What are FTND (Fagerström Test for Nicotine Dependence) and FTD (Frontotemporal Dementia)?

Definitions of FTND and FTD

FTND: Fagerström Test for Nicotine Dependence

The Fagerström Test for Nicotine Dependence (FTND) is a standardized 6-item screening questionnaire designed to assess the severity of physical nicotine dependence in tobacco users. 1

Key Assessment Components

The FTND evaluates nicotine dependence through specific questions about:

• Number of cigarettes smoked per day 1
• Time to first cigarette after waking (the most predictive single item for dependence severity) 1
• Difficulty refraining from smoking in forbidden places 2
• Which cigarette is most preferred during the day 2
• Smoking patterns when ill 2
• Prominence of morning smoking behavior 2

Clinical Utility and Interpretation

• The FTND primarily measures physical dependence on nicotine and helps determine appropriate treatment intensity, though it also captures approximately 20% of psychological dependence variance 3
• Scores correlate with the probability of successful smoking cessation, guiding clinicians in selecting appropriate pharmacotherapy doses (particularly nicotine replacement therapy dosing) 1
• The test demonstrates a two-factor structure: Factor 1 reflects persistence in maintaining nicotine levels during waking hours, while Factor 2 explains the urgency to restore nicotine levels after nighttime abstinence 2

Important Clinical Caveat

• FTND scores do not directly predict withdrawal symptom severity—withdrawal symptoms occur equally in smokers with both high and low dependence scores, meaning all smokers require assessment for withdrawal symptoms regardless of their FTND score 1
• The FTND has been validated across multiple populations and settings, demonstrating acceptable reliability (Cronbach's α typically 0.57-0.72) 4, 2

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FTD: Frontotemporal Dementia

Frontotemporal Dementia (FTD), specifically behavioral variant FTD (bvFTD), is a neurodegenerative disorder characterized by progressive changes in behavior, personality, and executive function, often presenting with symptoms that can mimic primary psychiatric disorders. 1

Core Clinical Features

The diagnosis of bvFTD relies on the international consensus diagnostic criteria, which include:

• Behavioral disinhibition (socially inappropriate behavior, loss of manners, impulsive actions) 1
• Apathy or inertia (loss of motivation, reduced initiative) 1
• Loss of sympathy or empathy (diminished response to others' needs, reduced social interest) 1
• Perseverative, stereotyped, or compulsive behaviors (simple repetitive movements, complex compulsive rituals, stereotypy of speech) 1
• Hyperorality and dietary changes (altered food preferences, binge eating, oral exploration of objects) 1
• Executive dysfunction with relative sparing of memory and visuospatial functions 1

Diagnostic Assessment Tools

• The Frontal Behavioral Inventory (FBI) assesses neurobehavioral symptoms, with a positive subscale score ≥12 supporting bvFTD over psychiatric disorders in patients with late-onset behavioral changes 1
• The Stereotypy Rating Inventory (SRI) helps distinguish bvFTD from primary psychiatric disorders, as stereotypies are more common in bvFTD 1
• Standard cognitive screening tools like the MMSE often remain normal in early bvFTD, making them inadequate for diagnosis 1
• The Montreal Cognitive Assessment (MoCA) demonstrates better discriminatory power than MMSE, with 88% classification accuracy (78% sensitivity, 98% specificity) 1

Critical Differential Diagnosis Considerations

• Many patients with suspected bvFTD do not fulfill formal DSM-5 criteria for other mental disorders, emphasizing the importance of rigorous psychiatric evaluation by experts familiar with FTD 1
• Specific FBI sub-items that favor bvFTD over psychiatric disorders include: aphasia and verbal apraxia, indifference/emotional flatness, alien hand and apraxia, and inappropriateness, whereas irritability is more indicative of primary psychiatric disorders 1
• Physical examination should assess for: parkinsonism (bradykinesia, rigidity, parkinsonian gait), motor neuron signs, primitive reflexes (grasp reflex), vertical eye-gaze palsy (particularly downward more than upward), and decreased velocity of saccades 1