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Tracs-cipd.com.auJournal of Geriatric Psychiatry and Neurology Inappropriate Sexual Behaviors in Dementia
Benjamin Black, Sunanda Muralee and Rajesh R. Tampi J Geriatr Psychiatry Neurol The online version of this article can be found at: can be found at:
Journal of Geriatric Psychiatry and Neurology
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Behaviors in Dementia
Benjamin Black, BS, Sunanda Muralee, MD, and Rajesh R. Tampi, MD, MS Dementias are the most common type of neurodegenerative disorder. Behavioral disturbances are seen in more than80% of patients suffering from these disorders. Although sexually inappropriate behaviors are not as common as someof the other behaviors seen in dementia, they can cause immense distress to all those who are affected. There are norandomized trials for the treatment of these behaviors, but the available data suggest efficacy for some commonly usedtreatment modalities. In this review, we systematically discuss various aspects of these behaviors and available treat-ments. (J Geriatr Psychiatry Neurol 2005;18:155-162) Keywords: dementia; behavioral disturbance; inappropriate sexual behaviors; hypersexuality
Dementia is a syndrome characterized by concurrent any given environment.2 Lyketsos et al showed that two impairments in cognition, behaviors, and activities of daily thirds of the patients with dementia will have behavioral living. It is the most common type of degenerative neu- disturbances at any one point in time. One third of out- ropsychiatric disorder, affecting about 5% of people older patients with dementia and four fifths of the patients liv- than 65 years and 20% of people older than 85 years.1 ing in long-term care facilities have behavioral Alzheimer's-type dementia (AD) is the most common form, disturbance.3,4 Behavioral disturbances can lead to followed by the vascular dementia and Lewy body disease.
increased morbidity, greater health care resource utiliza- Other less common causes of dementia are due to Parkin- tion, and premature institutionalization.5-7 son's disease, alcohol abuse, normal pressure hydro- Studies conducted over the past 3 decades have come cephalus, HIV infection, hypothyroidism, and deficiencies to dispel the notion that the elderly are not sexually active.
of Vitamin B12 and folic acid.
These studies have shown that 50% to 80% of people older Behavioral disturbances are common in dementia.
than 60 years were sexually active at least once a month These can be defined as behaviors that are unsafe and dis- and that regular sexual activity continues through the sev- ruptive and that interfere with the care of the patient in enth and the eighth decade.8,9 Factors that influence sex-ual behaviors in the elderly are the availability of a willingand able partner, the physical and mental health of the indi-vidual and partner, the availability of privacy, and past sex- Received October 7, 2004. Received revised February 7, 2005. Accepted ual history and practices.10,11 for publication February 8, 2005.
Inappropriate sexual behaviors should be seen as a part From the Department of Psychiatry, Yale University School of Medicine, of the symptom cluster of behavioral disturbances asso- New Haven, CT.
ciated with dementia. Using the same construct of behav- Address correspondence to: Rajesh R. Tampi, MD, MS, LV-121, Yale New ioral disturbance, they can be defined as sexual behaviors Haven Psychiatric Hospital, 184 Liberty Street, New Haven, CT 06519;e-mail: [email protected]
that are inappropriate, disruptive, and distressing andthat impair the care of the patient in a given environment.
This project is supported by funds from the Division of State, Community,and Public Health, Bureau of Health Professions (BHPr), the HealthResources and Services Administration (HRSA), and the Department of Health and Human Services (DHHS) under Grant No. 1 K01 HP 00071-02 and Geriatric Academic Career Award, $58,009. The information orcontent and conclusion are those of the author—Rajesh R. Tampi, MD, The best estimate is that 7% to 25% of demented patients MS—and should not be construed as the official position or policy of, nor exhibit inappropriate sexual behaviors.12,13 They are more should be any endorsements be inferred by the BHPr, HRSA, DHHS, or commonly found in men, although the exact sex ratios the U.S. government.
are not clear.14 These behaviors can be divided into 3 com- 2005 Sage Publications Journal of Geriatric Psychiatry and Neurology / Vol. 18, No. 3, September 2005 1. Sex talk: this is the most common form of inappro- hypersomnolence and increased sexual drive, is thought priate behavior and involves using foul language to be due to hypothalamic dysfunction. Lesions to the that is not in keeping with the patient's premorbid right hypothalamus and periventricular area can cause manic symptoms including increased sexual drive.23 2. Sexual acts: these include acts of touching, grab- bing, exposing, or masturbating. They can occur in private or in public areas.
3. Implied sexual acts: these include openly reading These behaviors can be very embarrassing for the relatives pornographic material or requesting unnecessary and caregivers.31 They may also lead to the confinement genital care.
of the individual to his residence or placement into askilled nursing facility. Such behaviors may create prob- lems for other residents, staff members, and families atthese places. Repeated masturbation can cause genital Four brain systems have been implicated in the neurobi- trauma. Sexual abuse can cause trauma as well, and it is ology of inappropriate sexual behaviors. These are the a risk factor for sexually transmitted diseases.32 False frontal lobes, the temporo-limbic system, the striatum, allegations may cause the unnecessary dismissal of an and the hypothalamus. Each system is thought to function accused staff member.31 Sexualized behaviors may also differently from the other, and we may be able to predict cause a conflict between ethical and legal responsibili- the type of inappropriate behaviors associated with each ties, since hindering sexual expression can be seen to vio- late the patient's autonomy, whereas failure to preventinappropriate behaviors can place the patient and others at risk for mental and physical trauma.33 This is the most well-studied of all the brain systems, andit mediates the expression of sexual behaviors. Dysfunc- tion of the frontal system typically involves disinhibitionrather than hypersexuality. It is commonly seen in demen- The first part of the assessment is to obtain a compre- tias, multiple sclerosis, and tumors.15-17 hensive history, including a thorough sexual history.33 Ifthe patient is severely impaired, then a history should be obtained from the caregivers or family members. It must Animal studies have shown that sexual behaviors are also be ensured that these behaviors are truly sexual and inap- mediated through the temporo-limbic system. In rats, propriate in nature and do not represent a desire for close- chronic stimulation of limbic systems results in hypersexual ness or comfort.34 It is also common for caregivers and the behaviors.18 In humans, bilateral lesions of the temporal staff at nursing homes to misinterpret some of these lobes result in Kluver-Bucy syndrome, which includes behaviors as being sexually disinhibited.35 History-taking autoerotic behaviors, hyperorality, and finger agnosia, as should be followed by a good mental status and physical well as placidity, loss of fear, and memory impairments.19 examination. Laboratory data, including neuroimaging Hypersexual behaviors have also been reported after tem- studies to rule out delirium, should also be obtained. Neu- poral lobe strokes, tumors, and epilepsy.20-22 Right-side ropsychological testing may help in evaluating the patient's temporal lobe lesions can produce altered sexual behav- level of cognitive functioning and in understanding his or iors more than the left, as it modulates emotions and the her deficits. It is important to have an open discussion about understanding of the affect associated with sexual these behaviors, and the distress they cause and how it should be handled. A thorough assessment, open communi-cation, and prompt intervention are the keys to success.
Some sexual behaviors are associated with lesions of the
corticostriatal circuits, and they can be theorized as beingobsessive-compulsive in nature. They are internally gen-erated and dysfunctional. These types of behaviors can be Central nervous system diseases. Strokes, tumors,
seen in Huntington's disease, Wilson's disease, and surgeries, and trauma to the brain can result in Tourette's syndrome.25-27 In patients with Parkinson's dis- inappropriate sexual behaviors. They often occur in people ease, increased sexual behaviors have been reported after with no prior history of such behaviors or in people who L-dopa therapy.28,29 have successfully managed to repress their sexual urgesmost of their lives.23,31 Hypothalamus
Lesions to the hypothalamus can lead to an increase in sex-
Delirium. This is a common complication seen in
ual behaviors.30 Kleine-Levin syndrome, characterized by patients with dementia and other medical disorders. These Inappropriate Sexual Behaviors in Dementia / Black et al behaviors often occur acutely and resolve once the have inappropriate behaviors. They often need reassurance underlying condition is treated.32 that these behaviors are secondary to the illness and nota reflection of their relationship. It may also be useful to Medications. Different classes of medications can
reframe their partner's sexual requests as calls for closeness cause or worsen these behaviors. Some of the more common and reassurance.31 drugs that are implicated are as follows: Behavior modification. When inappropriate
• Levodopa can cause sexualized behaviors in behaviors occur, sensitively explain to the patient why patients with Parkinson's disease.28 such behaviors are unacceptable. It is helpful to avoid • Alcohol and benzodiazepines impair cognition and confrontation, as it may cause excessive guilt or shame. Do not ignore these behaviors, as this may unwittingly • Stimulant drugs, including cocaine, can cause an reinforce them. Distraction may be a very useful technique increase in libido.
for some of the patients.36 In nursing homes, single roomsand provision for conjugal or home visits may help reduce Psychotic disorders. Inappropriate behaviors may
the frequency of such behaviors by satisfying the patient's be seen in these disorders. They are usually bizarre and normal sexual drive. For those patients who are already related to the underlying psychopathology. The behavior exhibiting inappropriate behaviors, avoidance of external may be due to the delusional misidentification of someone cues such as overstimulating television or radio programs else as their spouse. Delusions and hallucinations may lead is helpful. In the patients with a tendency to expose to false sexual allegations.
themselves or masturbate in public, trousers that open inthe back or that are without zippers may be helpful. For Mood disorders. Inappropriate behaviors can occur
those patients in understimulating environments, provision in patients with hypomania or mania. These behaviors may for adequate social activity is helpful. For sexual be due to an increase in libido, impaired judgment, or a misinterpretations, provide simple and repeated combination of both these conditions. Depressive disorders explanations of why such behaviors are unacceptable.
often produce sexual dysfunction and not inappropriatebehaviors.
Changing the attitudes of the family, caregivers,
and staff in the nursing homes. The care of patients with
Social factors. Lack of privacy, restrictive attitudes,
dementia at home or at a nursing home demands a high and social cues may result in inappropriate behaviors.31 degree of technical and interpersonal skills. Caregivers are These behaviors may be due to a lack of avenues for often caught between moral norms, a person's rights, and expression of normal sexual drive. In cognitively impaired providing appropriate care for their patients.33 This can lead elderly people, the viewing of sexually explicit television to confusion, anger, denial, helplessness, and sometimes shows and/or physical care by a staff member of the ambivalence and apathy. Suitable sex-education programs opposite sex may result in inappropriate behaviors.
for the family, the caregivers, and the staff at the nursinghomes can add to the quality of life of a demented person.
The need for normal sexua l expression while preventinginappropriate sexual behaviors should be emphasized.
There are very few studies that have systematically Three separate studies have demonstrated that greater reviewed the treatment of these behaviors. Most of the data knowledge of sexuality and aging is associated with a available to us are from case reports or case series. The more permissive attitude.37-39 choice of treatment depends upon the urgency of the sit-uation, the types of behaviors, and the underlying medical conditions of the patient. Both nonpharmacological and There are no double-blind placebo controlled trials for pharmacological treatments have been found to be effective.
any of the drugs that are used to treat these behaviors. Med-ications should only be used when all other treatment methods have failed. Follow the general rule in the elderly If these behaviors are due to certain social cues which are of starting the medications at a low dose and titrating misinterpreted, then modification of these cues usually slowly. It is important to be vigilant for side effects from leads to a reduction in these inappropriate behaviors.
these drugs. It is prudent to discontinue medications that Other nonpharmacological treatments that have been can precipitate or worsen these behaviors. Avoid medications found to be useful in reducing and/or eliminating these like benzodiazepines, as they can cause disinhibition. The behaviors include the following.
classes of medications that have been found to be useful inthe treatment of these behaviors include selective serotonin Supportive psychotherapy. This modality of
reuptake inhibitor (SSRI) antidepressants, antipsychotics, treatment is especially useful for spouses of patients who and hormonal agents, along with cimetidine and pindolol.
Journal of Geriatric Psychiatry and Neurology / Vol. 18, No. 3, September 2005 Table 1. Medications Used for Treating Inappropriate Sexual Behaviors
Dose of Drug No. of Patients Behaviors to be Treated Common Side Effects Gastrointestinal disturbance, asthenia, sweating, tremors, dizziness, anxiety, headache, sedation Gastrointestinal disturbance, sweating, dizziness, somnolence, tremors, headache, anxiety 150-200 mg/day Exposing, public masturbation, Sedation, gastrointestinal disturbance, weight repeated touching changes, anxiety, tremors, sweating Sedation, orthostatic hypotension, headache, 100-500 mg/day Sedation, orthostatic hypotension, dizziness, headache, gastrointestinal disturbance, priapism 100-300 mg/wk Weight changes, abdominal pain, dizziness, every 2 weeks (IM) fondling, attempting to have nausea, depression, insomnia, pelvic pain, sex with others breast pain, edema Forcing penis into the mouth of another resident 0.625 mg/day; 7.5 mg/month (IM) 600-1600 mg/day Masturbation, fondling, Gastrointestinal disturbance, confusion, increased exposing, sexual hallucination serum transaminases, rash, blood dyscrasias Verbal comments, hugging, Bradycardia, congestive heart failure, hypotension, lightheadedness, depression, nausea, vomiting Note: MPA, medroxyprogesterone acetate; IM, intramuscular. There are 2 case reports on the use of clomipramine, The SSRIs are thought to decrease inappropriate behav- a nonspecific norepinephrine and serotonin reuptake iors by their antiobsessional and antilibidinal effects.40,41 inhibitor, in the treatment of inappropriate sexual behav- They also tend to decrease sex hormone–induced aggres- iors in dementia.45 The first patient (repeatedly exposing sive behaviors.42 These medications are found to be safe himself), had failed medroxyprogesterone acetate and in overdoses and to have the added benefit of treating thioridazine trials. Clomipramine was started and titrated comorbid depression and anxiety disorders. The common to 150 mg daily. After 4 weeks, there was a significant side effects of these medications are gastrointestinal dis- decrease in his behaviors. In a second case (public mas- turbances, headache, insomnia, and sexual dysfunction.
turbation, repeated touching), the patient had failed There is 1 case report on the use of paroxetine in a 69- trials of thioridazine and buspirone. Clomipramine year-old man with disinhibition and dementia.43 This was started and titrated to 200 mg daily. The behaviors patient had failed treatments with haloperidol, chlorpro- ceased but he developed orthostatic hypotension. The mazine, lorazepam, lithium, and nortriptyline. The dose was clomipramine was discontinued and thioridazine was 20 mg daily and the effects were seen within 1 week. The restarted. As the behaviors reappeared, thioridazine was improvement was sustained at 3-month follow-up.
discontinued and clomipramine was reinitiated again. It There is 1 case report on the use of citalopram in a 90- was titrated to 175 mg daily without any adverse events.
year-old woman residing in a nursing home who had a 2- With the reintroduction of clomipramine, the behaviors year history of physical aggression and inappropriate disrobing at the pelvic area of male residents.44 Thispatient had failed a trial of paroxetine at 20 mg once daily.
Risperidone at 0.5 mg twice a day orally was effective in There are no known clinical trials in the elderly on the use decreasing the physical aggression but not the sexually of antipsychotic medications in the treatment of these inappropriate behaviors. It had to be discontinued because behaviors, but the available evidence points to their effi- of extrapyramidal side effects. Trials of valproic acid and cacy.46 These drugs are thought to decrease sexually inap- gabapentin were also ineffective. A trial of citalopram at propriate behaviors by their dopamine-blocking effects.
20 mg orally once daily was very effective in decreasing Although all antipsychotics are thought to be equally the aggressive and inappropriate behaviors within 1 week.
effective in treating these behaviors, atypicals are better These symptoms remained in remission at 9-month follow- tolerated in the elderly.47 up. The authors of the report postulated that the effec- There is 1 case report on the use of quetiapine in an tiveness of citalopram compared to paroxetine was probably 85-year-old man with dementia and parkinsonism who pre- because of its higher selectivity on serotonin reuptake sented with inappropriate sexual behaviors, that is, mas- turbating for several hours a day to the point of self-injury.48 Inappropriate Sexual Behaviors in Dementia / Black et al The patient had failed a 2-week trial of cyproterone acetate days. The mean serum levels of testosterone and LH were at 100 mg orally twice daily. He also developed diarrhea reduced by 90% and 60%, respectively, after 28 days. The from paroxetine at 5 mg orally once daily after only 2 levels of testosterone and LH returned to pretreatment doses. He responded well to quetiapine at 25 mg orally once levels within 4 weeks after the end of the trial. At 1-year daily. The sexual behaviors stopped within 2 days and did follow-up, 3 of the 4 patients were free of the inappropriate not recur in the 2-month follow-up period. There was no behaviors. The fourth patient had a return of some of the worsening of his parkinsonism or blood pressure during inappropriate behaviors but not to the same degree as the 2-month period.
before. The investigators concluded that the effect of thedrug was not only due to the reduction of the testosterone but also due to its inhibitory effect on the hypothalamic Trazodone is a presynaptic reuptake inhibitor and a mild postreceptor agonist of serotonin with a half-life of 5 to 9 Weiner et al50 reported 2 cases of sexually inappro- hours. Simpson et al reported a case series of 4 patients priate behaviors (molestation, exposure, masturbation, with dementia and inappropriate sexual behaviors who had and fondling) in demented men aged 72 years and 84 failed to respond to antipsychotics (thioridazine, haloperi- years, who failed a trial of thioridazine. The first patient dol, mesoridazine, and thiothixene) and benzodiazepines was treated with intramuscular MPA at 100 mg every 2 but responded to trazodone.49 They were men between weeks. At the end of 2 weeks, the testosterone level was the ages of 62 and 72 years. The dose range for trazodone reduced from 2.9 ng/mL to 1.7 ng/mL, with an accompa- was between 100 and 500 mg a day in divided doses. The nying reduction in these behaviors. The dose was increased response was thought to be due to the calming effect of the to 150 mg as the behaviors returned. The behaviors were drug and not its antidepressant effect. The main side completely eliminated within the next 2 weeks. In the effects of trazodone are headache, dry mouth, sedation, second case, the patient responded to 200 mg of intra- orthostatic hypotension, and weight gain. Priapism (painful muscular MPA within 2 weeks erection) occurs in 1 in 6000 patients and is due to the a-2 There are no case reports on the use of CPA in older blocking effect of the drug. In cases of priapism, emergency men. There are 2 case reports of women with inappropri- treatment is needed with an intracavernal injection of ate behaviors.51,52 The first patient was a woman with treatment-resistant schizophrenia and compulsive mas-turbation who responded well to CPA. The second case was of a 40-year-old woman with hypersexual behavior whoresponded to treatment with CPA.
Antiandrogens. The commonly used antiandrogens
are medroxyprogesterone acetate (MPA) and cyproterone Estrogens. These medications act by reducing LH and
acetate (CPA). The rationale behind their use is that the FSH secretion and thereby reducing testosterone reduction in serum testosterone level will impair sexual production. The common estrogens are diethylstilbestrol functioning, and this in turn will eliminate the (DES) and conjugated estrogen. Common side effects include fluid retention, nausea, vomiting, impotence, andgynecomastia. There are reports of increased cardiovascular Medroxyprogesterone acetate. MPA is a
and thromboembolic episodes in patients with prostate progesterone that decreases the level of testosterone by cancer who are treated with DES. Kyomen et al reported inhibiting the levels of pituitary luteinizing hormone (LH) the use of DES in a 94-year-old man with dementia and and follicle stimulating hormone (FSH). Though it is called sexualized aggression, including forcing his penis into the an antiandrogen, it does not possess antiandrogen effects mouth of another patient and thrashing his body against at the receptor levels. The major side effects are sedation, her.53 The patient responded to 1 mg of DES within 3 increased appetite, weight gain, fatigue, loss of body hair, weeks. Lothstein et al reported marked improvement in hot and cold flashes, mild diabetes, decreased ejaculatory symptoms in 38 out of 39 patients with dementia who volume, and symptoms of depression. Cooper reported the were treated with oral estrogen (0.625 mg daily) or with cases of 4 male nursing home patients with dementia and transdermal estrogen patches (0.5-0.10 mg).54 inappropriate behaviors (masturbation, exposure, fondling,and attempting to have sex with other patients).17 They were between the ages of 75 and 84 years and had failed These medications suppress the testosterone production behavioral management and treatment with thioridazine by stimulating the secretion of pituitary LH and FSH. This or chlorpromazine. They were administered MPA at 300 results in an increase in estrogen production, thereby mg intramuscularly per week for 1 year. Sexual activity decreasing the level of testosterone. Leuprolide acetate is of these patients was recorded 6 months before the trial, the common gonadotrophin-releasing hormone (GnRH) during the trial, and 1 year after the trial. These analog used in clinical practice. These drugs must be used undesirable sexual activities were reduced within 10 to 14 continuously to maintain their effectiveness. Common Journal of Geriatric Psychiatry and Neurology / Vol. 18, No. 3, September 2005 side effects include hot flashes, erectile dysfunction, decreased libido, and irritation at the injection sites. There There are no reports on the use of mood stabilizers in the are 2 case reports on their use in inappropriate behaviors.
treatment of inappropriate sexual behaviors, though these The first report is by Ott, in which he described the use medications are commonly used to treat bipolar disorder of leuprolide acetate in a 43-year-old man with dementia in the elderly and behavioral disturbances associated with and Kluver-Bucy syndrome with good effect.55 This patient dementia.59,60 Common side effects of these medications are had not responded to pindolol at 360 mg daily. The dose tremors, sedation, falls, and weight gain.
of leuprolide was 7.5 mg intramuscularly every month. Thesecond report was by Rich et al in a 39-year-old man with Cholinesterase Inhibitors and N-methyl
Huntington's disease and exhibitionism who responded well to leuprolide acetate.56 Cholinesterase inhibitors such as donepezil, rivastigmine, A discussion on the use of hormonal agents for the and galantamine have been found to be effective in treat- treatment of inappropriate sexual behaviors in the elderly ing cognitive dysfunction and behavioral disturbances is a very sensitive one. The issues raised include the inabil- associated with dementia.61 However, there are no reports ity of the subject to give informed consent, the side-effect on the use of these medications in the treatment of inap- profile of these drugs and the social stigma associated propriate sexual behaviors associated with dementia.
with using these drugs, which are seen as "chemical cas- The N-methyl D-aspartate (NMDA) receptor antago- tration." Though there is no literature on how to handle nist memantine has been approved for the use in moder- these issues, a pragmatic approach to resolve the ethical ate to severe AD. This medication has been found to be conflict is to have discussions with the caregivers and the effective in treating cognitive and behavioral disturbance family about the risk and benefits of these drugs. Finally, associated with AD.62 There are no current reports on using these medications as agents of last resort with ade- their use in elderly patients with inappropriate sexual quate documentation of failed trials may also help with decreasing the anxiety about their use.
Cimetidine is an H-2 receptor antagonist with antian-
The question that gets asked frequently is, Should 2 drogen effects. Wiseman et al completed a retrospective demented persons or 1 demented and 1 nondemented per- chart review of 17 men and 3 women with various inap- son be allowed to participate in a sexual relationship? propriate behaviors (masturbation, fondling, and preoc- The answer remains poorly defined, but use the safety-first cupation with sex, exposing self, and sexual hallucinations rule. If the persons are competent to understand, they and delusions about their spouse's fidelity).57 Of the 20 consent to form a relationship, there is no coercion by one patients in the review, 14 had responded to cimetidine at or other party, and they can express joy in such a rela- dose ranges from 600 to 1600 mg/day, spironolactone 75 tionship, then it is ethically acceptable to let them form mg daily, ketoconazole, or to all 3 medications combined such a relationship. Lichtenberg and Strzepek in their together. Response time ranged from 1 to 8 weeks. Com- review discussed several questions that can help determine mon side effects were nausea, arthralgia, and headaches.
the individual's capacity to consent to a sexual relation- Some of these patients also received clozapine, carba- ship.63 These questions test the individual's awareness mazepine, perphenazine, venlafaxine, and loxapine for about the relationship, the presence or absence of coercion, delusions, hallucinations, and irritability. Recall bias and moral values, ability to prevent abuse, and psychological subjective nature of the responses were the major limita- aspects of entering and terminating relationships. In many tions of this study.
cases, a psychiatric or neuropsychological consultationwill help in clarifying the issue of informed consent. Try to involve families in the decision-making process, though There is a case report of a 75-year-old demented man with dealing with their anxiety about this issue can be difficult.
aggressive and hypersexual behaviors (verbal comments,hugging, kissing, self exposure, and attempted fondling) who had failed treatment with haloperidol (1-3 mg daily)and hydroxyzine (50-150 mg). Both agitation and hyper- Dementia is a growing public health problem. Behavioral sexual behaviors diminished in response to pindolol at 40 problems associated with dementia are very common and mg daily along with haloperidol 3 mg daily and hydrox- are a major source of distress. These behaviors are also the yzine 100 mg daily. Time to response was 2 weeks. Com- most common reason for the placement of a demented mon side effects of pindolol are fatigue and hypotension.
individual into a skilled nursing facility. Inappropriate This drug is thought to reduce inappropriate behaviors by sexual behaviors are a less common but an extremely dis- decreasing adrenergic drive and thus decreasing agitation, tressing symptom seen in patients with dementia. There aggression, and inappropriate behaviors.58 are limited data on the various aspects of these behaviors Inappropriate Sexual Behaviors in Dementia / Black et al including definition, neurobiology, and treatments. Future 20. Monga TN, Monga M, Raina MS, Hardjasudarma M. Hyper- research should not only focus on effective treatments but sexuality in stroke. Arch Phys Med Rehabil. 1986;67:415-417.
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Metformin in Gestational Diabetes: The Offspring Follow-Up (MiG TOFU)Body composition at 2 years of age ANET A. ROWAN, MBCHB MALCOLM BATTIN, MD that because of continued exposure to nu- LAINE C. RUSH, PHD TRECIA WOULDES, PHD trient excess in utero, the subcutaneous ICTOR OBOLONKIN, BSC WILLIAM M. HAGUE, MD fat stores become overloaded and, thus,the fetus develops leptin and insulin re-sistance and deposits excess nutrients as