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1 Alzheimer s Disease: Update on Research, Treatment & Care Clinicopathological Classifications of FTD and Related Disorders Keith A. Josephs, MST, MD, MS Associate Professor & Consultant of Neurology Mayo Clinic

2 I do not have any disclosures

3 Learning Objectives To be able to recognize 3 clinical FTD syndromes & differentiate them from Alzheimer s dementia To understand how and why FTD is related to progressive e supranuclear palsy, corticobasal degeneration and motor neuron disease

4 Outline Three clinical FTD syndromes Behavioral variant FTD Semantic Dementia Progressive non-fluent aphasia Three related disorders Progressive supranuclear palsy Corticobasal degeneration Motor neuron disease

5 Frontotemporal Dementia (FTD) vs. Alzheimer s Disease (AD) Clinical FTD Personality and language AD Episodic memory Neuropsychology Imaging Pathology Executive & Recall & language spatial/perceptual dysfunction Frontal & Mesial temporal anterior lobe & temporal lobes temporoparietal TDP-43 or tau Beta-amyloid amyloid

6 FTD Over-arching term that encompasses 3 syndromes: Behavioral variant FTD (bvftd) Semantic Dementia (SD) Progressive non-fluent aphasia (PNFA) Characterized by varying degree of personality & behavioral changes and language impairment Neary et al. Neurology 1998

7 bvftd Clinical Insidious onset & gradual progression Personality and behavioral changes Impairment in personal conduct Loss of emotional responses Mental rigidity Apathy or disinhibition Reduced attention & easily distractible Hyperoral and dietary changes Utilization behavior

8 Miller et al. Neurology 2007

9 bvftd Clinical Language impairment can occur (dynamic aphasia), less prominent and occurs later in the disease course Stereotypies occur in up to 60% of patients with bvftd Compulsive type behaviors can be a presenting feature in up to 40% of bvftd patients Mendez et al. J Geriatr Psy N 1997; Josephs et al. Neurobiol Aging 2008

10 bvftd Imaging g (MRI)

11 bvftd Imaging g (FDG PET)

12 Porter et al. Eur J of Neurol 2007

13 bvftd Neuropsychology Poor performance on test of executive function and behavior Better performance on tests of episodic memory (especially recognition type tests) Relatively normal performance on test of visuospatial/perceptual function

14 SD Clinical Insidious onset & gradual progression Fluent spontaneous somewhat empty speech Loss of word meaning manifested by impaired naming and comprehension Semantic paraphasias (banana for peach) Surface dyslexia (is land for island)

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16 SD Clinical Behavioral changes can occur but tend to be later in the disease course and are more common when the right anterior temporal lobe is affected. Loss of object and face recognition also can occur especially when right temporal lobe is affected

17 SD Imaging g (MRI)

18 SD Imaging g (FDG PET)

19 64 y.o. woman presented with loss of recognition of familiar faces

20 SD Neuropsychology Poor performance on test of naming with failure to recognize the object even when target words are given Relatively better performance on tests of episodic memory Relatively normal performance on test of spatial/perceptual function

21 PNFA Clinical Insidious onset & gradual progression Agrammatism (I am gone house now for the wife) and telegraphic speech (get passport, need for trip) Majority will also have a motor speech impairment (apraxia of speech) with sound based errors and a non-fluent speech output

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23 PNFA Imaging g (MRI)

24 PNFA Imaging g (FGD PET)

25 PNFA Neuropsychology Poor performance on test of naming however the patient will recognize the target words when given Difficulty recognizing syntactically complex sentences Relatively better performance on tests of episodic memory Relatively normal performance on test of spatial/perceptual function

26 Summary of FTD FTD different from AD Three clinical syndromes bvftd (personality change) SD (loss of meaning for words) PNFA (speech output is not fluent) Classification is based on dominant feature, but features do overlap some

27 FTD Pathologies bvftd SD PNFA TDP-43 Tau

28 FTD complex bvftd SD PNFA TDP-43 Tau MND FTLD Pick s PSP CBD

29 FTD complex bvftd SD PNFA TDP-43 Tau MND FTLD PSP Pick CBD FTD-MND PSP CBD

30 Related Disorders Progressive supranuclear palsy (PSP) Corticobasal degeneration (CBD) Motor neuron disease (MND)

31 Clinical features associated with PSP Reptilian stare Difficulty looking up or down Stiffness of neck and trunk muscles Poor balance with lots of falls Some patients also have apathy, mild behavioral changes Subtype present with apraxia of speech Josephs et al., Brain 2007

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33 PSP Imaging g (FDG PET)

34 Clinical features associated with CBD Difficulty moving one arm or leg due to stiffness (rigidity) and dystonia Limb apraxia & myoclonus Trouble controlling movement of limb, i.e., the limb behaves as if it has a mind of its own (so-called alien limb) Behavioral changes can be prominent Present as PNFA initially

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38 CBD Imaging g (FDG PET)

39 FTD & MND A subset of patients with bvftd-like features also have clinical and pathological features of MND Predominance of lower MND findings Fasciculations (twitching of muscles) Muscle weakness Muscle wasting Flaccid dysarthria (breathy speech) Mackenzie, et al JNEN 2005

40 MND Upper motor neuron disease findings also occur and can occur in isolation so call FTD/PLS (can mimic PSP) Clinical findings Bulbar signs (spastic dysarthria - strained speech) Limb spasticity Babinski sign Josephs et al. Neurology 2007

41 MND If lower motor neuron disease is present, average disease duration about 2.3 years (FTD without MND = 7-15 years) If isolated upper motor neuron disease, disease duration about 4 years Therefore, important to diagnose these MND variants Josephs et al. Neurology 2006 & 2007

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43 bvftd vs. FTD-MND bvftd FTD-MND

44 Final Summary There is overlapping clinical & pathological l features between FTD (bvftd, SD and PNFA) and (PSP, CBD & MND) This suggest that these diseases share cortical regions of loss and possibly mechanism of neurodegeneration It remains important to keep them separate if important treatment and genetic discoveries are to be made.

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