Pharmacotherapy for inappropriate sexual behaviors in dementia: a systematic review of literature

Prevalence of and Factors Associated with Hypersexuality in Patients with Dementia: A Retrospective Cross-Sectional Study

INTRODUCTION

The psychological and behavioral symptoms of dementia are frequently observed in clinical practice, and those related to sexuality are particularly challenging. However, few studies have evaluated the prevalence or factors associated with hypersexuality in patients with dementia.

OBJECTIVES

This study aims to determine the prevalence of hypersexuality in patients with dementia, describe associated factors, and qualitatively report the most common presentations and treatments.

METHODS

This retrospective cross-sectional study collected data from semi-structured charts of dementia patients who were followed up at a secondary care reference center between 2015 and 2019. Results: Of 552 total patients, 52 (9.3%) were hypersexual, which was associated with male sex (P < .000; OR 2.95, 95% CI 1.73-5.01), frontotemporal dementia (P < .007), alcohol use (P < .015; OR 2.35, 95% CI 1.16-4.73) and tobacco use (P < .000; OR 2.88, 95% CI 1.61-5.13).

CONCLUSIONS

Although our findings were similar to the literature, their significant variability reflects the limited and low quality of the available evidence and a lack of standardization regarding terminology, definitions, and diagnostic criteria for hypersexuality.

Sexuality and neurodegenerative disease: An unmet challenge for patients, care-givers and treatment

BACKGROUND

Many factors affect sexuality in the elderly such as dementia which is a common cause of inappropriate sexual behaviors. These behavioral disturbances are distressing, disruptive and impair the care of the patient. Summery: The onset of dementia does not erase sexuality. Sexual expression can be an important aspect of wellbeing for older adults with dementia. This study gives a general overview about the relationship between sexuality and cognitive impairment. It starts with a general discussion of sexual aspects in the elderly. This is followed by research studies in this field including effects of dementia on sexual life, sexuality issues related to cognitive decline, inappropriate sexual behaviors in dementia patients and sexuality in healthcare institutions. We discuss also ethical aspects in relation with sexuality and dementia. Finally, we show different approaches to treat inappropriate sexual behaviors. Key messages: The discussion of sexuality in dementia raises many medical and ethical concerns. Inappropriate sexual behaviors are estimated to occur in about 7% to 25% of demented patients. The question is how to address such a delicate subject and discuss it in an easy way without making the patient feel humiliated or mistreated. This narrative review reveals sexual problems and difficult questions encountered in daily practice with patients suffering from cognitive impairment.

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.

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.

Sexuality and the Older Adult

PURPOSE OF REVIEW

This paper provides an overview of biopsychosocial components of sexuality in older adults, sexual expression in older LGBTQ and cognitively impaired adults, and inappropriate sexual behaviors (ISBs) in dementia.

RECENT FINDINGS

Sexual expression of older adults is influenced by diverse psychosocial and biologic determinants including ageist beliefs. Although the prevalence of sexual dysfunction increases with age, studies of sexual satisfaction reveal that only a minority experience significant distress. Stigma against sexual expression in LGBTQ older adults may cause concealment of sexual orientation from family or care providers due to fears of rejection. Cognitive impairment affects frequency of and satisfaction with sexual activity, as well as capacity to consent. Staff biases about sexuality can negatively impact sexual expression in healthcare settings. Dementia-related inappropriate sexual behaviors (ISBs) are common and distressing. Recent research has focused on early identification and prevention of ISB, in addition to management through non-pharmacologic and pharmacologic approaches. Sexuality remains integral to quality of life for many older adults and informed consideration of their needs is critical to healthcare delivery and institutional service planning. A comprehensive understanding of older adults' sexuality can enhance education, research, policy, and clinical care for this growing population.

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.

Nurses' experiences and reactions towards intimacy and sexuality expressions by nursing home residents: A qualitative study

OBJECTIVES

To better understand how nurses experience and react to intimate and sexual expressions of nursing home residents.

BACKGROUND

Although many nursing home residents continue to desire intimacy and sexual expression, they commonly perceive negative attitudes of nursing staff towards them as a major barrier to their sexual well-being. To eliminate this barrier, it is crucial to gain a more in-depth understanding of nurses' personal experiences and reactions towards intimacy and sexuality in aged care.

DESIGN

Our study used a qualitative design, rooted in grounded theory.

METHODS

Semi-structured interviews with 15 nurses between 34 and 59 years of age were conducted. Participating nurses were recruited from seven different nursing homes in Flanders, Belgium. We used the Qualitative Analysis Guide of Leuven (QUAGOL) for data analysis. We followed the COREQ guidelines to ensure rigour in our study.

RESULTS

Nurses experienced and dealt with intimate and sexual expressions of residents in an individual way, which was focused on setting and respecting their own sexual boundaries and those of residents and family members. Depending on their comfort level with residents' expressions, nurses responded in three ways: active facilitation, tolerance and termination. Nurses' responses depended on contextual factors, including their personal experiences with sexuality, the nature of their relationship with the residents involved, the presence of dementia and the organisational culture of the facility.

CONCLUSIONS

Nurses face a wide range of experiences and emotions when confronted with residents' expressions of sexuality and intimacy. A supportive approach is needed to guide nurses in dealing with these highly sensitive situations. This approach can be promoted at the institutional level through continuous educational programmes.

RELEVANCE TO CLINICAL PRACTICE

This study advocates a contextual and interpretative ethical approach to sexuality in older adults, taking as starting point nurses' own vulnerability and that of residents and relatives.

Inappropriate Sexual Behaviors Among Community-Dwelling Patients with Dementia

OBJECTIVE

Inappropriate sexual behaviors (ISBs) represent challenging and stressful manifestations of dementia and are highly burdening for patients, families, and healthcare providers. Nevertheless, ISBs have so far attracted limited clinical and scientific interest compared with other neuropsychiatric symptoms occurring in dementing illnesses. The authors aimed to systematically investigate the prevalence and characteristics of ISBs in a population of patients with dementia attending a memory clinic.

METHODS

In this cross-sectional study, individuals with dementia attending our memory clinic were consecutively enrolled between January 2015 and February 2016. Participating subjects underwent a detailed medical history collection and a comprehensive cognitive, functional, and neuropsychiatric assessment. The presence of ISBs (in the previous 30 days) was investigated by the adoption of an ad hoc questionnaire, administered to informants. A logistic regression model was carried out to identify sociodemographic and clinical variables associated with ISBs.

RESULTS

In the 195 patients (48.7% women) with dementia recruited for the study, ISBs were detected in 35 patients (17.9% of the total sample). The logistic regression model showed that male sex (OR: 5.14; 95% CI: 1.44-18.41) and anxiety (OR: 4.92; 95% CI: 1.44-16.84) were statistically significantly associated with the presence of ISBs.

CONCLUSION

ISBs represent common manifestations of dementing illnesses. Given the significant burden of ISBs on patients and families and the impact on care management, their occurrence should always be investigated in the clinical care of individuals with dementia. For this purpose, specific screening/assessment tools should be properly designed and validated.

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.

Sexuality in patients with Parkinson's disease, Alzheimer's disease, and other dementias

Sexual dysfunction (SD) is common among patients with Parkinson's disease (PD), Alzheimer's disease (AD), and other dementias. Sexual functioning and well-being of patients with PD and their partners are affected by many factors, including motor disabilities, non-motor symptoms (e.g., autonomic dysfunction, sleep disturbances, mood disorders, cognitive abnormalities, pain, and sensory disorders), medication effects, and relationship issues. The common sexual problems are decreased desire, erectile dysfunction, difficulties in reaching orgasm, and sexual dissatisfaction. Hypersexuality is one of a broad range of impulse control disorders reported in PD, attributed to antiparkinsonian therapy, mainly dopamine agonists. Involvement of a multidisciplinary team may enable a significant management of hypersexuality. Data on SD in demented patients are scarce, mainly reporting reduced frequency of sex and erectile dysfunction. Treatment of SD is advised at an early stage. Behavioral problems, including inappropriate sexual behavior (ISB), are distressing for patients and their caregivers and may reflect the prevailing behavior accompanying dementia (disinhibition or apathy associated with hyposexuality). The neurobiologic basis of ISB is still only vaguely understood but assessment and intervention are recommended as soon as ISB is suspected. Management of ISB in dementia demands a thorough evaluation and understanding of the behavior, and can be treated by non-pharmacologic and pharmacologic interventions.

Assessment methods and management of hypersexuality and paraphilic disorders

PURPOSE OF REVIEW

The recent implementation of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition introduced some important changes in the conceptualization of hypersexuality and paraphilic disorders. The destigmatization of nonnormative sexual behaviors could be viewed as positive, However, other changes are more controversial. In order to stimulate new research approaches and provide mental healthcare providers with appropriate treatment regimes, validated assessment and treatment methods are needed. The purpose of this article is to review the studies published between January 2013 and July 2014 that aimed at assessing the psychometric properties of the currently applied assessment instruments and treatment approaches for hypersexuality and hypersexual disorders or paraphilias and paraphilic disorder.

RECENT FINDINGS

Currently existing instruments can validly assess hypersexual behaviors in different populations (e.g. college students, gay and bisexual men, and patients with neurodegenerative disorders) and cultural backgrounds (e.g. Germany, Spain, and USA). Concerning the assessment of paraphilias, it was shown that combining different assessment methods show a better performance in distinguishing between patients with paraphilias and control groups. In addition to psychotherapeutic treatment, pharmacological agents aiming at a reduction of serum testosterone levels are used for hypersexual behaviors as well as paraphilic disorders.

SUMMARY

Although the currently applied assessment and treatment methods seem to perform quite well, more research about the assessment and evidence-based treatment is needed. This would help to overcome the existing unresolved issues concerning the conceptualization of hypersexual and paraphilic disorders.

Hypersexual behavior in frontotemporal dementia: a comparison with early-onset Alzheimer's disease

The basis of hypersexual behavior among patients with dementia is not entirely clear. Hypersexual behavior may be a particular feature of behavioral variant frontotemporal dementia (bvFTD), which affects ventromedial frontal and adjacent anterior temporal regions specialized in interpersonal behavior. Recent efforts to define hypersexual disorder indicate an increasing awareness of heightened sexual activity as a source of personal distress and functional impairment, and clarification of hypersexuality in bvFTD could contribute to understanding the neurobiology of this behavior. This study reviewed 47 patients with bvFTD compared to 58 patients with Alzheimer's disease (AD) for the presence of heightened sexual activity to the point of distress to caregivers and others. Hypersexual behavior occurred in 6 (13 %) bvFTD patients compared to none of the AD patients. Caregivers judged all six bvFTD patients with hypersexual behavior as having a dramatic increase in sexual frequency from premorbid levels. All had general disinhibition, poor impulse control, and actively sought sexual stimulation. They had widened sexual interests and experienced sexual arousal from previously unexciting stimuli. One patient, with early and predominant right anterior temporal involvement, was easily aroused by slight stimuli, such as touching her palms. Although previously considered to be predominantly disinhibited sexual behavior as part of generalized disinhibition, these patients with dementia illustrate varying degrees of increased sexual desire. We conclude that bvFTD is uniquely associated with hypersexuality; it is more than just cognitive impairment with frontal disinhibition but also involves alterations in sexual drive, possibly from right anterior temporal- limbic involvement in this disease.

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.

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.

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.

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.