What medications can decrease sexual deviance behavior in an elderly patient with dementia?

Management of Sexual Deviance Behavior in Dementia Patients

For inappropriate sexual behaviors in elderly dementia patients, start with SSRIs (citalopram 10-20 mg daily or sertraline 25-50 mg daily) as first-line pharmacological treatment after exhausting non-pharmacological interventions, reserving antiandrogen therapy (medroxyprogesterone acetate or estrogen patches) for cases that fail to respond to SSRIs within 4 weeks. 1, 2

Step 1: Rule Out Reversible Medical Triggers

Before initiating any medication, systematically investigate underlying causes that may be driving the sexual behaviors 3:

• Pain assessment and management - Untreated pain is a major contributor to behavioral disturbances in patients who cannot verbally communicate discomfort 3
• Infections - Check for urinary tract infections and pneumonia, which commonly trigger behavioral symptoms 3
• Metabolic disturbances - Evaluate for dehydration, constipation, and urinary retention 3
• Medication review - Discontinue all anticholinergic medications (diphenhydramine, oxybutynin, cyclobenzaprine) that worsen confusion and agitation 3

Step 2: Implement Non-Pharmacological Interventions First

Environmental and behavioral modifications must be attempted and documented as failed before considering medications 3:

• Environmental modifications - Ensure adequate supervision, provide structured daily routines, and simplify the environment with clear labels 3
• Communication strategies - Use calm tones, simple one-step commands, and allow adequate time for the patient to process information 3
• Caregiver education - Educate caregivers that behaviors are symptoms of dementia, not intentional actions 3
• Activity-based interventions - Provide tailored activities to individual abilities to redirect inappropriate behaviors 3

Step 3: First-Line Pharmacological Treatment - SSRIs

When non-pharmacological interventions fail and the behavior is significantly disruptive or dangerous 1, 4:

• Citalopram - Start at 10 mg daily, maximum 40 mg daily 3, 5

  • Well-tolerated with some patients experiencing nausea and sleep disturbances 3
  • Case report demonstrates successful reduction in inappropriate sexual behaviors at 20 mg daily 5

• Sertraline - Start at 25-50 mg daily, maximum 200 mg daily 3, 1

  • Minimal drug interactions and excellent tolerability 3
  • Preferred if patient is on multiple medications due to less effect on metabolism of other drugs 3

• Monitoring timeline - Assess response within 4 weeks using quantitative measures; if no clinically significant response after 4 weeks at adequate dose, taper and consider second-line options 3

Step 4: Second-Line Treatment - Antiandrogen Therapy

For males who fail to respond to SSRIs or when behaviors involve dangerous physical contact 1, 2:

• Medroxyprogesterone acetate - Antiandrogen therapy with monitoring of liver enzymes and coagulation parameters 1

• Estrogen patches - Transdermal estrogen led to excellent treatment results in elderly demented men with sexual disinhibition 2

  • Requires medical clearance before use 1
  • Preferred over oral estrogen due to better tolerability 1

• Cyproterone acetate - Alternative antiandrogen option (not available in all countries) 1

Step 5: Third-Line Options for Refractory Cases

When first and second-line treatments fail 1, 6:

• Carbamazepine - Case report demonstrates successful treatment of hypersexual behavior in a 78-year-old AD patient 6

  • Start at 125 mg twice daily, titrate to therapeutic blood level 3
  • Monitor liver enzymes and coagulation parameters 3

• LHRH agonists (leuprolide, triptorelin) - Reserved for severe, refractory cases 1

• Combination therapy - Reasonable if patient fails to respond to monotherapy 1

Critical Medications to AVOID

• Typical antipsychotics (haloperidol, fluphenazine) - 50% risk of tardive dyskinesia after 2 years of continuous use in elderly patients 3
• Benzodiazepines - Risk of tolerance, addiction, cognitive impairment, and paradoxical agitation in 10% of elderly patients 3
• Antipsychotics for sexual behaviors specifically - These are NOT indicated for inappropriate sexual behaviors unless there is concurrent severe agitation with psychotic features threatening substantial harm 3

Treatment Algorithm Summary

Unless the patient is engaging in or threatening dangerous acts involving physical contact:

1. First-line: SSRIs (citalopram or sertraline) for 4 weeks 1, 2
2. Second-line: Antiandrogens (medroxyprogesterone acetate or estrogen patches) 1, 2
3. Third-line: LHRH agonists or carbamazepine for refractory cases 1, 6

For dangerous physical contact behaviors:

1. Consider starting with antiandrogens concurrently with SSRIs 1
2. Escalate to LHRH agonists if inadequate response 1

Common Pitfalls to Avoid

• Underrecognition - Inappropriate sexual behaviors may be underrecognized and undertreated; actively monitor and document these behaviors 5
• Cultural and medicolegal considerations - Cultural, religious, and societal views of geriatric sexuality must be considered when evaluating and managing these behaviors 4
• Inadequate trial duration - Allow 4-8 weeks for full therapeutic effect of SSRIs before declaring treatment failure 3
• Indefinite continuation - Reassess need for continued medication every 3-6 months and attempt taper if behaviors have resolved 3

Monitoring and Safety

• Baseline assessment - Use tools like the Cohen-Mansfield Agitation Inventory or NPI-Q to quantify baseline severity 3
• Response evaluation - Reassess within 4 weeks using the same quantitative measure 3
• Side effect monitoring - Monitor for falls, metabolic changes, and cognitive worsening 3
• Ongoing reassessment - Even with positive response, periodically reassess the need for continued medication 3