MSGM Case Presentation April 2025

Title : Navigating the Challenges of Managing Sexual Disinhibition in Dementia

Prepared by Dr Kwa Schee Li

Supervised by Professor Terence Ong

Background

A 79-year-old man, with background history of hypertension, dyslipidemia, tachy-brady syndrome with mixed type vasovagal syncope with dual chamber pacemaker inserted in 2023, prostatomegaly with raised PSA, and hearing impairment on hearing aid. He was diagnosed with depression and Alzheimer Dementia in 2022.

First visit to memory clinic in January 2022

• Since 2020, the patient experienced a gradual decline in short-term memory,

  including an inability to recall his home address, despite having moved to the new residence five years ago. He had become increasingly repetitive and ceased playing golf due to the COVID-19 pandemic.

• Over the past 1 year, the patient felt worthless, struggled with self-doubt, and lost interest in activities he once enjoyed. He had withdrawn from friends and family and expressed feelings of hopelessness, including thoughts of suicide. There was no agitation or aggressive behaviour.

• He experienced poor sleep at night due to frequent urination and lower urinary tract symptoms (LUTS).

• Basic Activities Daily Living (BADL) independent without aid

• Instrumental Activity Daily Living (IADLs) were affected. He sometimes got lost while driving and had accidentally hit another car before. His wife took over to manage his finances. He could still help with hanging the laundry but no longer cook due to a past incident where he burned a pot.

• GDS 4

• MMSE: 22/30 (recall : 0, attention : 3/5, orientation : 8/10)

• MOCA: 15/30 (visuospatial : 2/5, attention : 4/6, Language : 0/3, abstraction : 1/2,

  delayed recall : 0/5, orientation : 5/6)

• MRI Brain March 2021 suggestive of features of Alzheimer Disease with vascular burden (GCA 1, MTA 2, Fazekas 2, Koedam 1)

• Not keen for CT-PET scan

• Diagnosed as Amnesic Mild Cognitive Impairment (MCI) and cognitive stimulating exercises were prescribed. He was started on escitalopram 5mg OD in January 2022 for depression

Progress

From March 2022 till January 2025

MMSE trend : 22/30 ( Jan 2022) → 21/30 ( March 2022) → 20/30 ( September 2023)

→ 13/30( march 2024) → 10/30 (October 2024) → 12/30 ( January 202

Social history

• He previously worked in the Air Force. He is currently living with his son’s family, making a total of six people in the single-storey house. He is a chronic active smoker.

Medications List

 Lactulose solution 15ml ON

 Bisacodyl e/c tablet 5mg OD

 Bisoprolol tablet 7.5mg OD

 Atorvastatin tablet 20mg OD

 Tamsulosin tablet 0.4mg ON

 Escitalopram tablet 10mg OD

 Finasteride tablet 0.5mg OD

 Donepezil tablet 10mg OD

 Memantine 20mg OD

Examination

 Coherent and relevant speech. Mildly agitated

 BP : 160/90, PR : 60 bpm

 Respiratory, CVS, abdomen and Neurological examinations were normal.

Investigation

 US KUB (Feb 2022): Prostate is enlarged measuring 64.0 mls in volume.

 MRI/MRA brain (March 2021) : GCA 1, MTA 2, Fazekas 2, Koedam 1 (features of

AD with vascular burden)

 TFT/B12/Folate/VDRL/HIV : normal

 FBC/ RP/LFT : normal

Sexual disinhibition in dementia is a distressing and embarrassing behaviour for both patient and the caregiver. It is difficult BPSD form to manage.

Learning Questions

1. What are the side effects of SSRI? Which antidepressant has a safer cardiovascular profile?

2. What is the role of dual cognitive enhancers in treating dementia?

3. What are the potential causes of sexual disinhibition in dementia patients?

4. What non-pharmacological management can you advise the patient and his caregiver for managing sexual disinhibition?

5. What are the pharmacological options for management sexual disinhibitions in this patient? In this case, what will be your next step of management since sexual disinhibition is not controlled with SSRIs?

6. What ethical considerations arise when managing sexual disinhibition in dementia?

Resources

1. Joller, P., Gupta, N., Seitz, D. P., Frank, C., Gibson, M., Gill, S. S. (2013). Approach to inappropriate sexual behaviour in people with dementia. Canadian family physician Medecin de famille canadien, 59(3), 255–260.

2. Yekehtaz, H., Farokhnia, M., Akhondzadeh, S. (2013). Cardiovascular considerations in antidepressant therapy: an evidence-based review. The journal of Tehran Heart Center, 8(4), 169–176.

3. Sarangi, A., Jones, H., Bangash, F., Gude, J. (2021). Treatment and Management of Sexual Disinhibition in Elderly Patients With Neurocognitive Disorders. Cureus, 13(10), e18463. https://doi.org/10.7759/cureus.18463

4. Black, B., Muralee, S., Tampi, R. R. (2005). Inappropriate sexual behaviors in dementia. Journal of geriatric psychiatry and neurology, 18(3), 155–162. https://doi.org/10.1177/0891988705277541

5. Ozkan, B., Wilkins, K., Muralee, S., Tampi, R. R. (2008). Pharmacotherapy for inappropriate sexual behaviors in dementia: a systematic review of literature. American journal of Alzheimer disease and other dementias, 23(4), 344–354. https://doi.org/10.1177/1533317508318369

6. Kabir, M. T., Uddin, M. S., Mamun, A. A., Jeandet, P., Aleya, L., Mansouri, R. A.,Ashraf, G. M., Mathew, B., Bin-Jumah, M. N., Abdel-Daim, M. M. (2020). Combination Drug Therapy for the Management of Alzheimer Disease. International journal of molecular sciences, 21(9), 3272. https://doi.org/10.3390/ijms21093272