Jul 18, 2016

Alzheimer's Care Sex and Dementia

The increased sexual behavior may be one way persons living with Alzheimer's and dementia try to communicate.

Alzheimer's sex

Dr. Rita Jablonski
Alzheimer's Reading Room

Sexuality is a topic that is not often encountered here in the ARR, but I wanted to broach it after receiving an email from a reader. Her husband has AD and continues to become deeply forgetful, moving backward in time.

In his world, they are young newlyweds and he wishes to shower his lovely wife with physical affection. He asks her several times a day to join him in the bedroom.

At night, he invites physical intimacy. In her world, they are in their late 70s and the physical act of intimacy is something that faded away some time ago.

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In fact, the physical act of intercourse is painful for her. She loves her husband dearly and does not want to upset or hurt him.

This is new behavior, and she wrote to me because she was very embarrassed and felt alone.

With her permission, I am sharing my response because I believe there are others out there who may be experiencing a similar situation. I also encounter this issue regularly in the Dementia Clinic where I work.

The first thing I examine when new sexual behavior occurs is medication.

Some medications can trigger hyper-sexuality in persons with dementia. These medicines are used with persons who have movement disorders, and include what are known as dopamine agonists—such as leva dopa or Sinemet (trade name).

Based on what the wife was describing, I do not think medicine is the issue in this particular case. I did, however, encounter a case study in the literature in which a male with dementia was taking cimetidine (Tagamet) and developed hyper-sexual behavior.

What I see in the majority of my male patients is moving backward in time and reliving memories of their youth. The concurrent shrinkage of the brain responsible for impulse control seems to amplify the behavior.

The reader described that in her email to me -- he thinks he is 18 again, and she is his girlfriend. Add to this recipe his lack of short-term memory, and you have kind of a memory-loop: think of a broken record, where the same piece of music plays over and over again because the needle can't jump out of the groove to the next section of the record.

Knowing the "why" behind the what is good, but the next piece, how to handle the behavior, gets a bit tricky. And, it is an area that I continue to help spousal caregivers with and I do not have definitive answers. Spouses often find it helpful to enter Alzheimer’s World and respond without arguing: “I love you, too.” One of my ladies found that giving her husband hugs and kisses was enough to reassure him.

Another one of my spousal caregivers was faced with a husband who would literally ask 10-plus times a day, “Honey, can we go lay down?” This was his euphemism for sex.

She would smile, give him a hug, and say, "OK, after we do [insert chore]."

Here is how their day played out. As they are eating breakfast, he would ask, “Can we go lay down?”

"Sure, right after we wash the breakfast dishes. Can you help me?" He would dry the dishes with her.

Twenty minutes later, he asks the same question. "Sure, right after we do this laundry. Can you help me?"

The wife would never say no, she simply redirected him and combined every verbal response with a physical act of love or support: a hug or a squeeze of his hand.

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Part of their routine was an nap every afternoon. When they lay down together, he would make romantic overtures. She would tell him that she has her period and can't have intercourse because she feels sore, but she is fine with kissing and cuddling. This response usually works, and he winds up falling asleep.

Once he falls asleep, she gets up and lets him continue to doze. For some reason, he does not introduce any sexual requests for the rest of the day until after dinner, and she uses the same strategies until bedtime.

The reality is, we are all sexual beings and we all want to feel wanted and loved.

The increased sexual behavior may be one way for the deeply forgetful person to communicate, "PLEASE DON’T LEAVE ME," "AM I STILL LOVABLE?" or "YOU are the ONLY THING that makes sense in my world."

So far, my female caregivers have all developed strategies to manage the behavior in a way that is comfortable for them. We have not used medication to manage the behavior, although the literature does make suggestions for prescribing female hormones to curb aggressive sexual behavior.

That is not something we have had to address (yet). I found a case study where the use of citalopram (Celexa, an anti-depressant) curbed this behavior. We do prescribe citalopram frequently in our practice for underlying depression -- I'm not sure if that that drug is helping with the behaviors.

The person who emailed me responded that this information was helpful. She was happy to know that she was not alone, that others also experienced this situation.

I have to offer a word of caution—what I described occurred with individuals who had been diagnosed with Alzheimer’s Dementia. There are hyper-sexual behaviors that can occur with persons diagnosed with frontal-temporal dementia, but that is beyond the scope of this blog.

The bottom line is that all behaviors in Alzheimer’s World are meaningful and represent ways that deeply forgetful persons communicate their feelings, needs, and fears. As caregivers, we enter their world and figure out the message.

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Rita Jablonski-Jaudon, PhD, CRNP, FAAN is an internationally recognized researcher and expert on non-drug ways to handle dementia-related behaviors. She is an Associate Professor at the School of Nursing at the University of Alabama at Birmingham and a nurse practitioner in The Memory Disorders Clinic at the Kirklin Clinic, UABMC, Birmingham, Alabama. rjablonski@uabmc.edu

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