Icd 10 Code for Family History of Dementia

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Enquiry Article

Age-Related Incidence and Family History in Frontotemporal Dementia: Data from the Swedish Dementia Registry

• Christer Nilsson,
• Maria Landqvist Waldö,
• Karin Nilsson,
• Alexander Santillo,
• Susanna Vestberg

ten

• Published: April x, 2014
• https://doi.org/10.1371/periodical.pone.0094901

Figures

Abstract

Objectives

Frontotemporal dementia (FTD) is considered to exist a mainly early-onset neurodegenerative disorder with a potent hereditary component. The aim of the study was to investigate age-related incidence and family history in FTD compared to other dementia disorders, especially Alzheimer'due south disease (AD).

Methods

The Swedish Dementia Registry (SveDem) registers all new cases of dementia diagnosed by the participating centres, including data on demographics, diagnosis, and investigations used. Data for the menstruation 2008–2011 were extracted and compared with age-related population information on a regional and national level.

Results

There were 20 305 patients registered in SveDem during 2008–2011, whereof 352 received a diagnosis of FTD. Mean age at diagnosis for FTD was 69.6 years and nigh seventy% of FTD cases were 65 years or older at the time of diagnosis. Both FTD and Advertizement showed an increased incidence with age, which reached a maximum in the age group 80–84 years at half-dozen.04 and 202 cases per 100 000 person-years, respectively. The proportion of cases with a positive family unit history was significantly lower in FTD than in AD.

Conclusions

Contrary to general opinion within the field, data from SveDem show that the incidence of FTD increases with historic period, and that the majority of cases are diagnosed after the age of 65 years. In addition, data from SveDem might suggest that the importance of hereditary factors in general is similar in FTD and AD. The recognition of these findings has important consequences for the diagnosis, treatment and care of patients with FTD.

Commendation: Nilsson C, Landqvist Waldö Chiliad, Nilsson Chiliad, Santillo A, Vestberg S (2014) Historic period-Related Incidence and Family History in Frontotemporal Dementia: Data from the Swedish Dementia Registry. PLoS ONE nine(4): e94901. https://doi.org/ten.1371/periodical.pone.0094901

Editor: Karl Herholz, Academy of Manchester, Uk

Received: February 3, 2014; Accepted: March twenty, 2014; Published: Apr 10, 2014

Copyright: © 2014 Nilsson et al. This is an open up-admission article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted utilise, distribution, and reproduction in whatsoever medium, provided the original author and source are credited.

Funding: The study was funded by grants from the regional understanding on medical training and clinical research (ALF) between the Skåne Regional Quango and Lund University. The funder had no role in report design, information collection and analysis, conclusion to publish, or preparation of the manuscript.

Competing interests: The authors have alleged that no competing interests be.

Introduction

The frontotemporal dementias (FTD) are a group of neurodegenerative disorders affecting primarily the frontal and temporal lobes of the encephalon, leading to various combinations of behavioural, cognitive and motor symptoms [1], [2]. Clinical syndromes within the FTD-spectrum include behavioural variant FTD (bvFTD), semantic dementia (SD), progressive non-fluent aphasia (PNFA) and FTD with motor neuron disease (FTD-MND) [ane]. The underlying pathology is heterogeneous, with classification based on the main constituents of neuronal inclusions found at autopsy [3].

Although the disorder was outset described by Choice more than than 100 years agone, formal clinical and neuropathological criteria were not developed until the mid-90s [4], [5]. Accordingly, diagnosis and collection of demographic data on FTD have largely been performed in specialized centres with a research involvement in the disorder [6]. Early case serial and prevalence studies suggested that FTD is an early-onset disorder with a mean age at onset around 53 years [ane], [7] and a prevalence of approximately fifteen–22 cases per 100 000 in the age group 45–64 years [2], [7]–[10], although lower figures have also been reported [xi]. Studies of the incidence in FTD are much fewer, only accept found similar rates in annual incidence for early on-onset FTD (<65 years) of 2.7–4.one cases per 100 000 person-years in the 45–64 yr age group [9], [10], [12]–[14]. Although the being of belatedly-onset cases of FTD (≥65 years) has been recognized, with a reported range for age at onset of 21–84 years [1], [2], [six], [9], the view of FTD every bit an early-onset dementia has largely prevailed [1], [9], [ten], [15]. Nevertheless, more than recent customs-based studies accept shown much higher incidence in tardily-onset FTD at sixteen.7 per 100 000 person-years, compared to one.3 in early-onset FTD [xiv], [16]. Information technology is thus possible that FTD might be underdiagnosed in the elderly population [2], [14], [16].

Many studies take reported that a high proportion of FTD cases have a positive family unit history for dementia [17]–[22]. Several known genetic mutations have been described that can pb to autosomal dominant hereditary FTD, estimated to business relationship for approximately 10–30% of cases [2], [19]–[21]. The remainder of patients with FTD are presumed to exist of sporadic origin, although it should be noted that no recessive mutations causing FTD have been described then far. On the basis of bachelor prove, information technology has been ended that the proportion of familial cases is higher in FTD than in other major neurodegenerative disorders [1], [nine]. However, the high customs prevalence of other types of dementia in the elderly might make estimates of the proportion of familial cases uncertain in FTD [ii].

The aim of the present study was to examination the hypothesis that the incidence of FTD increases with age and is higher in the elderly, similarly to other neurodegenerative disorders. Furthermore, the proportion of FTD cases with a positive family unit history was compared to family history in AD. For this purpose nosotros used data extracted from the Swedish Dementia Registry (SveDem) for the menstruation 2008–2011, encompassing twenty 305 new cases diagnosed with dementia, including 352 cases of FTD. The nowadays study supports the hypothesis of increasing incidence of FTD with historic period, like to other major neurodegenerative disorders, and that tardily-onset FTD is more common than early-onset FTD.

Methods

Written report design

The Swedish Dementia Registry (SveDem; www.svedem.se), is a national quality registry on dementia disorders, financed by the Swedish Association of Local Authorities and Regions and the Swedish Encephalon Power network. Uppsala Clinical Research Centre is responsible for the development and support of the database online. SveDem was started in 2007 with the purpose of improving time to diagnosis, diagnostic workup, handling and care of persons with dementia. New cases of dementia diagnosed at the participating primary care and specialist centres are registered. Nigh all centres (95%) specializing in the diagnosis of dementia (i.e. memory clinics) in Sweden use the registry [23]. For the purpose of the present study, anonymized data on diagnosis, date of diagnosis, investigations used, age, gender, diagnosing centre, place of habitation and family history for individuals registered in SveDem during the time period 2008–2011 was extracted.

Diagnosis is registered in SveDem past choosing from a list of diagnoses (early-onset AD, late-onset Ad, vascular dementia (VaD), Mixed Ad and VaD, FTD, Dementia with Lewy bodies (DLB), Parkinson illness dementia (PDD), Dementia of other causes and Dementia not specified). In addition, the primary and secondary ICD-10 codes are registered. In Sweden, the ICD-ten codes used for the diagnosis of dissimilar forms of dementia are made according to a consensus certificate [24]. To avoid cases with mistaken registration or frontotemporal syndromes of other causes, only patients registered as frontotemporal dementia and the ICD-ten codes F02.0 plus G31.0 were considered as FTD with a neurodegenerative cause. Registration of diagnosis in SveDem does not differentiate betwixt the different clinical syndromes of FTD (i.e. bvFTD, SD, PNFA or FTD-MND).

It is of import here to explain the nature of the Swedish health care quality registries, such as SveDem. Data are entered in a standardized fashion to enable follow up of diagnostic procedures, treatment and management, with the purpose of standardizing and improving wellness intendance nationally. Extracted data for scientific purposes are anonymised and cannot be combined with the individual patient'due south medical records. Adherence to the onetime [iv] and new [25] diagnostic criteria for FTD cannot therefore exist controlled for registered cases. To improve diagnostic specificity, we therefore also analysed age data in a subgroup of patients including just cases diagnosed in specialist centres that had performed both cognitive testing and neuroimaging. In a tertiary group, the data from cases that had performed lumbar puncture was analysed. Analysis of Advertising biomarkers (full-tau, phospho-tau and β-amyloid_1-42) in cerebrospinal fluid (CSF) is routinely used in clinical exercise in Sweden as office of the diagnostic procedure in the diagnosis of dementia and is always included if lumbar puncture is performed.

The presence or absence of a family history of dementia in first- and second-degree relatives is noted in the SveDem registration form. For classification purposes, the responses were divided into three categories: Positive family history (Aye), negative family history (No/None known) and Non known (reserved for when questions about family history have non been asked alternatively no response registered).

Statistical analysis

Incidence rates were calculated by dividing the number of diagnosed cases with the number of person-years in the population at risk, multiplied by 100 000. This was done for each age cohort every bit well as for the whole population in defined geographical regions. Data on population size in each historic period group and in each local council was obtained from publicly bachelor census figures for 2011 (Statistics Sweden; world wide web.scb.se). The population at risk was calculated past subtracting the number of cases with established dementia in each age accomplice using published estimates of dementia prevalence [14], [26].

Differences in gender distribution for each diagnosis, also as the distribution between early-onset and late-onset cases of FTD, were calculated by an verbal binomial exam. T-exam was used for statistical comparisons of age at diagnosis in Advertising and FTD. For comparison of the proportion of a positive family history in first and second-caste relatives between cases with Ad and FTD we used Fisher's exact test. In cases with FTD, the proportion of cases with a positive family history in different age groups was compared using Fisher's exact examination and Mantel-Haenszel chi-foursquare.

The statistical analyses were performed in R version 2.15.ii (The R Foundation for Statistical Calculating, http://world wide web.r-project.org/) and SPSS Statistics 18 for Windows (IBM Corporation, Somers, NY, Usa). A p-value beneath 0.05 was considered statistically significant.

Ethics argument

The project was approved by the Regional Ideals Commission of Lund University (Permit number 2012/137) and the SveDem Steering Committee. All registered individuals were informed about SveDem orally and in writing at the time of diagnosis and gave their consent to registration, with the possibility of failing participation, in accordance with Swedish legislation.

Results

In total, 20 305 cases of dementia were registered in SveDem during the menses 2008–2011. The number of cases and proportion of the dissimilar diagnoses registered are summarized in Table 1. As expected, AD was the most mutual diagnosis and accounted for 53% of all cases, including cases with mixed Advertizement and VaD. The range for historic period at diagnosis was very like for all the diagnoses and the previously known gender differences in Advertising (female person > male) and DLB/PDD (male person > female person) were confirmed (Table 1). In the FTD group there was a slightly college proportion of females at 56% (95% CI 50.0–60.6), with borderline statistical significance (p = 0.049).

Diagnosis of FTD

There were 352 cases of FTD registered during the investigated time period. Diagnoses of FTD were fabricated almost exclusively in specialist clinics (95%). The majority of centres that reported cases of FTD registered less than 6 cases (range 1–43). More than one third (37%) of the cases were registered in only 5 centres. While FTD accounted for 1.seven% of all cases overall, the proportion was greater in centres with a higher number of FTD cases. For instance, in our own center (Lund) the proportion of FTD was 4.2%.

In Sweden, certain basic diagnostic procedures are considered mandatory for a diagnosis of dementia and have to be performed before referral to a specialist eye. These basic procedures include history from patient and caregiver, physical examination, blood chemistry, cognitive screening tests and calculator tomography (CT) of the encephalon. Among all recorded FTD cases, 95.seven% had performed cerebral testing of some kind (MMSE, other screening tests, and/or examination by a neuropsychologist). The main reason given for not performing cognitive tests was that it was not possible due to the patient's condition. Structural neuroimaging (CT or MRI) was performed in 96.iii% and lumbar puncture in 64.4% of cases with FTD.

Incidence of FTD

For calculation of the total incidence of FTD, we chose to compare the smaller regions of Lund and Uppsala, with populations of 289 550 and 335 000 inhabitants, respectively, with the larger Stockholm region with 2 091 357 inhabitants. While the Lund and Uppsala regions each are dominated by a specialist eye located at the corresponding university hospital, both with research on FTD, there are ten non-academy specialist centres in the Stockholm region in parallel to the memory clinic at Karolinska University Hospital. The total annual incidence of FTD in these 3 regions was i.17 (Stockholm), 2.07 (Lund) and 3.21 (Uppsala) per 100 000 inhabitants.

The distribution of age at diagnosis in FTD cases is summarized in Fig 1A. In that location were significantly more FTD cases 65 years or older at the time of diagnosis (north = 245), than cases <65 years (n = 107). Early-onset cases represented 30.vi% of total FTD cases (95% CI 25.2–35.0; p<0.0001).

Figure 1. Historic period at diagnosis in FTD.

(A) Age at diagnosis in FTD cases registered in SveDem 2008–2011. (B) The proportion of FTD cases in each age grouping in the full FTD cohort (blue confined), compared to those cases diagnosed in specialist centres where investigations included cognitive testing and structural or functional imaging (carmine bars) and cases that had performed lumbar puncture with CSF assay (green bars).

https://doi.org/10.1371/journal.pone.0094901.g001

Symptoms of frontal lobe dysfunction occur both in VaD and AD. To minimize the risk for incorrect diagnosis of FTD, specially in older age groups, we performed further analysis of the age distribution afterward excluding cases that did non fulfil the following criteria: (one) diagnosis at a specialized middle, (2) utilise of structural (CT/MRI) or functional (SPECT/PET) neuroimaging, (3) apply of cognitive testing (MMSE, other screening tests, and/or examination by a neuropsychologist). Out of the 352 FTD cases, 314 cases fulfilled the above criteria. In addition, out of these 314 cases, the 206 cases that had performed lumbar puncture with CSF assay of AD biomarkers were analysed separately. The age distribution in these three groups was very similar except for a slightly lower proportion of cases in the age group eighty–84 years and a higher proportion of cases in the age group 65–69 years amongst cases that had performed lumbar puncture (Fig 1B).

Considering that the younger historic period cohorts are larger, the age-related incidence of FTD was calculated and compared to that of patients with AD (cases of mixed dementia were excluded). Both for FTD and AD, the highest incidence occurred in the age grouping lxxx–84 years at 6.04 and 202 cases per 100 000 person-years, respectively (Fig 2). Yet, the age distribution differed between the 2 disorders, with a higher proportion of early-onset cases in FTD, and the average historic period at diagnosis was significantly higher in Ad (77.4 years) compared to FTD (69.6 years) (p<0.0001). For comparison with previous studies on incidence, the incidence of FTD in the age groups 30–64 (early onset) and 65–99 (belatedly onset) years was also calculated. The incidence was 0.64 and 3.44 per 100 000 person-years in early on-onset and tardily-onset FTD, respectively.

Effigy 2. Historic period-related incidence in FTD and Ad.

The figures bear witness the incidence of FTD (A; blueish bars) and Advertizement (B; cerise confined) in relation to age (years). Values for incidence are given as cases per 100 000 person-years in each five twelvemonth age accomplice.

https://doi.org/x.1371/journal.pone.0094901.g002

Family history

The number of FTD cases with a family history of dementia was recorded and compared to Advertisement cases (Fig 3A). While 26.vii% of FTD cases had a first-degree relative with dementia, simply 7.6% had a 2d-caste relative and the number of FTD cases with both first- and second-degree relatives with dementia was even lower at 3.vii%, like to the frequencies of a positive family history for dementia in all patients diagnosed with dementia and registered in SveDem 2008–2011 (first-caste 29.4%, second-degree 7.6%). At that place was a significantly higher proportion of cases with a positive family unit history in AD than in FTD for both first-degree (34.eight% vs 26.seven%; p<0.0001) and 2nd-degree relatives (9.8% vs 7.6%; p = 0.033) (Fig 3A). We besides compared family history in different age groups for cases with FTD. Autonomously from a borderline-significant tendency (p = 0.051) towards a higher proportion of cases with a positive family history in first-degree relatives of early on onset cases (39–64 years), there were no larger differences between the different age groups (Fig 3B). Similarly, for AD, in that location was no major deviation in family unit history betwixt early on and tardily-onset cases (data not shown).

Figure 3. Family history in FTD and AD.

The data shown in (A) represents the response to questions on the presence of dementia in first-degree and second-degree relatives of patients diagnosed with AD (blue bars) and FTD (red bars). In (B), the responses in FTD cases are divided into age cohorts: 39–64, 65–fourscore, and 81–96 years. For classification purposes, the responses were divided into three categories: Positive family history (Yes), negative family history (No/None known) and Not known (reserved for when questions about family history take not been asked alternatively no response registered).

https://doi.org/10.1371/periodical.pone.0094901.g003

Discussion

In the largest study of age-related incidence to date, using a large community-based registry, we demonstrate that the incidence of clinically diagnosed FTD increases with age as has been previously reported in smaller populations [14], [16]. In a consecutive study of 100 patients with SD, 46% were diagnosed later on the age of 65 years [27], which also indicates that late-onset cases of FTD complex disorders might exist more than common than previously idea. Although the average age at diagnosis was significantly lower for FTD than AD, both disorders showed a maximum age-related incidence in the same age cohort (fourscore–84 years). This finding suggests that increasing age might exist a major risk factor in FTD, as in other major neurodegenerative disorders such as AD and PD [28], [29]. It should exist pointed out, yet, that nigh previous studies accept used age at onset rather than age at diagnosis which was used in this study. Although the apply of age at onset avoids problems of patient and doctor delay, the estimation of fourth dimension from onset to diagnosis is notoriously difficult and might exist subject to very different interpretation from case to case. Only cases diagnosed with FTD in each respective yr are registered in SveDem, thus avoiding the risk of inclusion of patients with a previous diagnosis of FTD.

While it is well documented that Ad affects more women than men, and the opposite is true for DLB/PDD, in that location is conflicting data on the gender ratio in FTD [i], [6], [8], [9]. There was only a slight preponderance of women (56%) than men that received a diagnosis of FTD in the present written report, supporting a more equal sex activity distribution in FTD than in AD, PDD or DLB. While data from SveDem reflects the distribution in the general population, previous discrepancies in gender ratio might reflect differences in recruitment strategy and the population studied.

The presence of a first-degree relative with dementia is common in both AD and FTD, suggesting that genetic risk factors are important in both these disorders [20], [30]. In FTD, several genetic mutations accept been described that can atomic number 82 to autosomal dominant hereditary illness [22]. Previous estimates of the proportion of familial FTD has varied betwixt ten–40% of cases [ane]–[2], [17]–[22], although the high community prevalence of other types of dementia in the elderly might make estimates of the proportion of familial cases uncertain [2].

The results of the present study confirm a loftier caste of positive family history in first-degree relatives of cases with Advertising and FTD. Cases with 2nd-caste relatives were uncommon and autosomal dominant mutations have more recently been estimated to account for but around 10% of cases with Advert and FTD [2], [21]. Data from SveDem also suggests that the proportion of cases with a positive family unit history is like in FTD and Advert.

The presence of a positive family history in FTD might, still, have been underestimated, especially in second-degree relatives. The questions used in SveDem exercise not specifically address the symptoms specific for FTD, and a significant proportion (15–25%) of responses were either "Non known" or information was missing. On the other manus, previous estimates of a high prevalence of positive family history in FTD might take been influenced past referral bias and inquiry interest in familial cases as well every bit the high prevalence of dementia in the general population [2]. Some other possible explanation for the lower proportion of familial FTD cases in SveDem could be that the available data does not differentiate between cases with bvFTD and the primary progressive aphasias (SD and PNFA). Autosomal dominant mutations and a positive family history are more common in bvFTD than in either SD or PNFA [22].

The chief limitation of the present report is that the clinical data leading to diagnosis is not available. Consequently, information technology is non possible to control the validity of the diagnosis in each individual instance. Furthermore, neuropathological confirmation of the diagnoses was not available. However, well-nigh all diagnoses of FTD in the SveDem accomplice were made at specialist centres. Loftier clinicopathological cyclopedia in early-onset dementia, with up to 97% specificity for bvFTD, has recently been demonstrated in a highly specialized center [31]. To minimize inclusion of frontotemporal syndromes with ambiguous cause only cases with ICD-10 codes co-ordinate to national consensus were used. More than important, analysis of data from only those cases diagnosed in specialist centres and that included both cerebral testing and neuroimaging demonstrated identical age distribution compared to the whole FTD accomplice. Neuroimaging greatly increases the specificity of a clinical diagnosis of FTD [32] and pathological findings on structural or functional imaging is a requirement for a diagnosis of probable FTD in the international consensus criteria published in 2011 [25]. Furthermore, lumbar puncture for analysis of AD biomarkers was performed in a loftier proportion of cases which increases detection of cases with underlying Advertizing pathology [33].

The number of FTD diagnoses differed greatly between participating centres and involvement and feel in FTD appears to be of greater importance for the diagnosis of FTD than the diagnostic procedures used. It is thus likely that FTD is still underdiagnosed in Sweden and this might be even more pronounced in the elderly. This is also supported past the relatively depression incidence of FTD seen compared to previously published estimates [9], [14].

There are several possible reasons why FTD might be underdiagnosed in the elderly: Starting time, the 1998 diagnostic criteria lists onset before 65 years of historic period equally one of the supportive criteria and late-onset cases are stated as existence rare [4], which might atomic number 82 to bias against the diagnosis of FTD in elderly patients with behavioural symptoms. Second, the behavioural symptoms of FTD might be more disruptive and noticeable in occupational and family settings, thereby alluring more clinical attention in early on-onset cases. Tertiary, many retentivity clinics accept a focus on early-onset cases which leads to referral bias. Fourth, equally the incidence of Advert increases very sharply with age and the ratio between cases of AD and FTD is much lower in early-onset dementia, there could be a greater recognition of FTD cases in younger age cohorts. Finally, there is accumulating evidence that the clinical and pathological features of FTD in the elderly differs from that of early-onset FTD, with memory problems and hippocampal sclerosis existence more than common, and frontal lobar atrophy less pronounced, in older patients [34], [35]. In support of this, the cases that failed to come across the new international consensus clinical criteria in a validation study were significantly older than the patients that fulfilled the criteria [25]. Taken together, symptoms of frontal lobe dysfunction in the elderly might often be attributed to other causes than FTD, such as VaD or AD. Prospective cohort studies, including neuropathological confirmation of the diagnosis, volition be needed to ostend the findings in this report.

In summary, information from SveDem suggest that increasing historic period is an important risk factor in FTD, as for other neurodegenerative disorders. The increased recognition of FTD in the elderly has of import consequences for dementia care. Compared to Advertising, patients with FTD often require other strategies for psychosocial back up and nursing [2], have no event of treatments with choline esterase inhibitors or memantin [2], [36], and are unsuitable as drivers at an before stage of the disease procedure compared to AD [37]. As the majority of patients with FTD in SveDem were to a higher place 65 years at diagnosis, our findings could also exist important in the recruitment of patients for clinical trials.

Acknowledgments

We would like to thank Helene Jacobsson, R&D Centre Skåne, for statistical back up and The Swedish Dementia Registry, SveDem (world wide web.svedem.se) for providing the information for the report.

Author Contributions

Conceived and designed the experiments: CN. Performed the experiments: CN. Analyzed the information: CN MLW KN Every bit SV. Wrote the paper: CN. Critical review of the manuscript: CN MLW KN AS SV.

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Source: https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0094901