Managing Hypersexuality in the Nursing Home – Where to Begin?

On March 18, 2010, In Behavior Management, Clinical / Nursing, Social Services, By Mark

"Won't you protect me?"

Today, we’ll talk about hypersexuality of the nursing home resident when there is no 2 –party consent for sexual advances, and what to do to manage this behavior.

In the nursing home industry, you’ll run across it sooner or later.  A little male resident who goes from female resident to female resident attempting to touch, kiss, and grope them inappropriately.  He disrobes in public… or worse.  He tries to go into their rooms.  He is sneaky and waits until staff are busy and no one is visible in the area.  He preys on the most vulnerable of our residents – the ones who are confused, demented, and who usually can’t report the incident.  He may also get brave and begin this behavior with your staff as they are attempting to shower or dress the resident.  This can set you up for worlds of trouble.

What we must do is stop the inappropriate behavior and safeguard our residents as well as our staff.  There is no sweeping this under the rug hoping it will go away!

If not, not only do we put our residents and staff at risk for sexual abuse, you almost definitely set yourself and your facility up for an immediate jeopardy tag(s).

You need to evaluate the initial inappropriate behavior by the resident and address it immediately.  If not, it only gets worse.  Some residents start off with trying to grope the CNAs.  You must educate your CNAs to report this sexual aggression and you must take interventions at that time.

We have to attempt to find the source of the behavior.  Is there a new medication the resident is taking?  Is it related to the patient’s dementia?  Is there a history of sexual abuse or sexual inappropriate behavior? Is there a UTI or psychiatric disorder?  Does the resident have delusions?

Is it actually sexual behavior?  For example, removing clothes or inappropriately touching the staff when hugged or assisted with baths may not necessarily be sexual aggression.  It could be disorientation or confusion on what is actually going on related to their dementia.  If the resident has targeted one specific female, it may very well be likely that he is confusing that resident/staff member with a spouse or significant other.

Obviously, we would attempt non-pharmocological interventions at first to redirect the resident but we’d also consider a medication regimen if unsuccessful.  Collaboration with appropriate mental health professionals can produce excellent non-pharmocological interventions.

A cognitive screen and lab work-ups should be completed for the resident.  Labs may include a blood glucose level, BUN, CBC, PSA, LH, Testosterone level, urinalysis, and liver function.  For aggressive hypersexualism, you should make use of your resources.  Keep your primary physician and medical director in the know.  Bring in your pharmacy consultant for medication review.  Bring in mental health professionals for geri-psyche as appropriate.  Room changes, frequent or even temporary 1-to-1 monitoring may be necessary to manage the behavior.  The family should be kept in the loop and they’re also a source for historical information on the resident to see if these behaviors have occurred in the past.  Staff education is a necessity and must be ongoing.

No medication, as far as I know, is currently approved for the treatment of sexually inappropriate behavior.  That being said, there are a number of medications that are commonly used for the purpose of managing these behaviors (or at least allowing the drug’s side effects to kick in effectively reducing sexual desire).  Let me tell you, it is usually a game of trial and error.  The local primary physician may not be well-versed with hypersexuality in long term care, so it is of utmost importance to make sure they are discussing options with your pharmacist and mental health provider.  Many times, it may take a combination drug therapy approach to effectively reduce or eliminate the undesirable behavior.

Common types of drugs used for the management of hypersexuality and sexual inappropriate behaviors in the long term care setting:

  • Chols (cholinesterase inhibitors) – may decrease libido, may help cognitive and behavioral issues – examples –  Aricept, Exelon, Razadyne
  • SSRIs – may decrease libido and offer better impulse control – Celexa, Paxil, Zoloft, Prozac, Androcur
  • Mood Stabilizers and Antipsychotics – (limited usefulness) may help calm aggressive behaviors – Risperdal, Lithium, Depakote
  • Antiandrogen agents – may decrease sexual aggression and misbehavior in men as well as decrease fantasies and urges – Provera, Depo-Provera
  • Leuprolide/LHRH agonists – may inhibit gonadotropin release and suppress testosterone production – Lupron, Zoladex
  • Estradiol – may increase estrogen levels and decrease sexual behavior.
  • Cimetidine (Tagamet) – may decrease hypersexual behaviors.

I am not a physician, nor a pharmacist.  I am not advising you to use any of the drugs listed above for your residents or for the treatment of any disease or condition.  However, one needs to know what options are available when attempting to manage the sexually inappropriate and sexually aggressive  resident in the LTC setting.

Every drug has side effects that must be monitored and many of the ones listed must have labs ordered with them.  Depo-Provera is a great drug for use with these behaviors, but I have seen residents swell after a few months on it.  There are also ethical considerations of altering the balance of a resident’s hormones for the purpose of behavior management.  Choose wisely, keep the family and physician in close conversation.  Update the care plans and monitor the resident closely for effectiveness of the drug as an intervention and for potential drug side effects.

Even with a combination of these drugs in place, it still may be impossible to manage the resident’s hypersexual behavior.  Don’t be afraid to utilize a short-stay geri-psyche facility or to discharge the resident altogether (to a safe environment).  I would much rather take a tag on inappropriate discharge than an IJ on sexual abuse in the facility.

I would love to hear your opinion on this and if you’ve had success with other measures.

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Confusion Over Sexuality in the Nursing Home

On March 16, 2010, In Administration, Behavior Management, Social Services, By Mark

Every facility at one point or another will have to come to terms with the expression of sexuality by their residents.  This creates a ton of confusion with the staff, administration, corporate, families, ombudsman, and surveyors. To tell you the truth, it can be very confusing if you’ve never had to deal with it before or had no one to teach you.  That was the case for me, as well.  So, after having dealt with a few of these situations, I can now offer you some guidance so you don’t pull your hair out wondering if you did the right thing.

At one particularly confused facility, I had two residents who had developed a fondness for each other and seemed to want alone time together.  At least that’s what the male resident who could make his own decisions said, even though his family was mortified at Dad doing that kind of thing.  His chosen mate, unfortunately, could not make decisions very well and was frequently confused.  When I inherited this facility, I found out the staff had been allowing the residents to have sex per the direction of the Ombudsman (who was watching out for those residents’ rights! :roll: ) and the confused female resident’s daughter who stated, “My Momma can have sex if she wants to…”

Hit the brakes!  Oh, no she can’t!  Not in my building if she can’t give consent.  Finding out this little bit of information gave me a headache and a few heart palpitations.  Let’s go through a couple of points to consider here.

  1. The major determining factor of whether to allow these two residents to have sexual interaction lies with the ability of both residents to give consent.
  2. It doesn’t matter whether the confused female’s daughter has a POA, guardianship, conservatorship, or anything else.  The resident is in the care of the nursing home.  True – when a resident is unable to make their own decisions, the resident’s rights are transferred to the Responsible Party or to an individual directed by a court.  However, this does not include the ability to violate their human rights.  Human rights remain with the resident.  A responsible party cannot direct for a resident to have sexual intercourse or be subjected to any form of such interaction any more than they can direct for the resident to receive a high dose of insulin when the resident is not even diabetic.
  3. An Ombudsman has no authority to direct anything in this situation.  (This was a particularly bad Ombudsman).  However, if the Ombudsman feels like the resident’s rights are being violated, they must report this to the State.  So, you need a protocol in place to shut down any potential deficiencies.

First and foremost, you should have some type of sexuality assessment tool in place to determine the resident’s ability to give consent.  Here is a generic one (click here) that borrows a bit from Lichtenberg & Strzepek, 1990, Lichtenberg, 1997, and an old Pro-Ed form I got from a colleague in 2001.  Feel free to modify and individualize it for your own facility.

As you can see, there are many points to consider in order to make a determination of the ability to give consent. Use an assessment.  Review the results with the IDT team, family, and physician.  There may need to be some ongoing education and reminders for the resident to ensure their continued understanding and safety.  Or, they simply may not pass at all.  Update the care plan with the sexuality assessment and ongoing plan.

I had a female resident at one facility whose former profession was prostitution.  She was moderately confused at times, but still had enough about her to select a male suitor to fancy.  The problem, other than her unpredictable state of mind, was that she had syphilis.  And, the particular resident she selected to be her fellow had HIV.  What a bad combination.  Of course, neither knew about the other’s condition and I couldn’t tell them due to HIPAA.  So, I had to develop a sexuality assessment for the facility which included risk of STDs.  He passed fine.  She didn’t.  I then had a long talk with both residents individually.  In my conversation with the male resident, I might have thrown in a few hypothetical situations that would help persuade a man not to pursue a woman. :-)    Right or wrong, it worked.  He stayed his distance from her and we didn’t have any problems.

Stay tuned for Part 2 where we’ll discuss behavior management for aggressive hypersexual residents when there is no consent for sexual interaction.

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You Can’t Have Mental Health Services – You’re on Medicare!

On January 8, 2010, In Administration, Behavior Management, By Mark

Male patient sitting in a wheel chair sticking his tongue out in front of a stethoscope

Something interesting I’m finding in many facilities, and let me tell you, I’m a little upset over it.  Apparently, there are nursing home administrators out there that are telling their facilities that no resident can have mental health services while they’re on Medicare Part A.  What?  This is a terrible management decision.  If your administrator or your company is doing this, tell them I’m taking their keys right now.  They shouldn’t even worry about coming in tomorrow.  Or give them a link to this website.

As I explained in the 5 C’s of Long Term Care, Care always comes first.  The simple reason that the decision was made not to provide mental health services to residents on Part A is that the facility would be required to pay for the services.  It’s carved out of the Part A RUG rate the facility receives.

Ok, so the facility pays for it…so what?  Let’s consider what happens if you don’t provide the needed mental health/psyche services for your resident.  Not only will you be out of compliance, you are potentially allowing the resident’s condition to worsen to a point where they may harm another resident if the appropriate interventions and medication adjustments are not performed, which is part of what you should be receiving from your contracted mental health provider.  Then, what are you looking at?  Lawsuits.  G-tags or even an IJ.  All because someone wanted to save money.

Here’s a hint to those penny-pinching administrators who don’t come out of their office.  Instead of trying to save money by withholding services necessary for a resident, why don’t you focus on taking better care of your residents, promoting your facility, and increasing your revenue that way.

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Snoezelen Rooms – A New Tool for Alzheimers?

On December 21, 2009, In Behavior Management, Clinical / Nursing, Social Services, By Mark

Do you Snoezel? If not, you might need to start!

The word “Snoezelen” comes from 2 Dutch words, “snuffelen” (to seek out or explore, or to sniff) and “doezelen” (to relax, doze, or snooze).  The Snoezelen experience offers sensory stimulation and relaxation through lights, sounds, smells, and textures, and it appears that it can be a beneficial tool in the treatment of individuals with mental health issues.

While not exactly new, Snoezelen is catching on.  The Snoezelen concept was actually developed in the late 1970’s by two Dutch therapists from the De Hartenberg Institute in Holland, a center for individuals with intellectual disabilities.  Jan Hulsegge and Ad Verheul set up a sensory environment in a tent at one of their annual summer fairs and generated impressive results with challenged clients, both verbal and nonverbal.

Since that time the Snoezelen concept has evolved into multi-sensory stimulation rooms in many different types of settings.  A Snoezelen Room offers a safe, client-based, pressure-free environment enhanced for interpersonal interactions.

Some common Snoezelen Room settings include:

  • Developmental Disability
  • Children with Special Needs
  • Autism
  • Mental Health
  • Post Traumatic Stress Disorder
  • Stroke & Traumatic Brain Injury
  • Pain Control
  • Dementia, Alzheimers, “Sundowners”

Snoezelen can be used in a variety of ways.  It is used primarily to educate, stimulate, relax, calm, or energize individuals through a multi-sensory or a single sensory experience.  The lighting, atmosphere, sounds, textures, etc. are all adapted specific to the needs of the resident. Whereas we normally think of only 5 senses, Snoezelen targets 7:

  1. Vision
  2. Touch
  3. Smell
  4. Hearing
  5. Taste
  6. Vestibular -- Balance, your body’s feedback on gravity, movement, and changing head positions.
  7. Proprioception -- Feedback from muscles, joints, and other parts of the body to provide an awareness of positioning.

 Although there are various items that can be incorporated, some common pieces of equipment that might be found in a Snoezelen room might include:

  • Aromatherapy
  • Blacklights, dimmed lighting
  • Music
  • Videos
  • Positioning & seating items, bean bag chairs
  • Bubble tubes
  • Projectors
  • Cushions
  • Fiber optics
  • Water fountains
  • Massage pillows
  • Tactile panels
  • Vibrating music products
  • Interactive panels, switches, buttons
  • Murals
  • Even puddings or candies

FlagHouse  has signed an exclusive distribution agreement for North America for Snoezelen equipment with ROMPA International who own the Snoezelen trademark.

The nursing home industry is increasingly adopting this innovative approach to dealing with behaviors.  Sensory therapy has proven an effective treatment in calming aggressive behaviors and improving mood.  A number of nursing home professionals have come to realize that this type of treatment can be fun while being an effective dementia intervention, even being used for “Sundowners” and various other Alzheimers behaviors.  Would this benefit your facility?

A couple of Snoezelen Room examples can be found below -- courtesy of YouTube:

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