Inappropriate sexual behaviors in cognitively impaired older individuals

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.

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

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.

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.

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.