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Dementia and Inappropriate Sexual Behavior

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Sexual feelings don’t have an expiration date. Older adults are still sexual beings, and many maintain their interest in sex into their 80s and 90s. But for people with dementia, these impulses can go awry when cognitive and personality changes lead to inappropriate sexual behavior (ISB).

Examples: Disrobing in front of others…public masturbation…uninhibited sexual talk…or the inappropriate or unwanted touching of health-care workers, other patients or even family members.

Some 5% to 20% of dementia patients exhibit some degree of ISB at some point during the course of their illness. It’s more common in group-living situations (where there may be more sexual triggers/opportunities for interaction with others). It affects both men and women (though more men), and it can occur with all forms of dementia, such as those caused by Alzheimer’s disease, frontotemporal dementia and vascular diseases, traumatic brain injury and others.

BROKEN BOUNDARIES

Because it’s natural for adults of all ages—including those with dementia—to have and sometimes act on sexual feelings and interests, it’s important to differentiate normal sexual expressions from ISB.

What can happen: Imagine that two widowed residents at a care facility spend a lot of time together. They might hold hands or kiss. This behavior may be considered normal as long as both of them have the cognitive capacity to understand who the other person is, welcome and enjoy the interactions and both are able to make informed decisions about the relationship—including the ability to say “yes” or “no.”

ISB, on the other hand, is a persistent and uninhibited sexual behavior that interferes with function and is directed toward oneself or toward an unwilling partner. Patients might make aggressive and inappropriate or sexually suggestive comments to others. They might touch others in ways that are unwelcome. The behavior may occur in public or when no one else is around.

ISB is challenging to address because most people, particularly family members, are uncomfortable talking about a patient’s sexuality. Health-care providers can help by initiating a conversation about sexual expression and distinguishing  between sexual expression and inappropriate sexual behavior.

WHAT CAUSES ISB?

There are several causes of ISB. A loss of neurons from progressive dementia, frontal lobe injury or an acute delirium may result in ISB. Additionally, some patients with dementia have other psychiatric problems (such as bipolar disorder) that can trigger hypersexuality, which is a common manifestation of the mania that can characterize bipolar disorder.

Another cause: Side effects from drugs and/or alcohol. Many common medications, including the Parkinson’s medication levodopa (Sinemet) and the sedative diazepam (Valium), may trigger symptoms of ISB.

When health-care providers such as physicians, nurse practitioners, neurologists and psychiatrists treat patients with ISB, they will start by looking for possible physical causes, including drug side effects. For some patients, simply changing medications can help. More often, treatment involves nondrug approaches including education and behavioral techniques.

BEST NONDRUG STRATEGIES

There are no FDA-approved treatments specifically for ISB. Antidepressants, mood stabilizers and other drugs can help some patients, but they are used only case-by-case—and usually as a last resort due to their potential side effects, which can be quite serious. What you can do instead…

Distraction. This can be as simple as giving someone something to do when he/she begins to exhibit unwanted sexual behaviors. The moment you hear a sexual comment, for example, try to bring the person’s attention elsewhere, maybe with an activity. Alternatively, you can lead the patient away from anything that could be triggering the behavior such as a TV show.

Boundary reminders. Patients with dementia might not be able to engage in lengthy conversations, but most can understand simple instructions, particularly when they’re delivered in a professional, no-nonsense tone. Example: A patient with wandering hands might be told, “No. I don’t like it when you touch me. Please stop.”

Identify sexual triggers. Patients with dementia often misinterpret social and environmental cues. ISB is usually triggered by specific people and situations, which vary from person to person. Once you are able to identify these triggers, you can take steps to avoid uncomfortable situations and prevent misinterpretations.

Example: An elderly man who is stimulated by the presence of young women. If you have such women visiting your home, you might arrange to keep him busy with a favorite activity in a different part of the house.

Another example: Someone who gets aroused during baths or other situations that involve nudity and/or touching. You can avoid this trigger by handing the patient a washcloth and encouraging him to wash himself. And it can be helpful to have someone of the gender that the patient is not attracted to perform care duties involving nudity or touching.

Change the environment. If someone is aroused by caregivers of only one sex, try to use care-
givers of the other sex—even for care that doesn’t involve intimacy. Change the channel on the TV when overtly sexual programs come on.

Hard-to-remove clothing. You can buy “adaptive” clothing with hooks or other fasteners that make it difficult to remove—helpful for someone who disrobes, masturbates in public or tries to engage other people in unwanted sexual activity. Twenty years ago, this type of clothing tended to look institutional. Now there are more stylish options available online.

Important: The use of adaptive clothing is sometimes controversial because it prevents an individual from having access to his own body. But it can be helpful in some cases. Discuss it with your loved one’s health-care provider.

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Source: Elizabeth Galik, PhD, CRNP, FAAN, associate professor at University of Maryland School of Nursing in Baltimore, where she also teaches in the adult and geriatric nurse practitioner program. She specializes in the neuropsychia­tric care of older adults with dementia and practices clinically as a nurse practitioner in community and long-term-care settings Date: November 1, 2017 Publication: Bottom Line Health
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