Understanding hypersexuality: a behavioral disorder of dementia

Abstract

Although a rare manifestation of Alzheimer's Disease, hypersexuality is one of the most embarrassing behaviors for both informal and formal caregivers. This article presents an overview of the causes of the problem along with strategies home care and hospice nurses can use to teach families how to decrease the social isolation these patients experience.

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vol. 21 •no. 1 •January 2003 © 2003 Lippincott Williams & Wilkins, Inc. Home Healthcare Nurse 43
The current healthcare system is unprepared to deal with
the numbers of elders anticipated in the future. The num-
ber of persons diagnosed with Alzheimer’s Disease and re-
lated disorders (ADRD) is predicted to increase drastically as the
population ages and the baby boomers reach the traditionally
defined “old” age of 65 years. Over 4 million persons currently
have Alzheimer’s Disease (AD) and the number is projected to
double in 40 years. At least one-half the nursing home population
is estimated to have AD. Of the population over age 85, 47% were
diagnosed with ADRD (Evans et al., 1989).
Sexuality, one of the basic needs in the human experience, in-
fluences everyone. Many stereotypes of sexuality and aging are
erroneous. As I was looking for a birthday card for a friend over
50, I was confronted repeatedly with the stereotype that sex is as-
sociated only with youth, energy, and attractiveness. The text on
the front of one birthday card stated, “You’re 50, but you haven’t
lost it!” The inside of the card read: “Look lower, you’ll see it.”
Although a rare manifestation
of Alzheimer’s Disease, hyper-
sexuality is one of the most
embarrassing behaviors for
both informal and formal care-
givers. This article presents an
overview of the causes of the
problem along with strategies
home care and hospice nurses
can use to teach families how
to decrease the social isolation
these patients experience.
A Behavioral Disorder of Dementia
Karen M. Robinson, DNS, RN, CS, FAAN

other types of inappropriate sexual
behavior is likely to occur. Thus, the
caregiver will be reluctant to allow
the nurse into the home alone, both
to protect the nurse and also to pre-
vent embarrassment on behalf of the
PWD. Once the nurse has communi-
cated that sexuality is an acceptable
part of the lives of older adults, it will
be much easier to address these sex-
ual problems.
Types of Hypersexuality
An overview of hypersexuality (Kuhn, Greiner, &
Arseneau, 1998) defines two types of behavior as
hypersexuality:
1. Persistent, uninhibited sexual behavior di-
rected at oneself or others; and
2. Inappropriate behavior in relation to others.
Examples of hypersexual behaviors include:
• compulsive masturbation in both public and
private locations;
• a pattern of lewd, suggestive language;
• fondling of breasts or other personal body
parts of caregivers/other patients;
• flirtation;
• disrobing of self or others; and
• overt sexual acts.
Hypersexual behavior is typically directed at a
number of people, not one particular relationship.
Hypersexuality is not a form of sexual intimacy
that may be retained in AD. The nurse must assess
this behavior as either retained sexual intimacy or
as a problem behavior.
Retained sexual intimacy is appropriate sexual
behaviors that occur in the wrong place. The fol-
lowing behaviors would be judged acceptable if
they occurred in private: removing one’s clothing,
masturbation, or other sexual contact. These be-
haviors may appear inappropriate because the
PWD is oblivious to his or her surroundings. The
nurse must ask, “Would this behavior be inappro-
priate if it occurred in private?”
Problem behavior has been reported to be the
most stressful aspect of caregiving burden (Payne
& Caro, 1997; Coen, Swanwick, O’Boyle, & Coakley,
1997). Caregivers’ reactions to these behaviors
may determine the total impact of the caregiving
experience. Sexuality is not an easy area for inter-
44 Home Healthcare Nurse vol. 21 •no. 1 •January 2003
The cards portray the stereotypes that sexual-
ity gradually fizzles out as we grow older, and that
sex is nonexistent in retirement. According to the
cards, physical attractiveness and beautiful bod-
ies are necessary for sexual relationships. The re-
ality of aging is that all people, whether able-bod-
ied or not, continue to have sexual feelings. Even
with physical changes and impaired health, the
decline in sexual activity is often less than ex-
pected (Russell, 1998).
Several studies have indicated that hypersexu-
ality is a rare problem behavior. Burns, Jacoby, &
Levy (1990) observed sexual disinhibition in only
7% of the 178 people studied in the community
with AD. Ryden, Bossenmaier, & McLachlan
(1991) noted “sexually aggressive behavior” in 4%
of the 124 nursing home residents with dementia
observed over a 7-day period. When observing
614 nursing home residents with dementia, “inap-
propriate sexual behavior” was observed in 5% of
the population (Wagner, Teri, & Orr-Rainey, 1995).
The frequency discussed above may increase
in spousal relationships. In a study of marital rela-
tions of 30 community-dwelling couples where
one partner had AD (Wright, 1993), “high sexual
activity” was reported to occur among 14% (all of
them male). Existing literature suggests that
males exhibit this problem behavior far more fre-
quently than females.
Of all the behavioral problems that exist, hy-
persexuality is one of the most embarrassing for
both informal and formal caregivers. Fortunately,
it is a relatively rare manifestation of AD. Home
care and hospices nurses encounter persons with
dementia (PWD) in home visit encounters as well
as in nursing homes. Caregivers who are family
members may be even more embarrassed by this
behavior; thus, hypersexuality may compound
the social isolation that gradually increases as the
disease progresses.
Caregivers may fear that inappropriate sexual
propositions will be made to the nurse and that
INAPPROPRIATE SEXUAL BEHAVIOR IS
A PROBLEM BEHAVIOR SYMPTOMATIC
OF DEMENTIA. HYPERSEXUALITY IS
NOT DELIBERATE BEHAVIOR.

vention because we each have our own prejudices
and we are also often fearful of offending others.
The nurse should teach the patient and care-
givers accurate information about dementia and
sexuality, such as the fact that sexual desires do
not diminish as the disease progresses. By dis-
cussing this knowledge, difficulties that might arise
can be anticipated before they actually happen.
This discussion can suggest ways to help per-
sons express their sexuality while being able to
manage inappropriate sexual behavior behavior
(Russell, 1998). Nurses need to be aware of the lead-
ership role inherent in management of hypersexual-
ity. Successful management can improve the quality
of life for the caregiver and family members.
The sexual relationship between the spousal
caregiver and the PWD most likely changes from
one in which an individual who had been inde-
pendent has become suddenly dependent upon
his or her partner. The shift from adult-adult rela-
tionship to a more parent-child relationship leads
to increased difficulty for one or both partners in
maintaining an active sexual relationship. For
many caregivers, the sheer stress and exhaustion
of their role may adversely affect their libido (Rus-
sell, 1998).
Possible Causes
Reasons for hypersexuality are highly complex.
Generally the literature attributes the behavior to
biochemical/physiological changes that accom-
pany dementia. Psychological needs also compli-
cate the biological explanation, which identifies
the temporal/frontal lobe of the brain as the area
for regulating libido. Persons who have injuries to
this part of the brain often exhibit aggression and
other behavioral problems including personality
changes and socially inappropriate sexual behav-
ior such as hypersexuality.
Dementias such as Pick’s Disease cause injury
to the temporal/frontal lobe of the brain. Persons
with Pick’s disease display a variety of these so-
cially inappropriate behaviors (Cummings & Ben-
son, 1992). Hypersexuality might also be caused
by a disruption in neural pathways related to sex
drive or hormonal changes occurring due to de-
mentia (Shapira & Cummings, 1989).
Psychological Causes
Loss of Self-Esteem and Self-Image: Other causes
of hypersexuality relate to the psychological need
for intimacy that is inappropriately expressed. As
dementia progresses, the person experiences loss
in areas of self-esteem and self-image. Sexual per-
formance has historically enhanced self-esteem.
Thus, hypersexuality may be a way of compen-
sating for the cognitive and functional losses that
are inherent in the progression of dementia. Sex-
ual performance may be a means of demonstrat-
ing control and mastery of a situation, especially
for men who are socialized into being more sexu-
ally aggressive than females.
Lack of Physical Closeness: Another psycho-
logical explanation may be related to the lack of
touching and intimacy that is synonymous with
healthcare of the elderly in institutions. Physical
closeness might be desired as a way to reduce the
loneliness, fear, and anxiety of the dementia expe-
rience and may take the form of physical aggres-
sion in persons not knowing how to appropriately
meet their needs for closeness and intimacy.
Forgetfulness of the Recent Past: Sexual activ-
ity may be initiated repeatedly because the person
has simply forgotten immediate past sexual acts.
For example, sexual intercourse may be initiated
over and over because the person has forgotten
prior experiences of sexual intercourse. Little re-
gard is exhibited for the partner apart from the sex
act itself. The PWD has no awareness of the self-
centered, demanding nature of this behavior.
Interpreting Hypersexuality
Inappropriate sexual behavior must be understood
to be a problem behavior symptomatic of demen-
tia. Hypersexuality is no different than other be-
havioral problems associated with dementia and is
not deliberate. No studies were found that demon-
strate that the person’s history was consistent with
hypersexuality. In our culture hypersexuality is un-
vol. 21 •no. 1 •January 2003 Home Healthcare Nurse 45
■Injuries to temporal/frontal lobe of the brain
results in aggression, personality changes
and socially inappropriate sexual behavior.
■A disruption in neural pathways related to
sex drive or hormonal changes occurring due
to dementia.
■An inappropriately expressed psychological
need for intimacy.
■The lack of touching and intimacy is
synonymous with healthcare of the
elderly in institutions.
■Forgetfulness of the recent past.
POSSIBLE CAUSES OF HYPERSEXUALITY

acceptable. Unfortunately, it evokes a “dirty old
man” and “loose old lady” stereotype.
The basis of the problem is a biological prob-
lem resulting in a behavioral disturbance. Sexual
manners are forgotten and social inhibitions usu-
ally restraining sexual drives are diminished and
lost over time. Thus, persons exhibiting this be-
havior should not be punished. This behavior sig-
nifies a need for intervention as does any other so-
cially inappropriate behavior.
Hypersexuality often demonstrates other
needs rather than sexual ones. When the PWD
crawls into bed with someone else, he or she may
not be thinking “sex” as much as a desire to feel
close to another body for warmth and connection.
Many elders have had long marriages consisting
of sleeping with another person for over 50 years.
Other persons might be misidentified as a spouse
or lover. From the perspective of the PWD, sexual
relations may be considered to be a normal part
of that relationship.
Inappropriate touching may be judged to be sex-
ually explicit to the bystander, but the PWD may be
unaware that a hand, shoulder, or breast is being
touched (Kuhn et al., 1998). Repeatedly touching
oneself may be a sign of boredom/self-stimulation.
Intervention is needed to substitute more appro-
priate activity to eliminate the boredom.
Interventions
Whatever the underlying cause, hypersexuality
creates major dilemmas for professional and fam-
ily caregivers. Family, caregivers, home care
workers, and hospice providers will not feel com-
fortable around the person who exhibits hyper-
sexuality. Intervention is needed to curtail this an-
tisocial behavior and restore a sense of
safety/comfort for all.
Most experts agree that be-
havioral/environmental inter-
vention is preferable to pharma-
cological treatments (Small,
1998; Kuhn et al., 1998), espe-
cially as a result of the Omnibus
Reconciliation Act of 1987
(OBRA ‘87, Public Law No. 100-
203). The OBRA regulations
served to facilitate public aware-
ness of the frequent misuse of
psychotropic medications in
nursing homes.
Traditional Interventions
Traditional behavioral interventions must be tried
first. One basic need of persons exhibiting hyper-
sexuality is the need for intimacy and to be con-
nected to others. Attempts should be made to have
these needs met in more appropriate ways (e.g.,
redirect behavior with food, drink, or conversa-
tion). Distraction may be effective by substituting
other activities such as walking and exercise.
Nurses often have difficulty dealing with their
own personal beliefs and feelings when working
with a person exhibiting hypersexuality. A central
dilemma for the nurse is the conflict between the
desire to protect and maintain dignity of the elder
opposed to the PWD’s desire to fulfill sexual needs.
Some approaches may include the following:
• Consider hypersexuality as a staff develop-
ment topic.
• Advanced Practice nurses can develop mod-
ules with relevant content related to hyper-
sexuality.
• Invite multidisciplinary experts to help nurses
work through ethical dilemmas concerning
sexuality and PWD (Ehrenfeld, Tabak, Bron-
ner, & Bergman, 1997).
• Nurses must be trained in practical skills to
avoid and decrease the frequency of a pa-
tient’s hypersexual incidents.
• Organizational policy and procedures should
include a section on hypersexuality so that in
orientation all nurses are instructed about
management of the behavior.
Families must be included in efforts to address
the problem by knowing in advance about the pos-
sibility of hypersexuality-related occurrences. Be-
cause of the threatening nature of hypersexuality,
family members should be informed about such in-
46 Home Healthcare Nurse vol. 21 •no. 1 •January 2003
HYPERSEXUAL BEHAVIOR IS TYPICALLY
DIRECTED AT A NUMBER OF INDIVIDUALS,
NOT AT ONE PARTICULAR RELATIONSHIP.
HYPERSEXUALITY IS NOT A FORM OF SEXUAL
INTIMACY THAT MAY BE RETAINED IN AD.
THE NURSE MUST ASSESS THIS BEHAVIOR
AS EITHER RETAINED SEXUAL INTIMACY
OR AS A PROBLEM BEHAVIOR.

cidents and receive special invitation to attend a
family careplaning session. Having family partici-
pate in decision making and problem solving cre-
ates a climate of partnership, not animosity, to-
ward staff. Management techniques can then be
suggested to which families are more likely to be
receptive.
Pharmacologic Interventions
A last resort, when other interventions have
failed, is consultation with the physician for rec-
ommended medication. There have been no con-
trolled studies of the pharmacological treatment
of hypersexuality. A review of current literature
indicates:
• Neuroleptics and benzodiazepines are com-
monly used for this problem but are usually in-
effective and poorly tolerated because of their
significant side effects (Stewart & Shin, 1997).
• Generally atypical antipsychotics with low
doses can be used because of their improved
side-effect profile. However, efficacy of these
drugs is not well documented in hypersexual-
ity (Lantz & Marin, 1996).
• Successful outcomes using buspirone (Tiller,
Dakis, & Shaw, 1988), trazodone (Simpson &
Foster, 1986), and paroxetine (Stewart & Shin,
1997) have been reported but further investi-
gation is needed.
• Treatment with Selective Serotonin Reuptake
Inhibitors (SSRIs) may constitute a relatively
safe, convenient, and effective strategy due to
their direct antilibidinal effect. Reduced libido
is commonly seen with SSRI treatment (Stew-
art & Shin, 1997).
Summary
Hypersexuality is a disturbing behavioral problem
in dementia. Nurses are vital in assisting clients
and their families to explore management tech-
niques. Nursing leadership is needed to help staff
and families define the exhibition of hypersexual-
ity as a behavioral, rather than sexual, problem.
The quality of life for both client and health pro-
fessional will be much improved when this leader-
ship is taken.
Karen M. Robinson, DNS, RN, CS, FAAN, is a Profes-
sor, University of Louisville School of Nursing,
Louisville, KY. Address for correspondence: c/o Uni-
versity of Louisville School of Nursing, HSC K Build-
ing, Louisville, KY 40292.
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vol. 21 •no. 1 •January 2003 Home Healthcare Nurse 47