Inappropriate Sexual Behavior In A Patient With Dementia

Sexual behavior in elderly is normal and sex drive remains intact at baseline levels. Societal stereotypes result in classification of all sexual behavior in elderly as inappropriate. It is important to distinguish appropriate vs inapproprate sexual behavior.

There is no global accepted definition of inappropriate sexual behavior. The determination of inappropriate behavior must be viewed in context to societal and environmental norms. This context and the risks or uneasiness of others usually determines if behavior has crossed the threshold needing intervention. If sexual activity interferes with normal activity, occurs at inappropriate times or infringes on the rights of others (staff or other residents/patients) then it is reasonable to associate this behavior as inappropriate sexual behavior.

Inappropriate sexual behavior can present as inappropriate talk (foul or threatening), sexual acts (touching, exposing, fondling), or implied sexual acts (requesting frequent and unnecessary genital care, etc.). Pathologically, if inappropriate sexual behavior presents as a deviation from normal behavior for the patient, it is usually associated with dementia changes and atrophy noted in the frontal lobes (frontotemporal dementia – FTD). Data suggests that men tend to be more aggressive while women tend to engage in verbal behavior. Up to 90% of patients with advancing dementia can develop behavioral disorders with sexual behavior changes affecting up to 20% of patients.

Keep in mind that delirium can induce changes in behavior that may present as inappropriate sexual behaviors. If the change is acute in nature, consider evaluation for delirium (see our downloadable file). Social factors should also be kept in mind as living in a long term facility makes it difficult to have private relationships and time. Other etiologies that should be evaluated include medication and substance abuse.

Environmental or sensory triggers may be the etiology of behaviors and should be addressed initially. Remove the triggers if possible. Care teams may also be adjusted to allow change in the gender of the care team members that reduce the behaviors.

If behaviors are not addressable by pharmacological means, doctors may consider treatment if behavior is deemed to be dangers to the patient or others. Antidepressants, anti-psychotics have been shown to reduce libido and other behaviors. Anti-androgens can also be used, but usually reserved to reduce testosterone levels and therefore libido. This is essentially chemical castration and has ethical and moral implications which need to be through reviewed and discussed with staff and family before implementing. The use of some of these agents in nursing home is difficult given various state level statues preventing chemical sedation/restraints (many of these same drugs are used to subdue individuals and therefore frowned on).

The best approach to addressing inappropriate sexual behavior remains understanding that sexual behavior in the elderly is normal. As long as the behavior is not disruptive and a harm to others it should be understood that sexual activity and sexual drive remains intact in older patients. Only when the behavior puts others at risk or makes others uncomfortable due to behavior outside of social norms should treatment be sought.

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