REVIEW ARTICLE

Cognitive functioning and its influence on sexual behavior

in normal aging and dementia
Carien Hartmans1, Hannie Comijs2 and Cees Jonker3
1
GGZ Altrecht, Institute for Clinical and Outpatient Mental Health Care, Den Dolder, The Netherlands
2
GGZ InGEEST, Department of Psychiatry, VU University Medical Center, Amsterdam, The Netherlands
3
EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
Correspondence to: C. Hartmans, MsC, E-mail: c.hartmans@altrecht.nl

Objective: Motivational aspects, emotional factors, and cognition, all of which require intact cognitive
functioning may be essential in sexual functioning. However, little is known about the association
between cognitive functioning and sexual behavior. The aim of this article is to review the current
evidence for the influence of cognitive functioning on sexual behavior in normal aging and dementia.
Methods: A systematic literature search was conducted in PubMed, Ovid, Cochrane, and PsycINFO
databases. The databases were searched for English language papers focusing on human studies
published relating cognitive functioning to sexual behavior in the aging population. Keywords included
sexual behavior, sexuality, cognitive functioning, healthy elderly, elderly, aging and dementia.
Results: Eight studies fulfilled our inclusion criteria. Of these studies, five included dementia patients
and/or their partners, whereas only three studies included healthy older persons. Although not
consistently, results indicated a trend that older people who are not demented and continue to engage
in sexual activity have better overall cognitive functioning. Cognitive decline and dementia seem to be
associated with diminished sexual behavior in older persons.
Conclusions: The association between cognitive functioning and sexual behavior in the aging population
is understudied. The results found are inconclusive. Copyright # 2013 John Wiley & Sons, Ltd.
Key words: sexual behavior; sexuality; cognitive functioning; healthy elderly; elderly; aging and dementia
History: Received 16 December 2012; Accepted 14 August 2013; Published online 9 September 2013 in Wiley Online Library
(wileyonlinelibrary.com)
DOI: 10.1002/gps.4025

Introduction of quality of life and can express the quality of a relation-

Sexuality is everywhere in today’s society, yet sexuality
in the elderly population is not well represented in
research studies. Studies researching knowledge and
attitudes about sexuality and aging are limited
(Beckman et al., 2008; Snyder and Zweig, 2010). In
the elderly community, talking about sexual behavior
also still seems to be a taboo. The same trend is seen
in health care services, as doctors, nurses, and
psychologists often leave the topic unaddressed because
of personal feelings and/or lack of knowledge (Gott
et al., 2004; Bouman et al., 2006: Miller and Byers,
2008; Voermans et al., 2012). However, over the last
century, sexual behavior has no longer been considered
solely in terms of reproduction. It has become an aspect
ship. Laumann et al. (2006) found subjective sexual
well-being to be correlated with overall happiness.
The intensity, quality, and frequency of sexual
functioning are indeed affected by age, but the reality
of aging is that everyone continues to have some form
of sexual feelings (Kaplan, 1990; Trudel et al., 2000;
Ginsberg et al., 2005). There are no fixed age limits
for sexual functioning, and the phases of the sexual
response cycle (excitement, plateau, orgasm, and reso-
lution) remain the same at all ages. Research shows
that sexual behavior remains present in elderly people
(Nicolosi et al., 2006; Lindau et al., 2007; Papaharitou
et al., 2008; Hyde et al., 2010; Schick et al., 2010). For
example, a study in 106 traditional cultures showed
that in 70% of these cultures, all men continued to

Copyright # 2013 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2014; 29: 441–446
442
have sex until a late age versus 84% of women (Winn
and Newton, 1982). These percentages are surprisingly
high considering how aging is related to changes in
physical functioning, disease, and loss of partner, all
of which affect sexual behavior. Although these factors
may account for a decline in frequency of sexual
activity, the interest in sexuality remains high (Matthias
et al., 1997).
Studies among dementia patients and their partners
also report continued sexual activity in some of the
couples. Ballard et al. (1997) found that among partners
of dementia patients, 23% of the couples reported contin-
uance of sexual activity (Ballard et al., 1997). Derouesné
found that among partners from community-dwelling
dementia patients, 70% showed indifference to sexual ac-
tivity, and 50% reported sexual behavioral modifications
(Derouesné et al., 1996). Cognitive decline is associated
with aging and dementia. Single case reports on
Alzheimer’s and sexuality indicated that dementia
patients can experience various problems ranging from
impaired cognitive sequencing during love making and
forgetfulness of previous love making to declines in
decision-making capacity (Davies et al., 1998).
In the current literature, sexual behavior is often
studied from a merely biological point of view as this
evolutionary behavior starts with autonomic or
endocrine responses. However, motivational aspects,
emotional factors, and cognition, all of which require
intact cognitive functioning, are also essential in sexual
functioning. Here, the complex interaction between
cognitive and sexual functioning is viewed from a
neurobiological perspective.
Cognitive functioning, sexual behavior, and the brain
It is virtually indisputable that all behavior, including
sexual drive, is mediated by the brain. Sexual function-
ing is the result of a complex interaction of central and
peripheral neural pathways (Dombrowski et al., 2000;
Pistoia et al., 2006). Sexual arousal is needed for sexual
behavior and involves higher cortical functions such as
parietal lobes, prefrontal cortex, hypothalamus, and
amygdala (Rees et al., 2007). Besides these important
structures, other studies report the septal region,
globus pallidus, and the ansa lenticularis to be of im-
portance in sexual drive and behavior (Horn and
Zasler, 1990; Baird et al., 2007; Rees et al., 2007).
Schnarch (2002) introduced the quantum model in
which two thresholds (arousal and orgasm) need to
be surpassed. The total level of stimulation before
reaching an orgasm is then considered an accumula-
tion of physical sensitivity and reflexes, senses, and
Copyright # 2013 John Wiley & Sons, Ltd.
C. Hartmans et al.
emotional and motivational functions (Schnarch,
2002). In the process of sexual functioning and
reaching an orgasm, there are several identified
moments in sexual behavior at which a decision is or
can be made. The decision-making process involves
aspects of judgment, consent, sense of self, sense of
other, and abstract thinking, all of which require intact
memory and executive functioning. Prefrontal roles
are also involved in various aspects of sexual behavior,
and their regulatory role is consistent with their
importance in other forms of emotion, behavior, and
cognition (Spinella, 2007).
Clearly, sexual behavior cannot solely rely on
autonomic and endocrine processes, as without the
emotional, cognitive, and motivational aspects, the
phase of arousal will not be surpassed. Therefore, cog-
nitive functioning is thought to also be of importance,
as is shown in Figure 1, in which cognitive functioning
is placed within the biological processes of sexual
functioning. To further study the association between
cognitive functioning and sexual behavior when aging,
we review current knowledge about the influence of
age-related cognitive functioning and dementia on
sexual behavior in the elderly population.
Methods
In order to identify relevant publications, an extensive
search was conducted in PubMed. The database was
searched for English language papers focusing on human
studies. Keywords included sexual behavior, sexuality,
cognitive functioning, healthy elderly, elderly, aging,
and dementia. In addition to the search in the electronic
databases, relevant papers were identified through
Figure 1 Cognitive functioning in the process of sexual functioning.
Int J Geriatr Psychiatry 2014; 29: 441–446
Cognitive function and sexual behavior
reference tracking and through a manual literature
search on the internet.
The publications were screened by the first author
to meet the following inclusion criteria: (i) a mean
age of 65 years and over; (ii) an indication of a
relationship between sex/sexuality and cognitive
functioning; and (iii) an indication of a relationship
between sex/sexuality and cognitive functioning in
dementia patients. The caregiver perspective was only
considered when studies reported an association
between cognitive functioning and sexual behavior in
dementia patients. Case reports and reviews were also
included. Additional searches in the databases Ovid,
Cochrane, and PsycINFO using comparable search
terms resulted in other citations included here. In
total, the search identified 73 citations. Excluded were
those that focused solely on somatic diseases, dysfunc-
tions, or medication (n = 31). Research papers that
study sexual behavior in dementia, but fail to measure
cognitive functioning, were also excluded (n = 26).
The cognitive measures used in these papers indicated
the severity of dementia and were not studied for their
association with sexual functioning. Finally, those
studies that focused on cognition as a process of
thinking instead of cognitive functioning were also
excluded (n = 8). This resulted in eight studies that
met the inclusion criteria.
Results
The major characteristics of the eight studies are
presented in Table 1. The studies provided relevant
information on sexual behavior or sexual interest and
cognitive functioning, all with an exploratory character.
Sexual behavior and cognitive functioning
Three studies examined sexual behavior and its associa-
tion with cognitive functioning in community-dwelling
older people. Two of those studies among older people
not suffering from dementia reported 33% of the
respondents was still sexually active, whereas 40% of
respondents reported was still interested in sex
(Dello Buono et al., 1998; Padoani et al., 2000). With
respect to the association between sex or sexuality and
cognitive functioning, the findings vary. The first study,
among community-dwelling menopausal women,
showed cognitive status not to be significantly corre-
lated with sexual satisfaction (Diamond et al., 2009),
whereas the other two studies among Italian older
people showed that respondents with continued sex-
ual interest and activity had better general cognitive
Copyright # 2013 John Wiley & Sons, Ltd.
443
functioning (Dello Buono et al., 1998; Padoani et al.,
2000). The absence of cognitive impairment was con-
sidered an important factor in maintaining a sexual
interest (Padoani et al., 2000).
Sexual behavior and dementia
The results on the association between sexual behavior
and cognitive functioning in dementia patients show
conflicting results. Derouesné et al. (1996) showed that
the changes in sexual behavior were not correlated with
general cognitive functioning and duration of dementia,
but to the severity of behavioral changes and limitations
in daily living activities as perceived by the spouse.
Ballard et al. (1997) found a trend toward an
association between better general cognitive functioning
and a continuing sexual relationship. Results further
indicated abstract thinking to be significantly associated
with a continuing sexual relationship.
Abnormal sexual behavior such as hypersexuality is of-
ten reported because of the impact it has on spouses and
caregivers. However, this behavior is rare in dementia
patients (Burns et al., 1990). One study compared sexual
changes in patients with Alzheimer’s and frontotemporal
dementia (FTD) and found the same frequency of
increased sex drive in both conditions (8%) (Miller
et al., 1995). Another study on the caregiver’s perception
of the influence of dementia on the sexuality of their mar-
riage showed that an increased demand for sex was found
in 5% of the couples (Eloniemi-Sulkava et al., 2002). The
reported inappropriate sexual behaviors are often the
result of the inability to take into account the feelings of
others and the contextual environment or to disinhibition
and are not necessarily related to the way the sexual
relationship was before the illness.
Discussion
Few studies have researched the association between
cognitive functioning and sexual behavior in the
elderly population, and the results found are inconclu-
sive. However, there seems to be an indication that
sexual activity in later life is associated with better
overall cognitive functioning (Dello Buono et al.,
1998; Padoani et al., 2000). The influence of general
cognitive functioning in maintaining a sexual relation-
ship in dementia remains unclear. One study showed
abstract thinking to be significantly associated with a
continuing sexual relationship in dementia patients
(Ballard et al., 1997). A single case study on dementia
and erectile functioning showed impaired cognitive
sequencing, forgetfulness, and declines in decision-
Int J Geriatr Psychiatry 2014; 29: 441–446
 Table 1 Studies reporting on sexual behavior, and cognitive functioning, and dementia in older adults
444
Authors N Subjects Mean (SD) age or Instruments Focus of study Results
range in years

Dello Buono 335 Patients from Range 65–106 LEIPAD, instrument to Aspects of sexual 33% of the respondents report
et al. (1998) general practitioner measure self-perceived interest and activity in was still interested in
functioning and well- older people sex. Better cognitive
being of the older functioning in sexually
people, and MMSE to interested respondents
measure general
cognitive functioning
Diamond 622 A community- 73.2 (7.4) A self-developed The correlates of sexual Cognitive status not
et al. (2009) dwelling sample of questionnaire composed satisfaction with cognition, significantly correlated
postmenopausal of standardized emotional, and physical with sexual satisfaction
women measures of successful functioning, positive individual
cognitive and emotional traits, and measures of

Copyright # 2013 John Wiley & Sons, Ltd.

aging. Items from FSFI attitudes towards aging
Padoani 352 Patients from Four age groups LEIPAD, instrument to The role of cognitive Cognitive functioning is
et al. (2000) general practioner mean scores of measure self-perceived functioning in sexual activity important in maintaining a
71.2; 79.3; 73.1; functioning and well- and interest in older people sexual interest
and 79.2 being of the older
people, and MMSE to
measure general
cognitive functioning
Ballard 47 Partners of married 66.7 (6.7) MIS with two additional Sexual relationships and Abstract thinking significantly
et al. (1997) patients with mild/ questions on actual satisfaction in married associated with a continuing
moderate dementia sexual activity and dementia sufferers sexual relationship and a
satisfaction. CAMCOG trend towards an association
items on cognitive between better general cognitive
functioning functioning and a continuing
sexual relationship.
Burns 178 Demented patients 80.4 (6.6) CAMCOG items on Behavioral disorders in Sexual disinhibition was seen in
et al. (1990) from two psychiatric cognitive functioning Alzheimer’s disease only 7% of the respondents.
hospitals and MMSE to measure
(outpatients, general cognitive
inpatients and day- functioning
care patients).
Derouesné Study I 135 Community-living 69.3(8.9) study PBQ, 44 items from Sexual behavioral changes Changes in sexual behavior
et al. (1996) Study II 100 demented patients I 68.1 (10.2) BPRS designed to in Alzheimer’s disease were not correlated with
study II explore mood and general cognitive functioning
behavioral changes in and duration of dementia
AD; two questions
concerning sexual
behavior for the first
study. Study II: a self
designed questionnaire
(95 questions) covering
five facets of sexual
relations

Int J Geriatr Psychiatry 2014; 29: 441–446

C. Hartmans et al.

(Continues)
Cognitive function and sexual behavior 445

making capacity to negatively influence sexual behavior

No significant difference for FLD

BPRS, Behavioral Pathology Rating Scale; CAMCOG, Cambridge mental disorders; DAS, Dyadic Adjustment Scale; FSFI, Female Sexual Function Index; MIS, Marital Intimacy Scale;
to take into account the feelings

environment, or to disinhibition
Inappropriate sexual behaviors
(Davies et al., 1998). This negative influence on sexual

reduced sexual drive (54 vs.

and AD regarding increased
sexual drive (8 vs. 8%) and
behavior could be explained by impaired frontal lobe

of others, and contextual

are the result of inability activity (Figure 1). Executive functions are essential in
Results

recognizing consequences resulting from one’s actions,

making the right decision, suppressing socially unaccept-
able responses, and finally recognizing similarities and
differences when compared with other situations or events.
Although the findings by Ballard and Davies imply that
23%). memory and executive functioning are important aspects
to engage in meaningful sexual behavior, more research
Sexual behavior in Alzheimer’s

is necessary to further objectify this association.

The study by Padoani et al. (2000) provided the best
Changes in sexuality after

disease and frontal lobe

evidence for an association between cognitive function-

Focus of study

the onset of dementia

ing and sexual behavior in the normal elderly popula-

tion. However, as in most other studies, cognitive
functioning was examined with a screening instrument
only. The studies on dementia also used screening
dementia

instruments only (mini mental state examination and

Cambridge examination for mental disorders). A
screening instrument is not sensitive or specific enough
relations; and (b) sexual

to measure the various and specific aspects of cognitive

MMSE, Mini Mental State Examination; MIS,Marital Intimacy Scale; PBQ, Psycho-Behavioral Questionnaire.
changes in frequency of

and MMSE to measure

other sexual behaviors

functioning. Future research should include more

sexual intercourse or
general atmosphere,

side of the marriage

Questions about (a)
Instruments

specific neuropsychological tests to study various

Questionnaire on

general cognitive
happiness, and

cognitive domains, such as executive functioning.

functioning

The results from the dementia studies included here

were based solely on caregiver’s perspectives. However,
especially in the early stages, dementia patients should
still be able to provide valuable information about sexual
behavior or intimacy themselves. Reporting information
72, (range 59–86)
Mean (SD) age or
range in years

from the caregiver’s perspective only may lead to biased

63 in FLD and

results because of social desirability. Future studies

70.5 in AD

should include interviews with the dementia patients.

patients

Studies on dementia describe hypersexuality to be a

rare phenomenon in elderly dementia patients (Burns
et al., 1990; Robinson, 2003). Hypersexuality is often a
Alzheimer’s disease

display of other needs rather than a purely sexual need

demented patients
Community-living

and their spouse/

(AD) and patients

with frontal lobe

and should therefore be considered as a non-inten-

dementia (FLD)
Subjects

Patients with

tional behavioral problem in dementia (Derouesné,

caregivers

2009). Miller et al. (1995) did not find any difference

in sexual behavior when comparing patients with
FTD and Alzheimer’s, although one would expect
FTD patients to report a higher percentage of hyper-
sexuality. Eloniemi-Sulkava et al. (2002) showed that
14 AD and

in dementia, the most likely change in sexual behavior

patients
14 FLD
N

is apathy or indifference. The nuclei and cortical

100

structures of the limbic system set the level of arousal

Table 1. (Continued)

and are involved in motivation and reinforcing behav-

iors (Figure 1). Many of these areas are also essential
Sulkava et al.

Miller et al.

for specific types of memory. In dementia, these

Eloniemi-
Authors

structures fail to interconnect successfully, which

(2002)

(1995)

could result in inadequate (motor) behavior such as

apathy, indifference, and hypersexuality.

Copyright # 2013 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2014; 29: 441–446
446
Finally, in today’s medical practice, sexual history is
seldom part of a consult, which is the result of physicians
not being routinely trained to explore a patient’s sexual
history (Gott et al., 2004; Baird et al., 2007). Educational
and geriatric programs should integrate analysis and
occurrence of problematic sexual behavior in their
curriculum (Shaw, 2001; Givson, 2004).
Conclusion
The consequences of cognitive aging or dementia on
sexual behavior in the elderly population are not well
studied. The few studies found are limited, methodo-
logically weak, and inconclusive. However, the results
indicated a trend for older people who continue to en-
gage in sexual activity in later life to have overall better
cognitive functioning. Future research should provide
more insight in the relationship between cognitive
functioning and sexual behavior in old age. Also, more
specific neuropsychological testing is needed to under-
stand which specific cognitive domains are crucial for
engaging in sexual behavior.
Conflict of interest
None declared.
Key points
• The consequences of cognitive aging or dementia
on sexual behavior in the elderly population are
not well studied.
•
The few studies found are limited, methodologically
weak, and inconclusive.
•
The results indicated a trend for older people who
continue to engage in sexual activity in later life to
have overall better cognitive functioning.
• To understand which specific domains of cognitive
functioning are crucial for sexual behavior, more
specific neuropsychological testing is needed.
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