Dementia, sexuality and consent in residential aged care facilities

Intimate relationships in residential aged care: what factors influence staff decisions to intervene?

Intimacy contributes to our well-being and extends into older age, despite cognitive or physical impairment. However, the ability to enjoy intimacy and express sexuality is often compromised-or even controlled-when one moves into residential aged care. The aim of this study was to identify what factors influence senior residential aged care staff when they make decisions regarding resident intimate relationships and sexual expression. The study used vignette methodology and a postal survey to explore reactions to a fictionalised case study of a couple-Norm and Carol-who develop a close, mutually satisfying relationship. Staff were first asked whether they would intervene in the relationship. Using an innovative approach, several variations to the case study were then presented to explore whether views about intervening changed according to varying contextual factors. Findings indicated that over 90% of respondents initially agreed that the relationship should continue, and only 10% indicated they would intervene. However, when the case study was varied, respondents indicated they were more likely to intervene, particularly if Norm was exhibiting distress in Carol's presence (89%), but also if Norm was married and his wife was living in the community (40%). Other factors including level of cognitive impairment and family disapproval were also found to influence staff views. This study provides insight into how residential aged care staff make decisions regarding the intimacy and sexuality of older people living in residential aged care and how personal views and values likely guide practice in the absence of formal policies.

The Role of Information in Later-Life Sexuality: An Invitation for Further Exploration

Despite the key role of information in realizing, questioning, or respecting one's sexual health, individuals' engagement with information about sex and sexuality remains understudied, particularly in older adult populations. Beginning with current understandings of later-life sexuality to contextualize how older adults may need, use, and manage information about their sexual lives and practices, this forum article follows with what is currently known about older adults' sexuality-related information needs and practices. We conclude with an invitation for collaboration between gerontologists and Library and Information Science scholars and professionals as a means to step outside the medicalization of older adults' sexuality and bolster our understandings of how information and later-life sexuality are mututally shaping.

Value pluralism about sexual intimacy in residential care

BACKGROUND

The existing literature on sexuality and intimacy in residential care tends to focus on either the question of rights, or the value of autonomy. Where the literature does reference values other than autonomy, such values are considered in the context of being a guide to whether or not a resident is autonomous, rather than being important values in their own right.

OBJECTIVE

This paper draws on qualitative data gathered as part of a larger study in order to inform practice on how care workers respond to intimacy issues that arise with residents with dementia and to inform a general ethics of sex and sexuality, demonstrating that an approach which permits value pluralism can be appropriate in certain contexts.

RESEARCH DESIGN

The qualitative data referred to in this paper was gathered from semi-structured interviews undertaken as part of a larger mixed-method research project. The interview text was analysed using Thorne's methodological approach, interpretive description.

PARTICIPANTS AND RESEARCH CONTEXT

The qualitative arm of the project consisted of semi-structured interviews conducted between October 2018 and October 2019 with participants (staff, residents and family members) recruited from 35 residential care homes in Aotearoa New Zealand.

ETHICAL CONSIDERATIONS

Participation was informed, voluntary and written consent was gained before interviews. The project was approved by the Massey University Human Ethics Committee (Northern), number NOR 18/25.

FINDINGS

Analysis of the scenarios presented in this paper shows that decision-making around sexual intimacy involving people with dementia in a residential care setting is complex and requires recognizing and weighing the different values that may be a in play.

CONCLUSION

A focus on safety and consent to the exclusion of other values which matter morally in this context is a mistake which prevents care workers from providing appropriately person-centred care to residents, as policies which focus on the goal of care allow space for critical examination of issues which are likely to be highly context-sensitive.

Feasibility and acceptability of an education and training e-resource to support the sexuality, intimacy and relationship needs of older care home residents: a mixed methods study

BACKGROUND

sexuality, intimacy and relationship needs are often a neglected aspect of the care of older adults in residential care facilities. Improving awareness, knowledge and improving attitudes about these needs among care staff could enhance quality of care and lead to better outcomes for residents.

OBJECTIVE

to evaluate the feasibility and acceptability of a co-designed education and training e-resource to help care staff support their residents' sexuality, intimacy and relationship needs.

METHODS

we delivered the education and training e-resource to five UK care homes over a 6-month period in a pre-post mixed methods study using surveys, focus groups and individual interviews.

RESULTS

fifty-nine members of staff from participating care homes undertook the education and training e-resource. 18/59 (31%) of participants completed all six modules and the pre-post surveys. Eleven participants participated in focus groups/interviews to explore experiences of using the e-resource. The e-resource was successfully implemented in the study homes and found to be acceptable. We found preliminary evidence of positive changes in staff attitudes. Factors that facilitated implementation included support from the care home manager. Barriers identified included IT infrastructure and technology.

CONCLUSIONS

the findings provide initial evidence that a co-designed education and training e-resource raised awareness of, and improved attitudes towards, older adults' sexuality and intimacy needs. This work provides the foundation for a next phase to establish the effectiveness of the e-resource on staff practice and resident outcomes.

Palliative Care, Intimacy, and Sexual Expression in the Older Adult Residential Care Context: "Living until You Don't"

Commonly, frail older adults move to residential care, a liminal space that is their home, sometimes a place of death, and a workplace. Residential facilities typically espouse person-centred values, which are variably interpreted. A critical approach to person-centred care that focuses on social citizenship begins to address issues endemic in diminishing opportunities for intimacy in the end-of-life residential context: risk-averse policies; limited education; ageism; and environments designed for staff convenience. A person-centred approach to residents' expressions of intimacy and sexuality can be supported throughout end-of-life care. The present study utilised a constructionist methodology to investigate meanings associated with intimacy in the palliative and end-of-life care context. There were 77 participants, including residents, family members and staff, from 35 residential facilities. Analysis identified four key themes: care home ethos and intimacy; everyday touch as intimacy; ephemeral intimacy; and intimacy mediated by the built environment. Residents' expressions of intimacy and sexuality are supported in facilities where clinical leaders provide a role-model for a commitment to social citizenship. Ageism, restrictive policies, care-rationing, functional care, and environmental hindrances contribute to limited intimacy and social death. Clinical leaders have a pivotal role in ensuring person-centred care through policies and practice that support residents' intimate reciprocity.

Sexual expression involving people with dementia living in long-term care facilities: staff's reactions

This study aims to explore and compare the reaction of long-term care staff towards situations of sexual intercourse in which one or both partners have dementia. Participants were 538 staff members at 28 Portuguese long-term care facilities. Data were collected using a printed questionnaire with seven vignettes with situations related to the sexuality of LTCF residents. In this study, three of these vignettes were analysed with situations in which residents were having relationships in their bedrooms: (1) one male resident and one female resident; (2) two residents with dementia; (3) two residents, one of them with dementia. For each of the vignettes, participants are asked what they think their 'colleagues' would do in each vignette, i.e. 'What do you think most of your colleagues would do?' The results revealed that when sexual relationships involved both partners living with dementia, the most selected reaction was 'Comment on what happened with supervision or direction', which may suggest that the situation was perceived as difficult or problematic. The most restrictive reactions were most often chosen when only one partner had dementia. This study suggests the need to improve and provide training, so that staff have knowledge and strategies that allow people living with dementia to preserve their sexual rights in long-term care facilities.

Approaches to Determine and Manage Sexual Consent Abilities for People With Cognitive Disabilities: Systematic Review

BACKGROUND

This review focused on how sexual consent ability was determined, managed, and enhanced in people with cognitive disabilities, with the aim of better understanding the recurring themes influencing the design and implementation of these approaches. If a person's consensual ability becomes compromised, owing to either an early or late-onset cognitive disability, the formal systems involved must establish plans to balance the individual's rights and restrictions on sexual expression. This review identified these plans, focusing on how they promoted the intimacy rights of the individual.

OBJECTIVE

This study aims to identify approaches that determine sexual consent ability in people with cognitive disabilities, identify the means of managing and enhancing sexual consent ability in people with cognitive disabilities, and note the recurring themes that influence how these approaches and management systems are designed and implemented.

METHODS

A systematic literature review was performed using EBSCOhost (Social Gerontology, CINAHL Plus, MEDLINE, and SocINDEX), Embase, PsyInfo, and Scopus to locate reports on terms expanded on sexual consent and cognitive disability.

RESULTS

In all, 47 articles were identified, featuring assessment practices, legal case studies, and clinical standards for managing sexual consent capacity in people with cognitive disabilities. A total of 8 studies (5/8, 63% qualitative and 3/8, 38% quantitative) were included out of the 47 articles identified. Approaches for determining sexual consent included functional capacity and person-centered, integrated, and contextual approaches. Management of sexual consent ability included education, attitude, and advanced directives and support networks. The recurring themes that influenced these approaches included the 3 legal criteria of consent, American Bar Association and American Psychological Association Model, Lichtenberg and Strzepek Instrument, Ames and Samowitz Instrument, Lyden approach, Mental Capacity Act of 2005, and Vancouver Coastal Health Authority of 2009.

CONCLUSIONS

Determining sexual consent takes a holistic approach, with individuals judged in terms of their adaptive abilities, capacities, and human rights. The attitudes of those using this holistic approach need to be balanced; otherwise, the sexual rights of assessed people could be moved either in favor or against them. The ideal outcome, after person-centered considerations of those living with cognitive disabilities includes the people themselves being involved in the process of personalizing these approaches used to facilitate healthy intimate relationships.

Sexuality, sexual expression in long-term care and the law

Balancing risk and safety in long-term care settings can be challenging while providing and respecting patients’/residents’ needs and rights in terms of sexual expression. We look at factors affecting the expression of sexuality, including staff attitudes and reactions, and the lack of policies governing sexuality. We review the various statute and case law, other legislative and quasi-legal provisions governing sexuality and sexual expression. Finally, we consider the need for clear policies and training for both staff and family members.

Nothing to be ashamed of: sex robots for older adults with disabilities

This paper spotlights ways in which sexual capacities relate to central human capabilities, such as the ability to generate a personally meaningful story of one's life; be physically, mentally and emotionally healthy; experience bodily integrity; affiliate and bond with others; feel and express a range of human emotions; and choose a plan of life. It sets forth a dignity-based argument for affording older people access to sex robots as part of reasonable efforts to support their central human capabilities at a floor level. The argument develops stepwise: (1) first, I dispel ageism and negative stereotypes about later-life sexuality, showing their deep historical roots in medicine and science; (2) second, I set forth a positive argument, grounded in capability accounts of justice, for deploying sex robots for older people with disabilities; (3) finally, after responding to objections, I conclude that sex robots are a reasonable way to support later-life sexuality for persons with disabilities. While often depicted as a product for younger, able-bodied people, this paper is a bid for reimagining sex robots as a product for older, disabled people.

'I do it my way': long-term care staff's perceptions of residents' sexual needs and suggestions for improvement in their management

This study is aimed at exploring to what extent staff perceive older residents in long-term care facilities (LTCFs) as still having sexual needs, and how they think care in relation to sexual issues could be improved. The sample was self-selected and comprised 2115 staff members (including managers, technical and care assistants) employed at 152 Spanish LTCFs. Data were collected in the second half of 2016. Participants were asked to estimate the proportion of older residents who had sexual needs in their institution and, by means of open-ended questions, they were also asked about how they satisfied such needs and how to improve care in relation to sexual issues. Responses to the open-ended questions were analysed using content analysis. Differences were assessed according to participants' work position. Results showed that most participants did not see sexual needs as being present in many (or even any) older people living in LTCFs. Masturbation was the most common way staff thought residents' sexual needs were being satisfied. The participants mentioned a broad range of measures to improve care regarding sexual issues, including providing more training opportunities for staff, guaranteeing privacy and improving negative attitudes held by family, residents or staff members. Work position influenced participants' responses: managers and technical staff were more likely to recognise sexual needs among residents, perceived a greater need for training, and proposed more ambitious and far-reaching improvements than care assistants.

Sexuality and the Older Adult

PURPOSE OF REVIEW

This paper provides an overview of biopsychosocial components of sexuality in older adults, sexual expression in older LGBTQ and cognitively impaired adults, and inappropriate sexual behaviors (ISBs) in dementia.

RECENT FINDINGS

Sexual expression of older adults is influenced by diverse psychosocial and biologic determinants including ageist beliefs. Although the prevalence of sexual dysfunction increases with age, studies of sexual satisfaction reveal that only a minority experience significant distress. Stigma against sexual expression in LGBTQ older adults may cause concealment of sexual orientation from family or care providers due to fears of rejection. Cognitive impairment affects frequency of and satisfaction with sexual activity, as well as capacity to consent. Staff biases about sexuality can negatively impact sexual expression in healthcare settings. Dementia-related inappropriate sexual behaviors (ISBs) are common and distressing. Recent research has focused on early identification and prevention of ISB, in addition to management through non-pharmacologic and pharmacologic approaches. Sexuality remains integral to quality of life for many older adults and informed consideration of their needs is critical to healthcare delivery and institutional service planning. A comprehensive understanding of older adults' sexuality can enhance education, research, policy, and clinical care for this growing population.

Organisational enablers and barriers to the recognition of sexuality in aged care: A systematic review

AIM

To identify organisational characteristics and practices that promote or inhibit the recognition of sexuality in the care of older people in health and aged care settings.

BACKGROUND

Sexuality in old age is poorly understood by health professionals and rarely addressed in care planning and delivery. Nurse managers are ideally placed to lead organisations in promoting a culture of acceptance that enables the expression of sexuality.

EVALUATION

A search for research/expert opinion papers published from January 2004 to February 2017 was undertaken. Two reviewers performed data extraction and appraisal of 34 included studies using Joanna Briggs Institute tools. The primarily qualitative research was analysed to identify 152 findings that were organised into 22 categories and combined into four syntheses.

KEY ISSUE(S)

An organisation's philosophies frame the way older people's sexuality is perceived. Cultivating a culture and environment of acceptance, engagement and knowledge and delivering care in a way that promotes opportunity for safe and private expression of sexuality are key enabling factors.

CONCLUSION(S)

Organisations and nurse leaders can support and facilitate older adults' expression of their sexuality through the review and development of philosophies, policies, procedures, staff attitudes and knowledge and the creation of a conducive environment.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse managers play a pivotal role in developing a sexuality-positive organisational ethos by ensuring policies, care practices, the environment and amenities are supportive of the expression of sexuality and by role modelling attitudes of respect and inclusivity.

[Sexual expression and sexuality regulation in Spanish long-term care homes for the elderly]

OBJECTIVES

The study had three objectives: (a) To determine how staff perceives the frequency of different sexual expressions in long-term care facilities for older people; (2) to quantify policies aimed at guaranteeing residents' sexual rights in such institutions, and (3) to determine factors influencing the presence of these kind of policies.

METHODS

A total of 160 Directors of Nursing and 623 technical staff from Spanish long term care residential facilities completed a self-administered questionnaire including ítems to assess the experience and estimated frequency of different sexual expressions, an inventory of policies regarding sexual expression, and the Spanish version of the Person-Centred Care Assessment Tool.

RESULTS

Certain sexual behaviours, such as kisses and hugs, or masturbation, are very frequent in nursing homes. Many participants have reported to staff members on having witnessed inappropriate sexual behaviours, such as exhibitionism (39%) or unwanted touching (27%). Policies in relation to guaranteeing residents' sexual rights were the most frequently mentioned. In contrast, there were fewer participants who mentioned policies regarding training or availability of helpful materials and resources. Factors such as occupational level (Directors of Nursing vs.technical staff), personal education, the centre commitment to person-centred care, and estimated frequency of sexual behaviour were associated with a higher presence of sexual expression policies.

CONCLUSION

Although sexual behaviours among residents are quite frequent, there is still room for improvement in policies that support residents' expression of sexuality. Person-centred care models might help to guarantee sexual rights of older people living in long-term care facilities.

Relational autonomy in action: Rethinking dementia and sexuality in care facilities

Background:

Caregivers and administrators in long-term facilities have fragile moral work in caring for residents with dementia. Residents are susceptible to barriers and vulnerabilities associated with the most intimate aspects of their lives, including how they express themselves sexually. The conditions for sexual agency are directly affected by caregivers’ perceptions and attitudes, as well as facility policies.

Objective:

This article aims to clarify how to approach capacity determinations as it relates to sexual activity, propose how to theorize about patient autonomy in this context, and suggest some considerations for finding an ethically responsible and practically feasible way to respect the sexual rights of this population.

Research Design:

The focus is on residents with early to moderate dementia in states of daily dependency on professional caregivers. The article critically examines existing empirical research on sexuality among persons with dementia, caregivers’ attitudes, and institutional roadblocks to enabling residents’ sexuality. A relational lens and insights from disability studies are used in the philosophical analysis.

Participants and Research Context:

No research participants were part of this analysis.

Ethical Considerations:

This article offers a conceptual analysis and normative framework only.

Findings:

The analysis highlights the delicate balance that capacity assessments for sexual activity have to strike; while caregivers should protect those who cannot give adequate consent, the denial of sexuality among residents can cause deep, long-ranging harms. Sexual agency features into an ongoing sense of self for many individuals with dementia, and the imposition of inappropriate standards and expectations for sexual autonomy can lead to unwarranted obstacles to sexual activity.

Discussion:

Recommendations include developing clear and inclusive institutional policies and practices of care, providing education for caregivers on how to discuss and document residents’ sexual preferences over time, and taking advantage of ethics consultation services.

Conclusion:

This analysis establishes the need for more research and discussion on this sensitive topic. Future research should investigate the specific responsibilities of caregivers in furthering the sexual interests of residents, how exactly to modify existing capacity instruments, and how best to support historically marginalized patients in their sexual identities.

The landscape of dementia inclusivity

A supported community gardening program became appealing and therapeutically beneficial to people living with the impacts of dementia and their carers, despite not targeting either cohort specifically. This paper discusses how this program provides insights into the landscape of dementia inclusivity. The gardens involved were spaces that allowed positive risk-taking opportunities, respectful intersubjectivity and active citizenship. Our research findings indicate that a meaningful response to the rising incidence of dementia may be to build upon social and geographical attributes of community gardens. Understanding the multifaceted nature of a dementia inclusive landscape will enable authentic engagement and rights-based support for people living with the impacts of dementia.

[Self- and informant-rating mood scales applied in elderly persons with Alzheimer's dementia, with or without a language disorder]

INTRODUCTION

Alzheimer's Dementia (AD) may be associated with symptoms of depression. In AD, problems of language expression or understanding will arise sooner or later. The aim of this study was to determine whether elderly persons with AD, with or without a language disorder, experience difficulties understanding and answering mood related questions. In addition to this, it was our object to test the validity of the answers of nurses as informants, on the mood of an elderly client.

METHODS

53 elderly persons, living in care homes, and their nurses, took part in the study. 25 participants had been diagnosed with Alzheimer's disease, 28 participants had no cognitive impairment. Language skills were tested using the SAN-test (Stichting Afasie Nederland) and subtests of the Aachen Aphasia Test (AAT). Mood was assessed with the Beck Depression Inventory-second edition (BDI-II-NL) and the Geriatric Depression Scale (GDS-30).

RESULTS

There were no significant differences in scores on the mood related questionnaires between participants without cognitive impairment and participants with Alzheimer's disease, with or without a language disorder. The correlation between self- and informant-rating was very limited. In general, nurses reported more depressive symptoms than the elderly persons did themselves. Disparities between self- and informant-ratings varied from informant scores overestimating low self-ratings of depression to informant scores underestimating high self-ratings.

CONCLUSION

Alzheimer's disease, whether or not it is complicated by a language disorder, does not disturb the normal score distribution on either test (BDI or GDS). This means that elderly persons with Alzheimer's disease are capable of adequately answering questions related to their own mood. However, considerable discrepancies were found between observer- and self-ratings of emotional wellbeing. Therefore it is important to not only take into account the information of an informant when testing for depression, but also the elderly person's own assessment of their mood.

Staff's reactions towards partnered sexual expressions involving people with dementia living in long-term care facilities

AIMS

To explore staff responses, in terms of common practices, towards partnered sexual relationships in long-term care facilities where one or both people involved have dementia. It also tries to determine personal and institutional factors influencing these responses.

BACKGROUND

Although some studies, mostly qualitative, have focused on reactions to residents' sexual expressions so far the issue has not been assessed in a study using large and diverse samples.

DESIGN

Cross-sectional quantitative study using vignette technique.

METHODS

Participants were 2,295 staff members at 152 Spanish long-term care facilities. Data were collected during 2016. A vignette describing sexual situations involving people with dementia was presented to participants. After the vignette, participants had to answer the question: "What do you think most of your colleagues would do in this situation?" with nine possible responses.

RESULTS

Results showed that relationships involving persons with dementia were perceived as potentially problematic by staff. In both conditions, discussing the case with a colleague or supervisor was the most frequently chosen reaction. More restrictive reactions were mentioned when only one person with dementia was involved in the relationship. Factors such as participants" age and years of experience, professional post and commitment to person-centred care practices were related with the frequency of common restriction practices.

CONCLUSION

Results highlight the importance of providing staff with clear guidelines regarding the management of specific sexual situations to avoid stereotyped restrictive reactions.

Sexual Assault and Justice for Older Women: A Critical Review of the Literature

This article provides a critical review of current literature on the sexual assault of older women-including an exploration of the specific features and emotional and physical impacts of older women's experiences-and highlights current gaps and future directions for research, practice, and theory. A review of the literature indicates that older women constitute only a small proportion of victim/survivors. However, there is evidence to suggest that existing research underestimates the extent of this issue. Older women face particular barriers to disclosure and accessing the justice system, resulting in their experiences remaining hidden. Many of these barriers also contribute toward older women's experiences being ignored, dismissed, or downplayed by potential bystanders. These barriers are explored in depth in this article and include cultural context, ageism, cognitive and health impairments, and living in a residential care setting. Responding to, and preventing, the sexual assault of older women requires a tailored approach-and we currently lack sufficient insight to develop appropriate responses. In closing, this article considers how we might work toward achieving "justice" for older women victim/survivors.

Intimacy and Sexuality in Institutionalized Dementia Care: Clinical-Ethical Considerations

Intimacy and sexuality expressed by nursing home residents with dementia remains an ethically sensitive issue for care facilities, nursing staff and family members. Dealing with residents' sexual longings and behaviour is extremely difficult, putting a burden on the caregivers as well as on the residents themselves and their relatives. The parties in question often do not know how to react when residents express themselves sexually. The overall aim of this article is to provide a number of clinical-ethical considerations addressing the following question: 'How can expressions of intimacy and sexuality by residents with dementia be dealt with in an ethically responsible way?' The considerations formulated are based on two cornerstones: (1) the current literature on older peoples' experiences regarding intimacy and sexuality after the onset of dementia, and (2) an anthropological-ethical framework addressing four fundamental pillars of human existence namely the decentred self, human embodiment, being-in-the-world and being-with-others. The resulting considerations are oriented toward the individual sphere, the partnership sphere, and the institutional sphere. The continuous interaction between these spheres leads to orientations that both empower the residents in question and respect the complex network of relationships that surrounds them.

"Behind Closed Doors with open minds?": A qualitative study exploring nursing home staff's narratives towards their roles and duties within the context of sexuality in dementia

BACKGROUND

Despite sexual expression being recognised as a fundamental human need, sexuality in old age is often ignored and frequently misunderstood, with residents with dementia in a nursing home often viewed as asexual or incapable of being sexually active.

OBJECTIVES

The current study aims to understand the views held by nursing care home staff towards dementia and sexuality and explore the roles they may adopt whilst responding and managing sexual needs and expression for residents with dementia.

METHODS

Face to face, in-depth, semi structured interviews were conducted with eight staff members working in two nursing homes in Greater London, United Kingdom. Data were analysed using Interpretative Phenomenological Analysis.

RESULTS

The findings suggest that representations of sexuality in dementia held by nursing home staff ranged from the perception that sexual expression in old age was part of human nature and a basic human right to others that proposed that with the loss of memory, people with dementia may also experience loss of interest in sexuality and intimacy. Based on the representation of sexuality held (personhood versus biomedical model), nursing home staff adopted a role or a combination of roles (a facilitator, an informant, a distractor, an empathiser, a safeguarder) that legitimised past and anticipated responses in managing sexual expression in the nursing home setting. Nursing home staff's responses varied depending on the severity of the condition, level of involvement of the resident's family and their own personal views on their duty of care, old age, sexuality and dementia.

CONCLUSION

The simplified binary labelling and classification of sexual behaviour in dementia as appropriate or inappropriate often applied in institutional settings, fails to account for complex factors that may influence staff's decisions on the ethical dilemmas raised by dementia. A role based continuum approach could help staff move away from rigid binary judgments and train them to adopt formal carer roles that promote a more contextualised rights based approach in the provision of dementia care.

Public Perspectives Toward the Sexual Behavior of an Individual With Dementia Residing in Long-Term Care

OBJECTIVE

This study examines public perspectives toward sexual behavior within a heterosexually married couple in which one individual has dementia and resides in a long-term care facility.

METHOD

Respondents included 318 adults in the Southern United States. Paired sample t tests were used to understand how the diagnosis of dementia statistically influenced participants' responses, and a logistic regression model was used to understand how a vignette character's sex and respondent characteristics influenced attitudes.

RESULTS

Fifty-eight percent of respondents believed that a sexual relationship should be permitted for an adult with dementia, and t tests revealed that dementia had a statistical effect on participants' responses. Sex of the vignette character was not a predictor of attitudes. Participant's qualitative rationales are offered for additional insight.

DISCUSSION

Respondents who felt that a couple should not engage in a sexual relationship commonly cited consent-related issues as their primary concern. Implications for policy development are discussed.

Content analysis of public opinion on sexual expression and dementia: Implications for nursing home policy development

Purpose

We examined public opinion of sexual expression and dementia to inform nursing home policy and practice.

Design and Methods

A content analysis was conducted on public comments (N=1194) posted in response to a New York Times article about a highly publicized legal case involving a husband engaging in sexual acts with his wife who had dementia, living in a nursing home. Researchers utilized constant comparative analysis to code the comments; reliability analysis showed moderately strong agreement at the subcategory level. Data were also coded to indicate whether the commenter thought the couple should or should not have been allowed to be sexual.

Results

One primary theme was identified: conditions necessary for someone to be sexual. Six categories were identified within this theme, with the public commentary considering factors such as marital relationships, intimacy needs and several sexual consent‐related issues as key conditions necessary to be sexual in a nursing home setting. Overall, the majority of commenters were in support of sexual expression for an individual with dementia in the described situation.

Discussion

This study revealed sexual expression among individuals with dementia is a contentious issue with strong public opinions about how this should be managed in a nursing home setting. These opinions should be considered as policy related to sexual expression in nursing homes is developed.

Recommendations for sexual expression management in long-term care: a qualitative needs assessment

AIMS

To conduct a qualitative needs assessment of Directors of Nursing regarding challenges and recommendations for addressing sexual expression and consent.

BACKGROUND

Sexual expression management among long-term care residents is a complex issue for nursing home staff. Little guidance is available for those wanting to follow a person-centred approach. Policies and procedures are needed, and must be usable across long-term care settings.

DESIGN

Qualitative design for in-depth exploration.

METHODS

Semi-structured interviews were conducted with 20 Directors of Nursing in the spring and summer of 2013, representing a range of regions, facility sizes and resident populations. Interview questions prompted them to identify recommendations that address challenges to improving sexual expression management in long-term care settings.

RESULTS

Comparative thematic analysis resulted in several codes, which were grouped into eight overall categories. Recommendation categories that addressed key challenges included: address the issue, make environmental changes, identify staff expertise, provide education and training, assess sexuality initially and recurrently, establish policies/procedures for sexual expression management, develop assessment tools for sexual expression and consent, and clarify legal issues. The recommendation to develop national guidelines was observed across categories.

DISCUSSION

Directors of Nursing report several challenges to sexual expression management in their facilities, and perceive their current methods to be ad hoc. A proactive approach to policy and procedure development is needed.

Sexual Consent Capacity Assessment with Older Adults

Many healthcare providers have a limited knowledge of sexual and intimate expression in later life, often due to attitudinal and informational limitations. Further, the likelihood of an older adult experiencing cognitive decline increases in a long-term care (LTC) setting, complicating the ability of the providers to know if the older adult can make his or her own sexual decisions, or has sexual consent capacity. Thus, the team is left to question if and how to support intimacy and/or sexuality among residents with intimacy needs. Psychologists working with LTC need to be aware and knowledgeable about sexual consent capacity in older adulthood to be prepared to conduct evaluations and participate in planning care. Limited research is available to consult for best practices in sexual consent capacity assessment; however, models of assessment have been developed based on the best available evidence, clinical judgment, and practice. Existing models will be discussed and an integrated model will be illustrated via a case study.

Nurses’ knowledge and attitudes toward aged sexuality in Flemish nursing homes

Background:

Admission to a nursing home does not necessarily diminish an older person’s desire for sexual expression and fulfillment. Given that nursing staff directly and indirectly influence the range of acceptable sexual expressions of nursing home residents, their knowledge and attitudes toward aged sexuality can have far-reaching effects on both the quality of care they provide to residents and the self-image and well-being of these residents.

Research objectives:

To investigate nursing staff’s knowledge and attitudes toward aged sexuality, to determine whether certain sociodemographic factors of the nursing staff relate to their knowledge and attitudes toward later-life sexuality, and to examine the relationship between knowledge and attitudes.

Research design:

Descriptive cross-sectional survey study.

Research participants and research context:

The administered questionnaire collected sociodemographic data and data from an adapted, Dutch version of the Aging Sexual Knowledge and Attitudes Scale. Data were collected from November 2011 through April 2012. A total of 43 geographically dispersed nursing homes in Flanders, Belgium, participated. Out of a potential research sample of 2228 nursing staff respondents, 1166 participated.

Ethical considerations:

The study protocol was approved by the Ethics Committee of the Faculty of Medicine of the KU Leuven.

Findings:

Nursing staff appeared to be moderately knowledgeable about aged sexuality and displayed a rather positive attitude toward sexuality in older people. Significant relationships between various variables were found both at univariable and multivariable levels. Knowledge and attitudes proved to be positively related, indicating that a higher level of knowledge of aged sexuality is associated with a more positive attitude toward sexuality in later life.

Discussion:

Research findings are discussed within a broader international context.

Conclusion:

There is room for improvement for both nursing staff’s knowledge and attitudes toward aged sexuality. This might be aided by appropriate educational interventions. Our results identified different target groups of nursing home staff for these interventions.

Intimacy between care home residents with dementia: Findings from a review of the literature

BACKGROUND

There is limited research on what family members and frontline care home staff consider to be the best responses to the sexual expression of a person with dementia, whilst at the same time respecting relatives' feelings, managing their possible distress and conflict, and how good practice should be reflected in care home policy and practice guidance.

METHODS

This literature review explored what is known of the views of relatives and care workers of new relationships or sexual intimacy between care home residents with dementia, whilst still married to another person. It reports the findings of searches of three databases undertaken in August 2014 (Medline, Embase and PsychINFO).

FINDINGS

Nine papers were found relevant to the research question. The following themes emerged from a synthesis of the papers located: sexuality in old age, dementia and sexuality, hyper-sexuality, views regarding sexuality of older people living in care homes, the law, ethics and consent, relationships and communication between care home and relatives, and new relationships or intimacy between residents with dementia.

CONCLUSION

While studies of residents' expression of sexuality and their engaging in sexual behaviour with other resident(s) may be challenging to manage in care home settings and can be emotionally painful or uncomfortable for families, the review found that studies are few in number and span emotional intimacy and distressing behaviour.

New relationships and intimacy in long-term care: The views of relatives of residents with dementia and care home staff

Background There is limited research on what family members and frontline care home staff consider to be the best responses to the sexual expression of a person with dementia, whilst at the same time respecting relatives' feelings, managing their possible distress and conflict. Methods This exploratory study investigated the views of relatives and care workers of new relationships or sexual intimacy between care home residents with dementia, whilst still married to another person. It reports the themes that emerged in qualitative interviews with eight relatives of people with dementia and with 12 frontline care home staff working in two English care homes. Interviews took place in 2015 using a hypothetical vignette that unfolded in four stages. Thematic analysis was used to analyse the data. Findings The views of care home staff and relatives had similarities in general terms regarding the problems arising around expressions of sexuality in care homes: indicting that a light-hearted or non-physical connection between residents is deemed acceptable, but the moment it becomes a sexual relationship then decision making becomes more complicated. Staff were inclined to turn to managers for advice and to consider separating residents. They expressed familiarity with distracting residents from situations that were of concern. Relatives were considerate of the difficulties and dilemmas faced by care home staff. Conclusion The use of a vignette facilitated discussion of a potentially sensitive topic. Areas for further research are identified.

The Complexities of Sexual Consent Among College Students: A Conceptual and Empirical Review

Headlines publicize controversies about sexual assault among college students, and universities face pressure to revise their sexual consent policies. What can the social science literature contribute to this discussion? In this article, we briefly discuss reasons for the recent upsurge in attention to these issues, the prevalence of sexual assault among college students, and aspects of college life that increase the risk of sexual assault and complicate sexual consent. We then review the conceptual challenges of defining sexual consent and the empirical research on how young people navigate sexual consent in their daily lives, focusing primarily on studies of U.S. and Canadian students. Integrating these conceptual issues and research findings, we discuss implications for consent policies, and we present five principles that could be useful for thinking about consent. Finally, we discuss some of the limitations of the existing research and suggest directions for future research.

Análise bioética da esterilização em pessoas com deficiência intelectual

O estudo analisa a opinião de juízes, médicos, psicólogos, membros de Comitê de Ética em Pesquisa, familiares de deficientes intelectuais e público em geral, sobre a esterilização de deficientes intelectuais, que consta na Lei n° 9.263, de 23 de janeiro de 1996. Os dados foram analisados sob a Declaração Universal sobre Bioética e Direitos Humanos, da Unesco, considerando o princípio da autonomia e seus artigos 7 e 8. Conclui-se, com este estudo, que a lei requer ajustes e deve considerar princípios da bioética relacionados com os direitos humanos e a deficiência intelectual, que fundamentam a normativa desde esta perspectiva, constituindo fonte valiosa e mais segura para futuras tomadas de decisões.

Public Attitudes Toward Sexual Expression in Long-Term Care: Does Context Matter?

The purpose of this study was to (a) examine how age and sex of long-term care (LTC) residents influence public attitudes toward sexuality in LTC and (b) understand how, in the absence of cognitive decline, residing in LTC influences the perception of sexuality as a basic human right. Attitudes were examined using a factorial vignette with a probability sample of 325 respondents from a southern state. Results indicate that attitudes were not statistically affected by a vignette character's age or sex; but respondent education level, parenthood status, and religious affiliation did have direct bearing on attitudes. The notion of sexuality as a basic human right for residents of LTC was ultimately challenged as 19% of respondents said that LTC residents should not be permitted to have sexual relations with their spouse in the facility.

Eternal sunshine of the spotless mind? An anthropological-ethical framework for understanding and dealing with sexuality in dementia care

Contemporary bioethics pays considerable attention to the ethical aspects of dementia care. However, ethical issues of sexuality especially as experienced by institutionalized persons with dementia are often overlooked. The relevant existing ethics literature generally applies an implicit philosophical anthropology that favors the principle of respect for autonomy and the concomitant notion of informed consent. In this article we will illustrate how this way of handling the issue fails in its duty to people with dementia. Our thesis is that a more inclusive philosophical anthropology is needed that also heeds the fate of this growing population. Drawing on the tradition of phenomenology, we will chalk out an anthropological framework that rests on four fundamental characteristics of human existence: the decentered self, human embodiment, being-in-the-world and being-with-others. Our aim in this article is thus to tentatively put forward a broader perspective for looking at aged sexuality in institutionalized people with dementia. Hopefully the developed framework will mark the beginning of a new and refreshed ethical reflection on the topic at hand.

Supporting residents' expression of sexuality: the initial construction of a sexuality assessment tool for residential aged care facilities

BACKGROUND

Sexuality is a key component of quality of life and well-being and a need to express one's sexuality continues into old age. Staff and families in residential aged care facilities often find expressions of sexuality by residents, particularly those living with dementia, challenging and facilities often struggle to address individuals' needs in this area. This paper describes the development of an assessment tool which enables residential aged care facilities to identify how supportive their organisation is of all residents' expression of their sexuality, and thereby improve where required.

METHODS

Multi-phase design using qualitative methods and a Delphi technique. Tool items were derived from the literature and verified by qualitative interviews with aged care facility staff, residents and families. The final item pool was confirmed via a reactive Delphi process.

RESULTS

A final item pool of sixty-nine items grouped into seven key areas allows facilities to score their compliance with the areas identified as being supportive of older people's expression of their sexuality in a residential aged care environment.

CONCLUSIONS

The sexuality assessment tool (SexAT) guides practice to support the normalization of sexuality in aged care homes and assists facilities to identify where enhancements to the environment, policies, procedures and practices, information and education/training are required. The tool also enables facilities to monitor initiatives in these areas over time.

Staff attitudes towards sexual relationships among institutionalized people with dementia: does an extreme cautionary stance predominate?

BACKGROUND

This study explores whether staff perceptions and reactions to sexual situations involving one or two persons with dementia (PWD) reflect an extreme cautionary stance (an overprotective and paternalist style) or a person-centered model of care (focusing on understanding the residents' perspective and their rights).

METHOD

Fifty-three staff members currently working in residential aged care facilities (RACFs) were purposively selected to participate in the study. Two vignettes describing sexual situations involving PWD were presented to participants. They were asked about their interpretation of the situation and how they would react. Data were analyzed using content analysis, aimed at identifying common themes in the responses.

RESULTS

When the sexual relationship involved a PWD and a cognitively intact resident, participants tended to define the situation as real (54.7%) or possible (35.8%) abuse, whereas when both parties had dementia it was more frequently conceptualized as a possibly abusive (39.6%) or non-abusive (37.7%) situation. The most frequent reaction to both situations was seeking the advice of other professionals.

CONCLUSION

The interpretation of the first situation is compatible with an extreme cautionary stance, whereas the second scenario is less clearly perceived as an example of abuse.

Philosophical issues in dementia

PURPOSE OF REVIEW

This review aims to consider the philosophical literature from the last 18 months relevant to dementia. Philosophical thought should underpin and strengthen developments in clinical practice. For instance, deepening our thoughts about personhood should support the development of person-centred care.

RECENT FINDINGS

There is relatively little work written by philosophers about dementia. But much of the writing by health and social care researchers and much empirical work in this field throws up philosophical issues. These do not solely concern personal identity, personhood and selfhood, even if the literature frequently refers to these topics. Instead we see, first, that there are other issues (around citizenship, rights, the nature of mind, of normality and of ageing) which deserve further philosophical attention and, secondly, that the discussions about personhood have moved beyond the concern that our persistence over time as individuals depends on memory to encompass a broader view which emphasizes instead the ability of people to continue to construct their life-worlds through their persisting meaningful relationships.

SUMMARY

Real interaction with people with dementia creates an increasingly nuanced account of the life-worlds of people with dementia, which should stimulate both philosophical work and clinical practice.

'We need to know what's going on': views of family members toward the sexual expression of people with dementia in residential aged care

This paper reports on a study which explored the views and attitudes of family members towards the sexual expression of residents with dementia in residential aged care facilities in two states in Australia. Recruitment was challenging and only seven family members agreed to an interview on this topic. Data were analysed using a constant comparative method. Family were generally supportive of residents' rights to sexual expression, but only some types of behaviours were approved of. There was an acknowledgement that responding to residents' sexuality was difficult for staff and many families believed that they should be kept informed of their relative's sexual behaviours and moreover be involved in decision making about it. Findings suggest the need for family education and a larger study to better understand the views and motivations of family carers and how these might impact on the sexual expression of the older person with dementia living in residential aged care.

Being central to decision making means I am still here!: the essence of decision making for people with dementia

The ability to make choices and decisions, and to have those decisions upheld, is central to self-determination. For people living with a diagnosis of dementia, however, it can be difficult to remain involved in decision making. While many studies show that people with mild or moderate dementia have the ability to participate in decision making, there are also indications that the attitudes of those around them, including health professionals and family carers, can sometimes be a barrier, and there is generally little understanding about the nature of decision making for this population. This small pilot study draws on van Manen's approach to phenomenology to explore the essence of decision making for people living with dementia. The findings highlight the importance of remaining central to decision making, and the key role that subtle support from carers plays in enabling this.