Older Adults: BVFTD Behavioral Variant Frontal Temporal Dementia or Schizophrenia?

By Pamela D. Wilson, MS, BS/BA, CG, CSA

legalOlder adults with offensive behaviors may have a diagnosis of BVFTD, behavioral variant frontal temporal dementia, or schizophrenia. Do you have the skill to tell the difference and to serve the estate planning needs of your clients?

The amazing outspoken, no longer politically correct, older adult who walked into your law office today may have a diagnosis of BVFTD or something else— possibly a mental illness. What is your expertise with BVFTD and schizophrenia?

BVFTD is a variety of frontal temporal dementia with symptoms unlike Alzheimer’s disease. Are you familiar enough to know whether an estate planning document for a client with this diagnosis will hold up in a will contest or a contested hearing about estate planning documents?

Taking a detour for a moment to change the subject to being politically correct, what term should be used to describe old people? Older adult, aging adult, elders, elderly, senior, senior citizen, or the old and amazingly outspoken? What term do you use to be respectful of your elderly clients?

Politically Correct Older Adults

behavioral variant frontal temporal dementiaIn 2017, the Journal of American Geriatrics Society made a style change about how they wanted contributors to write about older people (1) The term older adult was chosen to avoid negative stereotypes against aging. The American Society on Aging uses older adults on their website also retains the name Society on Aging. The Center for Elders and the Courts website uses elders, older adults, and older persons.

At some point we have to become an aging adult to become an older adult. At what age does life change from one description to the other?

Is it the time when we become outspoken and comfortable saying whatever we want because we can? Or does saying whatever we can have other hidden consequences about which we, our attorneys, or our family members should be more concerned?

Estate Planning and Mental Capacity

What age is old? The closer I age to 65, the younger the number seems. In my opinion, old age or becoming an older adult now begins around 85. We are all aging adults from birth to the end of life. 

Eighty-five is the age, according to the Alzheimer’s Association, that we are 33% more likely to have a dementia of diagnosis. This leads to the theory that being an older adult and memory loss are close partners. Does living to 85 or older pose more unpleasant risks than benefits?

Estate planning requires a degree of mental competency or capacity to understand the implications of the plan and the document being signed. What happens when a client walks into your office and you have no idea of what (or who) is presenting? This sweet older lady or gentleman that you knew years ago is different—very different.

What happens when a client you don’t know walks in and exhibits odd behaviors? The client tells you to draw up an estate plan that disinherits all of the children an inherits a famous actor who is a very close friend. If your memory serves correct, this actor has been deceased for a number of years. Are you mildly hesitant?

Politically Incorrect Older Adults

How many older adults do you know who say what they want? They don’t worry about who might be offended? Like children, interesting words come out of the mouth of older adults.

Thinking of outspoken adults, I remember Gilda Radner as Roseanne Rosannadanna (2), Lilly Tomlin as Ernestine the Telephone Lady (3), and Dana Carvey as the Church Lady (4). Do you remember these humorous skits that were very politically incorrect? Take a quick trip down memory lane and click to watch these videos that might bring a smile to your face. 

Returning to the discussion of BVFTD and behaviors. I had a favorite Aunt and Uncle in California that I visited often. At one of my last dinner visits, my aunt blurted out a derogatory mark about a person that I attributed to her age and upbringing. I did not think twice that this was more than a blooper.

After this visit, I learned that Aunt was diagnosed with dementia. At the time of the visit, there were no other obvious signs of Alzheimer’s like memory loss, repetitive behaviors, or questioning. Because I didn’t live nearby to see her frequently I had no idea of the frequency of the behaviors that might have been more formally diagnosed at BVFTD. My Uncle, the gentleman he was, would have never mentioned anything in respect of their lifelong marriage and his devotion to Aunt’s care.

Signs of BVFTD Behavioral Variant Frontal Temporal Dementia

The Association for Frontal Temporal Degeneration (5) confirms that unlike Alzheimer’s disease where memory is affected, with BVFTD, memory is spared and behaviors result.  Below is a list of behaviors associated with BVFTD that are confused with psychiatric disorders.

  • Paranoid or delusional behaviors
  • Verbal or physical aggression
  • Inappropriate behavior
  • Agitation and mood swings
  • Repetitive behaviors

Close Kin: BVFTD and Schizophrenia

Attorneys working in estate planning, elder law, or probate work with clients for whom a guardian is appointed. In my experience as a guardian, clients with a dual diagnosis of mental health and dementia were common. The challenge was obtaining treatment for either symptom. Few professionals felt qualified to stake a claim on a primary diagnosis.

Psychiatric hospitals, in the Colorado Front Range, did not want to accept my clients with a dual diagnosis of dementia and mental illness. Estate planning attorneys and guardians struggle to help these clients because the medical system often refuses to admit for treatment

According to Neurocase (6) research confirms that the symptoms of BVFTD in about 50% of cases overlap with an initial psychiatric diagnosis. The opposite also occurs. The consensus for BVFTD is that behaviors are primary and should not be better described by a psychiatric condition.

Diagnosing BVFTD

In situations of multiple diagnoses, the wise action for the estate planning, elder law, or probate attorney is to request a definitive diagnosis for the older adult. Appointments with a neuropsychologist and a psychiatrist may be necessary. A PET scan or an MRI may be beneficial. Blood work to identify the presence or absence of the APOE4 gene, a gene related to Alzheimer’s disease, will support a more definitive diagnosis.

A thorough review of medical records, if they exist, may include mention of unusual behaviors or behaviors related to a mental health concern. Collaboration between the specialties of neuropsychology and psychiatry may be necessary to determine which came first, the BVFTD or the mental health condition.

Knowing the diagnosis of the behaviors may support an estate plan that avoids challenges. Being proactive may avoid challenges at the time a guardian and conservator are appointed. Knowing the diagnosis will support a care and financial plan for the client. Family members, if involved, may become more understanding and less critical about the odd behaviors of a parent if they know the background of the diagnosis.

Collaborating with others in the healthcare and aging specialties supports better care for older adults. Professionals, when appointed, are better able to perform their responsibilities with less concern about timely and costly litigation.

Sources:

(1) Editorial. When It Comes to Older Adults, Language Matters: Journal of the American Geriatric Society Adopts Modified American Medical Association Style. JAGS 65:1386-1388, 2017. Doi: 10.1111/jgs.14941.

(2) Radner, Gilda. Weekend Update: Roseanne Rosannadanna on Smoking -SNL. 11/18/78. https://youtu.be/9hYGtXIqDa0

(3) Tomlin, Lilly. The Telephone Operator Calls General Motors. 3/20/17.  https://youtu.be/RT4__Nz5HWY

(4) Carvey, Dana. Oprah Winfrey: How Dana Carvey Created His Most Famous Characters. The Church Lady and Others. 2/14/15. https://youtu.be/IXG5EluavRM

(5) The Association for Frontal Temporal Degeneration. Behavioral Variant FTD  https://www.theaftd.org/what-is-ftd/ftd-disorders/behavioral-variant-ftd-bvftd/

(6) Kerssens, C.J. et. al. Schizophrenia as a Mimic of Behavioral Variant Frontotemporal Dementia. Neurocase, 2016 June; 22(3): 285-288 doi: 10.1080/13554794.2016.1187178

Pamela D. Wilson, MS, BS/BA, CG, CSA, a National Certified Guardian and Certified Senior Advisor, is a caregiving and elder care expert, advocate, and speaker. Pamela offers family caregivers programming and support to navigate the challenges of providing, navigating, and planning for care. She guides professionals practicing in estate planning, elder and probate law, and financial planning to create plans to address unexpected concerns identified in her past role as a professional fiduciary. Healthcare professionals are supported by Pamela’s expertise to increase responsiveness and sensitivity to the extensive range of care challenges faced by care recipients and caregivers.

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