When damage occurs in the center of the brain that controls sexual impulses, the impaired older person might display behavior that can be extremely upsetting to others.

It is not surprising, therefore, that when mentally impaired older people display uninhibited sexuality, it can cause distress to those around them. Sometimes that sexual behavior is the innocent consequence of the older person's impaired memory, confusion or disorientation, as illustrated in the following example.

Mrs. Mahler was divorced and living alone with her two small children when her mother died. Her father, who had had a stroke, had been very dependent upon her mother and was unable to live alone. Mrs. Mahler moved him into her apartment and set up a place for him to sleep in the living room. Weeks passed, and the family tried to adjust to the new arrangements. One night Mrs. Mahler awoke to find that her father had crept into her bed and was fondling her sexually. She panicked and became hysterical, unable to recognize that her father had forgotten where he was and that his wife had died, and that he thought he was getting into bed with his wife. Her father also became upset, although he was confused about the incident Mahler was so disturbed by the episode that she was no longer able to care for him or even relate to him as she had in the past so she arranged for a nursing home admission as quickly as she could. Although she could understand intellectually that her father's sexual behavior was harmless and not intentionally directed at her, she was emotionally unable to overcome her feelings of disgust.

This case points up the depth of our feelings when sexual taboos are violated. It takes a great deal of understanding and discussion to get over our upset feelings when the mentally impaired old man or woman we are concerned about is no longer able to conform to normal sexual mores. As in other problem behaviors, it must be seen as a symptom of mental impairment. But when the most fundamental taboos are forgotten, it is more difficult to accept the offending behavior as symptomatic.

Fortunately, inappropriate sexual behavior is not a problem in most mentally impaired aged, but when it does occur, it is often experienced as degenerate and degrading. Frequently the behavior takes the form of masturbation in public or handling of genitalia without awareness of the presence of others. If those who witness this behavior can understand that although there are deeply ingrained negative feelings about masturbation, it is not considered an abnormal or immoral act by most mental health processionals, they might be less inclined to overreact. It should be viewed as resulting from a loss of inhibition about the requirement of privacy. The appropriate response would be to distract the older person from what he is doing and get him to a private area.

Sometimes an increase in sexual activity is a reaction to anxiety or even to depression. This should be discussed with the older person's doctor, for if emotional symptoms are indeed the cause of the inappropriate sexual expressions, then they can be treated with medication, leading to a reduction of the sexual behavior.

Sometimes the uninhibited older person may make upsetting sexual remarks or advances. Although it can be shocking to hear vulgar and suggestive language from a previously polite, discreet person, it is best to handle this lightly, with humor, or even by ignoring the behavior.

We do not know why this particular behavior occurs in some and not in others. There is no known relation to a person's past sexual experiences. It should be viewed simply as one more change that can occur with advancing mental impairment.

When the older person still has the privacy of his own home or the home of a relative, the inappropriate sexual behavior need be understood only by the few persons who are responsible for his care. However, if he goes for walks unsupervised in the neighborhood, his sexual behavior can cause serious disturbances. Care must be taken to protect the older person who judgment is failing from wandering without supervision outside of his home, both for his own safety and dignity and for the comfort and protection of others. If sexual behavior occurs outside of home, the person who is supervising should remove the impaired older person from the embarrassing situation and, if then time, explain that the behavior is caused by mental impairment.

Occasionally, mentally impaired older persons who are in the protective setting of a nursing home also display overt sexual behavior. How this is handled depends very much on the skills of the nursing home staff and the level of training they have had in understanding this behavior.

In some ways it can be more difficult to manage the inappropriate behavior in an institution because of the lack of privacy. Often the staffs in nursing homes, despite their training, display a leering attitude and make fun of the older person displaying such behavior. Institutional staffs must be exposed to in-service training about sexuality in old age, understanding it as a normal drive and understanding as well the special problems posed when mental impairment leads to loss of judgment and inhibitions. Nursing homes employees are sometimes subject to sexual advances and they must learn to recognize these as signs of the patients inability to control impulsive behavior and to judge what is inappropriate. They must also learn, just as family members must learn, to understand their own strong feelings about sexuality and the aged, and they must learn the techniques of distracting the impaired older person from the sexual behavior and getting him to a more private area.

The staff must also exercise vigilance to protect against the exercise of socially inappropriate behavior, as when an impaired older person gets into bed with another confused patients. Although the experience may in fact be pleasant for both parties, the important issue is that the patients would not indulge in this public behavior if they were mentally intact. This calls for a protective attitude on the part of the staff to prevent upsetting both the patients and their families.

There has been much public discussion in recent years about the sexual needs and rights of institutional residents. This has centered on the needs of mentally normal persons who can handle their sexuality privately if they have the opportunity to do so. This is not applicable to the needs of the mentally impaired aged, who may no longer be able to distinguish between private and public areas and whose loss of inhibitions may lead to discreet behavior. The mentally impaired patients first need protection, then privacy.

(c) copyright 1998

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