Inappropriate behaviors and hypersexuality in individuals with dementia: An overview of a neglected issue

Abstract

Behavioral and psychological symptoms of dementia are very common in patients affected by dementia, and are associated with high rates of institutionalization. Behavioral and psychological symptoms of dementia consist of aggressive behavior, delusions, hallucinations, depression, apathy, wandering, stereotyped and inappropriate sexual behavior. Interestingly, the latter has been reported to be relatively uncommon, but causing immense distress to patients and their caregivers. The genesis of inappropriate behavior is considered a combination of neurological, psychological and social factors. Although assessment is mainly carried out by clinical observation and interviews with caregivers, the most appropriate management of behavioral and psychological symptoms of dementia, including hypersexuality, is a combination of pharmacological and non-pharmacological interventions, according to specific symptoms, degree of cognitive dysfunction and subtype of dementia. The present narrative review will mainly focus on aggressiveness, disinhibition, aberrant motor, and sexually inappropriate behavior diagnostic work-up and treatment, in an attempt to provide both the patients and their caregivers with useful information to better manage these symptoms and improve their quality of life. Space is particularly dedicated to inappropriate sexual behavior, which is still considered a neglected issue. Geriatr Gerontol Int 2017; 17: 865-874.

Measurement of sexual disinhibition in dementia: A systematic review

“…Measures that assess lewd/aberrant behavior range from vague wording (eg, “sexually inappropriate behavior?”) to explicit examples (eg, “public masturbation”) . Other examples of lewd/aberrant behavior described include disrobing in public, public masturbation, grabbing at one's own genitals or breasts, and delusions of spousal infidelity . Review indicated that 10 out of the 20 identified measures include some type of assessment of lewd/aberrant sexual behaviors (see Table ).…”

“…Sexual disinhibition (SD) is a neuropsychiatric symptom characterized by inappropriate sexual behaviors. [1][2][3] This symptom is found across dementia type [4][5][6] and is associated with negative outcomes for both the care recipient and caregiver, including inappropriate acute psychiatric hospitalization, 7 higher rates of care recipient institutionalization, 8 "shame" and "anger" experienced by the caregiver, [4][5][6] caregiver burden, and greater desire to place a care recipient in institutionalized care. 9 Despite these negative correlates, SD appears to be inconsistently identified in the literature, described in anywhere between 1.8% and 25% of dementia samples.…”

“…2,[13][14][15] Several different conceptualizations for SD also exist, including inappropriate physical and/or verbal sexual behavior, increased libido, overt acts with a sexual meaning, persistent uninhibited sexual behaviors, sexual talk, sexual acts, implied sexual acts, sexual comments, preoccupation with sex, sexual hallucinations, delusions of spousal infidelity, attempting to seduce others, and chasing others for sexual purposes. [1][2][3][4][5][6]8,[12][13][14][15][16][17][18][19][20][21][22] Lack of standardization may impede accurate characterization of SD by limiting the ability to directly compare results across studies. Agreement on how to define, term, and conceptualize SD in dementia is needed.…”

“…57 Other examples of lewd/aberrant behavior described include disrobing in public, public masturbation, grabbing at one's own genitals or breasts, and delusions of spousal infidelity. [1][2][3]18 Review indicated that 10 out of the 20 "Has your sex drive increased with the introduction of medications for Parkinson's disease?" "do you often find yourself preoccupied with sexual thoughts?"…”

“…Prior work has examined SD under terms including “sexual disinhibition,” “inappropriate sexual behavior,” “specific sexual behavior,” “aberrant behavior,” “disruptive behavior,” “hypersexual behavior,” “disinhibited behavior,” and “complex behavior,” among other terms . Several different conceptualizations for SD also exist, including inappropriate physical and/or verbal sexual behavior, increased libido, overt acts with a sexual meaning, persistent uninhibited sexual behaviors, sexual talk, sexual acts, implied sexual acts, sexual comments, preoccupation with sex, sexual hallucinations, delusions of spousal infidelity, attempting to seduce others, and chasing others for sexual purposes . Lack of standardization may impede accurate characterization of SD by limiting the ability to directly compare results across studies.…”