Low-dose cyproterone acetate treatment of sexual acting out in men with dementia

[Androgens and Parkinson's disease: the role in humans and in experiment]

Parkinson's disease (PD) is the second most common neurodegenerative disease after Alzheimer's disease. There is evidence that PD has a wider prevalence among men, which indicates the existing role of sex hormones in the pathogenesis of the disease. The article presents an overview of studies devoted to the study of sex differences in the incidence and symptoms of PD. Drug therapy with androgens, androgen precursors, antiandrogens and drugs that modify androgen metabolism is available for the treatment of various endocrine conditions, having translational significance for PD, but none of these drugs has yet shown sufficient effectiveness. Although PD has now been proven to be more common in men than in women, androgens do not always have any effect on the symptoms or progression of the disease. 5α-reductase inhibitors have shown neuroprotective and anti-dyskinetic activity and need further investigation. Despite the fact that the neuroprotective effect of dutasteride was observed only before damage to DA neurons, the absence of a negative effect makes it an attractive drug for use in patients with PD due to its anti-dyskinetic properties.

Androgens and Parkinson's Disease: A Review of Human Studies and Animal Models

Parkinson's disease (PD) is the second most common neurodegenerative disorder after Alzheimer's disease. A greater prevalence and incidence of PD are reported in men than in women, suggesting a potential contribution of sex, genetic difference and/or sex hormones. This review presents an overview of epidemiological and clinical studies investigating sex differences in the incidence and symptoms of PD. This sex difference is replicated in animal models of PD showing an important neuroprotective role of sex steroids. Therefore, although gender and genetic factors likely contribute to the sex difference in PD, focus here will be on sex hormones because of their neuroprotective role. Androgens receive less attention than estrogen. It is well known that endogenous androgens are more abundant in healthy men than in women and decrease with aging; lower levels are reported in PD men than in healthy male subjects. Drug treatments with androgens, androgen precursors, antiandrogens, and drugs modifying androgen metabolism are available to treat various endocrine conditions, thus having translational value for PD but none have yet given sufficient positive effects for PD. Variability in the androgen receptor is reported in humans and is an additional factor in the response to androgens. In animal models of PD used to study neuroprotective activity, the androgens testosterone and dihydrotestosterone have given inconsistent results. 5α-Reductase inhibitors have shown neuroprotective activity in animal models of PD and antidyskinetic activity. Hence, androgens have not consistently shown beneficial or deleterious effects in PD but numerous androgen-related drugs are available that could be repurposed for PD.

Sexuality and sexual dysfunctions in older people: a forgotten problem

This article considers sexuality in older adults and the associated stereotypes and stigmas that lead to this area being underappreciated. Normal physiological changes in ageing are discussed and how they can cause sexual dysfunction. The elderly population has a higher burden of comorbid physical illness and this review considers evidence on the interplay between physical health and sexual health. Mental illness is also strongly linked with sexual functioning and is discussed, as is the evidence on psychotropics and sexual side-effects. Attitudes on sexuality in long-term care settings are highlighted and approaches to managing sexual disinhibition are included.

Hypersexuality in dementia

Sexually disinhibited behaviours are quite common (prevalence 2–17%) in people with dementia, occurring with about equal frequency in men and women. Assessment of the behaviours, the contexts in which they arise and their risks is essential. It is important to manage the environment and to educate and discuss the issues with carers and families. Behavioural measures are helpful, although no specific behavioural intervention has been shown to be effective in this area. Several classes of drug may help to control the behaviours, but all are potentially harmful and none is licensed for hypersexuality in this population.

The use of cyproterone acetate in a forensic psychiatric cohort of male sex offenders and its associations with sexual activity and sexual functioning

BACKGROUND

Cyproterone acetate (CPA) is a steroidal anti-androgenic medication used in the field of psychiatry for the treatment of paraphilic disorders, hypersexuality, and inappropriate sexual behaviour which may be present in patients with disorders such as mild and major neurocognitive disorders. In the forensic psychiatric population, it is prescribed for these indications especially for patients with a history of committing a sexual offence or who are at moderate to high risk of recidivism.

OBJECTIVES

To investigate the use of CPA in a forensic psychiatric cohort of male sex offenders and its associations with sexual activity and sexual functioning.

METHODS

Seventy-six forensic psychiatric patients from Weskoppies Hospital in Pretoria, South Africa, participated in the study which measured their sexual functioning. A specifically designed questionnaire was used to capture relevant background information. The use of CPA was studied. The Changes in Sexual Functioning Questionnaire, Male Clinical Version (CSFQ-M-C) was used to measure sexual functioning of participants. The CSFQ-M-C scores, and those of all its subscales, of participants on CPA were compared to those not on the drug. Relevant statistical analyses were performed.

RESULTS

Thirteen out of the 76 participants were being treated with CPA (17.11%). In total, 53.85% of the participants on CPA and 65.08% not on CPA had scores indicating the presence of sexual dysfunction. The total CSFQ-M-C scores for participants on CPA (mean = 40.54; median = 42) were not statistically significantly lower than those not on the drug (mean = 41.22; median = 41). More notable is that the use of CPA in this population was associated with lower levels of desire, frequency of and pleasure from sexual activity. There was an association between having intellectual disability and being treated with CPA.

CONCLUSION

That all the participants were being treated with psychotropic medication could account for the high percentage of sexual dysfunction in any or all areas of sexual functioning and contribute to the small difference in CSFQ-M-C scores between the two groups. Only a tentative conclusion can be made that CPA may be more effective in decreasing levels of desire, frequency and pleasure related to sexual activity than other areas of sexual functioning. The indication for the use of CPA in this population should be assessed clinically according to patient circumstances and risk assessment.

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.

Self-inflicted foreign bodies in lower genitourinary tract in males: Our experience and review of literature

OBJECTIVES

To study retrospectively the frequency, demographic, phenomenological, and psychiatric profile in patients presented with self-insertion of foreign bodies in the lower genitourinary tract in our institute.

MATERIALS AND METHODS

From January 2009 to 2015, the records of patients admitted with self-insertion of foreign bodies into the lower urinary tract were analyzed retrospectively regarding demographic and phenomenological profile, the mode of presentation, diagnosis, management, complications, and possible contributing factors leading to the event.

RESULTS

Out of 17,978 inpatients, ten patients (0.055%) presented with foreign body insertion in the lower genitourinary tract in last 6 years. Mean age was 28.1 ± 13.9 (7-50) years. Objects used for insertion were varied from seeds, twigs to the electric wire. The contributing factors were lack of partner, misconception about masturbation, and underlying psychiatric illness. The presenting symptoms were pain and swelling of the penis, difficulty in voiding, and skin ulceration. The diagnosis was possible by simple observation in four patients, X-ray kidney, ureter, and bladder, and sonography of the pelvis in six patients. Five patients had endoscopic retrieval of foreign body, 2 had an open, suprapubic cystotomy, urethrotomy was needed in one patient, and forceps removal in two patients. There were no postoperative complications. Psychiatric profile was evaluated in nine patients.

CONCLUSIONS

Foreign body insertion to lower urinary tract was rare. A main cause for insertion of foreign bodies was autoerotism, misconceptions regarding masturbation, and underlying psychiatric illness. In addition to suitable method of surgical removal, counseling and psychiatric evaluation are necessary to prevent recurrences or for early detection of psychiatric problems.

Treatment of cognitive, psychiatric, and affective disorders associated with Parkinson's disease

Neuropsychiatric symptoms are common in Parkinson's disease (PD) and add significantly to the burden of disease. These symptoms are most commonly part of the disease spectrum owing to pathological changes within relevant brain regions. Neuropsychiatric problems include disorders of cognition, ranging from mild cognitive impairment to dementia, psychotic symptoms, including, most commonly, well-formed visual hallucinations and paranoid delusions, and mood disorders, such as depression and anxiety. The other common cause of neuropsychiatric problem is secondary to use of dopaminergic drugs. Some PD patients may develop behavioral disorders, including impulse control disorders (ICDs) and addictive symptoms. Psychosis can be due to a mixture of underlying pathology, with triggering or worsening of symptoms with changes to PD medications. Currently, management of these disorders primarily uses therapies developed for general psychiatry and cognitive neurology, rather than specifically for PD. However, significant adverse effects, such as worsening of the motor symptoms of PD, can limit use of some drug therapies. Identification of drug-induced symptoms, such as ICDs, enables withdrawal of the offending drug as the principal management strategy. Research is ongoing in an effort to develop more specific therapies for PD-related neuropsychiatric symptoms.

Management of inappropriate sexual behaviors in dementia: a literature review

BACKGROUND

This paper reviews published literature on the pharmacological and non-pharmacological treatment of inappropriate sexual behavior in dementia.

METHODS

A literature search of Psychinfo and Cochrane databases was performed and data from case reports and case series were analyzed.

RESULTS

No randomized controlled trials exist for any treatment of sexual disinhibition in dementia and there are no trials comparing different pharmacological agents. Case reports and case series report a wide range of pharmacotherapies as efficacious in the treatment of inappropriate sexual behaviors in dementia. There is only one case report of non-pharmacological strategies to manage inappropriate sexual behavior.

CONCLUSIONS

Inappropriate sexual behaviors in dementia can be difficult to treat. Frequently, multiple psychoactive medications are used and many pharmacotherapies are trialed prior to finding an effective agent. More research is needed to clarify the usefulness of these medications and to identify non-pharmacological strategies to prevent unnecessary use of medications.

Disinhibition: Clinical Challenges in the Long-Term Care Facility

Clinicians use the word disinhibition and its derivatives to describe a resident's behavior. Up to 30% of people with dementia may manifest behavioral disinhibition; sexual disinhibition is also a problem, but less frequently. Several causal relationships have been hypothesized, with frontal lobe deterioration among the best documented. Lobar lesions or trauma, seizure activity, cerebellar dysfunction, and drugs have been implicated as well. Behavioral disinhibition creates clinical challenges in the long-term care facility, and to date, no drug treatment has been approved for this indication. Behavioral interventions are the strategies of first choice. Reports of drug treatment are limited to case reports and very small studies.

Étude pilote préliminaire de l’acétate de cyprotérone dans les comportements agressifs associés aux démences sévères

INTRODUCTION

Behavioral symptoms are common in dementia, and seem to be more frequent in men than in women. Agitation is frequently responsible for caregiver burn-out and leads to institutionalization. The dramatic increase in the prevalence of Alzheimer's disease and related disorders requires better management of behavior symptoms. Although environmental adaptation has been proposed recently, for many years, psychoactive medications and physical restraints were the primary approach. However, in severely demented patients, both pharmacologic and non-pharmacologic treatments are inoperative. In this situation, alternative pharmacologic approach should be tested. Cyproterone acetate, an antiandrogen and progestative steroid has never been proposed to prevent aggressive behavior in dementia, but its favorable effect is well described in rat and monkey aggressivity.

PATIENTS AND METHODS

Cyproterone acetate was proposed for 19 demented patients who developed severe aggressive behaviors or an agitation unresponsive to psychoactive drugs (even in association) or to environmental adaptation. Clinical and behavioral analysis was carried out using the Cohen-Mansfield agitation inventory associated with an assessment of dependency in daily life activities, before and during treatment with cyproterone acetate. The behavioral status was stable, with permanent or repetitive agitation. Seven patients had vascular dementia, 7 had Alzheimer's disease, 2 had fronto-temporal degeneration, 2 had Huntington's disease and 1 a probable diffuse Lewy bodies disease. Fifteen patients had prominent aggressive behavior and 4 had predominant aberrant motor behavior with aggressive behavior.

RESULTS

Cyproterone (50 to 100mg - mean: 92.5mg daily) improved significantly aggressive and impulsive behavior related to Alzheimer's disease or vascular dementia but had no effect on aberrant motor behavior. When cyproterone was stopped, aggressive behaviors reappeared more rapidly in vascular dementia.

CONCLUSION

Cyproterone acetate is then an interesting choice when aggressive behavior is not improved with psychotropic drugs. A detailed clinical analysis is required to avoid the use of cyproterone in non-aggressive and non-impulsive patients. The results of this preliminary study suggest a randomized double-blind study should be carried out in the near future. The behavior improvement could be related to the blockage of androgen receptors, and simultaneously to the sedative effect of progestative drugs.