Early-onset of psychiatric features in mild frontotemporal dementia with impaired memory test: a case report and neuropsychological evaluation

Sintomas psiquiátricos prematuros em demência frontotemporal leve com desempenho deficitário em teste de memória: relato de caso e avaliação neuropsicológica

CARTAS AO EDITOR

Early-onset of psychiatric features in mild frontotemporal dementia with impaired memory test: a case report and neuropsychological evaluation

Sintomas psiquiátricos prematuros em demência frontotemporal leve com desempenho deficitário em teste de memória: relato de caso e avaliação neuropsicológica

Gabriel Coutinho^I; Dídia Fortes^II; Flavia Miele^III; Paulo Mattos^IV

^IUniversidade Federal do Rio de Janeiro (UFRJ), Instituto D'OR de Pesquisa e Ensino (ID'or), Centro de Neuropsicologia Aplicada (CNA), Programa de Ciências Morfológicas (PCM), Rio de Janeiro, RJ, Brazil

^IIUFRJ, Grupo de Estudos do Déficit de Atenção (GEDA), Rio de Janeiro, RJ, Brazil

^IIIUFRJ, CNA, ID'or, Rio de Janeiro, RJ, Brazil

^IVUFRJ, Faculdade de Medicina, CNA, ID'Or, Rio de Janeiro, RJ, Brazil

^{Correspondence}

Dear editor,

Frontotemporal dementia (FTD) is characterized by behavioral changes which may precede cognitive decline, being mainly a presenile disturbance with an insidious onset and high familial incidence¹. Degeneration affects mainly prefrontal and temporal anterior brain areas; executive functions (EFs) and language deficits are commonly found. Changes in eating habits and psychosis have being recently studied as earliest symptoms. We present a FTD case starting with mood symptoms, psychosis and compulsions to discuss differential diagnosis.

CASE

A., male, 61 years-old, right-handed, graduated, recently retired after working as a manager of a company. Relatives reported first mood changes when he was 56, presenting depressive and hippomaniac episodes of brief duration. A change of eating habits followed and the patient lost almost 10 kg in 3 months. A. believes his neighbors will sue him, despite the lack of reasons. He is spending hours a day organizing documents he believes will be necessary for the legal process; he started presenting fixed idea for cleaning, washing his hands many times a day. A.'s wife reported difficulties to return home after going to the church because he needs to ensure that people will not gather to speak at his back. There is a current though of bankruptcy, despite his high income; he sold his car because of this fear – even after checking his bank balance. He had no history of psychiatric disorders. He was afraid of taking his medicines because of the risk of being "poisoned".

Neuropsychological evaluation: A. presented difficulties to initiate behavior, such as telling the examiner when he finished the task. Performance in memory was below expected for age, both for visual and verbal material. Verbal memory was evaluated through a prose memory test, with weak performance in immediate recall, but a very similar performance in delayed recall – corresponding to normal ranges. The performance in Complex Figure was impaired after a 5 minute delay. Results revealed cognitive inflexibility, planning difficulties, impaired verbal fluency and formulation hypothesis ability and also perseveration. Language was normal. Results are in tables 1 and 2.

DISCUSSION

Psychiatric features, such as psychosis², bipolar disorder³ and obsessive-compulsive disorder (OCD)⁴ should be examined because those symptoms might be due to strokes or degenerative processes. In the present case, profile showing prominent EFs deficits, with constructional abilities unimpaired and a peculiar memory impairment, may be important to avoid the misdiagnose of FDT with psychiatric symptoms. Examinee's memory performance might be different from AD individuals mainly because immediate recall of prose memory does not exclusively demand long-term memory structures. This task overloads episodic buffer and central executive (working memory), and the influence of retention is more important in delayed recall. Baddeley and Wilson⁵ demonstrated that amnesic patients could perform normally in prose memory immediate recall, despite having a zero score in delayed recall. The current performance was the opposite, with weak performance in immediate recall, but good performance in delayed recall, showing no retention deficit. Complex figures demand planning abilities (EFs), which might explain impaired performance. This finding is extremely important to differentiate FTD and AD individuals.

Received in 10/18/2012

Approved in 11/12/2012

• 1. Neary D, Snowden J, Mann D. Frontotemporal dementia. Lancet Neurol. 2005;4:771-80.
• 2. Loy CT, Kril JJ, Trollor JN, Kiernan MC, Kwok JB, Vucic S, et. al. The case of a 48 year-old woman with bizarre and complex delusions. Nat Rev Neurol. 2010;6(3):175-9.
• 3. Prabhakar D, Balon R. Late-onset bipolar disorder: a case for careful appraisal. Psychiatry (Edgemont). 2010;7(1):34-7.
• 4. Frydman I, Ferreira-Garcia R, Borges M, Velakoulis D, Walterfang M, Fontenelle L. Dementia developing in late-onset and treatment-refractory obsessive-compulsive disorder. Cog Behav Neurol. 2010;23(3):205-8.
• 5.  Baddeley A, Wilson B. Prose recall and amnesia: implications for the structure of working memory. Neuropsychologia. 2002;40:1737-43.

Publication Dates

• Publication in this collection
  07 May 2013
• Date of issue
  2013