Chapter 16: Sexuality and Aging

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Welcome to the Deep Dive.

Today, we're cracking open Chapter 16 from Basic Geriatric Nursing,

the topic,

sexuality and aging.

This is a subject that society often sweeps under the rug or maybe treats with a bit of awkward surprise.

Yeah, absolutely.

There's this persistent myth that older adults are somehow asexual.

Exactly.

And we're here to challenge that directly using the insights from this chapter.

Well, it's crucial because, as the chapter lays out right from the start, sexuality is a basic human need.

It's fundamental, like needing food or water.

It doesn't disappear.

Not at all.

And it's broader than just the biological act.

The chapter stresses the psychological, social, even moral dimensions.

It's about affection, connection, emotional bonding that continues throughout life.

Okay, so let's bring in some data here because this isn't just a feeling.

The studies mentioned show what, 46 % of adults over 60 are sexually active?

That's the figure, yes.

And importantly, most view sex as important in a relationship, regardless of their age.

So our core term here is sexuality, in that broader sense.

Our goal today is really to walk you through the chapter's key ideas, the physical changes, the external factors that get in the way, and, critically for our audience, the nursing responsibilities.

Right.

If the need is still there, we have to understand how the body changes.

That's the first step.

Okay.

Let's get into those age -related physiological changes.

The chapter notes that, yes, sexual response time generally slows down.

It does.

But, and it seems key, the ability to enjoy sexuality in its various forms.

That remains.

Precisely.

The capacity for enjoyment is still there.

And when someone's usual pattern of sexual function is impaired persistently, that's what the book defines as altered sexual function, right?

Yep, exactly.

That's the clinical term we're looking at.

So maybe start with the changes typically seen in men.

Sure.

These are considered normal aging changes.

Things like a delayed reaction to stimuli, it just takes longer to achieve an erection.

And the erection itself might be different.

Yes.

Often less firm than in younger years.

Orgasm also takes longer to reach.

It might be shorter in duration.

And the ejaculation less forceful with less seminal fluid.

And then there's the refractory period, the time needed between orgasms, that definitely gets longer.

But beyond those normal changes, the most common issue needing clinical attention is probably erectile dysfunction, ED.

Ah, yes, ED.

It's defined pretty specifically, the inability to get or keep an erection firm enough for a satisfactory intercourse in more than half of attempts.

More than half, okay.

And what's really interesting and clinically important is that age itself isn't the only driver or even the main one sometimes.

What else is involved?

Often it's underlying health conditions.

Things like diabetes, depression, cardiovascular disease, these are major factors.

Assessment needs to look there first.

What about surgery?

Is the fear around prostatectomy and ED always justified?

Well, less so now.

The chapter points out that newer surgical techniques are much better at preserving the nerves involved.

So prostatectomy doesn't automatically mean ED anymore.

That's good news.

And if ED does occur from surgery or other causes, there are effective treatments.

Medications like sildenafil citrate Viagra or Tadalafil Cialis work well for many.

Okay, let's shift to women.

The changes there are mostly linked to hormonal shifts after menopause, right?

Lower estrogen and progesterone.

Primarily, yes.

And this often leads to something called dyspareunia.

Right, dyspareunia.

That's discomfort or pain during intercourse.

Exactly.

And the chapter estimates about a third of women over 65 experience it to some degree.

So what causes that discomfort specifically?

It can be irritation of the external genitals.

The term is pruridis vulvae.

But often it's due to changes inside.

The vaginal walls becoming thinner, drier, less elastic.

That's echotrophic vaginitis.

And those tissue changes can also mess with the natural balance of microorganisms, making vaginal yeast infections more likely.

Are there straightforward ways to manage this?

Thankfully, yes.

Often simple over -the -counter vaginal moisturizers or water -based lubricants are enough.

Big caution here, though.

Avoid petroleum -based products like Vaseline.

They can actually damage tissues.

Good tip.

What if OTC isn't enough?

Then you might look at very low -dose estrogen preparations.

These come as creams or vaginal rings, and they target the local symptoms with minimal estrogen getting into the bloodstream.

And there are other medications, too.

ERAAs?

Yes.

Estrogen receptor agonist antagonists like Tamoxifen and Riloxafen, they're sometimes called designer estrogens, they have specific effects.

But this brings us to a really critical point about hormone therapy in general, menopausal hormone therapy, or MHT.

Absolutely critical.

Now, MHT used to be prescribed much more widely, but major studies found significant risks, increased chances of heart attack, stroke, certain cancers, even dementia.

So it's used much more cautiously now.

Much more cautiously.

If it is prescribed, usually for severe symptoms in short term, the patient needs very close monitoring.

The risks and benefits have to be weighed very carefully.

That's a really important clinical warning.

Okay, so we've covered the body's internal changes.

But often, the bigger issues are external, right?

Illnesses, medications, things that interfere with sexual health.

Definitely.

Sometimes it's the condition, not the age itself that's the main barrier.

Like what?

Well, think about arthritis.

Joint pain obviously makes positioning difficult.

Or after a stroke, there might be weakness or paralysis that requires education on positioning or using assistive devices.

What about heart problems?

People worry a lot about that.

They do.

And the main issue there is often fear rather than actual high risk.

The physical strain of intercourse isn't usually excessive for most stable heart patients.

So the fear is disproportionate.

Generally, yes, but it's understandable.

It absolutely needs a direct conversation between the patient and their healthcare provider to clarify the real risk level for them.

That lack of conversation seems like a recurring theme.

It really is.

And think about surgeries like hysterectomy or mastectomy.

Yeah.

Physically, they don't necessarily prevent sexual function.

But psychologically, they can hugely impact a woman's feelings of desirability.

That requires counseling,

maybe lubrication support.

And depression.

Chronic depression is a massive factor.

It just dampens interest and responsiveness significantly.

Then there's incontinence.

Right.

Not a physical barrier to the act itself usually, but the embarrassment factor is huge.

People avoid intimacy because they're worried about leakage or odor.

So managing the incontinence is key.

Okay, let's talk about medications.

The chapter mentions a whole table, table 16 .1.

We can't list every drug, but what are the main categories nurses should be aware of?

This is super practical for assessment.

If someone reports changes in sexual function, you immediately think about two big groups.

First, drugs affecting blood flow and pressure.

Like antihypertensives.

Exactly.

Diuretics, beta blockers, ACE inhibitors, they're common culprits.

Second group, drugs acting on the central nervous system.

So antidepressants, opioids.

Right.

SSRIs, tricyclic antidepressants, opioids, even some miscellaneous drugs like methotrexate, cholesterol meds.

And don't forget, common OTCs like antihistamines can cause issues too.

It's quite a list.

It is.

And alcohol too.

Excessive intake can delay orgasm in women and cause ED in men.

There was an interesting point about Parkinson's medications though.

Ah, yeah.

A bit of a paradox.

Some anti -Parkinsonian drugs can actually increase sexual desire.

Oh.

But, and this is the important part, they don't necessarily improve performance.

So it can lead to increased desire, but also increased frustration.

That's important to know when assessing.

Wow.

Okay, so we have physical changes, illnesses, medications.

But sadly, the chapter points out the most common reason for decreased sexual activity isn't any of those.

No.

It's the loss of a partner.

That really stands out.

The partner gap statistic is quite stark.

It is.

Only 32 % of women over 70 have partners, compared to 59 % of men in that age group.

That loss often shifts the focus for older adults, especially women.

That's right.

While older men might still express a clear interest in the sexual act itself, older women often emphasize the need for companionship, intimacy, emotional connection more.

It becomes less about just sex and more about connection.

That makes sense.

Let's shift gears a bit to psychosocial aspects.

What about new relationships later in life?

Remarriage.

That can be complicated.

Families sometimes react strongly.

Adult children might worry about, say, dishonoring a deceased parent's memory or, more practically, about inheritance issues.

But the guiding principle?

The older adult's autonomy.

They have the right to decide what's best for them, who they want to be with.

Our role is to support that right.

And sometimes remarriage isn't the best option financially.

Exactly.

Especially for widows, remarriage can mean losing essential pensions or insurance benefits.

That's a major reason why cohabitation without marriage is pretty common among older adults.

So health professionals need to recognize these relationships as valid.

Absolutely.

Regardless of personal or cultural beliefs, we need to support the choices older adults make for their own well -being and financial security.

Now what about the specific needs of LGBTQ plus older adults?

The chapter highlights this group is growing.

Expected to double by 2030, yes.

And they often face what's called a double stigma.

Ageism plus discrimination based on sexual orientation or gender identity.

How does that play out in healthcare?

The system is often very heteronormative, meaning it assumes everyone is heterosexual.

This can make LGBTQ plus individuals feel invisible or underserved.

Many hesitate to disclose their orientation.

Why the hesitation?

Fear mainly.

Fear of receiving substandard care, fear of judgment, fear that their confidentiality won't be respected.

And not disclosing can have serious legal implications, especially for partners.

Huge implications.

In places without legal protections for same -sex couples, if there's no advanced directive or power of attorney naming a partner.

They might have no say in healthcare decisions or even be denied visitation.

Exactly.

So part of our role might be educating about the importance of these legal documents to protect their relationships and rights.

Okay.

Turning now to a really critical public health issue the chapter addresses.

Sexually transmitted infections, STIs, and older adults.

This often gets overlooked.

Massively overlooked.

And the stats are genuinely shocking.

Dulles.

Between 2015 and 2020, rates for chlamydia, gonorrhea, and syphilis actually doubled among people over 55.

Doubled.

Wow.

What about HIV AIDS?

Also a major concern.

Over half of all people living with HIV in the U .S.

are now age 50 or older.

Why is that?

Two main reasons.

One, people diagnosed years ago are living longer thanks to better treatments.

Two, the aging immune system is actually more susceptible to acquiring HIV infection.

And diagnosing AIDS in older adults is tricky.

The great imitator.

Yes, precisely.

Symptoms like fatigue, weight loss, cognitive changes can easily be mistaken for normal aging or dementia or other chronic conditions.

This leads to delayed diagnosis and treatment.

So why this rise in STIs overall in this age group?

Are they just more active?

Partly, yes.

They're generally healthier and living longer than previous generations.

But a huge factor is that many came of age before safer sex education was widespread.

They may not perceive themselves as being at risk or no current prevention methods.

So targeted education is essential.

Absolutely crucial.

We can't assume knowledge about condom use or risk factors.

This connects to the idea of rights and privacy, especially in care facilities.

Right.

In the community, older adults manage their own sex lives.

But in long -term care, finding privacy for intimacy is a real challenge, even for married couples.

But things are changing.

Facilities are becoming more accommodating.

There's definitely a shift.

More places now encourage appropriate physical affection, hand -holding, cuddling.

And there's a greater emphasis on respecting privacy, like knocking and waiting before entering a room, respecting a closed door.

But there's a crucial balance, right?

Protecting vulnerable residents.

Always.

Especially when cognitive impairment is involved.

Ensuring mutual consent is paramount.

If one person seems hesitant, uncomfortable, or resists an advance, even from a spouse.

And he has to stop.

Immediately.

That's non -negotiable.

Protecting vulnerable adults from unwanted sexual contact is a primary ethical duty.

OK.

This brings us squarely into the nursing role.

Let's walk through the nursing process, or clinical judgment model, as the book frames it, starting with assessment -recognizing cues.

The key here is a non -judgmental, private approach.

You need to ask directly, but sensitively, what cues are we looking for?

Things like,

are they currently sexually active?

Are they having any difficulties, pain, discomfort, any unusual discharge?

What else?

Do they have diseases or disabilities that interfere?

Are there emotional issues, like depression?

What medications are they taking?

Crucially,

what is their desired level of activity versus their current level?

What do they see as barriers?

And do they feel they have enough privacy?

And the book flags specific risk factors in box 16 .1.

Yes.

It summarizes them neatly.

Loss of partner is a big one.

Mobility problems.

Living in an institution.

And then chronic illness or medication side effects.

Those are key things to look out for.

Got it.

So based on that assessment, we move to planning, setting goals.

What are typical goals?

Generally, we want the patient to feel comfortable enough to verbalize their feelings and concerns about sexuality.

We want them to be able to discuss how aging or their illness affects this part of their life.

Okay, now the intervention is taking action.

What should the nurse actually do?

First and foremost, create a safe space for them to talk.

Encourage them to verbalize concerns.

Use open -ended questions in private.

Show you're willing to listen without judgment.

How has this aspect of your life changed as you've gotten older?

Something like that.

Second intervention.

Provide and protect privacy.

This means different things in different settings.

In the community, it might be ensuring uninterrupted time.

In facilities, it means allowing dating or visits without staff interference.

Making sure there are private spaces.

Perhaps facilitating conjugal visits if policies allow.

And always, always respecting a closed door.

And the third major action area deals with that really difficult issue.

Protecting the dignity of confused older adults who might exhibit inappropriate sexual behavior.

Right.

This requires sensitivity and specific strategies.

If someone is exposing themselves publicly, maybe simple clothing modifications can help like elastic waistbands instead of zippers.

What about public masturbation?

The first step is usually distraction.

Try to redirect their attention.

If that doesn't work, gently escort them to their room to provide privacy.

The absolute don't here is applying restraints or protective devices to prevent it.

That's unethical and inappropriate.

Okay.

What if the inappropriate behavior is directed at staff?

A confused resident making a sexual advance.

Again, the approach should be calm.

Attempt distraction first.

If necessary, temporarily stop the care interaction.

The key is not to overreact.

Why not?

Because the person likely doesn't understand their behavior is inappropriate due to their cognitive impairment.

Overreacting can escalate the situation, potentially leading to agitation or even aggression.

De -escalation and maintaining dignity are the goals.

That really covers the spectrum of care outlined in the chapter.

Thinking about everything we've discussed, what's the single most important message you think our listeners should take away?

I think it's that sexuality and its broadest sense of intimacy and connection persists throughout life.

Yes, physical changes happen, but they're often manageable.

The biggest hurdles are usually external illness, medications, lack of privacy, and especially partner loss.

And the nurse's role.

Is crucial.

It demands non -judgmental acceptance,

proactive assessment, actually asking the questions and then intervening thoughtfully to protect both privacy and dignity.

So thinking about that ethical dimension again, facilities are moving towards encouraging intimacy, which is good.

Yes.

But that challenge we touched on, ensuring true mutual consent when cognitive impairment is present, maybe in both partners, that seems like the ultimate tightrope walk.

It absolutely is.

It goes beyond just having a policy.

It requires constant vigilance, careful observation, and sound clinical judgment in every single interaction to uphold autonomy while ensuring safety.

It's an ongoing ethical challenge.

A profound challenge indeed.

Well, thank you for joining us on this deep dive into sexuality and aging.

We really hope this discussion helps you synthesize this vital area of geriatric nursing more effectively.

And a warm thank you from all of us here at the Last Minute Lecture Team.

Keep learning.