What is the recommended dose of medroxyprogesterone acetate (MPA) for managing sexually inappropriate behavior in elderly men?

Medroxyprogesterone Acetate Dosing for Sexually Inappropriate Behavior in Elderly Men

The recommended dose of medroxyprogesterone acetate (MPA) for managing sexually inappropriate behavior in elderly men with dementia is 400 mg intramuscularly per week, which has been shown to effectively reduce sexual acting out within 2 weeks of initiation. 1

Mechanism and Efficacy

MPA works by reducing testosterone levels, which leads to decreased sexual interest and activity. The evidence shows:

• Significant reduction in sexually inappropriate behaviors occurs within 2 weeks of starting treatment 1
• Treatment is associated with approximately 90% decline in serum testosterone and 60% decline in luteinizing hormone (LH) 1
• Efficacy has been demonstrated across multiple studies with success rates of 80-100% in reducing inappropriate sexual behaviors 2, 3

Dosing Regimen

Initial Dosing

• Standard dose: 400 mg intramuscularly weekly 4
• Duration of treatment typically ranges from 6 months to several years 4

Monitoring and Adjustment

• Monitor serum testosterone and LH levels regularly to confirm adequate suppression
• Clinical response should be evident within 2-3 weeks of initiating therapy 1, 2
• If inadequate response occurs, dose may need to be adjusted

Clinical Considerations

Patient Selection

• Best suited for elderly men with dementia who exhibit:
  • Public masturbation
  • Inappropriate sexual advances toward staff or other patients
  • Sexual behaviors that cannot be managed by behavioral interventions

Monitoring Parameters

• Testosterone levels (expect 90% reduction from baseline)
• LH levels (expect 60% reduction from baseline)
• Blood pressure
• Weight
• Blood glucose
• Gallbladder function

Potential Side Effects

Common side effects include:

• Weight gain
• Malaise
• Headaches
• Leg cramps
• Hypertension
• Gastrointestinal complaints
• Gallbladder stones
• Diabetes mellitus 4

Treatment Duration and Discontinuation

• Treatment duration is typically at least 6 months, with many patients requiring 1-2 years of therapy 4
• Upon discontinuation, testosterone and LH levels return to baseline 1
• Some patients may experience return of inappropriate behaviors after discontinuation, though often at reduced levels 1
• Consider gradual tapering rather than abrupt discontinuation

Alternative Approaches

If MPA is contraindicated or poorly tolerated, consider:

• Other hormonal agents (though less evidence supports their use)
• Behavioral interventions with increased supervision
• Environmental modifications to reduce triggers

Treatment Algorithm

1. Confirm diagnosis: Ensure behaviors are truly sexual in nature and not misinterpreted agitation
2. Try non-pharmacological approaches first: Behavioral interventions, redirection, environmental modifications
3. If unsuccessful, initiate MPA: 400 mg IM weekly
4. Monitor response: Assess behavior changes within 2-3 weeks
5. Continue therapy: Maintain for at least 6 months if effective
6. Monitor for side effects: Regular assessment of weight, blood pressure, and metabolic parameters
7. Consider discontinuation: After sustained period of behavioral control, with close monitoring for recurrence

MPA has demonstrated both safety and efficacy in treating sexually inappropriate behaviors in elderly men with dementia and should be considered as a first-line pharmacological treatment when non-pharmacological approaches have failed 1, 3.