From the Guidelines
For patients with frontotemporal dementia, cholinesterase inhibitors and memantine should be discontinued as they are not indicated for this condition and may not provide any clinically meaningful benefit 1. When managing frontotemporal dementia, it's essential to focus on treating symptoms rather than the disease itself, as there are no FDA-approved medications specifically for FTD.
- For behavioral symptoms like agitation, impulsivity, or compulsive behaviors, selective serotonin reuptake inhibitors (SSRIs) such as sertraline (50-200 mg daily), citalopram (10-40 mg daily), or escitalopram (10-20 mg daily) are commonly used.
- Atypical antipsychotics like quetiapine (25-200 mg daily) or risperidone (0.25-2 mg daily) may be prescribed cautiously for severe agitation or aggression, due to increased stroke and mortality risk in elderly patients with dementia.
- Trazodone (25-100 mg) can help with sleep disturbances and agitation. According to the 5th Canadian Consensus Conference on the diagnosis and treatment of dementia, discontinuation of cholinesterase inhibitors and memantine is recommended for individuals prescribed these medications for indications other than Alzheimer's disease, Parkinson's disease dementia, Lewy body dementia, or vascular dementia 1. Treatment should be individualized, starting with low doses and gradually increasing while monitoring for side effects. Non-pharmacological approaches like establishing routines, environmental modifications, and caregiver education are equally important components of comprehensive FTD management. Regular follow-up is essential to assess medication effectiveness and adjust treatment as the disease progresses. It's also crucial to consider the patient's preferences, prior expressed wishes, and collaborate with family or substitute decision makers when making treatment decisions, especially regarding the deprescription of anti-dementia drugs 1.
From the Research
Medications for Frontotemporal Dementia
- The serotoninergic system is tightly bound to frontal circuits, whose degeneration subserves frontotemporal dementia (FTD) 2.
- Selective serotonin reuptake inhibitors (SSRIs) have been shown to be beneficial in managing symptoms of FTD, including behavioral symptoms such as disinhibition, depressive symptoms, carbohydrate craving, and compulsions 3, 4.
- A systematic review of randomized controlled trials found that SSRIs, trazodone, and amphetamines may be effective in reducing some behavioral symptoms of FTD, but none of these medications had an impact on cognition 5.
- Other medications that have been tested in FTD include galantamine, idazoxan, lithium plus fluoxetine, lithium plus paroxetine, 1-deprenyl, moclobemide, methylphenidate, piracetam, rivastigmine, donepezil, olanzapine, risperidone, amantadine, guanfacine, allopurinol, and bromocriptine 6.
- Paroxetine has been shown to improve behavioral symptoms in patients with FTD, with significant improvements in caregiver stress 2.
- The use of paroxetine and other SSRIs in FTD has been associated with improvement in behavioral symptoms, but also with potential side effects such as diarrhea and increased anxiety 4.
Treatment Approaches
- A review of the literature on therapeutic trials in FTD outlines general recommendations for standards related to the development of future treatment studies in this disorder, including diagnostic criteria, tests of severity, experimental design, and outcome measures 6.
- Experts in FTD recommend arriving at a consensus to define standards for all clinical trials in FTD, including double-blind placebo-controlled trials 6.