How to manage increased sexual expression in an elderly patient with dementia in long-term care?

Management of Increased Sexual Expression in Elderly Patients with Dementia in Long-Term Care

Begin with a comprehensive assessment to determine whether the sexual expression is appropriate or inappropriate, evaluate consent capacity, and systematically investigate underlying causes before considering any intervention. 1, 2

Step 1: Characterize and Document the Behavior

Use the "DESCRIBE" approach to obtain detailed, contextual information about the sexual expression. 1

• Ask staff to describe the behavior "as if in a movie" - document specific antecedents, the exact nature of the behavior, and consequences (ABC charting). 1
• Clarify what staff mean by "increased sexual expression" as this encompasses a wide spectrum: appropriate expressions of intimacy with a consenting partner, masturbation in private spaces, inappropriate public sexual behaviors, or unwanted sexual advances toward others. 3, 2
• Determine if the behavior involves physical contact with others, verbal sexual comments, public exposure, or masturbation in private versus public spaces. 3
• Elicit the patient's perspective when possible to understand their experience and what they can describe about their needs. 1
• Document when behaviors occur, frequency, triggers, and impact on the patient and others using standardized tools if available. 1, 4

Step 2: Assess Sexual Consent Capacity

Evaluate whether the patient has capacity to consent to sexual activity, particularly if the behavior involves another person. 2, 5

• Assess the patient's ability to understand the nature of sexual activity, appreciate consequences, communicate choices, and demonstrate reasoning about the decision. 5
• Consider cognitive impairment severity, ability to recognize the other person, and understanding of the relationship context. 5
• Evaluate for potential exploitation or predatory situations where someone may be taking advantage of the patient's cognitive impairment. 1
• Document capacity assessment findings to guide decision-making about supporting or redirecting the behavior. 5

Step 3: Investigate Underlying Medical and Environmental Causes

Systematically rule out reversible medical conditions and environmental factors that may be driving inappropriate sexual behaviors. 1

• Pain assessment: Undiagnosed pain is a major contributor to behavioral disturbances in patients who cannot verbally communicate discomfort. 1, 6
• Infections: Check for urinary tract infections, which commonly trigger behavioral changes in dementia patients. 1, 6
• Medication review: Compile all medications including over-the-counter drugs and assess for anticholinergic properties, dopaminergic medications, or other agents that may disinhibit behavior. 1, 6
• Constipation and urinary retention: These physical discomforts can manifest as agitation or inappropriate behaviors. 1, 6
• Sensory impairments: Hearing or vision problems increase confusion and may contribute to misinterpretation of social cues. 1, 6
• Environmental triggers: Assess if behaviors occur during specific care activities (bathing, dressing) or in response to particular staff members or situations. 1

Step 4: Distinguish Appropriate from Inappropriate Sexual Expression

Recognize that sexual expression is not contraindicated in elderly patients with dementia, and appropriate consensual activity should be supported. 1, 2

If the behavior is appropriate and consensual:

• Support the patient's right to sexual expression and intimacy. 1
• Provide privacy for the patient and their consenting partner. 2
• Educate staff that sexual needs remain important to older adults and that dismissing these needs violates patient autonomy and dignity. 1, 2
• Address staff discomfort through education about sexuality in aging and dementia. 2
• Ensure the environment allows for safe, private intimate expression. 2

If the behavior is inappropriate (public, non-consensual, or distressing to others):

• Proceed to non-pharmacological interventions as first-line treatment. 6, 4

Step 5: Implement Non-Pharmacological Interventions First

Non-pharmacological approaches must be attempted and documented as failed before considering medications. 6, 7

• Redirection and distraction: Use photographs, objects from the past, or meaningful activities to redirect attention. 1, 7
• Environmental modifications: Ensure adequate supervision, remove triggering stimuli, and provide structured daily routines with predictable activities. 7, 8
• Increase meaningful activities: Provide physical exercise, creative activities (painting, music), and social engagement appropriate to cognitive level. 1, 7
• Communication strategies: Use calm tones, simple one-step commands, and gentle touch for reassurance rather than confrontation. 1, 7
• Privacy management: If masturbation is occurring in public spaces, gently redirect the patient to their private room without shaming. 2, 4
• Staff education: Train staff that behaviors are symptoms of dementia, not intentional actions, and teach appropriate responses. 7
• Address unmet needs: Consider if the behavior reflects loneliness, boredom, or need for physical affection that can be met through appropriate touch (hand massage, hugs from family). 7

Step 6: Pharmacological Treatment (Only if Non-Pharmacological Approaches Fail)

Medications should only be used when behaviors are severe, dangerous, or causing substantial distress after behavioral interventions have been systematically attempted and documented as insufficient. 6, 4

First-Line Pharmacological Treatment:

SSRIs are the preferred first-line medication for inappropriate sexual behaviors that persist despite non-pharmacological interventions. 3, 4

• Citalopram: Start 10 mg/day, maximum 40 mg/day. 6
• Sertraline: Start 25-50 mg/day, maximum 200 mg/day. 6
• Initiate at low dose and titrate to minimum effective dose. 6
• Evaluate response within 4 weeks using quantitative measures. 6
• If no clinically significant response after 4 weeks at adequate dose, taper and withdraw. 6

Second-Line Pharmacological Treatment (if SSRIs fail):

Antiandrogen therapy may be considered for persistent, severe inappropriate sexual behaviors in males that have not responded to SSRIs. 3, 4

• Medroxyprogesterone acetate or cyproterone acetate (where available) can be used as second-line agents. 3
• Requires medical clearance and discussion of risks including metabolic effects, cardiovascular risks, and bone density concerns. 3
• Reserve for cases involving dangerous physical contact or severe distress when other approaches have failed. 3

Third-Line Options (rarely needed):

• LHRH agonists (leuprolide, triptorelin) or estrogens may be considered in refractory cases with dangerous behaviors. 3
• These carry significant risks and should only be used in consultation with specialists. 3

What NOT to Use:

• Avoid antipsychotics unless the patient has concurrent psychotic features or severe agitation threatening substantial harm, as they increase mortality risk (1.6-1.7 times higher than placebo) without specific efficacy for sexual behaviors. 6
• Avoid benzodiazepines due to risk of paradoxical agitation (10% of elderly patients), cognitive worsening, and increased delirium. 6

Step 7: Monitoring and Reassessment

Regularly evaluate the effectiveness of interventions and reassess for new contributing factors. 7

• Monitor for medication side effects including extrapyramidal symptoms, falls, metabolic changes, and cognitive worsening. 6
• Attempt to taper or discontinue medications after 6 months of symptom stabilization. 8
• Conduct daily in-person examination if antipsychotics are used, with goal of discontinuing as soon as possible. 6
• Reassess for new medical conditions, medication changes, or environmental factors that may be contributing. 7

Critical Considerations and Common Pitfalls

Balance protection with autonomy - not all sexual expression requires intervention. 1, 2

• Avoid reflexive suppression: Staff discomfort should not drive treatment decisions; appropriate consensual sexual expression is a patient right. 1, 2
• Cultural and religious sensitivity: Consider the patient's lifelong values, cultural background, and religious beliefs when evaluating what constitutes "inappropriate" behavior. 1
• LGBT considerations: Be aware that older LGBT adults may face additional barriers to expressing sexuality in long-term care due to fear of discrimination. 1
• Avoid excessive medication: Do not use psychotropics as a substitute for addressing underlying causes or implementing behavioral interventions. 6, 7
• Document consent capacity: Failure to assess capacity can result in either inappropriate restriction of autonomy or failure to protect vulnerable patients from exploitation. 5
• Family involvement: Discuss the situation with family members sensitively, educating them about normal sexual needs in aging while addressing their concerns. 7, 2