Sexual Behavior in Elderly Patients With Dementia: An Expert Interview With Elizabeth Galik, PhD, CRNP, and Margaret Hammersla, MSN, CRNP

Barbara Boughton

October 01, 2009

October 1, 2009 — Editor's note: Although inappropriate sexual behavior in the elderly with dementia is not common, it can be problematic for healthcare providers, patients, and caregivers. Diagnosing and treating these behaviors is a challenge, especially in long-term care settings. A presentation that highlighted this highly charged issue was featured at the Gerontological Advanced Practice Nurse Association annual educational conference, held from October 1 to 3 in Savannah, Georgia.

To find out more about the scope and management of inappropriate sexual behavior in the elderly with dementia, Medscape Nurses interviewed presenters Elizabeth Galik, PhD, CRNP, and Margaret Hammersla, MSN, CRNP. Dr. Galik is an assistant professor at the University of Maryland School of Nursing in Baltimore, and specializes in the neuropsychiatric care of older adults with dementia. Ms. Hammersla is an instructor at the University of Maryland School of Nursing, and has designed and taught classes on dementia at the Copper Ridge Institute in Sykesville, Maryland. Dr. Galik and Ms. Hammersla have spoken at national and regional conferences about behavioral disturbances and sexuality in the elderly and about improving care for those with dementia.

Medscape: How common is inappropriate sexual behavior in the elderly with dementia?

Dr. Galik: There are a variety of estimates, but many researchers agree that inappropriate sexual behaviors occur in about 15% of elderly people with dementia. It occurs more often in long-term care settings, because that's where a large percentage of those with dementia live — often in close proximity. It's more common in men and patients with severe dementia, but the occurrence rate is similar among patients with different types of dementia. You don't necessarily see it more in people with Alzheimer's disease than in those with vascular dementia.

Generally, these behaviors interfere with normal activities of daily living, and are persistent, uninhibited, and directed toward oneself and an unwilling partner. That could mean masturbation or disrobing in a public setting, inappropriately touching a healthcare worker, or inappropriate sexual behavior between 2 residents in a long-term healthcare setting.

Medscape: What are the first steps in evaluating inappropriate sexual behavior in elderly patients with dementia?

Ms. Hammersla: The first step is to get a thorough history of the behavior — to find out what the behaviors are and how frequently they're occurring. Then the nurse or nurse practitioner should do both a mental status exam and a physical exam to see if there are any physical problems that might be contributing to or causing the behavior, including any medications.

It's also important to discuss the issues with caregivers and provide them with education. Sexual behavior is a hard thing for people to talk about, even in younger people, but it's really difficult to talk about in someone who is elderly and has dementia. That's why it's important to try to ease caregiver discomfort about the issue. It's also crucial to tease out what's appropriate and what's inappropriate — what behaviors may be fairly benign and what behaviors are causing harm.

Medscape: What behavioral and educational methods help a clinician treat inappropriate sexual behavior?

Dr. Galik: If it's not caused by an underlying medical condition or medication, you can start with nonpharmacologic interventions. If the behavior is between 2 residents who can't really consent to a sexual relationship, you might physically separate them or distract them with other activities. If a resident is touching a staff member inappropriately, you can ask that any hygiene be provided by someone of the same sex, and that "professional demeanor" is established. That means the healthcare worker would remind the resident of what the boundaries are. For those who disrobe in public places, there is adaptive clothing that has hooks and other features that make it more difficult to take off.

It's also important to educate caregivers about what's appropriate and what's inappropriate. For instance, 2 residents — perhaps at least 1 is married — might hold hands, go to activities together, and kiss occasionally. They both seem to enjoy the behavior. But that's where it ends. In these cases, you need to talk with their family members and discuss the fact that it may not really be causing any harm. That can be difficult for the caregiver, so in instances where they disallow the behavior, you might have to rely on separation strategies.

Medscape: What makes the problem of inappropriate sexual behavior in those with dementia so important, and why is education about it crucial?

Ms. Hammersla: Although it's not a widespread problem, it can come up frequently in long-term care settings. It often occurs in those with dementia who are ambulatory and exhibit behavioral disturbances. It can be distressing for everyone involved. People are often very uncomfortable talking about it, and don't know how to handle it. That's why it's important to get information about how to deal with the issue out there, because as the population ages, we will see more and more people with dementia in long-term care settings, and more who might have the problem of inappropriate sexual behavior.

Medscape: Are pharmacologic interventions for inappropriate sexual behavior used, and what is the nurse's role in these or other treatments?

Dr. Galik: Most of the research we have on pharmacologic interventions is not based on randomized controlled studies, but case reports. So we don't have gold-standard science about using medications for inappropriate sexual behavior in elderly patients with dementia, and it's generally an off-label use. We try to avoid pharmacologic management but, in some instances, it's needed to keep people residing in their community setting.

Selective serotonin reuptake inhibitors can reduce sexual drive and overall libido, and also reduce the obsessional symptoms that are often associated with these behaviors. Tricyclic antidepressants can also reduce behaviors that have become obsessional. If nothing else is working, then a sedating antidepressant might be one of the last choices. Mood stabilizers can also be helpful, depending on the underlying condition, and hormonal agents can have an impact sexual drive.

These cases can be very difficult to manage, so no matter what the treatment, it's important to discuss interventions with the nurse's interdisciplinary care team. The nurse should not feel that she or he is alone in dealing with this problem. The nurse's role is often to make sure an adequate assessment is done so that the healthcare team can pinpoint specific symptoms and identify a cause. Then you can move toward treatments.

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