Читать книгу Pathy's Principles and Practice of Geriatric Medicine - Группа авторов - Страница 133

There are many barriers to healthy expression of sexuality in older adults with dementia. As these adults lose functional independence and require more assistance, their personal privacy and ability to engage in sexual activities is diminished. There may also be ethical issues surrounding the ability of older adults with dementia to consent to sexual activity. People with more advanced cognitive decline may not be able to comprehend the ramifications of sexual activity and are at increased risk of sexual abuse. On the other hand, restricting sexual activity may be unfairly infringing upon their autonomy.⁴⁷ For older adults living in the community, caregivers who are familiar with their lifelong habits and beliefs, who may be surrogate decision‐makers in other aspects of their lives, can help provide a safe space for appropriate sexual activity. The situation becomes more complex for those who reside in long‐term care settings, which will be explored later in the chapter.

Sexually inappropriate behaviours may be a manifestation of dementia in some older adults. Some behaviours may be interpreted as misguided displays of affection or intimacy‐seeking (e.g. mistaking a person for their spouse, handholding), while others are disinhibited and inappropriate in most contexts (e.g. groping, lewd outbursts).⁴⁸ Older adults with dementia may not be able to understand the context behind their actions, such as the difference between touching an arm and touching a breast or why it is inappropriate to disrobe in public when it is fine to do so in one’s bedroom. They may also misinterpret the actions of others: for example, when a caregiver is assisting with personal hygiene, the patient may interpret these actions as sexual advances.⁴⁹

Initial management of sexually inappropriate behaviours first and foremost requires a comprehensive evaluation, including a detailed history, which may require collateral information from family members and caregivers. Identification of any past trauma, especially sexual trauma, is important. Potential triggers, such as new medications, loss of a spouse, and timing (such as night‐time, after an activity, or around personal care), should be identified. Other non‐sexual causes (such as genital itching leading to groping, or overheating causing disrobing) should be excluded. Based on the findings of this detailed assessment, non‐pharmacologic strategies should be initiated to reduce or avoid triggers. Some behavioural modification strategies include physically separating the inappropriate older adult from potential victims, providing tactile stimulation that distracts them from undesired behaviours (e.g. folding towels or playing with a stuffed animal), avoiding stimulating media on television and radio, and providing clothing that does not allow for easy exposure (e.g. pants without a front zipper).⁴⁹

If the above measures are not successful, pharmacologic therapies may be trialled based on specific symptoms. For example, if the sexually inappropriate behaviours coincide with psychotic features, a trial of antipsychotic may be reasonable. If there are obsessive symptoms, an SSRI could be considered. With any pharmacologic therapy, regular assessment for efficacy and side effects, and trials of de‐prescribing, are necessary. Unfortunately, there is little research on non‐pharmacologic interventions for sexually inappropriate behaviour. Case reports have described pharmacologic strategies for reducing sexually inappropriate behaviours, but this is controversial, and no strong evidence exists for one medication over another. Approaches have included antipsychotics, antidepressants, rivastigmine, anticonvulsants (carbamazepine, gabapentin), beta blockers, and anti‐androgens (including hormonal and non‐hormonal approaches).^49,50