Understanding and managing inappropriate sexual behavior in dementia - Lizzy Care Guide

Sometimes people with dementia can say or do things of a sexual nature that are inappropriate. This can be hard to adjust to and manage as a caregiver. Understand why this behavior occurs and what you can do to avoid it.

Your loved one may have started to use language that you have never heard them use before and which seems very out of character. Or a loved one who was previously very reserved, might have started to remove their clothes in public. 

These kinds of inappropriate sexual behaviors are a common and potentially very disruptive but they are one of the hardest things to talk about. When a loved one starts to behave in this way it can be embarrassing, it reduces their dignity and it might put their safety, or the safety of others, at risk. 

Inappropriate sexual behavior in a loved one is not a reflection of your relationship with them and it can be just as important for you to get help adjusting to or coping with these new behaviors as your loved one. 

Changes in sexual behavior can be extremely distressing to you, family members and friends. This course aims to help us understand why inappropriate sexual behavior can occur and how you can manage it. 

What is inappropriate sexual behavior

Inapproprate sexual behavior can include a wide range of behaviors such as inappropriate sexual comments, making sexual advances to others, talking about sex constantly and undressing or personal touching in public.

It can be useful to think about inappropriate sexual behaviour as breaking down into  three main categories: 

Sex talk

Sex talk is use of foul or inappropriate langugage. Some people with dementia make explicit sexual comments, which can be very uncomfortable. 

Sex acts

This might include acts of touching, grabbing, exposing, or masturbating. The act might occur in a private or in a public area. 

Implied sex acts

This would include things like openly reading pornographic materials or requesting unnecessary genital care. 

To understand why changes in sexual behavior occur continue to the next section.

Why do changes in sexual behavior happen?

The cognitive deteriation, lack of judgement and changes to personality that are part of dementia all play a role in changes to sexual attitudes and beavior. The most common change in sexual behaviour for people with dementia is apathy or indifference to sex. 

However, inappropriate sexual behavior, which is sometimes called sexually disinhibited behavior, or hypersexuality is much less common. Research indicates that the number of people with dementia who demonstrate sexual behavior that is inapropriate varies from 7% to as much as 17%.

Inappropriate sexual behavior seems to be more common for people who are in a nursing home or other facility. It is also reported to be more common in men than women and seems to occur more frequently at the mild stages of dementia. 

There are number of reasons that sexual behavior may increase with dementia.

Factors relating to the dementia diagnosis: 

• People with dementia can often experience a decline in their ability to remember normal etiquette and that includes speech and acts of a sexual nature. 
• People with dementia also suffer from sensory impairments which can result in the misinterpretation of cues such as those seen on television or in their carers. 
• Sexual disinhibition is a recognised feature of frontal lobe lesions and forms part of Kluver–Bucy syndrome, a very rare cerebral neurological disorder associated with damage to both temporal lobes.
• Disinhibition can also be caused due to organic brain disease, which can occur in frontotemporal dementias (FTD). 
• Delusions, hallucinations and misidentifications are all common for people with dementia and can result in actions or behaviors that are inappropriate or misjudged.  

Role of social factors:

• People with dementia can become unsettled if placed in unfamiliar environments. 
• An understimulating environment can also be a factor in behavior change for people with dementia.
• The lack of a usual sexual partner can cause confusion or be unsettling. 
• People with dementia often experience a loss of their own privacy. 

Psychological factors play a part:

• Pre-existing patterns of sexual activity and interests can continue or worsen following the development of dementia 
• Other changes in mood that commonly occur in dementia, such as depression and mania alos play a role in affecting sexual interest.

Drugs/medications can also contribute: 

• Alcohol and benzodiazepines can produce behavioural and sexual disinhibition in both healthy people and those with dementias
• l-DOPA, also known as levodopa has been known to cause hypersexuality in people with Parkinson’s disease.

Coping with inappropriate sexual behavior

Techniques for managing inappropriate sexual behavior

Provide reassurance: 

Reassuring the individual is vital in minimizing any hypersexual behaviors. Reinforce and remind your loved one about social norms. While this can become more difficult if your loved one is at an advanced stage of the disease it is still important to be a stabilizing influence on your loved one. 

Be firm: 

When inappropriate behaviors occur, sensitively explain to your loved one that such behaviors are not acceptable. Avoid confrontation and do not try to guilt or shame your loved one. State clearly and calmly that you do not like the behavior. You can use phrases like: “Please do not say that to me.” 

Make sure that your body language matches your words. People with dementia are better at reading the non-verbal signals. You can frown and shake your head as well as telling them that you don’t like their behavior. 

If your loved one is inappropriately touching you then place their hand back into their lap, look them in the eye and firmly tell them that the behavior will not be tolerated. 

Be consistent: 

Do not allow inappropriate behavior to happen one day and the next react to it. Take the same firm approach each time an inappropriate act occurs. 

Redirect their attention: 

Redirection can be an extremely useful tool. This might include offering your loved one a snack or a drink, quickly changing the topic of conversation, or proposing doing some exercise. 

You can also quickly respond with phrases like: 

• “Dad, are you hot? Is that why you’re taking off your shirt.” 
• “Mom, it’s cold in here, leave your shirt on.” 
• “Dad, are you fidgeting with your zipper because you need the bathroom? If you’re not then we can go out for a walk.”

Alleviate boredom: 

People with dementia can often be left in an under-simulated environment. The sexual behavior my be a response to their not being other activities to distract them. Make sure you have a schedule of activities and keep your loved one engaged throughout the day. You can offer your loved one something to do with their hands to keep them busy. Some people with dementia like textures so you can give them something to feel and play with. 

Offer physical attention: 

The type of physical attention you can provide will depend on your relationship to your loved one. 

If you are a spouse or partner then you can snuggle while watching TV or listening to the radio. Provide hugs. Dance with them. Offer them a massage to the back, shoulders, feet or hands. 

If you are a child or other family member then you can still hold their hand or give them hugs. 

It’s normal for anyone to crave intimacy so make sure that your routine incorporates meaningful quality time together with your loved one. 

Offer physical alternatives: 

Offer your loved one a blanket or stuffed animal to pet. 

How to handle undressing in public

If you loved one is undressing in public or has a tendency to exhibit themselves then you can consider practical solutions such as having them wear clothing that opens at the back or that doesn’t have a zipper. Keep an extra shawl or sweater around so you can quickly cover them. Make sure you keep an eye out for cues like fidgeting or fumbling with buttons or a zipper. Even when you are embarrassed or agitated keep your cool, if you shout at your loved one you may make the situation worse. 

If behavioral management isn’t working then you can investigate the use of a medication to help tamper down some of the inappropriate behaviors. See the next section for more information. 

Medication in the treatment of inappropriate sexual behavior

Research on inappropriate sexual in dementia has been limited and while many medication based interventions have been tried there isn’t sufficient evidence to suggest that they are effective and there is also a risk of adverse side effects to consider. Medications that have been tried to treat inappropriate sexual behavior in dementia include antidepressants, antipsychotics, anticonvulsants, cholinesterase inhibitors, hormonal agents, and beta-blockers. 

However, the use of medication can also produce a number of other side-effects that also need to be managed. If your loved one is receving a medication to help control some of their inappropriate sexual behavior it is important to keep an eye out for the emergence of any side effects. 

It is possible that a medication may still be of some benefit but before trying any medication we recommend a serious talk with your loved one’s clinical team. 

Talk with others

Managing inappropriate sexual behavior is what of the most challenging and stressful aspects of being a caregiver for dementia. Make sure that you look after yourself by giving yourself someone to talk to. 

If you have a case manager or clinical team very involved in your loved ones care then it is important to discuss your concerns with them so that you can work together. Don’t be too afraid or embarrassed to ask.  

If you need any additional help or guidance get in touch.