Sexual Behaviors in Dementia

Sexual Behaviors in dementia residents is not uncommon. NH residents are not asexual and sexual behavior is a natural part of being human, regardless of age. These behaviors can be very uncomfortable to deal with for staff due to the different views that each individual may have about such behavior. In my opinion, we must try to set aside our own judgements about sex and assess sexual behaviors on a case-by-case basis for each patient. Education of staff may need to be the first priority in order to address sexual behaviors in dementia and there are links to educational resources in the outline below.

Sexual behaviors in patients with dementia may be related to disinhibition or a loss of the ability to recognize societal norms and filter behavior and thoughts in the same manner as someone without dementia. We can see similar behaviors in other pathologies involving brain trauma, stroke, multiple sclerosis, and neurodegenerative disorders such as Huntington’s disease. The loss of a “filter” can lead to many of the behaviors that we see in dementia in addition sexual behaviors. We typically try to address these behaviors by finding and addressing an unmet need that may be triggering the behaviors. Sexual behaviors can be addressed in the same way but may require more creative solutions.

Frontotemporal dementia (FTD) often involves behavioral changes before memory loss and can present with hypersexual behaviors. FTD often presents with abnormal behaviors, but these patients may initially have no significant memory deficits. Sexual behaviors in FTD seem to be more prominent and may involve not just disinhibition but also an increased desire for sex (7).

As with all dementia behaviors, non-pharmacologic treatments are the mainstay of therapy. Attempting to find an unmet need and addressing that need should be the first approach. With sexual behaviors, this must involve recognition of the fact that sexual behaviors are a primal component of the human brain. When a disease state removes the filter that often suppresses these urges, they surface. Attempting to address the urges may involve creative solutions like dolls, toys, or redirection techniques. A search for potentially stimulating triggers should be performed and attempts to remove, or address, those triggers may be helpful. It is not uncommon for a dementia patient to perceive a sexual stimulus from something that we might not normally consider sexual.

Pharmacologic therapy is sometimes necessary but there is no consistent data to guide the use of medications to reduce these sexual behaviors in dementia (2). Almost all drug classes have been used to attempt to reduce these behaviors with varying levels of success. SSRIs are safe first line agents but even among this class there may be agents that are useful for one person but not for another. Antipsychotics are likewise often used with variable efficacy and these agents pose significant risks. Beta blockers, anti-epileptics, acetylcholinesterase inhibitors, cimetidine, finasteride, naltrexone and other drugs have been used with no consistent results. Hormonal agents, such as medroxyprogesterone, have also been used with some success but a careful evaluation of the risk/benefit profile should be performed. Use of hormonal agents is controversial and some view it as a form of “chemical castration.”

— Dr. David Shepherd

Assess capacity to engage in sexual relationships.

Education of staff

QUICK FAQ sheet –

A scoping review of education and training resources supporting care home staff in facilitating residents’ sexuality, intimacy and relational needs – PMC (nih.gov)

The findings suggest that education interventions can improve knowledge and/or change care staff attitudes, in the short-term, towards older people’s sexuality, intimacy and relational needs in care home settings, which can lead to facilitating staff to enhance person-centered care in this area of need.

The focus of the education interventions and resources was to increase knowledge and improve and/or change attitudes towards the:

(i) sexual expression of older people living in residential aged care,

(ii) sexuality and ageing and

(iii) expression of sexuality in people with dementia.

Sexuality in Nursing Homes Education Module -Kansas State University, Center on Aging

Challenging Behaviors in Dementia Care (Streaming) – Positive Approach to Care – Shop (teepasnow.com)

Management Approach

• Start with Non-pharmacologic strategies (8)
  • Define target behaviors
  • Rule out delirium
  • Consider mood disorder (depression, mania) or psychosis
  • Review environmental factors
  • Review cognitive and sensory factors
  • Educate and support caregivers
  • Consider specific behavioral methods
  • Involve other interested parties if necessary
• Reduce or stop any meds that may disinhibit behaviors such as benzodiazepines, dopamine agonists, anticholinergics, etc…
• Select a target symptoms/behavior and a timeline to assess efficacy of any approach to curb the behavior.
• Measure the efficacy of the approach
• Revise the strategy
• Consider pharmacologic treatments in extreme cases
• Document your efforts
• Repeat and keep trying.

References:

1. Approach to inappropriate sexual behaviour in people with dementia – PMC (nih.gov)
2. Treatment of Inappropriate Sexual Behavior in Dementia – PMC (nih.gov)
3. Extreme sexual behavior in dementia as a specific manifestation of disinhibition – PubMed (nih.gov) 
4. Treatment and Management of Sexual Disinhibition in Elderly Patients With Neurocognitive Disorders – PMC (nih.gov)
5. Hypersexuality in dementia | Advances in Psychiatric Treatment | Cambridge Core
6. Sexual Aggression between Residents in Nursing Homes-Literaure Synthesis for an Undercatagorized Issue
7. Hypersexual Behavior in Frontotemporal Dementia: A Comparison with Early-Onset Alzheimer’s Disease
8. Hypersexuality in dementia | Advances in Psychiatric Treatment | Cambridge Core