Psych · old-age
Dementia with Lewy bodies and Parkinson disease dementia
Also known as DLB · Dementia with Lewy bodies · Parkinson disease dementia · PDD · Lewy body dementia · Lewy body disease · Cortical Lewy body disease
Exam-exhaustive fellowship reference on dementia with Lewy bodies (DLB) and Parkinson disease dementia (PDD) — McKeith 2017 core features and biomarkers; 1-year rule; RBD; neuroleptic sensitivity; cholinesterase inhibitors; avoidance of high-potency D2 blockade; DaT SPECT; RANZCP/NICE/APA-aligned management. FRANZCP-primary, globally tagged.
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Red flags
- Suspected DLB/PDD and new antipsychotic planned — never use high-potency typicals (e.g. high-dose oral/IM haloperidol); extreme neuroleptic sensitivity risk including rigidity, reduced consciousness, and death
- Acute fluctuating attention with medical precipitant — treat as delirium first even if known Lewy body disease
- New or worsening visual hallucinations after starting dopamine blockers — stop agent and reassess diagnosis
- Severe rigidity, fever, autonomic instability after antipsychotic — NMS pathway; medical emergency
- Violent dream enactment with injury risk — urgent RBD safety measures (bed partner safety, bedroom hazards)
- Falls, orthostatic syncope, or aspiration with progressive LB dementia — urgent multidisciplinary risk reduction
Meet the patient
A 72-year-old retired surveyor is referred as "late-onset schizophrenia". He sees a tabby cat sitting on the end of his bed most evenings. It does not speak to him, and he is more puzzled than frightened by it.[1]
His wife moved into the spare room six years ago because he shouts and punches in his sleep. Some afternoons he cannot follow a sentence; other afternoons he does the crossword. His GP thinks it is depression. Nobody has watched him walk.[1][11]
Two exam questions are live. Which four features has that history just handed you? And what is the one prescription that could kill him this week? Everything below answers both.[1][4][5]
References18ShowHide
- [1]McKeith IG, Boeve BF, Dickson DW, et al. Diagnosis and management of dementia with Lewy bodies: Fourth consensus report of the DLB Consortium Neurology, 2017.PMID 28592453
- [2]McKeith IG, Dickson DW, Lowe J, et al. Diagnosis and management of dementia with Lewy bodies: third report of the DLB Consortium Neurology, 2005.PMID 16237129
- [3]Emre M, Aarsland D, Brown R, et al. Clinical diagnostic criteria for dementia associated with Parkinson's disease Mov Disord, 2007.PMID 17542011
- [4]McKeith I, Fairbairn A, Perry R, Thompson P, Perry E Neuroleptic sensitivity in patients with senile dementia of Lewy body type BMJ, 1992.PMID 1356550
- [5]McKeith IG, Ballard CG, Harrison RW Neuroleptic sensitivity to risperidone in Lewy body dementia Lancet, 1995.PMID 7544860
- [6]McKeith I, Del Ser T, Spano P, et al. Efficacy of rivastigmine in dementia with Lewy bodies: a randomised, double-blind, placebo-controlled international study Lancet, 2000.PMID 11145488
- [7]Emre M, Aarsland D, Albanese A, et al. Rivastigmine for dementia associated with Parkinson's disease N Engl J Med, 2004.PMID 15590953
- [8]Mori E, Ikeda M, Kosaka K; Donepezil-DLB Study Investigators Donepezil for dementia with Lewy bodies: a randomized, placebo-controlled trial Ann Neurol, 2012.PMID 22829268
- [9]Emre M, Tsolaki M, Bonuccelli U, et al. Memantine for patients with Parkinson's disease dementia or dementia with Lewy bodies: a randomised, double-blind, placebo-controlled trial Lancet Neurol, 2010.PMID 20729148
- [10]McKeith I, O'Brien J, Walker Z, et al. Sensitivity and specificity of dopamine transporter imaging with 123I-FP-CIT SPECT in dementia with Lewy bodies: a phase III, multicentre study Lancet Neurol, 2007.PMID 17362834
- [11]Ballard C, O'Brien J, Gray A, et al. Attention and fluctuating attention in patients with dementia with Lewy bodies and Alzheimer disease Arch Neurol, 2001.PMID 11405813
- [12]Aarsland D, Andersen K, Larsen JP, Lolk A, Kragh-Sørensen P Prevalence and characteristics of dementia in Parkinson disease: an 8-year prospective study Arch Neurol, 2003.PMID 12633150
- [13]Cummings J, Isaacson S, Mills R, et al. Pimavanserin for patients with Parkinson's disease psychosis: a randomised, placebo-controlled phase 3 trial Lancet, 2014.PMID 24183563
- [14]Pollak P, Tison F, Rascol O, et al. Clozapine in drug induced psychosis in Parkinson's disease: a randomised, placebo controlled study with open follow up J Neurol Neurosurg Psychiatry, 2004.PMID 15090561
- [15]Stinton C, McKeith I, Taylor JP, et al. Pharmacological Management of Lewy Body Dementia: A Systematic Review and Meta-Analysis Am J Psychiatry, 2015.PMID 26085043
- [16]Taylor JP, McKeith IG, Burn DJ, et al. New evidence on the management of Lewy body dementia Lancet Neurol, 2020.PMID 31519472
- [17]Schneider LS, Dagerman KS, Insel P Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials JAMA, 2005.PMID 16234500
- [18]Pink J, O'Brien J, Robinson L, Longson D; Guideline Committee Dementia: assessment, management and support: summary of updated NICE guidance BMJ, 2018.PMID 29925626