Dementia and Inappropriate Sexual Behavior
Although inappropriate sexual behavior in older adults with dementia is not widespread, it can be problematic for health care providers, patients, and caregivers. Treating these behaviors is a challenge, especially in long term care settings. Following are details of a case of sexually inappropriate behavior in an elderly patient with dementia.
This was initially treated with citalopram, a selective serotonin reuptake inhibitor (SSRI). However, one month later, as symptoms worsened, citalopram was discontinued and paroxetine, another SSRI, was started with interval increases in the dose when symptoms did not abate. Due to the persistence of the symptoms, valproate was added but was later changed to carbamazepine as the patient developed increased confusion and diarrhea. On intermediate follow-up at six months after his initial symptoms, and with the continuation of nonpharmacologic approaches that included redirecting, caregiver support group therapy, modifying clothing to prevent easy removal, and the trial of a same-sex caregiver, his family noted the persistence of sexually inappropriate talk; however, he made no physical attempts to engage in sexual behavior.
At the subsequent visit one month later, Mr. J's daughter reported significant caregiver stress, as Mr. J's sexual behavior had worsened with increased frequency of episodes, and he was now verbalizing about his female caregiver's body parts. At that time he was prescribed citalopram 20 mg daily.
One month later, with a report of worsening symptoms, the atypical antipsychotic quetiapine 12.5 mg daily was offered but, because of possible side effects, Mr. J's daughter decided to forgo this treatment.
Four weeks later, with no improvement in symptoms, Mr. J had moved in with his daughter because caregivers refused to care for Mr. J in light of his persistent sexual advances. The citalopram was discontinued; paroxetine 10 mg daily and an H2 blocker, cimetidine 200 mg twice daily, were initiated in combination.
After another six weeks, Mr. J's inappropriate behavior continued with inappropriate verbalization and removing his clothes in the presence of his 9-year-old granddaughter. Therefore, the dose of paroxetine was increased to 30 mg daily and cimetidine was discontinued because of the family's preferences related to the side effect profile. When his behaviors persisted another four weeks after that medication adjustment, the anticonvulsant/antimanic agent divalproex 125 mg twice daily was added but was later changed to the anticonvulsant carbamazepine 100 mg twice daily as the patient developed increased confusion and diarrhea.
During a telephone interview with the physician conducted seven months later, Mr. J's daughter reported that he was no longer taking carbamazepine but continued with paroxetine daily. His family noted the persistence of sexually inappropriate talk, but there were no physical attempts to engage in sexual behavior.
Multiple behavioral symptoms associated with dementia have been outlined in the literature, including but not limited to aggression, wandering, irritability, urinary incontinence, sleep disturbance, and sexual disinhibition.6-9 One of the most distressing behaviors, especially for caregivers, is inappropriate sexual behavior (ISB), which is also described in the literature as hypersexuality or sexual disinhibition.8
Although there are limited data on the prevalence of this condition, one small study showed that 7% of patients with AD demonstrated features of this condition.9 Sexuality is defined by the Oxford dictionary as a capacity for sexual feelings. Sexually inappropriate behavior can be defined as vigorous sexual drive or other sexually related problems that interfere with normal activities of daily living, or sexual behavior that is pursued at inappropriate times.10 The behaviors are often persistent and directed at others or toward the patient himself.11 Interestingly, a Canadian retrospective cross-sectional study of long term care, community-based, and inpatient elderly patients with dementia found that patients with all stages of dementia were affected and more commonly those with the vascular subtype.8
Community and Long Term Care
Nonpharmacologic and Pharmacologic Management
Interventions to assist with the management of ISB should start with nonpharmacologic management18, including environmental and behavioral interventions. Recommendations for such interventions include redirection, same-sex caregivers, clothing that closes or fastens in the back, and patient and caregiver counseling and education. Most often the limiting factor of effectiveness in employing these strategies is the degree of the patient's cognitive impairment. Providing privacy offers another method and is considered in some long term care facilities but continues to be a subject of discussion in the medical discipline.
There have been no well-designed studies to demonstrate the efficacy of the pharmacologic management of ISB in patients with dementia.17,19 To date, the general hope of medical management is to decrease the patient's sexual drive by using medications with the added effect of decreased libido, hormones that affect the hypothalamic-pituitary-gonadal axis leading to reduced testosterone, or substances with a sedating or calming effect. Small studies and/or case reports have shown variable success with antidepressants, anticonvulsant mood stabilizers, hormones (antiandrogens, estrogens, gonadotropin-releasing hormone analogs), antipsychotics, cholinesterase inhibitors, and cimetidine, a histamine H2 receptor antagonist.17,19 Therefore, the use of any one or combination of medications for this behavior is strictly off label.
SSRIs are sometimes used because of their side effect profile of causing decreased libido10,20 and may be advantageous in patients with comorbid depression and anxiety. Trazodone was found to be effective in four patients and thought to be secondary to a calming effect rather than antidepressant effect.21
Antipsychotics, which are possibly used for their dopamine antagonist effect,19 may be controversial because of their black-box warnings related to increased mortality in patients with dementia.
Hormonal agents such as cyproterone acetate, medroxyprogesterone acetate (MPA), diethylstilbestrol, and gonadotropin-releasing hormone analogues, reduce testosterone with the hope that sexual function and therefore ISB will be reduced. High-dose (100 to 400 mg/day) oral MPA may represent an effective and well-tolerated treatment option for patients displaying ISB according to one case series.22 However, suggesting and initiating hormonal treatment in a patient with dementia for the management of ISB can create a challenge because of the possible side effects, patients' inability to give informed consent, and the stigma associated with these medications.
The H2 antagonist, cimetidine, carries the possible side effect of decreased sexual activity and has therefore been tried separately or in combination with other previously mentioned treatments. Use of this medication has been limited because of its side effects, with one case reporting nausea, arthralgia, and headaches.23
• reviewing the patient's sexuality over his or her lifetime;
• redirecting the individual during an episode;
• recommending a caregiver support group to assist with education and venting frustrations;
• modifying clothing to prevent easy removal; and
• trying a same-sex caregiver.
Pharmacologic management presents a challenge because there is no official treatment guideline for ISB in elderly patients with dementia. The medications listed previously, either alone or in combination, have been used in small studies or demonstrated in case reports with their use, therefore remaining off label. When initiating medical treatment for ISB in elderly patients with dementia, carefully consider the potential medication side effects, drug-drug interactions, and drug-disease interactions. Future studies on the management of ISB in elderly patients with dementia are needed.
— Jasmine Amena Brathwaite, MD, is a graduate of the University of the West Indies, Barbados. Having completed a family medicine residency and geriatrics fellowship at the University of Arkansas for Medical Sciences (UAMS) in Little Rock, she is currently undergoing advanced/nonstandard training as a clinical educator as a second-year geriatrics fellow at the Donald W. Reynolds Department of Geriatrics, UAMS.
— Priya Mendiratta, MD, MPH, AGSF, is a graduate of the University of Nagpur, Mahatma Gandhi Institute of Medical Sciences in India and pursued a residency in internal medicine in India. She later received her MPH from Boston University of Public Health. Her training in the United States includes a family medicine residency and a two-year geriatrics fellowship at the Reynolds Department of Geriatrics at the University of Arkansas for Medical Sciences. She is also a 2013 American Geriatrics Association Fellow.
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