Management of Psychosis in PD, PDD, and DLB

This article, from the American Journal of Psychiatry, is a great review of research on the causes and treatment of neuropsychiatric symptoms in Dementia with Lewy bodies, Parkinson’s Disease Dementia, and Parkinson’s Disease (without dementia). It is basically an updated and research-laden version of the DLB chapter in the “Mind, Mood, and Memory” booklet, which is a Lewy Body Dementia bible.

You can find the article online at no charge here:

ajp.psychiatryonline.org/cgi/content/full/164/10/1491 –> HTML version

Applause sign (clap test) – updated research

Here’s some new research that probably speaks to the results that Dubois got in ’05 when he and other French researchers said that the “applause sign helps to discriminate PSP from FTD and PD.”

This newly-published research looks at those with PD and “various forms of atypical parkinsonism.” (I’ll have to get the full article to know which forms were included.) These Dutch researchers found: “Although the proportion with an abnormal clapping test was significantly higher in atypical parkinsonism, the clapping test did not discriminate well between Parkinson’s disease and atypical parkinsonism.”

Journal of Neurology. 2007 Oct 15; [Epub ahead of print] Diagnostic accuracy of the clapping test in Parkinsonian disorders.

Abdo WF, van Norden AG, de Laat KF, de Leeuw FE, Borm GF, Verbeek MM, Kremer PH, Bloem BR.
Parkinson Centre Nijmegen (ParC), Institute of Neurology, Radboud University Nijmegen Medical Centre, The Netherlands.

BACKGROUND : To determine the diagnostic value of the clapping test, which has been proposed as a reliable measure to differentiate between progressive supranuclear palsy (where performance is impaired) and Parkinson’s disease (where performance should be normal).

METHODS : Our study group included a large cohort of consecutive outpatients including 44 patients with Parkinson’s disease, 48 patients with various forms of atypical parkinsonism and 149 control subjects. All subjects performed the clapping test according to a standardized protocol.

RESULTS : Clapping test performance was normal in all control subjects, and impaired in 63% of the patients with atypical parkinsonism. Unexpectedly, we also found an impaired clapping test in 29% of the patients with Parkinson’s disease.

CONCLUSION : Although the proportion with an abnormal clapping test was significantly higher in atypical parkinsonism, the clapping test did not discriminate well between Parkinson’s disease and atypical parkinsonism.

PubMed ID#: 17934886

The “applause sign” is where you ask someone who might have PSP to clap. While clapping, you tell them to stop. The person with PSP continues to clap; it takes them awhile to stop.

In a study done by Dubois, 30 out of 42 patients diagnosed with PSP could not stop applauding immediately after being told to stop. Interestingly, none of those with FTD or PD had trouble stopping.

Here’s the abstract of the Dubois article (published 6/05 in Neurology):

*Neurology. 2005 Jun 28;64(12):2132-3.

“Applause sign” helps to discriminate PSP from FTD and PD.

Dubois B, Slachevsky A, Pillon B, Beato R, Villalponda JM, Litvan I.
INSERM, Fédération de Neurologie, Hôpital de la Salpêtrière, Paris, France.

“Applause sign” helps to discriminate PSP from FTD and PD
The “applause sign” is a simple test of motor control that helps to differentiate PSP from frontal or striatofrontal degenerative diseases. It was found in 0/39 controls, 0 of 24 patients with frontotemporal dementia (FTD), 0 of 17 patients with Parkinson disease (PD), and 30/42 patients with progressive supranuclear palsy (PSP). It discriminated PSP from FTD (p < 0.001) and PD (p < 0.00). The “three clap test” correctly identified 81.8% of the patients in the comparison PSP and FTD and 75% of the patients in the comparison of PSP and PD.

PubMed ID#: 15985587 (see pubmed.gov)

Neuroleptics and anticholinergics can be catastrophic in LBD

I recently came across an article in the Human Givens Journal (humangivens.com) from 2003 on the use of neuroleptics (anti-psychotics) with sometimes disastrous results in Lewy Body Dementia (LBD). A warning is also shared for anticholinergics.

In this article, the term “neuroleptics” refers to both typical and atypical anti-psychotics.

The article notes that those with LBD should avoid anticholinergics in any form, even over-the-counter cold remedies. One example of an anticholinergic that is a cold remedy is Benadryl. And usually sleeping aids have anticholinergic properties along with anti-bladder spasm meds. And on and on….

I have never found a complete list of all meds with anticholinergic properties but a website such as rxlist.com or drugs.com do mention these problems in the “Side Effects” section.

Robin

“To drive or not to drive, that is the question…1 solution”

I’m forwarding this email mostly for the good laugh but it does contain a very clever suggestion!

Robin

(From the LBDA Forum)
http://www.lewybodydementia.org/forum/viewtopic.php?t=480

Posted by: Linda
Posted: Mon Sep 03, 2007 5:49 pm
Post subject: To drive or not to drive, that is the question… 1 solution

Dad wad driving. He LOVED his keys. We really thought we would have to take the car away from both mom and dad to get him to stop. He came to visit us in Florida and got the car stuck in the mulch. We decided to just leave it there. After 3 or 4 days we started talking about how bad his vision was. (He WAS seeing things that were not there.) Then we brought up the fact that maybe it was time to let mom drive. It was MUCH easier than we thought. BUT, we knew when he returned to NC, he was going to make a break for it. SO, I went to the key store and had them make a key for the ignition that would NEVER start the car. We left the key to open the doors and trunk on his ring and replaced the ignition key with the dummy. Sure enough, when he returned home, he tried to start the car. Every time he comes in and says the car won’t start, we just point out the fact that he agreed not to drive because his eyes are so bad.

Back in February, I took him to the beach. On the way home, I needed to stop at the grocery store. He said he would wait in the car. He was in the passenger seat. “Don’t leave me, Dad.” (Famous last words.) When I came out, no dad! I just started laughing. I should have known better. After a while, I spotted the car at the far end of the strip mall. I ran as fast as I could, pushing the cart. When I almost reached the car. He took off. This happened two or three times before I caught him. I almost believed he was doing it just for fun. I just thought I’d share this, since so many days with LBD are so tough. Some things that happen are a blessing. When dad is gone, I’ll remember the day he exercised me at the grocery store.
_________________
Linda
Father has LBD, lives 400 miles away

American Family Physicians article on DLB

I ran across this 2006 article today in the American Family Physician journal. It’s a good, short description of dementia with Lewy bodies, intended for use by family practic physicians.

You can get the article free online at:

www.aafp.org/afp/20060401/1223.html –> in HTML

www.aafp.org/afp/20060401/1223.html –> in PDF

You might provide this article to your general/family practice MD!

The diagnostic criteria listed in Table 1 of the article is from 1996. The diagnostic criteria was updated in 2005. (The latest criteria are: McKeith IG, Dickson DW, Lowe J, et al. Diagnosis and management of dementia with Lewy bodies: third report of the DLB consortium. Neurology 2005;65:1863­72.)

Figure 1 offers a good comparison of AD and DLB.

In the section on pharmacological treatment of DLB, the authors state: “Patients with significant visual hallucinations are reported to have better response to cholinesterase inhibitor therapy than other patients with dementia; these medications improve fluctuating cognition, hallucinations, apathy, anxiety, and sleep disturbances.” (ChEIs include Aricept, Exelon, and Razadyne.)

And: “Patients who have dementia with Lewy bodies should not be given the older, typical D2-antagonist antipsychotic agents such as haloperidol (Haldol), fluphenazine (Prolixin), and chlorpromazine (Thorazine). Patient records should document this and caregivers should be informed. As many as one half of patients who have dementia with Lewy bodies who receive neuroleptic medications experience life-threatening adverse effects characterized by sedation, rigidity, postural instability, falls, increased confusion, and neuroleptic malignant syndrome, with an associated two- to threefold increase in mortality. Atypical antipsychotics may be tried in low doses, but these can cause similar adverse effects and increase the risk of stroke.”

The associated summary handout for patients and families is very disappointing:

www.aafp.org/afp/20060401/1230ph.html

Copied below is the abstract of the article.

Robin

—————————–

American Family Physician. 2006 Apr 1;73(7):1223-9.

Dementia with Lewy bodies: an emerging disease.Neef D, Walling AD.
Via Christi Family Medicine Residency, Wichita, Kansas 67218, USA.

Dementia with Lewy bodies appears to be the second most common form of dementia, accounting for about one in five cases. The condition is characterized by dementia accompanied by delirium, visual hallucinations, and parkinsonism. Other common symptoms include syncope, falls, sleep disorders, and depression. The presence of both Lewy bodies and amyloid plaques with deficiencies in both acetylcholine and dopamine neurotransmitters suggests that dementia with Lewy bodies represents the middle of a disease spectrum ranging from Alzheimer’s disease to Parkinson’s disease. The diagnosis of dementia with Lewy bodies is based on clinical features and exclusion of other diagnoses. Individualized behavioral, environmental, and pharmacologic therapies are used to alleviate symptoms and support patients and their families. Cholinesterase inhibitors are more effective in patients who have dementia with Lewy bodies than in those with Alzheimer’s disease. Conversely, patients who have dementia with Lewy bodies do not respond as well to antiparkinsonian medications. Anticholinergic medications should be avoided because they exacerbate the symptoms of dementia. Traditional antipsychotic medications can precipitate severe reactions and may double or triple the rate of mortality in patients who have dementia with Lewy bodies.

PubMed ID#: 16623209 (see pubmed.gov for abstract)