Violation of Laws in Frontotemporal Dementia: A Multicenter Study in Japan

Abstract

Although violations of laws, such as shoplifting, are considered to be common in frontotemporal dementia (FTD) patients, there have been few studies on this subject and the frequencies and types of such violations have not been clarified. The objective of this study was to conduct a retrospective investigation of FTD patients in the psychiatry departments of multiple institutions to determine the types and frequencies of any law violations and compare them with those of AD patients. All patients were examined between January 2011 and December 2015 at the specialized dementia outpatient clinics of 10 facilities (5 psychiatry departments of university hospitals, 5 psychiatric hospitals). According to diagnostic criteria, 73 behavior variant FTD (bvFTD) patients, 84 semantic variant of primary progressive aphasia (svPPA) patients, and 255 age- and sex-matched AD subjects as the control group were selected. The findings revealed a higher rate of law violations in the bvFTD and svPPA patients before the initial consultation as compared to the AD group (bvFTD: 33%, svPPA: 21%, AD: 6%) and that many patients had been referred due to such violations. Laws had been broken 4 times or 5 or more times in several cases in the FTD group before the initial consultation. Regarding rates for different types of violation, in bvFTD subjects, the highest rate was for theft, followed by nuisance acts and hit and run. In svPPA, theft had the highest rate, followed by ignoring road signs. There was no gender difference in law violations but they were more frequent when the disease was severe at the initial consultation in the FTD group. As the rates of law violations after the initial consultation were lower than before it, interventions were considered to have been effective. These findings may be useful for future prevention as well as to the legal system.

Keywords

Behavioral symptoms frontotemporal dementia legal system violation of laws

INTRODUCTION

Frontotemporal dementia (FTD) is a neurodegenerative disorder associated with a progressive decline in behavior and language. Its clinical syndromes are caused by focal degeneration of the frontal and anterior temporal lobes [1]. FTD is a common cause of early-onset dementia and incidence and prevalence are similar to those for early-onset Alzheimer’s disease (AD) [2]. From the initial phase of the disease, FTD is characterized by various behavioral and personality changes— such as disinhibition, apathy, lack of empathy, stereotypic behavior, and eating disorders— which have been mentioned as core symptoms in diagnosis criteria [3]. FTD can be classified into three clinical syndromes based on the early and predominant symptoms: behavior variant FTD (bvFTD) and two forms of primary progressive aphasia (PPA) syndrome, semantic variant PPA (svPPA) and non-fluent variant PPA (nfvPPA).

Patients with FTD often transgress social norms as a result of loss of empathy, stereotypic behavior, and a loss of insight into their own behavior and its consequences [4]. Their behavioral changes have been called social misconduct and antisocial behavior, and may be seen by society as violations of laws. Despite our considerable knowledge of FTD, there have been few attempts to investigate antisocial behavior (including criminal behavior and violations of laws) due to FTD and other dementing disorders in a systematic way. Among them are the study in North America by Liljegren and colleagues [5], and that in Europe by Diehl-Schmidt and colleagues [6], which revealed high crime rates in FTD patients.

Non-specialists can easily refer patients with FTD showing violation behavior for consultation to a psychiatric department, and patients with FTD showing violation behavior may also easily be misdiagnosed as having psychiatric disease by non-specialists [7]. Therefore, a nationwide multicenter study of psychiatric hospitals has been required. In addition, there has been a need for systematic studies on violations of laws in FTD in Japan and other East Asian countries because the increasing number of dementia patients has become a social problem in the region, and altered social behavior in such patients may be confounded by ethnic or social factors. The objective of the current research was by retrospectively investigating FTD patients examined at the psychiatry departments of multiple facilities, to determine the rates and types of law violations in a FTD group (bvFTD, svPPA) and compare them with those for AD patients as the control group.

METHODS

We investigated all patients examined at the specialized dementia outpatient clinics of 10 nationwide facilities (5 departments of psychiatry in university hospitals, 5 psychiatric hospitals) from January 2011 to December 2015. Patients with bvFTD and those with svPPA were extracted as the FTD group, having satisfied the diagnosis criteria of bvFTD and svPPA [3, 8]. Patients with predominantly left temporal atrophy presenting with loss of semantic knowledge of words and objects, as well as behavioral and personality changes that overlap with and often meet diagnostic criteria for bvFTD are also categorized as svPPA. Patients with nfvPPA were excluded because they were thought to be heterogeneous as a group, not numerous enough to enable meaningful comparisons with the other groups, and have relatively few law violations. Controls were age- and sex-matched subjects with AD according to the diagnostic criteria [9]. The final diagnoses at each facility had been made by senior neuropsychiatric specialists using a common protocol based on diagnosis criteria, imaging findings from brain MRI or CT, and common cognitive function batteries, as well as the usual battery of screening blood tests. We also used a standard psychiatric evaluation to exclude major functional psychiatric disorders. Patients with other diagnoses were excluded.

In all subjects, we ascertained age, gender, years of education, duration of disease, and cognitive function at the initial diagnosis (Mini-Mental State Examination, MMSE) [10] and dementia severity (Clinical Dementia Rating, CDR) [11], as well as referral reason if the subjects were referred by physicians.

Defining violations of laws as cases in which a problem with another person resulted in a police intervention or led to a legal intervention by a lawyer or other 3rd party, they were classified as driving-related violations (hit-and-run, ignoring road signs and signals, or speeding) theft, trespassing, violence (injury), inappropriate urination (or other acts) in a public place, other inappropriate acts of nuisance (such as sexual harassment and following somebody about), transportation fare evasion, and non-classifiable acts. We aggregated data for violations up to the time of initial consultations as well as after them, separately by rate and type. In this study, it was emphasized that the violations of laws had to have occurred at the time of onset of the disease or thereafter so that they would be those due to a substantive change from the patient’s premorbid state, rather than a longstanding character trait.

We compared the three groups for demographic differences, rates for referral, and violations of laws before and after the initial consultation. We also compared background data (age, gender, duration of disease, education years, MMSE, CDR) for patients with or without violations of laws before and after the initial consultation to determine if there were any significant differences. Data analyses were carried out using the SPSS software package. Statistical differences among the three groups were assessed by the Kruskal-Wallis test for non-parametric variables, as well as the chi-squared test with post hoc Fisher’s exact test for nominal variables.

The present research was a retrospective observational study using a database, not an interventional study. Adequate consideration was given toprotecting patient anonymity and approval was obtained from the ethics committee of each facility for research using databases.

RESULTS

Demographics

There were at total of 412 subjects consisting of byFTD (n = 73), syPPA (n = 84), and AD (n = 255) patients. Regarding region, 86 patients were from Tokyo, 159 from Osaka, 96 from Kumamoto, 57 from Ehime, and 14 were from Kochi. Regarding facility, 302 patients were from university hospitals and 110 from psychiatric hospitals. A comparison of the demographics of the three groups is shown in Table 1. The significant difference observed for CDR in the svPPA patients may mean that their disease was relatively mild; however, there was no significant difference between the FTD group (bvFTD and svPPA together) and the AD group (p = 0.495) in this respect.

Table 1

Demographic variables of the three patient groups

	bvFTD	svPPA	AD	p value
	n = 73	n = 84	n = 255
Age	66.8 (10.9)	69.7 (8.8)	69.3 (8.2)	0.068
Sex (M/F)	39/34	34/50	107/148	0.176
Education years	12.7 (5.0)	12.0 (3.1)	12.3 (2.8)	0.648
Disease duration (m)	48.1(29.3)	58.9 (42.4)	52.4 (34.3)	0.172
MMSE	18.0 (7.1)	18.1 (7.8)	16.9 (7.1)	0.321
CDR (0.5:1:2:3)	19:24:22:6	33:37:8:3	68:113:41:14	0.011
(n = 71)	(n = 81)	(n = 236)

Referral by patients’ doctors

Rates for referral of patients by general physicians for bvFTD, svPPA, and AD were 86%, 87%, and 81%, respectively and there was no significant difference. Rates for referral due to violations of laws were 25% for bvFTD (n = 57), 10% for svPPA (n = 67), and 3% for AD (n = 207) and significant differences were observed in the chi-squared test (p = 0.000). The rate for referral due to violations of laws was highest for bvFTD, followed by svPPA and AD.

Violations of laws before initial consultation

The rates for violations of laws by patients before the initial consultation were 33% for bvFTD (n = 73), 21% for svPPA (n = 84), and 6% for AD (n = 255). The chi-squared test showed that differences among the three groups were significant (p = 0.000). In the FTD group overall, the rate for violations before the initial consultation was 27% (n = 157), which was significantly higher than in the AD group (p = 0.000). The numbers of violations of laws before the initial consultation are shown in Fig. 1 (left). There were no subjects in the AD group with 4 or more violations, but there were 5 patients each with 4 violations and 5 or more violations in the FTD group overall.

Fig.1

Numbers of violations of laws before and after initial consultation.

The types of violations of laws before the initial consultation are shown in Fig. 2. For bvFTD, the rate for theft was the highest followed by nuisance acts and hit-and-run; and for svPPA, theft had the highest rate and then ignoring road signs. For AD, ignoring road signs had the highest rate.

Fig.2

Types of violation before initial consultation.

Differences in background data for with/without violations of laws before initial consultation

We investigated background data for patients with (n = 56) and without (n = 356) violations of laws before the initial consultation for all patients, including those with AD. Although there were no significant differences for age, duration of disease, education years, or MMSE, the difference for gender (with violations 62% for males, without violations 41% for females) was significant (p = 0.009). There was also a significant difference for CDR (p = 0.002). Thus, in the subjects overall, males with a greater severity of disease had a significantly higher rate of violations of laws before the initial consultation.

We also carried out an analysis to determine if there were any significant differences in background data between with (n = 42) and without (n = 115) violations of laws before the initial consultation in the FTD group overall. While there was no significant difference for age, gender, duration of disease, education years, or MMSE, the difference for CDR was significant (p = 0.002). This showed that the rate of violations before the initial consultation was higher when the severity of FTD was greater.

As a difference in the male/female ratio for violations had been observed, we analyzed the influence of driving-related violations on the male/female ratio. Among the 56 patients in the with violations group, 18 had driving-related violations and the male/female ratio was 12:6, whereas the male/female ratio for 38 subjects without driving-related violations was 22:16. The difference in ratio between the groups regarding ratio was not significant.

Violations of laws after initial consultation

The rates for patients with violations of laws after the initial consultation were 10% for bvFTD (n = 73), 11% for svPPA (n = 84), and 1% for AD (n = 255). Significant differences were observed in the chi-squared test (p = 0.000). For the FTD group overall (n = 157), the rate for violations before the initial consultation was also 10%, which was significantly higher than that in the AD group (p = 0.000). Thus, violation rates tended to decrease after the initialconsultation.

Frequencies of violations of laws for after the initial consultation are shown on the right of Fig. 1. We found that there was a drop in the frequencies in bvFTD and svPPA subjects from before the initial consultation. However, for AD, there was one patient in the five or more violations category after the initial consultation, though there were no patients before. Regarding types of violations of laws after the initial consultation, for bvFTD (n = 10), 5 patients committed theft and 2 acts of nuisance; for svPPA (n = 9), 3 patients committed theft and 2 ignored road signs; and for AD (n = 3), 2 patients committed acts of trespass.

DISCUSSION

This was the first study in an Asian country to investigate violations of laws in FTD patients at multiple facilities. The results showed that rates of violations in both bvFTD and svPPA patients before the initial consultation were higher than in AD patients. There were more referrals due to violations of laws in the FTD group. In the FTD group, before the initial consultation, there were patients with 4 or 5 or more violations. Regarding types of violation, for bvFTD, the rate was highest for theft, followed by nuisance acts and then hit-and-run, and for svPPA, theft had the highest rate and then came ignoring road signs. In AD, the highest rate was for ignoring road signs. Among all subjects including those with AD, violations of laws before the initial consultation were more numerous for male and severe patients, but for the FTD group by itself, no gender difference was noted. While there were still a large number of violations for bvFTD and svPPA after the initial consultation, there had been a decrease compared to before it.

As we expected, rates for violations of laws before the initial consultation were higher for bvFTD and svPPA than AD. Furthermore, there were several subjects in the 4 and 5 or more violations categories before the initial consultation. In the absence of a diagnosis, violations committed before an initial consultation could be referred to a court of law. Therefore, the public needs to be better educated about FTD. However, the greater number of law violation-related referrals for bvFTD and svPPA as compared to AD indicates that patients’ physicians suspected that such violations were probably FTD-related symptoms. Therefore it appears that doctors have achieved a certain degree of understanding of the disease.

Regarding previous studies, Mendez and colleagues reported that more than half of 28 patients with bvFTD displayed sociopathic behavior, such as unsolicited sexual behavior and traffic violations, compared with only 7% of AD patients [12]. Diehl-Schmidt and colleagues compared rates of criminal behavior (theft, willful damage to property, housebreaking, assault, or indecent behavior) in 32 bvFTD patients, 18 svPPA patients, and 33 AD patients [6]. They reported that rates were 54% and 56% in patients with bvFTD and svPPA, respectively, but only 12% in those with AD. Liljegren and colleagues reported criminal behavior in 42 of 545 patients (7.7%) with AD, 64 of 171 patients (37.4%) with bvFTD and 24 of 89 patients (27.0%) with svPPA.

As definitions of criminal behavior and methodology differ between the above studies, we cannot make a simple comparison. In addition, differences in legal systems and sociocultural factors are probably behind the lower rates for such behavior in Japan compared with those in Europe and the United States, and the overall crime rate in Japan is lower than that in European countries and the United States [13]. Our findings suggest that the way of dealing with dementia-related law violations in Japan differs from that in European countries and the United States, but on the other hand, they also highlight the fact that such violations are common to FTD patients regardless of cultural background.

Regarding types of violations, for bvFTD, theft was most frequent and then came acts of nuisance and hit-and-run. For svPPA, theft was most frequent followed by ignoring road signs. Ignoring road signs had the highest rate for AD. The high rates for theft and nuisance acts in bvFTD and theft in svPPA appear to arise from the tendency toward impulsive and disinhibited behavior in patients with these diseases and an association with orbital frontal damage has been previously reported [14]. Changes in the ability to avoid punishment are characteristic of anterior insular and lateral orbital frontal damage, areas that are vulnerable to bvFTD, and pathologic stealing has previously been reported as a symptom of bvFTD [14]. Also, it is important to mention that some of the present subjects had 4 or 5 or more violations before the initial consultation. This suggests that violations had become their routine stereotypic behavior [15].

Ignoring road signs, whose rate was second highest in the svPPA subjects, was considered to be due to the semantic memory impairment specific to svPPA. The anatomic substrate of svPPA is bilateral anterior temporal with some involvement of the orbitofrontal region. Thus, semantic memory impairment caused by anterior temporal degeneration, in combination with disinhibition due to orbitofrontal dysfunction may lead to ignoring road signs. On the other hand, visuo-spatial cognitive impairment and attention problems might be involved in the high rate of ignoring road signs in AD [16, 17]. The relatively high rate for acts of trespass in the present AD subjects was due to progression of the disease causing them to be a nuisance to neighbors by entering their houses repeatedly. So, the distinctive anatomies in bvFTD, svPPA, and AD appear to lead to different patterns of law violations. Our findings shed new light on the behaviors exhibited.

In the overall figures, interestingly, driving-related violations accounted for 30% in each group. This result is consistent with previous research in Japan comparing the driving behavior of FTD and AD patients [18]. The high rate for this sub-category will be an issue that the transportation authorities have to address in the future.

Regarding violations of laws after the initial consultation, while the higher rate of violations in FTD than in AD and the proportions of types of violations did not change, the percentage of violations in each group decreased. This may be due to interventions resulting from the consultations. However, we did not consider the effects of interventions or medication after the initial consultation so this will need to be studied in the future. In AD, the increase in the frequency of violations after the initial consultation was due to more patients causing trouble to their neighbors by repeatedly entering their houses as the disease progressed.

As the present research was purely a retrospective study using medical records, it is possible that the information concerning violations of laws obtained was insufficient. Therefore, the possibility of its inaccuracy regarding such points as numbers of law violations cannot be denied. There may also be bias from referral for psychiatric consultation. However, patients with bvFTD showing violation behavior can easily be referred to a psychiatry department for diagnosis. Thus, we felt confident about collecting psychiatric department referrals. Another limitation is the issue of dementia severity. Although there may be no difference in disease duration or MMSE score, equating dementia severity between AD and FTD patients is difficult. There are several measurement tools for equating dementia severity including that of bvFTD, among them FTLD-modified CDR and Functional Activities Questionnaire. However, unfortunately, as this was a multicenter retrospective study, we could not use these measurement tools. Finally, there may be other potentially confounding factors that can influence violations of laws, including other neuropsychiatric symptoms as well as medical, pharmacological, or social factors that we are unable to discuss. On the other hand, a strength of our study is that it was nationwide multicenter research including both university hospitals and psychiatric hospitals, and therefore, we believe our results are reliable and sufficiently valid.

In conclusion, our systematic multicenter study revealed that similar to previous studies, the rate of violations of laws was higher in FTD patients than AD patients in Japan. Such patients should be treated differently by the legal system, such as by obtaining a neuropsychiatric evaluation when dementia is suspected. Our research has provided important findings that should contribute to the development of a more flexible legal system.

DISCLOSURE STATEMENT

Authors’ disclosures available online (http://j-alz.com/manuscript-disclosures/17-0028r2).

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