Resources

  1. Lindau, ST., Dale, W., Feldmeth, GS, Gavrilova, N., Langa, K., Makelarski, J. & Wroblewski, K. (2018). Sexuality and Cognitive Status: A U.S. Nationally Representative Study of Home-Dwelling Older Adults.  J Am Geriatr Soc. 2018 Oct;66(10):1902-1910. doi: 10.1111/jgs.15511. Epub 2018 Sep https://www.ncbi.nlm.nih.gov/pubmed/30207599
  2. Bronner G (2015) Addressing Sexuality in Dementia: A Challenge for Healthcare Providers. J Alzheimers Dis Parkinsonism 5: 180. doi: 10.4172/2161-0460.1000180 https://www.omicsonline.org/open-access/addressing-sexuality-in-dementia-a-challenge-for-healthcare-providers-2161-0460-1000180.php?aid=42236

Transcript

Dr. Frank Domino:

Carol, aged 72, and Maurice, aged 76, are here today for Maurice's follow-up. Maurice was diagnosed with mild cognitive impairment a year ago, but exhibited symptoms even earlier. Today Carol is asking what lies ahead for both her and Maurie. She is particularly concerned about their intimacy. Maurie seems less affectionate and that worries her. They have always enjoyed a healthy sex life, and she is fearful for their future.

 

Hi, this is Frank Domino, Professor in the Department of Family Medicine and Community Health at the University of Massachusetts Medical School. And here today joining me to discuss intimacy issues in patients with cognitive impairment is Dr. Jill Terrien, Associate Professor and Director of the Nurse Practitioner Program at the University of Massachusetts Medical School's Graduate School of Nursing. Thanks for coming today, Jill.

 

Jill Terrien:

Thank you, Frank.

 

Dr. Domino:

Wow, so, Carol and Maurie are becoming a more common problem than we probably were used to in the past. How should primary care providers begin this discussion around intimacy, especially with older patients?

 

Jill Terrien:

I think it's a topic that is... Sometimes it's not easy to bring up. In our case here, we have Carol asking, so it's right out there on the table, which is great, but I think that intimacy, sexuality is all part of our patients' life. So it's something we really need to address when we think about our patients but also think about how they're aging in place and especially with cognitive changes and how that affects their caregivers, whether their caregiver is their partner or whether the caregiver is a friend, it's talking about anticipatory guidance in their relationship and what they see in their future.

 

Dr. Domino:

How about asking them about it? We were fortunate here that Carol brought it up. But how might you raise this question with the patient or a patient and their significant other?

 

Jill Terrien:

It comes under the umbrella of holistic care of the patient and how their life may be changing, especially if you're watching their cognition change, and kind of saying, "How are things going for you? How is your relationship?" So it's all talking about... When we say the the word "sexuality," I think sometimes we immediately think of intercourse and it's not just intercourse, it's closeness, it's intimacy, it's hand-holding, it's touching, it's kissing, it's not intercourse, just alone. So I think that it encompasses a whole wide range of how people be with each other and care for each other, and we do know that as dementia progresses, there are changes in that person.

 

Dr. Domino:

Well, so that raises the next question. What does the literature tell us about how intimacy changes in this population?

 

Jill Terrien:

So yes, this is interesting. So this episode is focusing on sexuality and home-dwelling older adults with cognitive changes, and you will see that the study by Lindau was really the first United States look at a nationally representative sample, and what they found is that sexuality is really common in adults ages 65 to 91 living at home with cognitive changes, that over 50% of them are sexually active, and then even in the older old, when they get into their 80s and 90s, 30% to 40% of them are sexually active as well.

 

Dr. Domino:

So that's both encouraging but also worrisome, because it does require you to investigate things with the patient and their family and make sure that there's no danger of people feeling obligated to do things or being forced to do things.

 

Jill Terrien:

Absolutely. That was addressed in this study, because there's a fine line sometimes, and when we talk about dementia is, it's not like we can say, "Okay, a year from now, your relationship will be like X because Maurie is gonna change." You don't know that. It is not on this continuum where we can predict. So what can we do as primary care providers, is provide this anticipatory guidance and have this open communication, and because Carol has brought this up today, it's really important that next time they come in, "How is it going? Things going okay?" Are there resources that we can offer to the patient and their partner to assist?

 

Dr. Domino:

I think it's a very high priority piece; quality of life is what you're trying to preserve especially as patients with cognitive decline worsen. And so being open to the discussion, raising it and at follow-up, checking in on it makes great sense. Any other thoughts about what we could be doing to help in particular Carol in this exchange? Is there anything we can do to reassure her or to at least make her feel grounded?

 

Jill Terrien:

Well, yes, I think that, again, I keep focusing kind of on open communication, but it's so important and I would thank Carol for bringing up the topic because it's not an easy topic. They found that less than 20% of patients will actually ask their healthcare provider about sexuality and any changes that they are experiencing. So I think that the advice we can say is, she needs to make sure that she stays in touch socially with others and maybe there's something that we can provide to Maurie where he can have some, she can have some respite, depending on what the situation is, but I think that it's important that she has good socialization with Maurie and possibly with others. And so I think that's one thing, resources, there was actually therapeutic touch was mentioned as a possible non-pharmacologic intervention in patients that feel that they are not having enough enough sexual gratification.

 

Dr. Domino:

For the patient or for the significant other?

 

Jill Terrien:

For the patient.

 

Dr. Domino:

Wow, interesting, very interesting.

 

Jill Terrien:

Because you touched on the part of are how things going, is it... Are people being forced to have intimacy, and that's a different conversation, but certainly a question that needs to be asked. How are things going, right, and you're gonna get the answers.

 

Dr. Domino:

I think that's great, it's startling to see that so few patients in this situation have those discussions with their healthcare provider. So it sounds like the takeaway points here are we really need to be open, ask those questions, don't wait for the patient to bring it up, offer suggestions and, as always, offer really close follow-up, because, again, the quality of life is really what we're trying to preserve, not really much more.

 

Jill Terrien:

Right, right.

 

Dr. Domino:

Jill, thanks so much.

 

Jill Terrien:

Thank you, Frank.

 

Dr. Domino:

Practice pointer: In your patients with cognitive decline and their families, inquire of their intimacy and closeness issues and provide good follow-up. Join us next time when we talk about the significant impact of treating periodontal disease and type 2 diabetes.