SEXUAL HEALTH AMONG OLDER ADULTS WITH MAJOR NEUROCOGNITIVE DISORDER IN LONG TERM CARE FACILITIES: WHAT DO WE KNOW?

Abstract

Introduction Sexual health among older adults in long term care facilities is a burgeoning area of interest, with more research on the topic published in the last two decades. A systematic review published in 2015 reviewed intimacy and sexuality among nursing home residents with major neurocognitive disorder (MNCD). It concluded that future research and training opportunities should be directed towards the development and implementation of guidelines for the care of the sexual health of patients with MNCD. A 2016 examination of nursing home policies regarding resident sexual activity found that the majority of nursing homes (63.4%) do not have policies dealing with resident sexual activity and of those that do, only 58.6% have written policies. A 2017 article in the Journal of American Academy of Psychiatry and the Law discussed discrepancies in policies regarding the determination of appropriate sexual behavior in long term care facilities. They stated that a scientific consensus on defining what is acceptable healthy sexual activity has not been reached. Part of the difficulty of having an overarching sexual health policy may be the complexities of determining sexual consent capacity in older adults as well as differentiating appropriate from inappropriate sexual behaviors in those with MNCD. The determination of sexual consent and appropriateness is highly complex and spans clinical, legal and ethical considerations. There is lack of a defined method to assess appropriate and inappropriate sexual behavior as well as low level evidence of effective treatments for inappropriate sexual behavior. In this presentation, we review some of the current thoughts on sexual consent in patients with MNCD who reside in long term care facilities. Methods Systematic literature review Results Clinical Considerations: Determining sexual consent capacity as described by Jennifer Hillman in a 2017 paper is structured around the three primary constructs of (1) knowledge, (2) reasoning, and (3) voluntariness. This is a multi-factorial process involving not only the patient, the family, and the physician, but an entire multidisciplinary team with the physician gathering information within the three primary constructs from the other parties to help determine sexual consent capacity. Furthermore, in instances where the patient is then found to lack sexual consent capacity but continues to have interest in sexual expression, an article by James posits a community approach where the staff and family can advocate for the patient's right to sexual expression while minimizing harm based on substituted judgment. The AMA Journal of Ethics presents an ethics case where the husband of a long term care resident continues to engage in sexual activity with his partner. The authors offer an approach to assessing capacity to consent to sexual activity. They contrast the consent required to make sexual decisions to that needed to make medical decisions and refer to Lichtenberg and Strzepek's approach to assessing residents’ capacity to consent to sexual activity. The authors describe a two-step process whereby the multidisciplinary team, after completing the assessment, observes residents in their milieu in order to determine if their behavior is consistent with their interview responses. Legal Considerations: A 2018 article in the Journal of the American Academy of Psychiatry and the Law reviews landmark cases in rights of self-determination and examines a specific case in which an individual was charged with assault for alleged sexual interactions with his wife who had Alzheimer's disease. This article looks to forensic psychiatrists to create a sexual advance directive as a means of asserting sexual activity in situations where an individual has neurocognitive impairment. Ethical Considerations: Samuel Director of the University of Colorado Department of Philosophy defends the Prior Consent Thesis describing a specific situation where sex between a competent and incompetent partner is permissible. The Prior Consent Thesis states that if a partner is competent and can give prior consent to sex with their partner that will take place after occurrence of dementia, assuming their partner is the same person they were when the partner with dementia gave consent, then the partner without dementia may permissibly have sex with the partner with dementia. Conclusions The current literature highlights the complexity of determining the sexual capacity of patients with dementia in long term care settings. Future research may examine how existing policies within the long term care facilities are implemented and how they are able to keep the patients safe while affording them the autonomy to express themselves. This research was funded by: Not applicable