This document discusses sexuality and nursing homes. It begins by outlining the objectives of discussing normal changes in sexuality with aging, expressions of sexuality in nursing home residents, and assessing and treating hypersexuality. It then explores how sexuality may change with aging and dementia. Several case studies are presented involving intimate behaviors between residents and ways staff may respond. The document notes that most elderly still desire intimacy and outlines barriers like lack of privacy. Treatment options discussed include non-pharmacological approaches like environmental changes and pharmacological approaches like SSRIs to reduce sex drive.

1. Sexuality and theSexuality and the
Nursing HomeNursing Home
Thomas Magnuson, M.D.Thomas Magnuson, M.D.
Assistant ProfessorAssistant Professor
Division of Geriatric PsychiatryDivision of Geriatric Psychiatry
UNMCUNMC

2. To Get Your Nursing CEUsTo Get Your Nursing CEUs
 After this program go toAfter this program go to www.unmc.edu/nursing/mkwww.unmc.edu/nursing/mk..
 Your program ID number for the June 14Your program ID number for the June 14thth
program is 10CE027.program is 10CE027.
 Instructions are on the website.Instructions are on the website.
 **All questions about continuing education credit and payment can be**All questions about continuing education credit and payment can be
directed towards the College of Nursing at UNMC.**directed towards the College of Nursing at UNMC.**
Heidi KaschkeHeidi Kaschke
Program Associate, Continuing Nursing EducationProgram Associate, Continuing Nursing Education
402-559-7487402-559-7487
hkaschke@unmc.eduhkaschke@unmc.edu

3. ObjectivesObjectives
 Identify normal changes in sexuality as we ageIdentify normal changes in sexuality as we age
 Discuss expressions of normal sexuality inDiscuss expressions of normal sexuality in
nursing home residentsnursing home residents
 Explore assessment and treatment ofExplore assessment and treatment of
hypersexualityhypersexuality

4. Sexuality and AgingSexuality and Aging
 Human driveHuman drive
 Diminishes with agingDiminishes with aging
 Other bodily changesOther bodily changes
 Mechanically less responsiveMechanically less responsive
 OpportunityOpportunity
 Partner passes away or is illPartner passes away or is ill
 Cultural biasCultural bias
 Images of beauty, sexualityImages of beauty, sexuality

5. Sexuality and DementiaSexuality and Dementia
 Partners must adapt to changePartners must adapt to change
 Degree of intimacyDegree of intimacy
 May be less interestedMay be less interested
 PatiencePatience
 May be clumsy, poorly coordinatedMay be clumsy, poorly coordinated
 See as appropriateSee as appropriate
 Be supportive of their desire for intimacyBe supportive of their desire for intimacy
 May alter what regarded as intimacyMay alter what regarded as intimacy
 Normal sexual activity may be unrealisticNormal sexual activity may be unrealistic
 May be uncomfortable, frustratingMay be uncomfortable, frustrating
 Persons views, attitudes on sexuality may changePersons views, attitudes on sexuality may change

6. Case OneCase One
 Elderly male with mild-moderate dementiaElderly male with mild-moderate dementia
 Wife is a daily visitorWife is a daily visitor
 Always pleasant and cooperative with staffAlways pleasant and cooperative with staff
 No roommateNo roommate
 Wife asks that a “Do not disturb” sign be placed onWife asks that a “Do not disturb” sign be placed on
the door for an hourthe door for an hour
 “…“…or should I lock the door?”or should I lock the door?”
 She clearly conveys that they will be intimateShe clearly conveys that they will be intimate
 What do you do?What do you do?

7. Case TwoCase Two
 Two demented residentsTwo demented residents
 Found naked in bed togetherFound naked in bed together
 Both still marriedBoth still married
 Both assent to the behaviorBoth assent to the behavior
 How do you report this?How do you report this?
 Serious resident-resident contactSerious resident-resident contact
 Do they have the capacity to have sex?Do they have the capacity to have sex?
 One family doesn’t careOne family doesn’t care
 The other family is upsetThe other family is upset
 What are you going to do?What are you going to do?

8. Sexuality in the Nursing HomeSexuality in the Nursing Home
 Most still want to be sexually activeMost still want to be sexually active
 Over 60% of elderly residents endorsed a desire for intimacyOver 60% of elderly residents endorsed a desire for intimacy
 52% of men 60-69 report intercourse in the previous 4 weeks52% of men 60-69 report intercourse in the previous 4 weeks
 Barriers to intimacy existBarriers to intimacy exist
 Lack of privacyLack of privacy
 Staff, family attitudesStaff, family attitudes
 Informed consent issuesInformed consent issues
 Lack of a partnerLack of a partner

9. Gone With the WindGone With the Wind
 Up to now in nursing home careUp to now in nursing home care
 Only an issue when hypersexualOnly an issue when hypersexual
 Normal sexuality not on the radar screenNormal sexuality not on the radar screen
 Like sexuality doesn’t existLike sexuality doesn’t exist
 Baby boomersBaby boomers
 Expect sexuality to be part of agingExpect sexuality to be part of aging
 Why do you think Viagra came out now?Why do you think Viagra came out now?
 Will demand the industry changeWill demand the industry change
 Activity therapy takes on a whole new meaningActivity therapy takes on a whole new meaning
 It’s not bingoIt’s not bingo
 Accommodate their needsAccommodate their needs
 Long-term and short-term relationshipsLong-term and short-term relationships

10. Lack of PrivacyLack of Privacy
 Multiple person roomsMultiple person rooms
 State-of-the-artState-of-the-art
 New facilities will be more accommodatingNew facilities will be more accommodating
 Routine interruptionsRoutine interruptions
 VitalsVitals
 MedicationsMedications
 HousekeepingHousekeeping
 Wandering residentsWandering residents
 Surprise!Surprise!
 Conjugal visit roomsConjugal visit rooms
 Wave of the futureWave of the future

11. Staff ResponsesStaff Responses
 Variable reportsVariable reports
 Generally positive attitudesGenerally positive attitudes
 Some uneasy about sexual behaviorSome uneasy about sexual behavior
 Seen as cute or disgustingSeen as cute or disgusting
 Wait until you’re 65Wait until you’re 65
 Leave baggage at the doorLeave baggage at the door
 Study monitoring staff responsesStudy monitoring staff responses
 Paid no notice and gave no assistPaid no notice and gave no assist
 94 inappropriate sexual behaviors94 inappropriate sexual behaviors
 Staff responded to none of themStaff responded to none of them
 Ignored 10/17 appropriate sexual behaviorsIgnored 10/17 appropriate sexual behaviors
 Kissing, hugging, caressingKissing, hugging, caressing

12. Informed ConsentInformed Consent
 What is importantWhat is important
 What form does the behavior take?What form does the behavior take?
 Is it consistent with previous beliefs or practices?Is it consistent with previous beliefs or practices?
 ContextContext
 Delusions another is one’s spouse?Delusions another is one’s spouse?
 Who initiates the behavior?Who initiates the behavior?
 Problem…to whom?Problem…to whom?
 Family, staff?Family, staff?
 Risks…to whom?Risks…to whom?
 STDs, exercise induced asthma?STDs, exercise induced asthma?
 Capacity to say no?Capacity to say no?

13. Informed ConsentInformed Consent
 Do they understand the relationship?Do they understand the relationship?
 Aware of initiatorAware of initiator
 Not confused thinking of spouseNot confused thinking of spouse
 Comfortable with level of intimacyComfortable with level of intimacy
 Can they avoid exploitation?Can they avoid exploitation?
 Consistent with beliefs, valuesConsistent with beliefs, values
 Say noSay no
 Do they understand the risks?Do they understand the risks?
 Time limited nature of the relationshipTime limited nature of the relationship
 How will they act when it ends?How will they act when it ends?

14. Lack of a PartnerLack of a Partner
 Many are widowedMany are widowed
 Lack a significant other upon admissionLack a significant other upon admission
 A dearth of new partnersA dearth of new partners
 Especially for female residentsEspecially for female residents
 The Beach Boys were right…The Beach Boys were right…
 Family concernsFamily concerns
 Angry, embarrassedAngry, embarrassed
 Companionship not valuedCompanionship not valued
 Few activities to promote relationshipsFew activities to promote relationships
 Fearful of exploitationFearful of exploitation
 Institutional oversight presentInstitutional oversight present

15. Case ThreeCase Three
 66 year old female with dementia66 year old female with dementia
 Mildly impairedMildly impaired
 No behavioral or psychiatric problemsNo behavioral or psychiatric problems
 Found to be masturbating in her bedFound to be masturbating in her bed
 Only when roommate is out of the roomOnly when roommate is out of the room
 No significant medical complications from theNo significant medical complications from the
behaviorbehavior
 Trauma from use of inappropriate objects, e.g.Trauma from use of inappropriate objects, e.g.
 What do you do?What do you do?

16. ““but I know it when I see it.”but I know it when I see it.”
U.S. Supreme Court Justice Potter StewartU.S. Supreme Court Justice Potter Stewart
-commenting that pornography is hard-commenting that pornography is hard
to define from ato define from a legal standpointlegal standpoint

17. HypersexualityHypersexuality
 DefinitionDefinition
 ExposureExposure
 Obscene sexual languageObscene sexual language
 Inappropriate masturbationInappropriate masturbation
 Propositioning of othersPropositioning of others
 Touching breasts and genitaliaTouching breasts and genitalia

18. HypersexualityHypersexuality
 Behavioral problemsBehavioral problems
 Common in dementiaCommon in dementia
 80% of demented patients at some point80% of demented patients at some point
 Aggression, agitation, disruptive vocalizations, etc.Aggression, agitation, disruptive vocalizations, etc.
 Hypersexuality a rare problemHypersexuality a rare problem
 2-25%2-25%
 One equal, most say more in malesOne equal, most say more in males
 Nursing home 18%Nursing home 18%
 Consults 1.8%Consults 1.8%
 Physical 87.8%Physical 87.8%
 Verbal 65.7%Verbal 65.7%

19. HypersexualityHypersexuality
 Significant issueSignificant issue
 ResidentResident
 May require medicationMay require medication
 May develop aggression, agitationMay develop aggression, agitation
 May have to moveMay have to move
 StaffStaff
 Usually young femalesUsually young females
 Open communication with supervisorOpen communication with supervisor
 Educate to recognize, manageEducate to recognize, manage
 This adds to burden, turnoverThis adds to burden, turnover

20. HypersexualityHypersexuality
 Why does this occur?Why does this occur?
 DisinhibitionDisinhibition
 Brain areas that control impulsiveness are damagedBrain areas that control impulsiveness are damaged
 Proposition, touch multiple residents, staffProposition, touch multiple residents, staff
 ManiaMania
 Delusions, hallucinationsDelusions, hallucinations
 Damage to other areas leads to delusions and hallucinationsDamage to other areas leads to delusions and hallucinations
 Mistakes staff for his wifeMistakes staff for his wife
 MedicationsMedications
 Parkinson’s agentsParkinson’s agents
 Also used in restless leg syndromeAlso used in restless leg syndrome
 TestosteroneTestosterone
 Given sometimes for weakness, depressionGiven sometimes for weakness, depression
 TumorTumor
 Great increase in sex driveGreat increase in sex drive

21. HypersexualityHypersexuality
 Make sure you see what you seeMake sure you see what you see
 Not all sexual acts are hypersexualNot all sexual acts are hypersexual
 With masturbation it is the context of masturbationWith masturbation it is the context of masturbation
 Standing with their pants downStanding with their pants down
 May not remember how to get them off for bedMay not remember how to get them off for bed
 Frustrated aphasic patients can swear appropriatelyFrustrated aphasic patients can swear appropriately
 Sexual terms blurt out, but not focusedSexual terms blurt out, but not focused
 Touching your bottomTouching your bottom
 Wants your attention as you walk by his wheelchairWants your attention as you walk by his wheelchair

22. ReportingReporting
 Context varies reportingContext varies reporting
 What if a female pats your bottom?What if a female pats your bottom?
 What if the couple is married?What if the couple is married?
 Staff member’s attitudes and beliefsStaff member’s attitudes and beliefs
 What is deemed normal varies greatlyWhat is deemed normal varies greatly
 This is a medical, not moral issueThis is a medical, not moral issue
 Extent of behaviorExtent of behavior
 Holding hands to intercourseHolding hands to intercourse
 Where is the line drawn?Where is the line drawn?

23. Case FourCase Four
 76 year old male with severe dementia76 year old male with severe dementia
 Grabs caregivers breasts and genitaliaGrabs caregivers breasts and genitalia
 Seen touching residents as wellSeen touching residents as well
 Assessment for medical causes unremarkableAssessment for medical causes unremarkable
 No quick fixNo quick fix
 Family embarrassedFamily embarrassed
 Other residents’ families are angryOther residents’ families are angry
 What do you do?What do you do?

24. TreatmentTreatment
 What not to doWhat not to do
 Ignore the behaviorIgnore the behavior
 Really…it won’t go awayReally…it won’t go away
 Get upsetGet upset
 Your emotional response to the behavior has a great dealYour emotional response to the behavior has a great deal
to do with making it better or worseto do with making it better or worse
 Tell them it is “inappropriate”Tell them it is “inappropriate”
 If they knew that…If they knew that…
 Send mixed messagesSend mixed messages
 Kisses, hugs, holding handsKisses, hugs, holding hands

25. TreatmentTreatment
 NonpharmacologicNonpharmacologic
 We must change our behavior to the residentWe must change our behavior to the resident
 They cannot learnThey cannot learn
 Return to room, close the doorReturn to room, close the door
 Appropriate except for placeAppropriate except for place
 Separate resident from the targetSeparate resident from the target
 Move to another unit, hallwayMove to another unit, hallway
 Use same sex staff membersUse same sex staff members
 Especially bathing, dressing, toiletingEspecially bathing, dressing, toileting
 PreventionPrevention
 ActivitiesActivities
 Clear identification as a medical professionalClear identification as a medical professional

26. TreatmentTreatment
 PharmacologicPharmacologic
 Usually start with an SSRI antidepressantUsually start with an SSRI antidepressant
 A side effectA side effect
 Reduces sex driveReduces sex drive
 Mechanical problemsMechanical problems
 Prozac (fluoxetine)Prozac (fluoxetine)
 Zoloft (sertraline)Zoloft (sertraline)
 Paxil (paroxetine)Paxil (paroxetine)
 Luvox (fluvoxamine)Luvox (fluvoxamine)
 Celexa (citalopram)Celexa (citalopram)
 Lexapro (escitalopram)Lexapro (escitalopram)

27. TreatmentTreatment
 SSRI antidepressantsSSRI antidepressants
 What to watch forWhat to watch for
 Nausea and/or diarrheaNausea and/or diarrhea
 JitteryJittery
 Insomnia/sedationInsomnia/sedation
 HeadacheHeadache
 Low sodiumLow sodium
 Rare GI bleedRare GI bleed

28. TreatmentTreatment
 PharmacolgicPharmacolgic
 Hormone treatmentHormone treatment
 Cyproterone and depo-proveraCyproterone and depo-provera
 Testosterone and LH levelsTestosterone and LH levels
 Oral and IMOral and IM
 EstrogenEstrogen
 Daily dosingDaily dosing
 Oral, patchOral, patch
 LeuprolideLeuprolide
 IM monthlyIM monthly

29. TreatmentTreatment
 Hormone treatmentHormone treatment
 What to watch forWhat to watch for
 Thromboembolism and strokeThromboembolism and stroke
 DepressionDepression
 Bone density lossBone density loss
 Weight gainWeight gain
 Hot flashes and gynecomastiaHot flashes and gynecomastia
 FatigueFatigue

30. TreatmentTreatment
 OthersOthers
 Exelon (rivastigmine)Exelon (rivastigmine)
 Tagamet (cimetidine)Tagamet (cimetidine)
 Neurontin (gabapentin)Neurontin (gabapentin)
 ClomipramineClomipramine

31. CasesCases
 Case OneCase One
 Normal behaviorNormal behavior
 Assure privacy, dignityAssure privacy, dignity
 Case TwoCase Two
 Assess competencyAssess competency
 Be aware of family concernsBe aware of family concerns
 Risks and benefits include mood, QOL issuesRisks and benefits include mood, QOL issues

32. CasesCases
 Case ThreeCase Three
 CLOSE THE DOOR!CLOSE THE DOOR!
 Case FourCase Four
 Begin nonpharmacologic interventionsBegin nonpharmacologic interventions
 Provide as much information as possible to PCPProvide as much information as possible to PCP
 Make sure all staff is trained in assessment andMake sure all staff is trained in assessment and
interventionsinterventions
 Communicate with familiesCommunicate with families
 Need for education, reassuranceNeed for education, reassurance

33. ObjectivesObjectives
 Identify normal changes in sexuality as we ageIdentify normal changes in sexuality as we age
 Discuss normal expressions of sexuality inDiscuss normal expressions of sexuality in
nursing home residentsnursing home residents
 Explore assessment and treatment ofExplore assessment and treatment of
hypersexualityhypersexuality

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