Is Intimacy OK When Your Partner Has Cognitive Decline?

It’s all about consent, but that’s a pretty gray area, say the experts

Ellen Uzelac,

AARP

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Published April 10, 2025

an older man and woman embrace. circles leave the woman's head, signifying cognitive decline

Kiersten Essenpreis

Here’s a problem no one wants to have: how to handle sex and intimacy when your partner is cognitively impaired.

It’s a heartbreaker — and a question In the Mood has received from multiple readers. Our experts offer their best advice.

When you have a partner — in this case, my wife — with cognitive decline, how do you know when it’s still OK to have sex with them?

Not surprisingly, every expert I interviewed started with consent.

“Consent is the same — no matter if you’re 20 or 50, if you have cognitive decline or don’t. If you cannot affirm that you have gotten proper consent, that’s where you back off,” says Padma Kandadai, a urogynecologist with Boston Medical Center.

But as I got into the weeds with my reporting, I learned that there is little that’s black-and-white about how a cognitively impaired person conveys consent — and a whole lot of gray. Here’s what you need to know.

Cognitive impairment is not one-size-fits-all. Depending on the individual and the cause, the progression of the decline could last years, says neuropsychologist Hayley Kristinsson, a health sciences clinical professor at the University of California, Irvine.

And it’s usually not a toggle switch — you aren't on one day and off the next. According to Kristinsson, cognitive decline often starts with occasional forgetting: which words to use, or details of recent events. At its most severe, she says, you have minimal awareness of your surroundings, and you no longer recognize familiar people.

To more fully understand what your wife is experiencing now and what to expect, certified sexuality educator Jane Fleishman suggests that the two of you consult a neurologist about her current stage of cognitive decline if you haven’t done so already.

Discuss consent early on. If you know your partner’s cognition is beginning to fail, certified sex therapist Chris Fariello suggests having a conversation about intimacy and asking her permission to make decisions about sexual engagement when she can no longer verbalize what she wants.

“Some people may lose the ability to be verbal, but they may still want to be sexual,” says Fariello, founder of the Philadelphia Institute for Individual, Relational & Sex Therapy, a therapy practice specializing in sexual health. “Any conversations about the future, including what sex looks like, are important conversations to have.”

A sex therapist can help navigate that discussion, he adds.

Right now, Fleishman says, there’s no assessment tool to determine whether someone with cognitive impairment is able to give consent, which makes that conversation so critical.

“The more you can face reality early on, the better off you’ll be,” she notes.

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When a partner can no longer speak, focus on nonverbal signals. Cognition can change day to day, hour to hour, even during a sexual activity — which is why family physician Evelin Dacker says it’s so important to focus on nonverbal cues.

“You have to attune to your partner, recognizing when they’re creating signs in their bodies that signify a yes,” says Dacker, who specializes in sexual health. Signs of a yes: making eye contact and smiling. Signs of a no: looking scared or confused.

“Take a step back and focus on how to read those signals — not just for sexuality, but everything,” Dacker says. “It’s about slowing down, being present and self-aware.”

Make sure you’re not deciding for your partner. When you want to have sex, Dacker says to ask yourself: “Am I paying attention to what she wants, too?”

“Before entering into an erotic space, take notice,” she says. “It’s all about noticing without projecting your own wants, needs and desires on the other person.”

Find new ways to be intimate and engaged. On a good day, when your partner comes over and hugs you, certified sex therapist Amanda Pasciucco suggests asking her: “Does this feel nice when I hug you back?”

She says the line of consent shifts conditionally, depending on how foggy or fuzzy your partner is. “If the person is confused or pulls away or is distressed, shut it down,” she says.

Things Pasciucco suggests you can do to stay close: touching her hair, cuddling, holding hands, giving her a foot rub, reading poetry to her or singing a favorite song.

“It’s very sad,” she says. “Sexual engagement becomes this different thing. Intimacy sometimes doesn’t mean sex anymore.”

Practice self-care. As cognitive impairment progresses and physical and emotional intimacy changes, handling it all can be challenging for caregivers.

“Caregivers deal with so much” as they grieve the loss of that intimacy and partnership, says Kristinsson.

When you reach that point, Kristinsson suggests focusing more on emotional closeness and shared activities that aren’t sexual in nature. Also, consider seeing a bereavement therapist and joining a caregiver support group where you can share your sadness with others.

One last tip: Seek out fulfilling friendships outside your partnership.

Do you have questions about sex or relationships as a 50-plus adult? Send them to sexafter50@aarp.org.

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