25 - Management

Management

Prescribing in older people CHAPTER 6 have been recommended as the first line of pharmacological treatment after ­attempting non-­pharmacological interventions. Several other categories of pharmacological interventions are listed in Table 6.7. Management To inform the management of inappropriate sexual behaviour, evaluation should include a medical history, physical examination, sexual history and medication review. The history should cover specifics of the demonstrated behaviour, such as potential precipitants and consequences including the frequencies of episodes, when and where they occur and with whom.3 Sometimes normal sexual behaviour, such as a patient masturbating in their bedroom, can be labelled as ‘disinhibition’, particularly in care home settings. In these cases, a discussion with staff and relatives about simple measures (e.g. a care plan to allow the resident periods of privacy in their room at set times each day) can avoid normal behaviours being pathologised. Non-­ pharmacological treatments should be tried first to prevent unnecessary prescription of psychotropics. Because of the complex nature of sexual disinhibition and varying origins of this behaviour, treatment will be most successful when tailored to the patient’s specific presentation.1 Studies on the pharmacological treatment of sexual disinhibition are limited and larger studies are necessary to establish a preferred medication regimen. In addition, there are few data available on treating these symptoms in women.1 A systematic review4 concluded that when treating patients with Alzheimer’s disease, vascular dementia or unspecified dementia, serotonergic agents including SSRIs and TCAs are recommended as a first-­line treatment, followed by antiandrogens as a second line, and luteinising hormone-­releasing hormone agonists and oestrogens as a third line. A literature review5 determined SSRIs to be the first line of treatment, antipsychotics to be the second line and hormonal modulators to be the third line (owing to cost and adverse effects).

Table 6.7  Pharmacological options in inappropriate sexual behaviour in older adults.1,6–8 Medication Drug Dose Mechanism of action Adverse effects Cautions/additional information Antiandrogens Cyproterone acetate Low dose 10mg/day9 High dose 50–100mg/day10   Cyproterone is licensed in the UK for hypersexuality in males: 50mg bd11 Reduction in serum testosterone level by inhibiting LH and FSH1 Gynaecomastia, galactorrhoea, elevated blood glucose, depression, osteoporosis1 Cyproterone acetate has been associated with risk of meningioma. Monitor patients for meningiomas and discontinue treatment if diagnosed.   Surgical implantation of hormonal therapy to reduce male sex drive is subject to the conditions of Section 57 of the UK MHA and requires patient consent and a second medical opinion.12 Medroxyprogesterone acetate (MPA) Oral 5mg/day7 Oral 100–400mg/ day13 IM 100–300mg/week every 2 weeks14 Reduction in testosterone1 Sedation, weight gain, hot flushes, depression, elevated blood glucose1 Finasteride (for men who have benign prostatic hyperplasia) 5mg/day7 Reduction in testosterone1 Gynaecomastia, testicular pain, depression1 Antidepressants SSRIs usually first-­line treatment Citalopram 20mg/day15 Decreased libido and antiobsessive effects Insomnia, somnolence, nausea, diarrhoea, headache, anorexia1 SSRIs cited as best first-­line treatment Escitalopram 10–20mg/day Paroxetine 20mg/day16 Clomipramine 150–175mg/day16 Decreased libido1 Postural hypotension, anticholinergic effects including constipation, dry mouth, urinary retention and memory impairment1 Anticholinergic activity less than ideal in this group of patients Trazodone 100–500mg/day16 Decreased libido1 Day-­time sedation, orthostatic hypotension, priapism, falls and fractures, delirium1 Mirtazapine 30mg/day16 Unknown Appetite increase, arthralgia, confusion, constipation, diarrhoea, dizziness, drowsiness, dry mouth, fatigue

Anticonvulsants Gabapentin 300–1800mg/day17 Increased GABA1 GI upset, skin reactions, confusion, nystagmus, dizziness, drowsiness6 Carbamazepine 200–800mg/day16 May help lower testosterone levels leading to decreased libido1 Dizziness, ataxia, drowsiness, diplopia, hyponatraemia, blood dyscrasias, severe skin reaction6 Potent enzyme inducer with many interactions Oxcarbazepine Starting dose 150mg/ day, titrated by 150mg/day in two divided doses. Average effective dose 600–750mg/ day in two divided doses18 May help lower testosterone levels leading to decreased libido1 Abdominal pain, alopecia, asthenia, ataxia, concentration impaired, depression, dizziness, drowsiness, hyponatraemia, nausea, nystagmus, skin reactions, vertigo, vision disorders, leucopenia Valproate Dose not specified but 50–200mg/day has been used Unknown Abdominal pain, tremor, agitation, alopecia (regrowth may be curly), anaemia, confusion, deafness, diarrhoea, drowsiness, haemorrhage, hallucination, headache, hepatic disorders Valproate causes serious harm in pregnancy and in children of men taking valproate (see Chapter 7). (Continued )

Antipsychotics Haloperidol 1.5–3mg/day16 Blocks dopamine receptors to decrease libido1 Cognitive decline, extrapyramidal symptoms, sedation, gait disturbances, falls, tardive dyskinesia, delirium, QT prolongation, increases in UTI and respiratory infections1 Increased risk of stroke and mortality in dementia. Extrapyramidal symptoms   First-­line treatment in cases where patients present with pathological irritability or unstable mood1 Olanzapine 2.5–15mg/day7 Arrhythmias, constipation, dizziness, drowsiness, dry mouth, erectile dysfunction, fatigue, galactorrhoea, gynaecomastia, hyperglycaemia, weight increase11 Quetiapine 25–75mg/day16 Appetite increased, asthenia, dysarthria, dyspepsia, dyspnoea, fever, headache, irritability, palpitations, peripheral oedema11 Zuclopenthixol 50mg IM monthly6 Tardive dyskinesia, delirium, QT prolongation, increases in UTI and respiratory infections, peripheral oedema, extrapyramidal effects1 Beta ­blockers Pindolol 5–40mg/day6,16 Decreased adrenergic drive1 Dizziness, sleep disturbance, headache, weakness, fatigue, GI upset Buspirone 10–60mg/day16,19 Unknown Abdominal pain, cold sweat, confusion, depression, dizziness, drowsiness, dry mouth, laryngeal pain, movement disorders, musculoskeletal pain, paraesthesia, skin reactions, tachycardia Table 6.7  (Continued ) Medication Drug Dose Mechanism of action Adverse effects Cautions/additional information

Cimetidine 600–1600mg/day14 Antiandrogen actions1 Worsening cognition, dizziness, nausea, arthralgia, headache1 A small study (n = 20) on elderly patients exhibiting hypersexual behaviours with dementia. This study found that 14 patients improved with cimetidine alone while six patients improved with a combination of cimetidine with ketoconazole or spironolactone.1 Ketoconazole 100–200mg/day20 Antiandrogen actions1 Sedation, headache, rash, photosensitivity, pruritus, hepatotoxicity, GI upset1 Gonadotropin and luteinising hormone-­ releasing hormone (GnRH and LHRH) agonists Leuprolide 7.5mg IM monthly6   Triptorelin is licensed in the UK for male hypersexuality: 11.25 mg IM every 12 weeks Decrease testosterone and decrease libido1 Hot flushes, decreased erectile dysfunction1 Caution: risk factors for osteoporosis L-­tryptophan supplementation Dose not specified Increases 5HT synthesis in brain, stimulating 5HT release and function1 High blood glucose, increased risk of bladder cancer, eosinophilia-­myalgia syndrome1 Naltrexone 100–150mg/day21 Unknown Abdominal pain, anxiety, appetite abnormal, arthralgia, asthenia, chest pain, dizziness, eye disorders, headache, hyperhidrosis, myalgia, nausea, palpitations, sexual dysfunction, skin reactions, sleep disorders, tachycardia, thirst Naltrexone is used after establishing normal liver and kidney function tests. (Continued )

Oestrogens Conjugated oestrogens   Diethylstilbestrol 0.625mg once daily 0.05–0.1mg/day transdermal patch8   1mg once to twice daily7 Decreased testosterone and decreased libido Weight gain, gynaecomastia, venous thromboembolism, risk of cardiovascular adverse effects, fluid retention, GI effects1 Rivastigmine Up to 4.5mg bd (oral)22   4.6–9.5mg/day (patch) Reduces behavioural symptoms by improving cognitive functioning1 Nausea, diarrhoea, urinary incontinence, syncope1 Conflicting evidence. Rivastigmine has been shown to help many patients with sexual disinhibition while donepezil may exacerbate these symptoms.1 Spironolactone 12.58–75mg/day20 Antiandrogen actions1 Hyperkalaemia, gynaecomastia, GI ulcers1 bd, twice a day; FSH, follicle-­stimulating hormone; GABA, gamma-­aminobutyric acid; GI, gastrointestinal; LH, luteinising hormone; MHA, Mental Health Act; UTI, urinary tract infection. Table 6.7  (Continued ) Medication Drug Dose Mechanism of action Adverse effects Cautions/additional information