Inappropriate Sexual Behavior In A Patient With Dementia
Sexual behavior in the elderly is normal, and sex drive remains intact at baseline levels. Societal stereotypes result in classifying all sexual behavior in the elderly as inappropriate. It is essential to distinguish appropriate vs inappropriate sexual behavior.
There is no globally accepted definition of inappropriate sexual behavior. Determining inappropriate behavior must be viewed within societal and environmental norms. This context and the risks or uneasiness of others usually determine if the behavior has crossed the threshold needing intervention. Suppose sexual activity interferes with regular exercise, occurs at inappropriate times, or infringes on the rights of others (staff or other residents/patients). In that case, it is reasonable to associate this behavior with inappropriate sexual behavior.
Inappropriate sexual behavior can present as wrong talk (foul or threatening), sexual acts (touching, exposing, fondling), or implied sexual acts (requesting frequent and unnecessary genital care, etc.). Pathologically, inappropriate sexual behavior presents as a deviation from normal behavior for the patient. In that case, 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 advanced dementia can develop behavioral disorders, with sexual behavior changes affecting up to 20% of patients.
Remember that delirium can induce changes in behavior that may present as inappropriate sexual behaviors. If the change is acute, consider evaluation for delirium (see our downloadable file). Social factors should also be considered, as living in a long-term facility makes having private relationships and time difficult. 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 changes in the gender of the care team members that reduce the behaviors.
Suppose behaviors are not addressable by pharmacological means. In that case, doctors may consider treatment if conduct is deemed dangerous to the patient or others. Antidepressants and anti-psychotics have been shown to reduce libido and other behaviors. Anti-androgens can also be used but are usually reserved to lower testosterone levels and libido. This is essentially chemical castration and has ethical and moral implications that must be reviewed and discussed with staff and family before implementation. Using some of these agents in nursing homes is difficult given various state-level statutes preventing chemical sedation/restraints (many drugs are used to subdue individuals and, therefore, are frowned upon).
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 harms others, it should be understood that sexual activity and sexual drive remain intact in older patients. Treatment should be sought only when the behavior puts others at risk or makes others uncomfortable due to conduct outside social norms.