Police Interactions Among Neuropathologically Confirmed Dementia Patients: Prevalence and Cause

Examining the propensity and nature of criminal risk behaviours in frontotemporal dementia syndromes and Alzheimer's disease

INTRODUCTION

Some people with dementia develop changes in behaviour and cognition that may lead to interactions with police or the legal system. However, large, prospective case-control studies examining these behaviours are lacking.

METHODS

One hundred and forty-four people with dementia and 53 controls completed the Misdemeanours and Transgressions Screener.

RESULTS

Criminal risk behaviours were reported in: 65.6% of behavioural-variant frontotemporal dementia, 46.2% of right-lateralised semantic dementia, and 27.0% of Alzheimer's disease patients. In 19.1% of patients these behaviours led to contact with police or authority figures. Compared to controls, people with dementia showed higher rates of physical assault (p = 0.024), financial/professional recklessness (p = 0.009), and inappropriate behaviours (p  = 0.052).

DISCUSSION

Criminal risk behaviours are common across dementia subtypes and may be one of the first clinical signs of frontotemporal dementia. Further research to understand how to balance risk minimisation with an individual's liberties as well as the inappropriate criminalisation of people with dementia is needed.

Highlights

The Misdemeanours and Transgressions Screener is a new tool to assess criminal risk behaviours.Forty-seven percent of patients with dementia show criminal risk behaviour after dementia onset.Behaviours included verbal abuse, traffic violations, physical assault.New onset of criminal risk behaviours >50 years is a clinical sign for frontotemporal dementia.

The Implications of Moral Neuroscience for Brain Disease: Review and Update

The last 2 decades have seen an explosion of neuroscience research on morality, with significant implications for brain disease. Many studies have proposed a neuromorality based on intuitive sentiments or emotions aimed at maintaining collaborative social groups. These moral emotions are normative, deontological, and action based, with a rapid evaluation of intentionality. The neuromoral circuitry interacts with the basic mechanisms of socioemotional cognition, including social perception, behavioral control, theory of mind, and social emotions such as empathy. Moral transgressions may result from primary disorders of moral intuitions, or they may be secondary moral impairments from disturbances in these other socioemotional cognitive mechanisms. The proposed neuromoral system for moral intuitions has its major hub in the ventromedial prefrontal cortex and engages other frontal regions as well as the anterior insulae, anterior temporal lobe structures, and right temporoparietal junction and adjacent posterior superior temporal sulcus. Brain diseases that affect these regions, such as behavioral variant frontotemporal dementia, may result in primary disturbances of moral behavior, including criminal behavior. Individuals with focal brain tumors and other lesions in the right temporal and medial frontal regions have committed moral violations. These transgressions can have social and legal consequences for the individuals and require increased awareness of neuromoral disturbances among such individuals with brain diseases.

Family History of Alzheimer's Disease Increases the Risk of COVID-19 Positivity: A SUMS Employees Cohort-based Study

Background

Substantial data indicate that genetic and environmental factors play a key role in determining the risk of Alzheimer's disease (AD). Moreover, it is known that having relatives with AD increases the risk of developing this disease.

Objective

This study is aimed at investigating whether having a family history of AD, may increase the risk of COVID-19 in a cohort-based study.

Material and Methods

Participants of this retrospective cohort study were previously enrolled in the SUMS Employees Cohort (SUMSEC). All participants including those whose SARS-CoV-2 infection was confirmed by positive PCR test and chest CT scan were requested to respond to interviewer-administered questionnaires. Moreover, AD was diagnosed via memory and thinking impairment, concentration problems, confusion with location, and problems in finishing daily tasks.

Results

The total numbers of female and male participants with a family history of AD were 463 and 222 individuals, respectively. When all types of family history of AD were considered, a 51.3% increase was found in the relative frequency of the participants with both family history of AD and confirmed COVID-19 compared with those only with a family history of AD.

Conclusion

Despite the limitations of our study, and from a broader perspective, our findings can further support the concept that AD risk haplotypes including APOE are linked to the same morbidities from cardiovascular disease and obesity that increase vulnerability to COVID-19. Given this consideration, millions of APOE ε4 carriers around the globe should be advised to take additional precautions to prevent life-threatening diseases such as COVID-19.

Culpability for offenses in frontotemporal dementia and other brain disorders

The responsibility of persons with brain disorders who commit offenses may depend on how their disorders alter brain mechanisms for culpability. Criminal behavior can result from brain disorders that alter social cognition including a neuromoral system of intuitive moral emotions that are absolute (deontological) normative codes and that includes an emotion-mediated evaluation of intentionality. This neuromoral system has its hub in the ventromedial prefrontal cortex (VMPFC) with other frontal, anterior temporal-amygdalar, insular, and right temporoparietal connections. Among brain disorders, investigators report offenses in persons with brain tumors, epilepsy, and traumatic brain injury, but it is those with a form of dementia with VMPFC pathology, behavioral variant frontotemporal dementia (bvFTD), who are most prone to criminal behavior. This review presents four new patients with bvFTD who were interviewed after committing offenses. These patients knew the nature of their acts and the wrongness of the type of action but lacked substantial capacity to experience the criminality of their conduct at the intuitive, deontological, moral emotional level. Disease in VMPFC and its amygdalar connections may impair moral emotions in these patients. These findings recommend evaluation for the experience of moral emotions and VMPFC-amygdala dysfunction among persons with antisocial behavior, with or without brain disease.

The risk of criminal behavior in the elderly and patients with neurodegenerative disease

Behavioral changes are commonly observed in patients with dementia and can lead to criminal offenses, even without a history of criminal or antisocial behavior. Due to the growth of the aging population, this poses a rising problem to deal with for the criminal justice system and in general for society. Criminal behavior may include minor crimes such as theft or traffic violations, but also serious crimes such as physical abuse, sexual offense, or murder. In the assessment of criminal behavior among elderly (first-time) offenders, it is important to be aware of possible neurodegenerative diseases at the time of the crime. This book chapter provides an overview on criminal behavior in the elderly and specifically discusses existing literature on patients suffering from a neurodegenerative disease, including Alzheimer disease, vascular dementia, frontotemporal dementia, Parkinson disease, and Huntington disease. Each section is introduced by a true case to illustrate how the presence of a neurodegenerative disease may affect the criminal judgment. The chapter ends with a summary, multifactorial model of crime risk, future perspectives, and concluding remarks.

Behavioral Variant Frontotemporal Dementia and Social and Criminal Transgressions

OBJECTIVE

Behavioral variant frontotemporal dementia (bvFTD) is associated with social and criminal transgressions; studies from countries around the world have documented such behavior in persons with this condition. An overview and analysis of social and criminal transgressions in bvFTD and their potential neurobiological mechanisms can provide a window for understanding the relationship of antisocial behavior and the brain.

METHODS

This review evaluated the literature on the frequency of social and criminal transgressions in bvFTD and the neurobiological disturbances that underlie them.

RESULTS

There is a high frequency of transgressions among patients with bvFTD due to impairments in neurocognition, such as social perception, behavioral regulation, and theory of mind, and impairments in social emotions, such as self-conscious emotions and empathy. Additionally, there is significant evidence for a specific impairment in an innate sense of morality. Alterations in these neurobiological processes result from predominantly right-hemisphere pathology in frontal (ventromedial, orbitofrontal, inferolateral frontal), anterior temporal (amygdala, temporal pole), limbic (anterior cingulate, amygdala), and insular regions.

CONCLUSIONS

Overlapping disturbances in neurocognition, social emotions, and moral reasoning result from disease in the mostly mesial and right-sided frontotemporal network necessary for responding emotionally to others and for behavioral control. With increased sophistication in neurobiological interventions, future goals may be the routine evaluation of these processes among individuals with bvFTD who engage in social and criminal transgressions and the targeting of these neurobiological mechanisms with behavioral, pharmacological, and other interventions.

Crime, mortality and neurocognitive disorders: A nationwide register study in Finland

OBJECTIVES

To explore mortality of patients with Alzheimer's disease (AD), frontotemporal dementia (FTD), or Lewy body dementias (LBD) who had criminal behavior in the year preceding diagnosis.

METHODS

Data were obtained from the nationwide registers. Mortality was compared between disorder groups with and without criminal acts and with the general population. The cohort included patients who had received a discharge register diagnosis of AD (N = 80,540), FTD (N = 1060), or LBD (N = 10,591) between 1998 and 2015. The incidences of crimes were calculated in the year preceding diagnosis. We further calculated age- and sex-adjusted survivals of different dementia groups with and without criminal acts, and in relation to the general population (SMR, Standardized Mortality Ratio).

RESULTS

Criminal behavior was more common in men than in women. It was associated with decreased mortality in the AD group. SMRs due to unnatural causes, and in the LBD and FTD female groups, were higher in patients with criminal behavior than in those without.

CONCLUSION

LBD and female FTD patients, who had criminal behavior before diagnosis, were at higher risk of death than patients without such behavior. Novel criminality in older adults may be associated with neurocognitive disorder, in which case medical attention is justified.

THE IMPLICATIONS OF FRONTOTEMPORAL DEMENTIA FOR BRAIN DYSFUNCTION IN PSYCHOPATHY

Understanding how psychopathy compares with brain disease can help clarify its underlying mechanisms. This literature review is a broad overview of the neurobiology of psychopathic traits in comparison to behavioral variant frontotemporal dementia (bvFTD), a disorder uniquely associated with criminal behavior. In addition to violation of social norms, both psychopathy and bvFTD result in impaired socioemotional perception and empathy, impulsivity, and altered moral judgment. Despite wide areas of decreased function in psychopathy, structural changes are primarily evident in amygdala and, to a lesser extent, anterior insula, whereas in bvFTD neuropathology involves a wider paralimbic region. In psychopathy, relatively intact medial prefrontal and anterior cingulate cortices facilitate theory of mind and psychopathic traits such as deceitfulness and manipulation, bold fearlessness, and risk-taking behavior. In conclusion, many frontotemporal areas are hypoactive in psychopathy and bvFTD, but differences in dysfunctional connectivity in psychopathy vs. direct involvement in bvFTD potentially explain similarities and differences between these two conditions.

A review of dementia, focusing on the distinct roles of viral protein corona and MMP9 in dementia: Potential pharmacotherapeutic priorities

Dementia, in particular, is a defining feature of Alzheimer's and Parkinson's diseases. Because of the combination of motor and cognitive impairments, Parkinson's disease dementia (PDD) has a greater impact on affected people than Alzheimer's disease dementia (ADD) and others. If one family member develops dementia, the other members will suffer greatly in terms of social and occupational functioning. Currently, no relevant treatment is available based on an examination of the absolute pathophysiology of dementia. As a result, our objective of current review encouraged to look for dementia pharmacotherapy based on their pathogenesis. We systematically searched electronic databases such as PubMed, Scopus, and ESCI for information on the pathophysiology of demetia, as well as their treatment with allopathic and herbal medications. By modulating intermediate proteins, oxidative stress, viral protein corona, and MMP9 are etiological factors that cause dementia. The pathophysiology of ADD was described by two hypotheses: the amyloid cascade hypothesis and the tau and tangle hypothesis. ADD is caused by an increase in amyloid-beta (Aβ) and neurofibrillary tangles in the cerebrum. The viral protein corona (VPC) is more contagious and helps to form amyloid-beta (Aβ) plaques and neurofibrillary tangles in the cerebrum. Thioredoxin interacting protein (TXNIP) inside the BBB encourages Aβ to become more engaged. PDD is caused by decreased or absent dopamine secretion from nerve cells in the substantia nigra, as well as PRKN gene deletion/duplication mutations, and shift in the PRKN-PACRG organisation, all of which are linked to ageing. This article discussed the pathophysiology of dementia, as well as a list of herbal medications that can easily cross the BBB and have a therapeutic effect on dementia.

Prevalence of dementia and mild cognitive impairment before incarceration

BACKGROUND

Accumulating evidence indicates that behaviors in Alzheimer's disease and related dementias could result in incarceration. Yet, the proportion of persons diagnosed with dementia and mild cognitive impairment (MCI) before they were incarcerated is largely unknown. By leveraging a national sample of mid- to late-life adults who were incarcerated, we determined the prevalence of dementia and MCI before their incarceration.

METHODS

In this current study, participants were Medicare-eligible U.S. veterans who transitioned from incarceration to the community in mid- to late-life from October 1, 2012, to September 30, 2018, after having been incarcerated for ≤10 consecutive years (N = 17,962). Medical claims data were used to determine clinical diagnoses of dementia and MCI up to three years before incarceration. Demographics, comorbidities, and duration of incarceration among those with dementia and MCI were compared to those with neither diagnosis.

RESULTS

Participants were >97% male, 65% non-Hispanic white, 30% non-Hispanic black, and 3.3% had a diagnosis of either dementia (2.5%) or MCI (0.8%) before their most recent incarceration. Individuals with MCI or dementia diagnoses were older, were more likely to be non-Hispanic white, had more medical and psychiatric comorbidities, and experienced homelessness and traumatic brain injury at higher rates than those with neither diagnosis. Average duration of incarceration was significantly shorter among those with MCI (201.8 [±248.0] days) or dementia (312.8 [±548.3] days), as compared to those with neither diagnosis (497.0 [±692.7] days) (p < 0.001).

CONCLUSIONS

These findings raise awareness of the proportion of incarcerated persons in the United States who have a diagnosis of MCI or dementia before they are incarcerated. Improved understanding of pathways linking cognitive impairment to incarceration in mid- to late-life are needed to inform appropriateness of incarceration, optimization of health care, and prevention of interpersonal harm in this medically vulnerable population.

Criminal Behavior in the Four Years Preceding Diagnosis of Neurocognitive Disorder: A Nationwide Register Study in Finland

OBJECTIVE

To explore the criminality of patients with subsequent diagnosis of Alzheimer's disease (AD), frontotemporal dementia (FTD), or Lewy body dementias (LBD) in the four years preceding diagnosis.

DESIGN

Nationwide register study.

SETTING

Data on Finnish patients were collected from the discharge register and data on criminal offending from the police register. Research findings were compared with the same-aged general population.

PARTICIPANTS

A total of 92,191 patients who had received a diagnosis of AD (N = 80,540), FTD (N = 1,060), and LBD (N = 10,591) between 1998 and 2015.

MEASUREMENTS

Incidences and types of crimes, the standardized criminality ratio (number of actual crimes per number of expected crimes), and the numbers of observed cases and person-years at risk counted in five-year age groups and separately for both genders and yearly.

RESULTS

At least one crime was committed by 1.6% of AD women and 12.8% of AD men, with corresponding figures of 5.3% and 23.5% in FTD, and 3.0% and 11.8% in LBD. The first crime was committed on average 2.7 (standard deviation 1.1) years before the diagnosis. The standardized criminality ratio was 1.85 (95% confidence interval [CI] 1.43-2.37) in FTD women and 1.75 (95% CI 1.54-1.98) in FTD men, and in AD 1.11 (95% CI 1.04-1.17) and 1.23 (95% CI 1.20-1.27), respectively. Traffic offences and crimes against property constituted 94% of all offences.

CONCLUSION

Criminal acts may occur several years prior to the diagnosis of dementia. If novel criminality occurs later in life, it may be associated with neurocognitive disorder.

Association of Neuropathologically Confirmed Frontotemporal Dementia and Alzheimer Disease With Criminal and Socially Inappropriate Behavior in a Swedish Cohort

IMPORTANCE

Criminal and socially inappropriate behavior is encountered among patients with dementia, and it is sometimes the first sign of a dementing disorder. This behavior constitutes a significant burden to society, patients' relatives, and patients themselves.

OBJECTIVES

To investigate and compare the prevalence and type of criminal and socially inappropriate behavior, as well as recurrence of criminal behavior, associated with Alzheimer disease (AD) and frontotemporal dementia (FTD) neuropathologically verified post mortem, and to assess whether there is a specific type of protein pathology more closely associated with criminal behavior in patients with FTD.

DESIGN, SETTING, AND PARTICIPANTS

Cohort study using medical record review of 220 Swedish patients with a postmortem neuropathologic diagnosis of AD (n = 101) or frontotemporal lobar degeneration (n = 119) (hereinafter referred to as FTD) diagnosed between January 1, 1967, and December 31, 2017.

MAIN OUTCOMES AND MEASURES

Patient notes containing reports of criminal and socially inappropriate behavior, as well as data on dominant protein pathology for patients with FTD, were duly reviewed and recorded. The Fisher exact test or logistic regression was used to assess possible differences between groups.

RESULTS

Of the 220 patients studied, 128 (58.2%) were female, the median (range) age at disease onset was 63 (30-88) years and at death was 72 (34-96) years, and the median (range) disease duration was 9 (1-28) years. Instances of criminal behavior were found in 65 of the 220 patients (29.5%): in 15 of the 101 patients (14.9%) with AD and 50 of the 119 patients (42.0%) with FTD (P < .001). Recurrence of criminal behavior was significantly higher in the FTD group (89.0%) than in the AD group (53.3%) (P = .04). Instances of socially inappropriate behavior were found in 57 patients (56.4%) with AD and 89 (74.8%) with FTD (P = .004). An expression of non-tau pathology increased the odds for criminal behavior by a factor of 9.0 (95% CI, 3.4-24.0) among patients with FTD.

CONCLUSIONS AND RELEVANCE

These results suggest that criminal and socially inappropriate behaviors may be more prevalent and criminal behaviors may be more recurrent in patients with FTD than in those with AD. Non-tau pathology, but not tau pathology, appears to be associated with criminal behavior. These findings may help with the clinical diagnostic process.