Tales From Geriatric Practice

Casanova on the Dementia Unit

Mark E. Williams, MD

Disclosures

April 19, 2021

Mark E. Williams, MD

"Doctor, you need to have a man-to-man talk with Antonio."

Antonio (not his real name) had been caught having sex with one of the other residents on the dementia unit. As a former foreign service worker, Antonio had held very high diplomatic positions in the US government. And as a world traveler, he was tanned, attractive, cultured, refined, and spoke quietly and sincerely, with a hint of an Eastern European accent. He was in his mid-seventies, with short hair and smiling eyes, and he always wore a starched open shirt with a sport coat.

Over the years, Antonio had developed a progressive dementia. When his wife died, he and his family felt that living in a life care community was the best option. At first, he resided in the assisted-living section. But when he began wandering at night, he was moved to the locked dementia unit.

Loss of impulse control, however, was not one of Antonio's difficulties, so I wondered what could be going on.

A Man Among Many Women in a '5-Star Hotel'

The 15-bed dementia unit was a beautifully decorated space with a large central parlor containing comfortable chairs and sofas. It reminded me of the waiting area of a 5-star hotel. The focal point was a large fireplace and a huge, flatscreen TV that was usually tuned to game shows such as The Price Is Right and Let's Make a Deal. Surrounding the parlor were the residents' private bedrooms. Antonio was one of only three men on the unit.

"Antonio, how are you doing today?" I asked.

"I am fine, thank you," he said. "You are looking well." (Always the diplomat.)

"Are you having any difficulties — any aches or pains?"

"No, I am just fine."

Antonio had what I would descriptively call "tea-party dementia." All of his social graces were preserved but he had very little short-term memory. I decided to be a bit more direct.

"Have you had any urinary symptoms, such as burning or having to void frequently?"

"You know I am an old man and I take longer to pee," he said, "but nothing has changed."

"Antonio, you were found with another resident in her bedroom."

"That is true, I do not deny it," he said. "You know I would never lie to you."

"Please tell me what happened."

"I was sitting in my usual spot, watching television, and my friend — they are all my friends — sat beside me and asked me to see something in her bedroom. I am sure you know that some of my friends invite me to their rooms at times. They always come for me and seem really eager to be alone with me."

"Antonio," I said, "it is important for you to keep to yourself and not visit a woman's room without a chaperone. Do you understand?"

"Yes, doctor, I understand."

"Is there anything I can do for you?"

"No, thank you," he said. "It is always good to see you."

Slightly puzzled, I tracked down the head nurse who had written the request for the "man-to-man talk."

The Women Complain — About Having to Wait

"We have a bit of a problem with Antonio," the nurse said. "He is very popular with the ladies, and on several occasions we have noticed him entering different rooms and staying for almost an hour. At least three different women seem to be involved. They initiate things, but Antonio does not object. He was certainly popular in assisted living before he moved to the unit."

"Have any of the women complained about mistreatment?" I asked.

"No, the women are happy," she said. "No one has complained about him, although some are starting to grumble about having to wait for his attentions. They are all widows, except for one — and her husband is upset because he has heard rumors about his wife's activities on the unit. She is not interested in her husband when he visits her."

What to Do?

In this situation, everyone was consenting. But what does consent mean in the setting of dementia? The women seemed fulfilled with the encounters, and Antonio did not mind. The issue of the husband was the most pressing, although I was aware that he was engaged in a semi-open relationship with another woman in the complex, so I wondered whether his wife sensed his infidelity in some way.

We tried separation, interruption, chaperones, and redirecting the women who were making the overtures to Antonio. But nothing seemed to work for more than a few days, and the women were getting restless.

I considered prescribing sertraline to lower Antonio's libido, even though that wasn't the core issue. But the situation smoldered with no clear solution, so I decided to give the sertraline a try. Within 2 weeks, the issue had subsided.

Feeling guilty, I went back to visit Antonio.

"How are you doing today?" I asked.

"I am doing well, but I have lost my manhood and my friends do not want to see me."

"I am sorry to hear that. Is there anything I can do for you?" (I knew the implicit answer to that question.) After seeing Antonio, I decided to stop the sertraline. We needed to find a better solution.

On a follow-up visit a few weeks later, Antonio confided to me that his manhood had returned. He was relieved because he had a new girlfriend (a young widow) from assisted living who now regularly visited him on the unit. The new girlfriend had told the other women not to bother Antonio.

The situation had resolved on its own.

Upon Reflection…

The notion that older people are not interested in sex is a myth; sex is important to people of all ages. However, the situation with Antonio raised the very real question of what consent means on a dementia unit. I wonder what next steps we might have taken had the young widow not shown an interest in Antonio and shooed the other women away.

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