How do you manage problematic disinhibited behaviors in patients with neurocognitive disorders?

This requires a problem-centered approach. I suggest the following thought process.

1. Analyse the root cause: Is it disinhibition? Unmet needs? Under/Overstimulating environment? Medication side effect?
2. For disinhibition (frontal lobe dysfunction): I have had success with gabapentin and low-dose Depakote.
3. For unmet needs: Redirection and distraction, providing adequate stimulation with things patients historically enjoyed - visual (photo albums, movies) or auditory (favorite music, etc.). I had success with using dolls and stuffed animals to help with unmet emotional needs.
4. Adjusting the environment: decrease the level of overall stimulation (and in some cases, more engagement helps), changing location and caregivers, using clothes that are ...

I see this problem, not infrequently, in patients in every stage of dementia, from MCI to severe dementia. Sertraline can be beneficial, but if not, lamotrigine or divalproex often work reasonably well.

This is a very important area since such behavior often results in caregiver stress and earlier placement in alternative facilities. First, a clear description of the problematic behavior (verbal, physical, timing, apparent precipitants, form of actual behavior, and how this is a change from pre-morbid behavior) should be obtained from caregivers and other informants, including the patient themselves. The impact of the behavior is critical to understanding the next steps (e.g., has the behavior resulted in arrest, legal repercussions, injury to the patient or others, stigma, etc.). Likewise, what is the etiology? (For instance, is the behavior a common sequelae of the personality changes seen sometimes in people with traumatic brain injury,...

When medical and other etiologies have been ruled out, and a medication approach is indicated, paroxetine if often the med of choice. Just as it is often not preferered for depression and anxiety due to it's sexual side effects, this becomes beneficial for this population.

Agree with Depakote, Paxil, or Thorazine, using one at a time or in combination.

The trifecta is Depakote, Thorazine, and Paxil.

I will search for etiology first. Is it physiological? Many patients do not have official partners at that age. As an example, eating is the most direct way to satisfy true biological hunger; other non-food factors like excessive dopamine/testosterone should also consider in mind.

SSRI is not always a good choice, and specifically paroxetine, due to antihistaminic effects, urinary retention (BPH). Priapism is one of the adverse reactions of Fluoxetine!

Many times, antipsychotic itself increase libido! (priapism).

I'm following this discussion to find out an acceptable scientific answer.

For self-injurious, repetitive behaviors in individuals with severe intellectual disabilities, naltrexone seems to be helpful.

The use of valproate in this context is common, but I try to avoid it. Valproate has significant cognitive and systemic toxicity as well as a host of drug-drug interactions. There is not much data to support its use for controlling behavioral agitation in patients with cognitive impairment, but quite a bit of data that it is ineffective and potentially harmful. Below is a brief review.

Carnahan & Saliba, PMID 36349525

After excluding a treatable etiology, if the behavior is still problematic and not amenable to environmental modification, anti-androgen Provera has worked for my patients.