Frontotemporal lobar degeneration
Synonyms and keywords:
Frontotemporal lobar degeneration, FTD, FTLD, Frontotemporal dementia, Picks disease

# Overview
Frontotemporal lobar degeneration (FTLD) is an umbrella term that refers to a group of progressive brain diseases, which are heterogeneous concerning neuropathology and etiology but share atrophy of the frontal and/or temporal cortex as a morphological feature. The clinical manifestations of the disorder depend on the primary site of atrophy and dominated by behavior alterations and language impairment.  The mean survival after diagnosis is from 3 to 10 years.

# Historical Perspective
Historically, patients having symptoms of frontotemporal lobe degeneration were diagnosed as  Pick disease after Arnold Pick described a 71-year-old man with dementia with behavioral symptoms and sensory aphasia for the first time in 1892. This patient demonstrated severe atrophy of frontotemporal lobes on autopsy.Histopathologic examination of tissue samples showed ballooned achromatic neurons, which was referred to as Pick cells and argyrophilic inclusions within frontal neurons that were referred to as Pick bodies( composed of insoluble filaments of the microtubule-associated protein tau). Later on, autosomal dominant forms of Pick disease were reported, and the mutations in the gene encoding the microtubule-associated protein tau (MAPT) located at 17q21 were identified. At present, 42 mutations in MAPT have been described in 119 families with FTLD or related disorders. However, in an estimated 60% to 70% of all patients with FTLD undergoing autopsy, no tau pathologic characteristics can be demonstrated. This autopy finding suggets that insoluble tau is not necessary for the clinical phenotype to develop..

# Classification
Frontotemporal lobe degeneration patients can be classified into three different clinical syndromes depending on the early and predominant symptoms. The overlap between these clinical syndromes can occur as the disease progresses to involve both temporal and frontal lobes more diffusely.
- Behavioural-Variant Frontotemporal Dementia (bvFTD)
- Semantic Dementia (SD)
- Progressive Nonfluent Aphasia (PNFA)

## Behavioural-Variant Frontotemporal Dementia (bvFTD)
Behavioral variant frontotemporal dementia is characterized by a progressive decline in executive and interpersonal skills, with altered emotions and the emergence of a variety of abnormal behaviors including disinhibition, obsessions, apathy, and stereotypes. The bvFTD can develop indolently, and early detection may depend on small changes of social circumstances, reduced libido, idiosyncratic lapses of taste or social awareness, and altered dietary or musical preferences.

## Semantic Dementia (SD)
Semantic dementia is also known as semantic variant primary progressive aphasia (svPPA) is a highly characteristic syndrome led by the progressive breakdown of semantic memorya type of long term memory system that stores knowledge about concepts and objects based on the individuals accumulated experience of the world. Typically, semantic dementia initially presents with progressive loss of semantic knowledge about words, concepts and objects.

## Progressive Nonfluent Aphasia (PNFA)
Progressive Nonfluent Aphasia (PNFA) is characterized by a progressive breakdown in language output with slow, impaired production, effortful speech, and comprehension of grammar, and motor speech deficits. Apraxia of speech is highly characteristic of PNFA, and dysarthria is more variably present. Some patients have expressive agrammatism with terse telegraphic phrases as the dominant feature of the disease, whereas, in others, the syndrome is dominated by speech sound (phonemic) or articulatory (phonetic, speech apraxic) errors.

## Frontotemporal Lobar Degeneration (FTLD) Overlap Syndromes
The frontotemporal degeneration spectrum overlaps with the syndromes of corticobasal degeneration(CBD), progressive supranuclear palsy(PSP), and FTD with motor neuron disease. CBD patients present with dystonia, limb apraxia, postural instability, Axial, and limb rigidity, myoclonus, supranuclear gaze palsies, the alien limb phenomenon, and cortical sensory loss. The progressive supranuclear palsy syndrome(PSP) is characterized by impairment of vertical gaze, frontal behavioral changes with marked cognitive slowing, and early postural instability with falls.

# Pathophysiology
FTLD is strongly familial, with up to 40% of patients having a history of a similar disorder within their family, indicating that genetic factors play a significant role in its etiology. An autosomal dominant pattern of inheritance is documented in about 10%. Three significant causal genes have been identified. Mutations in MAPT on chromosome 17 (71,160), not unexpectedly, drive FTLD-tau pathology. FTLD-TDP pathology, by contrast, is not, or perhaps only rarely, associated with mutations in the TDP-43 gene, TARDBP. Instead, it is represented by mutations in the progranulin gene (GRN) on chromosome 17 (9,34) or expansions in C9orf72 on chromosome 9 (40,134). Mutations in other genes have also, less commonly, been associated with FTLD. Of these, most notable are CHMP2B mutations on chromosome 3 (20,56,148) occurring almost exclusively within a single pedigree within the Jutland region of Denmark (20,56,74). NCI is present in such cases, and although these are ubiquitinated, the target protein remains to be identified. The classification, FTLD-UPS, has been applied in recognition of the involvement of the ubiquitin-proteasome system in the disease. The vast majority of cases with FTLD-FUS pathology appear to be sporadic. Other rare genetic forms of FTLD involve mutations in valosin containing protein (VCP) (174), SQSTMI (also known as p62), optineurin (OPTN) (104), ubiquitin 2 (UBQLN2) and TANK binding-kinase 1 (TBK1. Although collectively, such cases are numerically few, they do provide essential clues to pathogenesis since all involve TDP-43 proteinopathy, and all have functioned within the cells protein degradation systems. 

# Causes
FTD patients have an abnormal buildup of altered brain proteins in the frontal and temporal lobes of the brain, the tau protein, and the transactive response DNA binding protein-43 (TDP-43) are commonly involved. The specific functions of these proteins are not entirely known, but these proteins are critical for the proper function of neurons. In patients with FTD, these proteins are misfolded, clumped, or aggregate together, leading to atrophy of frontal and temporal lobes.
- Almost 60% of patients have sporadic or non familial form of disease
- Almost 40% of patients have family history of neurodegenerative disorder
- Almost 10-25% of patients following major gene mutations have been identified.
MAPT
GRN
C9ORF72
- MAPT
- GRN
- C9ORF72
- Following gene mutations are rare causes of FTD.
VCP
TARDBP,
FUS
CHMP2B
TBK1
- VCP
- TARDBP,
- FUS
- CHMP2B
- TBK1

# Differential Diagnosis
- Other neurocognitive disorders
- Alzheimer's disease
- Lewy bodies
- Parkinson's disease
- Other neurological conditions
- Corticobasal degeneration
- Motor neuron disease
- Progressive supranuclear palsy
- Other mental disorders and medical conditions
- Bipolar disorders
- Major depression
- Schizophrenia
- The following table outlines the main findings of the diseases which must be differentiated from dementia with frontotemporal lobar degeneration as they may share common characteristics of cognitive impairment:

# Epidemiology and Demographics
The prevalence of FTD in population-based studies varied from 2.7/100,00 to 9.4 /100,000 in the 60-69-year-old group in the Zuid-Holland district, Netherlands. Two studies reported a similar incidence of  FLD in adults with early-onset dementia in Cambridge, UK( 3.5/100,000 person-years in 45-64 years old group), and Rochester, USA( 3.3/100,000 person-years in 50-59 age group).
The majority of the patients manifest the disease in the sixth decade of life, but the age of onset can vary widely from the third to the ninth decade. Although FTLD is generally considered presenile dementia, individuals over the age of 65 years account for almost 2025% of all cases.

# Risk Factors
- Genetic predisposition
- There are no other risk factors.

# Screening
There is insufficient evidence to recommend routine screening for FTLD.

# Natural History, Complications, and Prognosis
The clinical course of  FTLD syndromes is steadily progressive, with declining function in everyday life, and patients are dependent for activities of daily living. With time they have cognitive, social, and neurological disabilities leading to complete dependency requiring institutional care. Based on a meta-analysis, the survival duration is highly variable among the FTD syndromes. The FTD associated with motor neuron disease is most aggressive and leads to death within three to five years of symptoms onset. However, patients with semantic dementia can survive for over a decade. There tends to be a convergence of syndromes with time, and the precise clinical trajectory is difficult to predict in individual cases. Wandering and intrusive behaviors, incontinence, apathy dysphagia, and mutism are common issues toward the end of life, and important sources of caregiver distress. Compared with other neurodegenerative diseases, caregivers of patients with FTD suffer from more burden.

# Diagnosis

## Diagnostic Study of Choice
There is no single gold standard test to diagnose frontotemporal degeneration. The diagnosis of this disorder generally involves the following.
- Medical history and detailed neurological examination
- Neuropsychological examination to assess language, memory,behavior, visual-spatial, and executive functions.
- Neuroimaging to determine brain atrophy.
- Lumbar puncture  and blood tests to rule out other diseases that can mimic FTLD

## History and Symptoms
Behavioral variant FTD  is the most common clinical subtype and comprise approximately half of all cases of FTD. The main clinical feature of bvFTD is a progressive change in personality and behavior. The following are the first behavioral changes in bvFTD.
- Disinhibition  Examples of disinhibition or socially inappropriate behavior include public urination without concern, and touching or kissing strangers.
- Hyperorality  Hyperorality  manifest as altered food preferences. For example, carbohydrate cravings, particularly for sweet foods, and binge eating.
- Apathy   Apathy manifests as losing interest in activities and social relationships. Patients may participate less in conversations and grow passive.
- Compulsive behaviors  Stereotyped, perseverative, or compulsive ritualistic behaviors include stereotyped speech and complex ritualistic behaviors such as cleaning, hoarding, or checking.
- Agitation
- Frequent mood changes
Most patients of FTLD lack insight into their behavioral changes and the distress experienced by family members.

## Physical Examination
- Patients with initial stages of disease generally lack cranial nerve, cerebellar, sensory, pyramidal, and extrapyramidal motor findings.
- Front release signs may be seen, but these findings are not specific to this disease.
- Parkinsonism may also emerge in advanced stages of the disease. and patients may have following physical findings.
Rigidity
Bradykinesia
Resting tremor
Mask like face
Magnetic gate
- Rigidity
- Bradykinesia
- Resting tremor
- Mask like face
- Magnetic gate
- Almost 10-15 % of patients with bvFTD may develop concomitant motor neuron disease.

## Laboratory Findings
Following tests may be  done to exclude other causes that can mimic the FTD.
- Thyroid function tests
- Vitamin B12
- HIV
- Syphilis
- CSF analysis

## Electrocardiogram
There are no ECG findings associated with FTLD.

## X-ray
There are no X ray findings associated with FTD.

## Echocardiography or Ultrasound
There are no echocardiography/ultrasound findings associated with FTLD.

## Neuroimaging with CT and MRI
Routine brain imaging with MRI or computed tomography (CT) is used to rule out other diseases mimicking FTD and usually remarkable only for cerebral atrophy. Some patients may show variable regional atrophy depending on the genetic and clinical phenotype.
In the majority of the patients, the following dominant patterns of regional loss are demonstrated.
- bv FTD: bilateral frontal atrophy, especially the medial frontal cortex and sometimes with anterior temporal lobe atrophy.
- sv PPA: left temporal lobe
- non-fluent variant of PPA: left insula and frontal operculum
- FTLD-FUS: bilateral caudate nuclei
- FTLD-TDP : right frontal, lateral temporal and parietal lobes
- FTLD-TDP due to C9orf72 mutation: bilateral hemispheres
- FTLD-tau: due to MAPT mutation: bilateral temporal lobes
- PNFA: mostly have perisylvian, left hemisphere atrophy, involving the frontal lobe and insula, extending into the temporal lobe

## Other Imaging Findings
A fluorodeoxyglucose positron emission tomography (FDG-PET) scan or SPECT (single photon emission CT) can help to differentiate between FTD and Alzheimer's disease. FDG-PET scans show functional changes in glucose metabolism of the brain and are often positive earlier than MRI.  SPECT reflects blood flow more than metabolic change; therefore, it is less sensitive to diagnose FTD. The FDA has approved three different versions of a PET tracer for amyloid  currently valuable to FTD diagnosis as a negative scan ruling out Alzheimers disease.

## Other Diagnostic Studies
Electrophysiologic testing is sometimes used to rule out nonspecific seizures in patients with  FTD.

# Diagnostic criteria for bvFTD
The International Behavioral Variant FTD Criteria Consortium (FTDC) published new criteria for bvFTD in 2011. The FTDC criteria synthesize clinical features, neuroimaging, neuropathology, and genetic testing . The FTDC criteria are structured as a diagnostic hierarchy. A diagnosis of possible bvFTD is based solely on the clinical syndrome and aims to identify patients at the mildest stages of the disease.
Possible bvFTD requires a combination of three of six clinical features:
Disinhibition
Apathy/inertia
Loss of sympathy/empathy
Perseverative/compulsive behaviors
Hyperorality
Dysexecutive neuropsychologic profile
Probable FTD requires the same clinical criteria, plus demonstrable functional decline and imaging findings that reflect the principal anatomic location of neurodegeneration in bvFTD (i.e., frontal and/or temporal lobe atrophy, hypometabolism, or hypoperfusion).

# Treatment

## Medical Therapy

### Non Pharmacological Intervention
First-line therapy for behavioral disturbances in FTLD should be nonpharmacological. The current drug therapies are modestly effective and have serious adverse effects. A management plan that does not include a nonpharmacological intervention will not be successful. The main goals of nonpharmacological treatment include family and caregiver education, behavioral, and physical interventions to minimize the occurrence and consequences of undesired behaviors. Additional helpful interventions include physical and speech therapy, home safety evaluations, and the implementation of augmentative communication devices. A frank discussion about end-of-life decisions and goals of care is imperative.

### Behavioural and Cognitive Symptoms
There is no cure for FTLD, and current pharmacotherapy focuses primarily on symptomatic, neurotransmitter base treatments. There is no drug developed for these patients, and the rationale for the use of medications is their efficacy in treating similar neurodegenerative disorders. Most of the FLTD treatments reported in the literature are based on single case reports or small series.
Drugs affecting the serotonin level have the most robust rationale since there is strong evidence of serotonin deficiency in these patients. Patients with FTD have alterations of serotonin metabolites in CSF and significant neural loss in the serotonergic dorsal raphe nuclei.  Many behavioral symptoms of FTLD, such as depression, disinhibition, compulsions, stereotypical movements, repetitive behaviors, and dysregulated eating, respond to selective serotonin reuptake inhibitors (SSRIs).
FLD patients with severe behavioral disturbances (agitation, psychosis) should be treated with atypical antipsychotic medications. This class of medications should be used with great caution, mainly due to two reasons. First, antipsychotic medications are associated with increased mortality in elderly patients with dementia, and secondly, these patients are susceptible to extrapyramidal side effects. Increased mortality appears to be related to infections and an increase in cardiovascular events. Furthermore, these medications may also reflect a nonspecific effect of sedation in this vulnerable population. Often, atypical antipsychotics are necessary only as a temporizing measure and can be tapered as patients become more apathetic as the disease progresses.
Patients with parkinsonism should be treated with a trail of levodopa/carbidopa. However the response to these medications is inadequate in CBD and PSP. Patients not responding to levodopa should receive dopamine agonists such as pramipexole or ropinirole.
Urinary incontinence is common in FLD patients and may occur due to multiple mechanisms.  For optimal treatment of bladder dysfunction, these patients should be referred for urodynamic studies to determine the underlying cause. Upper motor neuron dysfunction can be treated with anticholinergic drugs. However, anticholinergic drugs should be used with caution as they can exacerbate the cognitive and neuropsychiatric deficits. When necessary, trospium chloride or darifenacin are preferred medications due to lower CNS penetration. Intermittent catheterization should be considered for patients with lower motor neuron dysfunction.  Constipation is common in these patients and responds in most cases to a daily bowel regimen.

# Surgery
Surgery is not recommended for FLD patinets.

# Primary prevention
There are no established measures for the primary prevention of FTLD.

# Secondary Prevention
There are no established measures for the secondary prevention of FTLD.