sexual inappropriateness staff should avoid misinterpreti - PDF document

„SEXUAL INAPPROPRIATENESS „Staff should avoid misinterpreting nonsexualbehavior, such as confused wandering into another res-idents bedroom, as representing sexual disinhibition.Inappropriate sexual acts within a nursing facility tendto be remembered for a long time by staff and familymembers. There is often a tendency to label a residentas having sexual inappropriatenessŽ on the basis of afew instances.Therefore, accurate nursing notes andpossible precipitants and decrease the risk of inaccurateidentification of sexual impropriety.It is critical to address ethical dilemmas and valuejudgments inherent with assessing and treating theseissues. For example, before identifying and treating sexu-ally inappropriate behavior, it should be ascertainedwhether the behavior in question is truly inappropriateŽor whether it is based on a judgment relative to a staffmembers own personal moral or ethical values.It ishelpful to monitor the frequency and severity of any iden-tified behaviors, and open communication in the inter-disciplinaryteam meeting is recommended to explorethese issues. In a study by Pease,treatment team to acknowledge the occur-rence of sexual incidents and to offer supportto the staff members directly involved.Pharmacologic InterventionsAreviewof the literatureindicates thatthere have been few randomized controlledtrials regarding the use of medications toaddress sexual disinhibition in the olderPharmacologicmonal agents or various psychotropic med-ications. Table II lists the medications thathave been studied for treatment of sexualAntiandrogens.These agents exert theirclinical effect by reducing serum testos-terone levels leading to impaired sexualfunctioning, subsequently reducing inap-propriate sexual behaviors. Medroxyprog-esterone acetate (MPA) is a type of proges-terone that decreases testosterone by inhibiting pitu-itary luteinizing hormone (LH) and follicle-stimulatingThe main side effects of MPA that have been report-ed include sedation, weight gain, fatigue, hot and coldflashes, mild diabetes, depression, and loss of body hair.In a case series by Cooper,residents with dementia and inappropriate iors (masturbation, fondling, exposure, and attemptingintercourse with other residents) were followed. The resi-dents were between the ages of 75 and 84 and had failedbehavioral management and treatment with chlorpro-mazine and thioridazine. The intramuscular administra-tion of MPA at 300 mg weekly for 1 year was completed,and sexual inappropriateness was charted 6 months beforethe trial, during treatment, and for 1 year after the trial.Undesirable sexual behaviors were reduced within 10-14days following the initiation of MPA treatment. Levels oftestosterone and LH (which had fallen during the courseof treatment) returned to pretreatment levels within 4weeks after the trial ended. At the 1-year follow-up point,three out of the four residents were deemed to be free of Table II: Pharmacologic Management of Inappropriate Sexual Behaviors in Dementia Hormonal Agents Estrogens Gonadotrophin-releasing hormone analogs Serotonergic Agents Trazodone Atypical antipsychotics Carbamazepine alproic acid Annals of Long-Term Care / Volume 14 , Number 10 / October 2006 Annals of Long-Term Care / Volume 14 , Number 10 / October 2006„SEXUAL INAPPROPRIATENESS „Although there are no case reports documenting theuse of GnRH analogs in treating hypersexuality inolder patients with dementia, there is one case reportdocumenting the use of leuprolide acetate to success-fully treat sexual aggression in a 43-year-old male withdementia and Kluver-Bucy syndrome.Serotonergic Agents.Selective serotonin reuptakeinhibitors (SSRIs) are thought to decrease sexuallyinappropriate behaviors by reducing obsessive symp-toms and overall libido.found to be safe in overdose and has the added benefitof treating comorbid symptoms of depression and anx-iety. Potential side effects include headache, gastroin-testinal distress, insomnia, and sexual dysfunction.Acase report has documented the effectiveness ofparoxetine at 20 mg in a 69-year-old male with demen-Positive effects were seenwithin 1 week, and the positive response was sustainedat a 3-month follow-up.Another case reportby Raji etdetails the use of citalopram in a 90-year-oldwoman with a 2-year history of physical aggression,inappropriate disrobing, and grabbing at the pelvic areaof male residents of the nursing facility. A previous trialof paroxetine was unsuccessful, and a trial of risperidonehad resulted in only a partial response (decrease in phys-ical aggression but not sexual aggression) but warranteddiscontinuation due to the development of extrapyra-midal side effects. Trials of valproic acid and gabapentinwere also deemed to have been ineffective. Citalopramat 20 mg orally decreased both physical aggression andsexually inappropriate behaviors within 1 week, withsymptoms remaining in remission at a 9-month follow-up. The authors postulated that the effectiveness ofcitalopram (compared to paroxetine) was probably dueto its higher selectivity on serotonin reuptake inhibition.Two case reports have also documented successfultreatment of paraphilias in older men with dementiaThe first patient was repeatedlyexposing himself (including one incident involving hisgranddaughter) and had failed trials of MPA and thior-150 mg daily, resulting in a significant reduction in hissexual behaviors after 4 weeks. A second case involvedbation and frotteurism (becoming sexually aroused bytouching and rubbing oneself against another noncon-senting person). This patient had failed trials of bus-pirone and thioridazine. Clomipramine was titrated upiors. However, due to orthostatic hypotension thatdeveloped, clomipramine was discontinued and thiori-dazine was restarted. Sexual behaviors reappearedClomipramine was tolerated at a dose of 175 mg daily,with successful resolution of the offensive behaviors.Simpson and Fosterreported a case series of fourpatients between 62-72 years of age with dementia andsexual disinhibition who responded to trazodone afterfailing previous trials of antipsychotics (thioridazine,mesoridazine, thiothixene, and haloperidol) and ben-zodiazepines. Trazodone was dosed between 100 mgand 500 mg daily in divided doses. The positiveresponse was thought to be due to trazodonescalmingeffect and not its antidepressant action. Priapism is esti-mated to occur in 1 in 6000 patients taking trazodone,and is a potential side effect ofthe alpha-2 blockingaction of trazodone. This side effect requires emergencyintervention with intracavernal epinephrine injection.Antipsychotics. While there are no known clinical tri-als on the use of antipsychotics to treat sexually inap-propriate behaviors in the older adult, available evi-dence points to their possible efficacy.on reducing sexual disinhibition is thought to be due todopamine blockade. One case report involving the useof quetiapine in an 85-year-old man presenting withinappropriate sexual behaviors (masturbating to thepoint of genital trauma) and concurrent underlyingparkinsonism and dementia has been published.After failing a trial of cyproterone acetate and develop-ing diarrhea after 2 oral doses of paroxetine at 5 mgdaily, quetiapine was started at 25 mg daily (orally). Hisresume in the 2-month follow-up period. There was noexacerbation of parkinsonism, and blood pressureremained controlled during this 2-month period. Therecent black-box warning of sudden death with the use Reassessment by interdisciplinary team.Adjust ormodify treatment as indicated Sexual disinhibition episode reported bystaff Interdisciplinary team assesses patient/resident and documents detailed history per facility policy Sexual disinhibitionsubstantiated Contact healthcare providerfor furtherworkup Documentation in chart Providercompletes history,physical exam, and orders any indicated laboratory work Medical illness suspectedNoillnesssuspected Treat underlying medical condition meets with family Nonpharmacologic interventions proposed Interdisciplinary team re-evaluates Reassessment by interdisciplinary team Noresponse or only apartial response Care Plan team meets,proposes pharmacologicintervention, Monitorby interdisciplinary team Doses: 0.625-2.5 mg orally perday case reports outlined forothermedications Figure.Algorithm for evaluation and treatment of sexual disinhibition in residents with dementia. „SEXUAL INAPPROPRIATENESS „Annals of Long-Term Care / Volume 14 , Number 10 / October 2006 Annals of Long-Term Care / Volume 14 , Number 10 / October 2006„SEXUAL INAPPROPRIATENESS „When sexual disinhibition incidents are initiallyreported by staff members, the interdisciplinaryteam should thoroughly investigate, interview allrelevant personnel, including the resident himself orherself, and document the findings. If an episode ofsexual disinhibition is substantiated, the health careprovider should be contacted to complete an appro-priate physical exam and order any indicated labora-tory work to rule out an underlying medical illnessorcondition that could account for the sexual activ-ity being observed. If underlying medical conditionsare found, then treatment for these conditionsshould be ordered and the effect on the reported sex-ual behavior observed after completion of the inter-vention.If no underlying condition is suspected of causingthe behaviors, then the CarePlan team, including thelegal next-of-kin, and nonpharmacologic interventionsshould be discussed and ordered. Reassessment bytheinterdisciplinary team should be conducted on a regularbasis following these interventions.If a positive response is obtained, the current thera-py should be continued. If there is no response, or anunacceptable clinical response is noted, then the CarePlan team should again meet with the family or legalnext-of-kin. At this time, pharmacologic interventionsmay be discussed. Ifthe team feels that medicationtherapy would be useful, oral estrogen 0.625 to 2.5 mgevery day can be initiated in male residents. If estrogenneed to individualize therapy based on the limited dataavailable from case reports. Pharmacologic interven-tions for female residents with dementia having sexualdisinhibition would need to be individualized based onfrom the next-of-kin and the Care Plan updated toreflect the proposed therapy and the specific targetbehaviors to be addressed by the therapy. Once initiat-ed, observations for adverse side effects and response tothe medications should be regularly reassessed by theinterdisciplinaryteam. Adjustments to the dosage orchanges in therapy should ideally be discussed by theCare Plan team as needed or indicated. THE MEDICAL DIRECTORS ROLEThe LTC facilitys medical director can play a vital rolein overseeing the approach to the evaluation and man-agement of sexually inappropriate behaviors. He or sheshould also play a critical role in educating the staff ondifferentiating normal sexual expression in a residentwith dementia from those disinhibited sexual behaviorsthat may be pathological or dangerous to other resi-dents. The medical director is responsible for oversee-ing the implementation of all policies and proceduresin the facility involving resident care,involved in the development of all proposed facility-wide interventions, protocols, and policies for the resi-dents described here. Along with the residents attending physician, themedical director can greatly assist the nursing facility indealing with the potential inflammatoryreaction fromfamily members, staff, and the public at large that cansurround acts of sexual disinhibition that may rarelyoccur. The early involvement of the facility medicaldirector regarding any alleged incidents can be instru-mental in helping to oversee the proper evaluation ofsexual disinhibition in the LTC setting, and he or shecan act as a liaison between the administration, staff, SUMMARYSexual inappropriateness remains one of the leastunderstood and most difficult to treat behavioral issuesseen in LTC residents with dementia. Separating agita-tion and normal sexual expression from true sexual dis-inhibition can be difficult, and requires a thoroughevaluation on-site bythe residents healthcare providerand the interdisciplinary team. Careful evaluation ofthe residents past medical and sexual history shouldior should be addressed. When initial nonpharmacologic measures havefailed, pharmacologic agents should be considered aspart of the Care Planning process for that individualresident. Class I evidence indicates that estrogen ther-