Increased libido associated with donepezil treatment: a case report

Pharmacological and nonpharmacological approaches to reduce disinhibited behaviors in dementia: a systematic review

OBJECTIVES

Disinhibited behaviors in dementia are associated with multiple negative outcomes. However, effective interventions are under-researched. This systematic review aims to provide an overview of intervention studies that report outcome measures of disinhibited behaviors in dementia.

DESIGN

Systematic searches of the databases MEDLINE, EMBASE, and PsychINFO, Social Work Abstracts and Cochrane Central Register of Controlled Trial databases were conducted for publications published between 2002 and March 2020. We included hand-searched reviews, original articles, case reports, cohort studies, and randomized controlled trials (RCTs). All studies were rated for research quality. Statistical and clinical significance were considered for individual studies. Effect sizes were included where provided or calculated where possible. Mean effect sizes were calculated for RCTs only.

PARTICIPANTS

The systematic review included studies involving people living with dementia.

MEASUREMENTS

The Neuropsychiatric Inventory disinhibition subscale was used most often.

RESULTS

Nine pharmacological and 21 nonpharmacological intervention studies utilized different theoretical/clinical approaches. These included pain management, antidepressants, models of care, education and/or training, music-based approaches, and physical activity. The quality of research in RCTs was strong with a greater effect size in nonpharmacological compared to pharmacological approaches (mean Cohen's d = 0.49 and 0.27, respectively). Disinhibition was a secondary outcome in all studies.

CONCLUSION

Pharmacological (including pain management and antidepressants) and, more so, nonpharmacological (models of care, education/training, physical activity, and music) approaches were effective in reducing disinhibition.

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.

Acetylcholinesterase Inhibitors: Beneficial Effects on Comorbidities in Patients With Alzheimer's Disease

Elderly patients with Alzheimer's disease (AD) and other dementias are at high risk of polypharmacy and excessive polypharmacy for common coexisting medical conditions. Polypharmacy increases the risk of drug-drug and drug-disease interactions in these patients who may not be able to communicate early symptoms of adverse drug events. Three acetylcholinesterase inhibitors (ACHEIs) have been approved for AD: donepezil (Aricept), rivastigmine (Exelon), and galantamine (Razadyne). They are also used off-label for other causes of dementia such as Lewy body and vascular dementia. We here report evidence from the literature that ACHEI treatment, prescribed for cognitive impairment, can reduce the load of medications in patients with AD by also addressing cardiovascular, gastrointestinal, and other comorbidities. Using one drug to address multiple symptoms can reduce costs and improve medication compliance.

A case of Klinefelter syndrome with hypersexual desire

Klinefelter syndrome (KS) is a chromosomal disorder affecting males, with the typical karyotype of 47,XXY due to a supernumerary X chromosome, which causes progressive testicular failure resulting in androgen deficiency and infertility. Despite it being the most common sex chromosomal disorder, its diagnosis is easily missed. In addition to its classical clinical features of tall stature, gynaecomastia, small testes, and symptoms and signs of hypogonadism including infertility, KS is also often associated with neurocognitive, behavioural and psychiatric disorders.

We present a 44-year-old man with KS who, despite having erectile dysfunction, paradoxically had increased libido. He used sildenafil to overcome his erectile dysfunction. Hypersexuality was manifested by very frequent masturbation, multiple sexual partners most of whom were casual, and a sexual offence conviction at the age of 17 years.

Discussion focuses on the frequent failure of clinicians to diagnose KS, the neurocognitive, behavioural and psychiatric aspects of KS, this unusual presentation of hypersexuality in a man with KS, and the challenges of medical management of hypogonadism in a man with a history of a sexual offence.