Early Onset Dementia/Frontotemporal Dementia

The following is an excerpt from Dr. Hal S. Wortzel’s chapter regarding early onset dementia and frontotemporal dementia in Representing People With Dementia, a Practical Guide for Criminal Defense Lawyers (Elizabeth Kelley, ed). Dr. Wortzel is a forensic neuropsychiatrist at the Rocky Mountain MIRECC, where he serves as Director of Neuropsychiatric Consultation Services and Co-director for the National Suicide Risk Management Consultation Program.

Dr Wortzel and Elizabeth will speak on a panel on Dementia at the International Academy of Law and Mental Health in Barcelona this July.

Frontotemporal Dementia (FTD) represents a group of neurodegenerative disorders that attack the frontal and temporal aspects of the brain, resulting in progressive decline in functioning, especially as it relates to behavior and language abilities. FTD is the third most common neurodegenerative cause of dementia after Alzheimer’s disease and dementia with Lewy bodies, and a leading cause of young onset dementia. FTD is the most common cause of dementia among persons younger than age 60. FTD frequently presents with prominent behavioral changes, not infrequently leading to violations of both social norms and the law. It also causes impairment in language and higher order cognitive processes, often referred to as executive functions. Executive functions enable us to monitor our environment, come up with a plan to engage that environment, observe the success of that plan in relation to various goals, and make adaptations on the fly to optimize the plan. Stated differently, executive functions enable us to deploy goal-directed behaviors in a manner that comports with societal norms and expectations. Unlike many other dementing illnesses, memory and visuospatial functions are relatively spared in the early stages of illness, a circumstance that often leads to delayed diagnosis, and even diagnostic error. The constellation of impairment seen early on in FTD, with prominent behavioral disturbances frequently accompanied by relatively intact memory, makes FTD particularly salient to forensics, and presents some relatively unique challenges.

Representing a client suffering from FTD undoubtedly involves many challenges, starting with the fact that people with that illness may be undiagnosed at the time of their initial legal encounter. Attorneys enhance their ability to serve such clients by being able to recognize circumstances that might suggest FTD, and arranging for appropriate forensic neuropsychiatric consultation. Though there are very modest treatments available to address this progressive and devastating illness, the provision of a clear diagnosis, prognosis, and professional support can significantly improve quality of life and facilitate appropriate planning for patients and their families. Similarly, recognizing this illness may afford viable defense

strategies when behaviors yield criminal charges, or legal remedies when decision-making born of illness runs contrary to well-established principles and values demonstrated throughout their healthy adult life.