A variety of treatments have been used for inappropriate sexual behavior (ISB) in the demented.  The only medication with a double-blind study is conjugated estrogen, which was found quite effective for both aggression and ISB.  In seven cases, ISB patients improved after medroxyprogesterone.  Both of these treatments have been reported to be successful without significant side-effects.  I favor the estrogen as a first choice.

SSRI anti-depressants have been successful in paraphilias.  Two cases using clomipramine and one using paroxetine (Paxil) have been successful.  Sertraline (Zoloft) or citalopram (Celexa) would probably be better choices with fewer side-effects that clomipramine and longer acting than paroxetine.  Fluoxetine (Prozac) would also be good and very low cost, but many interfere with the metabolism of other meds.  Of course, paroxetine has the same drawback.

A number of other treatments have been less well researched.

Inappropriate Sexual Behavior Common with Dementia: Although some authors claim its rare, of the 133 consecutive demented patients admitted, 20 (15.0%) were reported to demonstrate ISB at home or during hospitalization. Patients with ISB had various types of dementia. There were no significant differences in patients with and without ISB in regard to age, age of onset, gender, educational level, or Mini-Mental State Examination scores. Inappropriate sexual behaviors in dementia: a preliminary report. Tsai SJ, Hwang JP, Yang CH, Liu KM, Lirng JF. Taipei. Alzheimer Dis Assoc Disord. 1999 Jan;13(1):60-2

Treatment

Carbamazepine May Have Helped Organic Brain Syndrome Case: In a 28-year-old male suffering severe brain injury due to an auto accident, traits of sexual exhibitionism, promiscuity, aggressive episodes, suspiciousness and low impulse control developed. Treatment with neuroleptics, benzodiazepines and antidepressants had no response. Carbamazepine at 1,200 mg/day reaching 8.8 mcg/ml after two months was associated with a marked improvement was observed with absence of exhibitionistic behavior and aggressive episodes, a tendency towards normalization of mood and anxiety, stabilization of his social and family relationships and starting some paid work. Organic personality disorder: response to carbamazepine. Munoz P, Gonzalez Torres MA. Bilbao. Actas Luso Esp Neurol Psiquiatr Cienc Afines. 1997 May-Jun;25(3):197-200

Cimetidine for Dementia Hypersexuality: 17 males 3 females. Cimetidine is antiandrogenic as are ketoconazole and spironolactone. Patients in the study had a preoccupation with sex, genital exposure, public masturbation, inappropriate touching or chasing, or sex delusions or hallucinations. Cimetidine was given at 600-1600 mg/d until response or side-effects then ketoconazole 100-200 mg or spironolactone 75 mg were added if necessary. Anti-psychotics were given for delusions, hallucinations, or irritability. 14 responded to cimetidine and the remaining six responded to the addition of a second agent. Well-tolerated. Cimetidine side-effects nausea, arthralgia, headache. Hypersexuality in patients with dementia: possible response to cimetidine. Wiseman SV, McAuley JW, Freidenberg GR, Freidenberg DL. Ohio State University. Neurology. 2000 May 23;54(10):2024

Clomipramine in Two Cases: Sexually inappropriate conduct often accompanies the disinhibition associated with dementia and neuropsychologic deficits. Two cases of paraphilia improved considerably while on clomipramine. This effect was not due to the sexual side effects of the drug (e.g., decreased ability to sustain an erection or orgasm). Careful monitoring for orthostasis, the increased risk of falls, and worsened confusion secondary to the potential risks of anticholinergic delirium and toxicity is needed. Clomipramine treatment of paraphilias in elderly demented patients. Leo RJ, Kim KY. State University of New York, Buffalo. J Geriatr Psychiatry Neurol. 1995 Apr;8(2):123-4

Cyproterone Might Have Helped Two Cases: Increased sexual activity in patients with dementia in two male patients who had dementia with pronounced sexual acting out, one with vascular dementia and the other patient with Parkinson's disease with associated dementia. After nonresponse to neuroleptics and sedatives, low-dose cyproterone acetate was associated with reduced sexual acting out without relevant side effects in both. Low-dose cyproterone acetate treatment of sexual acting out in men with dementia. Haussermann P, Goecker D, Beier K, Schroeder S. Munich, Germany. Int Psychogeriatr. 2003 Jun;15(2):181-6

Estrogen Helps Aggressive Behavior in DB: In a DB PC study design to investigate the efficacy and safety of short-term estrogen therapy in decreasing aggressive behaviors in elderly patients with moderate-to-severe dementia, estrogen therapy was associated with lower total aggression scores (P<0.030) and with decreased frequency of physical aggression (P<0.019) over the 4-week trial. Verbally aggressive behaviors were decreased relative to control subjects, although this effect was not statistically significant. No drug-vs.-placebo differences were found for resistive, sexual, or self-directed aggressive behaviors. No adverse effects from the estrogen were observed during the course of the study. Estrogen therapy and aggressive behavior in elderly patients with moderate-to-severe dementia: results from a short-term, randomized, double-blind trial. Kyomen HH, Satlin A, Hennen J, Wei JY. Harvard Medical. Am J Geriatr Psychiatry. 1999 Fall;7(4):339-48

Estrogen: Two Cases Physical Aggression and Sexual Inappropriateness Helped: Case 1. A 78-year-old white man had probable Alzheimer dementia and aggression (verbal and physical) that was nonresponsive to antipsychotic, antidepressant, and mood stabilizer therapy. However, conjugated estrogens 1.875 mg/d reduced his physical aggression by a 75%. Case 2. A 78-year-old African-American man with vascular dementia, physical aggression, and sexual inappropriateness was unsuccessfully managed with several antipsychotic and benzodiazepine trials. Conjugated estrogen 0.625 mg/day was associated with a decline in physical and sexual aggression by 80%, as well as a 55% reduction in sexual comments. Estrogen was well tolerated by both patients. Database searches were performed to identify case reports, letters, or clinical trials discussing estrogen use in aggressive elderly patients. As with previous reports, these cases suggest that conjugated estrogens may be used to reduce physical and sexual aggression associated with dementia in elderly men. Estrogen for dementia-related aggression in elderly men. Shelton PS, Brooks VG. Campbell University. Ann Pharmacother. 1999 Jul-Aug;33(7-8):808-12

Leuprolide in Two Cases: A patient with dementia and features of the Kluver-Bucy syndrome was treated for verbal, physical, and sexually aggressive behavior disturbances. Propranolol was effective in controlling verbal and physical aggression but not sexually aggressive and inappropriate behaviors. The latter responded completely to treatment with leuprolide. Leuprolide treatment of sexual aggression in a patient with Dementia and the Kluver-Bucy syndrome. Ott BR. Brown University. Clin Neuropharmacol. 1995 Oct;18(5):443-7; A case of Huntington's disease with exhibitionism is reported using leuprolide acetate (Lupron Depot, TAP Pharmaceuticals), a gonadotropin-releasing hormone agonist. Elimination of his deviant sexual behavior with few side effects suggests this regimen may be a safe and effective pharmacological treatment of the paraphilias. The occurrence of paraphilias in basal ganglia disorders is reviewed. Leuprolide acetate for exhibitionism in Huntington's disease. Rich SS, Ovsiew F. University of Chicago. Mov Disord. 1994 May;9(3):353-7

Medroxyprogesterone in Three Cases: Three demented patients with aggression, agitation, pacing, and restlessness received a therapeutic trial of the antiandrogen agents medroxyprogesterone acetate and luprolide acetate. Within 4 weeks, verbal and physical aggressivity had ceased; activity disturbances such as agitation, pacing, and restlessness were markedly reduced. One patient also manifested marked disinhibited and disruptive sexual behavior. Following treatment, that behavior also ceased. Further control studies assessing the efficacy and safety of antiandrogen agents are recommended. Antiandrogen treatment of aggressivity in men suffering from dementia. Amadeo M. University of Texas. J Geriatr Psychiatry Neurol. 1996 Jul;9(3):142-5

Medroxyprogesterone in Four Cases: Four demented male patients who manifested disruptive sexual behavior, including public masturbation and attempts to molest female patients, and who could not be managed by other means received a therapeutic trial of medroxyprogesterone acetate (MPA) for 1 year and were followed up for an additional year. Within 2 weeks of the start of MPA therapy, the sexual acting out had stopped; this was associated with a 90% and a 60% decline, respectively, of serum testosterone and LH. When MPA treatment was stopped, testosterone and LH returned to pretrial levels in all four men. One showed a return of sexual acting out, but this was at a reduced level and was successfully managed by firm nursing. MPA was used without adverse effects.  Medroxyprogesterone acetate (MPA) treatment of sexual acting out in men suffering from dementia. Cooper AJ. J Clin Psychiatry. 1987 Sep;48(9):368-70

Paroxetine Case Report: Paroxetine treatment of sexual disinhibition in dementia. Stewart JT, Shin KJ. Am J Psychiatry. 1997 Oct;154(10):1474