Care of the Elderly - The Need of the Hour.ppt

Caring for the Elderly needs to be taken on Priority. It can not be put on the back burner

1. Care of the Elderly:
Need of the Hour

2. SHHHHHH, we’re talking about
sex!

3. Sexuality in Elder
Care
Objectives:
•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. 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. Thoughts on
Sexuality
“Aging … is a metaphor for
asexuality”
H. Davies, et al

6. Thoughts on
Sexuality
What do the words “sex” and
“sexuality” mean to you?
What are some common attitudes
and beliefs held by staff?
Common staff reactions?

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. 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. Staff attitudes
What influences our attitudes and
beliefs on sex and sexuality?
•cultural values
•personal beliefs
•lack of understanding
•inadequate training

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. STATISTICS
Of 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. STATISTICS
A 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. STATISTICS
Another 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. STATISTICS
Among the most seriously
cognitively impaired elderly, 7%
are reported to exhibit sexually
disinhibited behaviour.

15. Sexuality &
Intimacy

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. SEXUALITY
Sexuality 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. 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. Intimacy
The need and ability to experience
emotional closeness with another
human being and to have that
emotional closeness predictably
reciprocated (Denis Dalley).

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. Sexually Dysinhibited
Behaviour
Incidence 4% -7%
Occurrence: both males and females
Both long term care and acute care
Particularly high with those with a
dementing illness

22. Changes secondary
to Dementia
Of Note:
Existing relationships adapt
New relationships form
Desires fluctuate

23. Dementia: Sexuality
& Intimacy
Changed sexual
behaviours
•Uncharacteristic?
Illness related
•Sexual desire –
what, when, where
Loss of inhibitions
•Advances towards
others
Diminishing sexual
interest
•Withdrawn, non-initiate
Increased sexual
demands
•Unreasonable,
exhausting
•“Objectified”

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. Causes of SDB
•Underlying Medical Problems
Labial Cancer Vaginitis
Prolapsed uterus UTI
Colorectal cancer Scabies

26. Causes of SDB
•Aggressive
response to
stressor of
institutionalization
•Threat, fear, loss
•Structure
•Tasks exceed ability
etc

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. Causes of SDB
•Need for
Intimacy
Desperation
for human
contact

29. Causes of SDB
•Panic associated
with death
–helps mask

30. Causes of SDB
impulse control
Age-related
Changes

31. Medication Adverse
Effects
A/D (tricyclics -desire, SSRIs -delayed ejaculation,
Trazodone –desire
Antihypertensives (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. SDB: Theoretical
Framework
Current condition
Physical
Mental
Habits,
Personality
Environment
Physical
Psychosocial
SDB
Due to Frustration
Negative Effects
SDB
Communicates
needs
SDB
Satisfies the need
Cohen-Mansfield, 1990

33. General Suggestions for
Basic Intervention

34. Disturbance in Memory and
Judgment
Reorient to person and place as possible
Use short simple instructions to direct to
room or redirect behaviour
Label rooms to help locate privacy
If SDB persists, use alternative clothing
•Pull-over shirt
•Elasticized pants
•Back-closing shirts etc.

35. Unmet Need for
Affection
Assign same caregiver consistently
Spend time with Resident/Pt.
Provide tactile stimulation e.g. touch, toys,
texture
Encourage verbalization re: sex and
sexual frustration
Reward for appropriate requests for
attention e.g. smile, hug, spend time

36. Death Anxiety
Spend time with Resident/Pt.
Encourage to verbalize feelings
about illness, end of life
Engage in life-review or reminisce
therapy as appropriate
Reinforce that he is not alone

37. Age-related changes
with
impulse control
Provide with limits for behaviour, outlining
acceptable and unacceptable behaviour in
the present environment
Reassure of acceptance
Problem solve to determine ways to manage
(situation triggers, alter situation)
Reward for appropriate requests for attention
e.g.. Smile, hug, spend time

38. Misinterpreting
Environmental Cues
Clothing removal
Self exposure
Masturbation
Inappropriate touch
Requests for kisses
Attempts to fondle
Clothing -hot, itchy, tight
Need to use bathroom
Boredom, frustration
Mistaken identity
Expressed need to touch
Misinterpret others
Behaviour Possible Explanation

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. Defining Capacity to
Consent to Sexual Relations
Ability 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. Defining Capacity to
Consent to Sexual Relations
Awareness 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. Our Approach

43. Our Approach to
Sexual Behaviours in
LTC
A 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. Steps in a problem
solving approach
1. Define the problem
•is there a problem?
•whose problem is it?
•who is it affecting?
•the resident? the family? other
residents? staff?

45. Steps in a problem
solving approach
2. Assess the person
•what is behind the behaviour?

46. Steps in a problem
solving approach
3. 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. Steps in a problem
solving approach
4. Evaluate and monitor

48. Challenges
Masturbation
•video clip
•applying the problem solving
approach

49. Challenges
Consenting Adults
•video clip
•applying the problem solving
approach

50. Policy Development
Having 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. Policy Development
•a statement of purpose
•definitions of sexuality and intimacy
•a definition of sexual expression
•a definition of capacity

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. Policy Development
•resident rights you may want to
consider include:
•the right to seek out and
engage in sexual expression

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. 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. 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. Ethical
Considerations
Some 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. 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. 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. Organizational Support of Sexual
Expression in LTC Facility
Area
Policy
Education
Access
Privacy
Environment
Interventions
Development of policies incorporating the sexual needs of
residents into care plans
Staff education tailored to the defined level of staff
Access to beauty salon, manicurist, cosmetics
Offering married couples own room
Do not disturb sign
Requiring knocking prior to entering room
Facilitation of conjugal/home visits to spouse
Provision for locked doors
Availability of a double bed

61. Responsibilities of Nursing Home
Staff Regarding Sexual Expression
Issues
Environment
Privacy Needs
Materials
Risk
Responsibilities
Maintain awareness, support sexual expression
Assist in maintaining privacy for sexual activity
Permit access to sexually explicit materials (magazines,
videos, etc)
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
(Messinger-Rapport et al, 2003)

62. KEY POINTS
People with dementia have lived with their sexuality for much longer than
they have lived with Dementia.
Not everyone with Dementia is heterosexual
Not everyone chooses to exercise his right to be a sexual being
Couples who work on their relationships can keep them stronger for longer
Maintaining a healthy sex life can improve overall quality of life for caregivers
and those with Dementia
Caregivers need to consider their own needs along side those who have
Dementia
The risk of sexual infections does not diminish with age
Sexual abuse of a person with Dementia can constitute a criminal offence

63. VideoClip
Backseat Bingo
6 min

64. Questions/
Comments

65. References
Archibald, C. “Sexuality and Dementia: The Role Dementia Plays When Sexual
Expression Becomes a Component of Residential Care Work” Alzheimer’s Care
Quarterly Apr./June 2003
Barnes, I. “Sexuality and Cognitive Impairment in Long Term Care” Canadian Nursing
Home Oct. 2001
Bonifazi, W. “Somebody to Love” Contemporary Long Term Care April 2000
Cohen-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.
2004
Lindau, S. et al “A Study of Sexuality and Health among Older Adults in the United
States” New England Journal of Medicine August 2007

66. References
Loue, S. “Intimacy and Institutionalized Cognitive Impaired Elderly”, Care
Management Journals Winter 2005
Roach, R. “Sexual Behavior of Nursing Home Residents: Staff Perceptions and
Responses” Journal of Advanced Nursing 2004
Robinson, J. & Molzahn, A. “Sexuality and Quality of Life” Journal Of
Gerontological Nursing March 2007
Teitelman, J. & Copolillo, A. “Guidelines for Recognition and Intervention”
Alzheimer’s Care Quarterly Summer 2002
Wallace, M. “Sexuality and Aging in Long Term Care” Annals of Long Term Care
February 2003
WHO Definition of Sexuality and Intimacy. Geneva: Author. (2003)

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. References
Videos:
Freedom of Sexual Expression
Backseat Bingo