Sexually inappropriate behaviour in demented elderly pe...

Sexually inappropriate behaviour in demented elderly people

Aim: To determine the prevalence, aetiology, and treatment profile of abnormal sexual behaviour in subjects with dementia in psychogeriatric practices.

Methods: A retrospective cross sectional study was conducted in a long term care psychiatry consultation service, community based geriatric psychiatry service, and an inpatient dementia behavioural unit in Edmonton, Canada.

Results: Forty one subjects (1.8%) had sexually inappropriate behaviour. Of those cognitively impaired subjects with sexually inappropriate behaviour, 20 (48.8%) were living in nursing homes and the rest, 21 (51.2%) in the community. Of these subjects, 53.7% had vascular dementia, 22% had Alzheimer's, and 9.8% had mild cognitive impairment. History of alcohol misuse and psychosis were reported in 14.6% and 9.8% of subjects respectively. Twenty seven (65.7%) had verbally inappropriate behaviour and 36 (87.8%) had physically inappropriate behaviour. In this study, verbally inappropriate behaviour was more commonly seen in the community sample (81%) than in the nursing home sample (50%) (p = 0.04). Behavioural treatment was also more commonly seen in the community sample (81%) than in the nursing home sample (45%) (p = 0.01).

Conclusion: In this study sexually inappropriate behaviour was seen in all stages of dementia, more commonly associated with subjects of vascular aetiology, and is as commonly seen in community dwelling subjects with dementia as in nursing home subjects.


K Alagiakrishnan, D Lim, A Brahim, A Wong, A Wood, A Senthilselvan, W Chimich, and L Kagan. 2005. Sexually inappropriate behaviour in demented elderly people. Postgrad Med J 81(957): 463–466.


Aggression and agitation are common problems seen in
the geriatric population with moderate to severe stages
of impaired cognition, and especially in long term care
patients with dementia. The prevalence of physically aggres-
sive behaviour increases with the progression of dementia,
and it often heralds a poor prognosis. [1,2] Behavioural
disorders, which include pacing, hitting, sexually inappropri-
ate behaviour, agitation, or aggression, represent a consider-
able source of stress to patients, families, and caregivers.

Sexuality is part of human nature throughout life. Being
elderly and sick does not necessarily mean that there is a
decline in sexual desire. Patients with dementia may become
sexually disinhibited as cognitive deficits progress. Caregivers
who are taking care of demented elderly people should expect
sexual behaviours to occur and they should be ready to
respond appropriately. Sexually inappropriate behaviour can
include verbal or physical abnormal behaviour. The physical
inappropriate behaviour includes sexual touching, fondling,
disrobing, masturbation, and sexual advances.

Abnormal sexual behaviour in the long term care setting
includes unwanted sexual advances such as climbing into
bed with other residents in a nursing home or actual
attempts of intercourse and aberrant sexual behaviour such
as sexual aggression. Sexual aggression manifesting itself as
hypersexuality may also be attributable to drugs, psychosis,
mania, and various neurological disorders including frontal
lobe lesions. [3] Inappropriate sexual behaviour in the demen-
ted person can be difficult to assess because the person may
not be able to explain their actions. While most sexually
aggressive behaviour/inappropriate sexual behaviour occurs
in the moderate to severe stages of Alzheimer’s dementia, it
may also be seen in early stages of fronto-temporal dementia
because of the lack of insight and disinhibition.

It may herald the worsening of dementia with executive
dyscontrol, sexual disinhibition, and tendency to impulsive
behaviour, particularly if there is impairment of frontal
subcortical circuits. These behaviours can compromise the
care of nursing home residents and the safety of the staff. The
predisposition of elderly patients with dementia to psycho-
tropic toxicity further complicates the management of such
aggressive behaviour. There are several possible causes of
inappropriate repetitive sexual behaviour in a patient with
dementia. The purpose of this study is to find out the
prevalence of sexual abnormal behaviour in subjects with
dementia at psychogeriatric practices in Edmonton and to
identify the aetiology, type of presentation, and treatment in
these subjects.


M E T H O D S

This is a retrospective cross sectional study at three centres in
Edmonton—the long term care psychiatric consulting ser-
vices, community based geriatric psychiatry, and inpatient
dementia behavioural unit. All charts (n = 2278) (commu-
nity based geriatric psychiatry—350, inpatient dementia
behavioural unit—274, and the rest from long term care
psychiatry consulting services) in the years 2001 and 2002
with a diagnosis of dementia were included in the study and
screened for documentation of sexually abnormal behaviour.
Diagnosis of dementia was made by DSM IV criteria. In this
study, sexually inappropriate behaviour was defined as
subjects having verbal or physical aberrant sexual beha-
viours, or both. Physically inappropriate behaviours include
unwanted sexual advances like touching inappropriately or
fondling and abnormal sexual behaviour like public mastur-
bation or disrobing or hypersexuality and actual attempts of
intercourse. Verbal inappropriate behaviours include foul or
bad or embarrassing language or sexual remarks. Subjects
who did not have the documentation of sexual inappropriate
behaviour and deceased patients whose charts were not
available were excluded from the study. Demographic
information, details about sexually abnormal behaviour,
and management were obtained. Ethics committee and site
administrative approval were obtained from all the centres
participating in the study.

Statistical analyses

Continuous variables were described with means and
standard deviations. Frequencies and percentages were used
to describe categorical data. We used x2 statistics for two by
two tables to test the statistically significant differences
between two proportions.


R E S U L T S

In this study, the prevalence of sexually inappropriate
behaviour was 1.8%. Among the 41 cognitively impaired
subjects with sexual inappropriate behaviour, age ranged
from 65 to 92 (mean (SD) 78.3 (7.5)). There were more men
(92.7%) than women (7.3%). Twenty (48.8%) were living in
nursing homes and the rest (51.2%) in the community. In the
study, almost the same proportion of subjects was seen by
community psychiatry (33.1%), long term care psychiatry
(39%), and the inpatient behavioural unit (27%).

Of these subjects, 54% had vascular dementia, 22% had
Alzheimer’s, and 9.8% had mild cognitive impairment. Mean
score on the Folstein mini-mental status examination in
these subjects was 18 (range 12–28). Alcohol misuse and
psychosis were reported in 14.6% and 9.8% of subjects
respectively (table 1). Twenty seven (65.7%) had verbally
inappropriate behaviour and 36 (87.8%) had physically
inappropriate behaviour. Among those with physically
inappropriate behaviour, 27 (65.7%) had documentation of
inappropriate touching and three (7.3%) had hypersexuality.
Twenty two (53.7%) had both verbal and physical inap-
propriate behaviour. Verbally inappropriate behaviour was
more commonly seen in the community sample (81%) than
in NH sample (50%) (p = 0.04) (fig 1).

___
Table 1 Patient characteristics with sexually
inappropriate behaviour in demented elderly patients

- Age
65-80: 24 (58.5%)
> 80: 17 (41.5%)

- Sex
Male: 38 (92.7%)
Female: 3 (7.3%)

- Living situation
Home: 11 (26.8%)
Supportive living: 10 (24.4%)
Nursing home: 20 (48.8%)

- Types of services
Community psychiatry: 14 (34.1%)
Long term care psychiatry: 16 (39.0 %)
Inpatient behavioural dementia unit: 11 (26.8%)

- Types of dementia
Mild cognitive impairment: 4 (9.8%)
Alzheimer’s: 9 (22.0%)
Vascular: 22 (53.6%)
Alcohol related: 5 (12.2%)
Others: 1 (2.4%)

- Types of psychiatric issues
Psychosis: 4 (9.8%)
Mania: 1 (2.4%)
Alcohol misuse: 6 (14.6%)
Substance misuse: 1 (2.4%)

- Neurological problems
Parkinson’s: 3 (7.3%)
Stroke: 16 (39.0%)
___

___
Figure 1 Presentation of sexually inappropriate behaviour.
*Significant (p = 0.039).
___


Twenty six (63.4%) had behavioural treatment, 18 (43.8%)
were taking antipsychotics, three (7.3%) were receiving
hormonal therapy, and six (14.6%) were taking cholinester-
ase inhibitors. Behavioural treatment was more commonly
seen in the community sample (81%) than in NH sample
(45%) (p = 0.01) (fig 2).

___
Figure 2 Management of sexually inappropriate behaviour.
*Significant (p = 0.019).
___


D I S C U S S I O N

Sexually inappropriate behaviour is generally known to be
more common in men than in women. Our results were
similar to other study results in that this type of behaviour is
more commonly seen in male subjects (93%). Sexually
inappropriate behaviour can be seen in different settings [4]
although more commonly reported in an institutional
setting. [5,6] Our study shows this challenging behaviour was
seen in both community dwelling subjects with dementia as
well as in nursing home subjects. Moreover our study also
points out that 51% of the sexually inappropriate subjects
were living and being managed within the community.

Previous studies found that higher prevalence of inap-
propriate sexual behaviour was found in severely demented
patients. [7-9] Sexual activity can increase in association with
progression of dementia. This can result in unreasonable and
exhausting demands on sexual partners at unacceptable
times and inappropriate places. Occasionally, physical
aggression may result if these needs are not met. These
patients are among the most difficult to manage and present
a tremendous challenge to the physicians. In our study,
sexually inappropriate behaviour was seen even in the stage
of mild cognitive impairment (9.8%). Previous studies had
reported that the prevalence of this behaviour ranges from
2.9% to 7% of Alzheimer’s dementia subjects. [8,9] In this study,
this behaviour was associated more commonly in vascular
dementia subjects group (54%) rather than Alzheimer’s
subjects group (22%). To our knowledge, our study is the
first one to show that this behaviour is more commonly
associated with vascular demented patients. Only 13 subjects
in this study had the clock drawing test done and all these
were abnormal drawings, suggesting executive dysfunction
may play a part in this behaviour

Sexually inappropriate behaviour can be very upsetting to
caregivers. A lot of what is seen in the demented elderly is
really sexually ambiguous behaviour such as disrobing, and
involves no sexual arousal. It is caused by disorganisation
secondary to cognitive impairment. On the other hand, a
repetitive sexually aggressive behaviour may be attributable
to a compulsive-impulsive range of symptoms and disorders. [3]
Like other repetitive and disruptive behaviours, the constant
inappropriate touching behaviour of opposite sex may be
postulated to fall within this range. The most common
inappropriate physical behaviour seen in our study subjects
was also inappropriate touching of the opposite sex (87.8%),
most commonly the homecare-caregivers.

When assessing abnormal behaviour it is necessary to take
behavioural history, which should specify the type of
abnormal behaviour, frequency of occurrence, duration of
the symptoms, and settings that produce the symptoms.
Always look for indicators of tendencies towards sexually
inappropriate behaviour such as jokes with sexual innuen-
dos. In some patients these do not necessarily represent an
intent towards sexual aggressive behaviour as they may not
comprehend the meaning of their own words.

Findings from this descriptive study and literature review
provide some useful insights regarding management of these
behaviours. Most of the treatments suggested for aggressive-
ness in dementia have only marginal benefit for controlling
sexual aggressiveness. Inappropriate sexual behaviours are
often better managed by non-pharmacological means, as
patients may be less responsive to psychoactive therapies.
Behavioural therapy includes redirecting the behaviour
verbally or if necessary physically. Firmly but gently identify
the behaviour and point out that it is unacceptable. Remind
the subject who you are, especially if the resident is confused.
Exposing and fondling genitals and public masturbation may
be minimised by choosing clothing that opens in the back
and by assigning manual activities such as folding towels. If
behavioural interventions fail, pharmacological therapy may
be necessary. These include drugs such as the newer
neuroleptics like risperidone, olanzapine, clozapine, and
quetiapine, and the selective serotonin reuptake inhibitors
(SSRIs), trazadone, buspirone, lithium and valproate. [10, 11]
Serotonin has a critical role in mood modulation and impulse
control. This explains, in part, the response of obsessive-
compulsive disorders to various proserotonergic agents. The
role of SSRIs in the treatment of obsessive-compulsive
disorders is well established. [3] The different inhibitory effects
of various SSRIs on the reuptake of serotonin, norepinephr-
ine, and dopamine is well known. Other possible mechan-
isms for the effectiveness of SSRI may be attributable to the
antilibidinal effects of SSRIs. [3]

Other drugs that have been used with varying success in
the treatment of sexual aggression include antiandrogens,
oestrogens, and gonadotropin releasing hormone analogues.
Sexually aggressive behaviour in men has been treated with
antiandrogens, oestrogen, and medroxy progesterone acet-
ate. [12, 13] The effectiveness of these drugs have been reported
mainly in case reports, and in most instances in younger
patients. Medroxyprogesterone (Amen, Cycrin, Depo-
Provera) and related hormonal agents have been used for
the treatment of intrusive disinhibited sexual behaviour. A
randomised controlled trial is needed to assess the true
efficacy of these agents in the management of sexually
aggressive behaviours. One study also points out that
cimetidine, which has antiandrogen properties, decreases
libido and hypersexual behaviour without serious side
effects. [14] Cholinesterase inhibitors have also been found to
be effective as a single therapy for this behaviour. [15]

In our study, behavioural treatment was seen in 63.4% of
subjects. Forty four per cent were taking antipsychotics, 48%
were taking antidepressants, and 7.3% were receiving
hormonal therapy and most of them were receiving
combination therapy with behavioural treatment. In this
study, only 14.6% were taking cholinesterase inhibitors in
combination with other therapies. In most of these subjects,
behavioural therapy or combined behavioural and pharma-
cological therapy was started at the time of behaviour,
whereas in some patients the previous drugs they were taking
before this behaviour were continued if the physician found
that to be appropriate.

Health professionals who are involved in the care of
demented elderly patients should be educated through
regular in-service training to prepare them to handle sexual
inappropriate behaviours. Policies and procedures for identi-
fying and dealing with this behaviour should also be enacted.
The limitations of the study are that this is a retrospective
chart review and it is a descriptive study. Most of these
subjects are reported cases by the healthcare workers and it is
possible that we may not be identifying all the subjects who
had this problem as family caregivers may not report it as
frequently as healthcare caregivers.


C O N C L U S I O N

In this study, sexually inappropriate behaviour was seen in
all stages of dementia including mild cognitive impairment,
more commonly associated with subjects with vascular
aetiology, and was as commonly seen in community dwelling
subjects with dementia as in nursing home subjects. Sexually
inappropriate behaviour is one of the most difficult beha-
viours to manage for both informal and formal caregivers.
Healthcare providers including those serving in the commu-
nity must be educated to manage this condition.

. . . . . . . . . . . . . . . . . . . . .
Authors’ affiliations

K Alagiakrishnan, D Lim, Division of Geriatric Medicine, Department of
Medicine, University of Alberta, Edmonton, Canada

A Brahim, Department of Psychiatry, Alberta Hospital, Edmonton,
Canada

A Wong, LongTerm Care Psychiatry Services, Edmonton, Canada

A Wood, Geriatric Psychiatry Service, Edmonton Mental Health Clinic,
Edmonton, Canada

A Senthilselvan, Department of Statistics and Epidemiology, University
of Alberta

W T Chimich, L Kagan, Department of Psychiatry, University of Alberta

Funding: none.

Conflicts of interest: none declared.


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