European Geriatric Medicine 7 (2016) 512–518

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Hot topic in geriatric medicine

Ageing and sexuality

L.J. Dominguez *, M. Barbagallo
Geriatric Unit, Department of Internal Medicine and Geriatrics, University of Palermo, Viale F. Scaduto 6/c, 90144 Palermo, Italy

A R T I C L E I N F O A B S T R A C T

Article history: Sexuality is a dimension that concerns human health with profound implications not only in the
Received 27 April 2016 biological and psychological aspects, but also in the social and cultural dimensions, affecting all ages of
Accepted 31 May 2016 life. Sexuality in old age is still conditioned by biases, prejudices and from a stereotyped vision, which
Available online 1 July 2016
considered older people as ‘‘asexual’’, in spite of several studies and surveys showing that older persons
have sexual potential to express. In population surveys, a fair number of men and women aged over
Keywords: 60 years reported having sex at least once a month. The most influential predictor of sexual activity
Sex
seems to be the physical health in older men, and the quality of the relationship in older women. The
Sexuality
most common sexual disorders are erectile dysfunction and delayed ejaculation in older men, and
Ageing
Elderly reduced sexual interest, arousal disorder, female orgasmic disorder, genitopelvic pain and ailments of
Erectile dysfunction penetration in older women. A careful evaluation can identify the presence and severity of disorders in
Inappropriate sexual behaviour different phases of the sexual response cycle. The management of sexual dysfunction in older people
Dementia may include reassurance, education, sex therapy and/or the use of drugs in specific cases. Sexuality in
patients with dementia may arise as inappropriate sexual behaviour (ISB) due to behavioural
disinhibition. Manifestations of ISB can be very distressing for family members and other caregivers and
can present substantial challenges for staff and health care providers in long term care. Although there is
no established treatment algorithm for dementia-related ISB, there are various non-pharmacological
and pharmacological treatments, which can help in the management of these patients.
! 2016 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.

age are similar to those in young age, with some variations, mainly
‘‘They spent unimaginable hours holding hands in the armchairs by in mode of expression [3]. Therefore, sexuality is a complex
the railing, they exchanged unhurried kisses, they enjoyed the concept, which comprises beliefs, attitudes, notions, fantasies,
rapture of caresses without the pitfalls of impatience.’’ values, communication, self and body image, personality, sociali-
Love in time of cholera, Gabriel Garcı́a Márquez. zation, and past experiences, which are strongly linked to identity,
orientation, and well-being [4]. These factors influence personal
manifestations of sexuality, and to a large extent, defines the
uniqueness of a person. Hence, human sexuality entails dimen-
1. Introduction sions, which go beyond the only physical expression. Possibly that
is why Pope Francis has recently declared that ‘‘sexuality is a
Sexuality can be viewed as a fundamental component of human marvellous gift of God to his creatures’’ in the post-synodal
life. Sex refers to physical aspects, particularly the act of sexual apostolic exhortation Amoris Laetitia [5].
intercourse; sexuality has a broader meaning, comprising not only Men and women in sexually active couples who maintained
the physical but also social and mental aspects. This human their sexual engagement in some form as they aged showed higher
dimension encompasses self, interactions with others, and various levels of marital happiness and lower levels of dissatisfaction and
stages of expression and affection throughout life [1]. Sexuality negative interactions than couples who were sexually inactive
also concerns human health with profound implications not only [6]. A recent report of the English Longitudinal Study on Ageing
in the biological and psychological aspects, but also in the social (ELSA) analysing data from 6833 participants aged 50–89 years
and cultural dimensions, affecting all ages [2]. Sexual needs in old showed significant associations of sexual activity with recall in
men and women and with number sequencing in men. These
* Corresponding author. Tel.: +39 09 16552 885; fax: +39 09 16552 952. results suggest that maintaining a healthy sex life in older
E-mail address: [email protected] (L.J. Dominguez). age could be instrumental in improving cognitive function and

http://dx.doi.org/10.1016/j.eurger.2016.05.013
1878-7649/! 2016 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
 L.J. Dominguez, M. Barbagallo / European Geriatric Medicine 7 (2016) 512–518 513

well-being [7]. However, it is common to consider older people as staff members tend to have more negative views of same-sex
‘‘asexual’’, or as persons with no right to feel sexual urges, to intimacy [14].
practice sex, and much less to express sexual desires, otherwise The first extensive survey about human sexual behaviour
considered perverse or insolent the seniors showing such interest comprising near 18,000 interviews was conducted by Alfred
even if only platonic [8]. Sexuality in old age is still conditioned Kinsey, who described a continuum of sexual orientation known as
by biases, prejudices and from a stereotyped vision, in spite of the Kinsey Scale published in the late 40’s. Unfortunately, he only
several studies and surveys showing that older persons have an included 3 women and 2 men aged over 80 years [15]. Afterwards,
undeniable sexual potential to express. Masters and Johnson recorded some of the first laboratory data on
In the present review, we summarize some myths and the anatomy and physiology of the human sexual response based
misconceptions about sexuality in old age, as well as the on direct observations from 1957 until 1965, dismantling many
approaches and management of the main sexual dysfunctions long-standing misconceptions. Masters and Johnson concluded
and inappropriate sexual behaviour, discussing possible difficul- that given a reasonably good health and the availability of an
ties that arise and affect the patients, their families, the geriatric interested partner, there is no absolute age at which sexual
institutions where they may live in, and the health care providers. abilities disappeared. They identify objectively specific changes in
male and female sexual responses with ageing – (i.e. longer time to
arousal in men, decreased speed and amount of vaginal lubrica-
2. Misconceptions and myths about sexuality and ageing tion), and observed that many older men and women are perfectly
capable of excitement and orgasm well into their 70’s and beyond
Sexuality in older people can represent ‘‘a dark continent’’, [16,17].
which most people, including physicians, prefer not to think about.
Regrettably, stereotypical thinking, prejudice and ignorance still
dominate current views on sexuality in old age. These are some of 3. Frequency of sexual activity in old age
the misconceptions and myths about it.
Older persons, either being capable or not, continue to have
2.1. ‘‘Sexuality does not exist in old age’’ sexual feelings and needs. Desire is not necessarily absent when
physical health alterations occur. A high proportion of people
The belief that sexuality vanishes during old age is frequent remain active in later life denying the myth and misconception
among the general population, but in particular among health care that ageing is always associated with sexual dysfunction. There is
providers. For example, a study showed that the majority of nurses evidence indicating that numerous persons aged over 60 years
interviewed did not believe that people in their 70’s had sexual remain sexually active [18–23]. Data from the National Survey of
needs [9]. Families and Households including 13,017 adults, from which
807 aged over 60 years showed that 53% reported sex in the last
2.2. ‘‘Sexuality among older persons is comical’’ month. Main determinants of sexual activity were age, education,
sense of self-worth, marital satisfaction, and length of marriage
Sexuality in old age is frequently seen as laughable, which is [18]. Two separate surveys using the Ageing Sexual Knowledge and
illustrated by the jokes about it and humorous birthday cards that Attitude Scale showed a moderate amount of knowledge and
refer to the potency decline over the years. This may be partly permissive attitudes with no significant differences between men
explained by the general attitudes linking sexuality to physical and women. Most participants were sexually active and seeking
attractiveness and beauty, incorrectly regarding both as necessary further information on the impact of chronic illness and
components for relationships, while the media creates an amusing medications on sexuality [20]. Among 319 Swedish men, 83%
picture of seniors’ sexuality. stated that sex was ‘‘very important’’, ‘‘important’’ or a ‘‘spice to
life’’. Physiological potency was present in 97% of those aged 50 to
2.3. ‘‘Sexuality among older persons is disgusting’’ 59 years, 76% of those aged 60 to 69 years and 51% in those aged
70 to 80 years. Most men with waning sexual function stated that
This stereotype makes older people feel shame or guilty about this distressed them. Hence, sexual function should be considered
feelings of sexual desire and precludes to openly express these in the clinical assessment of older men [21]. A study of sexuality
concerns and needs to the medical staff for fear of being branded as and health among 3005 older adults in the US reported current
inappropriate, bizarre, obscene, or as ‘‘dirty old people’’ [10]. sexual activity in 73% of adults aged 57 to 64, 53% of adults aged
65 to 74, and 26% of adults aged 75 to 84 years. Of those reporting
2.4. ‘‘Sexual activity in long-term care (LTC) facilities is against the good or excellent health, 81% men and 51% women had been
rules’’ sexually active in the past year vs 47% men and 26% women
reporting fair or poor health [22]. In a study interviewing over a
A study conducted in residential retirement facilities, which hundred older gay men, aged over 60 years, 86% declared to be
involved white men and women aged 80–102 years using an sexually active, with two thirds of them reporting sexual activity at
anonymous 117-item questionnaire found that 62% of men and least once a month [23].
30% of women over 80 years had had recent intercourse, and 87% Various factors comprising psychological aspects, medications
of men and 68% of women had had physical intimacy of some sort and disease, may predict sexual malfunction in impulse, desire,
[11]. Another study in 15 LTC facilities, interviewing seniors with pleasure and quality [24]. The main predictors of sexual interest
a mean age of 82 years showed that 81% of men and 75% of and activity in old age are previous level of sexual activity, sexual
women reported sexual desire, but were currently sexually interest of a partner, and overall physical health [18,19]. Quality of
inactive because of lack of opportunity [3]. life of patients with chronic diseases may be as well affected by
their general and sexual function, which is considerably related to
2.5. ‘‘Assumed to be heterosexual’’ overall satisfaction [25].
During ageing, the means of sexual expression may change,
The presence of lesbian, gay, bisexual and transgender (LGBT) with less focus on vaginal intercourse and more frequent sexual
older adults is often not considered [12,13]. A study reported that touching and other forms of intimacy [26]. A large survey in AARP
514 L.J. Dominguez, M. Barbagallo / European Geriatric Medicine 7 (2016) 512–518

members showed that the frequency of kissing or hugging was impairment, environmental restrictions, body image, and adverse
considerably higher than intercourse among persons aged over drugs effects. There is also societal discomfort with issues of
60 years. Indeed, sexual activity in its diverse forms is a central homosexuality, which is often not considered. Many LGBT elders
human need beginning at birth and continuing throughout may have not come out yet, may fear physical harm for coming out,
adulthood [2], as human nature is in continuous profound need and may have experience years of isolation and/or discrimination.
of intimacy and love, which translates into desire for affection Normal modifications associated with ageing are different for
and closeness, as well as comfort and familiarity with own and men and women. Specifically, women experience thinning of the
partner’s body. Touching, caressing, fondling, cuddling, hugging, vaginal walls, decreased or delayed vaginal lubrication leading
kissing, and hand-holding can all bring a sense of romance and to pain during intercourse, labia atrophy, shorten vagina, cervix
provide closeness. Smelling, hearing, tasting, and visual sensations may descend downward into the vagina, and there is loss of fat
are as well components of sexuality. A study conducted in veterans’ pad over pubic symphysis resulting in pain from direct pressure
homes in Taiwan using structured questionnaires reported signifi- over bone. These changes are accompanied with a declined libido,
cant, positive correlations among interpersonal intimacy and sexual responsiveness and comfort level because of derived
meaning of life [27]. Therefore, health care providers involved in dyspareunia [16]. Men require greater direct physical stimulation
the care of seniors, especially those in institutions, might consider of the penis to experience a somewhat weaker erection, orgasms
the development and implementation of interventions that are fewer and weaker, there is reduced force and amount of
promote a higher degree of interpersonal intimacy to help confront ejaculation, and an increased refractory period after ejaculation,
old age in a more positive manner. The expression of sexuality although sexual desire remains relatively stable [17].
among older adults results in a higher quality of life by fulfilling a It is worth mentioning that age is not a barrier to sexually
natural desire. It also may improve functional status and mood [1]. transmitted diseases because of risky behaviours (i.e., multiple
Fortunately, ageing sexual stigma beliefs may not be so sex partners, misperception of ‘‘risk’’ and erectile dysfunction [ED],
prevalent currently among the general population as cohorts drug use, changing social status [divorce, widowed], internet sites)
become more sexually liberal over time, although men seem to be may be seen in older as well as younger generations, but older
more susceptible to these beliefs. This was shown in an online people may be less aware of their risk [31]. Another concern is that
survey administered to a national sample of adults examining 15% new HIV/AIDS cases reported to the CDC in 2005 were in
trends in ageing sexual stigma attitudes by age group, generational persons 50 years and older, while nearly 2% of new diagnoses were
status, and gender with items of the Ageing Sexual Knowledge and in patients over 65 years of age [32].
Attitudes Scale. There were moderately permissive attitudes
toward ageing sexuality, indicating a low level of ageing sexual
stigma, with no significant differences between age groups. Men, 5. Sexual dysfunction
regardless of age and/or generation, were found to hold
significantly higher stigmatic beliefs than women or those The most frequent conditions of sexual dysfunction are ED
reporting ‘‘other’’ gender [28]. disorders and premature ejaculation in men, and sexual interest/
arousal disorder, orgasmic disorder, genitopelvic pain and
4. Barriers to sexual health ailments of penetration disorder in women.

The main barriers are related to the misconception of 5.1. Men

considering older people as asexual, mostly because of a general
discomfort and embarrassment with sexual issues. Even profes- ED, formerly called impotence, is defined by the inability to
sional caregivers are influenced by these social conventions achieve or sustain an erection that is adequate for sexual function.
resulting in prejudice and stereotypical thinking. This is somehow It is the most common form of sexual dysfunction in older men,
understandable because most physicians, nurses, and staff in affecting 20–40% of men aged 60–70 years, and 50–70% of those
institutions are not educated to manage sexual health aspects of aged 70–90 years [33]. Most of affected men have minimal or
older adults. Consequently, sexual health is often ignored in the moderate dysfunction [34]. A common cause of ED is radical
assessment of older adult health, prioritizing health issues that prostatectomy. A systematic analysis of ED post-radical prostatec-
seem to ‘‘matter more’’. For example, a study of 100 patients aged tomy for cancer showed that the rate of undisturbed ED was only
up to 86 years and their health care providers showed that less 20–25%, with no substantial change over the past 17 years
than 10% of providers asked patients about erection dysfunction [35]. This despairing picture seems to be changing with new
(ED), although over 90% of patients were interested in treatment procedure techniques. A study evaluating orgasmic dysfunction
[29]. Barriers for both, health care providers and older persons, are after robot-assisted prostatectomy (RARP) vs open radical prosta-
also related to personal beliefs (religious, cultural, etc.). In addition, tectomy (ORP) in 749 patients reported that although the rate of
many older adults have internalized these misconceptions, and climacturia was similar for both procedures (near 30%), painful
believe that sexuality is an inappropriate concern for them. They orgasm was more frequent after ORP vs RARP (11.6% vs 7.1%,
also may have lack of opportunity (no partners or privacy, i.e. in P = 0.04), and recovery from climacturia was faster and greater
LTC) and lack of knowledge because most belong to a cohort in after RARP vs ORP (8.5% vs 5%, at 24 months and 48% vs 15%, at
which sexual topics were forbidden. 84 months; P < 0.01) [36]. A study analysing data from 31,742
There are some changes in health providers’ knowledge and male health professionals aged 53–90 years in a prospective cohort,
attitudes toward later-life sexuality in recent years, exemplified excluding men with prostate cancer, examined the prevalence of
by a study in 1166 Flemish LTC nursing staff, where participants ED in the previous 3 months according to disease status and
appeared to be moderately knowledgeable about sexuality in old lifestyle risk factors. Various modifiable health behaviours were
age and exhibited a rather positive attitude toward sexuality in associated with maintenance of good erectile function, even after
older people. Knowledge and attitudes proved to be positively adjusting for comorbid conditions. Lifestyle factors most strongly
related, indicating that a higher level of knowledge is associated associated with ED were physical activity and leanness, which were
with a more positive attitude toward sexuality in later life [30]. more prevalent in persons aged 85–90 years [37].
Physical barriers to sexual health include normal ageing Premature ejaculation is the most common sexual dysfunction
modifications, pathological ageing changes, chronic pain, cognitive in younger men (20–38%), but it has not been well studied in older
 L.J. Dominguez, M. Barbagallo / European Geriatric Medicine 7 (2016) 512–518 515

men. A study of 860 men showed slightly lower rates in men aged Table 1
Drugs with possible negative impact on sexuality.
65 to 74 compared to men aged 57 to 64 (28.1 vs 29.5%) [22].
Antihypertensive agents (beta-blockers, diuretics, alpha-blockers, clonidine)
Major tranquilizers (sulpiride and barbiturates)
5.2. Women
Minor tranquilizers (benzodiazepines)
Anticholinergics
Female sexual interest/arousal disorder is likely the most Drugs with estrogenic action
common sexual disorder in older women, mediated in part by Antidepressants
lower levels of testosterone and by postmenopausal changes Lipid lowering drugs (clofibrate)
Salicylic (transient male infertility)
[38]. The prevalence of this disorder increases from about 10% in Antihistamines
premenopausal women to nearly 50% in women aged 60–80 years H2 receptor antagonists (cimetidine)
[39]. In a large epidemiological study involving 3005 US older Anorectics (fenfluramine)
adults, 43% of women aged 57–85 years reported low desire, 39% Antiblastic
Muscle relaxants
had difficulty with lubrication, and 34% had anorgasmia [22]. For
Neuroleptics
many widows, sex ceases to be a significant part of their life, which
does not necessarily indicate sexual dysfunction.
Genitopelvic pain/penetration disorder, formerly called dyspa- Table 2
Plissit model, a system used in sexology to evaluate the severity of sexual
reunia and vaginismus, is more common during and after
dysfunction, and to implement an adequate approach and intervention.
menopause due to atrophied and less lubricated vulvovaginal
P Obtaining permission from the client to initiate sexual discussion
tissue during sexual arousal [40]. Medical conditions (i.e. vulvitis,
LI Providing the limited and specific information
vulvodynia, vulvar vestibulitis, atrophy due to surgery or radia- SS Giving specific suggestions for the individual to proceed with sexual
tion) might be excluded. relations
IT Providing intensive therapy surrounding the issues of sexuality for that
person
6. Medical conditions and drugs affecting sexual health

A number of medical disorders impairing blood supply or

dysfunction for individual patients and the adequate approach and
innervation of genital tissue can be linked to sexual dysfunction.
intervention for the affected patients. It has been also used in fields
The most common conditions are cardiovascular disease (CVD),
involving extensive or life-threatening surgery or patients with
diabetes, depression, breast and prostate cancers, HIV/AIDS,
specific diseases, i.e. type 2 diabetes [49].
cognitive impairment and dementia, and osteoarthritis. In
The assessment of sexual dysfunction should include a
2763 postmenopausal women, coronary heart disease was
comprehensive medical and psychiatric history, drug review,
significantly associated with lack of sexual interest, arousal and
physical examination, assessment for cognitive impairment and
orgasmic disorders, and general discomfort with sex [41]. In
impact on sexual health decision making, laboratory tests with
1357 men with CVD, the prevalence of ED was 50.7% with a
eventual measurements of testosterone and prolactin levels, and
significant decline in sexual activity reported after the diagnosis
cerebral imaging in case of hypersexual behaviours. If there is
[42]. In a study of 373 men with type 2 diabetes aged 45–75 years,
concern about the patient’s capacity to consent to sexual activity, it
49.8% reported mild or moderate degrees of ED, and 24.8% had
is key to determine how well the person is able to understand the
complete ED [43]. Certainly, ED may be an indication of other
nature of the relationship, including any potential associated risk,
forms of vascular disease. Hence, clinical evaluation should be
and to what degree he or she can avoid coercion or exploitation. In
undertaken for possible occult CVD in men with ED not aware
order to properly assess the capacity to enter into intimate
of CVD.
relationships, MMSE score should be higher than 13–14, and a
Depression, anxiety, and drugs used to treat these disorders are
structured interview might be given by a person of the same sex.
risk factors for sexual dysfunction in women and men causing a
The evaluation includes older person’s awareness of the relation-
decline in desire and ability to perform [44]. In addition, men with
ship (e.g., knows who partner is, knows partner is not spouse,
ED are at higher risk of developing depression [45]. Major episodes
aware of who is initiating sexual contact, states level of intimacy
of psychosocial stress (i.e., loss of partner or job, medical crisis,
comfortable with), ability to avoid exploitation (e.g., knows about
prolonged illness, hospitalization) may lead to sexual dysfunction
relationship, knows what one wants from relationship, has ability
in older adults. Psychosocial evaluation and treatment in addition
to set limits if wants to/say no), and awareness of potential risks
to medical evaluation and treatment are warranted.
(e.g., that relationship may be time-limited, how might react when
Various medications can lead to sexual dysfunction, in
relationship ends) [50].
particular antihypertensive, antidepressants, antiandrogens, and
psychotropic medications [46]. A study found that nearly 60% of
8. Management of sexual dysfunction
persons on selective serotonin-reuptake inhibitors or venlafaxine
suffered from sexual dysfunction, with higher rates in men
Management of sexual dysfunction in older adults can include
[47]. The strongest proof of a casual effect is improvement in
reassurance, education, sex therapy, and/or medication. Reassur-
sexual function after withdrawal of the medication. Table 1 shows
ance depends on an open-minded health provider who recognizes
drugs with possible negative impact on sexuality.
that sexual intercourse and other expressions of sexuality may
remain significant for many older patients. It is necessary to listen
7. Assessment attentively and to emphasize the normality of sexuality in late life.
Education about usual modifications with normal ageing, about
The assessment of sexual dysfunction in older adults depends available interventions for treatable causes of sexual dysfunction,
mainly on a health provider who is comfortable and knowledge- and about sexually transmitted diseases and safe sex practices is
able about late-life sexuality, asking direct questions using essential. It is worth noting that many older adults went to school
common language, and listening carefully and patiently, preferably prior to the introduction of sexual education.
with the partner if available [48]. The PLISSIT model (Table 2) is General management includes the possibility to adapt sexual
a system used in sexology to explore the different levels of practices to personal physical limitations, pain control, use of
516 L.J. Dominguez, M. Barbagallo / European Geriatric Medicine 7 (2016) 512–518

lubricants and estrogenic gels/creams, and recommendations to Table 3

Neuropathology and clinical manifestations of ISB [56].
follow a healthy diet, adequate amounts of sleep, moderate and
regular exercise, decreasing alcohol intake, stress-management Location Symptoms Syndromes
techniques, and stop smoking. In specific cases psychotherapy and Frontal lobes Disinhibition Bipolar disorder
specific consultations (i.e., urologist or gynaecologist, couples or Dementia
marital therapist, psychiatrist) may be indicated [48,51]. Demyelinating disease
Several treatment options for ED are currently available (for an Neoplasia
Mesolimbic Hypersexuality Kluver-Bucy (temporal bilateral
extensive review, see reference Gareri et al.) [52]. The most
areas lesions)
commonly used agents are phosphodiesterase (PDE)-5 inhibitors, Ischemia
which have lower response rates in older vs younger men, but are Neoplasia
extensively used due to their safety, efficacy, and ease of use. Side Epilepsy
Striatum Obsessive-compulsive Obsessive-compulsive disorder
effects include skin flushing, headache, gastrointestinal discom-
sexual disorder Huntington chorea
fort, dizziness, back pain and blurred vision. Changes in visual Wilson’s disease
acuity while taking a PDE-5 inhibitor require urgent assessment to Tourette syndrome
exclude non-arteritic anterior ischemic optic neuropathy (NAION), Hypothalamus Increased sexual drive Kleine-Levin (sleeping beauty)
a rare condition characterized by the rapid onset of visual loss. Right hypothalamic and
periventricular lesions
However, the role of PDE-5 in the pathogenesis of NAION remains
controversial [53]. Risk factors for NAION include age, dyslipidae-
mia, diabetes, hypertension, and cigarette smoking. The combina-
tion of PDE-5 inhibitors and nitrates can lead to hypotension and (i.e. emotional triggers, misinterpretation of nonsexual acts such as
should be avoided in older men with a history of angina. Caution is routine nursing care, or drugs). It is crucial to remember that
as well needed in men with abnormal penile shape, history of behaviour always has a purpose, and that the person is not the
orthostatic hypotension, severe renal or hepatic disease, concomi- problem. Instead, the problem is the need or the feeling that the
tant use of certain antiviral and antifungal medications, and person is trying to communicate with the behaviour. Motivation of
diseases that increase the risk of priapism, such as multiple what is interpreted as ISB may have surprising nonsexual causes.
myeloma and leukaemia. Data from the National Report on For example, demented patients may stand with their pants down
Medicines Use in Italy 2014 [54] showed a 14.7% increase in merely because they do not remember how to get dressed
sildenafil defined daily dose (DDD)/1000 persons from 2013 to independently or because they feel warm. A demented patient may
2014, with an additional 27.7% increase from 2014 to 2015 unintentionally touch a nurse just seeking for help or attention.
[55]. These changes occurred when the patent of sildenafil expired Comprehensive cognitive, neurologic and genital assessment may
and the price of generic drugs was reduced by near 65–70% help unveil factors contributing to ISB (i.e., faecal impaction,
compared to the original. This probably reflects the unexpressed urinary tract infection). The St Andrew’s Sexual Behaviour
need of older persons with ED which is liberalized with improved Assessment (SASBA) instrument may be a helpful and reliable
accessibility to PDE-5 inhibitors. tool to evaluate and standardize the recording of ISB [25], and
support the rationale for subsequent therapies.
9. Inappropriate sexual behaviour (ISB) At present, there is no definitive evidence on the approaches
to manage ISB in demented patients. A limited number of studies
Sexuality in patients with dementia may arise as ISB due to are available, usually case reports or small series of cases, mostly
behavioural disinhibition, which is not uncommon in demented including men. These studies report some efficacy with the
patients. An estimated 80% of demented patients at some point most varied forms of non-pharmacological and pharmacological
show behavioural problems such as aggression, agitation, disrup- therapies.
tive vocalizations, etc. Observational studies and surveys report Common non-pharmacologic approaches comprise removal of
that 2–25% of patients with dementia exhibit ISB [2,25,56,57]. This precipitating factors, opportunities to relieve sexual urges, and
probably is an under-estimate, as caregivers may be embarrassed distraction strategies. It must be remembered that the patient
to talk about this behaviour with the health provider. Manifesta- does not have the ability to learn; hence, the health provider
tions of ISB can be very distressing for family members and other should search for modifications, both, in the environment and in
caregivers and can present substantial challenges for staff and amendable conditions of the patient [25]. For example, sometimes
health care providers in LTC. Examples of ISB include sexually is necessary to separate a patient from another resident or staff
explicit language, inappropriate touching of another person, member in LTC when these persons seem likely to be the trigger
requesting unnecessary genital care, viewing pornography in for ISB. Simple modifications may be beneficial, such as using
public, disrobing in public, handling genitals or masturbating in clothing that opens in the back, which cannot be easily removed.
public, and/or getting in bed with another resident. ISB may be Distraction with other activities can occasionally be of help (i.e.,
associated with other behavioural symptoms, such as agitation, handcrafting, art therapy, occupational therapy, exercising) [58].
aggression, and/or depression. ISB may occur in any type of In a small case-control study, Bardell et al. found benefit with
dementia, mostly in moderate to severe stages of Alzheimer’s consistent redirection and enhanced communication approaches
disease or even in early stages of frontotemporal dementia. ISB [59]. Use of same sex staff member for patient’s bathing, dressing,
may be as well present in other syndromes and clinical conditions and toileting may also be helpful. In some cases, creativity may
affecting specific areas of the brain linked to hypersexuality, be successful avoiding the need of medications. A case report
namely, frontal lobes, mesolimbic areas, striatum, and hypothala- described how a patient who was sexually aggressive toward
mus (Table 3) [56]. It is worth mentioning that delusions and women stopped his ISB after the introduction of a 3-foot-tall doll,
hallucinations may be wrongly interpreted as ISB (i.e., the patient as an alternative to his sexual impulsiveness [60]. If available,
may mistakes staff for his wife), while the use of dopamine a consultation with a geriatric multidisciplinary team may be
agonists for Parkinson’s disease, testosterone for weakness and necessary in non-responsive patients. Whatever the case may be,
depression, or cholinesterase inhibitors may induce ISB. non-pharmacological approaches may be tried first as patients
The assessment of ISB should cover details to understand the may be less responsive to psychoactive therapies, and also to avoid
possible trigger, such as potential precipitants and consequences adverse effects of medications. Education of the family about
 L.J. Dominguez, M. Barbagallo / European Geriatric Medicine 7 (2016) 512–518 517

patient’s ISB is often needed to help overcome an excessively Disclosure of interest

judgmental attitude. The patient’s cognitive impairment may
result in a lack of recognition of IBS as potentially unpleasant, The authors declare that they have no competing interest.
offensive or provocative to others.
Patients with ISB who do not respond to non-pharmacologic
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