Inappropriate sexual behaviors in cognitively impaired older individuals

Treatment and Management of Sexual Disinhibition in Elderly Patients With Neurocognitive Disorders

Sexual disinhibition is uncommon but challenging symptom to address in elderly patients with neurocognitive disorders. Due to the lack of large-scale studies, there is no gold standard treatment for sexual disinhibition, and treatment is largely left up to the discretion of the provider based on the severity and onset of the patient's symptoms. A review was conducted to investigate the non-pharmacological and pharmacological interventions for treating this condition. Articles that discussed treatments were screened for the type of treatment and possible side effects of medication if applicable. Thorough patient history should be taken prior to starting any drug therapy to rule out possible behavioral changes due to an existing medication side effect, delirium, or past mental or sexual health history. Non-pharmacological treatment has been generally recommended as first-line therapy over pharmacological treatment. Distraction/diversion of the patient when inappropriate sexual behaviors occur was the most common non-pharmacological intervention. Antidepressants were generally recommended as the first line of pharmacological treatment after attempting all possible non-pharmacological interventions. Several other categories of interventions are discussed as well in addition to the ethical implications of treating a patient for this condition.

The World Federation of Societies of Biological Psychiatry (WFSBP) 2020 guidelines for the pharmacological treatment of paraphilic disorders

Objectives: The primary aim of these guidelines is to evaluate the role of pharmacological agents in the treatment and management of patients with paraphilic disorders, with a focus on the treatment of adult males. Because such treatments are not delivered in isolation, the role of specific psychotherapeutic interventions is also briefly covered. These guidelines are intended for use in clinical practice by clinicians who diagnose and treat patients, including sexual offenders, with paraphilic disorders. The aim of these guidelines is to bring together different views on the appropriate treatment of paraphilic disorders from experts representing different countries in order to aid physicians in clinical decisions and to improve the quality of care.Methods: An extensive literature search was conducted using the English-language-literature indexed on MEDLINE/PubMed (1990-2018 for SSRIs) (1969-2018 for hormonal treatments), supplemented by other sources, including published reviews.Results: Each treatment recommendation was evaluated and discussed with respect to the strength of evidence for its efficacy, safety, tolerability, and feasibility. The type of medication used depends on the severity of the paraphilic disorder and the respective risk of behaviour endangering others. GnRH analogue treatment constitutes the most relevant treatment for patients with severe paraphilic disorders.Conclusions: An algorithm is proposed with different levels of treatment for different categories of paraphilic disorders accompanied by different risk levels.

Gender differences in presentation and management of behavioral and psychological symptoms associated with dementia among nursing home residents with moderate to severe dementia

Lack of identification and management of behavioral and psychological symptoms of dementia (BPSD) can negatively impact female residents. The purpose of this secondary data analysis was to explore gender differences in presentation and management of BPSD and quality of interactions between residents and staff. A total of 553 residents from 55 nursing homes were included. Males exhibited more apathy and sexually inappropriate behavior and females exhibited more anxiety and sadness. Anxiety and sexually inappropriate behavior were more likely to be addressed in care plans for males than females. There was no difference in how staff interacted with males or females.

Prevalence of and Preparedness to Address Inappropriate Sexual Behavior from Patients During Psychiatry Training: a Pilot Study

OBJECTIVE

Mental health providers experience inappropriate sexual behavior from patients. It is unclear if training programs adequately prepare trainees to respond to such behaviors. Additionally, trainees may not seek support and guidance from supervisors after an incident. This is an exploratory study to document the prevalence of and assess the preparedness of trainees to deal with inappropriate sexual behavior.

METHODS

A survey was administered to 58 psychiatry residents and 14 psychology interns at the NYU School of Medicine. A total of 22 questions were asked regarding participants' experiences with inappropriate sexual behavior, including prevalence of, and preparedness during, and support received after the behavior.

RESULTS

Of those who completed the survey, 89% of respondents had experienced inappropriate sexual behavior. Seventy percent said they had no training in responding to inappropriate sexual behavior, and 95% wanted more training. A minority of respondents consistently sought support after these events, and of those who did, only 60% of trainees did so with a supervisor.

CONCLUSION

Experiences involving inappropriate sexual behavior are prevalent among the mental health trainees surveyed, but most trainees did not feel that they received adequate training in preparation for or supervision after their experiences. Creating training or establishing protocols to respond to inappropriate sexual behavior may help trainees feel more capable and safer. Further studies are needed to understand inappropriate sexual behavior's impact on trainees and patient care, as well as to assess the efficacy of training and protocols developed to manage inappropriate sexual behavior.

The Role of Sexual Disinhibition to Predict Caregiver Burden and Desire to Institutionalize Among Family Dementia Caregivers

Neuropsychiatric symptoms in dementia are associated with greater caregiver burden and desire to institutionalize, though previous work largely examines the cumulative effects of many behavioral symptoms. Sexual disinhibition could be particularly stressful due to stigma attached to these behaviors. Links between care recipient sexual disinhibition, caregiver burden, and caregiver desire to institutionalize were examined by analyzing cross-sectional data from 730 family caregivers recruited online. Caregiver burden, caregiver desire to institutionalize, and neuropsychiatric symptoms, including sexual disinhibition, were assessed via caregiver report. Burden (P < .001) and desire to institutionalize (P = .008) were greater among caregivers who endorsed sexual disinhibition. Sexual disinhibition uniquely predicted desire to institutionalize after accounting for presence (P = .02) and severity (P = .03) of other neuropsychiatric symptoms. A similar pattern was seen for burden (presence P < .04; severity P = .06), and follow-up analyses revealed caregiver burden mediated the relationship between care recipient sexual disinhibition and caregiver desire to institutionalize (presence bias-corrected 95% confidence intervals [BC_a 95% CI] [0.003, 0.08], severity BC_a 95% CI [0.007, 0.06]). Sexual disinhibition appears to be a particularly difficult neuropsychiatric symptom for the family caregiver, contributing to desire to institutionalize via caregiver burden.

Measurement of sexual disinhibition in dementia: A systematic review

Sexual disinhibition in dementia is correlated with multiple negative care recipient and caregiver outcomes but remains largely overlooked in the literature. Its prevalence is not well understood, with studies reporting between 1.8% and 25% presence of sexual disinhibition in dementia samples. One reason for the variability in the reported presence of sexual disinhibition may be lack of standardized methods for assessment. Several widely used measures for neuropsychiatric symptoms do not include items to assess sexual disinhibition. When measures do include sexual disinhibition, it is not addressed in a consistent manner. Inconsistency in how questions about sexual disinhibition are phrased is problematic, given that recent work shows it can differentially influence endorsement. Working toward a gold standard of sexual disinhibition measurement in dementia is needed. To this end, a systematic review of the literature to identify potentially appropriate instruments for measurement of sexual disinhibition in this population was conducted through the Web of Science and PubMed databases between January 2019 and February 2019. An overview of the 20 measures identified in this search is provided. Each measure is evaluated for appropriateness of use in dementia samples through broad examination of psychometric properties, structure, and format and the extent to which measure content overlaps with current conceptualizations of sexual disinhibition in dementia. Five common content domains were identified: hypersexuality, lewd/aberrant sexual behavior, inappropriate sexual advances, inappropriate sexual comments, and socially disruptive sexual behavior. No single measure addressed all content domains. Directions for future research are identified and discussed.

Behavioral and psychological symptoms in Alzheimer's dementia and vascular dementia

Behavioral and psychological symptoms of dementia (BPSD) are highly prevalent and represent a significant burden for patients and their caregivers. Early recognition and management of these symptoms is crucial as they are associated with increased risk of institutionalization, impairments in daily functioning, reduced quality of life, and more rapid progression to severe dementia. This chapter will discuss the pathophysiology, proposed diagnostic criteria, clinical features, and management of BPSD, including apathy, depression, agitation/aggression, psychosis, and sleep disturbances. Apathy and depression are the most common overall, and apathy is associated with high symptom severity likely because of its greater persistence. Symptoms such as agitation, aggression, hallucinations, and delusions may be especially distressing and dangerous to patients and caregivers. Nonpharmacologic management should be considered first-line therapy in most cases due to the modest and inconsistent evidence base for pharmacologic agents and greater risk of harm. However, the judicious use of pharmacologic agents may be warranted when symptoms are dangerous and/or severely distressing.

Intimacy and Sexuality in Institutionalized Dementia Care: Clinical-Ethical Considerations

Intimacy and sexuality expressed by nursing home residents with dementia remains an ethically sensitive issue for care facilities, nursing staff and family members. Dealing with residents' sexual longings and behaviour is extremely difficult, putting a burden on the caregivers as well as on the residents themselves and their relatives. The parties in question often do not know how to react when residents express themselves sexually. The overall aim of this article is to provide a number of clinical-ethical considerations addressing the following question: 'How can expressions of intimacy and sexuality by residents with dementia be dealt with in an ethically responsible way?' The considerations formulated are based on two cornerstones: (1) the current literature on older peoples' experiences regarding intimacy and sexuality after the onset of dementia, and (2) an anthropological-ethical framework addressing four fundamental pillars of human existence namely the decentred self, human embodiment, being-in-the-world and being-with-others. The resulting considerations are oriented toward the individual sphere, the partnership sphere, and the institutional sphere. The continuous interaction between these spheres leads to orientations that both empower the residents in question and respect the complex network of relationships that surrounds them.

Sexual Behavior Among Persons With Cognitive Impairments

Although the cognitively impaired are frequently included in heterogeneous studies of problematic sexual behavior, the epidemiology, etiology, and approach to assessment and treatment of persons with dementia and intellectual disability are distinct from those of the general population. The incidence of inappropriate sexual behavior among the intellectually disabled is 15-33%; however, the nature tends to be more socially inappropriate than with violative intent. Limited sociosexual education is a large contributor, and better addressing this area offers a target for prevention and treatment. A thorough clinical assessment of problematic sexual behaviors in the cognitively impaired requires understanding the patient's internal experience, which can be challenging. Assessment tools validated for the general population have not been validated for this population. Very few studies have assessed treatment approaches specifically among the cognitively impaired; however, research does suggest utility in habilitative, psychotherapeutic, and pharmacologic approaches which have been validated among the general population.

Progestins used in endocrine therapy and the implications for the biosynthesis and metabolism of endogenous steroid hormones

Steroidogenesis refers to the de novo synthesis of steroid hormones from cholesterol by a number of sequential enzyme catalysed reactions in the adrenal and the gonads. In addition, circulating steroid hormone precursors are further metabolised in selected peripheral tissues. It has been suggested that the biosynthesis of endogenous steroid hormones can be modulated by progestins, used widely by women in female reproductive medicine. However, as a number of structurally diverse progestins with different pharmacological properties are available, it is possible that these synthetic compounds may vary in their effects on steroidogenesis. This review summarises the evidence indicating that progestins influence the biosynthesis of steroid hormones in the adrenal and gonads, as well as the metabolism of these endogenous hormones in the breast, highlighting the limitations to the current knowledge and directions for future research.

Citizenship, human rights, and dementia: Towards a new embodied relational ethic of sexuality

Sexual citizenship and sexual rights scholarship have made important contributions to broadening citizenship and more fully accommodating rights related to sexuality. However, this scholarship has concentrated primarily on the sexuality and intimacy-related needs of younger people and those who are not cognitively impaired. Consequently, it has inadvertently served to marginalize persons living with dementia who reside in long-term residential care settings. We argue that supporting sexual rights for persons with dementia requires a particular human rights ontology for citizenship-one that recognizes that corporeality is a fundamental source of self-expression, interdependence, and reciprocal engagement. This is an ontology that underpins our model of relational citizenship and that grounds our articulation of an ethic of embodied relational sexuality. In our view, this ethic offers important direction for the development of policy, legislation, and clinical guidelines to support sexual rights for persons with dementia in long-term residential care.

Management of Neuropsychiatric Symptoms in Neurocognitive Disorders

Dementias, renamed neurocognitive disorders (NCDs) in the DSM-5, are defined by acquired decline in cognitive and functional abilities. DSM-5 now also includes mild NCD, which incorporates the previous diagnosis of mild cognitive impairment. DSM-5 recognizes the following etiologies for NCDs: NCD due to Alzheimer's disease, vascular NCD, NCD with Lewy bodies, frontotemporal NCD, substance-/medication-induced NCD, NCD due to traumatic brain injury, NCD due to Huntington's disease, NCD due to HIV infection, NCD due to prion disease, and NCD due to other medical conditions. In this review, the authors discuss a wide variety of interventions that have been studied for the treatment and management of neuropsychiatric symptoms of patients with NCDs. In addition to nonpharmacological interventions, several classes of medications-including antipsychotics, antidepressants, anticonvulsants, and cholinesterase inhibitors-have been studied for this indication.

Treatment of Inappropriate Sexual Behavior in Dementia

Inappropriate sexual behavior (ISB) is a relatively common and potentially disruptive form of behavior in people with dementia. It can cause considerable distress and put placements and people at risk. Yet it is poorly researched and understood. In addition to non-pharmacological approaches to management, a wide range of classes of medication has been used in ISB, and the results have been reported as single cases or short series, though none has been the subject of a randomized clinical trial, in part because of the lack of a well-defined method of observing and measuring ISB, as well as the significant ethical considerations. Pharmacological treatments for which there is low-level evidence of efficacy in the literature include antidepressants, antipsychotics, anticonvulsants, cholinesterase inhibitors, hormonal agents, and beta-blockers. None of the drugs discussed here is licensed for use in ISB, and elderly people, particularly those with dementia, are at high risk of adverse effects. Caution is advised before using medication in this group of people. It is important to consider alternative non-pharmacological treatments, as well as discussing issues of ethics and consent with those involved, before initiating treatment. It is helpful to identify and monitor target symptoms. Pharmacological treatments should be started at low dose and titrated up slowly and carefully. Nevertheless, in some situations, medication may provide a useful part of a management plan for ISB.

Inappropriate behaviors and hypersexuality in individuals with dementia: An overview of a neglected issue

Behavioral and psychological symptoms of dementia are very common in patients affected by dementia, and are associated with high rates of institutionalization. Behavioral and psychological symptoms of dementia consist of aggressive behavior, delusions, hallucinations, depression, apathy, wandering, stereotyped and inappropriate sexual behavior. Interestingly, the latter has been reported to be relatively uncommon, but causing immense distress to patients and their caregivers. The genesis of inappropriate behavior is considered a combination of neurological, psychological and social factors. Although assessment is mainly carried out by clinical observation and interviews with caregivers, the most appropriate management of behavioral and psychological symptoms of dementia, including hypersexuality, is a combination of pharmacological and non-pharmacological interventions, according to specific symptoms, degree of cognitive dysfunction and subtype of dementia. The present narrative review will mainly focus on aggressiveness, disinhibition, aberrant motor, and sexually inappropriate behavior diagnostic work-up and treatment, in an attempt to provide both the patients and their caregivers with useful information to better manage these symptoms and improve their quality of life. Space is particularly dedicated to inappropriate sexual behavior, which is still considered a neglected issue. Geriatr Gerontol Int 2017; 17: 865-874.

Sexual Consent Capacity Assessment with Older Adults

Many healthcare providers have a limited knowledge of sexual and intimate expression in later life, often due to attitudinal and informational limitations. Further, the likelihood of an older adult experiencing cognitive decline increases in a long-term care (LTC) setting, complicating the ability of the providers to know if the older adult can make his or her own sexual decisions, or has sexual consent capacity. Thus, the team is left to question if and how to support intimacy and/or sexuality among residents with intimacy needs. Psychologists working with LTC need to be aware and knowledgeable about sexual consent capacity in older adulthood to be prepared to conduct evaluations and participate in planning care. Limited research is available to consult for best practices in sexual consent capacity assessment; however, models of assessment have been developed based on the best available evidence, clinical judgment, and practice. Existing models will be discussed and an integrated model will be illustrated via a case study.

Sexual disinhibition and dementia

To describe inappropriate sexual behaviour (ISB) observed in patients with dementia, we conducted searches using the Cochrane Library, PubMed, and Web of Science to find relevant articles, chapters, and books published from 1950 to 2014. Search terms used included 'hypersexuality', 'inappropriate sexual behaviors', and 'dementia'. Publications found through this indexed search were reviewed for further relevant references. Sexuality is a human's need to express intimacy, but persons with dementia may not know how to appropriately meet their needs for closeness and intimacy due to their decline in cognition. Generally, the interaction among brain, physical, psychological, and environmental factors can create what we call ISB. The most likely change in the sexual behaviour of a person with dementia is indifference. However, ISB in dementia appear to be of two types--intimacy-seeking and disinhibited--that differ in their association with dementia type, dementia severity and, possibly, other concurrent behavioural disorder. Tensions develop from uncertainties regarding which, or when, behaviours are to be considered 'inappropriate' (i.e. improper) or abnormal. While most ISB occur in the moderate to severe stages of Alzheimer's dementia, they may also be seen in early stages of frontotemporal dementia because of the lack of insight and disinhibition. ISB are often better managed by non-pharmacological means, as patients may be less responsive to psychoactive therapies, but non-pharmacological interventions do not always stop the behaviour.

Increased libido associated with donepezil treatment: a case report

Inappropriate verbal and physical sexual behaviour is not common among individuals with dementia, but when it does occur, it can have profound consequences. We report a case of 79-year-old woman with dementia of the Alzheimer's type who complained of increased libido after an increased dose of donepezil, which was being used along with tianeptine. Donepezil withdrawal led to the resolution of increased libido, but when it was reintroduced, increased libido reappeared once again (Naranjo score: 7). Increased libido was not reported by the patient during the 6-year follow-up period after donepezil withdrawal. A potential mechanism of acetylcholinesterase inhibitor-induced increased libido and the current literature on hypersexuality as a side-effect of donepezil treatment are discussed.

Behavioral effects of levodopa

In recent years, levodopa-induced behavioral changes have received increased attention in the medical literature and in clinical practice. The spectrum of these symptoms includes non-motor fluctuations with neuropsychiatric symptoms, compulsive behaviors such as punding, dopamine dysregulation syndrome, and impulse control disorders, psychosis and hallucinations, as well as hypomania and mania. Despite knowledge of the clinical features associated with these behaviors, many of them are probably underdiagnosed. Although the mechanisms underlying behavioral symptoms are still incompletely understood, recent data from imaging and pathological studies have increased our understanding and guided new treatment strategies. Appropriate management remains challenging, because reduction of levodopa (l-dopa) and dopaminergic treatment is often recommended; however, doses required for control of motor symptoms may still induce behavioral changes. Newer modes of delivery of dopaminergic treatment, deep brain stimulation, and nondopaminergic agents may either provide alternatives for treatment of these behavioral problems or permit treatment of parkinsonism with less risk of these behavioral disorders.

Rivastigmine in the treatment of hypersexuality in Alzheimer disease

Inappropriate sexual behaviors (ISB) represent uncommon and often misdiagnosed clinical disorders among patients with Alzheimer disease. So far, no randomized clinical trials regarding the treatment of ISB in demented people have been conducted, but available data from case series and isolated case reports suggest the efficacy of selective serotonin reuptake inhibitors (SSRIs), antipsychotics, antiandrogens, and H2-receptor antagonists. Controversial data exist on the therapeutic influence of cholinesterase inhibitors on sexual disorders. In the present article, we describe the case of an Alzheimer disease patient presenting hypersexuality, successfully treated with rivastigmine. Thus, we perform a revision of the existing literature regarding the therapeutical effect of cholinesterase inhibitors in the treatment of ISB.

Sexuality and couple intimacy in dementia

PURPOSE OF REVIEW

The review assesses recent research and its impact on understanding of intimacy and sexuality in older adults with dementia.

RECENT FINDINGS

There is no universally accepted definition of inappropriate sexual behaviors (ISBs), but they have been divided into overt acts associated with increased libido and uninhibited sexual behaviors directed at oneself or other people. Couples affected by dementia frequently maintain physical intimacy. Nonintercourse intimate activities may be preferred over intercourse. Early therapeutic interventions may assist partners in modifying activities, behaviors, and expectations about the future of the relationship. Inappropriate sexual behaviors are commonly due to the disruption of interconnected brain structures. Trauma to the temporal lobes may lead to hypersexuality and ISB. Trauma to the limbic system can produce changes in sexual preference. Both temporal and frontotemporal dementias, or either of them, often present with socially and sexually inappropriate behaviors. Huntington's disease can exhibit hypersexuality, pedophilia, promiscuity, and marital infidelity. The involvement of the medial striatum of the basal ganglia in this disease explains the prevalence of ISB. There is no consensus regarding first-line pharmacotherapy for ISB. Little information is known about the adverse effects.

SUMMARY

Clinicians and society need to consider how dementia might affect physical intimacy.

Influence of cognitive decline on sexuality in individuals with dementia and their caregivers

Sexuality is an important element of human life that is strongly influenced by the social environment. People assess themselves and relate their roles to one another in terms of sexuality. More attention must be directed at the sexual needs of individuals with dementia and their caregivers. A myth believed by society is that individuals with dementia are asexual and that sexual desires and needs for connection will wane over time; whereas in reality many couples living with dementia remain sexually active as the disease progresses. The sexual needs of individuals with dementia are similar to those of younger people but might vary in occurrence and expression. An increase or decline in sexual desire is dependent on the level of cognitive impairment. Sexuality in individuals with dementia may be expressed as inappropriate or hypersexual behavior due to disinhibition and forgetting social cues. Although hypersexuality is often less common than other challenging behaviors that can occur in dementia, it affects both the health of the individual with dementia and the health of his or her caregiver.

High-Dose Oral Medroxyprogesterone for Inappropriate Hypersexuality in Elderly Men with Dementia: A Case Series

OBJECTIVE

To retrospectively examine the utility of high-dose oral medroxyprogesterone (MPA) for the treatment of inappropriate hypersexuality (IH) in elderly men with dementia.

CASE SUMMARY

Ten men aged 65 years or older (median 79.5 years, range 65–93 years) were identified from all admissions at a 170-bed tertiary referral psychiatric hospital between December 2005 and January 2011. Admission records were used to identify subjects who received at least 100 mg daily of oral MPA. The primary outcome of successful treatment was chart documentation of a substantial decline in IH, such that subjects could return to preadmission residence. Data were collected to assess trends in dose, adverse effects, use of other symptom-modifying medications prior to MPA initiation, and successful return to preadmission placement. A trial serotoneric agent was used in 70% of subjects prior to MPA initiation. Sixty percent of subjects failed a trial of an antipsychotic, while 40% did not have response to the use of both a serotonergic agent and an antipsychotic before MPA was initiated. The average daily dose of MPA was 300 mg (range 100–400 mg/day). No adverse effects were documented from physician, nursing, or behavioral health rounding notes; however, adverse effects may not have been systematically assessed at the time of MPA administration. Seventy percent of subjects experienced favorable changes in target behaviors from MPA.

DISCUSSION

Few data exist on effective therapy options for treatment of IH. The minimum concentration of MPA needed to suppress IH in the male body is unknown. MPA was titrated upward, with the efficacy measure being a decrease in inappropriate behaviors. Use of MPA likely contributed to decreased IH; however, other factors involved in hospitalization could have contributed to improved behavior.

CONCLUSIONS

While requiring further study, high-dose (100–400 mg/day) oral MPA may represent an effective and well-tolerated treatment option for subjects displaying IH.

‘Inappropriate’ sexual behaviours in dementia

Human sexuality is a complex interaction of biological, social and emotional factors. When any or all of these factors are disrupted by a progressive dementia it is unsurprising that sexual ‘problems’ are identified. Most sexual behaviour ‘problems’ relate to expressions of normal sexuality complicated by changes in relationships, care needs and cognitive function, and complex ethical and legal considerations emerge. Rarely, new and severe hypersexual or paraphilic behaviours arise de novo, usually due to damage to certain brain areas, and sometimes due to medication side-effects, psychiatric disorder or delirium. Evidence and approaches to assess and to manage sexual behaviour problems in dementia are discussed.

Inappropriate sexual behaviour and dementia: An exploration of staff experiences

Research assessing the impact of inappropriate sexual behaviour (ISB) on staff working in dementia care is circumscribed, yet studies from comparable settings indicate that ISB appears uniquely challenging, particularly to personal and cultural values. This study explored staff experiences of ISB exhibited by older adults with a dementia. Fourteen staff working within an in-patient setting were interviewed. Participants’ experiences of ISB appeared underpinned by complex social and psychological processes. Shock, embarrassment and incomprehension were prominent when ISB was initially encountered. Knowledge of dementia, familiarity with patients and social norms were important in contextualising ISB and staff often minimised its impact by construing a lack of capacity. Feelings about ISB appeared equivocal and findings suggest that the effect of ISB should be routinely considered in preparing staff who work within dementia care.

Displays of inappropriate sexual behaviour by patients with progressive cognitive impairment: the forgotten form of challenging behaviour?

Persons with progressive cognitive impairment such as dementia or Alzheimer's disease may display an array of challenging behaviours. For instance, levels of agitation and aggression have been reported as high as 33% in home-dwelling individuals and 80% in those residing in institutions. One form of challenging behaviour that may be displayed by this group is inappropriate sexual behaviour (ISB), but it is often overshadowed by other behaviours such as aggression. Inappropriate sexual behaviour involves any verbal of physical action of a sexual nature which is displayed in an inappropriate social context. Examples of ISB include: exposure of genitals in public/ward environments, 'groping' of nurses and masturbation in public areas. It has been estimated that the prevalence of ISB ranges from 2% to 17% of individuals with progressive cognitive impairment. Although it is less frequent than other challenging behaviours, it still may have significant deleterious effects on the victim's health. This paper is a review of the available literature on the nature, effects and management of ISB in persons with progressive cognitive impairment. Possible avenues for future research are also explored.

Nurses' perceptions of sexuality in institutionalized elderly: a literature review

BACKGROUND

Institutionalized elderly continue to have the need for sexual expression and intimacy. Nurses often display negative responses when they are confronted with the sexual behavior of residents. They feel ashamed and do not know how to react. This generates feelings of discomfort, resulting in the denial of resident's needs and desires for sexual fulfillment.

OBJECTIVES

The objective of this review is to thoroughly analyze the literature about the knowledge, attitudes, and experiences of nursing staff toward sexuality in institutionalized elderly. We shed light onto the relationship between knowledge and attitudes, and determined whether certain demographic factors relate to the knowledge and attitudes of nursing home caregivers.

DESIGN

We conducted an extensive search of the electronic databases Medline, Cinahl, Psychinfo, Web of Science, Philosophers Index, Google Scholar, and Invert for papers published between January 1980 and September 2010. A broad range of search keywords was used.

FINDINGS

The quantitative studies revealed nursing staff to show rather positive attitudes toward later-life sexuality. However, the extent of the staff's knowledge regarding sexuality in the aged seemed to be very limited. There was no consensus found about the relationship between knowledge and attitudes. As regards the influence of demographic variables, the results were very ambiguous. The qualitative studies showed that caregivers hold rather conservative attitudes toward sexuality in institutionalized elderly. Feelings of discomfort prevailed. The responses to residents' sexual behavior were influenced by the staff's own level of comfort related to sexuality issues and the ethos within the institution where they work.

CONCLUSIONS

This review gives us a broad outline of the knowledge, attitudes, and experiences of geriatric nurses toward sexuality in institutionalized elderly. If we want the sexual needs of residents to be recognized, more research is needed. Especially needed are more in-depth qualitative studies that explore the experiences of nurses and managers. The development of a more accurate educational program could increase the knowledge of later-life sexuality and cultivate positive and permissive attitudes toward sexuality in the aged.

Sexual aggression between residents in nursing homes: literature synthesis of an underrecognized problem

Evidence exists suggesting that most sexual aggression against older adults occurs in long-term care facilities. Fellow residents are the most common perpetrators, often demonstrating inappropriate hypersexual behavior caused by dementing illness. This resident-to-resident sexual aggression (RRSA) is defined as sexual interactions between long-term care residents that, in a community setting, at least one of the recipients would be likely to construe as unwelcome and that have high potential to cause physical or psychological distress in one or both of the involved residents. Although RRSA may be common, and physical and psychological consequences for victims may be significant, this phenomenon has received little direct attention from researchers. This is a review of the existing literature and relevant related research examining elder sexual abuse and hypersexual behavior that describes the epidemiological features of this phenomenon, including risk factors for perpetrators and victims. The legitimate and recognized need for nursing home residents, even those with advanced dementing illness, to express themselves sexually makes preventing and managing sexual aggression in nursing homes more challenging. This review discusses the ethical dilemma this situation creates and the need to evaluate the capacity to consent to sexual activity of residents with dementing illness and to re-evaluate capacity as the diseases progress. Suggestions are offered for managing incidents of RRSA and for future research, including the importance of designing effective interventions.

The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of paraphilias

OBJECTIVES

The primary aim of these guidelines was to evaluate the role of pharmacological agents in the treatment and management of paraphilia, with a focus on the treatment of adults males. Because such treatments are not delivered in isolation, the role of specific psychosocial and psychotherapeutic interventions was also briefly covered. These guidelines are intended for use in clinical practice by clinicians who diagnose and treat patients with paraphilia. The aim of these guidelines is to improve the quality of care and to aid physicians in clinical decisions.

METHODS

The aim of these guidelines was to bring together different views on the appropriate treatment of paraphilias from experts representing different continents. To achieve this aim, an extensive literature search was conducted using the English language literature indexed on MEDLINE/PubMed (1990-2009 for SSRIs) (1969-2009 for antiandrogen treatments), supplemented by other sources, including published reviews.

RESULTS

Each treatment recommendation was evaluated and discussed with respect to the strength of evidence for its efficacy, safety, tolerability and feasibility.

CONCLUSIONS

An algorithm was proposed with six levels of treatment for different categories of paraphilias.