High Risk of Suicide in Behavioral Variant Frontotemporal Dementia

Similarities and differences in the prevalence and risk factors of suicidal behavior between caregivers and people with dementia: a systematic review

BACKGROUND

People with dementia and their caregivers are prone to suicidal behaviors due to difficulty adjusting to their initial caregiving role and due to emotional disturbances resulting from deterioration of functioning. The present systematic review (1) explored the prevalence of and risk factors for suicidal behavior and (2) assessed the similarities and differences in the prevalence and risk factors for suicidal behavior between people with dementia and their caregivers.

METHODS

A comprehensive literature search for research articles published between 1950 and 2023 was carried out using major databases, such as Google Scholar, Web of Science, PubMed, Scopus, PsycINFO, EMBASE, the Cochrane Library, and Medline.

RESULTS

A total of 40 research articles were selected for review. A total of 12 research articles revealed that the prevalence of suicidal behavior among caregivers ranged from 4.7% to 26%. However, the risk of suicidal behavior among people with dementia was inconsistent, as only 17 out of 28 selected studies reported the risk of suicidal behavior among people with dementia. The risk factors associated with suicidal behavior among caregivers of people with dementia could be both self-related and care receiver-related factors, whereas risk factors in people with dementia were self-related factors. Notably, greater cognitive decline, which impairs individuals' ability to carry out complex acts and planning, may lower their suicidal risk. Finally, assessment of the risk of bias indicated that 95% of the selected studies had unclear risk.

CONCLUSION

Self-related and care receiver-related factors should be assessed among caregivers of people with dementia to evaluate the risk of suicidal behavior. In addition, we recommend evaluating suicidal risk in people with dementia in the early phase of dementia when cognitive decline is less severe. However, as the majority of the selected studies had unclear risk of bias, future studies with improved methodologies are warranted to confirm our study findings.

Identifying clinical phenotypes of frontotemporal dementia in post-9/11 era veterans using natural language processing

Introduction

Frontotemporal dementia (FTD) encompasses a clinically and pathologically diverse group of neurodegenerative disorders, yet little work has quantified the unique phenotypic clinical presentations of FTD among post-9/11 era veterans. To identify phenotypes of FTD using natural language processing (NLP) aided medical chart reviews of post-9/11 era U.S. military Veterans diagnosed with FTD in Veterans Health Administration care.

Methods

A medical record chart review of clinician/provider notes was conducted using a Natural Language Processing (NLP) tool, which extracted features related to cognitive dysfunction. NLP features were further organized into seven Research Domain Criteria Initiative (RDoC) domains, which were clustered to identify distinct phenotypes.

Results

Veterans with FTD were more likely to have notes that reflected the RDoC domains, with cognitive and positive valence domains showing the greatest difference across groups. Clustering of domains identified three symptom phenotypes agnostic to time of an individual having FTD, categorized as Low (16.4%), Moderate (69.2%), and High (14.5%) distress. Comparison across distress groups showed significant differences in physical and psychological characteristics, particularly prior history of head injury, insomnia, cardiac issues, anxiety, and alcohol misuse. The clustering result within the FTD group demonstrated a phenotype variant that exhibited a combination of language and behavioral symptoms. This phenotype presented with manifestations indicative of both language-related impairments and behavioral changes, showcasing the coexistence of features from both domains within the same individual.

Discussion

This study suggests FTD also presents across a continuum of severity and symptom distress, both within and across variants. The intensity of distress evident in clinical notes tends to cluster with more co-occurring conditions. This examination of phenotypic heterogeneity in clinical notes indicates that sensitivity to FTD diagnosis may be correlated to overall symptom distress, and future work incorporating NLP and phenotyping may help promote strategies for early detection of FTD.

Psychiatric Screening Measures in Behavioral Variant Frontotemporal Dementia

OBJECTIVE

Behavioral variant frontotemporal dementia (bvFTD) is sometimes misdiagnosed as a primary psychiatric disorder, such as major depressive disorder, bipolar disorder, an anxiety disorder, autism spectrum disorder (ASD), or attention-deficit hyperactivity disorder (ADHD). Nonspecialists often use screening measures for primary psychiatric disorders in early assessments of persons with bvFTD. The investigators aimed to evaluate the manifestations of bvFTD in surveys intended to screen for primary psychiatric disorders.

METHODS

Patients with bvFTD (N=27) presenting to an academic neurobehavior specialty clinic and their caregivers were provided questionnaire packets including the Mood Disorder Questionnaire (MDQ), the Patient Health Questionnaire-9 (PHQ-9), the Generalized Anxiety Disorder-7 scale (GAD-7), the Adult ADHD Self-Report Scale, version 1.1, the Ritvo Autism and Asperger Diagnostic Scale, and the Neuropsychiatric Inventory Questionnaire. Established cutoff scores suggesting the presence of a primary psychiatric disorder were used to define a "positive" response. Individual questions from each screening questionnaire were examined for a more granular characterization of bvFTD.

RESULTS

Overall, 15% of bvFTD patients screened positive for bipolar disorder, 54% screened positive for ADHD, and 89% screened positive for ASD. Hyperactivity or hypersensitivity symptoms were infrequently endorsed. In addition, 57% of respondents screened positive for depressive symptoms on the PHQ-9, and 43% screened positive for anxiety symptoms on the GAD-7.

CONCLUSIONS

The use of cutoff scores on screening measures for primary psychiatric disorders resulted in potentially problematic positive screens of primary psychiatric disorders among persons with bvFTD. Identifying specific questions that distinguish between bvFTD and primary psychiatric disorders requires further study.

Suicidal behavior across a broad range of psychiatric disorders

Suicide is a leading cause of death worldwide. In 2020, some 12.2 million Americans seriously contemplated suicide, 3.2 million planned suicide attempts, and 1.2 million attempted suicide. Traditionally, the approach to treating suicidal behavior (SB) has been to treat the "underlying" psychiatric disorder. However, the number of diagnoses associated with SB is considerable. We could find no studies describing the range of disorders reported to be comorbid with SB. This narrative review summarizes literature documenting the occurrence of SB across the lifespan and the full range of psychiatric diagnoses, not only BPD and those that comprise MDE, It also describes the relevance of these observations to clinical practice, research, and nosology. The literature searches contained the terms "suicid*" and each individual psychiatric diagnosis and identified 587 studies. We did not include case reports, case series, studies only addressing suicidal ideation or non-suicidal self-injury (NSSI), studies on self-harm, not distinguishing between SB and NSSI and studies that did not include any individuals that met criteria for a specific DSM-5 diagnosis (n = 366). We found that SB (suicide and/or suicide attempt) was reported to be associated with 72 out of 145 diagnoses, although data quality varied. Thus, SB is not exclusively germane to Major Depressive Episode (MDE) and Borderline Personality Disorder (BPD), the only conditions for which it is a diagnostic criterion. That SB co-occurs with so many diagnoses reinforces the need to assess current and past SB regardless of diagnosis, and supports the addition of charting codes to the DSM-5 to indicate current or past SB. It also comports with new data that specific genes are associated with SB independent of psychiatric diagnoses, and suggests that SB should be managed with specific suicide prevention interventions in addition to treatments indicated for co-occurring diagnoses. SB diagnostic codes would help researchers and clinicians document and measure SB's trajectory and response to treatment over time, and, ultimately, help develop secondary and tertiary prevention strategies. As a separate diagnosis, SB would preclude situations in which a potentially life-threatening behavior is not accounted for by a diagnosis, a problem that is particularly salient when no mental disorder is present, as is sometimes the case.

Living with dementia: Why I am thinking of 'death'

BACKGROUND AND AIMS

Dementia is recognized globally as a massive burden on public health and wider society. It is a major cause of disability and mortality amongst older people. China has the largest population of people with dementia worldwide, accounting for approximately 25% of the entire global population of people with dementia. The study investigated the perceived experiences of care giving and care receiving in China, with one area identified in the data concerning the extent to which the participants discussed death. The research also explored the meaning of living with dementia in modern China, where the economy, demography and culture are rapidly changing.

METHOD

The qualitative approach of interpretative phenomenological analysis was used for this study. Semi-structured interviews were used for data collection.

FINDING

The paper reports on one specific finding concerning death as a way out of the situation that participants found themselves in.

CONCLUSION

The study described and interpreted one of the specific issues, 'death', in the participants' narratives. This finding reflects how psychological and social factors, such as stress, social support, healthcare cost, caring burden and medical practice have created the participants' thoughts of 'wishing to die' and the reasons why they believe 'death is a way to reduce burden'. It calls for an understanding, supportive social environment and a reconsideration of a culturally and economically appropriate family-based care system.

Social Cognition in Behavioral Variant Frontotemporal Dementia and Pathological Subtypes: A Narrative Review

Behavioral variant frontotemporal dementia (bvFTD) belongs to the spectrum of frontotemporal lobar degeneration (FTLD) and is characterized by frontal dysfunction with executive deficits and prominent socioemotional impairments. Social cognition, such as emotion processing, theory of mind, and empathy may significantly impact daily behavior in bvFTD. Abnormal protein accumulation of tau or TDP-43 are the main causes of neurodegeneration and cognitive decline. Differential diagnosis is difficult due to the heterogeneous pathology in bvFTD and the high clinicopathological overlap with other FTLD syndromes, especially in late disease stages. Despite recent advances, social cognition in bvFTD has not yet received sufficient attention, nor has its association with underlying pathology. This narrative review evaluates social behavior and social cognition in bvFTD, by relating these symptoms to neural correlates and underlying molecular pathology or genetic subtypes. Negative and positive behavioral symptoms, such as apathy and disinhibition, share similar brain atrophy and reflect social cognition. More complex social cognitive impairments are probably caused by the interference of executive impairments due to increasing neurodegeneration. Evidence suggests that underlying TDP-43 is associated with neuropsychiatric and early social cognitive dysfunction, while patients with underlying tau pathology are marked by strong cognitive dysfunction with increasing social impairments in later stages. Despite many current research gaps and controversies, finding distinct social cognitive markers in association to underlying pathology in bvFTD is essential for validating biomarkers, for clinical trials of novel therapies, and for clinical practice.

Completed Suicide by Firearm in an Individual With the Agrammatic Variant of Primary Progressive Aphasia: Case Report

The agrammatic or nonfluent variant of Primary Progressive Aphasia (nfvPPA) is a form of Frontotemporal Dementia (FTD) that is characterized by progressive language dysfunction, poor sentence construction, and low verbal fluency. Individuals with nfvPPA have intact insight into their decline, which may manifest as frustration and hopelessness, and show signs of impulsivity and disinhibition. Little is known about suicide risk in this patient population. Here we describe a case of an 84 year-old male with nfvPPA who, over the course of his care, experienced a decline in language and motoric functioning which coincided with increasing irritability and impulsivity. Despite this significant decline, he denied depressive symptoms or showed any suicidal tendencies, and he seemed to be looking forward to future events. His suicide, committed with a handgun during what appeared to be a rather innocuous trip to the garage, came as a significant shock to his spouse, family, and his clinical care team. To our knowledge, this is the first reported case of completed suicide in a patient with the nfvPPA subtype of FTD. Though this patient demonstrated demographic risk factors for suicide (advanced age, retired military veteran with easy access to firearms) there is a lack of data regarding how FTD may have contributed. Retained insight especially seems to be a risk factor for suicide across all forms of dementia. Impulsivity may be key when considering suicidality amongst FTD patients. Additionally, this case demonstrates the importance of addressing gun safety as there are few guidelines around gun ownership in this patient population.

Suicide risk in first year after dementia diagnosis in older adults

INTRODUCTION

Receiving a diagnosis of Alzheimer's disease or related dementias (ADRD) can be a pivotal and stressful period. We examined the risk of suicide in the first year after ADRD diagnosis relative to the general geriatric population.

METHODS

We identified a national cohort of Medicare fee-for-service beneficiaries aged ≥ 65 years with newly diagnosed ADRD (n = 2,667,987) linked to the National Death Index.

RESULTS

The suicide rate for the ADRD cohort was 26.42 per 100,000 person-years. The overall standardized mortality ratio (SMR) for suicide was 1.53 (95% confidence interval [CI] = 1.42, 1.65) with the highest risk among adults aged 65 to 74 years (SMR = 3.40, 95% CI = 2.94, 3.86) and the first 90 days after ADRD diagnosis. Rural residence and recent mental health, substance use, or chronic pain conditions were associated with increased suicide risk.

DISCUSSION

Results highlight the importance of suicide risk screening and support at the time of newly diagnosed dementia, particularly for patients aged < 75 years.

Patient and Relative Experiences and Decision-making About Genetic Testing and Counseling for Familial ALS and FTD: A Systematic Scoping Review

Genetic testing and counseling is an emerging part of care for patients with amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD) and their families. This scoping review aimed to map patients' and relatives' experiences of genetic testing and counseling for familial ALS and FTD and the factors influencing their decision to proceed with testing or counseling. Informed by the Joanna Briggs Institute methodology, 5 databases were systematically searched. Thirty studies from 39 references were included. A descriptive numerical summary analysis and narrative synthesis was conducted. Mostly positive diagnostic testing experiences were reported, but issues arose due to progressive disease and discordant results. Predictive testing impacted at-risk relatives, regardless of the result received, and psychosocial sequelae ranged from relief to guilt, worry or contemplating suicide. Four reproductive testing experiences were reported. Personal, familial and practical factors, and the lived experience of disease, informed decision-making. Greater uncertainty and complexity may be faced in familial ALS/FTD than in other late-onset neurodegenerative diseases due to clinical and genetic heterogeneity, and testing limitations. Genetic counseling models of care should consider this difference to ensure that individuals with, or at risk of, ALS/FTD are effectively managed. Implications for research and practice are discussed.

Severe Suicidality in Athletes with Chronic Traumatic Encephalopathy: A Case Series and Overview on Putative Ethiopathogenetic Mechanisms

Chronic traumatic encephalopathy (CTE) results from repetitive brain injuries and is a common neurotraumatic sequela in contact sports. CTE is often accompanied by neuropsychiatric symptoms, which could escalate to suicidal ideation (SI) and suicidal behaviour (SB). Nevertheless, fairly limited emphasis about the association between suicidality and CTE exists in medical literature. Here, we report two cases of retired professional athletes in high contact sports (boxing and ice hockey) who have developed similar clinical trajectories characterized by progressive neuropsychiatric symptoms compatible with a CTE diagnosis and subsequent SB in its severe forms (medical serious suicide attempt (SA) and completed suicide). In addition to the description of outlining clinical, neuropsychological, neuroimaging, and differential diagnosis elements related to these cases, we also hypothesized some mechanisms that might augment the suicide risk in CTE. They include those related to neurobiological (neuroanatomic/neuroinflammatory) dysfunctions as well as those pertaining to psychiatry and psychosocial maladaptation to neurotraumas and retirement from professional competitive activity. Findings described here can provide clinical pictures to improve the identification of patients with CTE and also potential mechanistic insights to refine the knowledge of eventual severe SB development, which might enable its earlier prevention.

Mental Disorders, Cognitive Impairment and the Risk of Suicide in Older Adults

More than 600 million people are aged 60 years and over are living in the world. The World Health Organization estimates that this number will double by 2025 to 2 billion older people. Suicide among people over the age of 60 is one of the most acute problems. The factors strongly associated with suicide are mentioned: physical illnesses, such as cancer, neurologic disorder, pain, liver disease, genital disorders, or rheumatoid disorders. Moreover, neurologic conditions, especially stroke, may affect decision-making processes, cognitive capacity, and language deficit. In addition to dementia, the most common mental disorders are mood and anxiety disorders. A common symptom of these disorders in the elderly is cognitive impairment. This study aimed to present the relationship between cognitive impairment due to dementia, mood disorders and anxiety, and an increased risk of suicide among older people. Dementia is a disease where the risk of suicide is significant. Many studies demonstrated that older adults with dementia had an increased risk of suicide death than those without dementia. Similar conclusions apply to prodromal dementia Depression is also a disease with a high risk of suicide. Many researchers found that a higher level of depression was associated with suicide attempts and suicide ideation. Bipolar disorder is the second entity in mood disorders with an increased risk of suicide among the elderly. Apart from suicidal thoughts, bipolar disorder is characterized by high mortality. In the group of anxiety disorders, the most significant risk of suicide occurs when depression is present. In turn, suicide thoughts are more common in social phobia than in other anxiety disorders. Suicide among the elderly is a serious public health problem. There is a positive correlation between mental disorders such as dementia, depression, bipolar disorder, or anxiety and the prevalence of suicide in the elderly. Therefore, the elderly should be comprehensively provided with psychiatric and psychological support.

Suicide in frontotemporal dementia and Huntington disease: analysis of family-reported pedigree data and implications for genetic healthcare for asymptomatic relatives

OBJECTIVE

Genomic testing for early-onset dementia is becoming more accessible, along with predictive testing for at-risk relatives; however, complex counselling issues are important to address. The topic of suicide often has stigma associated, and thoughts or experiences may not be volunteered without prompting. Little has been published with consideration to suicide rates in the context of family experiences and their significance in genetic counselling for relatives of people with Huntington disease and frontotemporal dementia.

DESIGN

This study included pedigree information for 267 symptomatic individuals with frontotemporal dementia or Huntington disease, provided via genetic counselling clinics.

MAIN OUTCOME MEASURES

Descriptive statistics and suicide rate calculations based on family reported pedigree data.

RESULTS

The suicide rate was 2996 per 100,000 compared with the population rate of 10 per 100,000. Approximately one in 15 families reported suicide of an affected family member, and file notes indicated that one in five families had experienced suicide, suicidal thoughts or suicide attempts in one or more affected, unaffected or pre-symptomatic relative.

CONCLUSION

Health professional awareness of family experiences, including suicide of a relative, is vital in facilitating client decisions about genetic testing, and in providing adequate psychosocial support during the process of genetic testing and adaption to results.

Assessment of Association between NINJ2 Polymorphisms and Suicide Attempts in an Iranian Population

Suicidal behavior as a psychological problem with high public health burden is associated with a number of genetically determined risk factors. In the current study, we investigated the association between two polymorphisms within the NINJ2 gene and risk of suicide in an Iranian population. The study included 295 individuals who attempted suicide with soft suicide methods, 234 suicide victims and 410 normal controls. The rs11833579 SNP was associated with death from suicide in a codominant model in that the AG genotype decreased the risk of death from suicide compared with the GG genotype (OR (95% CI) = 0.49 (0.34-0.71), adjusted P value = 4e-04). This SNP was also associated with death from suicide in dominant (AG + AA versus GG: OR (95% CI) = 0.63 (0.46-0.87), adjusted P value = 0.011) and overdominant (AG versus GG + AA: OR (95% CI) = 0.49 (0.35-0.69), adjusted P value < 0.0001) models. In addition, this SNP was associated with soft suicide attempts in a codominant model (AG versus AA + GG: OR (95% CI) = 0.7 (0.5-0.98), adjusted P value = 0.02). The rs3806263 SNP was associated with death from suicide in allelic (A versus G: OR (95% CI) = 1.48 (1.17-1.88), adjusted P value = 0.002), codominant (AA versus GG: OR (95% CI) = 3.14 (1.89-5.21), adjusted P value < 0.0001), recessive (AA versus GG + AG: OR (95% CI) = 3.47 (2.15-5.61), adjusted P value < 0.0001), overdominant (AG versus AA + GG: OR (95% CI) = 0.62 (0.45-0.87), adjusted P value = 0.0092) and log-additive models (OR (95% CI) = 1.45 (1.15-1.83), adjusted P value = 0.0034). When comparing allele/genotype frequencies of this SNP between suicide victims and soft suicide attempters, significant associations were found in allelic, codominant, recessive and log-additive models. The AG haplotype (rs11833579 and rs3806263, respectively) was significantly less prevalent among suicide victims compared with controls (OR (95% CI) = 0.37 (0.26-0.52), adjusted P value < 0.0001). This haplotype was also less prevalent among suicide victims vs. soft suicide attempters (OR (95% CI) = 0.43 (0.31-0.61), adjusted P value < 0.0001). The GA haplotype (rs11833579 and rs3806263, respectively) was less frequent among suicide victims compared with controls (OR (95% CI) = 0.63 (0.45-0.89), adjusted P value = 0.0156). Finally, the AA haplotype was more prevalent among suicide victims compared with both controls (OR (95% CI) = 2.37 (1.56-3.6), adjusted P value = 0.0002) and soft suicide attempters (OR (95% CI) = 1.92 (1.32-2.78), adjusted P value = 0.0012). Thus, these two SNPs might be regarded as genetic determinants of suicide risk in Iranian populations. Further studies in different populations are needed to verify these results.

Crossing Borders Between Frontotemporal Dementia and Psychiatric Disorders: An Updated Overview

Frontotemporal dementia (FTD) includes a group of neurocognitive syndromes, clinically characterized by altered behaviors, impairment of language proficiency, and altered executive functioning. FTD is one of the most frequently observed forms of dementia in the elderly population and the most common in presenile age. As for other subtypes of dementia, FTD incidence is constantly on the rise due to the steadily increasing age of the population, and its recognition is now becoming a determinant for clinicians. FTD and psychiatric disorders can overlap in terms of clinical presentations by sharing a common genetic predisposition and neuropathological mechanism in some cases. Nonetheless, this association is often unclear and underestimated. Since its first reports, research into FTD has constantly grown, with the identification of recent findings related to its neuropathology, genetic, clinical, and therapeutic issues. Literature is thriving on this topic, with numerous research articles published in recent years. In the present review, we aimed to provide an updated description of the clinical manifestations that link and potentially confound the diagnosis of FTD and psychiatric disorders in order to improve their differential diagnosis and early detection. In particular, we systematically reviewed the literature, considering articles specifically focused on the behavioral variant FTD, published after 2015 on the PubMed database.

Etiopathogenesis of Suicide: A Conceptual Analysis of Risk and Prevention Within a Comprehensive, Deterministic Model

Suicide is a rising global health concern receiving disproportionate attention in comparison to other health conditions. In spite of substantial technological and scientific advancements, suicide research has continued to move slowly in terms of clinical translation due to the complexity of neural mechanisms, and subjective experiences that seem to underpin this complex human behavior. This paper analyzes the concepts of risk and prevention in the context of suicide in an attempt to bridge the large methodological and theoretical gaps between the biological, psychological, and sociological dimensions. This paper aims to accomplish the following objectives: (1) operationalize the concepts of suicide risk and prevention as they relate to current knowledge and capabilities; (2) synthesize and integrate suicide research across biological, psychological, and sociological dimensions; (3) discuss limitations of each dimension in isolation; (4) suggest a model of etiopathogenesis that incorporates extant literature and bridges unnecessary gaps between dimensions; and (5) suggest future directions for multidimensional research through the inclusion of principles from the physical sciences. Ultimately, this paper provides a basis for a comprehensive model of suicide within a deterministic, chaotic system.