Pharmacologic Treatment of Sexual Inappropriateness in Long-Term Care Residents with Dementia
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Shilpa Srinivasan, MD, and Andrew D. Weinberg, MD, FACP
Although behavioral symptoms associated with dementia in geriatric long-term care (LTC) residents living in nursing facilities are common, sexual inappropriateness (sexual disinhibition) remains one of the least understood and treatable aspects of this disease. Separating agitation and normal sexual expression from any sexual disinhibition that may be present can be clinically challenging to the health care practitioner and LTC nursing staff. Family concerns and staff attitudes toward normal sexual expression between older adults living in a LTC nursing facility may also cause an inconsistent approach to the evaluation of sexual disinhibition.
REVIEW OF THE LITERATURE
It has been estimated that up to 90% of individuals with dementia will develop behavioral issues that are significant at some point along the course of their illness.1 Merriam et al2 have declared Alzheimer’s disease to be “the most widely encountered cause of psychiatric pathology associated with a specific neuropathologic substrate.”
The prevalence of dementia rises from approximately 5% in individuals ages 65-69 to 20% in those older than age 85.3 However, there is a paucity of research about the effects and management of cognitive impairments on sexuality in the older adult with dementia.
Sexual disinhibition may be regarded as sexually inappropriate or “acting out” behavior. Impulsive behavior and poor judgment often occur in dementia, and inappropriate sexual impulses that were once controlled by intact judgment or moral values may emerge. Such behaviors have been reported more commonly in men.4 As many as 7-25% of seriously cognitively impaired older adults are reported to display sexually inappropriate behaviors.5-7 Some examples include genital exposure, public masturbation, propositions to others for sexual intercourse, and attempts at coitus or fondling another person’s genitals or breasts.8 Additionally, sexual talk or sexual acts (such as openly reading pornographic material or requesting unnecessary genital care from staff members) may also occur.7 These behaviors can be disruptive and problematic for caregivers either in the community or in the LTC setting.
Causes of sexual disinhibition in the older individual are often multiple and include neurologic, psychiatric and social/environmental factors.9 Possible etiologic factors contributing to sexual disinhibition in the older adult are outlined in Table I. In individuals affected with Alzheimer’s disease, sexual disinhibition positively correlates with the clinical severity of dementia.5 However, this does not correlate with neuroimaging (CT scan) results. Frontal lobe injury is also known to be linked to sexual disinhibition, since inhibitory mechanisms that promote sexual self-control are impaired in these types of lesions.10 Subtypes of dementia that are frontal lobe-preponderant, including Pick’s disease and alcoholic dementia, may also be associated with sexually inappropriate behavior.
Reports have linked levodopa administration to hypersexuality when used in persons with Parkinson’s disease,11 and patients with brain damage have also been found to be more susceptible to the paradoxically disinhibiting effects of alcohol or benzodiazepines.12 Naguib and Levy13 examined the role of delirium in precipitating sexually inappropriate behaviors. In some cases, patients who have successfully controlled their heightened sexual impulsivity over a lifetime may regress after an episode of cognitive decline, such as that associated with an acute delirium. A stroke, cardiac event, vascular compromise, or surgery may also subsequently lead to sexual disinhibition.14 In such instances, sexual aggression is usually noted to be of an acute onset.
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