In frontotemporal dementia, what pharmacologic therapy is used to manage irritability and agitation?

• A. SSRIs
• B. Benzodiazepines
• C. Cholinesterase inhibitors
• D. Atypical antipsychotics

Answer: (D)

Irritability and agitation in frontotemporal dementia arise from frontal lobe dysfunction that drives disinhibition and aggressive behavior. When behavioral symptoms are prominent and pharmacologic help is needed, the preferred option is a second-generation (atypical) antipsychotic. These medications can reduce aggression and agitation without aiming to improve cognition, which is not the primary issue in FTD. They’re favored over benzodiazepines because long-term use can worsen sedation, falls, and cognitive function, and over cholinesterase inhibitors because those primarily target cognition and don’t address behavioral symptoms. SSRIs may help with some behavioral aspects in certain patients, but they’re not the main choice for controlling irritability and agitation. Use the lowest effective dose and monitor for side effects, including metabolic changes and extrapyramidal symptoms, and be mindful of the general increased mortality risk with antipsychotics in elderly dementia patients.