24 - Management of inappropriate sexual behaviour

Management of inappropriate sexual behaviour in older adults

680 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 6 Management of inappropriate sexual behaviour in older adults This section deals with sexual behaviours that are causing distress either to the person with dementia or to other people. Sexually inappropriate behaviours have been reported in between 1.8% and 25.9% of patients with neurocognitive disorders,1 and in people with dementia the prevalence rate is 2–17%, occurring with about equal frequency in men and women.2 Sexual symptoms are more prevalent in frontal lobe disorders (most commonly stroke and behavioural variant frontotemporal dementia) and in Parkinson’s (adverse effects of dopaminergic drugs), but can occur in any dementia subtype.1 These symptoms present a challenge for patients, carers and healthcare workers. Assessment of the behaviours, the contexts in which they arise and their risks is essential. It is important to manage the environment and to educate and discuss the behaviour with carers and families. Behavioural measures are probably helpful, although no specific intervention has been shown to be effective in this area. Several classes of drug may help to control aberrant sexual behaviours, but owing to the lack of large-­scale studies there is no gold standard treatment. No treatments are licensed for hypersexuality in this population and the medications used are all potentially harmful.2 A thorough history should be taken before starting any drug therapy to obtain the relevant medical, psychiatric, medication and sexual history. Changes in sexual behaviour can be caused by urinary or genital conditions, delirium or a medication side effect. Benzodiazepines, dopamine-­receptor agonists (e.g. apomorphine, pramipexole, rotigotine) and L-­dopa can cause hypersexuality.2 Non-­pharmacological treatment, such as distraction/diversion of the patient when inappropriate sexual behaviours occur,1 is recommended as first-­line therapy (Box 6.3). Antidepressants Box 6.3  Non-­pharmacological measures1 ■ ■Identify and treat medical causes for behaviour, e.g. urinary retention and genital disorders causing the patient to touch their genitals due to discomfort. Delirium can cause sexual disinhibition ■ ■Identify and treat any psychiatric disorder that may cause inappropriate sexual behaviour, e.g. mania or depression ■ ■If possible, stop or reduce dose of medication that may be causing the behaviour, e.g. benzodiazepines, dopamine agonists and high-­dose L-­dopa ■ ■Prevention: fulfil the need for intimacy/connection in other ways such as having meals in groups, conversation among peers and activities such as walking or exercise ■ ■Discussion with patient, caregivers and relatives to better understand the behaviour and explore attitudes to sexuality, which may inform therapy ■ ■Distraction or diversion, redirect behaviour, engage patients in activities that involve the hands and reduce sexual stimulation (e.g. iPads, magazines, TV) ■ ■Provide sensory and environmental stimulation (e.g. aromatherapy, music therapy, multisensory therapy, pet therapy). ■ ■Behavioural/cognitive behavioural therapy if available (though evidence is limited)