Raymond Ford is a 78-year-old man hospitalized for evaluation after visiting the ED because of a severe, persistent headache he'd had for 24 hours. (This case is a composite based on my clinical experience.) On admission to the ED, his blood pressure was 210/120 mmHg. His blood pressure and pain are now controlled (140/80 mmHg), and you are obtaining a health history. When asked what medications he is taking, Mr. Ford gives a list, including two drugs prescribed for hypertension: generic hydrochlorothiazide, a diuretic, and amlodipine (Norvasc), a calcium channel blocker. Since Mr. Ford's blood pressure was so high on admission, you ask whether he adheres to the medication regimen. “I don't take the pills,” he answers. “They don't let me function.” When you ask further—“What do you mean by ‘function’?”—Mr. Ford says, “You know, those medications don't let me work down there when I need to, so I stopped taking them.”
AN APPROACH TO ASSESSING SEXUAL FUNCTION
The PLISSIT model outlines an approach to sexual assessment and intervention and includes open-ended questions about sexuality. It has been used widely with older adults. (For more information on the importance of assessment and intervention, see Why Assess Sexual Health in Older Adults? page 54.1–8)
The first step in using the PLISSIT model is to ask permission (P) to begin the sexual assessment of the older adult, followed by a series of open-ended questions designed to elicit the patient's concerns about sexual health.9 (Some have interpreted “permission” in the PLISSIT model to mean giving the patient permission to discuss sexuality. See “Do Ask, Do Tell,” Sexually Speaking, July 2005.) Next, the nurse should provide the patient with limited information (LI) about normal and pathologic changes that may affect sexual health and try to dispel any misconceptions. Based on the patient's responses to the open-ended questions, the nurse then makes specific suggestions (SS) as part of a tailored plan of care. The last part of the model calls for intensive therapy (IT), which may be indicated for older patients with sexual problems other than those related to normal aging, disease, or environmental factors such as a lack of privacy. Patients recommended for therapy may include those who meet the criteria for sexual dysfunction as defined in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision, or those who have a disturbance in one or more phases of the sexual response cycle (desire, excitement, orgasm, resolution). The list of patients who require referral may also include those with a history of sexual abuse, depressive disorders that affect sexual function, or orgasmic dysfunction or other sexual problems that require management by a specialist. For those with chronic medical conditions that affect sexual desire and function, an extended version of the PLISSIT model is also available.10
read it | watch it | try it
Watch a video demonstrating the best practices for assessing sexual health in older adults at http://links.lww.com/A276.
A Closer Look
Get more information on why it's important to assess older adults' sexual health on page 54.
Try This: Sexuality Assessment for Older Adults
This shows the best practices in their original form. See page 57.
USING THE PLISSIT MODEL
Older patients will be most comfortable sharing information if they are not concerned about others overhearing them and passing judgment, so the nurse should conduct the sexual assessment in a quiet, private area. It's important to create an environment of open communication between nurse and patient. The nurse should maintain a nonjudgmental attitude and perform the assessment in a respectful manner that conveys an understanding of older adults' sexuality. The nurse should never laugh or look surprised at the patient's responses. It's also a good idea for an inexperienced nurse to rehearse with a colleague the questions to be asked and the responses to be given to the information provided by the patient. The more comfortable the nurse is with the assessment, the more comfortable the patient will be. (To see the segment of the online video in which a nurse demonstrates the use of the PLISSIT model with a patient, go to http://links.lww.com/A277.
Permission (P). The nurse should begin the assessment with a query along the lines of, “Mr. Ford, would it be all right if I asked you some questions about how your medication has affected your sexual health?” Asking the patient's permission helps the patient feel in control of the situation. A slightly different approach is to preface the question with an acknowledgment of the continuing sexual needs of older adults. For example, the nurse could say, “Many of my patients have problems with their sexual health as they age. Would it be okay if I asked you some questions about your sexual health?”
Open-ended questions. If the patient agrees, the nurse can then begin with general open-ended questions and progress to more specific ones. For example, the nurse might first ask, “What concerns you about your sexual health?” or “What changes have you noticed in your sexual feelings since you were first diagnosed or treated for your disease?” or “Has your sexual function changed since you started taking blood pressure medications?” After getting a sense of the patient's general concerns, the nurse can elicit more specific information with a follow-up question such as, “In what way does your medication affect your sexual function?” After a level of trust is established, the nurse might conclude by asking, “What thoughts have you had about enhancing your sexual health or relationship?”
Getting partners involved. A patient like Mr. Ford might reply this way: “A few weeks after they put me on that blood pressure pill, I couldn't get an erection. No matter how aroused I was, nothing was happening.” Such a response may be an opportunity to involve the patient's partner in the discussion and elicit the partner's concerns about sexual function and possible strategies for resolution. For example, the nurse might ask Mr. Ford, “Would you like your partner to join us in discussing this?” If Mr. Ford agrees, an open-ended question such as, “What concerns do you have about his sexual health?” would be appropriate for the partner.
Providing limited information (LI). Once the nurse understands the patient's concerns, the next step is to provide information about both normal and pathologic age-related changes that can affect sexual health, which is limited by the patient's desire to have this information and by the provider's professional skills. It's often helpful to affirm the continuing sexual needs of older adults and acknowledge that, in some cases, there may be barriers to sexual fulfillment, such as the lack of privacy commonly found in health care settings. More detailed information on the physical and psychological changes that affect the sexual health of older adults can be found in Sexuality in Midlife and Beyond: A Special Health Report from Harvard Medical School (purchase is required).2
Specific suggestions (SS) for patients like Mr. Ford might include a recommendation that he change his blood pressure medication or try an oral medication to treat erectile dysfunction. The nurse might say, for example, “I understand that the blood pressure medication you're taking often causes erectile dysfunction. If you say it's okay, I will ask your NP about switching you to another medication that doesn't have this side effect or adding a medication that might improve your erectile function.”
The nurse might also ask patients about ways in which they were able to achieve sexual fulfillment in the past. For example, if the patient once used erotic films or magazines, doing so again might promote sexual arousal, either alone or with a partner, and the nurse could consider making a specific suggestion about their use.
According to Higgins and colleagues, literature on sexuality and dementia shows that between 3% and 8% of older patients with dementia who live in community or residential settings exhibit sexual disinhibition or sexually inappropriate behavior toward care-takers and other patients.11 In these cases, specific suggestions may include a recommendation to caretakers to ensure that the patient has privacy in which to fulfill her or his sexual needs without imposing on others.
Intensive therapy (IT), while not appropriate for all patients, may be necessary when a sexual problem or dysfunction requires more than nursing care. For example, psychotherapy might be indicated in older adults who have been sexually abused, and the nurse should make the appropriate referral. Intensive therapy, in the form of behavior modification, might also be indicated in patients who exhibit hypersexual behavior that may be symptomatic of cognitive impairment, such as masturbating in public or making unwanted sexual advances toward other patients and staff members.
Interpreting the results. There is no numeric score for the PLISSIT model; however, after using it to guide the assessment of patients like Mr. Ford, a nurse will be better prepared to develop a plan of care that focuses on interventions to improve sexual health.
Sexuality is not widely addressed in nursing education programs, especially in relation to the care of older adults, so nurses are often uncomfortable managing sexual issues. The greatest challenge to the use of the PLISSIT model may be nurses' reluctance to adopt it.
Nurses should be aware that sexuality is important to older adults. According to Butler and Lewis,12
Sexuality—the physical and emotional responsiveness to sexual stimuli—goes beyond the sexual urge and sex act. For many older people it offers the opportunity to express not only passion but affection, esteem, and loyalty. It provides affirmative evidence that one can count on one's body and its functioning. It allows people to assert themselves positively. It carries with it the possibility of excitement and romance; it expresses delight in being alive.
Nursing education and staff development programs should include up-to-date information on the sexual health of older adults, including both emotional and physical aspects of healthy sexuality. Educational sessions may begin with a discussion of prevalent misconceptions—such as the notion that older adults should not have sexual concerns. Nurses should be encouraged to discuss their own feelings about older adults' sexuality. Moreover, the development of policies and procedures to manage sexual issues of older adult patients is important in all care settings.
The PLISSIT model may be used with many cultural groups. Because it's a model and does not rely on specific questions, translation into other languages isn't necessary. However, respect for culture-specific values should always be demonstrated. It's important to be aware that cultural factors are important to how older adults perceive themselves as sexual beings. With patients from certain cultures, nurses must exercise great sensitivity in seeking permission to discuss sexuality. They should consult an expert in a given culture if they're unsure of how to approach the sexual assessment of a patient with that particular cultural background.
Nurses should be sensitive to the various possible sexual identities of older adults and shouldn't assume that patients are heterosexual. The PLISSIT model can be used with homosexual patients, as well as those with gender identity concerns. If there's uncertainty about the patient's sexual orientation, the nurse can say, “Tell me about your partner” or ask, “What is your partner's attitude about your sexual relationship?”
COMMUNICATING THE RESULTS
Older adults are often uncomfortable with their sexuality and may be reluctant to discuss sexual health needs with nurses. This may be a reflection of their cultural and moral values, or it may have more to do with their feelings about aging. For example, some older adults may view the normal changes of aging and their effect on appearance as embarrassing or indicative of illness, which can result in a negative body image and a reluctance to pursue sexual health. It's important for nurses to consider the impact of normal and pathologic changes of aging on body image.
Communicating with families. Ideally, family members are present and capable of acting as an integral part of the interdisciplinary team. However, for older couples, especially those in relationships with new partners, it's often difficult for family members to understand or accept that their grandparent or parent or aunt or uncle, for example, has a sexual relationship with someone other than a long-time spouse or other familiar partner. A family meeting, with a counselor if needed, is appropriate in order to help family members understand and accept the older adult's relationship. In such a case, the nurse might encourage the older patient to be forthcoming about the new relationship in order to help relatives understand his continuing emotional and sexual needs.
Communicating with staff. Once the sexual assessment of the patient is complete, communication with other health care providers is necessary. In the case of Mr. Ford, one approach to documentation is the “SOAP” mnemonic, which could be used in the following way:
S [subjective]—“The blood pressure pills don't let me work down there when I need to, so I stopped taking them.”
O [objective]—Blood pressure is 210/110 mmHg upon admission to ED.
A [assessment]—Diminished sexual function is related to adverse effects of amlodipine.
P [plan]—Speak with the patient's physician or NP about alternative medication or adding an oral erectile dysfunction drug to the plan of care.
What evidence supports the use of the PLISSIT model to assess sexual health among older adults? PLISSIT is a model, not an instrument or tool; there are no psychometric testing results. But since the PLISSIT model was developed in 1976, it has been used extensively. For more on the use of the PLISSIT model, see “Erectile Dysfunction and Its Discontents,” Sexually Speaking, December 2006, and “Do Ask, Do Tell,” Sexually Speaking, July 2005.
Has this model been used with older adults with dementia? No. However, in patients with mild cognitive impairment, several areas of the model may be helpful, including asking permission (P) to discuss sexuality and providing limited information (LI) and specific suggestions (SS). Intensive therapy (IT), in the form of behavior modification, can also be appropriate. The information and suggestions must be part of the patient's plan of care and clearly communicated to the nursing staff. Moreover, the patient may need to be reminded frequently of the information and suggestions given. It's important to note that the older adult with dementia may not remember or recognize a spouse or long-term sexual partner and may not be capable of making decisions. Therefore, participation in sexual relationships must be carefully monitored in order to prevent coercion. A good treatment of these issues can be found in Kamel and Hajjar's “Sexuality in the Nursing Home, Part 2: Managing Abnormal Behavior—Legal and Ethical Issues.”13
Can I use this model to gather information from older men with erectile dysfunction? The incidence of erectile dysfunction rises greatly with age. Araujo and colleagues followed a group of 1,085 men between the ages of 40 and 70 for nine years and found that the number of erections they experienced per month declined by three, nine, and 13 among men in their 40s, 50s, and 60s, respectively.14 In my clinical experience, I've found that the PLISSIT model is appropriate for addressing sexual concerns about erectile dysfunction with older men, and I've used it extensively for this purpose.
Why Assess Sexual Health in Older Adults?
Sexual health remains a continuing concern for all adults, regardless of age. Lindau and colleagues recently studied a nationally representative sample of 3,005 older adults in the United States and concluded that 26% of Americans between the ages of 75 and 85 were sexually active (having had sex at least once in the previous year).1 They also found that sexual activity decreased with age: for example, 73% of those between 57 and 64 years of age and 53% of those between 65 and 74 were active.
Helping patients to manage their sexual health must be a priority for nurses in all settings. (To watch the portion of the online video in which the author discusses the importance of sexual assessment in older adults, go to http://links.lww.com/A278.) Older adults experience normal and pathologic changes as part of the aging process, and many of these affect sexual health. Addressing older adults' sexuality can increase their self-esteem and promote companionship; it can restore function, inspire healing, and enhance energy.
Normal age-related changes. In women, a loss of estrogen at menopause may result in a thinning of the vaginal wall and a reduction in vaginal lubrication in response to sexual stimulation, which can lead to pain during intercourse or avoidance of it altogether. Decreased lubrication can be treated with currently available gels.
With age, the vagina shortens, the labia atrophy, and the cervix may descend into the vagina, resulting in pain or discomfort. Uterine contractions may become less frequent, resulting in less-pleasurable orgasms. Moreover, postmenopausal women tend to return to the prearoused state faster than they would at an earlier age.2
Older men generally experience less frequent and weaker erections with less ejaculate and a longer refractory period between erections.2 The use of oral medications for erectile dysfunction such as sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis) can compensate for these normal age-related changes in men.
Pathologic changes. Common health problems associated with sexual dysfunction in older adults include depression, cardiovascular diseases,3 and diabetes.4 These illnesses can result in a decrease in libido or otherwise affect sexual function. For example, a lack of sexual desire is a common symptom of depression, and diabetes can alter circulation to the genital area, resulting in sexual dysfunction. Moreover, selective serotonin reuptake inhibitors, commonly used to treat depression, can result in sexual dysfunction,5 and antihypertensive agents commonly used by older adults (such as angiotensin-converting enzyme inhibitors and α- and β-blockers) can result in impotence and ejaculatory disturbances in older men.6
Cognitive impairment does not prevent sexual desire in older adults but may complicate its expression. Nagaratnam and Gayagay reported that cognitively impaired older adults may exhibit aggression and irritability as well as sexual behaviors including “cuddling, touching of the genitals, sexual remarks, propositioning, grabbing and groping, use of obscene language, and masturbating without shame.”7 In a study of 2,278 cognitively impaired older adults in a long-term care psychiatric consulting service in Edmonton, Canada, 41 patients (1.8%) displayed sexually inappropriate behavior.8 While this percentage may seem low, the authors point out that this behavior is among the most difficult to manage in people with cognitive impairment. There's a need for better definitions of this type of behavior, as well as management plans.
Nurses must be aware of the continuing sexual needs of older adults, even those who are cognitively impaired, and develop plans of care that promote respect and dignity.
Go to http://links.lww.com/A276 to watch a nurse use the PLISSIT model to discuss sexual health with an older patient and watch the health care team discuss strategies and interventions to help the patient overcome possible obstacles to normal sexual activity.
View this video in its entirety and then apply for CE credit at www.nursingcenter.com/AJNolderadults; click on the How to Try This series link. All videos are free and in a downloadable format (not streaming video) that requires Windows Media Player.
For more information on this and other geriatric assessment tools and best practices go to www.ConsultGeriRN.org—the clinical Web site of the Hartford Institute for Geriatric Nursing, New York University College of Nursing, and the Nurses Improving Care for Healthsystem Elders (NICHE) program. The site presents authoritative clinical products, resources, and continuing education opportunities that support individual nurses and practice settings.
Visit the Hartford Institute site, www.hartfordign.org, and the NICHE site, www.nicheprogram.org, for additional products and resources.
Go to www.nursingcenter.com/AJNolderadults and click on the How to Try This link to access all articles and videos in this series.
Medications and Sexuality
Several classes of drugs can have unwanted effects.
There are numerous barriers to achieving sexual health among older adults, including normal changes of aging and an increased incidence and prevalence of illness. An added barrier in older adults is the frequent use of medications to treat the illnesses associated with aging. Many of the most commonly taken medications can affect sexual function, including those in the following drug classes (note: this is not a comprehensive listing of all such medications):
1. antihypertensives, including angiotensin-converting enzyme inhibitors, α-blockers, β-blockers, calcium channel blockers, and thiazide diuretics
2. antidepressants, including selective serotonin reuptake inhibitors, tricyclic antidepressants, and monoamine oxidase inhibitors
3. cholesterol-lowering medications, including statins and fibric acid derivatives
4. other medications such as antipsychotics (such as the phenothiazines and the atypical antipsychotics such as risperidone [Risperdal]), seizure medications (such as carbamazepine [Tegretol]) and H2 blockers (such as cimetidine [Tagamet])