Perceptions surrounding what constitutes inappropriate sexual behavior (ISB) are complicated in patients with dementia. Normal expressions of intimacy in the elderly are often seen as absent or socially unacceptable.1 Although every human being needs love and companionship, many societal stigmas exist when considering intimacy in the elderly. Although the frequency of sexual activity decreases with increasing age, many older people remain sexually active. Those working in health care and social care are not immune to the many stereotypes and myths surrounding sexuality in the elderly. Frameworks for approaching sexuality, aging, and dementia should be established in care settings to ensure that professionals and support staff do not mislabel behaviors as ISB, and provide optimal, humanized care.2
ISB has no universally accepted definition. It consists of uninhibited sexual behaviors toward oneself or others, or overt acts correlated with increased libido. They include excessive sexual comments, hugging/kissing/preoccupation with sex, increased libido, grabbing at the breasts or genitals of residents or staff, masturbation in public, sexual hallucinations, delusions of spousal infidelity, attempting to seduce or chase residents or staff for sexual purposes, exposing one's genitals or disrobing in public, and changes in sexual preference.3 Another definition describes ISB as “a verbal or physical act of an explicit, or perceived, sexual nature, which is unacceptable within the social context in which it is carried out.”4
From a neurologic perspective, ISB is seen as an altered function of individual brain structures. This theory explains why patients with frontal lobe lesions may present with personality changes such as aggression, hypersexuality, and disinhibition.5 Kluver-Bucy syndrome, caused by temporal lobe disruption, is also associated with hypersexuality.6 Cognitive impairment involving difficulties with memory, attention, learning and decision-making, even without significant lobar damage, may generate a range of problematic sexual behavior.7
Psychosocial aspects of ISB further complicate a comprehensive definition. For those in institutionalized settings, a lack of physical and informational privacy, declining physical health, loss of partners, attitudes of adult children and staff, and a relative lack of partners can contribute to behaviors that blur the lines of what is normal versus what constitutes ISB.2 Moreover, boredom, loneliness, and the desire for human contact in a restrictive institutional setting may cause ISB in older residents looking for companionship or intimacy.8 Complicating matters further, sexuality in the elderly continues to be a neglected area of study, and many organizations feel unprepared for decision-making about this topic. Care must be taken by clinicians and support staff to avoid overusing the label “ISB” and focus on an individualized approach to sexuality in both elderly patients and those with dementia.2
The epidemiology of ISB in patients with dementia is complicated due to the sparsity of data. From case reports or series, the prevalence of ISB in dementia reportedly ranges from 7% to 25%.9 An increased prevalence occurs in those with higher levels of cognitive impairment, those in skilled nursing facilities, and in men, but the exact gender ratios are unclear.10,11 In a sample of 49 patients with Alzheimer's disease, ISB was found in 2 men and 1 woman.12 A preliminary report by Tsai et al.13 showed no significant difference in ISB prevalence among different types of dementia. Alagiakrishnan et al.11 reported that among cognitively impaired older adults with ISB, 9.8% had mild cognitive impairment, 22% had Alzheimer's disease, and 54% had vascular dementia. Hypoactive sexual and hypersexual behaviors have been observed in Huntington's disease. The prevalence rate of hypersexual behavior in women with Huntington's disease ranges from 2.1% to 25%.14 ISB has also been observed in individual cases of Lewy body and frontotemporal dementias; however, the exact prevalence in these forms of dementia is still unknown.11
ISB causes considerable distress to patients, families, and caregivers. Families and nursing staff face embarrassment, incomprehension, and problems related to a patient's behaviors. Caregivers face shock and the fear of losing their job due to making false claims. ISB can even lead to placement in a skilled nursing facility or forced confinement of the affected person.15 Genital trauma and increased rates of sexually transmitted diseases are potential consequences of sexual acts by those who are afflicted with ISB.16 Because hindering sexual expression can be viewed as an infringement of autonomy, inappropriate sexual conduct also creates tension between the legal and ethical responsibilities of clinicians.17
Management of ISB is challenging because of the lack of well-designed studies to establish evidence-based treatment strategies. A sequential approach is often recommended by starting with nonpharmacologic interventions such as distraction with other activities, discontinuation of medications that may increase disinhibition, and then by pharmacological if conservative measures failed.8 Management of ISB has been challenging in women with cognitive impairment, as most of the literature discusses ISB specifically in male patients.18 Pharmacological approaches for ISB in men involve anticonvulsants, anxiolytics, antidepressants, beta-blockers, cholinesterase inhibitors, estrogens, gonadotropin-releasing hormone analogues, cimetidine, and pindolol.9,17
We describe the clinical presentation and management of two women with ISB suffering from major neurocognitive disorders. We also review the literature for treatment strategies described for ISB in women.
Illustrative Case 1
An 85-year-old woman was brought to the emergency department by her daughter for a 1-week history of ISB manifested as obsessive talking about men, grabbing men in the nursing home where she resided, and attempting to engage in sexual activities with them. This behavior was uncharacteristic of the patient's previous behavior or personality. The patient was diagnosed with vascular dementia 5 years prior with a previous psychiatric history positive for panic attacks and one suicide attempt 20 years ago. She had a positive medical history for diabetes mellitus type 2, chronic obstructive pulmonary disease, hypothyroidism, and occasional bladder incontinence.
On admission, the patient was alert and oriented to time, place, and person. No gross evidence of attention deficits or delirium were noted. Her Saint Louis University Mental Status Examination (SLUMS) score was 20 (scores between 0 and 20 indicate dementia). She had positive insight about her uncontrollable feelings and thoughts towards men. She acknowledged their nature as intrusive and “obsessive-like thoughts.” Her laboratory testing, including follicle-stimulating hormone, luteinizing hormone, estrogen, thyroid-stimulating hormone, and free thyroxine levels were normal except for a positive urinalysis (77 white blood cells, large leukocyte esterase, 3 squamous cells). Subsequent urine culture was negative for growth. She was admitted to the geriatric psychiatry unit for further testing.
Her medication list included 50 mg of sitagliptin daily, 18 mcg inhalation of tiotropium once daily, 25 mg of trazodone twice a day, 75 mcg of levothyroxine once daily, 0.5 mg of alprazolam as needed, 300 mg of gabapentin three times daily, 50 mg of sumatriptan as needed, and 40 mg daily of pantoprazole, with no recent medication change. Her history was negative for current acute medical or psychiatric issues. On the mental status examination, her mood was described as “discouraged” by intrusive sexual thoughts, her affect was restricted, she had some speech latency, she denied any suicidal ideation, and her thought process was linear. Her appearance, behavior, attitude, and level of consciousness were unremarkable aside from some slight drowsiness.
After a positive urinalysis and pending cultures, she was started on an empirical course of sulfamethoxazole and trimethoprim for a possible urinary tract infection. Her cultures remained negative throughout her clinical course. On day 2 of admission, she was observed groping and attempting to disrobe a male patient in the psychiatric unit. She was started on 0.25 mg of risperidone twice daily for persistent ISB toward other patients observed on the inpatient unit. The sitagliptin was discontinued due to three episodes of hypoglycemia during inpatient admission. Endocrinology testing indicated that hypoglycemic episodes were not correlated with observed sexual behaviors.
Despite starting risperidone, the patient continued to display sexual advances toward male patients. Two days after starting risperidone, citalopram was initiated and titrated to 20 mg daily for better control of ISB. Her sexual urges resolved 3 days after starting citalopram, and she was discharged back to her nursing home after 5 days of observation during which no ISB were witnessed. A follow-up call at 8 weeks demonstrated maintenance of ISB resolution with continued use of risperidone and citalopram.
Illustrative Case 2
An 86-year-old woman was brought to the emergency department for a recent episode of chasing and attempting to kiss a male resident in the nursing home where she resides. After attempting to kiss the resident, the patient voiced suicidal ideations and was verbally hostile when staff tried to redirect her. She was diagnosed with Alzheimer's disease 9 months prior to presentation with no prior psychiatric history. Her past medical history was positive for hyperlipidemia and hypothyroidism. The patient recently completed a course of sulfamethoxazole and trimethoprim 2 days before admission for a urinary tract infection diagnosed at her living facility. Nursing staff claimed that she seemed more confused than usual in the last 2 days on top of her baseline of moderate to severe major neurocognitive disorder.
On admission, the patient was alert and oriented only to self and was uncooperative with the interviewer, demanding to go home. Mental status examination was significant for a hostile attitude, moderate agitation, a congruent and restless affect, tangential thought process with loose associations, no hallucinations, and no suicidal ideation. Testing of her fund of knowledge, insight, and judgement was limited due to lack of cooperation. Her most recent SLUMS examination score was 15. Her medical testing included normal thyroid-stimulating hormone level, low vitamin D level, and a positive urinalysis (large leukocyte esterase, 21 white blood cells, 15 squamous cells). Delirium due to her urinary tract infection, or due to antibiotic treatment, was suspected in this case. Her daily medications included 81 mg of aspirin daily, 10 mg of atorvastatin daily, 112 mcg of levothyroxine daily, and 1,000 mcg of B12, with no recent changes in medication.
On admission, she was started on 500 mg daily of valproic acid that was then increased to 750 mg daily, which completely controlled her ISB on the inpatient unit. She was started on a 7-day course of cefpodoxime due to persistence of urinalysis findings despite her completed course of sulfamethoxazole and trimethoprim. Urine culture from the time of admission showed no growth. On day 8 of admission, she was discharged to her facility with a valproic acid plasma level of 67 mcg/mL and displaying no signs of ISB.
Despite adherence to treatment, her disinhibited symptoms recurred 2 weeks later, with multiple attempts to kiss male residents and attempts to engage in a sexual activity with one resident. Failure by staff to distract her prompted rehospitalization. Repeat thyroid-stimulating hormone testing on admission was low despite normal free thyroxine levels, and valproic acid levels were within normal limits (66 mcg/mL). In light of the lack of improvement of her ISB, citalopram was started at 10 mg daily and her valproic acid was increased to 1,000 mg daily. ISB was not observed during her second hospitalization, and she was discharged back to her nursing facility.
On follow-up at 24 weeks, nursing staff indicated that her inappropriate behaviors had improved but were still occurring weekly. Staff claimed she was more directable during episodes, but still attempted to kiss staff intermittently. The patient's citalopram was increased to 20 mg daily due to persistence of ISB. After an increase in dose, her symptom frequency declined further but did not completely resolve. Although not fully resolved, her behaviors were managed by staff using behavioral modifications and redirection as she continued to take citalopram and valproic acid.
This article presents two cases of ISB in elderly women suffering from major neurocognitive disorders in the setting of nursing home care. Both patients' clinical presentation improved at least partially with the selective serotonin reuptake inhibitor (SSRI) citalopram after other treatment approaches (eg, diversion, risperidone, valproic acid) had failed. The severity of cognitive impairment may have accounted for the partial response to treatment in the second case. Objective scales like the St. Andrew's Sexual Behavioral Assessment suggest ISB should be ranked according to behavioral severity. Unfortunately, the correlation between severity of dementia and response of ISB to treatment is unclear.17 Importantly, the symptoms of ISB in each case were distinct. In our first case, an 85-year-old woman had intrusive, obsessive thoughts with insight that these thoughts were unwanted and uncontrolled. SSRIs are prescribed as first-line treatments for obsessive-compulsive disorder and related disorders with obsessive symptomology.19 In the second case, the patient had no insight regarding her ISB and was admitted due to aggression and failure to cooperate with attempts at redirection. The obsessive symptomology of the first case may explain why a complete resolution was seen with risperidone and citalopram, whereas the second case required both valproic acid and citalopram for only partial improvement of ISB.
SSRIs have been previously used in cognitively impaired men and women with ISB primarily because of their safety and anti-libidinal effect. In one previous case, citalopram was used to treat a 90-year-old woman with unspecified dementia who had a 2-year history of ISB toward male nursing home residents.20 The patient also had a history of physical aggression that was resolved with 0.5 mg of risperidone orally twice a day. This patient's sexual behavior (disrobing male patients) failed to respond to paroxetine 20 mg once daily but resolved after 1 week of citalopram at a dose of 20 mg orally once a day. The increased selectivity of serotonin reuptake inhibition seen with citalopram relative to paroxetine is theorized by the authors to have led to symptom resolution. An 85-year-old man with dementia of Alzheimer's type and ISB was successfully treated with 20 mg daily of citalopram, and other men with unspecified dementia have had symptom resolution with 20 mg/day of paroxetine or 15 to 30 mg of mirtazapine daily.21–23
In two cases, the initiation of an antipsychotic successfully treated ISB in women with dementia. Sarikaya and Sarikaya24 document the case of a 74-year-old heterosexual woman with a 6-year history of Alzheimer's disease who displayed ISB towards female granddaughters and female caregivers, despite 40 mg of citalopram daily prescribed for anxiety symptoms 2 years prior to ISB onset. Initiation of aripiprazole at the dose of 2.5 mg, increased to 10 mg daily, successfully controlled her symptoms.24 In another case, a 61-year-old woman with Lewy body dementia had a marked reduction in her ISB after the initiation of quetiapine at a dose of 75 mg daily.25
Nadal and Allgulander26 reported resolution of hypersexuality in a 49-year-old woman with frontotemporal dementia of Pick's type with administration of cyproterone acetate (CPA). CPA is a progesterone that is thought to suppress sexual urges and arousal by decreasing end organ androgen influence.27 Although antidepressants and antipsychotics failed to alleviate this patient's uncontrolled masturbation, a trial of 50 mg of CPA daily that was increased to 100 mg daily after 3 weeks led to the complete resolution of symptoms. Importantly, discontinuation of CPA did not lead to recurrence of symptoms in this patient.26 Furthermore, in a series of five cases of male patients with dementia and ISB, medroxyprogesterone acetate was used to successfully control the behaviors.28 Circulating androgens and intracellular androgen receptors in septal and hypothalamic brain areas have been shown to play a role in human sexual behavior.29 In cases of suspected or confirmed ISB, there may be a role in measuring testosterone because androgen imbalances have been linked to inappropriate behaviors. In women, the role of sexual hormones in ISB is unclear, and measurements of plasma levels could provide a better understanding of the pathophysiology of ISB in this population.
Three published cases of ISB in women suffering from neurocognitive disorders were attributed to the use of the cholinesterase inhibitor donepezil. A 72-year-old woman with mild cognitive impairment and an 81-year-old woman with mixed dementia both developed hypersexuality within 1 week of starting donepezil at 5 mg daily.30 The increased libido and hypersexuality resolved only after discontinuation of the donepezil. A more recent case involved a 79-year-old woman with Alzheimer's dementia who developed increased libido after starting a higher dose of donepezil (10 mg/day). Discontinuation of donepezil resolved the increased libido, but the symptoms recurred upon reintroduction of the drug.31 Although donepezil has been associated with a few case reports of hypersexuality in people who are cognitively impaired, rivastigmine, a less selective cholinesterase inhibitor, at 1.5 mg twice daily was found to be effective in managing hypersexual behaviors in a 72-year-old woman with dementia.32
The management of ISB in people with cognitive impairment is challenging, particularly in women due to the lack of studies. Assessment should include a thorough history, preferably from a reliable informant, including a sexual history. An evaluation of all patients with dementia should include screening with collateral history and targeted laboratory testing to rule out delirium.
Data on management of ISB in women are sparse; however, some efficacy has been demonstrated with antidepressants (with and without antipsychotics), hormonal agents, and cholinesterase inhibitors.
The superiority of SSRIs is inherent due to their safety profile in patients with dementia when compared to other pharmacological approaches (ie, antipsychotics). In many of these patients, an antipsychotic was also used due to the severity of behaviors associated with ISB or independent behaviors such as aggression. In at least two cases, the addition of an antipsychotic alone resolved or improved ISB in these women with dementia.24,25 Based on the cases reviewed here, a reasonable medical approach for women with dementia and ISB would be to start with an SSRI such as citalopram (up to 20 mg daily) and add an antipsychotic in case of a partial response to the SSRI or if the patient has other uncontrollable behaviors such as aggression. In refractory cases, clinicians may switch to a different SSRI or pursue suppression with progesterone compounds like CPA. Despite one case of ISB improvement with a cholinesterase inhibitor, other cases indicate that the mechanism of action of these drugs could cause further disinhibition.32Figure 1 summarizes an algorithm for management of ISB in women with dementia based on the cases reviewed here.
Stepwise approach to inappropriate sexual behavior (ISB) in women with dementia. A stepwise approach should be used in women with dementia who have ISB.1 First clinicians should confirm the behavior is ISB through a thorough history. Next, a physical examination, laboratory testing, and imaging should be used to rule out organic causes. If none are identified, nonpharmacological approaches to treatment should be tried. If these approaches fail, treatment with a selective serotonin reuptake inhibitor (SSRI)2 and/or an antipsychotic should be initiated. If these drugs fail, other medications such as anti-dementia drugs or cyproterone acetate (CPA)3 could be tested. UTI, urinary tract infection.
More research is needed to improve our understanding of this neglected presentation in older adults with dementia, especially in women. Until then, educating family members and caregivers about ISB and addressing the psychosocial factors that may have triggered those behaviors (loneliness, losses) are crucial to alleviate ISB's burden on patients and families.
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