Transcript Birds Do It Bees Do It Even Nursing Home Residents Do It

Sex in the Nursing Home
Satinderpal K. Sandhu, MD
Program Director Geriatric Fellowship
Summa Care Health System
Let’s Talk About Sex-in Older Adults
 Definitions of Sex and Sexuality
 Attitudes of Older Adults and By Older Adults about
Sex
 Aging and Sex
 Barriers and Policies Regarding Sex in the Nursing
Home
Case-Iowa NH
12/25/09 nurse TG walked into a room where Ben (former college professor) a 78 y.o.
resident had just finished having intercourse with Agnes (former school teacher)
an 87 y.o. resident-not his wife.
Ben was divorced, Agnes was married. Both had dementia. When the staff tried to
separate them Agnes began cursing, yelling and trying to hit the staff.
Not first time they were found in a “sexual” situation. In Nov 09 they had been found
in bed talking , both naked from the waist down. Staff not overly surprised-the two
had gravitated to each other, with Agnes calling Ben by her husbands name and
being calmed by his presence. At this time families of both residents were
notified. Ben’s daughter was worried that he would be kicked out. The DON said
the encounter reflected a normal human need, and no plans were being made to dc
him. Agnes’ family voiced no concerns.
The Dept of Inspections and Appeals was not notified as no abuse was viewed to have
occurred on the first occassion. After this recent incident though the facility did
try and discourage Ben from being with Agnes..ie 15 minute checks.
Gruley: Bloomberg News, July 2013
Case con’t (Sex in the Midwest)
Back to Xmas 09: TG had not actually witnessed Ben and Agnes having sex.
It was reported by her by two other nurses who had seen Ben standing
behind Agnes who was naked on all fours on the bed, with Ben as one of
the nurses said “going to town.”
Agnes was examined-vaginal area appeared red, bruises on lower shins.
The DON and administrator were contacted and called the families. Agnes’
son declined having his mother being examined at a hospital saying it
seemed like “ a mutual sexual act”. The son did not tell his father. Ben’s
daughter was just told that her father had been found naked again. As no
evidence of abuse existed, the state again not notified.
The NH took steps to avoid more sexual encounters between the two, keeping
them apart and having drugs prescribed to Ben to curb his sexual urges.
No more sexual episodes were documented.
Gruley: Bloomberg News, July 2013
What does the word Sex mean
Sex:
Noun
-Male/Female: synonymous with gender
-Either the male or female gender of a species esp as
differentiated with reference to the reproductive organs
Verb
-To ascertain the sex of a species
-To arouse sexually or increase the appeal of
Idiom
-To engage in sexual intercourse
Sexuality
-Closely linked with intimacy (emotional and physical)
-Basic human need:not affected by age
-Includes:
How one feels about oneself as a person
How one feels about being male or female
How one treats his/her body
How one lives/dresses
How one relates to members of the same and opposite sex
Sexual expression : all of the above +holding hands,
kissing, masturbating, touching and sexual intercourse.
The “Ick” Factor
Society’s Views of Sex in Seniors
Ageist
 Asexual
 Parents/Grandparents ≠ People
 Excluded from studies ie HIV/AIDS
 2007 NEJM study: 3005 individual between age 57-85

38% men and 22 % reported having discussed sex with a
physician since age 50.
 Only for the Young and Beautiful
 Surprise, Disgust and Inappropriate vs Cute
 College students more disgusted by the idea of 70-75 year olds
having sex then the idea of 30-35 year olds having sex.
 NH View: Behavior Problem
Sex IQ
1)
What percentage of individuals aged 75-85 in the US
reported being sexually active? (vaginal/oral)
a) 18%
b) 23%
c) 26%
2) In the above group what percentage of individuals report
having sex once a week or more?
a) 18%
b) 23%
c) 26 %
Global study revealed that in individuals between 70-80 yrs 53% of
men and 21% of women said they engaged in sexual intercourse
during the 12 months before being interviewed –(Nicolosi et al)
Seniors Gone Wild
 Dept of Health and Human Services 2013 report
- 2011-2012 : 2.2 million beneficiaries received free STD
screening and counseling (5% of all those on Medicaresame number as those who received free screening
colonoscopies)
66,000 received free HIV tests
- 2007-2011: 65+
Chlamydia infections: 31%
Syphilis infections:
52%
Sex IQ
According to the 2010 National Survey of Sexual Health
and Behavior, among college-age Americans, condoms
are used in 35% of sexual encounters, but in 55% of
sexual encounters among those 61 and older.
T/F
40% in college kids/ 6% in those 61+
They Want It-They Do It
 Living longer and Living healthier
 Access to Viagra
 Retirement communities/Assisted living are the new
college campuses
 Baby Boomers (1946-1964) are joining the ranks
Burn the bra-Gimme the pill generation
Effects of Aging on Sexual Function
Female
Male
Loss of estrogen
↓ vaginal lubrication
vasomotor symptoms
neurologic and psycho-social changes
( ie: irritability, anorgasmaia)
Sexual Problems
Lack of interest (testosterone)
Vaginal dryness
Dyspareunia
Decrease in clitoral sensitivity
Decrease in orgasmic intensity and
frequency
Sign changes in penile structure
↓ in elastic fibers, collagen, smooth
muscle, mechanical sensitivity→ ED
Most common cause of ED are vascular
causes
Sexual Problems
Difficulty in maintaining or achieving an
erection
Lack of interest
Climaxing too quickly or not able to
climax
Performance anxiety
Where there’s a Will, there’s a Way
Aging Changes
+
Disease
OA, DM, CAD, cancer and consequences, prolapses, pain
issues, and on and on
+
Medications
+
NH = NO SEX
Barriers to Sexual Expression in LTC
 Lack of privacy
 Double rooms/doors without locks/single beds
 Lack of a willing partner
 Loss of interest
 Negative attitudes of physicians and NH staff
 Bias of institution /staff
 Feeling unattractive
 Embarrassed and lack of understanding of their
feelings
Policies
 State and Federal Laws protect the right of NH residents to
have consensual sexual relations, to ensure privacy.
 Only are required to report incidents that potentially cause
harm
 No standard policy on how to do this

No current laws how to determine if patient with dementia can
consent
 Ohio Residents’ Rights
 Privacy for spouse visits, to share room if in same LTC-unless
not medically advisable, to upon reasonable request to have
room doors closed and not opened without knocking, except
in case of emergency or not medically advisable.
 No mention of policy of sex between non-married residents
or those with dementia.
AMDA survey 2013
 Spurred on by Bryan Gruley’s articles in Bloomberg
News
 23% had a sexual behavior policy in place
 13% provided training
 4% said there is no current need for educational
resources on sexuality and intimacy in LTC.
Sexual habits, preferences and orientation not asked
about routinely on admission –not part of MDS.
Blurred Lines
Dementia
Autonomy vs Safety aka Paternalism
How to determine consent?
Different decisions require different levels of
capacity
Do you understand the risk of undergoing a lobectomy and chemo
for lung cancer? VS Do you like ice cream?
Determining Decision Making Capacity
Grisso and Appelbaum framework for decision making capacity
1) able to communicate a choice
2) understand the relevant information
3) appreciate the situation and its consequences
4) display reasoning
Lichtenberg (1997) Decision Tree (promoted by PEAK)
MMSE >14
yes-continue eval
no- pt can’t consent
Ability to avoid exploitation
yes-continue eval
no-pt can’t consent
Patient’s awareness of the relationship
yes-continue eval
no-pt can’t consent
Patient’s awareness of risk
yes-continue eval
no-pt can’t consent
I Like Ice Cream!
Positive Indicators
Verbal expressions of pleasure while participating in the activity, eyes
crinkled, smiles, laughter, relaxed facial expression and body language,
nods positively
Negative Indicators
Closed Body Language, frown on face, angry verbal outbursts, grimacing,
psychomotor agitation, eyes wide open frightened look
Decisions about sex involve emotion, can be irrational and even have
harmful consequences in cognitively intact individuals
Decisions regarding whether or not to have sex are closer to those of ice cream
than surgery (Richardson and Lazar)
Tarzia et al: J Med Ethics 2012
Sex IQ
Federal regulations mandate that nursing homes inform
families if two consenting adults are engaged in a
romantic relationship.
T/F
Hebrew Home
Person Centered Care
“My biggest problem is my residents aren’t having enough
sex.”
Dan Reingold-President &CEO
Presumption is that someone with dementia CAN consent to
sex.
1995-Adopted a 4 page policy-updated in 2013
“have the right to seek out and engage in sexual expression”
www.hebrewhome.org
Gruley: Bloomberg News, July 2013, October 2013
Sandra Day O’Connor
Glen Campbell
Back to Agnes and Ben
-2010 the Inspection and Appeals board while looking into another incident at the
NH, heard about Agnes and Ben.
-March 12, 2010-cited the NH for failure to protect Agnes-placing the NH in
“immediate jeopardy” for being disqualified for Medicare/Medicaid patients.
-March 17, 2010-Ben was discharged. Next closest NH was 2 hours away from his
family.
-March 24, 2010-Both the administrator and DON fired.
-May 2010-I and A board said that Agnes had been “sexually assaulted” and the NH
had failed to report it. Home fined $47,000. Ended up paying $14,500 without
admitting wrong doing.
-September 2010-Agnes died at another facility. Shortly before her death son told
father about Xmas 09. Husband said he forgave his wife”there was nothing she
could have done.” Of note the family at this time had a lawsuit against the facility
saying Agnes had been raped.
-December 2010-Ben dies.
-No one ever asked either resident at any time what happened, what they felt about
what occurred.
Gruley: Bloomberg News, July 2013
DON and Administrator
-DON lost her nursing license-did not even go to a hearing
regarding her license due to depression.
2013- runs a child day care out of her home
-Administrator landed job at an assisted living facility. Left though
in June, 2012 after the Iowa Board of Nursing Home
Administrators accused him of professional incompetence. In
September of 2012 he was acquitted by the Iowa nursing home
board which said “testimony that the sex was consensual was
“more persuasive.” He was cited though for not following proper
procedures in discharging the man.
2013- the administrator of a pediatric care center in Iowa.
Gruley: Bloomberg News, July 2013
Summary
 Sexual relationships are important to the elderly.
 Senior Sex is happening at home and in the nursing
home.
 Policies regarding sex in the nursing home, especially
between residents with dementia are limited and lack
consistency.
 Education is needed for : patients, families, health care
staff, ltc administrators, nursing home regulators,
judges, lawyers-for all!
Sound Track for Sex in the NH Lecture
(not yet available on i-tunes)
 Let’s Talk About Sex: Salt-n-Pepa
 Sexy Back : Justin Timberlake
 Sexual Healing: Marvin Gaye
 I’m Too Sexy: Right Said Fred
 Blurred Lines: Robin Thicke
 I Want Your Sex: George Michael
 Let’s Do It (Let’s Fall in Love): Cole Porter sung by
Alanis Morissett
Shredded Wheat and Sex
“80 is the new 18”