What are the current guidelines for the pharmacological management of behavioral symptoms in patients with frontotemporal dementia?

Pharmacological management of behavioral symptoms in patients with frontotemporal dementia (FTD) is limited according to current UK guidelines. Specifically, acetylcholinesterase inhibitors (donepezil, rivastigmine, galantamine) and memantine are not recommended for people with frontotemporal dementia due to lack of evidence of benefit and potential off-label use concerns.

For managing behavioral symptoms such as agitation, aggression, distress, hallucinations, or delusions in dementia generally, antipsychotics should only be offered if the person is at risk of harming themselves or others, or if these symptoms cause severe distress. This applies broadly to dementia but is relevant to FTD if such symptoms occur. Antipsychotics should be used at the lowest effective dose, for the shortest possible time, with regular reassessment every 6 weeks, and stopped if no clear ongoing benefit is observed.

Before starting antipsychotics, a structured assessment should be conducted to explore causes of distress and non-pharmacological interventions should be offered first. Psychosocial and environmental interventions remain the initial and ongoing management approach for behavioral symptoms in dementia.

Valproate is not recommended for managing agitation or aggression in dementia unless indicated for another condition.