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Balachandran S, Matlock EL, Conroy ML, Lane CE. Behavioral Variant Frontotemporal Dementia: Diagnosis and Treatment Interventions. CURRENT GERIATRICS REPORTS 2021. [DOI: 10.1007/s13670-021-00360-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Abstract
Purpose of Review
The diagnosis and treatment of behavioral variant frontotemporal dementia is challenging and often delayed because of overlapping symptoms with more common dementia syndromes or primary psychiatric illnesses. The purpose of this paper is to explore the relevant presentation, diagnostic workup, pathophysiology, and both pharmacologic and non-pharmacologic management.
Recent Findings
Behavioral variant frontotemporal dementia is a highly heritable disorder. The gradual accumulation of diseased protein culminates in the destruction of those brain circuits responsible for much of one’s emotional and social functioning.
Summary
Behavioral variant frontotemporal dementia is a progressive neurodegenerative disorder with a far-reaching impact on patients and caregivers. Patients often present with emotional blunting, lack of empathy, apathy, and behavioral disinhibition. Non-pharmacologic interventions and caregiver support are the cornerstone of treatment. The use of cholinesterase inhibitors and memantine is not supported by the evidence. While current pharmacologic therapies target only certain symptoms, there are disease modifying agents currently in or nearing the clinical research stage.
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Abstract
PURPOSE OF REVIEW This article reviews the treatment of aggression and agitation in dementia. Both nonpharmacologic and pharmacologic approaches to responsive behaviors are discussed. Practical treatment strategies are applied to common behavioral symptoms. RECENT FINDINGS Aggressive and agitated behavior is common in dementia. Behavioral symptoms lead to reduced quality of life and distress for both patients and caregivers. They can also lead to poor outcomes and are associated with significant financial implications for the individual and health care system. A wide range of difficult behaviors exists, with limited evidence for deciding on treatment. Clinicians should integrate the available evidence with practical and commonsense strategies to target these difficult-to-treat behaviors. SUMMARY Treating aggression and agitation in dementia is challenging. Viewing behaviors as a response to either internal or external stimuli can help guide treatment. Treatment should emphasize nonpharmacologic approaches as an initial step, using practical and commonsense strategies. Caregivers and family should be actively involved in the planning and implementation of behavioral plans. It is essential to minimize both medical and nonmedical factors that may be contributing to behaviors. When pharmacologic options are required, it is important to choose medications that will target specific behavioral goals, having both practical consideration and the best evidence in mind.
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Logroscino G, Imbimbo BP, Lozupone M, Sardone R, Capozzo R, Battista P, Zecca C, Dibello V, Giannelli G, Bellomo A, Greco A, Daniele A, Seripa D, Panza F. Promising therapies for the treatment of frontotemporal dementia clinical phenotypes: from symptomatic to disease-modifying drugs. Expert Opin Pharmacother 2019; 20:1091-1107. [PMID: 31002267 DOI: 10.1080/14656566.2019.1598377] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Frontotemporal dementia (FTD) is a heterogeneous clinical entity that includes several disorders characterized by different cellular mechanisms. Distinctive clinical features in FTD include behavioral, affective, and cognitive symptoms. Unfortunately, little progress has been made over the past 20 years in terms of the development of effective disease-modifying drugs with the currently available symptomatic treatments having limited clinical utility. AREAS COVERED This article reviews the principal pharmacological intervention studies for FTD. These are predominantly randomized clinical trials and include symptomatic treatments and potential disease-modifying drugs. EXPERT OPINION There is insufficient evidence on effective treatments for FTD and studies with better methodological backgrounds are needed. Most studies reporting therapeutic benefits were conducted with selective serotonin reuptake inhibitors, while anti-dementia drugs have been ineffective in FTD. Since the underlying pathology of FTD mostly consists of abnormal tau protein or TDP-43 aggregates, treatments are being developed to interfere with their aggregation process or with the clearance of these proteins. Furthermore, disease-modifying treatments remain years away as demonstrated by the recent negative Phase III findings of a tau aggregation inhibitor (LMTM) for treating the behavioral variant of FTD. The results from current ongoing Phase I/II trials will hopefully give light to future treatment options.
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Affiliation(s)
- Giancarlo Logroscino
- a Neurodegenerative Disease Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs , University of Bari "Aldo Moro" , Bari , Italy.,b Department of Clinical Research in Neurology, Center for Neurodegenerative Diseases and the Aging Brain , University of Bari "Aldo Moro", "Pia Fondazione Cardinale G. Panico" , Lecce , Italy
| | - Bruno P Imbimbo
- c Department of Research and Development , Chiesi Farmaceutici , Parma , Italy
| | - Madia Lozupone
- a Neurodegenerative Disease Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs , University of Bari "Aldo Moro" , Bari , Italy
| | - Rodolfo Sardone
- d National Institute of Gastroenterology "Saverio de Bellis" , Research Hospital , Castellana Grotte Bari , Italy
| | - Rosa Capozzo
- b Department of Clinical Research in Neurology, Center for Neurodegenerative Diseases and the Aging Brain , University of Bari "Aldo Moro", "Pia Fondazione Cardinale G. Panico" , Lecce , Italy
| | - Petronilla Battista
- e Istituti Clinici Scientifici Maugeri SPA SB, IRCCS , Institute of Cassano Murge , Bari , Italy
| | - Chiara Zecca
- b Department of Clinical Research in Neurology, Center for Neurodegenerative Diseases and the Aging Brain , University of Bari "Aldo Moro", "Pia Fondazione Cardinale G. Panico" , Lecce , Italy
| | - Vittorio Dibello
- d National Institute of Gastroenterology "Saverio de Bellis" , Research Hospital , Castellana Grotte Bari , Italy.,f Interdisciplinary Department of Medicine (DIM), Section of Dentistry , University of Bari AldoMoro , Bari , Italy
| | - Gianluigi Giannelli
- d National Institute of Gastroenterology "Saverio de Bellis" , Research Hospital , Castellana Grotte Bari , Italy
| | - Antonello Bellomo
- g Psychiatric Unit, Department of Clinical and Experimental Medicine , University of Foggia , Foggia , Italy
| | - Antonio Greco
- h Geriatric Unit , Fondazione IRCCS "Casa Sollievo della Sofferenza" , Foggia , Italy
| | - Antonio Daniele
- i Institute of Neurology , Catholic University of Sacred Heart , Rome , Italy.,j Institute of Neurology, Fondazione Policlinico Universitario A. Gemelli IRCCS , Rome , Italy
| | - Davide Seripa
- h Geriatric Unit , Fondazione IRCCS "Casa Sollievo della Sofferenza" , Foggia , Italy
| | - Francesco Panza
- a Neurodegenerative Disease Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs , University of Bari "Aldo Moro" , Bari , Italy.,b Department of Clinical Research in Neurology, Center for Neurodegenerative Diseases and the Aging Brain , University of Bari "Aldo Moro", "Pia Fondazione Cardinale G. Panico" , Lecce , Italy.,d National Institute of Gastroenterology "Saverio de Bellis" , Research Hospital , Castellana Grotte Bari , Italy.,h Geriatric Unit , Fondazione IRCCS "Casa Sollievo della Sofferenza" , Foggia , Italy
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Abstract
Frontotemporal dementia (FTD) is a common young-onset dementia presenting with heterogeneous and distinct syndromes. It is characterized by progressive deficits in behavior, language, and executive function. The disease may exhibit similar characteristics to many psychiatric disorders owing to its prominent behavioral features. The concept of precision medicine has recently emerged, and it involves neurodegenerative disease treatment that is personalized to match an individual's specific pattern of neuroimaging, neuropathology, and genetic variability. In this paper, the pathophysiology underlying FTD, which is characterized by the selective degeneration of the frontal and temporal cortices, is reviewed. We also discuss recent advancements in FTD research from the perspectives of clinical, imaging, molecular characterizations, and treatment. This review focuses on the approach of precision medicine to manage the clinical and biological complexities of FTD.
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Affiliation(s)
- Mu-N Liu
- Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan.,Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Neurology, Memory and Aging Centre, University of California, San Francisco, San Francisco, CA, United States
| | - Chi-Ieong Lau
- Department of Neurology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan.,Applied Cognitive Neuroscience Group, Institute of Cognitive Neuroscience, University College London, London, United Kingdom.,College of Medicine, Fu-Jen Catholic University, Taipei, Taiwan
| | - Ching-Po Lin
- Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan.,Institute of Neuroscience, National Yang-Ming University, Taipei, Taiwan.,Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan
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Neural correlates of apathy in patients with neurodegenerative disorders: an activation likelihood estimation (ALE) meta-analysis. Brain Imaging Behav 2018; 13:1815-1834. [DOI: 10.1007/s11682-018-9959-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Fernández-Matarrubia M, Matías-Guiu JA, Cabrera-Martín MN, Moreno-Ramos T, Valles-Salgado M, Carreras JL, Matías-Guiu J. Different apathy clinical profile and neural correlates in behavioral variant frontotemporal dementia and Alzheimer's disease. Int J Geriatr Psychiatry 2018; 33:141-150. [PMID: 28240379 DOI: 10.1002/gps.4695] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 02/01/2017] [Indexed: 11/12/2022]
Abstract
OBJECTIVES Apathy is one of the most common and disabling syndromes of dementia. Clinical apathy expression and neuroanatomical basis of apathy seem to differ between behavioral variant frontotemporal dementia (bvFTD) and Alzheimer's disease (AD), although evidence is scarce and poorly understood. Our main purposes were to compare the clinical apathy profile from patients with bvFTD and AD and analyze the relationship between apathy and brain metabolism measured using positron emission tomography imaging with 18 F fluorodeoxyglucose (FDG-PET). METHODS Forty-two bvFTD, 42 AD, and 30 healthy volunteers without cognitive or behavioral complaints were included. Apathy was defined using Robert's 2009 diagnostic criteria, and specific apathy characteristics were assessed with the Lille Apathy Rating Scale. All participants underwent FDG-PET brain scan to provide data for voxel-based morphometric analysis. RESULTS Multivariate analysis showed that subjects affected by bvFTD displayed greater impairment of emotional apathy and self-awareness in comparison with AD sample. Additionally, FDG-PET imaging analyses revealed that apathy was associated with different neuroanatomical substrates in each dementia group: left lateral prefrontal, medial frontal/anterior cingulate, lateral orbitofrontal and anterior insular cortices in bvFTD, and right anterior cingulate in AD. CONCLUSIONS These results support that apathy is a complex syndrome, with different clinical expressions across different pathological conditions. Those differences in qualitative aspects of apathy seem to be associated with differences in the damage sites, as shown by our FDG-PET imaging analysis. Our findings provide a better knowledge about pathophysiology of apathy in dementia, which could have practical implications for therapeutic management. Copyright © 2017 John Wiley & Sons, Ltd.
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Affiliation(s)
- Marta Fernández-Matarrubia
- Department of Neurology, Hospital Clínico Universitario San Carlos, San Carlos Institute for Health Research (IdISSC), Universidad Complutense, Madrid, Spain
| | - Jordi A Matías-Guiu
- Department of Neurology, Hospital Clínico Universitario San Carlos, San Carlos Institute for Health Research (IdISSC), Universidad Complutense, Madrid, Spain
| | - María Nieves Cabrera-Martín
- Department of Nuclear Medicine, Hospital Clínico Universitario San Carlos, San Carlos Institute for Health Research (IdISSC), Universidad Complutense, Madrid, Spain
| | - Teresa Moreno-Ramos
- Department of Neurology, Hospital Clínico Universitario San Carlos, San Carlos Institute for Health Research (IdISSC), Universidad Complutense, Madrid, Spain
| | - María Valles-Salgado
- Department of Neurology, Hospital Clínico Universitario San Carlos, San Carlos Institute for Health Research (IdISSC), Universidad Complutense, Madrid, Spain
| | - José Luis Carreras
- Department of Nuclear Medicine, Hospital Clínico Universitario San Carlos, San Carlos Institute for Health Research (IdISSC), Universidad Complutense, Madrid, Spain
| | - Jorge Matías-Guiu
- Department of Neurology, Hospital Clínico Universitario San Carlos, San Carlos Institute for Health Research (IdISSC), Universidad Complutense, Madrid, Spain
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Young JJ, Lavakumar M, Tampi D, Balachandran S, Tampi RR. Frontotemporal dementia: latest evidence and clinical implications. Ther Adv Psychopharmacol 2018; 8:33-48. [PMID: 29344342 PMCID: PMC5761910 DOI: 10.1177/2045125317739818] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 09/26/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Frontotemporal dementia (FTD) describes a cluster of neurocognitive syndromes that present with impairment of executive functioning, changes in behavior, and a decrease in language proficiency. FTD is the second most common form of dementia in those younger than 65 years and is expected to increase in prevalence as the population ages. This goal in our review is to describe advances in the understanding of neurobiological pathology, classification, assessment, and treatment of FTD syndromes. METHODS PubMed was searched to obtain reviews and studies that pertain to advancements in genetics, neurobiology, neuroimaging, classification, and treatment of FTD syndromes. Articles were chosen with a predilection to more recent preclinical/clinical trials and systematic reviews. RESULTS Recent reviews and trials indicate a significant advancement in the understanding of molecular and neurobiological clinical correlates to variants of FTD. Genetic and histopathologic markers have only recently been discovered in the past decade. Current therapeutic modalities are limited, with most studies reporting improvement in symptoms with nonpharmacological interventions. However, a small number of studies have reported improvement of behavioral symptoms with selective serotonin reuptake inhibitor (SSRI) treatment. Stimulants may help with disinhibition, apathy, and risk-taking behavior. Memantine and cholinesterase inhibitors have not demonstrated efficacy in ameliorating FTD symptoms. Antipsychotics have been used to treat agitation and psychosis, but safety concerns and side effect profiles limit utilization in the general FTD population. Nevertheless, recent breakthroughs in the understanding of FTD pathology have led to developments in pharmacological interventions that focus on producing treatments with autoimmune, genetic, and molecular targets. CONCLUSION FTD is an underdiagnosed group of neurological syndromes comprising multiple variants with distinct neurobiological profiles and presentations. Recent advances suggest there is an array of potential novel therapeutic targets, although data concerning their effectiveness are still preliminary or preclinical. Further studies are required to develop pharmacological interventions, as there are currently no US Food and Drug administration approved treatments to manage FTD syndromes.
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Affiliation(s)
- Juan Joseph Young
- Department of Psychiatry, MetroHealth Medical Center, Cleveland, OH, USA Case Western Reserve University, Cleveland, OH, USA
| | - Mallika Lavakumar
- Department of Psychiatry, MetroHealth Medical Center, Cleveland, OH, USA Case Western Reserve University, Cleveland, OH, USA
| | - Deena Tampi
- Mercy Regional Medical Center, 3700 Kolbe Rd, Lorain, OH 44053, USA
| | - Silpa Balachandran
- Department of Psychiatry, MetroHealth Medical Center, Cleveland, OH, USA Case Western Reserve University, Cleveland, OH, USA
| | - Rajesh R Tampi
- MetroHealth Medical Center, Case Western Reserve University School of Medicine, 2500 MetroHealth Drive, Cleveland, OH 44109, USA
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Affiliation(s)
- Hani Raoul Khouzam
- Employee Behavioral Health Dartmouth, Hitchcock Medical Center, The Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- Behavioral Health Bureau, Monterey County Department of Health, Salinas, CA, USA
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Abstract
Today, frontotemporal dementia (FTD) remains one of the most common forms of early-onset dementia, that is, before the age of 65, thus posing several diagnostic challenges to clinicians since symptoms are often mistaken for psychiatric or neurological diseases causing a delay in correct diagnosis, and the majority of patients with FTD present with symptoms at ages between 50 and 60. Genetic components are established risk factors for FTD, but the influence of lifestyle, comorbidity, and environmental factors on the risk of FTD is still unclear. Approximately 40% of individuals with FTD have a family history of dementia but less than 10% have a clear autosomal dominant pattern of inheritance. Lack of insight is often an early clue to FTD. A tailored treatment option at an early phase can mitigate suffering and improve patients' and caregivers' quality of life.
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Affiliation(s)
| | - Knut Engedal
- Norwegian National Advisory Unit on Ageing and Health, Tønsberg, Norway
| | - Zeina Chemali
- Department of Neurology and Psychiatry, Neuropsychiatry Clinics, Massachusetts General Hospital, Boston, MA, USA Department of Psychiatry, Neuropsychiatry Clinics, Massachusetts General Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA
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Abstract
Emotional and behavioral dyscontrol are relatively common neuropsychiatric sequelae of traumatic brain injury and present substantial challenges to recovery and community participation. Among the most problematic and functionally disruptive of these types of behaviors are pathologic laughing and crying, affective lability, irritability, disinhibition, and aggression. Managing these problems effectively requires an understanding of their phenomenology, epidemiology, and clinical evaluation. This article reviews these issues and provides clinicians with brief and practical suggestions for the management of emotional and behavioral dyscontrol.
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Affiliation(s)
- David B Arciniegas
- Beth K. and Stuart C. Yudofsky Division of Neuropsychiatry, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA; Brain Injury Research Center, TIRR Memorial Hermann, Houston, TX, USA; Neuropsychiatry Service, Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Hal S Wortzel
- Beth K. and Stuart C. Yudofsky Division of Neuropsychiatry, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA; Neuropsychiatry Service, Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO, USA; VISN 19 MIRECC, Denver Veterans Medical Center, Denver, CO, USA
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Mittur A. Trazodone: properties and utility in multiple disorders. Expert Rev Clin Pharmacol 2014; 4:181-96. [DOI: 10.1586/ecp.10.138] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Chow TW, Alobaidy AA. Incorporating new diagnostic schemas, genetics, and proteinopathy into the evaluation of frontotemporal degeneration. Continuum (Minneap Minn) 2013; 19:438-56. [PMID: 23558488 PMCID: PMC10563897 DOI: 10.1212/01.con.0000429173.35439.9c] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Within the continuously growing body of knowledge in the field of dementia, frontotemporal degeneration stands out in importance as the second most common cause of early-onset dementia after Alzheimer disease. Neurologists, neuropsychologists, and speech pathologists are particularly involved in the diagnosis and recognition of etiologies for patients with deficits in frontal lobe function and language. RECENT FINDINGS The recent discovery of a novel mutant gene (C9ORF72) and the new nomenclature adopted for subclassification have significantly promoted our understanding of this disorder. SUMMARY This article relates the most recent consensus criteria for diagnosis of the two forms of frontotemporal degeneration (ie, behavioral and primary progressive aphasia variants) to basic neurologic principles and remind clinicians of the neuropsychiatric and neuroradiologic components that clarify frontotemporal degeneration diagnoses and guide management.
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Affiliation(s)
- Tiffany W Chow
- Baycrest Rotman Research Institute, 3560 Bathurst Street, 8th Floor Brain Health Complex, Toronto, ON M6A 2E1, Canada.
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Medical management of frontotemporal dementias: the importance of the caregiver in symptom assessment and guidance of treatment strategies. J Mol Neurosci 2011; 45:713-23. [PMID: 21647712 DOI: 10.1007/s12031-011-9558-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Accepted: 05/16/2011] [Indexed: 01/31/2023]
Abstract
There are no currently Food and Drug Administration-approved or proven off-label treatments for the frontotemporal dementias (FTD). Clinicians, caregivers, and patients struggle regularly to find therapeutic regimens that can alleviate the problematic behavioral and cognitive symptoms associated with these devastating conditions. Success is "hit or miss" and the lessons learned are largely anecdotal to date. Drug discovery in this area has been largely hampered by the heterogeneous clinical presentations and pathological phenotypes of disease that represent significant obstacles to progress in this area. Biologically, plausible treatment strategies include the use of antidepressants (selective serotonin reuptake inhibitors or serotonin-specific reuptake inhibitor and monoamine oxidase inhibitors), acetylcholinesterase inhibitors, N-methyl-D-aspartic acid antagonists, mood stabilizers, antipsychotics, stimulants, antihypertensives, and agents that may ameliorate the symptoms of parkinsonism, pseudobulbar affect, and motor neuron disease that can often coexist with FTD. These medications all carry potential risks as well as possible benefits for the person suffering from FTD, and a clear understanding of these factors is critical in selecting an appropriate therapeutic regimen to maximize cognition and daily functions, reduce behavioral symptoms, and alleviate caregiver burden in an individual patient. The role of the caregiver in tracking and reporting of symptoms and the effects of individual therapeutic interventions is pivotal in this process. This manuscript highlights the importance of establishing an effective therapeutic partnership between the physician and caregiver in the medical management of the person suffering from FTD.
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Jicha GA, Nelson PT. Management of frontotemporal dementia: targeting symptom management in such a heterogeneous disease requires a wide range of therapeutic options. Neurodegener Dis Manag 2011; 1:141-156. [PMID: 21927623 PMCID: PMC3172080 DOI: 10.2217/nmt.11.9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
There are no US FDA-approved therapies for the management of frontotemporal dementia (FTD). Evidence-based medicine that would support a FDA indication for the treatment of FTD requires large-scale, randomized, double-blind, placebo-controlled trials that do not currently exist. Progress in obtaining approval and therapeutic indications for FTD has been severely hampered by the heterogeneity of clinical and pathological phenotypes seen in various FTD disease states. These issues are often misinterpreted by clinicians, caregivers and patients suggesting that potential treatment options are nonexistent for this devastating disease. This article discusses these issues in the context of recent studies and publications investigating therapeutic options in FTD, and further suggests a rationale for individualized therapy in FTD. Targeting the myriad of symptoms seen in FTD requires recognition of such symptoms that may play primary or secondary roles in the spectrum of deficits that lead to functional disability in FTD, and the availability of a wide range of therapeutic options that may be helpful in alleviating such symptomatology. Fortunately, agents targeting the many cognitive, behavioral, psychiatric and motor symptoms that can be seen in FTD are readily available, having been previously developed and approved for symptomatic benefit in other disease states. In contrast to the widespread belief that beneficial treatments are not available for FTD today, our therapeutic armament is stocked with pharmacological tools that may improve quality of life for those suffering from this devastating and incurable class of degenerative diseases.
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Affiliation(s)
- Gregory A Jicha
- Sanders-Brown Center on Aging, 101 Sanders-Brown Building, University of Kentucky, Lexington, KY 40536-0230, USA
- University of Kentucky Alzheimer’s Disease Center, 101 Sanders-Brown Building, University of Kentucky, Lexington, KY 40536-0230, USA
- Department of Neurology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Peter T Nelson
- Sanders-Brown Center on Aging, 101 Sanders-Brown Building, University of Kentucky, Lexington, KY 40536-0230, USA
- University of Kentucky Alzheimer’s Disease Center, 101 Sanders-Brown Building, University of Kentucky, Lexington, KY 40536-0230, USA
- Department of Neuropathology, University of Kentucky College of Medicine, Lexington, KY, USA
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Chow TW, Binns MA, Cummings JL, Lam I, Black SE, Miller BL, Freedman M, Stuss DT, van Reekum R. Apathy symptom profile and behavioral associations in frontotemporal dementia vs dementia of Alzheimer type. ACTA ACUST UNITED AC 2009; 66:888-93. [PMID: 19597092 DOI: 10.1001/archneurol.2009.92] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Apathy is a common and significant problem in patients with dementia, regardless of its cause. Observations about frontosubcortical circuit syndromes indicate that apathy may have affective, behavioral, or cognitive manifestations. OBJECTIVES To explore whether the apathy manifested in frontotemporal dementia (FTD), with its predominantly anterior brain neuropathologic features, differs from the apathy in dementia of Alzheimer type (DAT), with its predominantly hippocampal- and temporoparietal-based neuropathologic features, and to determine whether other behavioral disturbances reported in frontosubcortical circuit syndromes correlate with apathy. DESIGN Analyses included individual items within Neuropsychiatric Inventory subscale items. Items of the apathy/indifference subscale were designated by consensus as affective (lacking in emotions), behavioral (inactive, chores abandoned), or cognitive (no interest in the activities of others). Proportions of correlated nonapathy Neuropsychiatric Inventory items were calculated. SETTING Several neurology specialty clinics contributed to our data set. PARTICIPANTS A total of 92 participants with FTD and 457 with DAT. MAIN OUTCOME MEASURES The Neuropsychiatric Inventory was analyzed. RESULTS Apathy was more prevalent in patients with FTD than in those with DAT, but when present, the specific apathy symptoms associated with both types of dementia were rarely restricted to 1 of the 3 domains of apathy. Dysphoria concurrent with apathy was unique to the DAT group and negatively correlated in the FTD group. Participants with affective apathy more frequently copresented with an orbital frontosubcortical syndrome in FTD (impulsivity and compulsions). Affective apathy also copresented with uncooperative agitation, anger, and physical agitation in both types of dementia. CONCLUSIONS Apathy is common in patients with FTD and DAT, although it is more common in those with FTD. When present, it usually involves changes in affect, behavior, and cognition. It is associated with behaviors that have previously been shown to affect patient safety, independence, and quality of life.
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Affiliation(s)
- Tiffany W Chow
- Baycrest Rotman Research Institute, University of Toronto, Toronto, Ontario M6A 2E1, Canada.
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Huey ED, Armstrong N, Momeni P, Grafman J. Challenges and new opportunities in the investigation of new drug therapies to treat frontotemporal dementia. Expert Opin Ther Targets 2009; 12:1367-76. [PMID: 18851693 DOI: 10.1517/14728222.12.11.1367] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Frontotemporal dementia spectrum disorders are a set of neurodegenerative disorders affecting the frontal and anterior temporal lobes. They are often fatal, and currently no medications have been shown to slow their progression. Recent developments in understanding these disorders may aid in developing treatments. OBJECTIVE To discuss the development of drug therapies for frontotemporal dementia spectrum disorders, both those under current investigation and those that could be targets for future investigation. METHODS This review is divided into four sections: First, a brief review of frontotemporal dementia spectrum disorders; second, a discussion of the challenges in the development of drug therapies third, a review of the current clinical trials; and finally a discussion of some recent discoveries, which have sparked new areas of investigation. CONCLUSIONS Hopefully, advances in understanding of frontotemporal dementia spectrum disorders and clinical trial design will aid the development of new treatments.
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Affiliation(s)
- Edward D Huey
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Cognitive Neuroscience Section, Building 10, Room 7D43, MSC 1440, Bethesda, MD 20892-1440, USA.
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Abstract
Primary progressive aphasia (PPA) is a neurodegenerative disease of insidious onset presenting with progressive isolated loss of language function, without significant impairment in other cognitive domains. Current diagnostic criteria require the language dysfunction to remain isolated for at least two years, and to remain the salient feature as the disease progresses, usually to involve other domains such as behavior, executive functions, and judgment. Although PPA in its early stages can usually be differentiated from probable Alzheimer's disease (PRAD) and the behavioral variant of frontotemporal lobar degeneration by the absence of significant changes in memory and behavior, and the preservation of activities daily living, progression of the disease often leads to deficits more consistent with the latter. Underlying etiologies remain heterogeneous: the neuropathological characteristics associated with frontotemporal lobar degeneration, cortocobasal degeneration, and motor neuron disease are usually found. There is a strong genetic susceptibility with affliction of first-degree relatives with similar disease in up to 40 to 50% in some series. Pathogenic mutations in genes coding for the proteins tau and progranulin have been isolated. These are leading to a better understanding of the neuropathological mechanisms and hopefully targeted disease-modifying therapy. Current therapy is limited to improving mood symptoms and targeting behavior changes as they develop. Referral to specialized centers where speech therapy, counseling, and education for both patient and caregiver are available may be helpful.
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Affiliation(s)
- Gabriel C Léger
- Neurology Service, Hôtel-Dieu du Centre Hospitalier de l'Univertité de Montréal, Montréal, Québec, Canada.
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Frontotemporal Dementia Treatment: Current Symptomatic Therapies and Implications of Recent Genetic, Biochemical, and Neuroimaging Studies. Alzheimer Dis Assoc Disord 2007; 21:S79-87. [DOI: 10.1097/wad.0b013e31815c345e] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Diehl-Schmid J, Pohl C, Perneczky R, Förstl H, Kurz A. Behavioral disturbances in the course of frontotemporal dementia. Dement Geriatr Cogn Disord 2007; 22:352-7. [PMID: 16954691 DOI: 10.1159/000095625] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/20/2006] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Behavioral disturbances are prominent in frontotemporal dementia (FTD), and their occurrence has been the topic of several investigations. Nonetheless, the prevalence and severity of behavioral disturbances of patients with FTD in different degrees of dementia severity have rarely been studied. OBJECTIVE The aim of this study was to assess and compare the prevalence and severity of behavioral disturbances in patients with mild FTD and in patients with moderate/severe dementia. METHODS We included 21 outpatients with mild FTD [Clinical Dementia Rating (CDR) = 1] and 19 patients with moderate or severe dementia (CDR = 2 or 3) in this study. Behavioral disturbances were assessed using the Neuropsychiatric Inventory (NPI). RESULTS We found a statistically significant difference in the total NPI scores between patients with mild FTD and patients with moderate or severe FTD, the latter scoring higher. Apathy was the most prevalent symptom in both patient groups (90.5 and 100%). Except appetite and eating disturbance, which appeared in 77.8% of the patients with moderate/severe dementia, all other symptoms were clearly less common (<50%). CONCLUSION The results highlight the variability of behavioral disturbances in mild and moderate/severe stages of FTD.
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Affiliation(s)
- J Diehl-Schmid
- Department of Psychiatry, Technische Universität Munchen, Munich, Germany.
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