In a 12-week crossover study, 26 patients with FTD received placebo or trazodone, 150 or 300 mg/d depending on dose tolerability. Irritability, agitation, depressive symptoms, and/or eating disorders improved significantly in 10 patients, and behavioral disturbances decreased >25% in 16 patients. Trazodone also was well tolerated.9
Dopamine use in FTD can contribute to behavioral dysregulation. D2 blockers occasionally are used to manage behavioral disturbances, but selective dopamine agonists might be more beneficial. Recent studies suggest that bromocriptine, a D1 and D2 dopaminergic agonist, may improve select frontal features and perseveration in dementia.10
In one case report, quantitative EEG correlated with SPECT showed that methylphenidate, dose unknown, helped improve behavior and normalize profoundly imbalanced bifrontotemporal slowing.11
Recommendation. Try sertraline, 50 to 125 mg/d, or fluoxetine, 20 mg/d, to address behavioral symptoms. Paroxetine is another option, but use it cautiously as its anticholinergic properties could cause confusion in older patients. If the patient does not respond to the SSRI after 6 to 8 weeks, try trazodone, 150 to 300 mg/d.
Conclusion: The 15-month mark
We started citalopram, 20 mg/d, to treat Mr. A’s apathy and anxiety; and memantine, 5 mg/d titrated to 10 mg bid, to try to slow his cognitive and functional decline. Donepezil, 10 mg/d, was continued.
We encouraged Mr. A’s wife and daughter to take him to adult day care as often as possible. Mr. A also was placed on a waiting list for a skilled nursing facility.
Mr. A continued to worsen. Fifteen months after initial presentation, he is incontinent of urine and feces and needs help performing most basic ADLs. He continues to overeat and has gained 6.3 pounds over 4 months. His MMSE score (12/30) indicates severe cognitive impairment.
The authors’ observations
Many patients with FTD eventually need long-term placement, a change in environment marked by unfamiliar faces and disrupted routines. Patients often react by becoming disorganized, irritable, and agitated.
No standard method exists to structure this transition for FTD patients. In rare cases, patients have been transferred to secure units for medication management until stabilized.12
Help calm the patient’s fears by describing the typical nursing home and the range of services it offers. Arrange a meeting with the patient, primary care physician, and the nursing home’s intake coordinator to review available services. Make sure the patient and caregiver receive brochures and other literature about the facility.
Related resources
- Association for Frontotemporal Dementias. www.ftd-picks.org.
- National Institute of Neurological Disorders and Stroke. Pick’s Disease Information Page. Available at: www.ninds.nih.gov/disorders/picks/picks.htm. Accessed Jan. 11, 2005.
- Family Caregiver Alliance. Frontotemporal Dementia. Available at: www.caregiver.org/caregiver/jsp/content_node.jsp?nodeid=573&expandnodeid=384. Accessed Jan. 11, 2005.
- Bromocriptine • Parlodel
- Bupropion • Wellbutrin
- Citalopram • Celexa
- Donepezil • Aricept
- Fluoxetine • Prozac
- Memantine • Namenda
- Methylphenidate • Concerta, Ritalin
- Paroxetine • Paxil
- Sertraline • Zoloft
- Trazodone • Desyrel
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Acknowledgment
This project is supported by the Division of State, Community, and Public Health, Bureau of Health Professions (BHPr), Health Resources and Services Administration (HSRA), Department of Health and Human Services (DHHS) under grant 1 K01 HP 00071-01 and Geriatric Academic Career Award. The information is that of Dr. Tampi and should not be construed as the official position or policy of, nor should any endorsements be inferred by, the BPHr, HRSA, DHHS or the U.S. Government.”