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Environmental dependency behaviours in frontotemporal dementia: have we been underrating them?

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Abstract

Environmental dependency (ED) behaviours, such as imitation behaviour (IB) and incidental utilization behaviour (UB), are considered pathognomonic of a frontal lesion and can play a unique role in diagnosing behavioural variant frontotemporal dementia (bvFTD). However, with only few focused observations of ED behaviour reported in earlier studies, their roles in the diagnosis of bvFTD have so far remained supportive. In this observational study, conducted in the cognitive clinic of a tertiary-care hospital, we explored the hypotheses that a focused and systematic search could uncover more ED behaviours in patients with bvFTD, and that the presence of ED behaviours such as incidental UB and IB should allow us to cleanly differentiate bvFTD from AD. Forty-one bvFTD patients and 75 probable AD patients, all diagnosed using accepted criteria, were seen by a neurologist and a neuropsychologist. Information regarding ED behaviour was obtained from the caregiver’s history, observations for spontaneous behaviour and induction of the behaviour in the clinic. All ED behaviours were significantly more frequent in bvFTD compared with AD. UB (78 %; 66 % incidental) and IB (59 %) occurred exclusively in bvFTD. Multi-pronged and focused clinical assessment contributed to the high frequency of ED behaviours. Nearly two-thirds of bvFTD patients, but none with AD, showed three or more ED behaviours. We concluded that ED behaviours are more common in bvFTD than is currently recognized. UB, IB or three ED behaviours, if present, could clearly differentiate bvFTD from AD. A focused search should consistently uncover ED behaviours in bvFTD patients.

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Acknowledgments

We thank Swapna Sucharita for her help with collecting and recording some of the data used in the study and Dr Avijit Hazra for his comments on our statistical analysis.

Conflicts of interest

None of the authors have any conflict of interest to declare.

Ethical standard

The study was approved by the local ethics committee of Apollo Gleneagles Hospitals, Kolkata.

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Correspondence to Amitabha Ghosh.

Appendix

Appendix

The utilization behaviour questionnaire [9]

The following questions relating to utilization behaviour (UB) should be asked:

  • Have there been instances of the patient reaching out, picking up and using an object that was around, in settings that would be socially inappropriate and not in keeping with the patient’s need?

  • If so, what was the object used?

  • Was the object deliberately handed over to the patient, or deliberately brought near the patient, within the patient’s field of vision?

  • Did the patient use the object appropriately or just toy with the object? How exactly did the patient use the object?

  • Did the patient use the object in this manner only once or on more than one occasion?

  • Do you think the patient’s behaviour was unusual compared to how the patient was before the onset of illness?

  • Did you ask the patient not to use the object in this manner? If so, how did the patient respond?

  • Did you ask for an explanation from the patient regarding this behaviour? If so, how did the patient respond?

If required, illustrative examples of UB may be given to ensure that the symptom is correctly understood. When a patient exhibits UB with different objects, the questions should be repeated for each of them.

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Ghosh, A., Dutt, A., Bhargava, P. et al. Environmental dependency behaviours in frontotemporal dementia: have we been underrating them?. J Neurol 260, 861–868 (2013). https://doi.org/10.1007/s00415-012-6722-0

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  • DOI: https://doi.org/10.1007/s00415-012-6722-0

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