10.6092/issn.2531-6133/14697
Keynote speech for the annual Colloquium of the University of Bologna Law Review, February 22nd, 2021, Alma Mater Studiorum - University of Bologna (Bologna, Italy)
 
 
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Mirko  Avesani
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Front Temporal Dementia and Imputability: The Role of Forensic Neurosciences in the Ability to Understand and Want
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llVOLUME 6                                  llISSUE 2                       CONFERENCE PAPERS



                          UNIVERSITY OF BOLOGNA LAW REVIEW
                          https://doi.org/10.6092/issn.2531‐6133/14697

            Received: 29 Aug. 2021 | Accepted: 29 Aug. 2021 | Published: 3 Apr. 2022

                                                 A

               Front Temporal Dementia and Imputability
The Role of Forensic Neurosciences in the Ability to Understand and Want


                                         MIRKO AVESANI
Medical Doctor, Professor of Physiological Psychology and Neurocriminology at the European
Forensic Institute (E.F.I.) of Malta, specialist in Neurology, PhD in Neurosciences. Doctor Avesani
is clinical neurologist at the Division of Neurology of the “Carlo Poma” Hospital in Mantua (Italy),
forensic neurologist and criminologist specialized in Neurolaw. The author would like to thank
Giovanna Ciccarone, High school Professor at the Liceo scientifico statale “Guidonia”(Rome,
Italy), for the assistance on translation.

 @ mirko.avesani@gmail.com



                             CONFERENCE OR MEETING PROCEEDING

”Lectio magistralis” held at the second edition of the University of Bologna Law Review annual
Colloquium, held in Bologna and online on the 22nd of February 2021.


                                            KEYWORDS
                   Neurolaw; Dementia; Delirium; Imputability; Behavioral Disorder




                                                143
                            FRONT TEMPORAL DEMENTIA AND IMPUTABILITY


      INTRODUCTION

In all forms of dementia, neuropsychiatric symptoms are present alongside cognitive ones.
For a long time, the latter have been considered characteristic of dementias, and only since
2011 has their presence been recognized as a distinctive clinical element.1
           In the new criteria proposed by the National Institute on Aging and the
Alzheimer Association, dementia is diagnosed when there are “cognitive or
neuropsychiatric symptoms that interfere with the ability to perform work or usual
activities and represent a decline from previous levels of functioning and performance,
not explained by delirium or major psychiatric disorders”.2
           The evaluation of neuropsychiatric symptoms represents a focus in the approach
to the patient with dementia, both for their relevance from the diagnostic point of view,
for the impact on the quality of life of the patient and the family, and also because they
constitute one of the outcomes of the therapeutic intervention (pharmacological and non-
pharmacological) of dementia.3
           The presence of neuropsychiatric symptoms [hereinafter N.P.S.] involves an
increase in the risk of early institutionalization, with the same neurological severity of
dementia, it causes extreme disability and worse cognitive performance, a reduction in
the quality of life of patients and caregivers, a significant increase in social costs and
stress for the caregiver.4
           The definition and characterization of non-cognitive symptoms, as well as the
appropriate methodology and assessment tools when diagnosing, are still a subject of
debate. It is a symptom complex that is not easily characterized in a homogeneous way;
for a long time, the generic expression “non-cognitive symptoms” was used to define
everything that appeared different from the nucleus or syndrome considered central in
dementia.        In 1996, the Consensus Conference of the International Psychogeriatric
Association [hereinafter I.P.A.] published a definition of these symptoms, promoting the
term Behavioral and Psychological Symptoms of Dementia [hereinafter B.P.S.D.].
According to the I.P.A., “the term behavioral disturbances should be replaced with that of
behavioral and psychological symptoms of dementia (B.P.S.D.) defined as: symptoms of

1
  Guy M. McKhann et al., The diagnosis of dementia due to Alzheimer’s disease: recommendations from the National
  Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease, 7 THE J.
  ALZHEIMER’S ASS’N 263 (2011).
2
  Angelo Bianchetti et al., I nuovi criteri per la diagnosi di demenza e di Mild Cognitive Impairment dovuti alla malattia
  di Alzheimer [The new criteria for a dementia and Mild Cognitive Impairment diagnosis due to Alzheimer’s disease], 2
  ASSOCIAZIONE ITALIANA PSICOGERIATRIA [ITALIAN ASS’N PSYCHOGERIATRICS] 90 (2011) (Ita.).
3
  Helen C. Kales et al., Assessment and management of behavioral and psychological symptoms of dementia, 350 BRIT.
  MED. J. (2015).
4
  RENZO ROZZINI ET AL., MEDICINA DELLA FRAGILITà. MANUALE DI LAVORO [MEDICINE OF FRAILTY. WORKING MANUAL]
  189-2013 (2014).
                                                          144
2022]                           UNIVERSITY OF BOLOGNA LAW REVIEW                                     [Vol. 6:2


altered perception, thought content, mood of behavior frequently present in patients
with dementia”.5 These symptoms are grouped according to the frequency and level of
stress caused and complexity in management.6

      2. DEMENTIA WITH BEHAVIORAL DISORDERS

We have just seen that all dementias present behavioral disturbances in their syndromic
procession. There are, however, some that, more than others, have behavioral disorders
at onset as their gold standard. Among them we have the family of fronto-temporal
dementias, which, together with Lewy body dementia and frontal variant Alzheimer’s
dementia, are those with an elective self-presence with neuropsychiatric symptoms,
followed by vascular dementia (Va.D.) and from substance abuse dementia (alcohol and
drugs).
          This is because the frontal lobe is involved and the circuitry that, from it, leads to
the nuclei of the base, in particular to the caudate nucleus. This circuitry is involved in
the ability to self-control. Since it is the first to deteriorate in these forms of dementia,
often the patient who is affected by this disease comes to the attention of a psychiatrist
before a neurologist is consulted. It is not infrequent that these patients are treated for
extended periods, even years, in psychiatric institutions, demonstrating a poor response
to psychotherapeutic treatments, until the appearance of cognitive deficits leads these
patients to a neurologist. They are the kind of patients who, in their medical history,
might have, at the onset of the disease, some criminal proceedings for minor crimes that
they would never have committed, a sign of a change in character. The writer remembers
having diagnosed fronto-temporal dementia, a behavioral variant, in a seventy-five-year-
old lady, who was the recipient of a summons for stealing a low-value lipstick (e2.90) at
the supermarket, an action that she would never have purposely executed and that had
negative consequences on her family as well.
          The lady, apparently well-kempt and still in order in terms of clothing and
self-care, nevertheless showed a kind of trivialization of the problem, which she did not
understand. She was not at all aware of having to undergo a criminal trial for theft, and
this alerted the writer who, instead of limiting himself to a basic neurological vision,
spent time performing neuropsychological tests, from which the impairment of the
functions underlying the frontal lobe, such as the ability to criticize and judge, to plan
and to solve problems, clearly emerged.


5
  Sanford I. Finkel et al., Behavioral and psychological signs and symptoms of dementia: a consensus statement on
  current knowledge and implications for research and treatment, 8 INT’L PSYCHOGERIATRCIS 497 (1996).
6
  See International Psychogeriatric Association, Better Mental Health for Older People http://www.ipa-online.org
  (last visited Feb. 13, 2022).
                                                      145
                          FRONT TEMPORAL DEMENTIA AND IMPUTABILITY


At that point, as a first action, I advised a morpho-volumetric Magnetic resonance imaging
[hereinafter M.R.I.], of the second and third level tests, and I entrusted it to a good criminal
lawyer, who was able to ask for an expert opinion from which emerged his inability to
understand and decide for himself, for a frontal dementia-temporal, electively behavioral
variant, of intermediate degree. The M.R.I. images, in fact, allowed to demonstrate a severe
atrophy of the left frontal lobe, consistent with the tests, which also showed a language
deficit.

        3. DEMENTIA AND IMPUTABILITY

One of the most complex questions to answer, and much debated, is the following, well
expressed by the title of an article that I propose to the reader: “When can a person with
dementia be held liable for her actions?”.7
            The relatively recent data gives us the measure of how much this problem is
relevant, not only in the civil field but, also and above all, in the criminal field, where
responsibility is personal.
            This article proposes, for example, two problem questions in the civil field, which
are useful for a reflection on the criminal one as well. Here are the two scenarios and their
solutions:

       • Case 1: Lisa G. is suffering from dementia, lives in a nursing home and has spilled
         paint on the parquet floor. In an attempt to remove the stains with unsuitable
         products, she damaged the parquet. Does she have to pay for the damage herself
         and pay for the repair work? The civil liability insurance found that Lisa G. was not
         required to compensate for the damage caused as she was unable to discern.
         Consequently, the insurance company is not obliged to do so either. Consequently,
         the health care institution that suffered the damage had to bear the costs. The
         family would have preferred the liability insurance to pay for the damage, as Lisa
         G. has been paying premiums for years.

       • Case 2: Margrit K. has dementia and still lives at home alone. She wrongly disposed
         of her waste bags, and the municipality imposed a 150 franc fine on her. Her son
         challenged it in front of the competent court. The latter ruled that in these
         situations, it is very likely to have a lack of imputability or reduced imputability.
7
    Sanford I. Finkel et al., Behavioral and Psychological Signs and Symptoms of Dementia: Implications for
    Research and Treatment, 8 INT’L PSYCHOGERIATRICS 497 (1997). Quando una persona affetta da demenza
    può essere ritenuta responsabile?      [When can a person with dementia be held liable for her
    actions?], AUGUSTE, Alzheimer Schweiz [Alzheimer Switzerland], April 2019, https://www.alzheimer-
    schweiz.ch/it/auguste/diritto/detail/quando-una-persona-affetta-da-demenza-puo-essere-ritenuta-
    responsabile.


                                                    146
2022]                      UNIVERSITY OF BOLOGNA LAW REVIEW                           [Vol. 6:2


        The case must be reviewed by the court of first instance. If, due to dementia,
        Margrit K. was no longer able to judge which garbage bag was to be used, she is not
        liable. In that case the sentence would have been revoked. The article concludes in
        this way:

           Both cases show that a diagnosis of dementia does not automatically
           equate to an inability to discern. Many factors play a role. It is often
           difficult to determine whether or not the person concerned is
           incapable of discernment or imputable in the concrete situation.
           However, if you are not aware of the consequences of your actions,
           you cannot under any circumstances be held responsible [t/n original
           article in German, French and Italian].

Therefore, the question is when, and by what means, can a person with dementia be
considered aware or not of the consequences of their actions, or capable of
“understanding” pursuant to art. 85 of the Italian Criminal Code?
         The answer is very complex and cannot ignore an important consideration: there
is no single type of dementia; instead, there is a vast variety of forms of dementia, due to
different etiopathogenesis and different neuronal networks involved.
         Once, Alois Alzheimer identified the “Queen” of dementias by means of an
anatomo-clinical correlation between the memory defect (or, better, of the different
forms of memory) and an atrophy in a particular brain area (the hippocampus, seat of
our ability to memorize). In later times, sophisticated work of study and classification
has made it possible to identify alternative forms of dementia, some of which do not
necessarily entail a loss of memory. However , they are no less relevant from the point of
view of imputability, as they affect areas (such as the frontal lobes) which are the seat of
our capacity for criticism and judgment, as well as for impulse control and of our inner
needs.Therefore, a complete answer to this question must consider the different forms of
dementia known today, their evolutionary fate, and the consequences of it on the side of
so-called behavioral disorders (B.P.S.D.).

     4. BEHAVIORAL DISORDERS IN DEMENTIA

Let’s start by considering the field of behavioral disorders, a real problem that underlies
the evaluation of a demented patient’s ability to understand and / or want.
         Internationally, behavioral disorders have been defined as “alterations in
perception, thought content, mood or behavior, which are frequently observed


                                             147
                            FRONT TEMPORAL DEMENTIA AND IMPUTABILITY


in patients with dementia”.8
           The term, “behavioral and psychological symptoms of dementia” ( B.P.S.D.), is
intended to function as an “umbrella” term,                                 covering various paroxysmal
manifestations, and not necessarily as a definition of a specific clinical condition.9
           What we must immediately bear in mind is this fact: 90% of people with
dementia will experience cognitive behavioral symptoms during their illness, which are
severe enough to become a problem on their own.10
           They are symptoms of dementia, identified by Alzheimer’s himself, and appear at
any stage of dementia.11
           We must also bear in mind that their severity is independent of the severity of
the disease. Put simply, the severity of these disorders does not correlate with cognitive
impairment (memory impairment and other higher cortical functions), which is why it
can happen (and this is to be borne in mind in the criminal context) that a patient with an
apparently mild (only from a cognitive point of view) dementia, is already in the throes of
a severe behavioral disorder.
           It happens, as we will see later when we will mention the different forms of
dementia, in those so-called “frontal” forms of dementia (the “frontal-temporal
dementias” or the “front-front” variant of Alzheimer’s dementia), where the peculiar
stigmata is precisely the dis-control of impulses, and the inability to resist a provocation,
with a reaction that is often uncontrolled and disproportionate to the stimulus.
           A characteristic aspect of behavioral disorders, beyond the fact that they are
seen in all forms and stages of dementia , is their probable correlation with some types of
dementia. In Alzheimer’s, it seems that delusions and hallucinations may predominate;
in Lewv body dementia, we can find aggressive behavior and hallucinations, especially
visual; in the fronto-temporal dementias, as mentioned before, we can encounter
delusions and disturbances of social conduct, with the appearance of abilities;12 in
dementia secondary to Huntington’s chorea (which always affects the frontal and
fronto-caudal network) we can see early onset depression with later psychotic

8
   Sanford I. Finkel & Alistair Burns, Behavioral and Psychological Symptoms of Dementia: A Clinical and Research
   Update, 12 INT’L PSYCHOGERIATRICS 9 (2000). Behavioral and Psychological Signs and Symptoms of Dementia:
   Implications for Research and Treatment, Proceedings of an international consensus conference held in
   Lansdowne, Virginia (April, 1996), in 8 INTERNATIONAL PSYCHOGERIATRICS 1996, at Suppl. 3:215-552.
 9
   See S. I. Finkel and A. Burns, Behavioral and Psychological Symptoms of Dementia (BPSD): a clinical and research
   update, 12 INTERNATIONAL PSYCHOGERIATRICS (2000); 9–12.
10
   See I.P.A’s update of 2000.Michael S. Mega et al., The Spectrum of Behavioral Changes in Alzheimer’s Disease, 46
   NEUROLOGY 130 (1996).
11
   See, e.g., B. Reisberg et al., The stage specific temporal course of Alzheimer’s disease: functional and behavioural
   concomitants upon cross-sectional and longitudinal observation. in REVIEW. PROG. CLIN BIOL RES 1989; 317: 23-41.
12
   See, e.g., Sonia Rosso et al., Complex compulsive behaviour in the temporal variant of frontotemporal dementia, 248
   J. NEUROLOGY 965 (2001) ; Bruce Cumming et al., Cortical Area MT and the Perception of Stereoscopic Depth, 394
   NATURE 677 (1998).
                                                         148
2022]                               UNIVERSITY OF BOLOGNA LAW REVIEW                                          [Vol. 6:2


disorders;13 finally, in vascular dementia, we can find emotional instability, agitation or
apathy (depending on the site affected by the cerebral stroke, be it ischemic or
hemorrhagic).
           In all cases, behavioral disorders are the cause of severe stress on caregivers,14
the most frequent cause of medical intervention, drug prescription, and even
institutionalization.15
           They cause a reduced quality of life of the patient and the caregiver,16 increase in
disability,17 increase in the economic costs of disease.18 The last problem also includes
possible compensation for damages (pursuant to articles 2043-2059 of the Italian Civil
Code) if the patient is not correctly studied in the entirety of his disorder, and is thus
wrongly held capable of understanding and / or wanting.

       5. CLASSIFICATION B.P.S.D.

More recently, a working group of the International Society to Advance Alzheimer’s
Research [hereinafter I.S.T.A.A.R.T.] and Treatment (Neuropsychiatric Syndromes
Professional Interest Area (N.P.S.-P.I.A.) of I.S.T.A.A.R.T.) has produced a series of
recommendations and among these the use of the term “neuropsychiatric symptoms of
dementia” (neuropsychiatric symptoms (N.P.S.) grouping them into five clusters (in
decreasing order of prevalence): depression, apathy, sleep disturbances, agitation and
psychosis.19
           To try to classify behavioral, or neuropsychiatric, disorders, we can bear in mind
that they fall into two broad categories: altered behavioral symptoms and altered
psychological symptoms.



13
   J.L.Cummings, Behavioural and psychiatric symptoms associated with Hungtington’s disease, ADV NEUROL
   (1995); 65:179-186.
14
   See J.L. Cummings ., Behavioural and psychiatric symptoms associated with Hungtington’s disease, ADV NEUROL
   (1995).
15
   See generally Elizabeth J. Colerick & Linda K. George, Predictors of Institutionalization among Caregivers of
   Patients with Alzheimer’s Disease, 34 J. AM. GERIATRICS SOC’Y 493 (1986). Neil Morris & Dylan M. Jones, Memory
   Updating in Working Memory: The Role of the Central Executive, 81 BRIT. J. PSYCH. 111 (1990); Steele et al., Alcol
   myopia: Its prized and dangerous effects, in AMERICAN PSYCHOLOGIST 1990, 45(8), 921-933; B.F. O’ Donnell et al.,
   Incontinence and troublesome behaviors predict institutionalization in dementia, 5 JOURNAL OF GERIATRIC PSYCHIATRY
   AND NEUROLOGY 45 (1992).
16
   See Gary T. Deimling & David M. Bass, Symptoms of Mental Impairment Among Elderly Adults and Their Effects
   on Family Caregivers, 41 J. GERONTOLOGY 778 (1986); see also M.S. Bourgeois et al., When Primary and Secondary
   Caregivers Disagree: Predictors and Psychosocial Consequences, 11 PSYCHOL. & AGING 527 (1996).
17
   See E.B. Brody, Are We for Mental Health As Well As Against Mental Illness? The Significance for Psychiatry of a Global
   Mental Health Coalition, 139 AM. J. PSYCHIATRY 1588 (1982).
18
   See Jiska Cohen-Mansfield, Stress in Nursing Home Staff: A Review and a Theoretical Model, 14 J. APPLIED
   GERONTOLOGY 444 (1995).
19
   See Yonas E. Geda et al., Neuropsychiatric Symptoms in Alzheimer’s Disease: Past Progress and Anticipation of the
   Future, 9 ALZHEIMER’S & DEMENTIA 602 (2013).
                                                           149
                            FRONT TEMPORAL DEMENTIA AND IMPUTABILITY


Altered behavioral symptoms are usually identified by observation of the patient, and
include aggression, yelling, continuous movement, agitation, sexual disinhibition,
culturally inappropriate behavior, hoarding, swearing and stalking.
           Altered psychological symptoms, usually and mainly assessed on the basis of
interviews with patients and relatives, include anxiety, depressive mood, hallucinations
and delusions.
           It is important to mention their prevalence, or the number of cases in the general
population. Since it is a chronic disease, in patients with delayed diagnosis (with rare
exceptions such as dementia in Creutzfeldt Jakob spongiform encephalopathy) for several
years, the prevalence is quite high.20

       6. FREQUENCY

N.P.S. (meaning “neuropsychiatric symptoms”) tend to be fluctuating and their
persistence throughout the course of dementia (especially in Alzheimer’s disease) can be
variable. Depression and anxiety have a prevalence of 60% at two years, delusions and
hallucinations tend to have a lower persistence (in 30% of cases it is present for the
course of the disease), agitation, irritability and wandering tend to be more persistent
(about 80% at two years of observation), apathy is the symptom with greater prevalence
and persistence over time.21
           Delirium has a frequency between 10 and 37% depending on the studies.22 The
most frequent forms are the delusion of persecution and paranoia,23 but there are others.
There are practically five most frequent delusions:I) delusion of theft ( most common);
the patient hides things and does not remember where he has placed them; in the most
serious cases, he believes that people enter the house to steal what, in reality, they have
lost; II)delusion of loss; the patient does not recognize his home as he remembers that
of his childhood; a desire to return to a childhood home is present even years after first
institutionalization; III) the spouse or caregiver is an impostor (Capgras phenomenon); IV)
delirium of abandonment; the patient believes there is a conspiracy to institutionalize or
abandon him; V)delusion of infidelity, sexual or otherwise, on the part of the spouse; the
patient believes he is betrayed.
           We must bear in mind, and this is especially relevant for lawyers who defend a
suspect suspected of dementia and judges who decide those cases, that the delusion can

20
   See Cohen GD & Bergen M Hasegawa K, Finkel SI Psychogeriatrics in the 1990’s, INT PSYCHOGERIATR. (1990) Spring;
   2(1): 7-8.
21
   See Rianne M. van der Linde et al., Longitudinal Course of Behavioural and Psychological Symptoms of Dementia:
   Systematic Review, 209 BRIT. J. PSYCHIATRY 366 (2016).
22
   See R.E. Wragg et al., Overview of Depression and Psychosis in Alzheimer’s Disease, 146 AM. J. PSYCHIATRY 577 (1989).
23
   See supra note 15, Morris.
                                                          150
2022]                               UNIVERSITY OF BOLOGNA LAW REVIEW                                      [Vol. 6:2


lead to aggression, not always desired or controllable by the patient. To this end, I recall
an example, a clinical case in which I was asked for a report by the judge of the criminal
court of Verona, on a patient in a nursing home in eastern Verona. One evening, tired
of hearing her roommate (also demented) scream, she got up in a delirium of thievery
(she thought she had thieves in the house) and crushed her forehead and nose with a
chair. The police officers intervened, reported to the Verona Public Prosecutor’s Office,
and the patient was served a summons for serious personal injury. Since she was only
transportable in a wheelchair and was in a state of very serious dementia (she was not even
aware of what she had done), the judge immediately deemed necessary, rather than an
expert opinion, a report by the neurologist who followed her for dementia, given previous
relationships exhibited by family members.
             The patient, clearly incapable of understanding and willing, was declared not only
unable to stand trial but not attributable pursuant to art. 85 of the Italian Criminal Code.
In this case, the patient was also very cognitively impaired but, as we have already said,
the opposite can also happen, namely that the behavioral disorder is the onset indicator
of dementia, when the cognitive aspect still seems to be preserved.
             This is why, in approaching the examination of imputability, one must always keep
in mind, alongside the purely psychiatric aspect, the neurological-organic aspect of the
behavioral disorder.
             Among other symptoms, we have hallucinations, with a frequency ranging from
14 to 29%. The most frequent are visual ones and occur in moderate dementia.24 They
increase markedly, so much so that they become one of the diagnostic criteria in Lewy
body dementia, where they settle on a frequency of 80%.
             The most frequent form is to see people who are not there. In some cases, these
hallucinations can generate agitation, and in this case they must be treated. The origin
seems to be the difficulty in recognizing faces or objects (visual agnosia or
prosopagnosia) associated with difficulty in distinguishing light-dark contrasts. It is
advisable that each patient is assessed on the visual ability and that the environments
are adequately illuminated in order to reduce visual hallucinations.
             Then we have the misidentifications. They are disorders in perception. Unlike
delusions, which do not follow an external stimulus, misidentifications are alterations in
the perception, or misperceptions, of external stimuli that are processed until they
become real delusions.
             Misidentifications can be of four types: presence of people in the house or ghost
tenant syndrome, inability to recognize oneself in the mirror, inability to recognize
24
     See Carol F. Lippa et al., Alzheimer’s Disease and Lewy Body Disease: A Comparative Clinicopathological Study, 35
     ANNALS NEUROLOGY 81 (1994).
                                                          151
                           FRONT TEMPORAL DEMENTIA AND IMPUTABILITY


other people, inability to recognize what is happening on the T.V. with the belief that
people seen on T.V. are present in real space. We then have particular syndromes.
Capgras or impostor syndrome, which makes one believe that a person has been replaced
by an identical copy, is associated with the lack of affective signs and this leads the
patient to the conclusion that the person is an impostor. Fregoli syndrome makes people
believe that they dress like different people in order not to be recognised by others.
There is also inter-metamorphosis, whereby the physical appearance of one person
corresponds to that of another.
           Depression affects 40-50% of patients. While in the initial forms of dementia the
diagnosis can be made during an interview, in the more advanced stages of dementia,
language and communication difficulties make it even more challenging.
Apathy affects about 50% of the demented. It manifests itself as a loss of interest in daily
activities and personal care. It can be confused with major depression, but unlike in case
of the latter, the patientdoes not have dysphoria and typical vegetative symptoms.
           Anxiety can be isolated or linked to other Borderline Personality Disorders
(B.P.D.s). It manifests itself with anxiety about finances, illness, and the future. The most
common manifestation is Godot syndrome, in which the patient repeatedly asks about an
event that is about to take place. Another form is the fear of being alone, especially when
the cohabiting caregiver leaves the room in which the patient is for short moments.
Then we have the phenomenon called wandering (or Wandering) which is particularly
tiring for the caregiver. This term includes the continuous search of the caregiver, the
stalking, walking, trying ineffectively to perform a task, and walking without purpose,
often associated with the alteration of the sleep-wake rhythm, as well as hyperactivity,
the attempt to return to a childhood home, and escape attempts from the care facility.
           Agitation is defined as inappropriate verbal, vocal or motoric activity that does not
result from a person’s needs or confusion.25 It is a sign and symptom of lack of comfort or
discontent and puts the patient at risk of fracture. But not all agitation should be treated
pharmacologically, and, when treated, it is necessary to be clear about what triggered it
(one counts as an agitation due to a state of anxiety, as a delirium, another as an agitation
due to a depressive syndrome). Above all, certain drugs (such as benzodiazepines) should
be avoided, to avoid the so-called “paradox effect” (accentuation of agitation leading to
delirium).26




25
   See Jiska Cohen-Mansfield & Nathan BilliG, Agitated Behaviors in the Elderly: I.A. Conceptual Review, 34 J. AM.
   GERIATRICS SOC’Y 711 (1986).
26
   See Cohen G.D., Biopsychiatry in Alzheimer’s disease, ANNU REV GERONTOL GERIATR. (1989); 9: 216-231.
                                                       152
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     7. THE DELIRIUM

Delirium has a high probability of occurring in the demented. It must therefore be
recognized and distinguished from other B.P.S.D.s. There are key criteria.
In order to speak of delirium, the following elements must be present: I) acute onset and
fluctuating course; II)lack of attention.
To these must be added one of the following symptoms: III) disorganized thinking:
hallucinations with agitation; IV) altered level of consciousness.
        Delirium must be immediately identified. It is important to notice that it has
many causes, including some “exogenous”, or from external factors, and not only from
dementia. Among the “exogenous” causes infections, especially urinary ones, the intake
of some drugs (we remember the antibiotics of the quinolone family), malnutrition or
dehydration, some metabolic diseases (liver or kidney), and changes in the caregiver or
environmental surgical interventions are considered highly relevant. Some of these
causes can cause delirium in a patient who is not demented, a situation that must be kept
in mind in the criminal sphere, given that, in these situations, the delusion then
disappears leaving a person intact. If accused of a crime during the state of delirium, it
must be investigated, studied and identified.

     8. ETIOLOGY OF B.P.S.D.

B.P.S.D.s arise from various causes. At the moment it is considered a single model that
provides genetic alterations:        receptor polymorphism, neurobiological aspects,
neurochemical and neuropathological psychological aspects:            personality, stress
response and social aspects: changes in the environment, caregiver problems.
        They depend on an alteration at the level of neuronal transmission within the
central nervous system. The neurotransmitters involved in dementia are acetylcholine
(the main neurotransmitter involved), dopamine, norepinephrine, serotonin and
glutamate. The latter is an excitatory amino acid which, in dementia, can cause the
so-called “glutamate excitotoxicity”.
        It must be kept in balance because its deficiency, in the long run, generates
problems, including psychotic symptoms. On the other hand, with respect to the other
neurotransmitters, the cholinergic deficit causes memory loss, hallucination and
delirium, a deficit of dopamine causes alteration of working memory and aggression, the
noradrenergic one generates depression, while the reduction of serotonin creates
depression, anxiety, agitation, restlessness, aggression. Not all symptoms and signs
respond to drug therapy. Some of them (anxiety, depression, sleep disturbances, mania,
delusions and hallucinations, verbal or physical aggression,    inappropriate     sexual
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behavior) can be treated to a certain extent. Others, do not respond to drugs: wandering,
urinating or defecating inappropriately, dressing and undressing inappropriately,
endlessly repeating acts (perseveration) or vocalizations, hoarding, eating “inedible”
things, aiming or snatching the means protection, pushing the wheelchair against others
or against the wall and other antisocial gestures.

      9. EVALUATION OF BEHAVIORAL DISORDERS

The assessment of behavioral disturbances in patients with dementia presents a
methodological and clinical challenge. The coexistence of cognitive impairment with
behavioral alterations makes it difficult for both the family members and the operators
to observe and characterize individual disorders. For this reason, various tools have been
developed for evaluating the global and specific characteristics of behavioral
symptoms.27 Many of these assess a narrow range of behavioral disorders, without
analyzing their characteristics as a whole. Direct observation of behavioral disorders is
often limited to institutionalized subjects or may only be possible in specialized centers,
so in most cases an interview is made with the caregiver who reports the disorders
observed by him at home. There is a tendency on the part of family members to over or
underestimate the present disorders, depending on the relationship with the patient or
the stress due to the care burden.
          Cummings developed a behavioral disorder rating scale called NeuroPsychiatric
Inventory [hereinafter N.P.I.], able to assess, on the basis of information obtained from
the caregiver, the frequency and severity of behavioral disorders through the use of a
questionnaire.28
          The N.P.I. allows to evaluate a wide range of behavioral disorders, for the
accuracy        of      twelve:           delusions,         hallucinations,          agitation-aggression,
dysphoria-depression,ansia, euphoria-exaltation, apathy-indifference, disinhibition,
irritability-lability, aberrant motor behavior, sleep disorders, appetite and eating
disorders. The single items are explored with further sub-items that allow to obtain
more detailed information. Behavioral disorders are graded with a differentiated score
by frequency (0: never, 1: rarely, 2: sometimes, 3: frequently, 4: almost constantly) and
severity (1: mild, 2: moderate, 3: severe). The overall score, therefore, ranges from zero
to 144, and is an index of the severity of the disturbance. The evaluation of stress on the
caregiver also follows, with a score from zero (none) to five (severe) for each disorder, so

27
   See Alberto Costa et al., The Need for Harmonisation and Innovation of Neuropsychological Assessment in
   Neurodegenerative Dementias in Europe: Consensus Document of the Joint Program for Neurodegenerative Diseases
   Working Group, 9 ALZHEIMER’S RSCH. & THERAPY, Apr. 17, 2017, at 1.
28
   See Jeffrey L. Cummings et al., The Neuropsychiatric Inventory: Comprehensive Assessment of Psychopathology in
   Dementia, 44 NEUROLOGY 2308 (1994).
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the overall stress, on the twelve items, varies from zero to sixty. This scale has proved to
be an objective and effective tool for the assessment of behavioral disorders in patients
suffering from various types of dementia (A.D., V.D. and frontotemporal dementia); it
can also be an aid in the differentiation of the various forms of dementia.29 There are
different versions of the N.P.I. for use in institutionalized patients and for
self-assessment by patient caregivers.
           An aspect that deserves particular attention concerns the evaluation of
depression. There are numerous tools in this regard, both scales that detect the presence
of depressive symptoms through direct request to patients (such as the Geriatric
Depression Scale) and observational scales (better applicable even in the most serious
patients). The Cornell Scale was specially designed for the assessment of depressive
symptoms in demented patients.30                     It uses a standardized series of items detected
through an interview with a person who knows the patient (family member or operator)
and a semi-structured interview with the patient.

       10. THE TREATMENT OF B.P.S.D.. NOTES ON CURRENT EUROPEAN
       RESEARCH.

The treatment of N.P.S. represents one of the main outcomes in the care of the demented
patient and is often a challenge that requires a multimodal approach, which includes the
education of family members and caregivers, the use of drugs and behavioral or other
non-pharmacological procedures. The intensity of the treatment, the choice of strategies
(non-pharmacological, environmental, pharmacological approach) and the choice of the
type of pharmacological treatment depend on various clinical and socio-environmental
factors.31 The approach to the patient with N.P.S. requires a systematic assessment of the
environmental and relational factors that may have contributed to the onset of symptoms.
           An operative method is described by Kales and is called “D.I.C.E.” (Describe,
Investigate, Create, Examine).The program details the conditions of the patient,
caregivers and the environment at each step of the approach and describes the
“concrete” and environmental behavioral interventions that should be considered. In
short, the components are: D: Describe - the situations and contexts related to the
appearance of behaviors; I: Investigate - examine aspects of the patient’s health, drug
treatments, sleep disorders or physiological variables; C: Create - develop a plan for the
prevention and management of behavioral problems shared with the caregiver and

29
   See Giuliano Binetti et al., Behavioral Disorders in Alzheimer Disease: A Transcultural Perspective, 55 ARCH. NEUROL.
   539 (1998).
30
   See George S. Alexopoulos et al., Cornell Scale for Depression in Dementia, 23 BIOLOGICAL PSYCHIATRY 271 (1988).
31
   See Angelo Bianchetti et al., Pharmacological Treatment of Alzheimer’s Disease, 18 AGING CLINICAL EXPERIMENTAL
   RSCH. 158 (2006).
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                        FRONT TEMPORAL DEMENTIA AND IMPUTABILITY


operators; E: Examine - evaluate the effects of the interventions and make changes if
necessary.32
          Pharmacological interventions should be reserved for situations in which N.P.S.
put the patient or caregivers at risk, when symptoms are very disturbing or when non-
pharmacological approaches are not possible or have been found to be ineffective.
          Pharmacological treatment of B.P.S.D.s should be undertaken after making sure
that B.P.S.D. have no physical causes are not caused by other drugs they do not respond to
non-pharmacological interventions.
          In the following cases, it is possible to make use of drugs: I)if someone has made
an accurate diagnosis of the level of deterioration; II) if all non-pharmacological welfare
and management measures have been applied at the family and environmental level; III)if
the cause of the symptoms, for example a disease, has been looked for; if the possible side
effects of the drugs have been evaluated according to the characteristics of the patient;
IV) if the particular response to drugs of the demented subject has been considered, for
example the paradoxical effect of benzodiazepines.
          A European multicentre study is underway, funded by the European Union, of
which the undersigned is part as coordinator of the Dementia Center of the Mantua
Hospital.33 The study is called RECage (REspectful Caring for the AGitated Elderly), and it
is committed to identifying the most effective ways of taking charge and treating
behavioral decompensation, which often requires temporary hospitalization of the
patient in the so-called Special Care Unit type B [hereinafter S.C.U.-B.] centers where an
attempt is made to treat the disorder with non-pharmacological treatment, allocating
this only to temporary phases. The results are compared with those obtained by the
Special Care Unit type A [hereinafter S.C.U.-A.], where the patient is received and treated
pharmacologically. The leaders of this study are Prof. Carlo Alberto Defanti and Dr. Sara
Fascendini, respectively Health Director and Primary of one of the S.C.U.-B. leaders in
Italy, the one present in Gazzaniga (B.G.), managed by F.E.R.B. Onlus. This is due to the
fact that, to date, there are no univocal answers on the strategies to be adopted in the
event of behavioral decompensation.              There are ten European hospitals enrolled,
including the Dementia Neurology Center of the Civil Hospital of Mantua, coordinated by
the author.
          In S.C.U.-A., where behavioral decompensation is treated pharmacologically,
there are rules for prescribing the therapy:I)In the demented elderly the dosages are
32
   See Helen C. Kales et al., Management of Neuropsychiatric Symptoms of Dementia in Clinical Settings:
   Recommendations from a Multidisciplinary Expert Panel, 62 J. AM. GERIATRIC SOC’Y 762 (2014).
33
   See Mirko Avesani et al., Respectful Caring for the AGitated Elderly, ASST MANTOVA (https://www.asst-
   mantova.it/recage) (last visited Feb. 12, 2022).


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lower than in the young and non-demented people; II) Hypoalbuminemia causes the
drug to remain in the site of action for longer; III) Reduced hepatic and renal metabolism
slows their elimination with the risk of toxicity and interaction; IV) Their half-life is
increased because being lipophilic they accumulate in the increased fat mass of the old
man. V)Lewy’s dementia manifests hypersensitivity to neuroleptic drugs.
        The drugs to be prescribed belong to the families of antipsychotics (typical and
atypical, i.e. first and second generation), of antidepressants, benzodiazepines, and
anticonvulsants. Obviously, the pharmacological choice cannot be separated from a
correct nosographic and nosographic identificationetiopathogenesis of the B.P.S.D. type.


     11. INVESTIGATORS RECOMMENDED IN INVESTIGATED / ACCUSED
     PATIENTS

By now, the classic psychiatric report is completely outdated, considering that, as we
have seen, there are neuropsychiatric symptoms associated with dementia, which are of
neurological relevance.
        First of all, a thorough neurological evaluation is needed with at least first and
second level tests (by first level the author suggests e.g. the Mini Mental Test Evaluation,
[hereinafter M.M.S.E.]; by second level the author suggests e.g. the clock test and the
Frontal Assessment Battery [hereinafter F.A.B.].          The integration of the clinical
examination (which highlights any apraxias, or visual field deficit, or language deficit in
informal interview, or orientation deficit or presence of delusions and hallucinations, as
well as neuromotor focal deficits) with these three tests, allows the diagnoser to
investigate different cognitive functions, both cortical and subcortical, both frontal,
temporal lobe and hippocampus.
        To these tests, the N.P.I. scale must be applied, to better investigate behavioral
disorders and the Geriatric Depression scale [hereinafter G.D.S.], a scale that helps us to
understand the degree of depression and the quality of the head in the context of a possible
decay. cognitive with probable dementia manifestation.
        It is also important to understand the progress and time of presentation, if it was
gradual and progressive or acute / subacute. It is essential to understand if the disorders
are fluctuating or persistent, if they reduce the person’s personal autonomy. Below we
present the two rating scales Activities of Daily Living [hereinafter A.D.L.] and
Instrumental Activities of Daily Living [hereinafter I.A.D.L.].
        To calculate the A.D.L. index, a simplified scale is used which provides for the
assignment of a point for each independent function in order to obtain a total


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performance result ranging from 0 (complete dependence) to 6 (independence in all
functions). For the attribution of the score it is necessary to translate the three-point
assessment scale (without assistance, partial assistance, or complete assistance) into the
dichotomous classification “employee / independent”. Also for the calculation of the
I.A.D.L. index, a simplified scale is used which provides for the assignment of a point for
each independent function in order to obtain a total performance result that varies from
0 (complete dependence) to 8 (independence in all functions). After this evaluation, it is
advisable to proceed with the complete Neuropsychological tests, in order to have both a
confirmation and a better characterization of the deficits.
        It is acceptable, if the patient is being investigated for a differential psychiatric
pathology diagnosis, to proceed with the personality tests: Minnesota Multiphasic
Personality   Inventory-2     (M.M.P.I.-2);    Million   Clinical   Multiaxis    Inventory-III
(M.C.M.I.-III); Dissociative Experiences Scale-III (D.E.S. II). In subsequent steps, we move
on to laboratory and instrumental evaluation, which have now become fundamental. At
the laboratory level, by means of a lumbar puncture we evaluate the alterations of some
cerebrospinal fluid (C.S.F.) proteins (protein 14.33, sign of neuronal necrosis; protein TAU,
pTAU, B-amyloid 1-42, ratio pTAU / B-amyloid 1-42) and the presence of some antibodies
that today characterize some forms of encephalopathy, autoimmune encephalopathies
(among these antibodies to N-methyl-D-aspartate (N.M.D.A) receptor, and other
neuronal receptors). They are newly discovered encephalopathies that can begin with
neuropsychiatric disorders as well as with epileptic seizures. The onset of a disorder of
this type, in a person who was in full well-being, must always make us keep this
possibility in mind. At the instrumental level, in addition to a classic M.R.I., a morpho
volumetric M.R.I. is essential to understand which brain areas are subject to atrophy. It is
also important to perform a P.E.T-C.T. scan with fludeoxyglucose, to highlight brain areas
with.. reduced cerebral metabolism, to be compared with neuropsychological tests and
clinical examination.     Furthermore, a new method is gaining ground: Functional
Magnetic Resonance Imaging [hereinafter f.M.R.I] in resting state mode. This method,
combining the high temporal definition of the electroencephalography [hereinafter
E.E.G.] (in the order of multiple sclerosis) with the high definition of the f.M.R.I, allows to
highlight activations and deactivations related to brain electrical biorhythms using the
so-called independent components (I.C.A.) technique.




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