Frost RN MNCommunity Mental Health NurseCheryl Murphy MD FRCPCSeniors Mental HealthObjectivesBriefly review issues related to sexuality in people with cognitive impairmentDiscuss the challenges in re ID: 897511
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1 Sarah Krieger - Frost RN MN Community Me
Sarah Krieger - Frost RN MN Community Mental Health Nurse Cheryl Murphy, MD, FRCPC Seniors Mental Health Objectives ï Briefly review issues related to sexuality in people with cognitive impairment ï Discuss the challenges in recognizing when sex
2 ual behavior is inappropriate ï Revie
ual behavior is inappropriate ï Review current evidence for the management of inappropriate sexual behavior Sexuality and Sexual Expression The basic need to belong, to be desired, to share oneself with another does not end with dementia. ï
3 Sexuality is not what we do, but who
Sexuality is not what we do, but who we are. Sexuality/Sexual Behavior ï Sexuality is a fundamental part of human existence. ï How we show closeness/express love. Sexual Expression ï Sexually oriented expression: ï Words, gestures, or mo
4 vements (including reaching, pursuing o
vements (including reaching, pursuing or touching) which appear to be motivated by the desire for sexual gratification) Holmes, D., Reingold, J., & Teresi, J. (1997) Sexuality in Cognitive Impairment ï The need for close human contact does not
5 decline with age or dementia ï Those
decline with age or dementia ï Those with dementia communicate with behavior rather than speech ï Impact is often decreased sex drive ï Dementia deprives individuals of cultural norms Myths ï 3 myths ï Older adults are not sexually desir
6 able ï Older adults are not sexually
able ï Older adults are not sexually desirous ï Older adults are not sexually capable Normal Sexuality ï 60% of ânormalâ older persons have active interest in sexual activity. ï Stats from the NOCA 1998 survey ï report that 48% of
7 men and women over 60 are sexually acti
men and women over 60 are sexually active. Dispelling the Myths ï Men over age 60: ï 61% are sexually active ï 61% say sex is better or at least as satisfying as it was at 40. ï 76% say sex is equally as emotionally satisfying as it was at
8 40 ï 72% say sex is an important part
40 ï 72% say sex is an important part of a relationship Dispelling the Myths ï Women over 60 ï 37% are sexually active ï 62% say sex is better or at least equally as physically satisfying as it was at 40. ï 69% say sex is equally as emoti
9 onally satisfying as it was at 40. ï
onally satisfying as it was at 40. ï 47% say sex is important in a relationship. Inappropriate Sexual Behavior ï Focus on behaviors that are ï unwanted ï âinappropriateâ ï challenging ï To ï Family ï Other residents ï Clinical
10 staff / administrators ï Range of nor
staff / administrators ï Range of normal gets defined by the culture of the environment Inappropriate Sexual Behavior ï Ozkan et al (2008) ISB grouped into 3 common types: ï Sex talk ï Most common ï Sexual acts ï Implied sexual acts ï
11 pornography Inappropriate Sexual Behavi
pornography Inappropriate Sexual Behavior ï Definition: ï No one recognized definition ï Encompasses range of behaviors such as: ï Verbal requests for sex ï Unwanted touching ï Masturbation ï Ambiguous behaviors (appearing naked or inc
12 ompletely dressed) ï âsexual disinh
ompletely dressed) ï âsexual disinhibitionâ ï Frontal system: disinhibition ï Normal etiquette may be forgotten ï Temporolimbic: hypersexual behavior ï Striatum: obsessive - compulsive sexual behavior ï Hypothalamus: increased sex dr
13 ive ï Multiple neurotransmitter and ho
ive ï Multiple neurotransmitter and hormonal systems Neurobiology Scope of the Problem ï Not common (2.6 - 15%) ï Greater # in nursing homes ï Comprise an important component of BPSD ï defined as âbehaviors that are unsafe, disruptive an
14 d interfere with careâ (/zkan et al 2
d interfere with careâ (/zkan et al 2008) ï Sex ratio unclear ï No differences based on type of dementia ï Low frequency but highly emotionally laden Case of Mr. I.M. Proper ï 80 year old divorced man living in Level I care for several y
15 ears. ï Progressive aphasia ï Very p
ears. ï Progressive aphasia ï Very private person ï Referral ï At mealtime exposes himself to his female table partner Is This Inappropriate Sexual Behavior? Assessment of ISB ï Comprehensive exam including thorough sex history. ï Is
16 this a new behavior? ï ? Related to un
this a new behavior? ï ? Related to underlying cognitive changes or exacerbation of life - long characteristics ï ? Related to underlying psychiatric disorder or use of dopamine agents ï ?UTI Assessment of ISB ï Potential underlying causes:
17 ï Unmet needs (toileting, UTI) ï Un
ï Unmet needs (toileting, UTI) ï Uncomfortable clothing (too tight, restrictive..) ï Misinterpretation (organic brain changes lead to misinterpretation of cues) ï Consider context: ï What is âappropriateâ with oneâs partner (or will
18 ing other) is not âappropriateâ wit
ing other) is not âappropriateâ with someone else Assessment of ISB ï What is the target symptom? ï Specifically identify what the symptom and treatment goals are ï Who, what, when? ï Does behavior occur with all staff? One staff? Only
19 men/women? During a particular activi
men/women? During a particular activity, ie bathing? Assessment of ISB ï Assessment (Litchenburg 1997, Litchenburg & Strzepek 1990) ï What form does behavior take? ï In what context? ï How frequently? ï What are contributing factors? ï
20 Is there a problem? ï Whose problem
Is there a problem? ï Whose problem is it? ï What are the risks involved? ï To whom? ï Are the participants competent? Competency? ï No issue regarding consensual relationships between âcompetentâ adults ï Setting dependent? ï In
21 formed consent vs tacit consent? ï Spe
formed consent vs tacit consent? ï Specific competency ï Institutional policy ï Challenges? Case of Mrs. Lonely ï 84 year old widow with 3 grown children who live out of the province. Always âvery properâ. ï Moderately severe - seve
22 re mixed dementia with persistent and
re mixed dementia with persistent and rapid decline. ï Moved from âassisted livingâ to ,TC, dementia care. Case of Mr. Heart ï 80+ year old married man with 2 children living locally. ï Moderately severe - severe AD Case of Mr. & Mrs.
23 Lonely - Heart ï Seen holding hands,
Lonely - Heart ï Seen holding hands, sitting together, seeking each other out. ï Found lying on his bed together in an embrace, fully clothed. Is This Inappropriate Sexual Behavior? Ethics of ISB ï Guidelines for assessing appropriatenes
24 s of relationship: ï awareness of rel
s of relationship: ï awareness of relationship ï who is initiating relationship ï do they think this person is their spouse ï can they state what level of relationship they are comfortable with ï ability to avoid exploitation ï is thi
25 s behavior consistent with formerly held
s behavior consistent with formerly held values/beliefs ï can they say ânoâ ï Awareness of potential risks Ethics of ISB ï Not overly realistic regarding relationships in advanced cognitive impairment. Case of Mr. I.S. Bea ï 70 year ne
26 ver married man - was the favorite unc
ver married man - was the favorite uncle of his nephews. Various careers which all involved public service. ï Moderate dementia, vascular with prominent disinhibition. Case of Mr. I.S. Bea ï Frequent requests for sexual interaction with s
27 taff, verbally graphic, âgrabbingâ
taff, verbally graphic, âgrabbingâ at breasts and crotch of female staff. ï Noted to be touching a co resident who was felt to be vulnerable due to cognitive and physical impairment. ï 1:1 caregiver for safety of co residents. Is This Inap
28 propriate Sexual Behavior? Management o
propriate Sexual Behavior? Management of ISB ï Approach ï Define target behaviors ï Rule out delirium ï Review cognitive and sensory factors ï Review environmental factors ï Educate and support caregivers ï If fails ï Consider nonpha
29 ramacological approaches ï Consider dr
ramacological approaches ï Consider drug therapy Non Pharmacological Strategies ï Comprehensive review of Psychological approaches to the management of Neuropsychiatric symptoms of dementia (Livingston et al 2005): ï No one strategy was prove
30 n effective for any one type of behavio
n effective for any one type of behavior. ï Only behavior management therapies, specific types of caregiver/residential care staff education (and possibly cognitive stimulation) have any lasting effectiveness. ï Lack of evidence should not be
31 interpreted as lack of efficacy. ï M
interpreted as lack of efficacy. ï Modification of social cues ï Environmental manipulation (ie rear closing clothing, objects to handle) ï Supportive psychotherapy (aimed at caregivers) ï Behavior Modification ï Change attitudes of staf
32 f/family Non Pharmacological Strategies
f/family Non Pharmacological Strategies Non Pharmacological Strategies ï Avoid becoming angry or embarrassing the individual ï Seek a âreasonâ or explanation for behavior ï Gently, but firmly remind individual that behavior is inappropriat
33 e or unwanted Non Pharmacological Strate
e or unwanted Non Pharmacological Strategies ï Try to increase level of appropriate affection ï hugging, hand holding, dancing ï Try distraction ï Remove to a private place ï Consider practical solutions ï rear access clothing ï âPink
34 Pantherâ ï tactile objects Pharmaco
Pantherâ ï tactile objects Pharmacotherapy of ISB ï No one medication or class of medication has been proven effective for treatment of ISB ï No current medication has approval for use in these problems (off label use) ï No randomized, d
35 ouble blind, placebo controlled studies
ouble blind, placebo controlled studies What do you do? Pharmacotherapy of ISB ï Goal is to suppress sexual fantasies, sexual urges and behaviors ï Case report / series evidence for ï Antidepressants ï Anticonvulsants ï Antipsychotics ï
36 Anti - Dementia drugs ï Hormonal ag
Anti - Dementia drugs ï Hormonal agents ï other Antidepressants for ISB ï Generally used as first line agents but case report evidence only ï citalopram ï paroxetine ï sertraline ï clomipramine ï Case series for trazodone (Simpson
37 et al, 1986) ï Antiobsessional and an
et al, 1986) ï Antiobsessional and antilibidinal effects Pharmacotherapy of ISB ï When 1 st line agents donât work? ï Debate in the literature ï Consider ï Antipsychotics ï Antiepileptics ï Antidementia drugs ï Hormone treatment An
38 tipsychotics for ISB No known clinical t
tipsychotics for ISB No known clinical trials ï Case report evidence ï quetiapine ï haloperidol ï Thought to decrease ISB by their dopamine blocking effects and elevation of prolactin. ï Balance risk/benefit re:side effects ï Case repor
39 ts for: ï gabapentin ï carbamazepine
ts for: ï gabapentin ï carbamazepine ï Mixed evidence for BPSD, no studies for ISB ï valproate ï lamotigine ï May be helpful because of mood stabilizing effect, antiandrogenic and antiprogestin effects. Mood Stabilizers for ISB ï choli
40 nesterase inhibitors ï rivastigmine â
nesterase inhibitors ï rivastigmine â case report ï donepezil â case report - increased libido in 2 patients ï memantine: no current literature for ISB Antidementia Drugs for ISB Hormonal Agents for ISB ï Antiandrogens ï Medroxyproge
41 sterone â 3 small case series ï Cyp
sterone â 3 small case series ï Cyproterone â 2 case reports (female) ï decrease testosterone by inhibiting LH / FSH ï Estrogens ï DES or conjugated estrogen ï case report / series (38/39 pts) ï GnRH analogues ï leuprolide â 2
42 case reports ï Fully informed consent
case reports ï Fully informed consent by legally authorized caregiver ï Ethical considerations ï US state regulators concerns re: chemical restraint ï Anderson Light & Holroyd (2006) ï 5 treatment refractory pts with ISB ï All improved w
43 ith MPA ï 2 had med d/c because of sta
ith MPA ï 2 had med d/c because of state regulators - lost placements due to behavior. Hormonal Agents for ISB Other drugs for ISB ï Cimetidine ï Retrospective chart review ï H2 receptor antagonist with antiandrogen effects ï Longterm us
44 e at high doses decreases testosterone b
e at high doses decreases testosterone binding to androgen receptor and inhibits the hydroxylation of estradiol ï Pindolol: ï Thought to work by decreasing adrenergic drive which decreases agitation, aggression and inappropriate behavior ï Ca
45 se report Choosing an agent ï Consider
se report Choosing an agent ï Consider ï Target symptoms ï Urgency ï Goal of treatment ï Risk / benefit ï Informed consent ï Risk of not using any medications History (Sexual, Medical, Psychiatric, Medications, Pre - morbid personality,
46 Cognition, Functions) â (Neurological
Cognition, Functions) â (Neurological disorders: Parkinsonâs, Multiple sclerosis, Huntingtonâs, Stroke) â Investigations (Blood tests, Urine examination, Vit B12 & folate levels, VDRL, and Neuroimaging) â Treat disorder â (Primary neuro
47 psychiatric disorder, Delirium, Drug eff
psychiatric disorder, Delirium, Drug effect) â Remove offending drugs â Type of behaviors â â Inappropriate expression of normal sexual drive Inappropriate sexual behaviors â â Support expression of normal sexual drive Non - pharmacologi
48 cal management (Redirection, Privacy, At
cal management (Redirection, Privacy, Attire) â Inadequate response Pharmacotherapy â No confusion â Confusion â Cholinesterase inhibitors +/ - Memantine â â Antipsychoticsâ Psychotic â Hypersexual â Manic â Anticonvulsan
49 t mood stabilizers /Impulsive â â S
t mood stabilizers /Impulsive â â SSRIs, Clomipramine â Obsessive Depressed â Antidepressants/Trazodone â Inadequate response/side - effects Other drugs â Cimetidine, Pindolol â Inadequate response/side - effects Hormonal agents â
50 MPA***, CPA****, GnRh analogues stig
MPA***, CPA****, GnRh analogues stigma of chemical castration) * Combine with behavioral management ** Selective Serotonin Reuptake Inhibitors *** Medroxyprogesterone Acetate **** Cyproterone Acetate Figure 1. Algorithm for the treatment of inap
51 propriate sexual behaviors. Pharmacother
propriate sexual behaviors. Pharmacotherapy for Inappropriate Sexual Behaviors / Ozkan et al ISB Messages ï Uncommon but problematic ï Assessment: ï Is it sexually inappropriate? ï ?underlying causes ï Target behaviors ï Nonpharm approach
52 es ï Consider pharmacologic approaches
es ï Consider pharmacologic approaches ï Risk/benefit of drug treatment ï Implement ï Evaluate References ï Harris, L;&Weir, M. Inappropriate Sexual Behavior in Dementia: A Review of the Treatment Literature. Sexuality and Disability V
53 ol 16, #3 Sept 1998. ï Anderson - Lig
ol 16, #3 Sept 1998. ï Anderson - Light, S. & Holroyd, S. The Use of Medroxyprogesterone acetate for Treatment of Sexually Inappropriate Behavior in Patients with Dementia. Journal of Psychiatry and Neuroscience (2006) Mar; 31(2) 132 - 134. Re
54 ferences ï Series, H & Degano, P. Hype
ferences ï Series, H & Degano, P. Hypersexuality in Dementia. Advances in Psychiatric Treatment (2005) Vol 11, 424 - 431. ï Zeiss, A., Davies, H. & Tinklenberg, J An Observational Study of Sexual Behavior in Demented Male Patients. Journal of
55 Gerontology (1996) vol 51A, No 6, 325 -
Gerontology (1996) vol 51A, No 6, 325 - 329. References ï Hashmi, F., Krady, A., Qayum, F & Grossberg, G. Sexually Disinhibited Behavior in the Cognitively Impaired Elderly. Clinical Geriatrics (2000). ï Ozkan, B., Wilkins, K., Muralee, S. & T
56 ampi, R. Pharmacotherapy for Inappropri
ampi, R. Pharmacotherapy for Inappropriate Sexual Behaviors in Dementia: A Systematic Review of the Literature. American Journal Alzheimers Disease and Other Dementia (2008) May. References ï Rabins, P., Lyketsos, C & Steele, C. Practical De
57 mentia Care, 2 nd Ed (2006) Oxford Pres
mentia Care, 2 nd Ed (2006) Oxford Press. ï Tosto, G., Talarico,G, Lenzi, G.L. & Bruno, G. Effect of citalopram in treating hypersexuality in an Alzheimers Disease case. Neurological Sciences (2008) Sep;29(4):269 - 70 References ï Livingsto
58 n, G., Johnston, K., Katona,C., Paton, J
n, G., Johnston, K., Katona,C., Paton, J.& Lyketsos, C. (2005) Systematic Review of Psychological Approaches to the Management of Neuropsychiatric Symptoms of Dementia. American Journal of Psychiatry 162:11, Nov 2005. ï Lichtenburg (1997) ï
59 Lichtenburg Strepek (1990) References ï
Lichtenburg Strepek (1990) References ï MacKnight, C. & Rojas - Fernandez, C (2000) Journal of the American Geriatrics Society Jun; 48(6):707. Quetiapine for sexually inappropriate behavior. ï Kamel, H. & Hajjar, R. (2003) Sexuality in the Nu
60 rsing Home, Part 2: Managing Abnormal B
rsing Home, Part 2: Managing Abnormal Behavior - Legal and Ethical Issues. Journal of American Medical Directors Association. Jul/Aug. References ï Tabak, N. & Shemesh - Kigili, R. (2006) Nursing Forum. Sexuality and Alzheimerâs Disease: Can t