Long-Term Care Survey Alert

Survey says: Special attention to staff training required.

Sex in the facility? It may not have potential as a new TV show, but the topic definitely warrants new consideration by today’s nursing home administrators and clinicians.

A new report from AMDA (formerly the American Medical Directors Association) reveals that many nursing home professionals have so far dismissed or overlooked the need for staff training and policies regarding nursing home residents’ sexuality.

Background: A July 2013 report from the news agency Bloomberg News sparked interest this year in the topic of sexuality and long-term care. In response, AMDA, with input from Bloomberg, developed a survey to learn more about nursing home professionals’ attitudes regarding residents’ sexuality and related nursing home policy. The survey results, released in late October, show that just 13 percent of survey respondents work for a nursing facility that provides any staff training related to aging and sexual behavior.

Translated: Most nursing home workers are “significantly undertrained” on the topic of sexual behavior among residents, says AMDA — and that can easily lead to costly strikes at survey time. Worse, survey missteps of the sexual variety are particularly likely to attract negative media attention, further damaging your facility’s reputation.

The Bloomberg report featured a 2009 case involving residents at Windmill Manor, a nursing home in Coralville, Iowa. A nurse discovered that an 87-year-old woman with dementia had just had intercourse with a 78-year-old male resident, also with dementia. Was the sex consensual? What role did the residents’ family members rightly have in influencing the course of the couple’s relationship? (The woman was married). Had the nursing home employees failed to protect the residents’ best interests? If the sex was consensual, did the nursing home now have a responsibility to protect the residents’ right to sexual privacy? Did the facility have a responsibility to report the incident?

The questions are complex, but nursing homes should not avoid them. A head-in-the-sand attitude will almost certainly lead to survey trouble and legal liability in the future, particularly as baby boomers age, experts say.

Pamela Atwood, director of life enrichment and dementia care at Hebrew Health Care in West Hartford, Connecticut, encourages facility administrators and clinicians to face the issues head on, with a positive mindset. As a generation, baby boomers are more open about sexuality and intimacy than previous generations — and their attitudes aren’t likely to change upon admission to a nursing home, reminds Atwood.

Room For Improvement

The need for clear policies and improved staff training is becoming increasingly evident. The AMDA survey revealed that less than a quarter of nursing homes (23 percent) have policies in place on intimacy and sexual behavior among residents. Furthermore, 31 percent have no plans to tackle the delicate topic.

Thirty-four percent of respondents reported that they had received no formal training related to sexual behavior and intimacy among nursing home residents. Among those who had received training, 46 percent had attended a continuing education session or workshop, and 39 percent had read a journal article; just 30 percent reported participation in a formal training program.

Among those whose facilities had some sort of related policy on the books, 35 percent reported general policies regarding sexual behavior among residents; only 19 percent specifically addressed how to determine a resident’s capacity for consent, and even fewer — 14 percent — addressed sexual activity by patients with diagnosed dementia.

If training is lacking, so is regulation. Most states follow a federal guideline that requires no private room accommodation in nursing homes. Eighteen states protect married couples’ rights to conjugal visits within the long-term care setting. Just four states define the right of unmarried couples to have private visits.

Balancing Act

Some critics are concerned that nursing homes do little to support sex among seniors, while others insist that many facilities do too little when it comes to protecting vulnerable residents from sexual abuse.

The balance between safety and sexual autonomy may not be easy, but most providers will do well to take both criticisms to heart. Although allegations of sexual abuse are the most likely to lead to survey citations and legal action, nursing homes intent on providing the best person-centered care may also need to be more proactive in protecting residents’ right to sexual privacy and intimacy.

AMDA is urging providers to change the “prevailing paradigm” of “silence and invisibility.” In large part, progress will come when facilities begin talking about seniors’ sexuality — the good and the bad — and respond in earnest with policies that respond to residents’ needs.

Nursing homes should craft policies carefully, says Thomas Magnuson, M.D., assistant professor of geriatric psychiatry at the University of Nebraska Medical Center and a physician affiliated with the Home Instead Center for Successful Aging, in Omaha, Nebraska.

Starting point: Offer training that helps staff understand how sexuality changes with age. Although sexual drive diminishes with age, sexual desire can persist into life’s later stages.

Research suggests that among those aged 65 to 74 years old, about two-thirds of men and 40 percent of women are sexually active (defined as having had sex with a partner at least once in the previous twelve months). Among 75- to 85-year-olds, the percentages are still relatively high: 38 of men and 17 percent of women are sexually active.

Baby boomers, in particular, expect sexuality to be a part of aging, says Magnuson — and nursing homes should be prepared. A survey released in September by the Center on Aging at Kansas State University warns of institutional barriers to sexual expression in long-term care, from lack of physical privacy to staff gossip about resident couples.

Staff training should also stress that dementia can affect residents’ sexual side. In some cases, hypersexuality becomes a concern (see sidebar, Sexual Abuse: A Cautionary Tale).