Unwanted Advances Sexuality Case

Presentation 75-year old ambulatory male 75-year old ambulatory male Routinely touches female staff members when they are bathing, toileting or dressing him Routinely touches female staff members when they are bathing, toileting or dressing him No particular staff members as targets No particular staff members as targets Says “I’m sorry” when CNAs ask him to stop, then does it again Says “I’m sorry” when CNAs ask him to stop, then does it again Now seen touching a female resident in her room Now seen touching a female resident in her room

Ongoing Medical Conditions Dementia Dementia Heart disease Heart disease High blood pressure High blood pressure Hypothyroidism Hypothyroidism Enlarged prostate/ incontinence Enlarged prostate/ incontinence Skin cancer Skin cancer Constipation Constipation Arthritis Arthritis Restless Leg Syndrome Restless Leg Syndrome

Recent Medical Issues None None

Medications Aricept and Namenda Aricept and Namenda Lasix Lasix Metoprolol Metoprolol Synthroid Synthroid Flomax Flomax Senna/MOM/Fleets/Colace Senna/MOM/Fleets/Colace Ultram/APAP/Vicodin Ultram/APAP/Vicodin Mirapex Mirapex

Medical Assessment Possible causes Possible causes Medical conditions Medical conditions Medication-induced hyperthyroidism Medication-induced hyperthyroidism Dementia Dementia Elevated testosterone level Elevated testosterone level Mania Mania Delirium Delirium Medications Medications Mirapex Mirapex

Medical Assessment Laboratory tests Laboratory tests CBC and BMP are normal CBC and BMP are normal UA is normal UA is normal Thyroid tests are normal Thyroid tests are normal Testosterone level is low Testosterone level is low

Medical Management Assumed to be secondary to dementia Assumed to be secondary to dementia 5-10% of dementia patients display hypersexuality 5-10% of dementia patients display hypersexuality Mirapex discontinued Mirapex discontinued Clonazepam added for RLS Clonazepam added for RLS No other medication changes made No other medication changes made Possible use of other medications Possible use of other medications No FDA indication No FDA indication Certain antidepressants Certain antidepressants Hormone treatment Hormone treatment

Nursing Management The resident is noted to target younger CNAs and nurses The resident is noted to target younger CNAs and nurses More mature caregivers More mature caregivers Male caregivers employed when possible Male caregivers employed when possible Use a white jacket, other props Use a white jacket, other props To more fully identify the female caregiver as a nurse To more fully identify the female caregiver as a nurse Scheduled caregiving Scheduled caregiving Rapid, safe completion of task Rapid, safe completion of task Care plan protocol for this issues posted in medical chart, on MAR Care plan protocol for this issues posted in medical chart, on MAR

Nursing Management Patient monitored in public areas Patient monitored in public areas Behavior documented on an hourly basis Behavior documented on an hourly basis Encouraged to sit with male residents or less vulnerable females Encouraged to sit with male residents or less vulnerable females Male staff help as much as possible with activities, meals Male staff help as much as possible with activities, meals No mixed messages sent No mixed messages sent More physically demonstrative female staff encouraged to refrain from supportive hugs, hand holding, using terms of endearment (“Honey”) with the resident More physically demonstrative female staff encouraged to refrain from supportive hugs, hand holding, using terms of endearment (“Honey”) with the resident Firm, clear and calm redirection Firm, clear and calm redirection “Please stop” rather than “That’s inappropriate” “Please stop” rather than “That’s inappropriate”

Nursing Management Make sure is not misidentification Make sure is not misidentification Believes person(s) are spouse or girlfriend Believes person(s) are spouse or girlfriend Make sure nursing assistant concerns are addressed Make sure nursing assistant concerns are addressed Embarrassment Embarrassment Disgust Disgust Education about this as part of the illness is a must Education about this as part of the illness is a must Uncomfortable for residents, staff and families Uncomfortable for residents, staff and families

Outcome Elimination of Mirapex Elimination of Mirapex May have been helpful May have been helpful No need to move onto other agents No need to move onto other agents Nursing interventions Nursing interventions Cut down on frequency of events Cut down on frequency of events No further incidents with other residents No further incidents with other residents New staff orientation discussed these issues New staff orientation discussed these issues Care plan placed on chart, on MAR, for nursing staff less familiar with resident was effective Care plan placed on chart, on MAR, for nursing staff less familiar with resident was effective