As many as 25% of people with dementia demonstrate inappropriate sexual behaviour
Such behaviour encompasses a range of sexual expressions representing a change from baseline behaviours or context, including inappropriate sexual comments, self-exposure, public masturbation, and unwanted sexual touching. Patients with any dementia subtype can exhibit these behaviours, which can cause substantial distress for patients, families, and staff, but stigma and uncertainty about management can result in under-reporting. 1 Roughly 15% of reported cases occur among females.2
Not all sexual expression in people with dementia is inappropriate
Appropriateness of sexual behaviours is subjective and often specific to the setting or caregiver.3 Clinicians should consider people’s cultural and relational context (i.e., what is appropriate in one setting may be inappropriate in another), their orientation to context, and capacity to consent when determining if the behaviour is inappropriate.3
New-onset inappropriate sexual behaviour requires a structured assessment, including medication review
Medical triggers (e.g., delirium) and comorbid behavioural and psychological symptoms of dementia should be assessed.4 Clinicians should review medications and deprescribe potential triggers (e.g., dopamine agonists).2 Unmet needs for intimacy, social connection, environmental stimulation, or personal care should be explored.3
Helpful first-line treatments include behavioural and environmental interventions5
Behavioural strategies (e.g., caregiver education, gentle redirection), environmental modification (e.g., private space, caregiver change), and distracting activities often improve these behaviours and are preferred and well tolerated by patients.4
When pharmacotherapy is needed, selective serotonin reuptake inhibitors (SSRIs) and hormonal agents have the best evidence
Evidence for use of medications is limited, but SSRIs and — for male patients — hormonal agents (e.g., finasteride) are the best tolerated options and most frequently associated with symptom improvement in case studies (Appendix 1, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.260633/tab-related-content).2 Pharmacotherapy that may benefit comorbid symptoms (e.g., SSRIs in patients with comorbid agitation) minimizes polypharmacy. Physicians should consider referral to a psychiatrist or geriatric specialist if behaviours are refractory to initial behavioural and pharmacologic interventions.
Supplementary Information
Footnotes
Competing interests: Natasha Lane reports funding from the Canadian Institutes of Health Research, Providence Health Care Research Institute, Michael Smith Health Research BC Engage Award, and Carraresi Foundation. Dallas Seitz reports funding from the University Health Foundation and Alberta Roche Collaboration in Health, and a role on the board of directors of the Alzheimer Society of Alberta and Northwest Territories. Jennifer Watt reports an honorarium from the Canadian Coalition for Seniors’ Mental Health. No other competing interests were declared.
This article has been peer reviewed.
References
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