Lewy body dementia excerpts from curriculum on dementia for healthcare professionals

Someone in our local support group recently sent me this link to US Dept. of Health and Human Services’s curriculum for physicians (especially primary care physicians) and healthcare professionals (social workers, psychologists, pharmacists, emergency department staffs, dentists, etc.) on dementia. Though the web address includes the term “Alzheimer’s,” Lewy body dementia is well-covered in this curriculum:

Training Curriculum: Alzheimer’s Disease and Related Dementias
Health Resources and Services Administration (part of Dept of HHS)

Here are some excerpts on Lewy body dementia.



Overview of Mild Cognitive Impairment and Dementia for an Interprofessional Team (Module 1)

LBD Overview: Dementia with Lewy Bodies and Parkinson’s Disease Dementia
* Lewy body dementia (LBD) covers 2 related conditions—dementia with Lewy bodies (DLB) and Parkinson’s disease dementia (PDD).
* The defining features of LBD include motor Parkinsonism and cognitive impairments.
* Timing of dementia onset distinguishes between DLB and PDD.
* Diagnosis of LBD is challenging, even among experts.
* LBD, Parkinson’s disease (PD), and AD have many genetic similarities.
– However, differences in phenotypes have clinical implications.
– Location of Lewy bodies also influences disease manifestations.

LBD: Prevalence and Demographics
* Prevalence estimated at 1.3 million cases of LBD in the United States.
* Reportedly high number of underdiagnosed and frequently misdiagnosed cases.
* Difficult to estimate prevalence of DLB separately from PDD.
* Affects up to 5% of elderly people and up to 30% of all dementia cases.

DLB: Incidence and Prevalence
* Accounts for 4.2% of all community-diagnosed dementia, with incidence of 3.8% of new dementia cases.
* Affects more men than women and increases in incidence with age.
* Affects people at a younger age than does PDD.

PDD: Incidence and Prevalence
* PD affects about 1 million Americans.
* The percentage of people with PDD increases with increasing duration of PD. Approximately 80% of patients with PD will eventually develop PDD.
* 15–20% of persons with PD have MCI, which is associated with a poor quality of life and more severe motor symptoms.
* PD incidence increases with age.
* PD rates differ among different races.
* Incidence of PD is higher in specific ethnicities—Asians, Europeans, North Africans, North and South Americans—but highest among Ashkenazi Jews.

LBD/PDD Risk Factors
* In general, there are few risk factors for LBD: Male, older than age 60, and possible genetic predisposition.
* An important risk factor for PDD is duration of PD. Probability of developing PDD is approximately 80% with extended time since PD diagnosis.
* Other (nonspecific) risk factors for PDD include “atypical” Parkinsonian features, specific medical problems, non-motor symptoms, and rapid eye movement (REM) sleep behavior disorder (RBD).

LBD Symptoms
* The defining features of LBD include motor Parkinsonism and cognitive impairments.
* Clinical manifestations of DLB and PDD are initially different but become more similar as the disease progresses.
* Comparison of DLB versus AD found some similarities and numerous differences.
* Hallmark symptoms in early-stage PDD are movement related and also include:
– Cognitive impairments
– RBD, visuoperceptual changes, and depression
– However, memory intact throughout most of the stages of PDD.
* Greater impairments are associated with DLB than with PDD.

LBD Progression and Mortality
* The prodromal stage is characterized by dysautonomia, olfactory dysfunction, RBD, and psychiatric symptoms that are apparent years before onset of dementia (possibly decades earlier with DLB).
* Far less is known regarding progression of LBD compared with knowledge on Alzheimer’s disease. The Lewy Body Disease Association (LBDA) estimates an average duration of 5 to 7 years, with a range from 2 to 20 years.
* Survival time is shorter in DLB compared with Alzheimer’s disease.
* Men with DLB have increased mortality versus men with AD.

Diagnosing Dementia (Module 2)

Diagnosing Lewy Body Dementias (LBD)
* LBD syndromes include DLB and PDD. Both are aging-related dementias.
* Major distinction between DLB and PDD is the temporal sequence of appearance of clinical symptoms.
– DLB if dementia within 1 year after Parkinsonian symptoms
– PDD if dementia years after PD diagnosed/Parkinsonian symptoms

Distinguishing Between Lewy Body Dementias (LBD) and Alzheimer’s Disease
* Memory impairment not prominent feature of early LBD.
* Similar manifestations between LBD and late-stage AD
* DLB has similar mean age of onset as AD (around age 68) but PD has earlier onset.
* DLB has more rapid course of progression than AD or other dementias.

Understanding Early-Stage Dementia for an Interprofessional Team (Module 5)

Early-Stage Lewy Body Dementia (LBD): Overview
* LBD encompasses dementia with Lewy bodies (DLB) and Parkinson’s Disease Dementia (PDD).
* Defining features of LBD include motor Parkinsonism and cognitive impairments .
* DLB and PDD share many clinical and pathological similarities and are sometimes considered as different points on a spectrum.
– PDD is characterized by a period of pure motor symptoms first; cognitive symptoms develop more than a year after onset of movement problems.
– DLB occurs in older adults with Parkinsonism who develop dementia/cognitive symptoms within 1 year of motor symptoms and is often associated with a more severe course than PDD.
* LBD rate of decline is much faster and its survival time is shorter compared with AD.
* Greater impairments are associated with DLB than with PDD.

Early-Stage LBD: Clinical Manifestations
* Marked attentional and executive function disorders are present in LBD with significant cognitive fluctuations.
* Rapid eye movement (REM) behavioral disorder (RBD) is a sleep difficulty predominantly associated with LBD.
* Mild cognitive impairment (MCI) is present at the time of PD diagnosis in about one-third of individuals and in approximately half of all older adults afflicted with nondemented Parkinson’s disease after 5 years.
* Hallucinations are among the most common core features of DLB prior to the initial evaluation, followed by Parkinsonism and cognitive fluctuations.

LBD Versus Alzheimer’s Disease
LBD and Alzheimer’s disease have some similarities and numerous differences. Compared with persons with Alzheimer’s disease, persons with LBD are:
* More likely to have psychiatric symptoms and more functional impairments at time of diagnosis.
* More likely to have sleep disturbances, cognitive fluctuations, well-formed visual hallucinations, and muscle rigidity or Parkinsonian movement problems early in the disease.
* Likely to have pronounced visuospatial impairments in LBD that appear earlier in the disease course.
* More likely to have memory remains intact throughout most of the stages of PDD and LBD.
* More likely to have nonmotor behavioral symptoms.

General Strategies for Managing Behavioral and Psychological Symptoms of Dementia (BPSD)
* Patient engagement: contributes to greater sense of well-being
* Physical activity: can improve cognitive thinking, physical fitness, and mood; promising evidence that physical activity programs may improve ability to perform activities of daily living
* Communication: allow person living with dementia sufficient time to respond; use simple commands; use a calm voice; avoid harsh tones and negative words; offer no more than two simple choices; help person find appropriate words for self-expression; lightly touch the person to provide reassurance if upset
* Cognitive stimulation: evidence of some benefit to persons with early- to middle-stage dementia; stimulate thinking, concentration, and memory in social settings. Reminiscence therapy.
* Sensory stimulation: music therapy; white noise; art/craft therapy; bright light therapy
* Environmental changes: remove clutter; use labels and visual cues (signs, arrows pointing to bathroom)
* Task simplification: break tasks into simple sets; use cues (verbal, tactile) or prompts at each stage; create structured daily routines.
* Other interventions being investigated include animal-assisted therapies, massage, reflexology, herbal supplements, etc.

Understanding the Middle Stage of Dementia for the Interprofessional Team (Module 6)

Middle-Stage Lewy Body Dementia (LBD): Including DLB and PDD
* Cognitive deterioration less consistent versus Alzheimer’s disease.
* Manifestations: Impaired thinking; Parkinsonian movement impairments; Visual hallucinations; Deterioration of language skills; Sleep disorders; Behavioral/mood symptoms; Alterations in autonomic body functions

Behavioral and Psychological Symptoms of Dementia (BPSD)
* Common symptoms include mood disorders, sleep disorders, psychotic symptoms, and agitation.
* These are predominantly caused by progressive damage to brain.

The DICE (describe, investigate, create, evaluate) Approach
(see slides)

Sleep Disorders: LBD
* Sleep disturbances affect up to 90% persons with LBD.
* REM sleep behavior disorder (RBD): Is suggestive of LBD. Is predictive for neurodegeneration in Parkinson’s disease. May precede dementia and worsen prognosis.
* People with Parkinson’s disease may experience excessive daytime sleepiness.
* People with Parkinson’s disease‒MCI (mild cognitive impairment) have poorer sleep efficiency and more nontremor features of Parkinson’s disease.

Treating Sleep Disorders in Dementia
* Nonpharmacologic interventions:
– Sleep hygiene
– Sleep restriction therapy
– Cognitive behavioral therapy
– Light therapy
– Continuous positive airway pressure therapy (CPAP) for sleep apnea (OSA)
* Melatonin/melatonin agonists
* Medications (especially sedative-hypnotics or antipsychotics) can have significant adverse effects.

Psychotic Symptoms
* Psychotic symptoms: More prevalent in PLwD during the middle-and later stages of dementia.
* Delusions: False beliefs that persist despite consistent evidence to the contrary. Generally simple and nonbizarre.
* Hallucinations: Sensory experiences that cannot be verified by anyone except the person experiencing them.
* Most commonly visual or auditory in dementia.

Palliative and End-of-Life Care for Persons Living with Dementia (Module 12)

Behavioral and Psychological Symptoms of End-Stage Dementia
* Behavioral and psychological symptoms of dementia may become more prominent in advanced dementia.
* New onset or acute behavioral problems are usually indicative of a new problem.
* Agitation requires prompt attention and evaluation; management should begin with nonpharmacologic interventions.
* PLwD should be assessed for sleep problems, delirium, and pain.