May/June 2015

Dementia and Inappropriate Sexual Behavior
By Jasmine Amena Brathwaite, MD, and Priya Mendiratta, MD, MPH, AGSF
Today's Geriatric Medicine
Vol. 8 No. 3 P. 26

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.

Case Report
An 89-year-old white male was seen in clinic with his daughter who reported that he frequently removed his clothes and touched his genital area. He had been sexually inactive prior to the death of his wife of 50 years two months ago, and lived at home with a caregiver. Past medical history was significant for peripheral arterial disease (PAD), hypertension, and AD. Since his previous visit, his behaviors had worsened with increased frequency, and he verbalized inappropriate sexual comments directed toward his female caregiver.

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.

Conclusion
Despite nonpharmacologic and limited pharmacologic interventions, inappropriate sexual behavior in older adults with dementia is challenging to manage.

Case Details
Mr. J, an 89-year-old male with a past medical history of PAD, hypertension, benign prostatic hypertrophy, previous deep vein thrombosis, and dementia, presented to clinic with his daughter. She reported that his caregiver had voiced concern because Mr. J had frequently been removing his clothes and touching his genital region throughout each day. A retired baker, Mr. J had previously lived with his wife of 50 years who had died two months prior. At a previous visit he had reported that he and his wife were no longer sexually active. Physical examination, including the genital area, was negative for any abnormalities. It was suggested that his family and caregivers try to redirect him from the sexual behaviors and then return for follow-up.

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.

Overview
Census data have demonstrated that the number of elderly individuals aged 65 and older will double between 2000 and 2030.1 With the increasing number of elderly in the community, the frequency of age-related physiologic and pathologic changes will increase. And with the increasing prevalence of AD, the most recent data estimate escalation to a 40% increase in its prevalence by the year 2025.2 AD is particularly challenging because of patients' neurologic dysfunction resulting in memory loss, communication difficulty, and disorientation, among other changes, which leads to a high burden of suffering for patients, their caregivers, and the community with extended disease trajectory,3 cost,4 and caregiver stress.5

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
In the community, ISB is an issue for families caring for a relative, especially when there are minors also residing in the home, and when paid caregivers refuse to work in such an environment. When individuals are admitted to facilities, the issues can be ethical (does the patient truly understand/have the capacity to say no?), medical (possible risk of infection transmission),12 and/or legal, as these behaviors are often directed toward staff or other residents, and if the behaviors are directed at the patient himself, they often occur in public areas. This circumstance can likewise be problematic for patients with ISB who live in the community.

Sexual Incidents
Sexual incidents can be categorized as sexual talk, such as the use of foul language, describing previous sexual acts, or suggesting sexual encounters; sexual acts such as public masturbation, exposing genitalia, touching others' breasts, buttocks, thighs, or genitalia; and implied sexual acts such as requesting unnecessary genital care or openly reading pornography.13 Interestingly, these behaviors could be a manifestation of cognitive domain dysfunction seen in patients with dementia or an outward expression of the desire for sexual and nonsexual intimacy previously experienced in life. Individuals with dementia lack awareness of their surroundings, and if some of these behaviors occurred in private they would be more acceptable, therefore making these behaviors difficult to classify. In other situations, some medications, such as antiparkinsonian agents, have been implicated in sexually inappropriate behaviors.14

Nonpharmacologic and Pharmacologic Management
The appropriate medical management of patients with ISB is most effective and beneficial when it employs an interdisciplinary approach along with staff and caregiver education.12 Basic information on human sexuality over a patient's lifetime may be helpful15 as some incidents could be expressions of his or her desire for intimacy or attention. One study found that staff experienced shock, embarrassment, and incomprehension when initially encountering inappropriate sexual behavior.16 Understanding dementia symptoms and familiarity with patients and social norms were important and suggest that the effect of ISB should be routinely considered in preparing staff who work in dementia care settings.17

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 

Summary
Nonpharmacologic interventions recommended to address ISB in patients with dementia include the following:

• 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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