What is the appropriate treatment for inappropriate sexual behavior in elderly males, specifically the role of Premarin (conjugated estrogens)?

Management of Inappropriate Sexual Behavior in Elderly Males

Premarin (conjugated estrogens) is not a first-line treatment for inappropriate sexual behavior in elderly males and should be considered only after other pharmacological options have failed due to its significant side effect profile.

Assessment of Inappropriate Sexual Behavior

Before initiating any treatment, a thorough evaluation should be conducted:

• Assess for underlying causes:

  • Cognitive impairment/dementia (particularly with right frontal lobe involvement) 1
  • Medication side effects (especially hormone therapy or opioids) 2
  • Psychological factors (anxiety, depression, relationship issues) 2
  • History of sexual dysfunction or paraphilia

• Document specific behaviors to establish baseline and monitor treatment response 3

Treatment Algorithm

First-Line Treatments:

1. Non-pharmacological approaches:

   • Behavioral interventions (redirection, establishing routines)
   • Environmental modifications (privacy when appropriate, reducing triggers)
   • Caregiver education and support

2. Pharmacological options:

   • SSRIs (sertraline, paroxetine, fluoxetine, citalopram) 4, 5
     • Begin with low doses and titrate slowly
     • Monitor for side effects including serotonin syndrome
     • Avoid in patients with bipolar disorder due to risk of mania 2

Second-Line Treatments:

1. Antiandrogens:
   • Medroxyprogesterone acetate 4, 1
     • Well-tolerated and effective in multiple case reports
   • Cyproterone acetate (where available) 4

Third-Line Treatments:

1. LHRH agonists:

   • Leuprolide or triptorelin 4
   • Consider when behaviors are severe and other treatments have failed

2. Estrogen therapy (including Premarin):

   • Reserved for cases resistant to other treatments 4, 5
   • Transdermal estrogen patch may be preferred over oral Premarin 5
   • Requires medical clearance due to cardiovascular risks 2

Important Considerations and Cautions

• Cardiovascular risk assessment is essential before initiating hormonal treatments, especially estrogens 2

  • Sexual activity is equivalent to walking 1 mile in 20 minutes or climbing 2 flights of stairs in 20 seconds
  • Patients unable to perform these activities should be referred to cardiology

• Monitoring requirements:

  • Regular assessment of behavior changes
  • Cardiovascular monitoring
  • Monitoring for feminizing effects with estrogen therapy

• Ethical considerations:

  • Informed consent (from patient or surrogate decision-maker)
  • Balance between patient autonomy and safety of others
  • Least restrictive intervention principle

Evidence Limitations

The evidence for treating inappropriate sexual behavior in elderly males is limited to case reports and small case series. No randomized controlled trials exist specifically for Premarin in this population 4, 6. Treatment decisions must be made carefully, weighing potential benefits against risks, particularly with hormonal therapies like Premarin that carry significant cardiovascular and other risks.