Lewy Body Dementia

Article Author:
Ali Haider
Article Editor:
Juan Carlos Sánchez-Manso
Updated:
5/5/2019 10:38:18 PM
PubMed Link:
Lewy Body Dementia

Introduction

Lewy Body Dementia (LBD) encompasses two clinical entities, namely dementia with Lewy bodies and Parkinson disease dementia. It is a progressive degenerative brain disorder characterized by dementia, psychosis, and features of parkinsonism. Symptoms fluctuate with time and vary among different individuals. Diagnosis of LBD requires thorough clinical examination as many of its features overlap with other dementia disorders. It is the third most common type of dementia after Alzheimer disease and Vascular dementia. It characterizes by the deposition of Lewy bodies in the brain that are intraneuronal cytoplasmic inclusion bodies having aggregates of alpha-synuclein and ubiquitin.[1][2][3]

Etiology

The etiology of LBD is still unknown. Genetics, environmental factors, and changes linked to aging, however, may have a role and still require further research.

Epidemiology

LBD is an under-diagnosed condition as it is poorly understood and its clinical features overlap with other more common disorders, like Parkinson's disease and Alzheimer's disease. [4]Studies have shown, however, that it accounts for up to 20% to 30% of all dementia cases. It is more common in men, and incidence increases with advancing age. It is prevalent in Asian, African, and European races. A family history of LBD and Parkinson disease increases a patient's risk.

Pathophysiology

Like Alzheimer disease, LBD presents with acetylcholine deficiency, but it is more pronounced in LBD. Decreased levels of acetylcholine in temporal and parietal cortex result in visual hallucinations (a prominent feature of LBD), while up-regulation of muscarinic M1 receptors in the temporal lobe results in delusions. Dopamine levels also diminish.

Histopathology

The pathology of LBD overlaps that of Parkinson's disease and Alzheimer's disease. Neuronal cytoplasmic inclusion bodies, called Lewy bodies (comprising aggregates of ubiquitin and alpha-synuclein) and found within brain parenchyma (mainly in the brainstem, limbic system, and cerebral cortex), are characteristic of Lewy body dementia. [5][6][7]Genetic mutations, environmental toxins, and the aging process can lead to misfolding of alpha-synuclein and its accumulation in the form of Lewy bodies via oxidative stress and mitochondrial dysfunction. The location of Lewy bodies determines the clinical presentation. If Lewy bodies develop initially in the brainstem and cerebral cortex, then dementia sets on early, and we call it dementia with Lewy bodies; however, if Lewy bodies develop initially in the brain stem only and extend to cerebral cortex later, then dementia occurs late in the disease process and we call it Parkinson disease dementia. Other features include Lewy neuritis, senile plaques, neurofibrillary tangles, and neuronal loss in the substantia nigra, locus coeruleus, and Meynert nucleus.

History and Physical

There is a large variation in symptoms manifested among patients and their time of onset. The main features include progressive dementia (mainly affects attention and executive function, memory loss is not common but can occur later in the disease process), fluctuation cognitive function (with variation in attention and episodes of drowsiness), visual hallucinations (detailed and recurrent), and features of parkinsonism like muscular rigidity, tremors, and bradykinesia.[3][8][9][10]

 Other less common features include REM sleep behavior disorder, autonomic dysfunction, unexplained falls, depression, and sensitivity to antipsychotic medication.

Diagnostic Criteria

  • Probable LBD: progressive dementia + 2 main features.
  • Possible LBD: progressive dementia + 1 main feature.

Types

  1. Dementia with Lewy Bodies: dementia occurring first or within one year of movement disorder.
  2. Parkinson Disease Dementia: dementia occurring in a patient who receives a diagnosed of Parkinson's disease and then develops dementia symptoms after one year or more of the diagnosis.

Evaluation

No precise test can accurately diagnose LBD. Usually, a thorough workup, including the following, is useful to reach an alternative working diagnosis or rules out similar conditions:

  • Detailed history and examination
  • Assessment of mental function
  • Blood tests (e.g., vitamin B12 levels, chemistry panel, thyroid profile, syphilis, HIV) to rule out other causes of dementia 
  • Imaging studies (e.g., CT scan, MRI scan, SPECT scan, PET scan)
  • Cerebrospinal fluid examinations have no significant role when conducted in these patients
  • Sleep evaluation for REM sleep behavior disorder

Due to the incomplete specificity in the clinical diagnosis and the pathological definition of the disease, a postmortem biopsy or autopsy is the only method to secure a definite diagnosis.

Treatment / Management

Pharmacological Management

  1. Cholinesterase inhibitors: Used to treat the cognitive symptoms of LBD and are the mainstay of treatment. Initially developed for Alzheimer disease treatment, they are probably more effective in patients with LBD. These include rivastigmine, galantamine, and donepezil.
  2. Carbidopa-Levodopa: Used to treat movement symptoms.; however, it has serious side effects and can lead to delusions, hallucinations, and confusion and practitioners should use them with caution in these patients, and they should start with low doses if required.
  3. Atypical antipsychotics: Used to treat hallucinations that cause significant distress in patients not responding to standard cholinesterase inhibitors. Commonly used drugs include clozapine, quetiapine, and aripiprazole. Use with caution due to neuroleptic sensitivity in these patients.
  4. Clonazepam: Used for REM sleep behavior disorder.
  5. SSRIs: Depression is common in patients with LBD and often requires antidepressant therapy.

Support and Therapies

Patient and caregiver education regarding symptoms of a disease and their management is necessary. Understanding the disease helps the caregivers cope with everyday challenges. They require home modifications occasionally and individual patient needs should specifically guide them.[11][12][13]

Patients can take part in different therapies to improve their quality of life, including:

  • Physiotherapy
  • Occupational therapy
  • Speech therapy
  • Support groups
  • Individual and family psychotherapies.

Differential Diagnosis

It is of utmost importance to differentiate LBD from similar conditions since it is more responsive to certain medications if used early in the disease course.

Similar conditions include:

  • Parkinson disease
  • Alzheimer disease
  • Frontotemporal dementia
  • Prion-related diseases

Prognosis

The prognosis of LBD is fair to poor. Patients die from multiple complications like falls, immobility, cardiac complications, medication side effects, pneumonia, swallowing problems, and depression leading to suicide. The average life expectancy is only five to eight years after the initial diagnosis. This also can be due to a lack of knowledge regarding LBD among physicians and the population and difficulty in differentiating it from other similar conditions which leads to a delay in diagnosis which delays the onset of specific therapy. Health professionals need to improve awareness regarding LBD and there should develop investigative methods to ensure its early diagnosis.

Enhancing Healthcare Team Outcomes

The diagnosis and management of patients with LBD is extremely difficult and requires a multidisciplinary team that includes the primary care provider, psychiatrist, neurologist, radiologist, behavior specialist, and an internist. Once the diagnosis is made, there is no effective treatment and the condition is progressive. All the available pharmacological agents are only used to treat behavioral symptoms. Home care nurses play a vital role in regularly assessing the patient and providing support services.

Support and Therapies

Patient and caregiver education regarding symptoms of a disease and their management is necessary. Understanding the disease helps the caregivers cope with everyday challenges. They require home modifications occasionally and individual patient needs should specifically guide them.

The outcomes for most patients is guarded and the quality of life is poor. Most patients eventually end up in a long term care facility, where optimal treatment for basic living activities is not always provided.[14][15][16]


References

[1] King E,O'Brien JT,Donaghy P,Morris C,Barnett N,Olsen K,Martin-Ruiz C,Taylor JP,Thomas AJ, Peripheral inflammation in mild cognitive impairment with possible and probable Lewy body disease and Alzheimer's disease. International psychogeriatrics. 2019 Mar 11;     [PubMed PMID: 30854988]
[2] Londos E,Hansson O,Rosén I,Englund E, Extreme sleep pattern in Lewy body dementia: a hypothalamic matter? BMJ case reports. 2019 Mar 9;     [PubMed PMID: 30852516]
[3] Chin KS,Teodorczuk A,Watson R, Dementia with Lewy bodies: Challenges in the diagnosis and management. The Australian and New Zealand journal of psychiatry. 2019 Mar 8;     [PubMed PMID: 30848660]
[4] Brenowitz WD,Keene CD,Hawes SE,Hubbard RA,Longstreth WT Jr,Woltjer RL,Crane PK,Larson EB,Kukull WA, Alzheimer's disease neuropathologic change, Lewy body disease, and vascular brain injury in clinic- and community-based samples. Neurobiology of aging. 2017 May;     [PubMed PMID: 28236716]
[5] Chen X,Kordich JK,Williams ET,Levine N,Cole-Strauss A,Marshall L,Labrie V,Ma J,Lipton JW,Moore DJ, Parkinson's disease-linked {i}D620N VPS35{/i} knockin mice manifest tau neuropathology and dopaminergic neurodegeneration. Proceedings of the National Academy of Sciences of the United States of America. 2019 Mar 6;     [PubMed PMID: 30842285]
[6] Lin YW,Truong D, Diffuse Lewy body disease. Journal of the neurological sciences. 2019 Feb 20;     [PubMed PMID: 30807982]
[7] Kasanuki K,Koga S,Dickson DW,Sato K,Iseki E,Ichimiya Y,Arai H, Mixed Alzheimer's and Lewy-related Pathology Can Cause Corticobasal Syndrome with Visual Hallucinations. Internal medicine (Tokyo, Japan). 2019 Feb 25;     [PubMed PMID: 30799336]
[8] Hofmann W,Wille E,Kaminsky S, [Guideline-conform exact diagnosis and coding of dementia]. Zeitschrift fur Gerontologie und Geriatrie. 2019 Mar 4;     [PubMed PMID: 30830315]
[9] Rocha Cabrero F,Morrison EH, Lewy Bodies 2019 Jan;     [PubMed PMID: 30725641]
[10] Durcan R,Donaghy P,Osborne C,Taylor JP,Thomas AJ, Imaging in prodromal dementia with lewy bodies: Where do we stand? International journal of geriatric psychiatry. 2019 Feb 3;     [PubMed PMID: 30714199]
[11] Armstrong MJ, Lewy Body Dementias. Continuum (Minneapolis, Minn.). 2019 Feb;     [PubMed PMID: 30707190]
[12] Yilmaz A,Fuchs D,Price RW,Spudich S,Blennow K,Zetterberg H,Gisslén M, Cerebrospinal Fluid Concentrations of the Synaptic Marker Neurogranin in Neuro-HIV and Other Neurological Disorders. Current HIV/AIDS reports. 2019 Jan 16;     [PubMed PMID: 30649659]
[13] Younce JR,Davis AA,Black KJ, A Systematic Review and Case Series of Ziprasidone for Psychosis in Parkinson's Disease. Journal of Parkinson's disease. 2019;     [PubMed PMID: 30475775]
[14] Armstrong MJ,Alliance S,Corsentino P,DeKosky ST,Taylor A, Cause of Death and End-of-Life Experiences in Individuals with Dementia with Lewy Bodies. Journal of the American Geriatrics Society. 2019 Jan;     [PubMed PMID: 30291740]
[15] Siderowf A,Aarsland D,Mollenhauer B,Goldman JG,Ravina B, Biomarkers for cognitive impairment in Lewy body disorders: Status and relevance for clinical trials. Movement disorders : official journal of the Movement Disorder Society. 2018 Apr;     [PubMed PMID: 29624752]
[16] Morrin H,Fang T,Servant D,Aarsland D,Rajkumar AP, Systematic review of the efficacy of non-pharmacological interventions in people with Lewy body dementia. International psychogeriatrics. 2018 Mar;     [PubMed PMID: 28988547]