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Guideline Summary
Guideline Title
Sexuality in the older adult. In: Evidence-based geriatric nursing protocols for best practice.
Bibliographic Source(s)
Wallace Kazer M. Issues regarding sexuality. In: Boltz M, Capezuti E, Fulmer T, Zwicker D, editor(s). Evidence-based geriatric nursing protocols for best practice. 4th ed. New York (NY): Springer Publishing Company; 2012. p. 500-15.
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Arena JM, Wallace M. Issues regarding sexuality. In: Capezuti E, Zwicker D, Mezey M, Fulmer T, editor(s). Evidence-based geriatric nursing protocols for best practice. 3rd ed. New York (NY): Springer Publishing Company; 2008 Jan. p. 629-47.

Scope

Disease/Condition(s)

Sexual health

Guideline Category
Evaluation
Management
Clinical Specialty
Family Practice
Geriatrics
Nursing
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Nurses
Physician Assistants
Physicians
Guideline Objective(s)

To provide a standard of practice protocol to enhance the sexual health of older adults

Target Population

Older adults

Interventions and Practices Considered

Assessment/Evaluation

  1. Use of the Permission, Limited Information, Specific Suggestion, Intensive Therapy (PLISSIT) model
  2. Assessment for presence of physiologic changes and medical conditions
  3. Medication review

Management

  1. Communication and education
  2. Health management
  3. Sexual enhancement
Major Outcomes Considered

Quality of life

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Although the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument (described in Chapter 1 of the original guideline document, Evidence-based Geriatric Nursing Protocols for Best Practice, 4th ed.) was created to critically appraise clinical practice guidelines, the process and criteria can also be applied to the development and evaluation of clinical practice protocols. Thus, the AGREE instrument has been expanded (i.e., AGREE II) for that purpose to standardize the creation and revision of the geriatric nursing practice guidelines.

The Search for Evidence Process

Locating the best evidence in the published research is dependent on framing a focused, searchable clinical question. The PICO format—an acronym for population, intervention (or occurrence or risk factor), comparison (or control), and outcome—can frame an effective literature search. The editors enlisted the assistance of the New York University Health Sciences librarian to ensure a standardized and efficient approach to collecting evidence on clinical topics. A literature search was conducted to find the best available evidence for each clinical question addressed. The results were rated for level of evidence and sent to the respective chapter author(s) to provide possible substantiation for the nursing practice protocol being developed.

In addition to rating each literature citation as to its level of evidence, each citation was given a general classification, coded as "Risks," "Assessment," "Prevention," "Management," "Evaluation/Follow-up," or "Comprehensive." The citations were organized in a searchable database for later retrieval and output to chapter authors. All authors had to review the evidence and decide on its quality and relevance for inclusion in their chapter or protocol. They had the option, of course, to reject or not use the evidence provided as a result of the search or to dispute the applied level of evidence.

Developing a Search Strategy

Development of a search strategy to capture best evidence begins with database selection and translation of search terms into the controlled vocabulary of the database, if possible. In descending order of importance, the three major databases for finding the best primary evidence for most clinical nursing questions are the Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Medline or PubMed. In addition, the PsycINFO database was used to ensure capture of relevant evidence in the psychology and behavioral sciences literature for many of the topics. Synthesis sources such as UpToDate® and British Medical Journal (BMJ) Clinical Evidence and abstract journals such as Evidence Based Nursing supplemented the initial searches. Searching of other specialty databases may have to be warranted depending on the clinical question.

It bears noting that the database architecture can be exploited to limit the search to articles tagged with the publication type "meta-analysis" in Medline or "systematic review" in CINAHL. Filtering by standard age groups such as "65 and over" is another standard categorical limit for narrowing for relevance. A literature search retrieves the initial citations that begin to provide evidence. Appraisal of the initial literature retrieved may lead the searcher to other cited articles, triggering new ideas for expanding or narrowing the literature search with related descriptors or terms in the article abstract.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Evidence

Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews)

Level II: Single experimental study (randomized controlled trials [RCTs])

Level III: Quasi-experimental studies

Level IV: Non-experimental studies

Level V: Care report/program evaluation/narrative literature reviews

Level VI: Opinions of respected authorities/consensus panels

AGREE Next Steps Consortium (2009). Appraisal of guidelines for research & evaluation II. Retrieved from http://www.agreetrust.org/?o=1397 External Web Site Policy.

Adapted from: Melnyck, B. M. & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & health care: A guide to best practice. Philadelphia, PA: Lippincott Williams & Wilkins and Stetler, C.B., Morsi, D., Rucki, S., Broughton, S., Corrigan, B., Fitzgerald, J., et al. (1998). Utilization-focused integrative reviews in a nursing service. Applied Nursing Research, 11(4) 195-206.

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

Not stated

Recommendations

Major Recommendations

Levels of evidence (I–VI) are defined at the end of the "Major Recommendations" field.

Assessment

  • The Permission, Limited Information, Specific Suggestion, Intensive Therapy (PLISSIT) model (Annon, 1976 [Level IV]) begins by first seeking permission (P) to discuss sexuality with an older adult. The next step of the model affords an opportunity for the nurse to share limited information (LI) with the older adult. What about SSIT?
  • Ask open-ended questions such as "Can you tell me how you express your sexuality?" or "What concerns you about your sexuality?" and "How has your sexuality changed as you have aged?"
  • Assess for presence of physiological changes through a health history, review of systems, and physical examination for the presence of normal and aging changes that impact sexual health.
  • Review medications among older adults, especially those commonly used to treat medical illnesses that also impact sexuality, such as antidepressants and antihypertensives.
  • Assess medical conditions that have been associated with poor sexual health and functioning including depression, cardiac disease, stroke and aphasia, Parkinson's disease (PD), and diabetes.

Nursing Care Strategies

Communication and Education

  • Discuss normal age-related physiological changes.
  • Address how the effects of medications and medical conditions may affect one's sexual function.
  • Facilitate communication with older adults and their families regarding sexual health as desired, including the following:
    • Encourage family meetings with open discussion of issues if desired.
    • Teach about safe sex practices.
    • Discuss use of condoms to prevent transmission of sexually transmitted infections (STIs) and human immunodeficiency virus (HIV).

Health Management

  • Perform a thorough patient assessment.
  • Conduct a health history, review of systems, and physical examination.
  • Effectively manage chronic illness.
  • Improve glucose monitoring and control among diabetics.
  • Ensure appropriate treatment of depression and screening for depression (see the National Guideline Clearinghouse [NGC] summary of the Hartford Institute for Geriatric Nursing guideline Depression in older adults).
  • Discontinue and substitute medications that may result in sexual dysfunction (e.g., hypertension or depression medications).
  • Accurately assess and document older adults' ability to make informed decisions (see the NGC summary of the Hartford Institute for Geriatric Nursing guideline Health care decision making).
  • Participation in sexual relationships may be considered abusive if an older adult is not capable of making decisions.

Sexual Enhancement

  • Compensate for normal changes of aging.
    • Females:
      • Use of artificial water-based lubricants
      • Use of estrogen creams (Freedman et al., 2009 [Level II])
    • Males:
      • Recognizing the possibility for more time and direct stimulation for arousal caused by aging changes. Use of oral erectile agents for erectile dysfunction (Wespes et al., 2007 [Level II]).
  • Environmental adaptations
    • Ensure privacy and safety among long-term care and community-dwelling residents (Wallace, 2008 [Level V]).

Follow-up Monitoring of Condition

Sexual outcomes are difficult to directly assess and measure. However, with the illustrated link between sexual health and quality of life, quality of life measures such as the Short Form (SF)-36 Health Survey External Web Site Policy may be used to determine the effectiveness of interventions to promote sexual health.

Definitions:

Levels of Evidence

Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews)

Level II: Single experimental study (randomized controlled trials [RCTs])

Level III: Quasi-experimental studies

Level IV: Non-experimental studies

Level V: Care report/program evaluation/narrative literature reviews

Level VI: Opinions of respected authorities/consensus panels

AGREE Next Steps Consortium (2009). Appraisal of guidelines for research & evaluation II. Retrieved from http://www.agreetrust.org/?o=1397 External Web Site Policy.

Adapted from: Melnyck, B. M. & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & health care: A guide to best practice. Philadelphia, PA: Lippincott Williams & Wilkins and Stetler, C.B., Morsi, D., Rucki, S., Broughton, S., Corrigan, B., Fitzgerald, J., et al. (1998). Utilization-focused integrative reviews in a nursing service. Applied Nursing Research, 11(4) 195-206.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for selected recommendations (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Patients

  • High quality of life as measured by a standardized quality of life assessment
  • Privacy, dignity, and respect surrounding their sexuality
  • Communication and education regarding sexual health as desired
  • Ability to pursue sexual health free of pathological and problematic sexual behaviors

Nurses

  • Inclusion of sexual health questions in routine history and physical
  • Frequent reassessment of patients for changes in sexual health

Institutions

  • Inclusion of sexual health questions on intake and reassessment measures
  • Provision of education on the ongoing sexual needs of older adults and appropriate interventions to manage these needs with dignity and respect
  • Provision of needed privacy for individuals to maintain intimacy and sexual health (e.g., in long-term care)
Potential Harms

Not stated

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Chart Documentation/Checklists/Forms
Mobile Device Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Wallace Kazer M. Issues regarding sexuality. In: Boltz M, Capezuti E, Fulmer T, Zwicker D, editor(s). Evidence-based geriatric nursing protocols for best practice. 4th ed. New York (NY): Springer Publishing Company; 2012. p. 500-15.
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2008 (revised 2012)
Guideline Developer(s)
Hartford Institute for Geriatric Nursing - Academic Institution
Guideline Developer Comment

The guidelines were developed by a group of nursing experts from across the country as part of the Nurses Improving Care for Health System Elders (NICHE) project, under sponsorship of the Hartford Institute for Geriatric Nursing, New York University College of Nursing.

Source(s) of Funding

Hartford Institute for Geriatric Nursing

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Primary Author: Meredith Wallace Kazer, PhD, APRN, A/GNP-BC, Associate Professor, Fairfield University, Fairfield, CT

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Arena JM, Wallace M. Issues regarding sexuality. In: Capezuti E, Zwicker D, Mezey M, Fulmer T, editor(s). Evidence-based geriatric nursing protocols for best practice. 3rd ed. New York (NY): Springer Publishing Company; 2008 Jan. p. 629-47.

Guideline Availability

Electronic copies: Available from the Hartford Institute for Geriatric Nursing Web site External Web Site Policy.

Copies of the book Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th edition: Available from Springer Publishing Company, 536 Broadway, New York, NY 10012; Phone: (212) 431-4370; Fax: (212) 941-7842; Web: www.springerpub.com External Web Site Policy.

Availability of Companion Documents

The following is available:

The ConsultGeriRN app for mobile devices is available from the Hartford Institute for Geriatric Nursing Web site External Web Site Policy.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on June 16, 2008. The information was verified by the guideline developer on August 4, 2008. This NGC summary was completed by ECRI Institute on June 25, 2013. The updated information was verified by the guideline developer on August 6, 2013.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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