Sexually Inappropriate Behavior In the LTC Setting

Transcription

1 Sexually Inappropriate Behavior In the LTC Setting Douglas F. Steenblock, MD Iowa Veteran s Home

2 Dr. Steenblock does not have a relationship with a commercial interest but may discuss off-label uses of a commercial product and will disclose this to the audience.

3 Iowa Veterans Home

4 Misconceptions and Myths about Sexuality and Aging Sexuality in seniors is: Nonexistent. Comical. Disgusting. Against the rules in LTC facilities. Assumed to be heterosexual. Primarily intercourse.

5 How active are they? Prevalence of sexual activity (with another): 75% of % of % of Men slightly more active than women. Prevalence of masturbation: Single: 55% of men and 23% of women. Roughly the same for partnered. Drops with age.

6 Why is Sexual Activity on the Rise? Healthier Treatments (Viagra and hormonal) Boomers (sexual revolution) Retirement communities

7 Sexually Transmitted Diseases Increased incidence of chlamydia and syphilis Increase in Medicare STD screenings Outbreaks in some retirement communities Seniors not practicing safe sex

8

9 Age Related Changes Women: Men: Vaginal dryness Vaginal atrophy Decreased lubrication Hot flashes Erectile dysfunction Delayed/hurried orgasm

10 Obstacles to Sexual Activity in LTC Facilities Lack of privacy Lack of willing partners Health concerns Lack of information for staff/family Attitude of staff/family

11 Medical Conditions That Can Interfere with Sexual Activity Arthritis Chronic pain Heart disease Diabetes Stroke Incontinence Surgery (mast, gyn, urol)

12 Medications That Can Interfere With Sexual Activity Antidepressants (and other psych meds) Antihypertensives Antihistamines Treatments for BPH and prostate CA Treatments for peptic ulcer disease Opioids Others

13 Sexuality in Nursing Homes 13% offered staff specific training 23-30% had a specific policy

14 When should sexual behavior in a LTC facility be considered inappropriate? Questions to consider:

15 Intent of resident?

16 Is anyone being harmed?

17 Is anyone being taken advantage of?

18 Are the residents involved in the activity consenting?

19 Do the residents involved in the activity all have adequate decisionmaking capacity (DMC)? If not, how does that resident s decision-maker feel about the activity?

20 Does the activity break any laws?

21 Is the activity unsafe or unhealthy?

22 Is the activity disruptive or intrusive? Does it violate the rights of other residents?

23 Is the activity undignified for the resident? Is it consistent with their past behavior/attitudes?

24 Are your own feelings or attitudes affecting your judgment on this matter?

25

26 Assessing Consent: Lichtenberg s Questions 1. Aware of relationship? 2. Able to avoid exploitation? 3. Aware of risks?

27 Patient s awareness of the relationship Is the patient aware of who is initiating sexual contact? Does the patient believe that the other person is a spouse and, thus, acquiesces out of a delusional belief, or [is he/she] cognizant of the other s identity and intent? Can the patient state what level of sexual intimacy [he/she] would be comfortable with?

28 Patient s ability to avoid exploitation: Is the behavior consistent with formerly held beliefs/values? Does the patient have the capacity to say no to uninvited sexual contact?

29 Patient s awareness of potential risks: Does the patient realize that this relationship may be time limited (if placement on unit is temporary)? Can the patient describe how [he/she] will react when the relationship ends?

30 Sexually Inappropriate Behavior (SIB)

31 Examples Touching staff or peers in a sexual manner Unwanted sexual comments Asking for unnecessary genital care Masturbating in public Exposing oneself deliberately Exposing others to pornography Intimacy seeking (AD) Sexual aggression/coercion

32 Intent/Context The confused person who misidentifies/misinterprets. The impulsive person. The menacing aggressor. The lonely person. The manic person.

33 How common is SIB in those with cognitive impairment? Various authors have reported rates as low as 1.8% and as high as 25%: Probably in 5-10% range Most authors report that the vast majority are male May be more common in vascular, alcoholic or frontotemporal dementias

34 Disorders associated with SIB: Dementia (Alz, vasc, frontotemp, etc.) Traumatic Brain Injury Stroke Parkinson s Disease (medication?) Huntington s Disease Kluver-Bucy Syndrome (seen in various brain disorders) Bipolar mania Substance use Personality disorder

35 Causes: Biological Disorders with frontal lobe dysfunction. Cannot remember social norms. Delusions or hallucinations can lead to misidentity. Sensory impairment. Substances: Dopaminergic, benzodiazepines, alcohol.

36 Causes: Environmental Lack of privacy Understimulation Misinterpretation of cues Unfamiliarity

37 Causes: Psychological Premorbid sexual habits Mood changes Lack of sexual outlets Poor impulse control

38 If related to dementia, SIB may subside as disease progresses. But in some cases, such as TBI, behaviors may persist indefinitely

39 Management of SIB Advice to Staff:

40 Document carefully

41 Inform and involve family early on

42 Gather detailed information

43 Be creative and individualized One size doesn t fit all

44 Be aware of your own feelings and attitudes Don t overreact

45 History Find out from staff precisely what happened (ABC): Gratified? Aggressive? Confused? Talk to family about past behaviors. In some cases, may want to get criminal background check.

46 Non-Pharmacologic Interventions Distract/redirect Modify environment Reinforce positive behavior Don t reinforce negative behavior (be robotic) Firm limits with meaningful consequences Develop appropriate sexual outlets Special clothing (jumpsuit w/ zipper back) Treat co-morbid psychiatric disorders

47 What about the lonely person? Don t cause them to feel ashamed or embarrassed. But clear boundaries must be communicated. Leave them feeling like this was a misunderstanding and it s still possible to work together.

48 Pharmacologic Should be last resort

49 Antidepressants Effectiveness not well established Takes 1-4 weeks to see benefit SSRIs: Paroxetine Citalopram Sertraline Others TCAs

50 Antipsychotics/Mood stabilizers More beneficial if psychotic or manic; effectiveness not well established for this indication Antipsychotics QUETIAPINE Risperidone Olanzapine Ziprasidone Aripiprazole Haloperidol Mood Stabilizers Carbamazepine Divalproex Lithium

51 Hormonal CONSENT Off-label use Only for males Testosterone levels (pre and post treatment) May be more effective in cases where sexual gratification occurs (erection) Side effects: Weight gain, retain fluid, thromboembolic events, gynecomastia Many Types; no one treatment is considered more effective than others

52 Types of Homonal Treatments Medroxyprogesterone 150 to 300 mg IM q 2-4 weeks Estrogen to 2.5 mg po q day (also in patch) Leuprolide 3.75 to 15 mg IM q 2-4 weeks Others

53 Others Cimetadine 600 to 1600 mg q day Trazodone Cholinesterase inhibitors Finasteride

54 Questions/Comments

55 References -Alagiakrishnan K, Lim D, Brahim A, Wong A, Wood A, Senthilselvan A, ChimichWT, Kagan L. Sexually inappropriate behaviour in demented elderly people.postgrad Med J Jul;81(957): PubMed PMID: ; PubMed CentralPMCID: PMC Alkhalil C, Tanvir F, Alkhalil B, Lowenthal DT. Treatment of sexual disinhibition in dementia: case reports and review of the literature. Am J Ther May-Jun;11(3): Review. PubMed PMID: Alkhalil C, Hahar N, Alkhalil B, Zavros G, Lowenthal DT. Can gabapentin be asafe alternative to hormonal therapy in the treatment of inappropriate sexualbehavior in demented patients? Int Urol Nephrol. 2003;35(2): PubMed PMID: Anneser JM, Jox RJ, Borasio GD. Inappropriate sexual behaviour in a case ofals and FTD: successful treatment with sertraline. Amyotroph Lateral Scler Jun;8(3): PubMed PMID: Black B, Muralee S, Tampi RR. Inappropriate sexual behaviors in dementia. JGeriatr Psychiatry Neurol Sep;18(3): PubMed PMID: Caldy J. Consenting Adults: Making Sex Safer for Senior Residents. Caring For The Ages, AMDA. June 2015 Vol. 16, No. 6 -de Medeiros K, Rosenberg PB, Baker AS, Onyike CU. Improper sexual behaviors in elders with dementia living in residential care. Dement Geriatr Cogn Disord.2008;26(4): Epub 2008 Oct 16. PubMed PMID: Dominguez L, Barbagallo M, Ageing and Sexuality. European Geriatric Medicine 7 (2016) Guay DR. Inappropriate sexual behaviors in cognitively impaired older individuals. Am J Geriatr Pharmacother Dec;6(5): Review. PubMedPMID: Hajjar RR, Kamel HK. Sexuality in the nursing home, part 1: attitudes and barriers to sexual expression. J Am Med Dir Assoc Mar- Apr;5(2 Suppl):S42-7.Review. PubMed PMID: Harris, L. & Wier, M. Inappropriate sexual behavior in dementia: A review of the treatment literature. Sexuality and Disability, 16, Haussermann P, Goecker D, Beier K, Schroeder S. Low-dose cyproterone acetate treatment of sexual acting out in men with dementia. Int Psychogeriatr. 2003Jun;15(2): PubMed PMID: Johnson C, Knight C, Alderman N. Challenges associated with the definition and assessment of inappropriate sexual behaviour amongst individuals with anacquired neurological impairment. Brain Inj Jun;20(7): Review.PubMed PMID: Kamel HK, Hajjar RR. Sexuality in the nursing home, part 2: managing abnormal behavior--legal and ethical issues. J Am Med Dir Assoc Mar-Apr;5(2Suppl):S Review. PubMed PMID: Kettl, P. Inappropriate Sexual Behavior in Long-Term Care. Annals of LTC, Vol 16, Dec Light SA, Holroyd S. The use of medroxyprogesterone acetate for the treatment of sexually inappropriate behaviour in patients with dementia. J PsychiatryNeurosci Mar;31(2): PubMed PMID: ; PubMed Central PMCID:PMC Lichtenberg, P. & Strzepek, D. Assessments of institutionalized dementia patients' competencies to participate in intimate relationships. Gerontologist, , Lichtenberg, P. A. Clinical perspectives on sexual issues in nursing homes. Top Geriatr Rehabil, , 1-10

56 References (continued) -Mahieu L, Gastmans C. Older residents perspectives on aged sexuality in institutionalized elderly care: A systematic literature review. International Journal of Nursing Studies 52 (2015) Lindau S, et al. A Study of Sexuality and Health among Older Adults in the United States. N Engl J Med 2007;357: Na HR, Lee JW, Park SM, Ko SB, Kim S, Cho ST. Inappropriate sexual behaviors in patients with vascular dementia: possible response to finasteride. J AmGeriatr Soc Nov;57(11): PubMed PMID: Nagaratnam N, Gayagay G Jr. Hypersexuality in nursing care facilities a descriptive study. Arch Gerontol Geriatr Nov- Dec;35(3): PubMedPMID: Ott BR. Leuprolide treatment of sexual aggression in a patient with Dementia and the Klüver-Bucy syndrome. Clin Neuropharmacol Oct;18(5): PubMedPMID: Ozkan B, Wilkins K, Muralee S, Tampi RR. Pharmacotherapy for inappropriate sexual behaviors in dementia: a systematic review of literature. Am J Alzheimers Dis Other Demen Aug-Sep;23(4): Review. PubMed PMID: Prakash R, Pathak A, Munda S, Bagati D. Quetiapine effective in treatment of inappropriate sexual behavior of lewy body disease with predominant frontal lobe signs. Am J Alzheimers Dis Other Demen Apr-May;24(2): Epub 2009 Jan 7. PubMed PMID: Series, H and Degano P. Hypersexuality in Dementia. Advances in Psychiatric Treatment (11) : Reilly DR, Delva NJ, Hudson RW. Protocols for the use of cyproterone, medroxyprogesterone, and leuprolide in the treatment of paraphilia. Can JPsychiatry Aug;45(6): Review. PubMed PMID: Shilpa Srinivasan, MD, and Andrew D. Weinberg, MD, FAC Pharmacologic Treatment of Sexual Inappropriateness in Long-Term Care Residents with Dementia. Annals of LTC Oct (10). -Tsai SJ, Hwang JP, Yang CH, Liu KM, Lirng JF. Inappropriate sexual behaviors in dementia: a preliminary report. Alzheimer Dis Assoc Disord. 1999Jan;13(1):60-2. PubMed PMID: Tucker I. Management of inappropriate sexual behaviors in dementia: a literature review. Int Psychogeriatr Mar 15:1-10. [Epub ahead of print]pubmed PMID: Wallace M, Safer M. Hypersexuality among cognitively impaired older adults.geriatr Nurs Jul-Aug;30(4): Epub 2009 Apr 8. Review. PubMed PMID: Zeiss AM, Davies HD, Tinklenberg JR. An observational study of sexual behavior in demented male patients. J Gerontol A Biol Sci Med Sci. 1996Nov;51(6):M PubMed PMID: