Inappropriate Sexual Behavior in Long-Term Care

Author Affiliations: Dr. Kettl is Clinical Professor of Psychiatry, Penn State College of Medicine, Hershey, PA, and on staff at Lancaster General Hospital, Lancaster, PA. _____________________________________________________________________________________________________________________

As people age, physical problems may increase but sexuality remains an active interest. It is estimated that approximately 60% of normal older persons have an interest in maintaining sexual activity.¹ In a survey of men age 60-69 years, 52% had attempted sexual intercourse in the previous four weeks.² Today, nursing home staff and administrators recognize that sexual expression and interest continue with many older residents. There is a recognition that “regardless of age, every individual has a need for love, intimacy and companionship,”³ including those in long-term care (LTC) facilities. Nursing home staff generally accept a resident’s sexual expression, and one survey of nursing home staff showed that staff had a “generally positive orientation towards residents’ sexual expression, which was expressed with respect to cognitively impaired residents as well as to those who were cognitively intact.”⁴

Unfortunately, sexual expression can become sexual misbehavior in the LTC setting. Young female nursing aides are often the target of sexual misbehavior, and this experience further contributes to the burden of their difficult, physically and emotionally demanding work and can add to the problem of job turnover in LTC settings. Vulnerable residents, especially those suffering from dementia or physical disabilities that prevent mobility, are potential victims of sexual abuse.

Unfortunately, these healthcare providers and residents have the least amount of training to manage these behaviors, and frequently have little experience. Staff of LTC facilities require ongoing training on how to recognize inappropriate sexual behavior and intervene to protect other residents and themselves. Addressing sexual misbehavior in LTC is an important aspect of managing the facility milieu and supporting staff, and intervening in treatable situations.

Evaluating Sexual Behavior

Remarkably little is known about normal sexual behavior among older adults, and much less is known about normal sexual behavior in adults living in LTC facilities. Decisions about what is appropriate, therefore, are often made on the spot, with key decisions made by staff at the facility. Sometimes these decisions are made in discussion with key administrative staff members, but often they are spontaneous reactions by staff who are often overwhelmed by other duties. These decisions are also often based in myth concerning sexuality in older adults, including ideas that they are asexual, have no sexual needs, or feel sexually unattractive.⁵

Some clear examples of inappropriate sexual behavior are evident in LTC settings. A descriptive survey of eight patients referred to a geriatrician in Australia documented some instances of sexual misbehavior.⁶ One man, for example, acted in an uninhibited manner and would touch the breasts of female staff when they assisted him in the shower. Another resident would put his hand down a female resident’s pants. Another man would make inappropriate sexual comments to staff members, touch their genitals, or try to rearrange their clothing. Interestingly, all eight patients had demonstrated neurologic pathology. Six had had strokes, one had Parkinson’s disease, and one had Alzheimer’s disease. Of these eight patients, seven were males.⁶

Evaluating sexual expression among nursing home residents first requires an assessment of their ability to give consent to the sexual behavior. Lichtenberg and Strzepek⁷ suggest three basic questions to evaluate a resident’s ability to participate in an intimate relationship:

1. Is the patient aware of the relationship? Is the patient aware of who is initiating the sexual contact? Does the patient believe that the other person is a spouse, or do they know the other person’s identity and intent? Can the patient state what level of sexual intimacy with which they would be comfortable?

2. What is the patient’s ability to avoid exploitation? Is the behavior consistent with formerly held beliefs or values? Moreover, does the patient have the capacity to say no to uninvited sexual contact?

3. What is the patient’s awareness of potential risks? If the patient realized that the relationship may be time limited, can they describe how they will act if the relationship ends?

Evaluating the ability of residents to give consent to sexual behavior or expression can be a difficult task. However, if both residents are able to give consent, then they are both free to make choices in this area of their life. LTC staff typically do not object to sexual expression for these individuals as long as sexual contact occurs in privacy, and residents are at least somewhat discreet in communicating their relationship to others in the facility.

If one or both members of the couple is cognitively impaired, the situation becomes much more difficult to evaluate. Depending on the severity of the dementia, one or both individuals may not be able to fully understand or “consent” to sex. Here, each situation is a bit different. If the couple has had a longstanding relationship, sexuality is generally accepted to be a part of their relationship, as long as there is no abuse, injury, or complaint from either party. For example, if a couple has been married for decades, and one partner takes his spouse home for a visit and sexual expression occurs during the visit, this is generally thought not to be a problem.

Nursing homes often place married couples in the same room to facilitate closeness in their ongoing relationship. Managing the situation when one member of the married couple is cognitively impaired and the other member desires a continued sexual relationship can be problematic. In that case, staff would need to pay special attention that the relationship remains caring and does not become abusive.

Sexual problems typically arise in the nursing home when one member of the pair is not able to give consent, or when there is a question of violence or abuse in the sexual relationship. In one survey of patients in China admitted to a geriatric psychiatry inpatient unit, inappropriate sexual behavior was assessed by a questionnaire completed by each patient’s caregivers.⁸ Fifteen percent had some form of inappropriate sexual behavior either before or during the hospitalization. Those exhibiting inappropriate sexual behavior did not differ from other patients with regard to their age, gender, educational level, or Mini-Mental State Examination score.⁸

An observational survey of 40 patients in a U.S. nursing home showed that 18% of patients displayed a sexually inappropriate behavior.⁹ When it occurred, these behaviors were usually both brief and minor. A Canadian study showed that only 1.8% of patients referred to nursing home consultation services, a community geriatric psychiatry service, or an inpatient dementia psychiatry service demonstrated sexually inappropriate behavior.¹⁰ Of these patients, 65.7% demonstrated verbally inappropriate behavior, and 87.8% demonstrated physically sexually inappropriate behavior. While hypersexuality in the nursing home occurs, it is not as common as other mental health issues.¹¹

Educating Nursing Aides

As mentioned, the majority of “hands-on care” in LTC facilities is delivered by nursing aides, who, unfortunately, typically have the least amount of training. The complex issue of recognizing and managing sexually inappropriate behavior often falls on their shoulders. These caregivers are usually the “eyes and ears” of the staff. Usually young females are most likely to experience physical or sexual assault. It is essential that they be educated to recognize this behavior, and know that sexual assault is not appropriate in this or any setting. Nursing aides should know whom to address for further guidance, and have a supervisor who is comfortable discussing these concerns. Likewise, behavioral management strategies to help to control this behavior typically will fall to them to enforce. Taking time to educate aides about these issues and how to effectively manage problems along the way is a useful investment of time. Knowing that they can seek the counsel of more experienced staff may well help to decrease work tensions, and help to guide them to a greater work satisfaction. Time spent in additional training may help to decrease staff turnover.

Assessment of Inappropriate Sexual Behavior

An appropriate assessment will hopefully lead to an appropriate diagnosis and treatment. Is this a new behavior related to the patient’s dementia or is it simply another presentation of life-long sexual misbehavior? Can these symptoms be related to a psychiatric disorder, use of dopamine agonists, or a urinary tract infection? Once the source is identified, treatment of the underlying psychiatric or medical disorder or removing the offending medication can be very effective.

A way of evaluating the sexual misbehavior in the patient should be agreed upon by the staff of the nursing home before initiating treatment. The problem should be specifically identified as well as a way to measure the problem behavior. Is the treatment goal decreasing sexual physical aggression? If so, a way of measuring the frequency of physical assault is necessary. Because this behavior is so threatening and so uncomfortable, even a low level of the behavior can be intolerable to some staff members. A treatment that decreases the behavior by half may be viewed by some caregivers as ineffective. However, it may also be viewed as partially successful. Treatment can only be evaluated if a systematic way of measuring the behavior is in place before initiating any treatment trial.

Psychiatric/Neurological Causes
Assessment of the sexually inappropriate behavior first involves a good understanding of the exact nature of the behavior. Those with cognitive impairment frequently display disorganized behaviors such as walking out of a bathroom partially clothed or disrobing.⁹ These behaviors are more a symptom of their disorganization or confusion from their dementia rather than inappropriate sexual expression. However, verbal sexually inappropriate behavior as well as physical sexual attack occurs. It should be noted as to whether this occurs primarily with staff or peers. Is one individual—either a staff member or peer—selected to be the victim? Why is that one person selected as a sexual object? For example, if a patient misperceives another resident as being his/her spouse, often separating the two can help to eliminate the behavior. If the resident engages in inappropriate sexual behavior during bathing, having other staff members bathe him/her or be present during bathing or personal care may be helpful so the patient does not misperceive that physical contact.

If the patient suffers from dementia, the type of dementia may provide useful information. Those with frontotemporal dementia may demonstrate increased sexuality, grandiosity, and impulsiveness,¹² making these individuals a treatment challenge. Infarcts in the frontal lobes can also be associated with sexual disinhibition in patients.⁶ Likewise, a personality change can be seen commonly in individuals with Alzheimer’s disease. Explaining that the personality change is secondary to the brain injury from the dementing illness can be helpful in gaining a family’s understanding and support for intervention.

The more challenging patients are those in whom the inappropriate sexual behavior is a representation of the brain injury from their dementia, or a continuation of life-long sexual pathology. For these patients, nonpharmacologic or behavioral management strategies should be implemented first.¹³ Evaluating when and with whom these behaviors occur presents opportunity for behavioral intervention. If sexual misbehavior is directed toward a peer, separating the two individuals can be helpful. If sexual misbehavior is directed toward young female staff during personal care such as bathing, having other staff perhaps of the opposite sex deliver personal care can be helpful. It should be remembered that if the patient has significant dementia, behavioral intervention implies changing our behavior in caregiving, not “teaching” him/her more appropriate ways of response. Because the dementia leads to poor judgment and poor short-term memory, the ability of patients with dementia to benefit from such education is quite limited.

In reviewing the sexual misbehavior, does the behavior seem to fit a psychiatric syndrome? For example, sexual misbehavior or overactivity that comes in episodes associated with decreased sleep and grandiosity may be a representation of a manic episode of bipolar disorder. Is the patient psychotic? Does he believe that staff are tormenting him, or disrobing him for sexual activity rather than personal care? Is she hearing voices with sexual content? These symptoms may respond to antipsychotic medication.

Sexual History
In addition to understanding the patient’s symptom presentation, it is also important to understand the patient’s premorbid relationship history and history of sexual expression. If the patient had a poor quality of prior interpersonal relationships, he may simply be reenacting life-long behaviors in the nursing home. Likewise, premorbid sexual pathology or problems in sexual expression can continue as well. Interviewing family members or caregivers can be helpful in obtaining this important history.

Gender
The gender of the patient may also be an important part of the assessment. Data on the differences in prevalence of sexual misbehavior in males and females are scant. Black et al¹⁴ in their review state that “the best estimate is that 7% to 25% of demented patients exhibit inappropriate sexual behaviors. They are more commonly found in men.” Series and Degano¹⁵ concur that rates of sexually disinhibited behavior in patients with dementia range from 2% to 17%. However, they describe nearly equal frequency of this behavior in men (8%) and women (7%). In the prior case series described, seven of eight patients referred for care of sexually inappropriate behavior were male.6 Generally, in the experience of many clinicians, male patients are more often referred for treatment of sexual misbehavior.

Physical Exam and Lab Tests
The importance of obtaining a good and thorough history of the inappropriate sexual behavior has already been discussed. A routine physical evaluation along with a rectal and prostate exam may also be helpful. A mental status exam can help to establish the presence of psychotic symptoms, and a cognitive screen can further elucidate the presence of a dementia and/or its severity.

After the history is obtained, several lab tests can be helpful and are suggested as a “routine” evaluation of sexually inappropriate behavior. Suggested labs for work-up of inappropriate sexual behavior include:

• prostate-specific antigen (PSA)
• luteinizing hormone (LH), testosterone levels
• urinalysis
• liver function tests (LFTs)

Checking PSA levels may also be helpful since antiandrogen compounds are used in the treatment of prostate cancer. Because elevated PSAs are common health problems in older men, checking this can be an important health screen before treatment is initiated.

While the antiandrogen compounds can be helpful in the management of these difficult patients, the use of these medications can also be associated with unwelcome side effects. Monitoring testosterone and LH levels can be helpful in monitoring therapy. However, because sex involves more than hormones, sexual misbehavior also involves more than testosterone, and reducing levels of testosterone does not always eliminate the sexual misbehavior.

Urinalysis can help to document the presence of a urinary tract infection, which can lead to focused attention by the patient on genitals. Finally, because the medications about to be reviewed are metabolized by the liver, checking LFTs before initiating therapy is helpful.

Medication Review
The assessment should include a review of the patient’s medication list. The use of dopamine agonists for Parkinson’s disease and restless legs syndrome can lead to hypersexuality and agitation¹⁶ in some patients. Likewise, a urinary tract infection can lead to delirium, but also to itching or pain on urination. Frequent manual manipulation of genitals may be inappropriate sexual behavior, but it may also be a representation of dysuria from a urinary tract infection.

Pharmacologic Interventions
Unfortunately, even the best behavioral assessment, review of medical and psychiatric symptoms, and behavioral interventions can sometimes lead to no change in this difficult behavior. Ongoing sexual misbehavior can adversely impact the quality of life of patients and caregivers’ ability to care for them. So, in those cases, medication interventions can be selected to try to limit or eliminate sexually inappropriate behavior. Before initiating these medications, it is useful to obtain substituted consent from family members or from powers of attorney who direct the care of the patient. Usually, if they are informed of the thorough assessment that has been conducted, as well as the failure of behavioral interventions, they will consent to medication intervention for inappropriate sexual behavior. The consent, of course, should include information concerning the potential side effects of these medications, as well as how these side effects will be monitored and managed.

The data supporting the use of medications in the treatment of sexual misbehavior in dementia are limited and typically are based on case reports or case series. However, case series do present a variety of options in treating patients with sexual misbehavior in the nursing home.

No medication is approved by the Food and Drug Administration for the treatment of sexually inappropriate behavior. However, a number of existing medications are often used for that purpose in hopes that an extension of their benefits—or even side effects—may be helpful in decreasing sexual misbehavior (Table).

If the patient is suffering from dementia, the first medications that may be tried are the ChoIs if he/she is not already receiving them. ChoIs not only can help cognitive symptoms but may also be of benefit in some behavioral symptoms. At least one case report describes the efficacy of rivastigmine in a woman with sexual misbehavior.¹⁷

Selective serotonin reuptake inhibitors (SSRIs) also are considered as potential treatment for sexual misbehavior.¹⁸ Sexual side effects, including decrease in libido, can be seen with the use of these medications, and they are sometimes given in hopes of inducing this side effect. However, few data are available on how often these agents are helpful for sexual misbehavior in dementia. ChoIs and SSRIs can be used in patients of both genders who display inappropriate sexual behavior.

Antiandrogen agents can also be used in men to decrease sexual aggression and misbehavior.^19,20 Medroxyprogesterone acetate inhibits pituitary gonadotropin release and is used as a contraceptive agent in women. These agents decrease testosterone levels, but also can be associated with the potentially severe side effects of venous thromboembolism and bone density loss. In using them, it is helpful to first obtain a baseline testosterone level and LH level. After treatment for a month, these levels should be rechecked to evaluate whether the levels have been significantly reduced. Significant reductions in the hormone levels have been associated with decreased sexual misbehavior in one case series.¹⁹

Leuprolide (3.75 mg IM q mo) can also be helpful in the treatment of sexual misbehavior in men with dementia.²⁰ Leuprolide also inhibits gonadotropin release, suppressing ovarian and testicular hormone production. In the first 2 weeks of leuprolide treatment, testosterone levels can transiently increase. Flutamide (250 mg po q 8 hr) can also be given with leuprolide in the first few weeks of treatment. Flutamide is an antiandrogen compound that inhibits androgen uptake. Leuprolide has advantages in that it can be given intramuscularly monthly, and administration can be easier in patients with agitation. Bone density loss and rare pulmonary embolism are potential side effects of this medication. In addition, with the use of this compound, testosterone and LH levels should be checked before and 1 month following initiating treatment.

Estradiol (0.05 mg/day patch) patches are occasionally used for inappropriate sexual behavior in men. This medication increases estrogen levels, with the hope that it will affect the balance of sex hormones leading to decreased sexual behavior in general, in addition to decreased sexually inappropriate behavior. Serious adverse reactions including increased risk of stroke, myocardial infarction, venous thromboembolism, or mood changes can accompany their use. More minor side effects of gastrointestinal upset or weight gain may also occur. Again, few data are available to determine exact efficacy.

Cimetidine has been shown to be a nonhormonal antiandrogen agent in rats, with one study of 20 patients with dementia with problematic hypersexual behavior showing that 14 responded to cimetidine treatment alone.²¹ The range in dosage used for cimetidine was from 600 mg to 1600 mg per day. Thus, cimetidine represents another pharmacologic treatment option for sexual misbehavior in patients of both genders in LTC settings.

Summary

Sexual misbehavior, when present, can tax the caregiving resources of staff and can diminish the quality of life of residents who display the behavior. Sexual misbehavior should be investigated as any other symptom, with a clear description of the problem behavior, an evaluation of past relationship and sexual problems, and a review of current medications, and include a urinalysis and PSA in the work-up. This careful assessment should lead to a diagnosis. Behavioral management by the nursing home staff should be the first intervention chosen for the behavior, and family members and powers of attorney should be involved in the process of assessing the behavior and searching for interventions. If behavioral management strategies are ineffective, medications including the cholinesterase inhibitors, specific serotonin reuptake inhibitors, and even cimetidine may be helpful in individuals of both genders with inappropriate sexual behavior. Antiandrogen compounds may also be helpful in men with sexual misbehavior.

Managers in the LTC setting should include training about inappropriate sexual activity in the basic training and orientation for all staff. A recognition that sexuality continues into old age should be appreciated, and methods of recognizing all needs of residents should be an ongoing goal. However, inappropriate sexual behavior should also be recognized and managed. Nursing home aides have the most physical contact with residents and are most likely to experience misbehavior or assault. They should be educated about basic concepts of competence, as well as given clear education that neither verbal nor physical sexual assault will be tolerated.

In assessing and treating sexual misbehavior in the nursing home, clinicians must combine medical assessment skills as well as interpersonal skills to communicate treatment goals and their effectiveness to nursing home staff and family members alike. Managing sexual misbehavior in the nursing home involves caring for the patient, educating the family, and working with nursing home staff to optimize care for this difficult group of patients.

The author reports no relevant financial relationships.