Although sexual activity decreases in the elderly, sexual interest can remain at baseline (1). Societal stereotypes often result in the classification of all sexual behavior among older adults as inappropriate or pathologic, thus it is important to distinguish appropriate versus inappropriate sexual behavior (ISB). Unfortunately, there is no globally accepted definition of ISB, so this determination must be predicated upon what is viewed as normative within the contexts of the environment, as well as the risk or discomfort inflicted upon others.  If the sexual activity interferes with normal activities, occurs at socially inappropriate times, or infringes on the rights of others, it is reasonable to deem it as ISB.

ISB encompasses three types of behaviors:

Sexual talk (foul, threatening, or abusive language),

Sexual acts (touching, exposing, public masturbation, fondling),

c)                  Implied sexual acts (public pornography, requesting unnecessary genital care) (1, 2).

ISB is most frequently described among patients with dementia and is generally related to disinhibition associated with frontal lobe changes/dementia. The data are mixed with regards to whether men engage in ISB more often than women; however men may be more apt to demonstrate aggressive behaviors, while women may be more likely to engage in ISB which is verbal in nature (3,4).

Secondary causes of ISB, some of which may be potentially reversible include the following:

Physical Factors:  Dementia, tumors, stroke, epilepsy, Wilson’s disease, Tourette’s  Syndrome, Klein Levin Syndrome (5), depression, delirium, electrolyte abnormalities, urinary tract infections, constipation, or fecal impaction.

Social Factors: Loss of partner, lack of privacy, misinterpretation of cues, understimulating surroundings. These circumstances may occur in long-term care facilities, where the model of living may make it challenging to have private sexual relationships (6).

Substance Abuse: Alcohol, cocaine.

Medication-related adverse effects: Anticholinergics, benzodiazepines, psychostimulants, anti-Parkinsonian agents (1).

Management:

Non-Pharmacologic Management   Although there is no standardized approach/ algorithm for the management of ISB, clinicians should begin with non-pharmacologic interventions which are least intrusive. Environmental or sensory triggers that may precipitate ISB should be identified and removed if possible, or redirect patients from those triggers. Care teams may decide to use same-sex caregivers if appropriate, clothing that fastens in the back and distraction activities that involve the use of hands.  Conversely, with cognitively intact and consenting adults, long-term care facilities may offer private and appropriate opportunities for persons to engage in sexual activities. Long-term care facilities should also ensure call lights and telephones are within reach during sexual activity (4). Additionally, perceptions of long-term care facility staff towards residents’ expressing sexuality may affect management, and it is therefore imperative that staff undergo training interventions focusing on improving knowledge of and attitudes towards sexuality and dementia (7).

Pharmacologic Management   When considering pharmacotherapies, it is important to note that all pharmacologic treatments for ISB are off-label and poorly studied. Many experts advocate reserving the use of pharmacologic management for ISB to situations in which a patient is engaging in or threatening dangerous acts involving intimate physical contact.

Antidepressants: In case-controlled studies, Citalopram and other SSRIs have been utilized to decrease libido and obsessive behaviors with few adverse effects, but poor effectiveness (2).

Antipsychotics: Haldoperidol and Quetiapine have both been described as marginally effective, and associated with a high level of side effects (2).

Antiandrogens:  Generally reserved for refractory cases to reduce testosterone levels and libido considering their stigma of providing “chemical castration”.  Medroxyprogesterone acetate is the most commonly used of these agents (8).

Anticonvulsants: Gabapentin and Carbamazepine have been utilized by some experts as a second line therapy for its off-labeled effects to decrease libido and sexual function.

Cholinesterase inhibitors: Conflicting results regarding dementia-related ISB (9). One case report elucidated reduction of ISB with Rivastigmine however, a number of trials demonstrated symptomatic worsening with Donepezil.

Reporting and Legal Issues   Federal regulations mandate that institutional care be as least restrictive as possible to maintain a safe environment (10).  Consequently, the dilemma of preserving an individual’s right to sexual expression while also ensuring others are not at risk of physical or mental harm, could contribute to underreporting of ISB.  It is important for health care facilities to have clear policies and procedures in place for patients, families and staff.  Staff educational programs which examine staff values, patient’s rights, and how to provide the most appropriate care are suggested (6).