Management of Inappropriate Sexual Behavior in Advanced Dementia with Medroxyprogesterone Acetate
Medroxyprogesterone acetate (MPA) is recommended as an effective pharmacological treatment option for inappropriate sexual behaviors in patients with advanced dementia who are already on citalopram. 1, 2
First-Line Pharmacological Options
- SSRIs like citalopram are considered first-line pharmacological treatments for hypersexual behaviors in patients with dementia 1
- Citalopram (Celexa) is well tolerated at doses of 10-40 mg per day, with some patients experiencing nausea and sleep disturbances 3
- Case reports have demonstrated successful treatment of inappropriate sexual behaviors in dementia patients with citalopram 4
Adding Medroxyprogesterone Acetate (MPA)
- Medroxyprogesterone acetate is specifically recommended for treating sexual disinhibition in men with dementia 1, 5
- Clinical studies show that MPA can effectively reduce inappropriate sexual behaviors within 2 weeks of initiation, with a 90% decline in serum testosterone and 60% decline in luteinizing hormone 2
- MPA has been used successfully without significant adverse effects in elderly men with dementia exhibiting sexual acting out behaviors 2, 5
Dosing and Administration
- Start MPA at a low dose and titrate gradually while monitoring for response 6
- Treatment effects typically begin within 2 weeks of starting MPA 2
- Monitor serum testosterone and luteinizing hormone levels to assess biochemical response to treatment 2
Monitoring and Follow-up
- Evaluate response to MPA within 30 days; if minimal improvement is observed, consider alternative treatments 1
- Consider tapering or discontinuing MPA after 6 months of symptom stabilization 1
- Be aware that when MPA treatment is stopped, testosterone and LH levels typically return to pretreatment levels, which may lead to recurrence of behaviors in some patients 2
Important Considerations
- Investigate and treat potential underlying causes of behavioral changes before adding MPA to the existing citalopram regimen 1
- Avoid medications with significant anticholinergic effects, which can worsen cognitive symptoms in patients with dementia 1
- Conventional antipsychotics like haloperidol should not be used as first-line management for inappropriate sexual behaviors 1
Alternative Options if MPA is Ineffective
- Carbamazepine can be considered as an alternative if citalopram and MPA combination is ineffective 1
- Other antiandrogens such as cyproterone acetate or LHRH agonists may be considered as third-line agents 7
Caution
- None of the medications discussed are FDA-approved specifically for inappropriate sexual behaviors in dementia 6
- Elderly patients with dementia are at higher risk for adverse effects, so careful monitoring is essential 6
- Discuss issues of ethics and consent with caregivers before initiating treatment 6