless of age, ability, or sexual preference.Intimacy is a basic need, which people with Dementia and their carers should be able to express, WITHOUT FEAR OF DISAPPROVAL!
    25. 25. Causes of SDB• Underlying Medical Problems Labial Cancer Vaginitis Prolapsed uterus UTI Colorectal cancer Scabies
    26. 26. Causes of SDB• Aggressive response to stressor of institutionalization • Threat, fear, loss • Structure • Tasks exceed ability etc
    27. 27. Causes of SDB• Dementia/Depression - misunderstanding of environmental cues - not adhering to social norms - disturbance in memory, judgment - psychological conflicts acted out through sexual behaviour - frustration, confusion - boredom, inability to concentrate
    28. 28. Causes of SDB• Need for Intimacy Desperation for human contact
    29. 29. Causes of SDB• Panic associated with death – helps mask
    30. 30. Causes of SDB↓ impulse control Age-related Changes
    31. 31. Medication Adverse EffectsA/D (tricyclics - ↓desire, SSRIs - delayed ejaculation, Trazodone – ↑desireAntihypertensives (analapril, diuretics)Antianxiety (inhibition of orgasm)Narcotics (↓ desire)Antifungals (ketoconazole – erectile dysfunction)Anticoagulants (Heparin – priapism)H2 antagonists (Ranitidine – gynaecomastia)Anti-lipid (Niacin - ↓ desire) (Finger et al, 1997; Thomas et al, 2003; Rizvi et al, 2002)
    32. 32. SDB: Theoretical Framework Habits, Personality SDB Satisfies the need Current condition Physical SDB Unsatisfied Communicates Mental Need needs Environment SDB Physical Due to Frustration Psychosocial Negative EffectsCohen-Mansfield, 1990
    33. 33. General Suggestions for Basic Intervention
    34. 34. Disturbance in Memory and JudgmentReorient to person and place as possibleUse short simple instructions to direct to room or redirect behaviourLabel rooms to help locate privacyIf SDB persists, use alternative clothing • Pull-over shirt • Elasticized pants • Back-closing shirts etc.
    35. 35. Unmet Need for AffectionAssign same caregiver consistentlySpend time with Resident/Pt.Provide tactile stimulation e.g. touch, toys, textureEncourage verbalization re: sex and sexual frustrationReward for appropriate requests for attention e.g. smile, hug, spend time
    36. 36. Death AnxietySpend time with Resident/Pt.Encourage to verbalize feelings about illness, end of lifeEngage in life-review or reminisce therapy as appropriateReinforce that he is not alone
    37. 37. Age-related changes with ↓ impulse controlProvide with limits for behaviour, outlining acceptable and unacceptable behaviour in the present environmentReassure of acceptanceProblem solve to determine ways to manage (situation triggers, alter situation)Reward for appropriate requests for attention e.g.. Smile, hug, spend time
    38. 38. Misinterpreting Environmental Cues Behaviour Possible ExplanationClothing removal Clothing - hot, itchy, tightSelf exposure Need to use bathroomMasturbation Boredom, frustrationInappropriate touch Mistaken identityRequests for kisses Expressed need to touchAttempts to fondle Misinterpret others
    39. 39. Principles• Observation• Assessment of past and present• Identification of unsatisfied needs• Adaptation of intervention to needs, personal characteristics, environment• Trial of several alternatives• Assessment of approach used (Groul, 2005)
    40. 40. Defining Capacity to Consent to Sexual RelationsAbility to Avoid Exploitation • Is the behaviour consistent with formerly held beliefs and values? • Does the person recognize the concept of choice and voluntariness? • Does the person have the information needed to make a decision? • Does the person have a guardian? (Alzheimer Mb., 2006)
    41. 41. Defining Capacity to Consent to Sexual RelationsAwareness of Potential Risks • Does the person realize that sexual contact may be time limited? • Can the person describe how she/he will respond if and when contact ends? • Is the person aware of any potential physical and emotional harm? • Can the person take precautions against risks? (Teitelman, 2002)
    42. 42. Our Approach
    43. 43. Our Approach to Sexual Behaviours in LTCA Problem-Solving Approach We need to ask ourselves:• is the behaviour really sexually motivated?• is this “normal” behaviour for this individual?• is there a trigger for the behaviour?• who is this really affecting? • staff? other residents? families?
    44. 44. Steps in a problem solving approach1. Define the problem • is there a problem? • whose problem is it? • who is it affecting? • the resident? the family? other residents? staff?
    45. 45. Steps in a problem solving approach2. Assess the person• what is behind the behaviour?
    46. 46. Steps in a problem solving approach3. Develop a plan• what is the desired outcome?• as a team, decide on the interventions and recommendations you want to put into place • work with the resident, the family, other residents, the interdisciplinary team and staff on all shifts
    47. 47. Steps in a problem solving approach4. Evaluate and monitor
    48. 48. ChallengesMasturbation• video clip• applying the problem solving approach
    49. 49. ChallengesConsenting Adults• video clip• applying the problem solving approach
    50. 50. Policy DevelopmentHaving a policy in place provides guidance for looking at a situation in a more objective way.What do you need to take into consideration when trying to develop a policy on sexuality?
    51. 51. Policy Development• a statement of purpose• definitions of sexuality and intimacy• a definition of sexual expression• a definition of capacity
    52. 52. Policy Development• what individual rights do you want to include in the policy? • the resident’s rights • the rights of other residents, families and staff
    53. 53. Policy Development• resident rights you may want to consider include: • the right to seek out and engage in sexual expression
    54. 54. Policy Development• the right to obtain materials with legal but sexually explicit content for personal use• the right to privacy in support of sexual expression
    55. 55. Policy Development• the impact on other residents, family, staff • who is the recipient of the sexual expression? • what if a cognitively impaired resident is the recipient of the sexual expression?
    56. 56. Policy Development• what will you do if there is no consensus among the resident, other residents, staff and family?• include a reminder that each incident needs to be considered individually• what is your commitment to on-going staff/family education?
    57. 57. Ethical ConsiderationsSome thoughts on ethical considerations:• views on sexuality and the elderly are often not a reflection of the values of the resident, but rather the values and attitudes of staff and the facility
    58. 58. Ethical Considerations• at what point do we, as staff, have the right to decide what is inappropriate touching?• how do we tell the family?• how do we decide whether a relationship will continue? • determine capacity?
    59. 59. Ethical Considerations• how do we determine that we are “caring” for a resident, not “controlling” a resident?• how do we decide whether the “then” self controls the destiny of the “now” self?
    60. 60. Organizational Support of Sexual Expression in LTC FacilityArea InterventionsPolicy Development of policies incorporating the sexual needs of residents into care plansEducation Staff education tailored to the defined level of staffAccess Access to beauty salon, manicurist, cosmeticsPrivacy Offering married couples own room Do not disturb sign Requiring knocking prior to entering room Facilitation of conjugal/home visits to spouseEnvironment Provision for locked doors Availability of a double bed
    61. 61. Responsibilities of Nursing Home Staff Regarding Sexual ExpressionIssues ResponsibilitiesEnvironment Maintain awareness, support sexual expressionPrivacy Needs Assist in maintaining privacy for sexual activityMaterials Permit access to sexually explicit materials (magazines, videos, etc)Risk Identify situations requiring intervention, such as: • involvement of those with impaired cognition • presence of medical condition that might limit or require adaptation of sexual activity • risk of communicable disease – STDs • public expression offensive to others • emotional distress, possibly requiring counselling
    62. 62. KEY POINTSPeople with dementia have lived with their sexuality for much longer than they have lived with Dementia.Not everyone with Dementia is heterosexualNot everyone chooses to exercise his right to be a sexual beingCouples who work on their relationships can keep them stronger for longerMaintaining a healthy sex life can improve overall quality of life for caregivers and those with DementiaCaregivers need to consider their own needs along side those who have DementiaThe risk of sexual infections does not diminish with ageSexual abuse of a person with Dementia can constitute a criminal offence
    63. 63. Video ClipBackseat Bingo 6 min
    64. 64. Questions/Comments
    65. 65. ReferencesArchibald, C. “Sexuality and Dementia: The Role Dementia Plays When Sexual Expression Becomes a Component of Residential Care Work” Alzheimer’s Care Quarterly Apr./June 2003Barnes, I. “Sexuality and Cognitive Impairment in Long Term Care” Canadian Nursing Home Oct. 2001Bonifazi, W. “Somebody to Love” Contemporary Long Term Care April 2000Cohen-Mansfield, J. Theoretical Frameworks for Behavioural Problems in Dementia. Alzheimer’s Care Quarterly, 1(4):8-21. (1990)Groulx, B. Screaming and Wailing in Dementia. Canadian Alzheimer Disease Review,7-11. (2005)Hajjar, R. & Kamel, H. “Sexuality in the Nursing Home, Part 1: Attitudes and Barriers to Sexual Expression” Journal of American Medical Directors Association Mar./Apr. 2004Lindau, S. et al “A Study of Sexuality and Health among Older Adults in the United States” New England Journal of Medicine August 2007
    66. 66. ReferencesLoue, S. “Intimacy and Institutionalized Cognitive Impaired Elderly”, Care Management Journals Winter 2005Roach, R. “Sexual Behavior of Nursing Home Residents: Staff Perceptions and Responses” Journal of Advanced Nursing 2004Robinson, J. & Molzahn, A. “Sexuality and Quality of Life” Journal Of Gerontological Nursing March 2007Teitelman, J. & Copolillo, A. “Guidelines for Recognition and Intervention” Alzheimer’s Care Quarterly Summer 2002Wallace, M. “Sexuality and Aging in Long Term Care” Annals of Long Term Care February 2003WHO Definition of Sexuality and Intimacy. Geneva: Author. (2003)
    67. 67. Reference (Modules)“Intimacy, Sexuality and Sexual Behaviour in Dementia: How to Develop Practice Guidelines and Policy for LTC Facilities” (McMaster website)Sex and Sexuality in Long Term Care: Mod. 2: Sexuality and Dementia“Staff Education Manual: Resident Sexuality in the Nursing Home” The National Alzheimer Centre of the Hebrew Home for the Aged at Riverdale
    68. 68. ReferencesVideos:Freedom of Sexual ExpressionBackseat Bingo
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