Antipsychotics in Dementia Lewy Bodies

1. Antipsychotics in
Dementia Lewy Bodies
Ade Wijaya, MD – September 2020

2. Introduction
Dementia
Visual
Hallucination
DLB
McKeith IG, Dickson DW, Lowe J, et al. Diagnosis and management of dementia with Lewy bodies: third report of the DLB Consortium. Neurology 2005;65:1863–1872.

3. Behavioral and Psychological Symptoms
Psychosis Anxiety Depression
Apathy Agitation
Borroni B, Agosti C, Padovani A. Behavioral and psychological symptoms in dementia with Lewy‐bodies (DLB): frequency and relationship with disease severity and motor impairment. Arch Gerontol Geriatr2008;46:101–106.

4. Most Common Symptoms
Delusion
Hallucination
QOL
Aarsland D, Ballard C, Larsen JP, McKeith I. A comparative study of psychiatric symptoms in dementia with Lewy bodies and Parkinson's disease with and without dementia. Int J Geriatr Psychiatry 2001;16:528–536.
Bostrom F, Jonsson L, Minthon L, Londos E. Patients with dementia with Lewy bodies have more impaired quality of life than patients with Alzheimer disease.Alzheimer Dis Assoc Disord 2007;21:150–154.

5. DLB Core Clinical Features
• Fluctuating cognition with pronounced variations in
attention and alertness
• Recurrent visual hallucinations that are typically well
formed and detailed
• REM sleep behavior disorder, which may precede cognitive
decline
• One or more spontaneous cardinal features of
parkinsonism: these are bradykinesia (defined as slowness
of movement and decrement in amplitude or speed), rest
tremor, or rigidity
*The first 3 typically occur early and may persist throughout the course
McKeith IG, Galasko D, Kosaka K, et al. Consensus guidelines for the clinical and pathologic diagnosis of dementia with Lewy bodies (DLB): report of the Consortium on DLB International Workshop. Neurology 1996; 47:1113–1124.
McKeith IG, Dickson DW, Lowe J, et al. Dementia with Lewy bodies: diagnosis and management: third report of the DLB Consortium. Neurology 2005;65:1863–1872.

6. Supportive Clinical Features
• Severe sensitivity to antipsychotic agents
• Postural instability
• Repeated falls
• Syncope or other transient episodes of unresponsiveness
• Severe autonomic dysfunction, e.g., constipation, orthostatic hypotension, urinary incontinence
• Hypersomnia
• Hyposmia
• Hallucinations in other modalities
• Systematized delusions
• Apathy
• Anxiety
• Depression
McKeith IG, Galasko D, Kosaka K, et al. Consensus guidelines for the clinical and pathologic diagnosis of dementia with Lewy bodies (DLB): report of the Consortium on DLB International Workshop. Neurology 1996; 47:1113–1124.
McKeith IG, Dickson DW, Lowe J, et al. Dementia with Lewy bodies: diagnosis and management: third report of the DLB Consortium. Neurology 2005;65:1863–1872.

7. Management
Armstrong MJ, Weintraub D. The case for antipsychotics in dementia with Lewy bodies. Movement disorders clinical practice. 2017 Jan;4(1):32.

8. Management
Armstrong MJ, Weintraub D. The case for antipsychotics in dementia with Lewy bodies. Movement disorders clinical practice. 2017 Jan;4(1):32.

9. Antipsychotic Selection
• Expert consensus favors clozapine use given its evidence in
PD psychosis and a lower risk of worsening parkinsonism.
However: risk of agranulocytosis (0.38%) and need routine
blood work
• Haloperidol was associated with the highest 6-months
mortality rate; quetiapine had the lowest risk
• Slow titration
Maust DT, Kim HM, Seyfried LS, et al.Antipsychotics, other psychotropics, and the risk of death in patients with dementia: number needed to harm. JAMA Psychiatry 2015;72:438–445.
Seppi K, Weintraub D, Coelho M, et al. The Movement Disorder Society evidence‐based medicine review update: treatments for the non‐motor symptoms of Parkinson's disease. Mov Disord 2011;26(suppl 3):S42–S80.

10. Summary
• Effective and safe treatment options for psychosis in
patients with DLB remain an unmet need
• Avoid antipsychotic use
• If fail, antipsychotics can be a reasonable strategy after
shared decision making if the risks of ongoing symptoms
outweigh those associated with treatment.

11. THANK YOU