When a patient with dementia displays inappropriate sexual behaviour in a residential setting such as a nursing home, this often causes disruption to the whole fabric of life in the home. Occasionally, old-age psychiatrists are asked by general practitioners to provide assistance in managing such cases. In this article, Drs Richard Law-Min and Denise Cope explore the possible causes of, and discuss strategies to deal with, such disruptive behaviour.

Around 750000 people suffer from dementia in the UK, with AlzheimerÕs disease being the commonest cause (accounting for approximately 60per cent of cases)1. It is estimated that this figure will increase to 840000 by 20262. The prevalence of dementia is approximately 5per cent in those aged over 65years. Behavioural disturbances occur in about 60per cent of those with dementia3. One study of a population of nursing home residents with dementia estimated the prevalence of inappropriate sexual behaviour (ISB) to be about 5per cent4. However, the true prevalence is difficult to measure as it depends on what is construed to be ISB. Depending on the tolerance level of staff, the problem might be under- or over-reported. It may also be reported under the rubric of behavioural features of dementia.

Defining inappropriate sexual behaviour
ISB encompasses a range of behaviour including suggestive language, flirtatious behaviour, fondling, removing oneÕs clothes or masturbating in public, and other blatant sexual acts. As the term ÔinappropriateÕ implies, it refers to behaviour unacceptable to society or the individual reporting it. For example, a behaviour such as removing oneÕs clothes would be judged acceptable if done in private. Such behaviours can be due to increased libido, but more typically reflect a lack of inhibition. Another term frequently used is Ôsexual disinhibitionÕ.

ISB varies in severity and frequency but typically persists. It is directed mainly towards others but can be directed towards oneself. It can start suddenly or insidiously and is usually out of keeping with the patientÕs character. There is no evidence to suggest a link with a pre-morbid history of such behaviour or sexual offending6. ISB is more common in males than in females. The reason as to why this is so, however, is unclear.

Although ISB is uncommon, it can cause major distress and embarrassment to other residents and carers. It also poses many challenges to those professionals trying to curb the behaviour. Staff usually ask general practitioners to intervene when such behaviour becomes unmanageable. When general practitioners make a referral to the old-age psychiatric services, they generally have tried the person concerned on psychotropic medication but with minimal or no effect on the behaviour.

Causes
Many reasons have been postulated for ISB. However, the causes are often complex and are a combination of biological, psychological, and social factors. Biological factors

It has been suggested that disruption to the neural pathway related to sex drive or hormonal changes secondary to dementia may be responsible5. ISB has also been observed in conditions where the frontal lobe or temporal lobe (involved in regulating sexual drive) have been damaged, such as major head injury, PickÕs disease and Kluver-Bucy syndrome (characterized by placidity, hyperorality, and hypersexuality). It has also been reported in multiple sclerosis, subthalamic infarction, WilsonÕs disease and as a side-effect of antiparkinsonian drugs.

Psychological factors
In some instances, it has been postulated that ISB could be linked with a psychological need for intimacy that has become sexualized6. It is viewed as a compensatory mechanism for losses of cognitive functions and functioning, with the aim of boosting self-esteem. For some, it may represent mastery or a way of exerting control or power over another11. Loss of memory for Ôsexual etiquetteÕ, sensory loss, impulsivity, misidentification of others for their spouse, or loss of judgement and insight can all contribute to ISB.

Social factors
People with dementia can often lead a lonely and under-stimulated existence. ISB may be a means of self-stimulation, of getting attention, or to gain physical proximity in order to reduce loneliness or boredom, frustration or anxiety.

Assessment
It is essential to have a detailed description of every incident (the antecedents, the behaviour, and the consequences). Asking ÔHow, how often, how long, how severe, why, when, where, with whomÕ questions are quite helpful in identifying the underlying cause. In some instances, a change in the environment, for example, contact with certain people or spouse visiting less frequently, can act as a trigger. Any concurrent physical problems such as constipation, urinary tract infection, or electrolyte imbalance cannot be overlooked, and if present, should be treated. The resulting Ôacute on chronicÕ confusional state may be responsible for the ISB rather than the dementia itself. A co-morbid mood disorder (e.g. a relapse of a bipolar affective disorder or a psychotic illness) may cause ISB and must be identified and treated. The medication chart will also need to be reviewed in order to remove any medications that may cause or exacerbate the behaviour.

Management
Behavioural and/or environmental modifications should be tried first for two main reasons. First, older people (especially those with Lewy-Body dementia) are more sensitive to psychotropic medication8 and are at increased risk of falls while remaining on them9. Second, there is no robust evidence for the effectiveness of psychotropic medication for managing difficult behaviour1,10 including ISB12. In principle, psychotropic drugs are used when non-pharmacological interventions are not suited for the individual or fail (e.g. symptoms too severe). Although non-drug strategies are effective in reducing behavioural problems7, no studies have actually addressed the specific issue of ISB. It is the authorsÕ opinion that they should nevertheless be attempted first.

In practice, medication is probably used more readily than it should be. This may reflect a lack of resources in nursing homes (including staff shortages and a lack of skills) and the expectation upon general practitioners to prescribe medication and to do something quickly. Because many patients with dementia cannot consent to treatment, medications are given in their best interest. Although drugs are commonly used, most of them are not licensed for behavioural problems or ISB.

Non-pharmacological interventions
One useful approach to dealing with ISB is distraction, whereby the personÕs behaviour is directed to things such as conversation, food, music, and activities like walking and exercise.

This helps to relieve boredom and provides an alternative means of self-stimulation. Attempts should be made to separate the person from the target of their attentions. If the behaviour is an attempt to gain attention, then the subject may benefit from increased attention by nursing staff or spouse.

For someone who tends to masturbate or undress in front of others, modification of clothing, which makes undressing difficult, can work. Although a change of environment, by having the person moved to a different home, can resolve the problem, such a move can result in the problem simply being transferred from one home to another. Merely telling the person to stop the behaviour does not work as he or she often has poor understanding or forgets what has been said. The above suggestions are not meant to be prescriptive as each case is different. What is important is to identify and address the actual triggers, and some degree of imagination may be required to fit the interventions to the patient. When these interventions do not succeed, it is possible that the real triggers have not been identified and addressed. It is important that all staff adopt a consistent approach with the person, so that no mixed messages are given out and only the desired behaviours are rewarded. Staff may require education on the subject of ISB6.

Pharmacological interventions
There is no strong evidence of drug effectiveness in the treatment of ISB in elderly patients with dementia. There are no controlled trials and most evidence of efficacy is based on case reports. These include successful use of buspirone13, trazodone14, paroxetine15, clomipramine16 and cimetidine17 (an H2-receptor antagonist; dosage between 600 to 1600mg/day).

In the case of trazodone, it is postulated that its successful use in patients with ISB may be related to the taming effect of the drug in animal models of aggression. Cimetidine has been shown to have antiandrogenic effects in rats by blocking testosterone synthesis. Just like SSRIs, the effects of buspirone and domipramine are related to increase in serotonin level. Success with anti-androgens such as medroxyprogesterone18 (300mg intramuscularly weekly) has also been reported. Cyproterone acetate (100mg/day) has been tried in dementia but not in the elderly19. There are some reports on the use of oestrogens (e.g. diethylstilbestrol 1mg/day) in elderly demented men20. Use of GnRH analogues (such as leuprolide acetate) has been reported in young dementia only21.

In view of the limited evidence available, SSRIs are probably a good first option to try as they have the least problematic side-effect profile. It is suggested that SSRIs are effective because of their anti-obsessional effects and ISB may be a form of obsessive compulsive disorder22.

Reduced libido is also a common side-effect of SSRIs which may be useful in this situation. Tricyclics should be avoided as they can cause postural hypotension and increased confusion in the elderly. Anti-androgens and oestrogens may have a role to play as a last resort. However, their use is controversial and raises ethical and legal issues in this group of patients. They also potentially have more serious side-effects.

Although antipsychotic medications as chlorpromazine, risperidone, or olanzapine are probably commonly used, there is no good evidence of efficacy for their use in ISB.

Conclusion
Inappropriate sexual behaviour is an uncommon but distressing behaviour in dementia. If not tackled early, it can jeopardise a personÕs placement and can lead to hospital admission. The causes are complex and the behaviour is challenging to treat. Non-pharmacological interventions should be attempted first before considering psychotropic or other medications. The evidence base for efficacy of these drugs is limited. Old-age psychiatrists and mental-health nurses have a role in educating staff and helping them to manage this problem.

References
1. Drugs and Therapeutic Bulletin. Drugs for disruptive features in dementia. Drugs and Therapeutic Bulletin 2003; 41(1): 1Ð4

2. Department of Health. National Service Framework for Older People. 2001; HMSO, London

3. Lyketsos CG, Steinberg M, Tschanz JT, et al. Mental and behavioural disturbances in dementia: findings from the Cache County Study on Memory in Aging. Am J Psychiatry 2000; 157: 708Ð14

4. Wagner AW, Teri L, Orr-Rainey N. Behaviour problems of residents with dementia in special care units. AlzheimerÕs Disease and Associated Disorders 1995; 9(3): 121Ð7

5. Shapira J, Cummings JL. AlzheimerÕs disease: changes in sexual behaviour. Medical Aspects of Human Sexuality 1989; 6: 32Ð5

6. Kuhn RD, Greiner D, Arseneau L. Addressing hypersexuality in AlzheimerÕs disease. J Geontological Nursing 1998; 24(4): 44Ð50

7. Camp CJ, Cohen-Mansfield J, Capezuti EA. Use of nonpharmacologic interventions among nursing home residents with dementia. Psychiatric Services 2002; 53: 1397Ð1401

8. Burns A, Baldwin R. Prescribing psychotropic drugs for the elderly. Advances in Psychiatric Treatment 1994; 1: 24Ð31

9. Thapa PB, Gideon P, Fought RL, et al. Psychotropic drugs and the risk of recurrent falls in ambulatory nursing home residents. Am J Epidemiol 1995; 142: 202Ð11

10. Bartels SJ, Dums AR, Oxman TE, et al. Evidence-based practices in geriatric mental health care. Psychiatric Services 2002; 53(11): 1419Ð31

11. Robinson KM. Understanding hypersexuality, a behavioural disorder of dementia. Home Healthcare Nurse 2003; 21(1): 43Ð7

12. Levitsky AM, Owens NJ. Pharmacologic treatment of hypersexuality and paraphilias in nursing home residents. J Am Geriatr Soc 1999; 47: 231Ð4

13. Tiller JWG, Dakis JA, Shaw JM. Short-term buspirone treatment in disinhibition with dementia. Lancet 1988; 2(8609): 510

14. Simpson DM, Foster D. Improvement in organically disturbed behaviour with trazodone treatment. J Clin Psychiatry 1986; 47(4): 191Ð3

15. Stewart JT, Shin KJ. Paroxetine treatment of sexual disinhibition in dementia. Am J Psychiatry 1997; 154: 1474

16. Leo RJ, Kim KY. Clomipramine treatment of paraphilias in elderly demented patients. J Geriatr Psychiatry Neurol 1995; 8: 123Ð4

17. Wiseman SV, McAuley JW, Freidenberg GR, et al. Hypersexuality in patients with dementia: Possible response to cimetidine. Neurology 2000; 54: 2

18. Cooper AJ. Medroxyprogesterone acetate (MPA) treatment of sexual acting out in men suffering from dementia. J Clin psychiatry 1987; 48: 368Ð70

19. Nadal M, Allgulander S. Normalization of sexual berhaviour in a female with dementia after treatment with cyproterone. Int J Geriatr Psychiatry 1993; 8: 265Ð7

20. Lothstein LM, Fogg-Waberski J, Reynolds P. Risk management and treatment of sexual disinhibition in geriatric patients. Conn Med 1997; 61: 609Ð18

21. Ott BR. Leuprolide treatment of sexual aggression in a patient with dementia and the Kluver-Bucy syndrome. Clin Neuropharmacol 1995; 18: 443Ð7

22. Kafta MP. Sertraline pharmacology for paraphilias and paraphilia-related disorders: an open trial. Ann Clin Psychiatry 1994; 6: 189Ð95

Dr Richard Law-Min is Specialist Registrar in Old Age Psychiatry, Alderney Hospital, Poole; Dr Denise Cope is Consultant in Old Age Psychiatry, Alderney Community Hospital Ringwood Road, Parkstone, Poole, Dorset

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