Erratum zu diesem Artikel: Erratum Arq Neuropsiquiatr 2024; 82(02): e1-e1
DOI: 10.1055/s-0044-1779740
Keywords Frontotemporal Dementia - Aging - Dementia
Palavras-chave Demência Frontotemporal - Envelhecimento - Demência
INTRODUCTION
Since the last decades, Brazil has been facing population aging, with impacts on demographics,
economics, and on the health care system. The prevalence of age-related disorders,
such as dementias, is increasing and represents one of the most frequent causes of
mortality.[1 ] In particular, young-onset dementias represent a major challenge for the clinical
management, as specialized health professionals and adequate structures are lacking,[2 ] thus increasing the burden of patients and families.
Frontotemporal dementia (FTD) is the second most frequent cause of young-onset dementia,
following Alzheimer's disease (AD).[3 ] FTD is actually defined as a clinical syndrome with three phenotypes: the behavioral
variant (bvFTD) and two language variants, nonfluent/agrammatic primary progressive
aphasia (nf/aPPA) and semantic variant (svPPA).[3 ] The behavioral variant is the most common presentation, and manifests with variable
degrees of personality changes and behavioral disorders.[4 ] The language variants manifest major language disturbance as early symptoms: while
patients with nf/aPPA present with effortful speech or agrammatism, svPPA patients
exhibit reduced single-word comprehension associated to impaired naming in confrontation
tests.[5 ]
Data from high-income countries suggest that the prevalence of FTD is estimated as
15–22 cases/100.000, with higher incidence among individuals from 45 to 64 years-old.[6 ] No study specifically addressed the prevalence of FTD in Brazil, but epidemiological
surveys of dementia found a prevalence of 0.18%, in individuals older than 65 years-old.[7 ]
Although FTD is not a frequent disorder, it should be pointed out that FTD and other
young-onset dementias represent a major challenge for medical care, especially in
Brazil and in other low- and middle-income countries, where medical facilities and
specialized health care teams are insufficient.[2 ] Of note, FTD is associated with faster decline and higher caregiver burden, compared
with AD,[3 ] thus requiring more health care resources.
In this scenario, it is essential to ascertain the difficulties Brazilian physicians
face on the diagnostic workup, and the local struggles in the care of FTD patients
as well. National surveys may provide valuable information for improving the public
awareness, the clinical care and the research in FTD.[8 ]
[9 ] This study aimed to investigate current practices on the diagnosis and management
of FTD in Brazil. Moreover, we also assessed the existing facilities and we investigated
which are the main limits for clinical practice and research development in the field
of FTD, from the perspective of physicians.
METHODS
The questionnaire was elaborated by the Scientific Department of Cognitive Neurology
and Aging from the Brazilian Academy of Neurology. Questions from similar studies[8 ]
[9 ] were also included in the present survey.
The questionnaire (Supplementary Material - https://www.arquivosdeneuropsiquiatria.org/wp-content/uploads/2023/07/ANP-2023.0016-Supplementary-Material.pdf ) was created on an online platform (Google Forms®) and was available for answering
from 9th November 2020 to 26th January 2021. The survey comprised 29 questions, divided in four parts. The total
estimated time to respond to it was five minutes. The first part collected general
information from the respondent: city/state, affiliation, medical specialty, composition
of the health team, number of FTD patients followed by the participant, annual number
of new diagnosis of FTD, number of genetic cases, experience in clinical research
in FTD, and facilities (data bank, neuroimaging bank, biobank, brain bank). This first
part also addressed how the participant conducted clinical investigation of suspected
FTD cases, by presenting questions about the clinical interview (which are the key
questions usually asked on the medical interview) and the cognitive/behavioral assessment.
The second part presented questions about clinical management. There were questions
about the availability of support groups for family and caregivers, and previous experience
with clinical trials. This part also addressed the participant's experience with pharmacological
treatment of FTD (use of antipsychotics, antiseizure medication [ASM], serotonin reuptake
inhibitors, trazodone and psychostimulants).
The third part proposed questions regarding personal opinion on diagnostic and management
of FTD. The questionnaire asked about which are the participant's main limit in the
diagnostic procedure of FTD (difficulty to perform formal neuropsychological testing,
genetic investigation, CSF biomarkers, structural or functional neuroimaging) and
which are the main causes of misdiagnosis of FTD on the participant's view. This part
also asked whether the participant considers CSF biomarkers for AD and social cognition
tests to be useful in the diagnostic investigation of FTD, and whether he/she considers
episodic memory impairment a valuable feature to distinguish FTD from AD.
Finally, the fourth part collected participant's suggestions to improve clinical care
and to improve FTD research, by making questions about the need of new epidemiological
studies, new cognitive/behavioral tools, facilitation of genetic investigation, and
the proposal of a common national protocol for research purposes.
The invitation to participate was sent by email to all neurologists affiliated to
the Brazilian Academy of Neurology (n = 3658), and to all physicians who attended the XII Meeting of Researchers on Alzheimer's
disease, in 2019 (n = 187), a multidisciplinary meeting. In addition, the invitation was also diffused
to physicians through social media.
This study was approved by the Executive Committee of the Brazilian Academy of Neurology.
All participants provided formal consent to this study. As a matter of confidentiality,
all answers were processed anonymously.
RESULTS
Two hundred fifty-six physicians answered the survey. Respondents were from all but
eight Brazilian states ([Figure 1 ]). The majority of respondents were from Minas Gerais and São Paulo states. Neurologists
were the most frequent specialists, followed by geriatricians and psychiatrists ([Table 1 ]). Most respondents were set at private clinics, followed by public hospital/clinic
and public university hospital ([Table 1 ]). Most services do not have databases, do not offer genetic counselling and have
no experience in clinical research ([Figure 2 ]).
Figure 1 Geographical distribution of respondents. Brazil is a federation of 26 states and
one federal district. The country is composed of five geographical regions: North,
North East, Center-West, Southeast, and South.
Table 1
Profile of the respondents: characterization of institutions and clinical experience
(raw numbers)
In what type of service do you see patients with frontotemporal dementia (FTD)?
Private clinic
Private hospital or clinic
Public hospital or clinic
Private university service
Public university service
114
21
59
6
56
What is your medical specialty?
Internal Medicine
Geriatrics
Neurology
Psychiatry
Other
2
47
163
36
8
Which professionals make up the service in which you work?
Geriatrician
Neurologist
Neuropsychologist
Occupational therapist
Psychiatrist
Speech therapist
116
201
100
68
129
89
How many patients with FTD (all variants) do you currently see?
< 1/month
1/month
2–10/month
11–20/month
> 20/month
57
74
112
6
7
How many new FTD diagnoses (all variants) do you make per year, approximately?
1–5
6–10
11–15
> 15
177
51
10
18
Does your service have a database of patients with FTD?
None
Neuroimaging
Clinical and cognitive-behavioral
Clinical
Brain
Biological samples
177
14
45
43
6
5
Figure 2 Answers for the following questions: (A ) Does your service offer genetic counselling? (B ) Does your service currently conduct research on frontotemporal dementia (FTD)? (C ) Does your service offer help (support group) for caregivers of patients with FTD?
(D ) Has your service ever participated in a Pharmacological Clinical Trial in FTD? (E ) Has your service ever participated in a non-pharmacological Clinical Trial in FTD?
(F ) Do you consider the measurement of CSF biomarkers (Abeta, Tau and P-Tau) to be a
useful tool in the diagnostic investigation of FTD? (G ) Do you consider episodic memory deficit to be a good marker to differentiate FTD
from Alzheimer's disease? (H ) Do you consider that the assessment of functions related to social cognition (recognition
of emotions, theory of mind, emotional processing, among others) contributes to improving
the diagnosis of FTD?
The majority of respondents (112/256) reported following 2–10 FTD patients per month;
177/256 reported establishing 1–5 new FTD diagnoses per year ([Table 1 ]). Most physicians (224/256) do not follow patients or families with confirmed genetic
mutations. The most frequent genetic mutations under clinical follow-up were c9orf72 (n = 17), GRN (n = 10) and MAPT (n = 9). The majority of genetic cases are under neurological assistance (23/26).
Maniform symptoms, language deficits and family history were the most common aspects
investigated in the clinical interview of patients with suspected FTD ([Table 2 ]). The majority of respondents reported that they did not use specific tools to investigate
behavioral symptoms ([Table 2 ]). The Neuropsychiatric Inventory was the most frequent tool to assess behavioral
disorders. The Mini-Mental State Exam (MMSE), the Frontal Assessment Battery (FAB)
and the Montreal Cognitive Assessment (MoCA) were the most frequent cognitive tools
employed by the respondents ([Table 2 ]).
Table 2
Clinical procedures for the diagnosis of Frontotemporal dementia [percentages (raw
number)]
Neurologists
(n = 163)
Psychiatrists
(n = 36)
Geriatricians
(n = 47)
General practitioner
(n = 2)
Other
(n = 8)
ALL
(n = 256)
What aspects do you usually investigate in the interview of suspected patients?
Family history
80.3% (131)
86.1% (31)
87.2% (41)
50% (1)
100% (8)
83% (212)
Orientation deficits
61.3% (100)
47.2% (17)
64.8% (24)
100% (2)
62.5% (5)
58% (148)
Memory disorders
66.8% (109)
63.9% (23)
68% (32)
50% (1)
87.5% (7)
67% (172)
Language deficits
82.2% (134)
94.4% (34)
76.6% (36)
50% (1)
87.5% (7)
83% (212)
Depression
71.1% (116)
72.2% (26)
72.3% (34)
50% (1)
87.5% (7)
72% (184)
Maniform symptoms
80.3% (131)
86.1% (31)
93.6% (44)
50% (1)
87.5% (7)
84% (214)
Learning deficits
34.3% (56)
36.1% (13)
35.1% (17)
50% (1)
37.5% (3)
35% (90)
Behavioral changes
60.1% (98)
100% (36)
0% (0)
0% (0)
100% (8)
55% (142)
Which neuropsychological tests do you routinely use and/or recommend for investigating
suspected cases?
ACE-R or ACE-III
9.8% (16)
16.7% (6)
10.6% (5)
0% (0)
12.5% (1)
11% (28)
DRS-MATTIS
19.3% (32)
11.1% (4)
17% (8)
100% (2)
12.5% (1)
18% (47)
MMSE
59.5% (97)
69.4% (25)
80.8% (38)
100% (2)
87.5% (7)
66% (169)
Frontal Assessment Battery
53.4% (87)
61.1% (22)
61.7% (29)
100% (2)
100% (8)
58% (148)
Lexical Fluency
42.3% (69)
44.4% (16)
46.8% (22)
50% (1)
37.5% (3)
43% (111)
Figure Memory Test BCSB
47.2% (77)
41.7% (15)
53.2% (25)
100% (2)
50% (4)
48% (123)
Mini-SEA
6.1% (10)
16.7% (6)
17% (8)
0% (0)
0% (0)
9% (24)
MoCA
54% (88)
80.5% (29)
46.8% (22)
50% (1)
100% (8)
58% (148)
RAVLT
9.2% (15)
25% (9)
10.6% (5)
100% (2)
0% (0)
12% (31)
Stroop
18.4% (30)
19.4% (7)
25.5% (12)
50% (1)
25% (2)
20% (52)
WCST
12.9% (21)
16.7% (6)
8.5% (4)
0% (0)
0% (0)
12% (31)
Other
6.1% (10)
8.3% (3)
2.1% (1)
0% (0)
0% (0)
5.4% (14)
How do you investigate behavioral changes in suspected patients?
CBI
6.1% (10)
2.8% (1)
6.4% (3)
0% (0)
0% (0)
5% (14)
FBI
9.2% (15)
11.1% (4)
12.8% (6)
50% (1)
0% (0)
10% (26)
FTD-FRS
0.6% (1)
2.8% (1)
4.2% (2)
0% (0)
0% (0)
1% (4)
FTLD-CDR
1.8% (3)
0% (0)
4.2% (2)
0% (0)
0% (0)
2% (5)
NPI
37.4% (61)
61.1% (22)
38.3% (18)
100% (2)
37.5% (3)
41% (106)
SAS
5.5% (9)
2.8% (1)
4.2% (2)
0% (0)
0% (0)
5% (12)
Structured interview
3% (50)
27.8% (10)
36.2% (17)
0% (0)
25% (2)
31% (79)
Unstructured interview
68.7% (112)
66.7% (24)
66% (31)
0% (0)
75% (6)
68% (173)
Which is the biggest difficulty you face in the diagnostic investigation of FTD?
Genetic investigation
62.6% (102)
14.9% (7)
32% (15)
50% (1)
0% (0)
49% (125)
CSF biomarkers
11% (18)
11.1% (4)
8.5% (4)
0% (0)
37.5% (3)
11% (29)
Structural neuroimaging (CT or MRI)
3% (5)
0% (0)
6.4% (3)
0% (0)
0% (0)
3% (8)
Functional neuroimaging (SPECT or PET)
11.7% (19)
25% (9)
17% (8)
50% (1)
25% (2)
15% (39)
Formal cognitive assessment
11.7% (19)
34% (16)
36.1% (17)
0% (0)
37.5% (3)
21% (55)
Abbreviations: ACE-III, Addenbrooke Cognitive Evaluation – 3rd version; Addenbrooke Cognitive Evaluation – Revised; BCSB, Brief Cognitive Screening
Battery; CBI, Cambridge Behavioral Inventory; CSF, cerebrospinal fluid; CT, computed
tomography; DRS-MATTIS, Dementia Rating Scale; FBI, Frontal Behavioral Inventory;
FTD-FRS, Frontotemporal Dementia Rating Scale; FTLD-CDR, Frontotemporal Lobar Degeneration-Modified
Clinical Dementia Rating; Mini-SEA, Short Version of the Social Cognition and Emotional
Battery; MMSE, Mini-Mental State Exam; MoCA, Montreal Cognitive Assessment; MRI, magnetic
resonance imaging; NPI, Neuropsychiatric Inventory; PET, Positron Emission Tomography;
RAVLT, Rey Auditory Verbal Learning Test; SAS, Starkstein Apathy Scale; SPECT, single
photon emission computed tomography; WCST, Wisconsin Card Sorting Test.
Trazodone was the most common drug employed in the pharmacological treatment of behavioral
disorders associated with FTD, followed by antipsychotics, ASMs, and psychostimulants.
Neurologists and geriatricians use trazodone more frequently than psychiatrists; neurologists
rarely use psychostimulants, which are more commonly prescribed by geriatricians and
psychiatrists. Antipsychotics are similarly used by all specialists. Finally, geriatricians
use ASM more frequently than other specialists.
Among the challenges in the diagnostic framework of FTD, most respondents (125/256)
reported the difficulty in performing genetic testing as the main limit, followed
by difficulties in conducting formal neuropsychological testing (55/256), functional
neuroimaging (39/256), CSF biomarkers (29/256) and structural neuroimaging (8/256).
According to this survey, the three most relevant disorders for the differential diagnosis
of FTD are AD (n = 211), bipolar disorder (n = 117) and dementia with Lewy bodies (n = 92) ([Table 3 ]). Interestingly, neurologists and psychiatrists did not differ in these responses
regarding differential diagnosis. However, geriatricians differed from them, as they
ranked late-onset schizophrenia as the third more relevant misdiagnosis, while neurologists
and psychiatrists considered dementia with Lewy bodies ([Table 3 ]).
Table 3
The main disorders more relevant for differential diagnosis with Frontotemporal dementia
(percentages and raw numbers)
In your opinion, what are the THREE main differential diagnoses of FTD?
Neurologists
(n = 163)
Psychiatrists
(n = 36)
Geriatricians
(n = 47)
General practitioner
(n = 2)
Other
(n = 8)
Alzheimer's Disease
84% (137)
83.3% (30)
74.4% (35)
100% (2)
87.5% (7)
ADHD
3% (5)
5.5% (2)
2.1% (1)
0% (0)
0% (0)
Corticobasal syndrome
26.4% (43)
22.2% (8)
21.2% (10)
100% (2)
25% (2)
Bipolar disorder
41.7% (68)
63.9% (23)
48.9% (23)
0% (0)
37.5% (3)
Late schizophrenia
22.7% (37)
27.8% (10)
38.3% (18)
0% (0)
25% (2)
Lewy Body Dementia
38.6% (63)
33.3% (12)
29.8% (14)
50% (1)
25% (2)
Major depression disorder
20.2% (33)
13.9% (5)
25.5% (12)
0% (0)
62.5% (5)
OCD
8% (13)
13.9% (5)
8.5% (4)
0% (0)
0% (0)
PSP
19% (31)
8.3% (3)
21.2% (10)
50% (1)
25% (2)
Other primary psychiatric disorder
24.5% (40)
25% (9)
17% (8)
0% (0)
25% (2)
Other disease
0.6% (1)
0% (0)
4.2% (2)
0% (0)
0% (0)
Abbreviations: ADHD, Attention deficit and hyperactivity disorder; FTD, Frontotemporal
dementia; OCD, Obsessive-compulsive disorder; PSP, Progressive supranuclear palsy.
Most respondents (93%) considered that the assessment of social cognition is useful
for the diagnosis of FTD, but only 63% considered that AD CSF biomarkers are helpful
in the diagnostic procedures ([Figure 2 ]). Episodic memory impairment was considered a good marker to differentiate AD from
FTD by 42% respondents ([Figure 2 ]).
Regarding the proposals for advancing the knowledge and for improving the assistance
of FTD patients in Brazil, the respondents ranked as top 1 priority the creation of
a common protocol for the diagnosis and management of FTD patients, followed by the
development and validation of new behavioral tools adapted for Brazilian population.
DISCUSSION
This is the first effort to investigate current practices in the field of FTD in Brazil.
A similar initiative has been conducted in Italy[8 ] and a previous study collected data from Latin America, mainly from Argentina and
Mexico.[9 ] This survey collected data exclusively from Brazil, thus providing useful information
about how FTD patients are managed in the Brazilian scenario, and also providing valuable
data to improve the research and the assistance of FTD patients in the country.
The present findings do not bring information on the prevalence or the incidence of
FTD in Brazil. While the design of the Italian survey[8 ] enabled the estimation of the total number of cases, our study does not allow this
calculation, as it is possible that two or more respondents assist FTD patients at
the same center. Therefore, we could overestimate the total number of FTD patients
under clinical follow-up in Brazil.
Most respondents were from the Southeast of Brazil, which is the wealthiest region
in the country. This may reflect the unequal distribution of medical specialists across
the country. Brazil has a continental territory with marked regional disparities,
and the local health services follow this uneven socioeconomic picture. Of note, most
respondents were from São Paulo and Minas Gerais states, where there are active research
centers dedicated to dementia. This highlights the need to spread new centers and
to improve the existing ones across the country, to promote public awareness on dementia,
to ameliorate the care of patients, and to facilitate the training of health professionals
specialized in dementia care.
This survey depicts a challenging scenario for the assistance of FTD patients in Brazil.
Some responses indicate that medical training on FTD is insufficient among Brazilian
physicians. For instance, “behavioural changes,” which are considered an essential
feature for the diagnosis of bvFTD,[4 ] are not commonly inquired on the medical interview of suspected patients. Furthermore,
the respondents recommended cognitive tools that are not accurate for the diagnosis
of FTD, such as the MMSE and the FAB. These data bring to light the need to improve
medical training concerning the assistance to FTD patients.
Most respondents (88%) do not follow patients or families with confirmed genetic mutations.
Interestingly, most physicians (88%) who follow genetic cases are neurologists. This
may be due to the fact that genetic cases usually have earlier onset of symptoms and
may present with overlapping syndromes such as motor neuron disease and/or parkinsonism,
thus requiring neurological assistance. The c9orf72 genetic expansion was reported as the most frequent genetic cause of FTD under clinical
follow-up, being more common than GRN and MAPT . Previous data indicated that GRN and MAPT were the most frequent genetic causes of FTD in two Brazilian reference centers,[10 ] and c9orf72 expansion was present in 7.1% of familial cases in another study.[11 ] Overall, the few numbers of reported genetic cases in this survey may be explained
by the difficulties in performing genetic investigation in Brazil. Indeed, genetic
testing is not covered by the public health system, and is available only in research
protocols or in private laboratories. According to our survey, only 14% of services
offer genetic counselling. As a matter of comparison, genetic analyses along with
counselling are available in around half of Italian centers.[8 ] In line with these difficulties, the majority of respondents (125/256) reported
the difficulty in performing genetic investigation as the most relevant limit they
face in the diagnostic procedures of FTD.
Besides genetic testing, other challenges in the FTD framework were also pointed out
by the respondents. For instance, the difficulty to perform formal neuropsychological
assessment was the second most frequently reported limitation in FTD diagnostic investigation,
being more reported than CSF or neuroimaging investigation. This highlights that the
medical assistance in Brazil is limited not only by the lack of advanced technological
facilities (e.g., molecular neuroimaging) but also by the scarce number of health
professionals specialized in dementia.[2 ]
The management of behavioral symptoms of FTD is a clinical challenge. There are no
specific medications, and physicians usually employ off-label pharmacological treatments.[12 ] There is evidence of benefit with trazodone,[12 ]
[13 ] and it is frequently used by Brazilian physicians. Similarly, antipsychotics are
also commonly employed. ASM and psychostimulants may be used as mood stabilizers and
for treatment of apathy, respectively.[12 ] Interestingly, our results suggest that neurologists prescribe these drugs less
frequently than geriatricians and psychiatrists.
AD was ranked as the most important diagnosis to be differentiated from FTD, in agreement
with a previous Latin-American survey.[9 ] Surprisingly, only 63% of respondents considered AD CSF biomarkers as a useful tool
in the diagnostic framework of FTD. Even if there is no specific biomarker for FTD,
CSF biomarkers can accurately differentiate FTD from AD,[14 ]
[15 ]
[16 ] which is the main cause of misdiagnosis with FTD. Some reasons may explain the low
proportion of physicians who consider AD CSF biomarkers relevant in the diagnostic
procedures of FTD. First, the difficulty in performing CSF analyses, as AD biomarkers
are expensive and are covered neither by the public health system nor by local medical
insurance companies. Moreover, physicians lack experience with CSF markers and there
are still methodological issues on biomarkers measurements (e.g., high interlaboratory
variability regarding the absolute values of markers), which hamper the widespread
use of these tools. The development of CSF biomarkers specific for FTD, and also the
perspective of new therapies that will target specific pathophysiological pathways
of FTD may change this scenario in the following years.
This survey also collected information regarding the perception of how cognitive assessment
may help in the diagnosis of FTD. Most physicians (93%) consider that social cognition
tests (e.g., theory of mind and facial emotion recognition tests) are useful for the
diagnosis. Even if the investigation of social cognition is not formally recommended
in consensual criteria of FTD,[4 ] there is increasing evidence that this investigation provides accurate clinical
distinction between bvFTD and AD.[17 ]
[18 ]
[19 ]
[20 ] Of note, the evaluation of social cognition has been recently recommended to distinguish
bvFTD from other primary psychiatric disorders.[21 ]
On the contrary, the majority of respondents (58%) consider that episodic memory impairment
is not a good parameter to differentiate bvFTD from AD. This is in line with increasing
evidences showing that episodic memory may be impaired in bvFTD, in a pattern similar
to that observed in AD.[22 ]
[23 ]
The creation of a common protocol for the diagnosis and management of FTD patients
was ranked as top 1 priority to improve the knowledge and the assistance of FTD patients
in Brazil. Importantly, the Brazilian Academy of Neurology recently proposed recommendations
for the diagnosis of FTD.[24 ] This initiative may help to standardize diagnostic procedures across the country.
It should also be noted that a FTD Brazilian Research Group (http://dgp.cnpq.br/dgp/espelhogrupo/308304 ) was created and formally registered at the scientific platform of the Brazilian
National Council for scientific and Technological Development (CNPq). This group is
open to all researchers on the field and aims to facilitate collaborative research
among Brazilian scientists.
This survey also shows that research facilities are lacking in the country. Besides
the aforementioned difficulties in performing genetic investigation, most centers
do not dispose of advanced resources, such as molecular neuroimaging and brain bank.
Most of Latin American countries also face these difficulties.[25 ] Even if there has been a marked increase in the Brazilian scientific production
on FTD in recent years, most papers refer to clinical and neuropsychological studies,[26 ] which have limited impact on the understanding of the underlying pathophysiological
basis of FTD. State-of-art research requires appropriate funding for researchers and
for improving medical facilities. However, there has been a progressive reduction
on Brazilian government investment in scientific research,[27 ] thus precluding the scientific development of the country.
The shortcomings of this study should be pointed out. As the invitation to participate
was widely diffused through social media, it is not possible to estimate the rate
of acceptance of participation. Naturally, there is a sample bias, as those who accept
to answer the survey have some familiarity with FTD. Therefore, we are aware that
these results are not representative of all physicians in Brazil. We did not collect
data about the respondents' medical training. This information is necessary to estimate
whether clinical practices vary according to the level of education and experience
in the field of FTD. Finally, all data are from the perspective of clinicians, rather
than using systems-level data which may provide a more accurate and objective picture
of current practice.
The present results highlight the need for education and medical training in diagnostic
procedures and in the management of FTD in Brazil. It also highlights the need of
structural improvement in advanced facilities for diagnostic and research purposes,
as the access to molecular neuroimaging, genetic testing and biological investigation
with biomarkers is extremely difficult, even in the few reference centers established
in the country. In the perspective of disease-modifying treatments of FTD, it is essential
to improve the diagnosis, either by molecular neuroimaging or by genetic tests. We
expect that the present study may provide valuable insights for the medical education,
clinical training of physicians, and for the development of research in the field
of FTD in Brazil.
