Inappropriate sexual behaviors in cognitively impaired older individuals

https://doi.org/10.1016/j.amjopharm.2008.12.004Get rights and content

Abstract

Background: Agitated and aggressive behaviors are common in older patients with dementia (33% of the community-dwelling and 80% of the institutionalized populations). Although inappropriate verbal and physical sexual behaviors are among the least common of these actions, they can be profoundly disruptive to caregivers (spouse, institutional staff, or both) and other individuals in the immediate surroundings. Substantial mental and physical harm can occur secondary to these behaviors. The common perception is that such behavior cannot be treated.

Objective: This review summarizes the epidemiology, etiology, and biology of abnormal sexual behaviors in cognitively impaired older individuals and highlights potentially useful drug therapies.

Methods: Primary research and review articles in the English language were identified through a search of MEDLINE/PubMed (1966-September 2008). Search terms included aged, hypersexuality, sexual disorders, paraphilia, sexual behaviors, tricyclic antidepressants, selective serotonin reuptake inhibitors, medroxyprogesterone acetate, cyproterone acetate, estrogens, LHRH agonists, leuprolide, and triptorelin. The bibliographies of all articles obtained were also reviewed for relevant citations. All articles involving abnormal sexual behaviors in older humans were reviewed.

Results: Use of pharmacotherapy in managing inappropriate sexual behaviors in cognitively impaired older individuals has been detailed in only 23 case reports and case series (N = 55 subjects). Additional supportive data from case reports and case series are available in nonsexual agitation/aggression in elderly patients with dementia (N = 16 subjects) and abnormal sexual behaviors in cognitively intact elderly (N = 2 subjects). One comparative trial in nonsexual agitation/aggression in elderly patients with dementia also exists (N = 27 subjects). There are no practice guidelines available for the treatment of abnormal sexual behaviors in the cognitively impaired elderly population. Recommendations must be individualized on the basis of clinical exigency and pragmatism; they should also be predicated on medical clearance to use estrogen or antiandrogen (progestogen, luteinizing hormone-releasing hormone [LHRH] agonist) therapies, if necessary. Very few data exist regarding the treatment of females of any age exhibiting abnormal sexual behaviors. For males, reasonable data support the use of serotoninergics (eg, tricyclic antidepressants [TCAs], selective serotonin reuptake inhibitors [SSRIs]), estrogens (oral, transdermal), antiandrogens (cyproterone acetate, medroxyprogesterone acetate), and the LHRH agonists (eg, leuprolide, triptorelin). Comparative trial data, both within and between these drug classes from the paraphilia literature, provide additional information that can be used to generate at least a provisional approach to drug treatment of abnormal sexual behaviors in older subjects with impaired cognition.

Conclusions: In general, unless the patient is engaging in or threatening dangerous acts involving physical contact, serotoninergics (first choice, SSRIs; second choice, TCAs) are first-line agents followed by antiandrogens (cyproterone acetate or medroxyprogesterone acetate) as second-line agents. LHRH agonists (first choice) and estrogens (second choice) are considered third-line agents. Combination therapy is reasonable if the patient fails to respond to monotherapy.

References (102)

  • MF Weiner et al.

    Intramuscular medroxyprogesterone acetate for sexual aggression in elderly men

    Lancet

    (1992)
  • CG Lyketsos et al.

    Mental and behavioral disturbances in dementia: Findings from the Cache County Study on Memory in Aging

    Am J Psychiatry

    (2000)
  • M Margallo-Lana et al.

    Prevalence and pharmacological management of behavioural and psychological symptoms amongst dementia sufferers living in care environments

    Int J Geriatr Psychiatry

    (2001)
  • SI Finkel et al.

    Behavioral and psychological signs and symptoms of dementia: A consensus statement on current knowledge and implications for research and treatment

    Int Psychogeriatr

    (1996)
  • C Steele et al.

    Psychiatric symptoms and nursing home placement of patients with Alzheimer's disease

    Am J Psychiatry

    (1990)
  • BF O'Donnell et al.

    Incontinence and troublesome behaviors predict institutionalization in dementia

    J Geriatr Psychiatry Neurol

    (1992)
  • W Marsiglio et al.

    Sexual relations in later life: A national study of married persons

    J Gerontol

    (1991)
  • A Comfort et al.

    Sexuality and aging: An overview

    Clin Geriatr Med

    (1991)
  • C Johnson et al.

    Challenges associated with the definition and assessment of inappropriate sexual behaviour amongst individuals with an acquired neurological impairment

    Brain Inj

    (2006)
  • DR Kuhn et al.

    Addressing hypersexuality in Alzheimer's disease

    J Gerontol Nurs

    (1998)
  • A Higgins et al.

    Hypersexuality and dementia: Dealing with inappropriate sexual expression

    Br J Nurs

    (2004-2005)
  • LK Wright

    Alzheimer's Disease and Marriage

    (1993)
  • C Derouesné et al.

    Sexual behavioral changes in Alzheimer disease

    Alzheimer Dis Assoc Disord

    (1996)
  • SJ Tsai et al.

    Inappropriate sexual behaviors in dementia: A preliminary report

    Alzheimer Dis Assoc Disord

    (1999)
  • K Alagiakrishnan et al.

    Sexually inappropriate behaviour in demented elderly people

    Postgrad Med J

    (2005)
  • AM Zeiss et al.

    An observational study of sexual behavior in demented male patients

    J Gerontol A Biol Sci Med Sci

    (1996)
  • JM Lesser et al.

    Sexually inappropriate behaviors. Assessment necessitates careful medical and psychological evaluation and sensitivity

    Geriatrics

    (2005)
  • P Sloane

    Sexual behavior in residents with dementia. Guidelines explain how to respond

    Contemp Longterm Care

    (1993)
  • I Arnulf et al.

    Kleine-Levin syndrome: A systematic review of 186 cases in the literature

    Brain

    (2005)
  • I Goscínski et al.

    The Kluver-Bucy syndrome

    Acta Neurochir (Wien)

    (1997)
  • I Goscínski et al.

    The Kluver-Bucy syndrome

    J Neurosurg Sci

    (1997)
  • JL Cummings

    Behavioral and psychiatric symptoms associated with Huntington's disease

    Adv Neurol

    (1995)
  • BL Miller et al.

    Hypersexuality or altered sexual preference following brain injury

    J Neurol Neurosurg Psychiatry

    (1986)
  • RJ Uitti et al.

    Hypersexuality with antiparkinsonian therapy

    Clin Neuropharmacol

    (1989)
  • CH Markham et al.

    Parkinson's disease and levodopa. A five-year follow-up and review

    West J Med

    (1974)
  • MH Lam et al.

    Sexual disinhibition in schizophrenia possibly induced by risperidone and quetiapine

    Psychiatry Clin Neurosci

    (2007)
  • M Nickel et al.

    Cabergoline treatment in men with psychogenic erectile dysfunction: A randomized, double-blind, placebo-controlled study

    Int J Impot Res

    (2007)
  • M Wittstock et al.

    Cabergoline can increase penile erections and libido

    Neurology

    (2002)
  • HH Fernandez et al.

    Clozapine for dopaminergicinduced paraphilias in Parkinson's disease

    Mov Disord

    (1998)
  • MP Kafka

    The monoamine hypothesis for the pathophysiology of paraphilic disorders: An update

    Ann NY Acad Sci

    (2003)
  • FM Saleh et al.

    Sex hormones, neurotransmitters, and psychopharmacological treatments in men with paraphilic disorders

    J Child Sex Abus

    (2003)
  • PT Loosen et al.

    Effects on behavior of modulation of gonadal function in men with gonadotropin-releasing hormone antagonists

    Am J Psychiatry

    (1994)
  • Guay DR. Drug treatment of paraphilias. Clin Ther. In...
  • F Neumann et al.

    Discovery, development, mode of action, and clinical use of cyproterone acetate

    J Int Med Res

    (1975)
  • SR Stitch

    Steroid chemistry

    J Int Med Res

    (1975)
  • K Vosbeck et al.

    The influence of antiandrogens on the excretion of FSH, LH, and 17-ketosteroids in males

    Hormone Metab Res

    (1971)
  • Cyproterone acetate, medroxyprogesterone acetate, leuprolide, triptorelin

  • RS Jurzyk et al.

    Antiandrogens in the treatment of acne and hirsutism

    Am Fam Physician

    (1992)
  • P Jungers et al.

    Hormone modulation in systemic lupus erythematosus. Preliminary clinical and hormone results with cyproterone acetate

    Arthritis Rheum

    (1985)
  • T Eriksson et al.

    Irradiation therapy prevents gynecomastia in sex offenders treated with antiandrogens

    J Clin Psychiatry

    (1998)
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