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SEXUALITY ISSUES IN AGING
Nursing Standard of Practice Protocol: Sexuality in Older Adults

Jacqueline M. Arena, BS, BSN, RN, Meredith Wallace, PhD, APRN

Evidence-Based Content - Updated March 2008


The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:

 

Goal 

To enhance the sexual health of older adults.  

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Overview

Although it is generally believed that sexual desires decrease with age, several researchers have identified that sexual desires, thoughts, and actions continue throughout all decades of life. Human touch and healthy sex lives evoke sentiments of joy, romance, affection, passion, and intimacy, whereas despondency and depression often result from an inability to express one’s sexuality. Health care providers play an important role in assessing and managing normal and pathological aging changes in order to improve the sexual health of older adults. 

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Background and Statement of Problem

A. Definitions

1. Sexuality: a central aspect of being human throughout life and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy, and reproduction. 1

2. Sexual health: a state of physical, emotional, mental, and social well-being related to sexuality. 1

3. Sexual dysfunction: impairment in normal sexual functioning. 2

B. Etiology and/or Epidemiology

1. Despite the continuing sexual needs of older adults, many barriers prevent sexual health among older adults. 3

2. Health care providers often lack knowledge and comfort in discussing sexual issues with older adults. 4

3. The older population is more susceptible to many disabling medical conditions; a number of medical conditions are associated with poor sexual health and functioning. 4 including cardiac disease;5 stroke and aphasia;6 Parkinson's disease; 7 diabetes; 8 BPH; 9 and dental problems 10 that make sexuality difficult.

4. Medications among older adults, especially those commonly used to treat medical illnesses, also impact sexuality, such as antidepressants 11 and antihypertensives. 12

5. Normal aging changes, such as a higher frequency of vaginal dryness in women and erectile dysfunction in men, make sexual health difficult to achieve. 20, 21

6. Environmental barriers also present barriers to sexual health among older adults. 13 

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Assessment

A. The PLISSIT model 14 begins by first seeking permission (P) to discuss sexuality with an older adult. The next step of the model affords an opportunity for the health care provider to share limited information (LI) with the older adult. The PLISSIT model 14 begins by firs seeking permission (P) to discuss sexuality with an older adult. The next step of the model affords an opportunity for the health care provider to share limited information (LI) with the older adult. The next step guides the health care provider to provide specific suggestions (SS) to improve sexual health. The final part calls for intensive therapy (IT) when needed for clients whose sexual dysfunction goes beyond the scope of nursing management.

B. Ask open-ended questions such as "Can you tell me how you express your sexuality", "What concerns you about your sexuality?" and "How has your sexuality changed as you have aged?"

C. Assess for presence of physiological changes through a health history, review of systems, and physical examination for the presence of normal and aging changes that impact sexual health.

D. Review medications among older adults, especially those commonly used to treat medical illnesses that also impact sexuality, such as antidepressants 11 and antihypertensives. 12

E. Assess medical conditions that have been associated with poor sexual health and functioning 15 including cardiac disease, 5 stroke and aphasia;6 Parkinson's disease; 7 diabetes; 8 BPH; 9 and dental problems. 10 

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Nursing Care Strategies

A. Communication and Education

1. Discuss normal age-related physiological changes.

2. Address how the effects of medications/medical conditions may affect one’s sexual function.

3. Facilitate communication with older adults and their families regarding sexual health as desired, including:

a. Encourage family meetings with open discussion of issues if desired.

b. Teach about safe sex practices.

c. Discuss use of condoms to prevent transmission of STDs and HIV.

B. Health Management

1. Perform a thorough patient assessment.

2. Conduct a health history, review of systems, and physical examination.

3. Effectively manage chronic illness.

4. Improve glucose monitoring and control among diabetics.

5. Ensure appropriate treatment of depression and screening for depression. (See Depression topic).

6. Discontinue/substitute medications that may result in sexual dysfunction (e.g., hypertension or depression medications).

7. Accurately assess and document older adults' ability to make informed decisions. (See Treatment Decision Making topic).

8. Participation in sexual relationships may be considered abusive if an older adult is not capable of making decisions.

C. Sexual Enhancement

1. Compensate for normal changes of aging

a. Females:

i. Use of artificial water-based lubricants

ii. Treatment of FSAD with sildenafil citrate (Viagra). 16

iii. Use of centrally acting serotonin agonists and vasodilating creams. 17

b. Males:

i. Recognizing the possibility for more time and direct stimulation for arousal due to aging changes

ii. Use of sildenafil citrate (Viagra) for erectile dysfunction. 18

2. Environmental Adaptations

a. Ensure privacy and safety among long-term-care and community-dwelling residents. 19 

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Expected Outcomes

A. Patients will:

1. Report high quality of life as measured by a standardized quality of life assessment.

2. Be provided with privacy, dignity, and respect surrounding their sexuality.

3. Receive communication and education regarding sexual health as desired.

4. Be able to pursue sexual health free of pathological and problematic sexual behaviors.

B. Health care providers will:

1. Include sexual health questions in their routine history and physical.

2. Frequently reassess patients for changes in sexual health.

C. Institutions will:

1. Include sexual health questions on intake and reassessment measures.

2. Provide education on the ongoing sexual needs of older adults and appropriate interventions to manage these needs with dignity and respect.

3. Provide needed privacy for individuals to maintain intimacy and sexual health (e.g., in long-term care). 

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Follow-up Monitoring of Condition

Sexual outcomes are difficult to directly assess and measure. However, with the illustrated link between sexual health and quality of life, quality of life measures such as the SF-36 Health Survey may be used to determine the effectiveness of interventions to promote sexual health. Retrieved March 7, 2007, at http://www.rand.org/health/surveys/sf36item/question.html

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For Definition of Levels of Quantitative Evidence Click Here

Reprinted with permission from Springer Publishing Company. Fletcher, K. 2008. Sexuality in older adults. In E. Capezuti, D. Zwicker, M. Mezey, & T. Fulmer (Eds.) Evidence-Based Geriatric Nursing Protocols for Best Practice (3rd ed), New York: Springer Publishing Company, Inc. ed.).

 

References

1. World Health Organization (2004). Sexual Health: A New Focus for WHO. Progress in Reproductive Health Research. Retrieved May 10, 2005. Evidence Level VI: Respected Opinion.

2. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Evidence Level VI: Respected Opinion.

3. Zeiss, A. M., & Kasl-Godley, J. (2001). Sexuality in older adults' relationships. Generations, 25, (2), 18-25. Evidence Level V: Review.

4. Gott, M., Hinchliff, S., & Galena, E. (2004). General practitioner attitudes to discussing sexual health issues with older people. Social Science & Medicine, 58(11), 2093–2103. Evidence Level IV: Nonexperimental Study.

5. Addis, I. B., Ireland, C. C., Vittinghoff, E., Lin, F., Stuenkel, C. A., & Hulley, S. (2005). Sexual activity and function in postmenopausal women with heart disease. Obstetrics and Gynecology, 106, 121–127. Evidence Level II: Single Experimental Study.

6. Lemieux, L., Cohen-Schneider, R., & Holzapfel, S. (2001). Aphasia and sexuality. Sexuality and Disability, 19(4), 253–266. Evidence Level IV: Nonexperimental Study.

7. Mott, S., Kenrick, M., Dixon, M., & Bird, G. (2005). Sexual limitations in people living with Parkinson’s disease. Australian Journal on Ageing, 24(4), 196–202. Evidence Level IV: Nonexperimental Study.

8. Rockliffe-Fidler, C., & Kiemle, G. (2003). Sexual function in diabetic women: A psychological perspective. Sexual and Relationship Therapy, 18(2), 143–159. Evidence Level IV: Nonexperimental Study.

9. Rosen, R. C. (2006). Assessment of sexual dysfunction in patients with benign prostatic hyperplasia. BJU International, 97(Suppl. 2), 29–33; discussion 44–45. Evidence Level V: Review.

10. Heydecke, G., Thomason, J. M., Lund, J. P., & Feine, J. S. (2005). The impact of conventional and implant supported prostheses on social and sexual activities in edentulous adults results from a randomized trial 2 months after treatment. Journal of Dentistry, 33(8), 649–657.

11. Montejo, A. L., Llorca, G., Izquierdo, J. A., & Rico-Villademoros, F. (2001). Incidence of sexual dysfunction associated with antidepressant agents: A prospective multicenter study of 1,022 outpatients. Spanish working group for the study of psychotropic-related sexual dysfunction. The Journal of Clinical Psychiatry, 62 (Suppl. 3), 10–21. Evidence Level IV: Nonexperimental Study.

12. Girerd, X., Mounier-Vehier, C., Fauvel, J. P., Marquand, A., Babici, D., & Hanon, O. (2003). Medical management of libido disturbances in treated hypertensive patients: Differences between men and women. Arch Mal Coeur Vaiss, 96(7–8), 758–762. Evidence Level IV: Nonexperimental Study.

13. Hajjar, R. R.,&Kamel, H. K. (2004). Sexuality in the nursing home, part 1: Attitudes and barriers to sexual expression. Journal of the American Medical Directors Association, 5(2 Suppl.), S42–S47. Evidence Level V: Review.

14. Annon, J. (1976). The PLISSIT model: A proposed conceptual scheme for behavioral treatment of sexual problems. Journal of Sex Education Therapy, 2(2), 1–15. Evidence Level VI: Respected Opinion.

15. Morley, J. E., & Tariq, S. H. (2003). Sexuality and disease. Clinics in Geriatric Medicine, 19(3), 563–573. Evidence Level V: Review.

16. Berman, J. R., Berman, L. A., Toler, S. M., Gill, J., Haughie, S., & Sildenafil Study Group. (2003). Safety and efficacy of sildenafil citrate for the treatment of female sexual arousal disorder: A double-blind, placebo-controlled study. The Journal of Urology, 170(6 Pt 1), 2333–2338. Evidence Level II: Single Experimental Study.

17. Walsh, K. E., & Berman, J. R. (2004). Sexual dysfunction in the older woman: An overview of the current understanding and management. Drugs & Aging, 21(10), 655–675. Evidence Level V: Review.

18. Fink, H. A., MacDonald, R., Rutks, I. R., Nelson, D. B., & Wilt, T. J. (2002). Sildenafil for male erectile dysfunction: A systematic review and meta-analysis. Archives of Internal Medicine, 162(12), 1349–1360. Evidence Level I: Systematic Review.

19. Wallace, M. (2003). Sexuality in long-term care. Annals of Long Term Care, 11(2), 53–59. Evidence Level V: Review.

20. Araujo, A. B., Mohr, B. A., & McKinlay, J. B. (2004). Changes in sexual function in middle-aged and older men: Longitudinal data from the Massachusetts male aging study. Journal of the American Geriatrics Society, 52(9), 1502–1509. Evidence Level IV: Nonexperimental Study.

21. Harvard Medical School (2003). Sexuality in midlife and beyond: A special report from Harvard Medical School. Boston: Harvard Health Publications. Evidence Level VI: Respected Opinion.

 

Last updated - March 2008

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