Frontal lobe dysfunction

Dr Letitia Dobranici
MHSOP
Middlemore Hospital
2015

Functional Frontal Lobe Anatomy

Largest of all lobes
SA: ~1/3 / hemisphere
3 major areas in each lobe
Dorsolateral aspect
Medial aspect
Inferior orbital aspect

Executive functions
Are a set of mental skills that help you get things
done.
Executive function helps you:
Manage time
Pay attention
Switch focus
Plan and organize
Remember details
Avoid saying or doing the wrong thing
Do things based on your experience/feedback
Prioritize

What happens if EF dont work?

Finds it hard to figure out how to get started on a task
Can focus on small details or the overall picture, but not both at
the same time
Has trouble figuring out how much time a task requires
Does things either quickly and messily or slowly and incompletely
Finds it hard to incorporate feedback into work or an activity
Sticks with a plan, even when its clear that the plan isnt working
Has trouble paying attention and is easily distracted
Loses a train of thought when interrupted
Needs to be told the directions many times
Has trouble making decisions
Has a tough time switching gears from one activity to another
Doesnt always have the words to explain something in detail
Needs help processing what something feels/sounds/looks like
Isnt able to think about or do more than one thing at a time
Remembers information better using cues, abbreviations or
acronyms

Diseases Commonly Associated

With Frontal Lobe Lesions

Traumatic brain injury

Gunshot wound
Closed head injury
Widespread stretching and shearing of fibers throughout
Frontal lobe more vulnerable
Contusions and intracerebral hematomas

Frontal Lobe seizures

Usually secondary to trauma

Difficult to diagnose: can be odd (laughter, crying, verbal automatism,
complex gestures)

Diseases Commonly Associated with Frontal Lobe Lesions

Vascular disease
Tumors
Multiple Sclerosis
Degenerative diseases
Picks disease (frontotemporal dementia)
Huntingtons disease
Infectious diseases
Neurosyphilis
Herpes simplex encephalitis

Diseases Commonly Associated

with
Frontal Lobe Lesions

Psychiatric Illness proposed associations

Depression
Schizophrenia
OCD
PTSD
ADHD

Diseases Affecting the Frontal Lobe

Schizophrenia
Abnormality in the mesocortical dopaminergic
projection
Decrease in blood flow to the frontal lobes, and
frontal lobe atrophy

Parkinsons Disease
Loss of dopamine cells in the substantia nigra
that project to the prefrontal cortex

Korsakoffs
Alcohol-induced damage to the dorsomedial
thalamus and a deficiency in frontal lobe
catecholamines

Frontotemporal dementia

Clinical presentation- behavioural type

Disinhibition Examples of disinhibition or socially inappropriate behavior
include touching or kissing strangers, public urination, and flatulence without
concern. Patients may make offensive remarks or invade others personal
space. Patients with FTD may exhibit utilization behaviors, such as playing with
objects in their surroundings or taking others personal items.
Apathy and loss of empathy Apathy manifests as losing interest and/or
motivation for activities and social relationships. Patients may participate less
in conversations and grow passive. Apathy is mistaken frequently for
depression. As patients lose empathy, caregivers may describe patients as cold
or unfeeling towards others emotions.
Hyperorality Hyperorality and dietary changes manifest as altered food
preferences, such as carbohydrate cravings, particularly for sweet foods, and
binge eating. Increased consumption of alcohol or tobacco may occur. Patients
may eat beyond satiety or put excessive amounts of food in their mouths that
cannot be chewed properly. They may attempt to consume inedible objects.
Compulsive behaviors Perseverative, stereotyped, or compulsive ritualistic
behaviors include stereotyped speech, simple repetitive movements, and
complex ritualistic behaviors such as hoarding, checking, or cleaning.
Patients with FTD can develop a rigid personality, rigid food preferences, and
inflexibility to changes in routine.
Lack of insight

Questions to be asked?
Has the patient has said or done anything in public that
has embarrassed others?
Does the patient appear to have a lack of disgust?
Does the patient seem indifferent or oblivious to others
feelings and less warm or affectionate, especially toward
grandchildren or pets?
Have food preferences changed or table manners
declined?
Does the patient seem more concerned with timekeeping
or tend to watch the clock?
Has there been a change in the patients sense of humor?
Has the patient developed new hobbies or interests
pursued obsessively, especially with a religious or spiritual
bent?

Speech and language problems

Some subtypes of frontotemporal dementia are marked by

the impairment or loss of speech and language difficulties.
Primary progressive aphasia, one subtype, is
characterized by an increasing difficulty in using and
understanding written and spoken language. For example,
people may have trouble finding the right word to use in
speech or naming objects.
People with another subtype, semantic dementia, utter
grammatically correct speech that has no relevance to the
conversation at hand. They may have difficulty
understanding written or spoken language, or they may
have difficulty recalling the words for common objects.

Movement disorders

Rarer subtypes of frontotemporal dementia are

characterized by problems with movement, similar
to those associated with Parkinson's disease or
amyotrophic lateral sclerosis.
Movement-related signs and symptoms may include:
Tremor
Rigidity
Muscle spasms
Poor coordination
Difficulty swallowing
Muscle weakness

FAB

Table 1: Diagnostic criteria for apathy.

Lack of motivation relative to the patients previous level of functioning or

the standards of his or her age and culture,
as indicated either by subjective account or observation by others.
Presence, with lack of motivation, of at least one symptom belonging to
each of the following three domains.
(i) Diminished goal-directed behavior:
(a) lack of effort,
(b) dependency on others to structure activity.
(ii) Diminished goal-directed cognition:
(a) lack of interest in learning new things or in new experiences,
(b) lack of concern about ones personal problems.
(iii) Diminished emotion:
(a) unchanging affect,
(b) lack of emotional responsivity to positive or negative events.
The symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning. The symptoms are
not due to a diminished level of consciousness or the direct physiological
effects of a substance (e.g., a drug of abuse, a medication).

Adapted from Starkstein [30].