Open Journal of Geriatrics ISSN: 2639-359X Volume 2, Issue 2, 2019, PP: 23-31 Managing Sexually Inappropriate Behaviour among the Older Adults with Dementia Rachelle Tan-Patanao1, Eden XJ Tay2, WT Chang3, SC Lim4* 1Resident Physician, Department of Geriatric Medicine, Changi General Hospital, Singapore. 2Family Medicine Resident, MOH Holdings (MOHH), Singapore. 3Principal Clinical Pharmacist, Department of Pharmacy, Ng Teng Fong General Hospital, Singpore. 4Adjunct Associate Professor, Senior Consultant, Department of Geriatric Medicine, Changi General Hospital, Singapore. [email protected] *Corresponding Author: Si Ching Lim (MB.ChB, MRCP), Adjunct Associate Professor, Senior Consultant, Department of Geriatric Medicine, Changi General Hospital, Singapore. Abstract Neuropsychiatric symptoms of dementia are more distressing for the caregivers of persons with dementia, compared to the cognitive symptoms. Inappropriate sexual behavior or hypersexuality is one of the behavioral problems which cause significant caregiver stress and without proper management, may result in institutionalization and social isolation. There is currently no official treatment guideline in the management of inappropriate sexual behavior in dementia. Successful management of sexual disinhibition is often multifactorial and the approach should be individualized with non-pharmacological and pharmacological approach. Keywords: dementia, BPSD, hypersexuality, sexual disinhibition, inappropriate sexual behavior (ISB) Introduction depression [1, 5, 6] while inappropriate sexual behavior (ISB, also known as sexually disinhibited behavior, or The dementia syndrome is an umbrella of hypersexuality) is estimated to be present in 2-17% of neurodegenerative disorders which progressively dementia patients. [7] It is more commonly associated impacts on the person’s cognition, resulting in with vascular type of dementia, [8] with higher emergence of behavioural symptoms and decline in prevalence in residents of skilled nursing facilities their abilities to carry out their routine activities of (25%) and in those with severe dementia. [9, 10] ISB can daily living. Behavioral and psychological symptoms be a threat to the mental and physical health of patients of dementia are common among the persons with and others. [11] It often results in increase care burden, dementia, the symptom spectrum includes agitation, [12] feelings of anxiety, embarrassment or unease in aberrant motor behavior, anxiety, elation, irritability, the caregivers causing disruption in the continuity depression, apathy, disinhibition, delusions, hallu- of care at home, [13] hence leading to increased risk of cinations, and sleep or appetite changes. A cross- institutionalization. [14] sectional study by Lyketsos CG et al, estimated the prevalence of the neuropsychiatric symptoms of Currently, there is no established treatment algorithm dementia is about 50% to 80% among persons with in the management of dementia related sexual dementia throughout the course of the disease. [1, 2, 3] disinhibition. Approach should be individualized which Based on a local study done in 2013, the prevalence can either be non-pharmacological interventions, of BPSD amongst the study population with dementia pharmacological interventions or a combination of was 67.9 percent. [4] both. The most common BPSD reported in people with This paper illustrates two cases of sexually dementia are apathy, depression, anxiety and inappropriate behavior in an acute hospital setting, Open Journal of Geriatrics V2 . I2 . 2019 23 Managing Sexually Inappropriate Behaviour among the Older Adults with Dementia and their management strategies. A short review of admission, he had sporadic episodes of auditory non-pharmacological and pharmacological treatment hallucinations together with behavioral change. The methods is also summarized. diagnosis of probable mixed Vascular and Alzheimer’s Dementia, likely Frontotemporal predominance with Patient 1 Behavioral and Psychotic Symptoms (BPSD) was most Mr. A is a 72 years old Malay Gentleman, widowed, with likely. The behavioral problems were causing distress a background history of hypertension, hyperlipidemia, to the caregivers, and he occasionally threatened ward a previous right sided pontine infarct conservatively nurses with assault. Various non-pharmacological managed with single anti-platelet therapy (Aspirin strategies were tried but failed. Pharmacological 100mg OM), asymptomatic infrarenal abdominal management was initiated to manage his incessant aortic aneurysm and previous deep vein thrombosis demands for sexual acts. of the left lower limb. He was community ambulant These included: prior to admission, lives with his son and daughter with no designated full time caregiver. blocker were chosen. All these were chosen He had recently been discharged from Rehabilitative • Fluvoxamine, Gabapentin and Finasteride, β Medicine for a short stint of rehabilitation after an dysfunction. open mesh repair for an inguinal hernia. During his for their off-label indications of causing sexual stay, he was referred to Geriatric Medicine as they Donepezil for component of probable Alzheimer had incidentally noted possible cognitive impairment. • About 2 months after his discharge, he was noted by DementiaOlanzapine and for also aggression, for its libido on as lowering required effects. basis. his family to have developed behavioral changes at His behavioral symptoms gradually improved, and his home with aberrant vocalisation of loud sounds and • sexual disinhibition was kept under control with the moans, which could last late into the night. His loud above medications. He remained clinically well and vocalisation would sometimes be accusatory in nature, stable on discharge 3 weeks later. where he accused his children of not taking good care of him despite his advanced age, and on occasions, Patient 2 escalated to physical agitation where he would bang Mr. Y is a 91-year old gentleman with a background history of ischemic heart disease, hypertension, never translated to physical violence against his family his fists onto tables or hard surfaces. Thankfully this hyperlipidemia, chronic kidney disease and benign members, and he was admitted for further workup of prostatic hypertrophy. He is pre-morbidly ADL this subacute behavioral change. independent and lives with two tenants. He has a During his inpatient stay, Mr. A exhibited symptoms of fulltime caregiver who is a domestic worker. Mr. Y was admitted for syncope lasting for one minute, explicit and suggestive in both his choice of words and with no preceding symptoms. Physical examination actions.sexual disinhibition His verbalisation towards increased the nursing in both staff, volume being was unremarkable. Neurological examination showed and intensity, with increasing physical agitation as no evidence of localizing signs. His GCS was 15/15 well, at times requiring physical restraints. The routine throughout. lab investigations were all unremarkable. Blood tests Initial investigations including CT brain were for HIV and VDRL serologies were negative. Magnetic unremarkable, except for 24-holter which showed Resonance Imaging (MRI) of his brain revealed runs of supraventricular tachycardia (SVT) with moderate global cortical atrophy, with no acute infarct, hemorrhage or pathological leptomeningeal enhancement on a background of chronic vascular asymptomaticno significant duringpauses. runs Cardiologists of SVT. recommended microinfarcts. β blocker if needed but was not given, since he was The syncopal episode was likely due to postural Further corroborative cognitive history revealed > hypotension likely attributed to SVT and 6 months history of short-term memory loss, with medications Alfuzosin and Perindropil. Perindopril agnosia and executive dysfunction. His family also was discontinued and Alfuzosin was switched to revealed that in the months prior to his previous Tamsulosin. 24 Open Journal of Geriatrics V2 . I2 . 2019 Managing Sexually Inappropriate Behaviour among the Older Adults with Dementia During his hospital stay, Mr. Y was noted to be agitated in males. [18] Women seem to show more verbal with sleep wake reversal. Cognitive and behavioral disinhibition. [19] In the context of dementia, ISB may history from family was suggestive of dementia. His be an attempt to seek emotional connection, love and abbreviated mental test score was 4/10 and Chinese relief for anxiety and insecurity. [20] Bearing in mind, MMSE was 14/28. Family reported that Mr. Y touched sexual needs are still present among the elderly, [8] it is his female caregiver inappropriately at night, and if he could not sleep, he would wander into the maid’s or emotional needs had breached the boundaries to room. In view of this, the family had to change maid becomesometimes pathological. difficult to differentiate In an institution when physiologicalsetting like four times in eight months. nursing home and hospital, there is no privacy to allow for intimacy and sexual acts among the older Mr. Y was started on Escitalopram, and Finasteride residents are often frowned upon by society. [7] was added for BPH which since he had postural ISB can be categorized into sex talk (using foul libido which might be helpful in treating sexual language), sexual acts (acts of touching, grabbing, disinhibition.hypotension with Dementia α blocker. education Finasteride and alsocounselling reduces exposing the genitals or masturbating), and implied was done to the family and advised