What hormone medications can be given to an elderly geriatric psychiatry patient with psychiatric issues and sexually aggressive behavior?

Hormone Medications for Sexually Aggressive Geriatric Psychiatry Patients

For elderly patients with dementia exhibiting sexually aggressive behavior, SSRIs (citalopram 10-40 mg/day or sertraline 25-200 mg/day) should be tried first for 4-8 weeks; if unsuccessful, medroxyprogesterone acetate (MPA) 100-400 mg IM weekly or oral estrogen patches are second-line hormone options, with leuprolide (LHRH agonist) reserved as third-line for severe, refractory cases. 1, 2, 3

Treatment Algorithm for Sexually Aggressive Behavior

Step 1: Rule Out Reversible Medical Causes

• Systematically investigate infections (UTIs, pneumonia), pain, constipation, urinary retention, dehydration, and medication side effects (especially anticholinergic agents) that commonly trigger behavioral disturbances in cognitively impaired elderly patients who cannot verbally communicate discomfort 4
• Review all medications to identify and discontinue anticholinergic drugs (diphenhydramine, oxybutynin, cyclobenzaprine) that worsen agitation and confusion 4

Step 2: First-Line Pharmacological Treatment - SSRIs

• Start with citalopram 10 mg/day (maximum 40 mg/day) or sertraline 25-50 mg/day (maximum 200 mg/day) as first-line agents for sexually inappropriate behaviors 1, 3
• Allow 4-8 weeks for full therapeutic effect at adequate dosing before declaring treatment failure 4, 1
• SSRIs are preferred because they have the best safety profile in elderly patients, with minimal drug interactions and excellent tolerability 5, 1
• Assess response using quantitative measures (Cohen-Mansfield Agitation Inventory or NPI-Q) at 4 weeks 4

Step 3: Second-Line Hormone Treatment - Antiandrogens

If SSRIs fail after adequate trial:

• Medroxyprogesterone acetate (MPA) is the most studied antiandrogen for sexually inappropriate behavior in elderly men with dementia 1, 2

  • Dosing: 100-400 mg IM weekly or 300-400 mg oral daily 1
  • MPA has been used successfully in multiple case series to control inappropriate sexual behaviors in men with dementia 2
  • Medical clearance required before initiating antiandrogen therapy 1

• Cyproterone acetate is an alternative antiandrogen option if MPA is not available or tolerated 1

Step 4: Third-Line Hormone Treatment - Estrogen or LHRH Agonists

For severe, refractory cases threatening physical contact or dangerous acts:

• Estrogen patches (transdermal preferred over oral) led to excellent treatment results in elderly demented men with sexual disinhibition 3

  • Lower cardiovascular risk with transdermal administration compared to oral 6
  • Medical clearance required to ensure no contraindications to estrogen therapy 1

• Leuprolide (LHRH agonist) 7.5 mg IM monthly is reserved for the most severe cases 1, 7

  • Leuprolide demonstrated complete response in treating sexually aggressive behaviors that failed to respond to other treatments 7
  • LHRH agonists are considered third-line due to more significant side effects and cost 1

• Triptorelin is an alternative LHRH agonist option 1

Critical Safety Considerations

Before Initiating Hormone Therapy

• Discuss with patient (if feasible) and surrogate decision maker the risks, benefits, expected treatment goals, and alternative approaches 4
• Obtain medical clearance specifically for estrogen or antiandrogen therapy, including cardiovascular assessment, liver function, and prostate evaluation in men 1
• Document that behavioral interventions have been attempted and proven insufficient 4

Monitoring Requirements

• Evaluate response within 4 weeks of initiating treatment using the same quantitative measure used at baseline 4
• Monitor for side effects including cardiovascular effects (estrogen), metabolic changes (MPA), and hormonal suppression effects (LHRH agonists) 1
• Reassess need for continued treatment every 3-6 months, with goal of using minimum effective dose for shortest duration 4

What NOT to Use

• Avoid benzodiazepines as they cause paradoxical agitation in approximately 10% of elderly patients, worsen cognitive function, and increase fall risk 4, 8
• Avoid typical antipsychotics (haloperidol) as first-line for sexual aggression, as they carry 50% risk of tardive dyskinesia after 2 years and increased mortality risk (1.6-1.7 times higher than placebo) in elderly dementia patients 4
• Avoid anticholinergic medications (diphenhydramine) as they worsen agitation and confusion in dementia patients 4

Important Caveats

Gender Considerations

• Very few data exist regarding treatment of females exhibiting abnormal sexual behaviors at any age 1
• The evidence base for hormone treatments is primarily derived from male patients with sexually inappropriate behaviors 1, 2, 3

Combination Therapy

• Combination therapy is reasonable if the patient fails to respond to monotherapy (e.g., SSRI plus antiandrogen) 1
• However, start with monotherapy and document failure before adding additional agents to minimize polypharmacy risks in elderly patients 4

Non-Pharmacological Interventions

• Environmental modifications (adequate lighting, reducing excessive noise, structured routines) must be implemented alongside pharmacological treatment 4
• Caregiver education that sexually inappropriate behaviors are symptoms of dementia, not intentional actions, is essential 4
• Ensure adequate supervision and environmental safety, including removal of hazardous items 4