The Basics
Lewy Body Dementia (LBD) is the second most common neurodegenerative dementia after Alzheimer disease. LBD encompasses two clinical entities: dementia with Lewy bodies (DLB) and this type of dementia
What is Parkinson disease dementia (PDD)?
When suspicious for DLB, one should assess for executive dysfunction, attentional and which other clinical sign?
What is visuospatial deficits?
Which progresses faster, DLB or AD?
What is DLB?
Survival 5-8 years after onset of symptoms. It is important to have this conversation with family regarding expectations for progression of disease and advice from our palliative care colleagues.
Patients should have what cognitive assessments done?
MoCA (Montreal Cognitive Assessment) and neuropsychological testing
Functions of memory and naming not usually affected with pts with LBD early in cours
It is important to review LBD patients' medication lists to avoid which types of medications (due to their SE)?
What are anticholinergic medications, benzodiazepines, TCAs, antipsychotics? (think: Benadryl, urinary frequency medications). These can exacerbate patient's symptoms of DLB.
DLB and PDD are similar in that they both have which pathologic protein?
What is alpha synuclein (contribute to Lewy bodies and Lewy neurites)?
Trouble with solving problems, doing multiple things at once, planning ahead, staying organized are examples of what?
What is executive dysfunction?
Delirium occurs more often in AD or DLB?
What is DLB? Occurs in 25% of patients with DLB (compared to 7% of patients with AD). Delirium happens earlier in life, are later diagnosed with DLB. Antipsychotics should be avoided in patients with DLB
MRI findings with DLB typically show what findings?
Generalized cortical atrophy in nonspecific pattern, preservation of medial temporal lobe
Donepezil, rivastigmine, galantamine are medications that may improve cognitive symptoms in patients with DLB. To which drug class do they belong?
Lewy body pathology can be categorized as: neocortical, limbic, transitional, brainstem predominant, amygdala predominant or this neurologic location
What is olfactory bulb?
Trouble with being able to follow along plots or keep up with conversations, maintaining train of thought, staying focused are properties of what?
What are impairments in attention?
Visual hallucinations (typically well-formed and usually with people or animals) occur in what percentage of people with DLB?
What is up to 80%?
Hallucinations can occur early on with disease (especially compared to AD)
What might an EEG show on patient with DLB?
What is appropriate management for REM Sleep Behavior Disorder?
What is melatonin?
Also important to ensure safe environment (avoid sharp furniture near bed, additional padding nearby). Review med recs to avoid medications that can worsen RBD.
Main features of DLB include cognitive fluctuations, parkinsonism, and what sleep abnormality?
What is REM sleep behavior disorder?
Becoming lost in places that are familiar (house, neighborhood), difficulty recognizing objects, trouble driving (parking, following distance) are characteristics of what dysfunction?
What is visuospatial dysfunction?
In DLB, executive function, attentional, visuospatial abilities are impacted. When these are affected, one should determine if these are impacting function, which is the definition of dementia. If not impacting function, consider MCI 2/2 Lewy bodies
What imaging modality helps differentiate DLB from AD?
What is dopamine transporter imaging? This has 80% sensitivity, 92% specificity. With it one can see decreased dopamine transporter uptake in the basal ganglia on PET/SPECT which is fseen in PD, multiple system atrophy, progressive supranuclear palsy, corticobasal degeneration and some frontotemporal dementias.
How can one test for DLB with laboratory studies?
What are alpha synuclein skin bx test and in the CSF. The skin bx test are nerve fiber punch biospies from the posterior cervical, posterior thigh, posterior distal leg region, they have sensitivity >92%. CSF study for alpha synuclein will detect this in DLB, PD, RBD, and primary autonomic failure (sensitivity range 59%-95% and specificity range 83%-98%). No serum markers available.
Psychiatric onset DLB can include late onset depressive disorder and psychosis. What is a medication that can be used for this psychosis?
What are quetiapine and clozapine? Important to monitor for SE; there are no approved medications to treat DLB psychosis.
Memantine/cholinesterase inhibitors may be trialed initially and if no improvement, you could reach for these.
If symptoms of dementia occur before/in 1 year of bradykinesia, rigid tone, or resting tremor, what is this considered?
What is DLB?
Dementia starts after 1 year of onset of motor symptoms or with dx of PD, considered PDD
If someone can participate in conversations and keep up with tasks one day but at other times they cannot do these things or will blankly stare or display confusion, what is this a sign of?
What are cognitive fluctuations? These are characteristic of LBD.
What is the cingulate island sign? Metabolism is normal in posterior cingulate when compared to the reduced metabolism in cuneus and precuneus.
What is GBA, SNCA, APOE, BIN1, TMEM175, TPCN1, SCARB2?
Which medications could be utilized to target parkinsonism seen in DLB patients?
What are levodopa or zonisimide. Typically levodopa alone or can trial with zonisimide.