Frontal lobe dementia and sexually inappropriate behaviors

Identify and define inappropriate sexual behavior (ISB) in the context of a patient with dementia.

Assessment

Although sexual activity decreases in the elderly, sexual interest can remain at baseline (1). Societal stereotypes often result in the classification of all sexual behavior among older adults as inappropriate or pathologic, thus it is important to distinguish appropriate versus inappropriate sexual behavior (ISB). Unfortunately, there is no globally accepted definition of ISB, so this determination must be predicated upon what is viewed as normative within the contexts of the environment, as well as the risk or discomfort inflicted upon others.  If the sexual activity interferes with normal activities, occurs at socially inappropriate times, or infringes on the rights of others, it is reasonable to deem it as ISB.

ISB encompasses three types of behaviors:

Sexual talk (foul, threatening, or abusive language),

Sexual acts (touching, exposing, public masturbation, fondling),

c)                  Implied sexual acts (public pornography, requesting unnecessary genital care) (1, 2).

ISB is most frequently described among patients with dementia and is generally related to disinhibition associated with frontal lobe changes/dementia. The data are mixed with regards to whether men engage in ISB more often than women; however men may be more apt to demonstrate aggressive behaviors, while women may be more likely to engage in ISB which is verbal in nature (3,4).

Secondary causes of ISB, some of which may be potentially reversible include the following:

Physical Factors:  Dementia, tumors, stroke, epilepsy, Wilson’s disease, Tourette’s  Syndrome, Klein Levin Syndrome (5), depression, delirium, electrolyte abnormalities, urinary tract infections, constipation, or fecal impaction.

Social Factors: Loss of partner, lack of privacy, misinterpretation of cues, understimulating surroundings. These circumstances may occur in long-term care facilities, where the model of living may make it challenging to have private sexual relationships (6).

Substance Abuse: Alcohol, cocaine.

Medication-related adverse effects: Anticholinergics, benzodiazepines, psychostimulants, anti-Parkinsonian agents (1).

Management:

Non-Pharmacologic Management   Although there is no standardized approach/ algorithm for the management of ISB, clinicians should begin with non-pharmacologic interventions which are least intrusive. Environmental or sensory triggers that may precipitate ISB should be identified and removed if possible, or redirect patients from those triggers. Care teams may decide to use same-sex caregivers if appropriate, clothing that fastens in the back and distraction activities that involve the use of hands.  Conversely, with cognitively intact and consenting adults, long-term care facilities may offer private and appropriate opportunities for persons to engage in sexual activities. Long-term care facilities should also ensure call lights and telephones are within reach during sexual activity (4). Additionally, perceptions of long-term care facility staff towards residents’ expressing sexuality may affect management, and it is therefore imperative that staff undergo training interventions focusing on improving knowledge of and attitudes towards sexuality and dementia (7).

Pharmacologic Management   When considering pharmacotherapies, it is important to note that all pharmacologic treatments for ISB are off-label and poorly studied. Many experts advocate reserving the use of pharmacologic management for ISB to situations in which a patient is engaging in or threatening dangerous acts involving intimate physical contact.

Antidepressants: In case-controlled studies, Citalopram and other SSRIs have been utilized to decrease libido and obsessive behaviors with few adverse effects, but poor effectiveness (2).

Antipsychotics: Haldoperidol and Quetiapine have both been described as marginally effective, and associated with a high level of side effects (2).

Antiandrogens:  Generally reserved for refractory cases to reduce testosterone levels and libido considering their stigma of providing “chemical castration”.  Medroxyprogesterone acetate is the most commonly used of these agents (8).

Anticonvulsants: Gabapentin and Carbamazepine have been utilized by some experts as a second line therapy for its off-labeled effects to decrease libido and sexual function.

Cholinesterase inhibitors: Conflicting results regarding dementia-related ISB (9). One case report elucidated reduction of ISB with Rivastigmine however, a number of trials demonstrated symptomatic worsening with Donepezil.

Reporting and Legal Issues   Federal regulations mandate that institutional care be as least restrictive as possible to maintain a safe environment (10).  Consequently, the dilemma of preserving an individual’s right to sexual expression while also ensuring others are not at risk of physical or mental harm, could contribute to underreporting of ISB.  It is important for health care facilities to have clear policies and procedures in place for patients, families and staff.  Staff educational programs which examine staff values, patient’s rights, and how to provide the most appropriate care are suggested (6).

Context

Older adults with dementia, living in the community or in long term care facilities, exhibiting ISB.

Action

Assess and manage ISB in patients with dementia.

Incidence / Prevalence

Behavioral issues may develop in up to 90% of patients with dementing disorders (11).  The prevalence of inappropriate sexual behaviors is estimated at 2-17% of patients with dementia (12), with one study estimating that up to 25% of patients with Alzheimer’s dementia may exhibit ISB (13).

Underlying Sciences

Dementias (or Major Neurocognitive Disorders) are acquired neurodegenerative processes marked by cognitive function impaired across at least 2 domains (complex attention, executive function, learning and memory, language, perceptual-motor, and social cognition) that are not otherwise explained by a psychiatric or delirium cause, and are severe enough to interfere with independent functioning in social or occupational environments.  It is related to physical brain pathology (plaques and neurofibrillary tangles, Lewy bodies, vascular or traumatic brain injury, etc) that damages key neurologic pathways.  Alongside these disorders, there often exists an underlying behavioral component. One study demonstrated that 58% of patients with Alzheimer’s dementia had behavioral symptomatology (14). These behavioral symptoms may manifest as inappropriate sexual behavior.

Science Principles

Objectives

Identify and define inappropriate sexual behavior (ISB) in the context of a dementing disorder.

Describe pharmacologic and non-pharmacologic strategies for managing ISB.

Keywords/Tags

Review of Systems (ROS)

Geriatric Topics

ACGME Compentencies

Science Principles

References

1.            Joller P, Gupta N, Sitz DP, Frank C, Gibson M, Gill SS.  Approach to inappropriate sexual behaviour in people with dementia.  Can Fam Physician. 2013; 59:255-60.

2.            Bardell A, Lau T, and Federoff JP. Inappropriate sexual behavior in a geriatric population. Int Psychoger. 2011; 23(7):1182-1188.

3.            Robinson KM.  Understanding hypersexuality: a behavioral disorder in dementia.  Home Healthcare Nurse. 2003; 21:43-7.

4.            Wick JY, Zanni GR.  Disinhibition: clinical challenges in the long-term care facility.  Consult Pharm. 2005; 20:1006-18.

5.            Ozkan B, Wilkins K, Muralee S, Tampi RR.  Pharmacotherpy for inappropriate sexual behaviors in dementia: a systemic review of literature.  Am J Alzheimers Dis Other Demen. 2008; 23(4):344-54.

6.            Wallace M, Safer M. Hypersexuality among cognitively impaired older adults. Geriatr Nurs. 2009; 30(4):230-7.

7.            Di Napoli EA, Breland, GL, and Allen RS. Staff knowledge and perceptions of sexuality and dementia of older adults in nursing homes. J Aging Health. 2013; 25: 1087.

8.            Cross B, DeYoung R, Furmaga S. High-dose oral medroxyprogesterone for inappropriate hypersexuality in elderly men with dementia: A case series. Annal Pharmacol. 2013; 47(1):e1.

9.            Alagiakrishnan K, Sclater A, Robertson D. Role of cholinesterase inhibitor in the management of sexual aggression in an elderly demented woman. J Am Geriatr Soc. 2003; 51(9):1326.

10.          42 CFR 483 – The Patient’s Bill of Rights.  September 1991.

11.          Srinivasan S, Wienberg A. Pharmacologic treatment of sexual inappropriateness in long term care residents with dementia.  Annals of Long Term Care. 2006 Vol 14(10).

12.          Series H, Dégano P. Hypersexuality in dementia. Adv in Psych Treat. 2005; 11:424-31.

13.          Mendez M, Shapira J. Hypersexual behavior in frontotemporal dementia: A comparison with early-onset Alzheimer’s disease. Arch Sex Behav. 2013; 42:501-09.

14.          Reisberg B, Borenstein J, Salob SP, Ferris SH, Franssen E, Georgotas A. Behavioral symptoms in Alzheimer’s disease: phenomenology and treatment. J Clin Psychiatry. 1987: 48 Suppl:9-15.

Copyright

Users are free to download and distribute Geriatric Fast Facts for informational, educational and research purposes only. Citation:  Alexandrea Bear MD, Sean Marks MD, Steven Denson MD - Fast Fact #53: Inappropriate Sexual Behavior (ISB) and the Dementia Patient. November 2014. See Term of Use for additional information.

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