Influence of Sexuality on the Health of the Elderly in Process of Dementia: Integrative Review

Objective: this work sought to inquire on the influence of sexuality on the health of the elderly during dementia. Materials and Methods: this was an integrative review. A careful search was conducted in nine databases; however, only five databases provided articles fulfilling the scope of the study: Medline, Lilacs, BDENF, Scopus, and Web of Science (WoS). The health science descriptors (DeCS) were adopted: “sexualidad”, “demencia” and “anciano”, and the descriptors cataloged in the Medical Subject Headings (MeSH): “sexuality”, “dementia” and “aged”. After applying the inclusion criteria, eight articles were selected to comprise the study sample. Results: the practice of sexuality influences upon the health of the elderly with dementia with some beneficial effects, given that it provides, especially, better perception of quality of life and wellbeing. Nevertheless, it cannot be generalized due to methodological insufficiency evidenced in


Introduction
Sexuality is defined as a multidimensional construct in which the individual expresses feelings, thoughts, and cognition, such as demonstrations of intimacy, affection, love, touch, affection, hugging, including sexual contact itself (1)(2)(3)(4)(5). Eroticism stands out as the greatest attribute of sexuality (6), but it is not linked only to it because it also indicates the exaltation of sex within the context of the arts, through painting and literature, for example. This characteristic distinguishes eroticism from pornography, given that the latter is more concerned with the sexual act than with the aesthetic aspects present in eroticism (7).
In this sense, "eroticism is an art that has as its raw material the sexual act, seen in a produced and beautiful manner, without vulgarity, that is, without treating sex in a banal or mediocre way, but beautifully and elegantly" (8:30). Thus, there is a separation between the individual and the sexual act, in addition to being associated with a dimension of fantasies that reveals all the individual's sexual and loving activities (9). In addition, it is worth noting that eroticism is also included in the field of sexuality (10).
Sexuality is considered a basic human need, essential for health (11,12), for quality of life (13)(14)(15)(16)(17), and for wellbeing (18,19), whose expression begins at birth (19), remains in old age (1,20,21), and ends only with the death of the individual (22). Therefore, there is no age group in which sexuality is extinct. On the contrary, the majority of the elderly refer to maintaining sexual interests, although their expression may be influenced by the hormonal decline observed physiologically during old age (23). This means that, although the elderly suffer a decline in their hormonal and organic functions, which reflect on sexual performance, like lack of vaginal lubrication and difficulty in erection, they remain able to enjoy sexuality satisfactorily.
The elderly are defined as individual aged 65 years or over in economically developed countries and 60 years or more in developing countries (24). The demographic transition of the elderly population is being modified and one of the determining factors is the reduction of mortality rates, mainly due to the implementation of public policies for the protection and promotion of health. As a result, there is an increase in the proportion of elderly people, which causes significant changes in the age structure of the population (25), it is estimated that, by 2050, the number of elderly people will increase from 12.3 % to 21.5 % of the global population (26).
With the ageing process, attention is turned to this population's health, including all the aspects that determine and condition their health, like sexuality (27). A few decades ago, it was thought that the elderly, even if healthy, had no interest in having sex. However, in recent years, this thinking has changed because the benefits of sexual activity, such as promoting physical and psychological well-being are widely publicized, in addition to reducing physical and mental problems associated with aging (28).
The elderly reveal that sexuality is an integral part of their identity, social relationships, and mental health. Intimacy and interpersonal relationships, in addition to promoting benefits in maintaining mood and reducing disabilities, promote a better perception of quality of life and act as a protective factor against various diseases, such as arthritis (23).
However, contrary to what has been proclaimed for so long, the ability to fully experience sexuality is not lost with age; it just changes (24). However, due to the judgment and surveillance that society keeps on the elderly, imputing them that only younger people are conditioned to experience sexuality, they end up inhibiting their sexual identity, which should be expressed naturally. As a result of this inhibition, the individual's mental health may be affected by not feeling allowed to perform said act (29).
The belief that the elderly are asexual and have no sexual desires is strongly present in society (23,(30)(31)(32)(33)(34)(35)(36)(37)(38), even among health professionals (23,30). In view of this, the quantitative limitation of studies that address sexuality in old age is justified in part. Furthermore, when it comes to sexuality among the elderly with dementia, the limitation becomes more evident (31).
It is noteworthy that population aging becomes a problem at a time when society is not able to face its own aging process and, consequently, expresses negative attitudes towards this stage of the life cycle. Thus, it is essential to increase studies on prejudices against old age, in addition to stereotypes linked to sexuality at this age, as they are topics of relevance to public health and rarely addressed in the scientific community (26).
Elderly people living with some form of dementia are mistakenly considered unfit for any type of sexual act and unable to feel pleasure. Furthermore, most studies addressing this theme refer to the so-called "inappropriate sexual behavior" (39), resulting from brain disorders that trigger hyper-sexuality processes, which leads the individual to practice libidinous acts, such as pedophilia and promiscuity (40).
In this sense, better understanding of the experience of sexuality in old age has significant potential to promote better quality of life for people with dementia (30). Considering the importance of the theme, the limitation of published studies and the need to reorient professional practices for the promotion and protection of the health of the elderly, the following research question was elaborated: is there an influence of sexuality on the health of the elderly in process of dementia? In order to answer it, the objective of this study was to verify the influence of sexuality on the health of the elderly in the process of dementia.

Materials and methods
This was an integrative literature review, characterized by representing the highest degree of comprehension among the reviews, allowing the inclusion of articles with different methodological designs to promote a complete understanding of the object studied, including information from the theoretical and empirical literature (41).
The review was constructed by using the PICO strategy, methodological acronym to refer to the following elements: problem, intervention, control or comparison and outcome. It is a systematic method that aids in identifying relevant key words for the theme and, consequently, increases the possibility of finding studies strictly related to the research question, which reduces bias and avoids unnecessary searches (42,43).
Thus, in the present study, the first element (P) consisted of elderly people with dementia; the second (I), in the experience of sexuality and the fourth element (O), in the influence of sexuality on health. It is highlighted that the third element (C) was not adopted in this study because of referring to the comparison/control.
The bibliographic survey was conducted in September 2019 in nine databases: Virtual Library in Health (BVS, for the term in Portuguese), Medical Literature Analysis and Retrieval System Online (Medline), Scopus, Scientific Electronic Library Online (SciELO), Latin American and Caribbean Literature in Health Sciences (Li-Lacs, for the term in Spanish), Nursing Database (BDENF, for the term in Portuguese), Spanish Bibliographic Index on Health Sciences (IBECS, for the term in Spanish), Science Direct, and Web of Science. Health Sciences Descriptors (DeCS) were adopted: "sexualidad", "demencia" and "anciano", in addition to the descriptors cataloged in the Medical Subject Headings (MeSH): "sexuality", "dementia", and "aged", both intercalated with the Boolean operator AND.
The search, selection, and extraction of articles were carried out by the first five authors. For the search, the authors were subjected to two stages of face-to-face drawings, so that all members had the same probability, different from zero, of being chosen. The first stage consisted of drawing the databases among the authors, which led to five defined bases for the corresponding author to perform the search, selection, and extraction. Even so, four bases remained that were allocated to the second stage of the drawing. In this, the remaining bases were listed in alphabetical order and the authors who would assume the second responsibility of searching, selecting, and extracting the articles were randomly selected.
After the authors notified the completion of the search, selection and extraction, the articles were subjected to criticalreflective reading, and the main elements were recorded in two synoptic tables. Thereafter, a rotation was made, so that 100 % of the articles were read by all the authors, with their respective contributions in the tables cited. It should be noted that the last author contributed to the content review, scientific adequacy, general analysis, and approval of the final version.
To systematize the methodological path, the PRISMA flowchart (44) was used and studies involving the following inclusion criteria were included: articles from different methodological approaches published in the last six years (2014-2019), without idiomatic restrictions, available for download and which addressed relevant information on how sexuality influences the health of the elderly with dementia. It is noteworthy that all studies that addressed hyper-sexuality due to dementias were excluded, as they understand that this situation is configured as a morbid state of behavioral changes (45), which deviates totally from the theme studied. After applying the criteria and screening the articles, nine studies were selected for discussion, as illustrated in Figure 1.

Discussion
Sexuality is considered a lifelong component of the human being (54,55) and, when experienced satisfactorily by the elderly with dementia, it provides health and quality of life (49,51,53), preserves identity and autonomy, reduces loneliness rates and feelings of fear (23), decreases pain sensitivity, increases the capacity for relaxation, and reduces depression rates (48); furthermore, it improves mental health and increases performance in some cognitive dimensions assessed through functional tests (52,56,57). It is, therefore, a fundamental aspect of the human experience (48,58), in addition to being considered an indispensable experience for active aging (59). From this perspective, it may be stated that sexuality constitutes a universal need that transcends age group, disabilities, or cognitive decline (48).
It is known, in the scientific setting, that sexuality and intimate relationships are unique and, to date, nothing exists that can replace them, not even social relationships or friendships in general (60). This inference points to the need to value sexuality in the elderly population with dementia because their experience is unique and obeys a physiological and emotional need for each individual, influencing aspects of self-image, mental health, and social relationships (34).
Corroborating this statement, studies (61, 62) reveal that, for many elderly people with and without dementia, sexuality is still important. Furthermore, the rights to privacy and sexual expression are receiving greater recognition and scientific acceptance, as they are important parts of the lives of elderly people in process of dementia (63).
In view of the diversity of sexual desires present in the elderly with dementia, one must distinguish when sexual behavior is appropriate or inappropriate. Expressions considered appropriate are those that must be encouraged, while inappropriate behaviors must be repressed to avoid damage to those involved, with emphasis on the elderly in the dementia process. Therefore, the challenge must focus on the healthy and safe exercise of these individuals' sexuality and monitor its repercussions on their health. Inappropriate behaviors are defined as those characterized as unsafe, disturbing and which impair care, such as sexually explicit verbal expressions and libidinous acts (grabbing, exposing genitals, touching, masturbating in public, among others) (23,64,65).
It is worth noting that the construction of this study was based on the following steps: identification of the theme and selection of the research question; establishment of inclusion and exclusion criteria of studies/sampling or literature search; definition of information to be extracted from selected studies/categorization of studies; evaluation of studies included; interpretation of results; presentation of the knowledge review/synthesis (46:9).
Because this study does not involve the participation of human beings and because it was built through a literature review, evaluation by a research ethics committee was waived, as established by Resolution 510, of 07 April 2016, from the Brazilian National Health Council.

Results
The analysis of the selected studies showed a scientific gap on the subject, given that merely 2.5 % were eligible to answer the proposed objective (23,47,48,(49)(50)(51)(52)(53). It was also identified that most research (75 %) addressed the sexuality in the elderly with or without dementia who live in homes for the aged (23,48,(49)(50)(51)(52). The other characteristics of the studies are described in Tables 1 and 2  Intimacy and sexuality of nursing home residents with dementia: a systematic review (49) Provide a structured overview of all elements of intimacy across the spectrum of intimacy and sexuality in people with dementia, within the context of specialized residential care.
Systematic review with articles indexed in PubMed, PsychInfo, and Medline Did not have.

Iacub R, Rodríguez R (2015)
The eroticism of persons with dementia in nursing homes for the elderly (50) Present the models with which rest institutions organize the eroticism of their residents, especially for those who suffer from dementias. Assess the ease of use, quality, and effectiveness of an educational intervention to increase knowledge and improve the attitudes of staff towards the expression of sexuality by people with dementia living in residential facilities for the elderly.
Mixed-method study using online educational interventions and questionnaires, followed by a semi-structured interview Nursing undergraduate students, nurses, caregivers, and therapists.
Otherwise, it is evident that sexual expression among elderly people with dementia is characterized by being a healthy experience and that it can be encouraged if they so wish. However, to avoid abuse, respect their autonomy, and ensure safety in the practice of sexuality (23), this incentive must be accompanied by mechanisms capable of assessing the degree of consent of those involved.
The central question is to define exactly when the cognitive decline indicates the need to limit the experience of sexuality (50). For this, ethical aspects related to decision making can be useful in the practice in which this situation exists (30). The principle that guides care for the elderly with dementia regarding sexuality is protection and it is observed that health staff and family members adopt this protective behavior to prevent physical or mental abuse (49).
In addition, literature reports indicate that healthy partners express embarrassment in exercising sexual practices with the spouse who, due to the dementia process, is no longer able to recognize him. It is also mentioned that the male spouse reports feelings of guilt for having sex with his wife without having knowledge of her real will or consent, given the decline in decision-making capacity as dementia progresses. Therefore, dilemma exists regarding conflicts between the protection of those involved and the satisfaction of the couples' sexual desires (39).
In the case of nursing homes, supporting sexuality among the elderly implies several ethical dilemmas (66) because it is a work environment for professionals and a home environment for elderly residents. When dealing with people with dementia, the complexity of the theme increases; in that of balancing protection against harm and respecting the autonomy of those involved (48). Furthermore, such experiences become even more complicated, given that, in these places, sexuality and sexual activity are rarely encouraged. This fact is justified, as some professionals are still adept at the perception that their experience should be avoided (48,67). Sexual intimacy can contribute to relief of loneliness and fear related with the dementia process, in addition to preserving the identity of the elderly in their family, in the face of losses resulting from the dementia process, such as making financial decisions.

B (47)
There is a reduction in the impact of dementia on the life of an elderly couple, who experience sexual practices, and patients evolve more satisfactorily when sexually active, that is, sex can influence as a balance factor from the good emotional understanding between the couple.
C (48) Sexuality also has beneficial effects for the elderly, like pleasure and intimacy, decreased sensitivity to pain, increased relaxation, and lower levels of depression.

E (49)
The expression of intimacy and sexuality is considered a lifelong element of human beings and its influence on quality of life is scientifically recognized.
Open discussion and a more liberal view among stakeholders on the topic are prerequisites for changing the subculture of care staff. This would allow misunderstandings about intimacy and sexuality in the elderly with dementia to be addressed more easily and, thus, promote improvements in the quality of life of the elderly living in nursing homes.

F (50)
The focus on people with dementia should investigate all aspects that improve their quality of life, among which eroticism is certainly relevant. In this sense, the role of residences is to guarantee the right to manifest eroticism and sexuality, through a control that protects residents suffering from dementia and allows them quality of life. Thus, sexuality and its quantitative-qualitative variables, such as eroticism, influence upon the better perception of quality of life of the elderly.

G (51)
Friendship, love, intimacy and sexuality are still embedded in the lives of couples. It is emphasized that educational programs are needed for the residential care staff to improve the appropriate knowledge and skills and, with this, optimize the quality of life of people with dementia and their spouses through comprehensive care, which involves encouragement and support for sexuality.
H (52) Our study revealed data similar to a population-based study conducted in Europe, which found that sexual activity in old age is associated with better mental health conditions, better quality of life, lower rates of loneliness and, in English men, better performance in some aspects of the cognitive function test.

I (53)
Facilitating a care environment that supports verbalization and expression of sexual preference, need, and desire of people with dementia can improve their quality of life, health, and well-being, as well as reduce potential tensions among staff, elderly, and families.
However, it is emphasized that the objective of long-term care should be based on preserving and restoring communicative abilities and dignifying the identity of the elderly with dementia. In this perspective, it is necessary to create guidelines in residential institutions to systematize and direct care to the elderly in this context (48). Additionally, staff working in these locations should receive training to improve knowledge and skills so that, thus, they can optimize the quality of life and well-being of people with dementia and their spouses (51,53).
Another important aspect to consider is related to professional training on the subject. The teaching staff must include sexuality, aging, and dementia in the educational curriculum and in professional training to avoid the centrality of care in pathological aspects and provide a holistic view of the elderly person (30,32). Within this holistic care, sexuality is highlighted because it constitutes a factor of equilibrium between the couple experiencing dementia (47), the fact that most of these elderly people are sexually active (56) and the importance of sexuality in their reaffirmation in society, which would improve their self-esteem and mental health (23).
A study supporting the inference that professionals are not prepared to address the theme was conducted in Nottingham, the United Kingdom. The researchers investigated the attitudes of nurses and caregivers towards the sexuality of elderly people living in nursing homes. The results showed that the variables "young age" and "time of work experience less than five years" were the most associated with negative and restrictive attitudes when the subject was sexuality in old age (68). However, it is recognized that education and training on aging must be carried out from the early years of life, which will contribute to reducing prejudice against the elderly (26).
In addition, it is essential to increase the health staff performance with the elderly to reconstruct paradigms and reduce non-permissive attitudes in order to increase the quality of life of this population (26). The elderly need to break free from sexist norms and devalue old age within the context of sexuality, pre-established by society and media networks (69). On the other hand, biological, psychological, and social aspects must be considered in the sexuality of the elderly, so that they can enjoy it fully and naturally (69).
It is worth mentioning that the theme is promising and points to the need for more studies that contribute to the innovation of scientific interventions in the care of the elderly with dementia regarding sexuality (47). Furthermore, the ethical, political and legal evidence regarding the sexuality of those with and without dementia supports the idea that sexuality in this population is an integral and legitimate need (1).
Perhaps, within the perspective of recognizing the importance of sexuality in the lives of the elderly, in recent years, science has progressed in therapeutic options to combat sexual dysfunction. As an example, surgical methods, penile prostheses, hormonal treatment, psychotherapy and oral medications or drugs injected directly in the male genital organ are mentioned (70).
Lastly, there was a quantitative limitation of articles on the theme. Most studies focus on inappropriate sexual behaviors and hyper-or hypo-sexuality due to the dementia process, contributing to restricted reflections on the benefits of sexuality among elderly people living with dementia.
A survey (39) showed few studies with significant methodological design and absence of reliable evaluation instruments, with the majority of the studies found referring to forums and literature reviews. Thus, it is necessary to conduct research that demonstrates in depth the influence of sexuality in this population, given that it may constitute another approach to health promotion and protection for the elderly with dementia.

Conclusions
The results indicate that the practice of sexuality among the elderly with dementia has some beneficial health effects. Nevertheless, it cannot be generalized, by virtue of the methodological insufficiency evidenced in the studies found to construct this review.
However, health professionals can guide and encourage their exercise whenever it is desired by the elderly to comply with the active aging proposal, which includes the theme in their care plans. Thus, it will be possible to add better quality to the years of life, especially in individuals enduring some type of dementia.
Conflicts of interest: None declared.