Sexuality and Disability

, Volume 29, Issue 2, pp 143–156 | Cite as

The Complex Nature of Inappropriate Sexual Behaviors in Patients with Dementia: Can We Put it into a Frame?

  • Marianna S. Tsatali
  • Magda N. Tsolaki
  • Tessa P. Christodoulou
  • Vasileios T. Papaliagkas
Original Paper


Sexuality constitutes an inseparable aspect of human life, strongly influenced and affected by the social environment. Similarly, it plays a crucial role on how people assess themselves and relate to others. Elderly sexual needs are similar to those of younger people, but may vary in frequency, intensity and expression. Sexual activity may show fluctuations across lifespan, gradually declining with age; however, it is not uncommon for a significant percent of elderly to remain sexually active. As for patients with dementia, there is either an increase or even a decline in sexual desire, which means less sexual activity especially in cases of severe cognitive dysfunction. Often sexuality in patients with dementia may arise as Inappropriate Sexual Behavior (ISB) due to behavioral disinhibition which is a common pattern of the disease. The present review examines sexual function and behavior in patients with dementia considering a number of aspects including but not limited to possible causes and interpretations, its associated anatomy, neurochemistry, pathophysiology and treatment.


Sexuality Elderly Inappropriate sexual behavior Greece 


  1. 1.
    Johnson, C., Knight, C., Alderman, N.: Challenges associated with the definition and assessment of inappropriate sexual behaviour amongst individuals with an acquired neurological impairment. Brain Inj. 20(7), 687–693 (2006)PubMedCrossRefGoogle Scholar
  2. 2.
    World Health Organization. Sexual health. Available: health/gender/sexualhealth.htm#2 (2008). Cited 12 May 2008
  3. 3.
    Alagiakrishnan, K., Lim, D., Brahim, A., Wong, A., Wood, A., Senthilselvan, A., Chimich, W.T., Kagan, L.: Sexually inappropriate behavior in demented elderly people. Postgrad. Med. J. 81(957), 463–466 (2005)PubMedCrossRefGoogle Scholar
  4. 4.
    Hajjar, R.R., Kamel, H.K.: Sexuality in the nursing home, part 1: attitudes and barriers to sexual expression. J. Am. Med. Dir. Assoc. 4(3), 152–156 (2003)PubMedCrossRefGoogle Scholar
  5. 5.
    Kautz, D., Dickey, C.A., Stevens, M.N.: Using research to identify why nurses do not meet established sexuality nursing care standards. J. Nurs. Qual. Assur. 4(3), 69–78 (1990)PubMedGoogle Scholar
  6. 6.
    Gamel, C., Hengeveld, M.W., Davis, B., Van der Tweel, I.: Factors that influence the provision of sexual health care by Dutch cancer nurses. Int. J. Nurs. Stud. 32(3), 301–314 (1995)PubMedCrossRefGoogle Scholar
  7. 7.
    Cort, E.: Nurses’ attitudes to sexuality in caring for cancer patients. Nurs. Times 94(42), 54–56 (1998)PubMedGoogle Scholar
  8. 8.
    Richardson, J.P., Lazur, A.: Sexuality in the nursing home patient. Am. Fam. Physician 51(1), 121–124 (1995)PubMedGoogle Scholar
  9. 9.
    Kathleen, S., Mayers, P., McBride, D.: Sexuality training for caretakers of geriatric residents in long term care facilities. Sex. Disabil. 16(3), 227–236 (1998)CrossRefGoogle Scholar
  10. 10.
    Russell, P.: Sexuality in the lives of older people. Nurs. Stand. 13(8), 49–53 (1998)PubMedGoogle Scholar
  11. 11.
    Marsiglio, W., Donnelly, D.: Sexual relations in later life: a national study of married persons. Gerontology 46(6), 338–344 (1991)Google Scholar
  12. 12.
    Comfort, A., Dial, L.K.: Sexuality and aging: an overview. Clin. Geriatr. Med. 7(1), 1–7 (1991)PubMedGoogle Scholar
  13. 13.
    Steinke, E.E.: Knowledge and attitudes of older adults about sexuality in ageing: a comparison of two studies. J. Adv. Nurs. 19(3), 477–485 (1994)PubMedCrossRefGoogle Scholar
  14. 14.
    Trudel, G., Turgeon, L., Piché, L.: Marital and sexual aspects of old age. Sex. Relatsh. Ther. 15(4), 381–406 (2000)CrossRefGoogle Scholar
  15. 15.
    Lindau, S.T., Schumm, L.P., Laumann, E.O., Levinson, W., O’Muircheartaigh, C.A., Waite, L.J.: A study of sexuality and health among older adults in the United States. N. Engl. J. Med. 357(8), 762–774 (2007)PubMedCrossRefGoogle Scholar
  16. 16.
    Meston, C.M.: Aging and sexuality. West. J. Med. 176(4), 285–290 (1997)Google Scholar
  17. 17.
    Amieva, H., Lafont, S., Auriacombe, S., Le Carret, N., Dartigues, J.F., Orgogozo, J.M., Colette, F.: Inhibitory breakdown and dementia of the Alzheimer type: a general phenomenon? J. Clin. Exp. Neuropsychol. 24, 503–516 (2002)PubMedCrossRefGoogle Scholar
  18. 18.
    Amieva, H., Phillips, L., Della Sala, S.: Behavioral dysexecutive symptoms in normal aging. Brain Cogn. 53, 129–132 (2003)PubMedCrossRefGoogle Scholar
  19. 19.
    Rainville, C., Amieva, H., Lafont, S., Dartigues, J.F., Orgogozo, J.M., Fabrigoule, C.: Executive function deficits in patients with dementia of the Alzheimer’s type: a study with a tower of London task. Arch. Clin. Neuropsychol. 17, 513–530 (2002)PubMedGoogle Scholar
  20. 20.
    Alzheimer’s Society. Demography—Policy position paper. (2007). Published 2003. Accessed 27 June 2007
  21. 21.
    Vloeberghs, E., Van Dam, D., Franck, F., Staufenbiel, M., De Deyn, P.P.: Mood and male sexual behaviour in the APP23 model of Alzheimer’s disease. Behav. Brain Res. 180(2), 145–146 (2007)CrossRefGoogle Scholar
  22. 22.
    Black, B., Muralee, S., Tampi, R.R.: Inappropriate sexual behaviours in dementia. J. Geriatric. Psychiatry Neurol. 18(3), 155–162 (2005)CrossRefGoogle Scholar
  23. 23.
    Harris, L., Wier, M.: Inappropriate sexual behaviour in dementia: a review of the treatment literature. Sex. Disabil. 16(3), 205–217 (1998)CrossRefGoogle Scholar
  24. 24.
    Higgins, A., Barker, P., Begley, C.M.: Hypersexuality and dementia: dealing with inappropriate sexual expression. Br. J. Nurs. 13(22), 1330–1334 (2004)PubMedGoogle Scholar
  25. 25.
    Wallace, M., Safer, M.: Hypersexuality among cognitively impaired older adults. Geriatr. Nurs. 30(4), 230–237 (2009)PubMedCrossRefGoogle Scholar
  26. 26.
    Bird, M., Moniz-Cook, E. Challenging behavior in dementia: a psychosocial approach to intervention. Handbook of the clinical psychology of ageing, p 443. (2008)Google Scholar
  27. 27.
    Alkhalil, C., Tanvir, F., Alkhalil, B., Lowenthal, D.T.: Treatment of sexual disinhibition in dementia: case reports and review of the literature. Am. J. Ther. 11(3), 231–235 (2004)PubMedCrossRefGoogle Scholar
  28. 28.
    Philo, S.W., Richie, M.F., Kaas, M.J.: Inappropriate sexual behaviour. J. Gerontol. Nurs. 22(11), 17–22 (1996)PubMedGoogle Scholar
  29. 29.
    Coen, R.F., Swanwick, G.R., O’Boyle, C.A., Coakley, D. Int. J. Geriatr. Psychiatry 12(3), 331–336. (1997)Google Scholar
  30. 30.
    Steele, C., Rovner, B., Chase, G.A., Folstein, M.: Psychiatric symptoms and nursing home placement of patients with Alzheimer’s disease. Am. J. Psychiatr. 147, 1049–1051 (1990)PubMedGoogle Scholar
  31. 31.
    Onishi, J., Suzuki, Y., Umegaki, H., Endo, H., Kawamura, T., Imaizumi, M., Iguchi, A.: Behavioral, psychological and physical symptoms in group homes for older adults with dementia. Int. Psychogeriatr. 18(1), 75–86 (2006)PubMedCrossRefGoogle Scholar
  32. 32.
    Knight, C., Alderman, N., Johnson, C., Green, S., Birkett-Swan, L., Yorstan, G.: The St Andrew’s sexual behaviour assessment (SASBA): development of a standardized recording instrument for the measurement and assessment of challenging sexual behaviour in people with progressive and acquired neurological impairment. Neurol. Rehabil. 18(2), 129–159 (2008)CrossRefGoogle Scholar
  33. 33.
    Szasz, G.: Sexual incidents in an extended care unit for aged men. J. Am. Geriatr. Soc. 31(7), 407–411 (1983)PubMedGoogle Scholar
  34. 34.
    Wick, J.Y., Zanni, G.R.: Disinhibition: clinical challenges in the long-term care facility. Consult. Pharm. 20(12), 1006–1018 (2005)PubMedCrossRefGoogle Scholar
  35. 35.
    de Medeiros, K., Rosenberg, P.B., Baker, A.S., Onyike, C.U.: Improper sexual behaviours in elders with dementia living in residential care. Dement. Geriatr. Cogn. Disord. 26(4), 370–377 (2008)PubMedCrossRefGoogle Scholar
  36. 36.
    Death, A.K., McGrath, K.C., Handelsman, D.J.: Valproate is an anti-androgen and anti-progestin. Steroids 70, 946–953 (2005)PubMedCrossRefGoogle Scholar
  37. 37.
    Robinson, K.M.: Understanding hypersexuality: a behaviorial disorder of dementia. J. Home health care 21(1), 43–47 (2003)CrossRefGoogle Scholar
  38. 38.
    GuaY, D.R.P.: Inappropriate sexual behaviours in cognitively impaired older individuals. Am. J. Geriatr. Pharmacother. 6(5), 269–288 (2008)PubMedCrossRefGoogle Scholar
  39. 39.
    Baikie, E.: The impact of dementia on marital relationships. Sex. Relationship Ther. 17(3), 289–299 (2002)CrossRefGoogle Scholar
  40. 40.
    Matsuoka, K., Miyamoto, Y., Ito, H., Kurita, H.: Relationship between behaviorial disturbances and characteristics of patients in special units for dementia. Psychiatry Clin. Neurosci. 57(6), 569–574 (2003)PubMedGoogle Scholar
  41. 41.
    Ozkan, B., Wilkins, K., Muralee, S., Tampi, R.R.: Pharmacotherapy for inappropriate sexual behaviours in dementia: A systematic review of literature. Am. J. Alzheimers Dis. Other Demen. 23(4), 344–354 (2008)PubMedCrossRefGoogle Scholar
  42. 42.
    Tucker, I.: Management of inappropriate sexual behaviours in dementia: a literature review. Int. Psychogeriatr. 22(5), 683–692 (2010)PubMedCrossRefGoogle Scholar
  43. 43.
    Robinson, K.M.: Understanding hypersexuality: a behaviorial disorder of dementia. J. Home Health Care 21(1), 43–47 (2003)CrossRefGoogle Scholar
  44. 44.
    Series, H., Degano, P.: Hypersexuality in dementia. Adv. Psychiatr. Treat. 11, 424–431 (2005)CrossRefGoogle Scholar
  45. 45.
    Buhr, G.T., White, H.K.: Difficult behaviours in long-term care patients with dementia. J. Am. Med. Dir. Assoc. 7, 180–192 (2006)PubMedCrossRefGoogle Scholar
  46. 46.
    Lesser, J.M., Hughes, S.V., Jemelka, J.R., et al.: Sexually inappropriate behaviours: assessment necessitates careful medical and psychological evaluation and sensitivity. Geriatrics 80, 34–37 (2005)Google Scholar
  47. 47.
    Meston, Frolich.: The neurobiology of sexual function. Arch. Gen. Psychiatr. 57(11), 1012–1030 (2000)PubMedCrossRefGoogle Scholar
  48. 48.
    Daniell, H.W.: Dementia and testosterone levels in men. JAMA 293(5), 551 (2005)PubMedCrossRefGoogle Scholar
  49. 49.
    Hogervorst, E., Combrinck, M., Smith, A.D.: Testosterone and gonadotropin levels in men with dementia. Neuro. Endocrinol. Lett. 24(3–4), 203–208 (2003)PubMedGoogle Scholar
  50. 50.
    Tsai, S.J., Hwang, J.P., Yang, C.H., Liu, K.M.: Inappropriate sexual behaviours in dementia: a preliminary report. Alzheimer Dis. Assoc. Disord. 13(1), 60–62 (1999)PubMedCrossRefGoogle Scholar
  51. 51.
    Derouesne, C., Guigot, J., Chermat, V., Winchester, N., Lacomblez, L.: Sexual behavioural changes in Alzheimer disease. Alzheimer Dis. Assoc. Disord. Summer 10(2), 86–92 (1996)CrossRefGoogle Scholar
  52. 52.
    Ryden, M.B.: Aggressive behaviour in persons with dementia who live in the community. Alzheimer Dis. Assoc. Disord. 2(4), 342–355 (1988)PubMedCrossRefGoogle Scholar
  53. 53.
    Ryden, M.B., Bossenmaier, M., McLachlan, C.: Aggressive behaviour in cognitively impaired nursing home residents. Res. Nurs. Health 14(2), 87–95 (1991)PubMedCrossRefGoogle Scholar
  54. 54.
    Kolanowski, A.M., Garr, M.: The relation of premorbid factors to aggressive physical behaviour in dementia. J. Neurosci. Nurs. 31(5), 278–284 (1999)PubMedCrossRefGoogle Scholar
  55. 55.
    Burns, A., Jacoby, R., Leby, R.: Psychiatric phenomenon in Alzheimer’s disease. IV: disorders of behavior. Br. J. Psychiatr. 157, 86–94 (1990)CrossRefGoogle Scholar
  56. 56.
    Kamel, H.K., Hajjar, R.R.: Sexuality in the nursing home, part 2: managing abnormal behaviour—legal and ethical issues. J. Am. Med. Dir. Assoc. 4(4), 203–206 (2004)CrossRefGoogle Scholar
  57. 57.
    Archibald, C.: Sexuality and dementia in residential care—whose responsibility? Sex. Relatsh. Ther. 17(3), 301–309 (2002)CrossRefGoogle Scholar
  58. 58.
    Wiseman, S.V., McAuley, J.W., Freidenberg, G.R., Freidenberg, D.L.: Hypersexuality in patients with dementia: possible response to cimetidine. Neurology 54(10), 2024 (2000)PubMedGoogle Scholar
  59. 59.
    Alkhalil, C., Tanvir, F., Klkhalil, B., et al.: Treatment of sexual disinhibition in dementia. Case reports and review of the literature. Am. J. Ther. 11(3), 231–235 (2004)PubMedCrossRefGoogle Scholar
  60. 60.
    Baldwin, D.S.: Sexual dysfunction associated with antidepressant drugs. Exp. Opin. Drug. Safety 3, 457–470 (2004)CrossRefGoogle Scholar
  61. 61.
    Levinsky, A.M., Owen, N.J.: Pharmacologic treatment of hypersexuality and paraphiliac in nursing home residents. J. Am. Geriatr. Soc. 47, 231–234 (1999)Google Scholar
  62. 62.
    Light, S.A., Holroyd, S.: The use of medroxyprogesterone acetate for the treatment of sexually inappropriate behaviour in patients with dementia. J. Psychiatr. Neurosci. 31(2), 132–134 (2006)Google Scholar
  63. 63.
    Haussermanmn, P., Goecker, D., Beier, K., et al.: Low dose cyproterone acetate treatment of sexual acting out in men with dementia. Int. Psychogeriatr. 15(2), 181–186 (2003)CrossRefGoogle Scholar
  64. 64.
    Kyomen, H.H., Noble, K.W., Wie, J.Y.: The use of estrogen to decrease aggressive physical behaviour in elderly men with dementia. J. Am. Geriatr. Soc. 39(11), 1110–1112 (1991)PubMedGoogle Scholar
  65. 65.
    Chemali, Z.: Donepezil and hypersexuality: a report of two cases. Primary Psychiatr. 10(7), 78–79 (2003)Google Scholar
  66. 66.
    Ott, B.R.: Leuprolide treatment of sexual aggression in a patient with dementia and Kluver-Bucy syndrome. Clin. Neuropharmacol. 18, 443–447 (1995)PubMedCrossRefGoogle Scholar
  67. 67.
    Stewart, J.T., Shin, K.J.: Paroxetine treatment of sexual disinhibition in dementia. Am. J. Psychiatr. 154, 1474 (1997)PubMedGoogle Scholar
  68. 68.
    Alagiakrishnan, K., Sclater, A., Robertson, D.: Role of cholinesterase inhibitor in the management of sexual aggression in an elderly demented woman. J. Am. Geriatr. Soc. 51(9), 1326 (2003)PubMedGoogle Scholar
  69. 69.
    Herrman, N., Lanctot, K., Myszak, M.: Effectiveness of gabapentin for the treatment of behavioural disorders in dementia. J. Clin. Psychopharmacol. 20, 90–93 (2000)CrossRefGoogle Scholar
  70. 70.
    Miller, L.J.: Gabapentin for treatment of behavioural and psychological symptoms of dementia. Ann. Pharmacother. 35(4), 427–431 (2001)PubMedCrossRefGoogle Scholar
  71. 71.
    Freyman, N., Michael, R., Dodel, R., et al.: Successful treatment of sexual disinhibition in dementia with carbamazepine. Pharmacopsychiatry 38, 144–145 (2005)CrossRefGoogle Scholar
  72. 72.
    Kamel, H.K., Hajjar, R.R.: Sexuality in the nursing home, part 2: managing abnormal behaviour-legal and ethical issues. J. Am. Med. Dir. Assoc. 5(2), 48–52 (2004)CrossRefGoogle Scholar
  73. 73.
    Mayers, K.S., McBride, D.: Sexuality training for caretakers of geriatric residents in long term care facilities. Sex. Disabil. 16(3), 227–236 (1998)CrossRefGoogle Scholar
  74. 74.
    Peate, I.: Sexuality and sexual health promotion for the older person. Br. J. Nurs. 13(4), 188–193 (2004)PubMedGoogle Scholar
  75. 75.
    Zencius, A., Wesolowski, M.D., Burke, W.H., Hough, S., Zencius, A.: Managing hypersexual disorders in brain-injured clients. Brain Inj. 4(2), 175–181 (1990)PubMedCrossRefGoogle Scholar
  76. 76.
    Lyder, C.H.: NPs play major role in promoting sexuality among institutionalized elderly. Nurse Pract. 17(9), 10–13 (1992)PubMedCrossRefGoogle Scholar
  77. 77.
    Roach, S.M.: Sexual behaviour of nursing home residents: staff perceptions and responses. J. Adv. Nurs. 48(4), 371–379 (2004)PubMedCrossRefGoogle Scholar
  78. 78.
    Holmes, D., Reingold, J., Teresi, J.: Sexual expression and dementia. Views of caregivers: a pilot study. Int. J Geriatr. Psychiatr. 12(7), 695–701 (1997)CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Marianna S. Tsatali
    • 1
  • Magda N. Tsolaki
    • 1
  • Tessa P. Christodoulou
    • 2
    • 3
  • Vasileios T. Papaliagkas
    • 4
  1. 1.3rd Department of Neurology, Greek Alzheimer AssociationAristotle University of ThessalonikiThessalonikiGreece
  2. 2.ThessalonikiGreece
  3. 3.Greek Alzheimer’s AssociationThessalonikiGreece
  4. 4.Department of Physiology, Faculty of MedicineAristotle University of ThessalonikiThessalonikiGreece

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