To provide family physicians with an update on the approach to diagnosis and management of inappropriate sexual behaviour ISB in persons with dementia.
No level I studies were identified; most articles provided level III evidence. Inappropriate sexual behaviour is common in people with dementia. A variety of factors eg, cultural, religious, societal views of geriatric sexuality, medicolegal issues might complicate evaluation of this behaviour, and must be considered to allow suitable management of individual patients. Tools to assist in documenting ISB are available. Creative nonpharmacologic interventions for ISB might be effective Sexualised behaviour in dementia tailored to individual patients.
A number of drug treatments eg, antidepressant, antiandrogen, antipsychotic, and anticonvulsant medications have been proposed for symptoms that do not adequately respond to nonpharmacologic interventions. However, evidence to support drug treatments is limited, adverse effects remain an important consideration, and it is unclear which Sexualised behaviour in dementia be used as first-line versus second-line treatments.
Although there is no empirically established treatment algorithm for dementia-related ISB, existing literature provides some evidence for various nonpharmacologic and pharmacologic treatments. Further high-quality research is urgently needed to guide family physicians who manage patients with dementia-related ISB.
A broad spectrum of behavioural and psychological symptoms can develop in Alzheimer disease and related dementias, and increase the risk of poor outcomes for both patients and their caregivers. All individuals—regardless of their age or medical condition—need love, touch, companionship, and intimacy. Care must be taken not to pathologize appropriate sexual behaviour. Perceptions of what constitutes appropriate behaviour vary between individuals, and might be influenced by a host of factors, such as religious beliefs or prevailing societal views Sexualised behaviour in dementia elderly persons.
Examples of ISB include lewd or suggestive language, implied sexual acts eg, requesting unnecessary genital care, viewing pornography in publicand overt sexual acts "Sexualised behaviour in dementia," touching, grabbing, or disrobing of self or others, public masturbation.
In this article, we provide an update on the evaluation and management of dementia-related ISB. He has been living in a nursing home for the past 2 years. He begins approaching female nursing home residents with sexual suggestions, which is upsetting for his family.
Despite a move to a different floor, he continues to make inappropriate verbal and sometimes physical sexual advances toward female residents and staff. Behavioural strategies produce limited success. Nursing staff and his family ask you for something to help control Mr A. Reference lists Sexualised behaviour in dementia pertinent papers were also searched to identify other relevant articles for inclusion.
Levels of evidence were cited where appropriate. No level I studies were found, and most articles provided only level III evidence eg, case reports.
One exception was Sexualised behaviour in dementia controlled case series level II evidence. Evaluation of "Sexualised behaviour in dementia" can have complex ethical and medico-legal implications. An approach to assessing capacity to engage in a sexual relationship is detailed in Box 1.
To guide optimal management of ISB, the evaluation should include a thorough medical history and physical examination and targeted laboratory testing. Valuable collateral history can be obtained from family members, regular caregivers, or other nursing home residents Box 2.
The history should also cover specifics of the demonstrated behaviour, such as potential precipitants and consequences. Precipitants could include environmental or emotional triggers, misinterpretation of nonsexual acts eg, routine nursing careor medications eg, benzodiazepines, dopamine agonists, androgen supplements.
Seeking to understand the motivation for possible inappropriate public displays can sometimes yield unexpected and nonsexual causes that can be more easily addressed.
For example, patients with dementia might fail to wear appropriate clothing in public simply because they have forgotten to get dressed or because they are too warm. Their cognitive impairment might result in a lack of recognition of this behaviour as potentially provocative or offensive to others.
In this case, it might be useful to provide the patient with clothing that opens in the back so that it cannot be easily removed. The sudden emergence of ISB can herald delirium, and a comprehensive approach is needed to rule out underlying medical illness.
Careful neurologic and cognitive assessment as well as genital examination might also help uncover contributors to ISB eg, urinary tract infection, fecal impaction. The evaluation should be carefully documented to help support the rationale Sexualised behaviour in dementia subsequent treatments.
Unfortunately, the literature on management of dementia-related ISB is sparse, and the few existing studies have important limitations. Most articles on this topic are based on single case reports or small case series. No randomized controlled trials RCTs have been Sexualised behaviour in dementia to establish the efficacy or safety of the many proposed treatments of ISB, and it is unclear in which order these treatments should be used when patients fail to respond to initial treatments.
The generalizability of the existing literature is questionable; for example, most published case reports involve men, and it is uncertain how women might respond to some proposed treatments. Nonetheless, guidance can be given by extrapolating from what is known about the management of other behavioural and psychological symptoms of dementia. Discontinuing medications that worsen disinhibition eg, benzodiazepines, dopamine agonists might reduce ISB.
Drug treatments should be prescribed only if symptoms fail to respond to more conservative measures, as many medications have important toxicities that can offset their potential benefits. Clinicians should select a target symptom and reasonable timeline to help gauge whether a new treatment has proven effective.
Nonpharmacologic interventions need to be adapted to the individual patient. Common examples include removal of precipitating factors, distraction strategies, and opportunities to relieve sexual urges. In the nursing home setting, it might be necessary to separate a patient from another resident or staff member when the other person appears to be the trigger for ISB eg, by reminding the patient of his spouse.
Separation can be achieved by moving one resident to another floor in the nursing home. Distraction with other activities can sometimes help eg, participation in crafts to occupy the hands and prevent inappropriate touching or public masturbation. In a controlled case series, Bardell et al found consistent redirection and enhanced communication through an interpreter to be effective approaches level II evidence.
Although not specific to ISB, an Australian study compared usual care for dementia-related behaviour to individualized assessment and care delivered by a multidisciplinary team eg, a nurse with to geriatric Sexualised behaviour in dementia and geriatric medicine specialists. Access to the multidisciplinary team was effective in reducing dementia-related behaviour and was associated with less use of psychotropic medications level II evidence.
In some cases, creativity might lead to success without the need to resort to medication. For example, a case report describes the provision of a 3-foot-tall stuffed doll to a man with dementia who was sexually aggressive toward women in his nursing home. His ISB stopped after introduction of the doll, as it provided an alternate means of sexual release level III evidence. Patients with persistent ISB might require the addition of drug treatment. Many different medications have been proposed for this treatment, and clinicians must carefully weigh the potential benefits and harms of each Table 1.
"Sexualised behaviour in dementia" treatments should be tailored to the individual patient. Comorbid conditions might serve to guide decisions eg, estrogens should be avoided in patients with a history of venous thromboembolism. As all pharmacologic treatments of ISB represent off-label prescribing, it is important to maintain communication with patients and family members about the potential benefits and risks of treatment and to document these discussions.
Hormonal treatments might be controversial, as they are sometimes viewed as a form of chemical castration. Pharmacologic treatments proposed for ISB: Many antidepressant drugs are known to provoke sexual dysfunction, and thus it is not surprising they have been proposed to treat ISB. Antidepressant treatment has the potential added benefit of treating other dementia-related behavioural disturbances. In some case reports, paroxetine and citalopram had benefits within 1 week of treatment and lasting effects were observed at follow-up several months later.
The antidepressant trazodone improved ISB in 4 patients with dementia.
Medroxyprogesterone acetate is a synthetic progestin used for several indications in women and for lowering testosterone production in men. Several case reports level III evidence 24 — 27 and one small controlled case series level II evidence 9 describe successful use of medroxyprogesterone acetate for dementia-related ISB. Cyproterone acetate is another synthetic progestin and antiandrogen that works by blocking androgen receptors.
One report described successful use of low-dose oral cyproterone acetate 10 mg daily for 2 male patients with dementia-related ISB that had not responded to treatment with antipsychotic or sedative medication level III evidence. This drug is commonly used to treat benign prostatic hyperplasia, and has the potential to produce low libido and erectile dysfunction.
A case series describes use of finasteride to treat ISB in 11 elderly men with vascular dementia. Estrogens decrease secretion of hormone and follicle-stimulating hormone, which lowers testosterone production and typically results "Sexualised behaviour in dementia" reduced libido.