SAVANNAH, GA. – Little research exists on inappropriate sexual behavior in patients with dementia. The behaviors, while distressing and disruptive, are poorly defined, and data on the neurobiology, prevalence, assessment, and treatment are lacking.
An estimated 7%-25% of patients with dementia exhibit such behavior, Dr. Alicia A. Romeo reported. Males are far more likely than females to engage in inappropriate sexual behavior, but the types of behaviors do not vary by sex.
Few studies have looked at prevalence rates for sexually inappropriate behaviors in dementia, and discussion among symposium members and the audience indicated that such behaviors often go unreported, noted Dr. Romeo, a psychiatrist in the Geropsychiatry Program at the Boston VA Healthcare System and an instructor at Harvard Medical School, Boston.
The few data that do exist suggest that nonpharmacologic and pharmacologic treatments can work. Behavioral modification can be “very effective,” she said. For example, ensuring adequate social activity is crucial. Adjustment of social cues given to these patients makes a significant difference. For instance, when nursing assistants wear white coats, it signals they are medical professionals.
Nonpharmacologic therapy also can involve supportive psychotherapy for the family and caregivers, and additional staff training–including a “suitable” sex education program. With no Food and Drug Administration–approved medication for treatment for such behaviors, what little research there is addresses off-label use. And with no double-blind placebo-controlled trials, researchers can only look at case reports to identify possible medical therapies.
Medications found to be useful in the treatment of inappropriate sexual behaviors in patients with dementia include anticonvulsants; antidementia agents; antidepressants such as trazodone; cimetidine, a histamine H2 receptor antagonist; and pindolol, a beta-blocker, she reported.
Three case reports suggest that antipsychotics might be an option, but she advised against using them, citing the side effects. (The FDA issued an advisory and black box warning in 2005 about the risk of atypical antipsychotics in elderly patients with dementia. Three years later, the agency revised labeling for conventional antipsychotics with wording stating that “elderly patients with dementia-related psychosis who are treated with antipsychotic drugs have an increased risk of death [“All Antipsychotics Get Warnings About Elderly,” July 2008, p. 9].) Clinicians should first consult with the family and document everything.
Use medications only when other methods fail, and use them in combination with other treatments, she advised. The choice of treatments depends upon the urgency of the situation, the types of behaviors manifested, and the patient's underlying medical conditions.
Dr. Romeo offered an algorithm to help make treatment decisions. It was developed by the session's chair, Dr. Rajesh R. Tampi of Yale University, New Haven, Conn., who has coauthored articles on the subject (J. Geriatr. Psychiatry Neurol. 2005;18:155–62 and Am. J. Alzheimers Dis. Other Demen. 2008;234:344–54).
Four brain systems have been implicated in the neurobiology, Dr. Romeo said. The frontal system dysfunction typically involves disinhibition. Temporo-limbic system and hypothalamic disorders are associated with hypersexual behavior. Striatum dysfunction is associated with obsession.
Future research should focus on effective treatments as well as early detection and prevention, she said. But defining what constitutes inappropriate behavior can be tricky, and ethical issues can arise over what's appropriate and inappropriate.
Improved interaction between the clinician and caregivers, including nurses, will help in early detection and treatment of these behaviors,” Dr. Tampi said in an interview. Neither Dr. Romeo nor Dr. Tampi reported any conflicts.