Year : 2015 | Volume
: 2 | Issue : 2 | Page : 106--108
Exploring frontotemporal dementia through a case report: An emerging public health concern in disguise
Nitin Khadilkar1, Swateja Nimkar2,
1 Deaconess Cross Pointe Psychiatric Hospital, Evansville, USA
2 College of Nursing and Health Professions, University of Southern Indiana, Evansville, USA
Deaconess Cross Pointe Psychiatric Hospital, 7200 E. Indiana Street, Evansville
Dementia has been declared by the World Health Organization as a significant public health problem around the world. Frontotemporal dementia (FTD) is a lesser known, yet the second most common type of dementia among older adults under the age of 65 years. Age of onset in FTD is around late fifties, which is not typical for a diagnosis of dementia. In dementia, it is common to see psychiatric symptoms such as hallucinations or delusions as initial presentations. However, FTD may mimic mood disorders. Unfortunately, there are no definitive treatments or ways to prevent FTD. Additionally, challenges such as an earlier age of onset, delay in diagnosis, and difficulties with placement in nursing homes may be encountered while treating FTD patients. Here, we explore FTD through the case of a 61-year-old Caucasian female who initially presented with suicidal ideations.
|How to cite this article:|
Khadilkar N, Nimkar S. Exploring frontotemporal dementia through a case report: An emerging public health concern in disguise.J Geriatr Ment Health 2015;2:106-108
|How to cite this URL:|
Khadilkar N, Nimkar S. Exploring frontotemporal dementia through a case report: An emerging public health concern in disguise. J Geriatr Ment Health [serial online] 2015 [cited 2019 Dec 12 ];2:106-108
Available from: http://www.jgmh.org/text.asp?2015/2/2/106/174278
Among the 47 million cases of dementia worldwide, approximately 10% reside in India, and these numbers are expected to double by 2030. , Undoubtedly, dementia and its subtypes are garnering significant attention in clinical fields as well as research, and have been declared as a global public health priority.  This article uses a clinical case study methodology to explore frontotemporal dementia (FTD), a common dementia subtype characterized by relatively selective and progressive degeneration of frontal or temporal brain regions. 
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (American Psychiatric Association, 2013) classifies FTD as frontotemporal neurocognitive disorder with behavioral or language variants. 
According to Iroka et al. (2015), a younger age of onset around late fifties, behavioral changes such as blunting of emotions, and relatively preserved memory are features of this illness.  Among the variants of FTD, behavioral variants are most common.  It is the second most common type of dementia in adults under 65 years, and often accompanied by mild-to-moderate weight gain occurring as a result of eating disturbances in some FTD patients. 
The patient, a 61-year-old Caucasian female, was brought to the emergency room (ER) by her husband for the assessment of suicidal ideations and angry behavior. She was reportedly having frequent verbal arguments with her husband. During an argument, she reported feeling like she did not want to live and that she may overdose on medications. They were going through financial troubles, and had to sell their house. The patient was raised by her parents, and has two siblings. Given the suicidal risk, she was admitted to the inpatient psychiatry unit. She reported difficulty falling asleep and weight gain in recent weeks. She subjectively denied significant depression and had no insight into events leading up to admission. Her affect was rather neutral with periodic perplexity about her actions. Her thought process was organized and there was no hallucination or delusion. Her short-term memory and long-term memory were both intact. She was diagnosed with major depression, and was started on sertraline and melatonin. She expressed financial concerns, but denied feeling suicidal or hopeless, and wanted to be discharged. She did not appear to be an imminent risk to herself or others, and so she was discharged to go home. However, she was brought back to ER within a few days because she said to her husband that she may just go ahead and overdose on medications. She was admitted to inpatient psychiatry unit. Again, depressed feelings or sad affect were not evident in her in spite of the reported hopelessness and thoughts to overdose. Duloxetine was started as mood replacing sertraline. She was provided counseling. She asked for discharge. She was referred to a partial hospitalization program. Nonetheless, she did not participate in the treatment and quit. At home, she was compliant with her medications. Within a few weeks, she was readmitted for suicidal concerns. Upon assessment, it was evident that actions and behavior of the patient in recent weeks have been out of character for her. Particularly noteworthy were her angry behaviors like throwing things at her husband, frequent arguments, irritability, lack of concentration, lack of judgment, and lack of insight. These findings were carefully reviewed in the presence of the patient. She expressed some remorse but there was no appropriate affect. There was no evidence for psychosis. There were no manic symptoms such as euphoric mood, grandiosity, pressured speech, or excessive energy. There was no history of stroke, head injury, or seizures.
On mini-mental status examination (MMSE) and clock-drawing test, she scored well. Complete blood count (CBC), comprehensive metabolic panel (CMP), thyroid stimulating hormone (TSH), vitamin B12, and folate were within normal limits. Neurological examination did not reveal any abnormalities. There were no abnormal movements or muscle stiffness. Computed tomography (CT) scan of brain was obtained. It showed prominent frontal atrophy for her age. Possibility of FTD was strongly considered. The collateral information from the family confirmed that her behavior was irrational, erratic and she lacked judgment. Diagnosis of FTD was made. The diagnosis, symptoms, and prognosis were reviewed in the presence of the patient. The patient was able to understand and accept that for the most part. The patient decided to stay with her sister to avoid arguments with husband and frequent ER visits. The patient was referred neuropsychological testing for further assessment of the neurocognitive status, but results were unavailable at the time of writing this paper. Upon follow-up, her outpatient psychiatrist noted some improvement on olanzapine but the patient was gaining weight, and hence, cross taper to Aripiprazole was being tried. For 3 months following the last hospitalization, there were no suicidal threats or ER visits.
Overall, FTD is a progressive deterioration characterized by the decline in socially appropriate behavior, loss of sympathy or empathy, executive task impairment, and loss of insight.  It is not uncommon for FTD to be misdiagnosed in the initial stages because of the symptoms that may overlap with other psychiatric illnesses.  Literature shows that Indian patients diagnosed on the basis of currently known FTD criteria are already suffering from advanced stages of the disease at the time of diagnosis. 
In this case, the accurate diagnosis was missed for a few months which included several ER visits, several mental health evaluations, and three inpatient hospitalizations. There was some suspicion initially for personality disorder in addition to mental health diagnoses such as major depression. Clinicians should consider FTD while evaluating patients with erratic behavior, lack of judgment, and apathy. It is imperative to acknowledge that there is no definite prevention or treatment available for FTD. Challenges such as an earlier age of onset, delay in diagnosis, and difficulties with placement in nursing homes may be encountered while treating FTD patients. Also, family relationships may get problematic due to these symptoms, behavioral issues, and lack of empathy. Hence, the socioeconomic burden associated with FTD is high.  Emotional and behavioral symptoms may respond to selective serotonin reuptake inhibitors (SSRIs) or atypical antipsychotics. However, the evidence for using SSRIs or antipsychotics is limited. Additionally, just as in any other case of dementia, it is important to address safety concerns and educate the family and caregivers of the patient.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
|1||World Health Organization. Dementia: A Public Health Priority. Geneva: Switzerland: World Health Organization (WHO) Press; 2012. p. 102.|
|2||Ghosh A, Dutt A, Ghosh M, Bhargava P, Rao S. Using the revised diagnostic criteria for frontotemporal dementia in India: Evidence of an advanced and florid disease. PLoS One 2013;8:e60999.|
|3||Warren JD, Rohrer JD, Rossor MN. Clinical review. Frontotemporal dementia. BMJ 2013;347:f4827.|
|4||American Psychiatric Association. The Diagnostic and Statistical Manual: DSM 5. Washington, DC: American Psychiatric Publishing; 2013. p. 991.|
|5||Iroka N, Jehangir W, Li JL, Pattan V, Yousif A, Mishra AK. Paranoid personality masking an atypical case of frontotemporal dementia. J Clin Med Res 2015;7:364-6.|
|6||Piguet O, Petersén A, Yin Ka Lam B, Gabery S, Murphy K, Hodges JR, et al. Eating and hypothalamus changes in behavioral-variant frontotemporal dementia. Ann Neurol 2011;69:312-9.|
|7||Rascovsky K, Hodges JR, Knopman D, Mendez MF, Kramer JH, Neuhaus J, et al. Sensitivity of revised diagnostic criteria for the behavioural variant of frontotemporal dementia. Brain 2011;134: 2456-77.|
|8||Wylie MA, Shnall A, Onyike CU, Huey ED. Management of frontotemporal dementia in mental health and multidisciplinary settings. Int Rev Psychiatry 2013;25:230-6.|
|9||Chemali Z, Withall A, Daffner KR. The plight of caring for young patients with frontotemporal dementia. Am J Alzheimers Dis Other Demen 2010;25:109-15.|