Page 72 Complete Your CE Test Online - Click Here ● ● Liver functioning: Hepatic (liver) blood flow, liver mass, and liver metabolic activity may decrease with age. It is important that liver functioning be assessed if the patient is taking drugs that are metabolized by the liver or if taking drugs that have the potential to damage the liver. ● ● Renal functioning: Renal function also decreases with age, but this decrease varies considerably among older adults. Since the kidneys excrete most drugs, it is important to be aware of kidney functioning and remain alert to possible build-ups of potentially toxic levels of drugs. ● ● Gastric functioning: Aging causes a decrease in gastric motility and affects the gastrointestinal absorption surface. These factors may cause a decrease in or delayed absorption of acidic drugs. ● ● Vision changes: Age-related reduction in visual acuity may make it difficult for older adults to read drug labels, thereby increasing the risk to take the wrong medication. ● ● Recognize that prescribing medications to older patients requires special considerations. It is very important that you become familiar with the most commonly used measure of medication appropriateness for older patients, the “Beers criteria” which identifies medication use that may be inappropriate for older adults [20]. Nursing consideration: The Beers Criteria is a comprehensive, systematic review and grading of the evidence on drug-related problems and adverse drug events in older adults [20]. It assists nurses and healthcare providers in measuring prescription quality and the safety of all medications that older adults take. Sexual assessment Mr. Grimes, a 78-year-old retired construction supervisor, arrives at his physician’s office for a routine checkup. His blood pressure is unusually high, despite the fact that he was prescribed anti-hypertensive medication several months ago. When questioned, Mr. Grimes says, “I only take my blood pressure pills a couple times a week.” When asked why, he explains that, “since I’ve been taking those things, I can’t satisfy my wife. When I don’t take them too often, things are better.” Sexuality and sexual functioning are life-long issues for all persons. Health care professionals sometimes forget or do not believe that these issues are important to older adults. Research shows that interest in sex and sexuality continues throughout the life span [21,22]. Therefore, it is important that a sexual history be part of the assessment of older adults. This can improve disease prevention and other education efforts, while developing strategies to treat STDs and HIV/AIDS in older adults. First, be aware of changes in the reproductive tract that occur with aging. In men, sperm production and testosterone levels decrease [14,21]. The time needed to become aroused and to ejaculate increases, and the refractory period lengthens. The firmness and force of ejaculation decreases [9]. Oral medications for erectile dysfunction, such as sildenafil (e.g. Viagra) and tadalafil (e.g. Cialis), are often able to compensate for normal age-related changes in the sexual functioning of men, and may lead to riskier sexual behavior in this population [21,23]. According to the CDC, 15% of new STD and HIV infections occur in adults over the age of 50. In women, as estrogen levels decrease, the thickness, elasticity and lubrication of vaginal tissues decreases [9,14]. The declining levels of both estrogen and progesterone production provides an environment for more frequent occurrences of vaginal infections in older women. Also, these changes may cause abrasions and tears during sexual intercourse because of the drier and thinner vaginal walls, promoting an environment for viral or other pathogen entry [24]. Intercourse can also become painful or uncomfortable, leading women to avoid sexual intercourse. The use of vaginal lubricants can help alleviate dryness and reduce discomfort [21]. Glandular tissue in the breasts decreases, and there is an increase in the amount of time it takes for arousal to occur [9]. The vagina shortens, the labia atrophy and the cervix may descend into the vagina, which causes discomfort. Orgasms may become less intense and less gratifying. Additionally, post-menopausal women generally return to the pre-arousal state more quickly than younger women [21,22]. In addition to normal age-related changes, cardiovascular disease, depression and diabetes have been associated with sexual dysfunction and/or a decrease in libido [21]. Persons with these conditions should receive sexual counseling as necessary. Nursing consideration: Nurses must also be aware of medications that may cause sexual dysfunction. These include certain types of antihypertensives, selective serotonin reuptake inhibitors (SSRIs) used to treat depression, and beta blockers [21]. Mr. Grimes, mentioned in the previous scenario, is not taking his antihypertensive medication because of adverse sexual effects. When performing a pharmacological assessment, as well as a sexual assessment, be sure to explain the potential for these types of sexual side effects and possible options for medications. Sexual assessment requires that a nurse ask patients questions that are highly personal and intimate in nature. If a nurse is uncomfortable with such an assessment, s/he will most likely transmit this discomfort to the patient. The more confident and comfortable the nurse is with sexual assessment, the more at ease the patient will be [21,25]. The nurse must maintain an objective, non-judgmental attitude and conduct the assessment in a quiet, private area. One framework that may be used when conducting a sexual assessment is the PLISSIT model [21,25]. PLISSIT is a valuable tool that facilitates open communication about sexuality and identifies appropriate levels of intervention [21,25]: ● ● P (permission): “P” involves seeking permission to begin the sexual assessment. Because of the personal and sensitive nature of these questions, ask permission to begin the history while assuring the individual that these discussions of sexuality and intimacy are an important part of history taking for all older adults. Asking for permission also preserves the patient’s dignity and allows them some control over the assessment process. For example, you might begin by asking the patient, “Mr. Grimes, would it be all right if I asked you some questions about your sexual health?” After permission is obtained, you could proceed by asking, “what kinds of changes have you noticed in your sexual health since you began taking your heart medication?” Make the questions pertinent to your patient’s situation. If appropriate, you might ask the patient if s/he would like his or her sexual partner to take part in the discussion. Respect his or her response, whether it is “yes” or “no.” ● ● LI (limited information): Limited information involves sharing information unique to the patient’s own concerns/issues or their particular illnesses. For example, if specific medications are linked to the patient’s sexual difficulties, information about medication side effects could be provided. Other types of limited information might include discussing normal age-related changes in the reproductive system or the effects of certain diseases on sexual functioning. This is the time to dispel myths about sexuality and intimacy with aging by identifying risks for contracting STDs and HIV/AIDS unique to older adults, while providing strategies for the screening, education and reinforcement of safe sex practices. ● ● SS (specific suggestions): This means that you will offer specific suggestions tailored to your patient’s situation/concerns. For example, if sexual dysfunction is related to painful intercourse due to vaginal dryness, you could recommend the use of vaginal lubricants. ● ● IT (intensive therapy): Intensive therapy is indicated when sexual dysfunction requires more than nursing interventions. For example, if the patient is exhibiting inappropriate sexual behaviors (e.g. exposing oneself in public), or has suffered from sexual abuse, intensive therapy is indicated, and a specialized referral must be made. In summary, sexual history/assessment is important for persons of all ages. Sexuality and sexual functioning are important throughout the lifespan. These are highly sensitive subjects and must be handled objectively with tact and discretion. A barrier to sexual assessment may be the discomfort of the nurse as well as the patient. Use of an assessment tool, such as the PLISSIT model, may help to initiate and direct the assessment and increase the comfort of the nurse, the patient and the patient’s partner.