Is it Pick’s (bvFTD), or end-stage bipolar? Maybe it’s our approach

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A Dove Press case series published last month suggests that some seniors may exhibit what appears to be behavioral-variant frontotemporal degeneration, or Pick’s Disease – the disease that killed my dad – when in fact they may be in late stages bipolar disorder.

“Although bipolar disorder has been understood classically as a cyclic disease with full recovery between mood episodes, in the last decade, evidence has accumulated supporting progressive features,” reported the authors, who hailed from hospitals in the Netherlands, Toronto, Canada, and Case Western Reserve University in Cleveland.

In four case studies, they examine men (ages 78, 70, 65, and 62) who all had diagnoses of bipolar disorder in younger years. However, these men began to exhibit symptoms that transcend bipolar “evolving into frontotemporal dementia mimic,” to take from the paper’s headline. These are symptoms such as apathy, disinhibition, loss of empathy, and compulsiveness.

These men did not progress after seven years of follow up to end-of-life phases for people with FTD, which include aphasia (inability to speak or understand language) or the inability to swallow, which eventually leads to starvation – exactly the sort of death my father died.

I found this study interesting because dad had been diagnosed with bipolar along the way. In our community, not known for its quality psychiatrists, “bipolar” was a label one psychiatrist in particular (now retired, thank God) threw onto everyone, including my dad.

I suppose the good news here is, just because your loved one may be exhibiting some of these FTD-like symptoms, they may be having a bipolar episode and not doomed to death by an incurable disease.

Case 1

The first subject was 78, diagnosed with bipolar 1 at age 18. His wife said all he wanted to do was eat cheese, smoke cigarettes and lay on the couch. He then evolved into masturbating in public and constantly watching the clock. He no longer could start a conversation and instead began to repeat what other people said.

My dad did all of these things, minus the masturbation, thank goodness. However, I do remember my mother saying to my dad, many years ago when I was a young boy, “Benny get your hand out of your pants!” A lot.

This man did not display mood or psychotic symptoms while displaying these other outrageous behaviors. Various brain scans and other tests also ruled out FTD.

With no real explanation for any of this, I can only imagine the family’s frustration.

Case 2

This man is 70 years old and displaying memory problems. He was diagnosed bipolar 1 17 years ago after a suicide attempt. He did well on lithium until he forgot to take it. He later was given carbamazepine (Tegretol) and mirtazapine (an antidepressant). He began to “obsess on religion,” “impulsively bought a car,” and began “inappropriate social behavior” such as “visiting the swimming pool without his denture.”

Wow. I wish my dad had such problems. Driving to the swimming pool at age 70, dentures or no dentures! I would have loved to seen him driving and getting about at that age.

I’m not sure I’d call these FTD symptoms at all, although the family did report that the man displayed a lack of empathy. I’d argue a lack of empathy to some people may not be a lack of empathy to others.

At any rate, after six years, he was stable and symptoms could not be attributed to bipolar or FTD.

I’m wondering why this man was a case study at all.

Case 3

This 65-year-old man was brought to the memory clinic by his wife and daughter. The man admitted he always had been controlling and compulsive, with an urge to clean excessively. He apparently began having hallucinations during a bout with pneumonia, although the hallucinations continued when the pneumonia disappeared.

“Furthermore, he tried to force his wife to excessively buy items and was increasingly snacking,” the case study reported.

His symptoms could not be attributed to bipolar disorder or FTD.

A man who wants to clean all the time and take his wife shopping? I wonder if some women would be taking him to the altar instead of the psychiatrist.

Case 4

This is a 62-year-old male who came to the memory clinic using the wrong words, among other problems. He had been diagnosed bipolar 1 30 years ago.

After a recent hospitalization due to mania, he had asked a 6-year-old girl to accompany him on a canoe trip. He also spoke excessively during a funeral speech and made personal comments to female strangers.

A link between bipolar disorder and FTD?

“A possible link between bipolar disorder and bvFTD has also been suggested by case reports on patients presenting with manic symptoms as a first manifestation of bvFTD,” the authors reported.  “Executive disturbances (carrying out tasks, even tasks as innate as spitting out water after brushing your teeth) are the most prominent feature in the neuropsychological examination in bvFTD, however executive impairment is common in elderly patients with bipolar disorder as well.”

The bottom line in all of this? The authors say: “Our case series is a reminder that clinicians should reject a diagnosis of bvFTD in patients with bipolar disorder in the absence of obvious clinical and radiological progression over time.”

My thoughts? Meet people with dementia where they’re at. Focus on what’s left; not what’s lost.

As Mike Good from “Together in This” posted just the other day on LinkedIn, “We’re looking at everything all wrong.”

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