Want to know more

Protocol: Sexuality in the Older Adult

Meredith Wallace, PhD, APRN, A/GNP-BC
Reprinted with permission from Springer Publishing Company. Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition, © Springer Publishing Company, LLC.  These protocols were revised and tested in NICHE hospitals.

Evidence-Based Content - Updated July 2012

The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:



To enhance the sexual health of older adults.  

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Although it is generally believed that sexual desires decrease with age, researchers have identified that sexual desires, thoughts, and actions continue throughout all decades of life. Human touch and healthy sex lives evoke sentiments of joy, romance, affection, passion, and intimacy, whereas despondency and depression often result from an inability to express one’s sexuality. Health care providers play an important role in assessing and managing normal and pathological aging changes in order to improve the sexual health of older adults. 

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Background and Statement of the Problem

A. Definitions

1. Sexuality: a central aspect of being human throughout life and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy, and reproduction. 1

2. Sexual health: a state of physical, emotional, mental, and social well-being related to sexuality. 1

3. Sexual dysfunction: impairment in normal sexual functioning. 2

B. Etiology and/or Epidemiology

1. Despite the continuing sexual needs of older adults, many barriers prevent sexual health among older adults.

2. Health care providers often lack knowledge and comfort in discussing sexual issues with older adults. 3

3. The older population is more susceptible to many disabling medical conditions; a number of medical conditions are associated with poor sexual health and functioning 4, including depression, cardiac disease, stroke and aphasia, Parkinson's disease (PD), and diabetes that make sexuality difficult.

4. Medications among older adults, especially those commonly used to treat medical illnesses, also impact sexuality, such as antidepressants 5 and antihypertensives.5

5. Normal aging changes, such as a higher frequency of vaginal dryness in women and erectile dysfunction (ED) in men, make sexual health difficult to achieve. 67

6. Environmental barriers also present barriers to sexual health among older adults. 8 

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A. The Permission, Limited Information, Specific Suggestion, Intensive Therapy (PLISSIT) model 9 begins by first seeking permission (P) to discuss sexuality with an older adult. The next step of the model affords an opportunity for the health care provider to share limited information (LI) with the older adult.

B. Ask open-ended questions such as "Can you tell me how you express your sexuality", "What concerns you about your sexuality?" and "How has your sexuality changed as you have aged?"

C. 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.

D. Review medications among older adults, especially those commonly used to treat medical illnesses that also impact sexuality, such as antidepressants and antihypertensives. 

E. Assess medical conditions that have been associated with poor sexual health and functioning such as depression, cardiac disease, stroke and aphasia, PD, and diabetes. 

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Nursing Care Strategies

A. Communication and Education

1. Discuss normal age-related physiological changes.

2. Address how the effects of medications/medical conditions may affect one’s sexual function.

3. Facilitate communication with older adults and their families regarding sexual health as desired, including:

a. Encourage family meetings with open discussion of issues if desired.

b. Teach about safe sex practices.

c. Discuss use of condoms to prevent transmission of sexually transmitted infections (STIs) and HIV.

B. Health Management

1. Perform a thorough patient assessment.

2. Conduct a health history, review of systems, and physical examination.

3. Effectively manage chronic illness.

4. Improve glucose monitoring and control among diabetics.

5. Ensure appropriate treatment of depression and screening for depression. (See Depression topic).

6. Discontinue and substitute medications that may result in sexual dysfunction (e.g., hypertension or depression medications).

7. Accurately assess and document older adults' ability to make informed decisions. (See Treatment Decision Making topic).

8. Participation in sexual relationships may be considered abusive if an older adult is not capable of making decisions.

C. Sexual Enhancement

1. Compensate for normal changes of aging

a. Females:

i. Use of artificial water-based lubricants

ii. Use of estrogen creams 10

b. Males:

i. Recognizing the possibility for more time and direct stimulation for arousal caused by aging changes

ii. Use of oral erectile agents for ED 11

2. Environmental Adaptations

a. Ensure privacy and safety among long-term-care and community-dwelling residents. 12 

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Expected Outcomes

A. Patients will:

1. Report high quality of life as measured by a standardized quality of life assessment.

2. Be provided with privacy, dignity, and respect surrounding their sexuality.

3. Receive communication and education regarding sexual health as desired.

4. Be able to pursue sexual health free of pathological and problematic sexual behaviors.

B. Nurses will:

1. Include sexual health questions in their routine history and physical.

2. Frequently reassess patients for changes in sexual health.

C. Institutions will:

1. Include sexual health questions on intake and reassessment measures.

2. Provide education on the ongoing sexual needs of older adults and appropriate interventions to manage these needs with dignity and respect.

3. Provide needed privacy for individuals to maintain intimacy and sexual health (e.g., in long-term care). 

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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 SF-36 Health Survey may be used to determine the effectiveness of interventions to promote sexual health. Retrieved from http://www.rand.org/health/surveys/sf36item/question.html

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For Definition of Levels of Quantitative Evidence Click Here



1. World Health Organization (2010). Sexual Health: A New Focus for WHO. Progress in Reproductive Health Research. Retrieved May 10, 2010. Evidence Level VI: Respected Opinion.

2. American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Evidence Level VI: Respected Opinion.

3. Gott, M., Hinchliff, S., & Galena, E. (2004). General practitioner attitudes to discussing sexual health issues with older people. Social Science & Medicine, 58(11), 2093–2103. Evidence Level IV: Nonexperimental Study.

4. Morley, J. E., & Tariq, S. H. (2003). Sexuality and disease. Clinics in Geriatric Medicine, 19(3), 563–573. Evidence Level V: Review.

5. Montejo, A. L., Llorca, G., Izquierdo, J. A., & Rico-Villademoros, F. (2001). Incidence of sexual dysfunction associated with antidepressant agents: A prospective multicenter study of 1,022 outpatients. Spanish working group for the study of psychotropic-related sexual dysfunction. The Journal of Clinical Psychiatry, 62 (Suppl. 3), 10–21. Evidence Level IV: Nonexperimental Study.

6. Kessenich, C.R., & Cichon, M.J. (2001). Hormonal decline in elderly men and male menopause. Geriatric Nursing, 22(1), 24-27. Evidence Level V.

7. Lobo, R.A. (2007). Menopause: Endicronology, consequences of estrogen deficiency, effects of hormone replacement therapy, treatment regimens. In V.L. Katz, G.M. Lentz, R.A. Lobo, & D.M. Gershenson (Eds.), Comprehensive gynecology (5th ed.). Philadelphia, PA: Mosby Elsevier. Evidence Level VI. 

8. Hajjar, R. R., & Kamel, H. K. (2004). Sexuality in the nursing home, part 1: Attitudes and barriers to sexual expression. Journal of the American Medical Directors Association, 5(2 Suppl.), S42–S47. Evidence Level V: Review.

9. Annon, J. (1976). The PLISSIT model: A proposed conceptual scheme for behavioral treatment of sexual problems. Journal of Sex Education Therapy, 2(2), 1–15. Evidence Level VI: Respected Opinion.

10. Freedman, M., Kaunitz, A.M., Reape, K.Z., Hait, H., & Shu, H. (2009). Twice-weekly synthetic conjugated estrogens vaginal cream for the treatment of vaginal atrophy. Menopause, 16(4), 735-741. Evidence Level II.

11. Wallace, M. (2008). How to try this; Sexuality assessment. American Journal of Nursing, 108(7), 40-48. Evidence Level V.

12. Wespes, E., Moncada, I., Schmitt, H., Jungwirth, A., Chan, M., & Varanese, L. (2007). The influence of age on treatment outcomes in men with erectile dysfunction treated with two regimens of tadalafil: Results of the SURE study. BJU International, 99(1), 121-126. Evidence Level II.



Last updated - July 2012

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