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Lewy body dementia webinar final

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Presentation made by Drs. Charles Driscoll and Ms. Angela Taylor at the live webinar hosted by AlzPossible on the 29th of May, 2014. See recording at http://www.alzpossible.org/wordpress-3.1.4/wordpress/webinars-2/dementia-with-lewy-bodies/

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Lewy body dementia webinar final

  1. 1. Dementia with Lewy Bodies: Charles E. Driscoll, MD, FAAFP Geriatrician; Emeritus Professor of Family Medicine University of Virginia Lynchburg, VA Angela Taylor Director of Programs Lewy Body Dementia Association Lilburn, GA Clarity Emerging from Confusion
  2. 2. Poll • Do you work with or know someone who has Lewy Body Dementia? • Yes • No
  3. 3. Abbreviations • DLB – Dementia with Lewy Bodies • LB – Lewy Body • LBD – Lewy Body Dementia • MMSE – Mini Mental State Examination • PDD – Parkinson’s Disease Dementia • REM – Rapid Eye Movement
  4. 4. Learning Objectives Recognize it! Know how it differs from other dementias Understand LB is a spectrum of diseases Treatment and Management issues Family Care and Support Issues
  5. 5. The Slow Road of Discovery Dr. Friedrich Lewy identifies protein 1912 Hallmarks described in 1996 Added to International Classification of Diseases in 2005 Today, recognized as the second most common form of progressive dementia
  6. 6. Micrograph of brain cells containing a Lewy body which is an abnormal aggregation of protein Lewy bodies can be more easily detected using special antibody staining against the α-synuclein protein Tau protein and tangles within a neuron cell
  7. 7. The Many Faces of Lewy Body
  8. 8. Case Scenario - Hal • Hal, a veteran, retired from his work as an auto mechanic at age 68. • His boss had noticed a number of Hal’s repairs needed some review and “tweaking”. • Hal’s wife noticed he is more forgetful, becomes confused when following directions, and has some difficulties finding “the right word” in conversation. • Health is good with BP 134/84 and his only medications are a baby aspirin and a multi-vitamin daily. • Smokes 1ppd.
  9. 9. Poll… • Select the elements necessary to make a diagnosis of dementia • Demonstrated memory loss • Hallucinations • Interference with day to day function • Delusions • 2 or more cognitive areas involved
  10. 10. Does He Have Dementia? Necessary Elements for a diagnosis: Memory loss: subjective and objective Trouble in a second cognitive domain Language, Executive Function, Motor Skills, Social Skills, Visual- Spatial, Learning, Attention Interference with day-to-day function
  11. 11. Poll – open ended question • Name 3 symptoms that might suggest a diagnosis of DLB? Please use your Questions tab to enter three such symptoms (separated by commas)
  12. 12. Another Look at Our Patient, Hal Having been diagnosed with early dementia, Hal is seen again in 6 months. His wife notes some new problems: • He is sleeping and barely rousable for long periods during the day • He has become suspicious when his wife leaves the house, and thinks she is trying to sell their home • Sleep at night is disrupted by nightmares with “hitting at something in the dream” • A “sedative” was prescribed for the sleep problem, but it had paradoxical effects, raising his anxiety and restlessness
  13. 13. What Clues Can Suggest DLB? Fluctuation – good days and bad days REM sleep behavior disorder Difficulty with complex mental activities Day-time sleepiness Medication sensitivity – tranquilizers and neuroleptics Motor dysfunction Vivid hallucinations/Delusions Autonomic dysfunction Abnormal brain imaging
  14. 14. REM Sleep Behavior Disorder • Acting out dreams • Sometimes injured by falling out of bed • Sometimes injure sleep mate • May appear years before DLB diagnosis • Red flag symptom REM sleep behavior disorder Difficulty with complex mental activities Fluctuation – good days and bad days Day-time sleepiness Medication sensitivity Vivid hallucinations/Delusions Motor dysfunction Autonomic dysfunction Abnormal brain imaging
  15. 15. Difficulty with Complex Mental Activities • Executive function severely impaired • Visuospatial dysfunction • Decline in attention • Memory often relatively spared in the early stage REM sleep behavior disorder Difficulty with complex mental activities Fluctuation – good days and bad days Day-time sleepiness Medication sensitivity Vivid hallucinations/Delusions Motor dysfunction Autonomic dysfunction Abnormal brain imaging
  16. 16. Cognitive Fluctuation • Most difficult to define and identify • Fluctuation of MMSE scores by >5 points up & down over 6-month period • Family members say: • “appears drowsy, but awake”, “looks dazed” • “not aware of what is going on” • “can be fine one day and confused the next” • Minutes, hours or days between periods REM sleep behavior disorder Difficulty with complex mental activities Fluctuation – good days and bad days Day-time sleepiness Medication sensitivity Vivid hallucinations/Delusions Motor dysfunction Autonomic dysfunction Abnormal brain imaging
  17. 17. Hallucinations and Delusions Hallucinations – usually visual • more frequent in patients with poor eyesight • not unpleasant, but very real Delusions – usually misidentificati on type • someone is present in the room • phantom boarder delusion • people are stealing things REM sleep behavior disorder Difficulty with complex mental activities Fluctuation – good days and bad days Day-time sleepiness Medication sensitivity Vivid hallucinations/Delusions Motor dysfunction Autonomic dysfunction Abnormal brain imaging
  18. 18. Motor Dysfunction • Fine motor skills are lost • Rigidity • Parkinson symptoms • Tremor • Slowness of movement (bradykinesia) • Shuffling gait • Loss of balance • Falls REM sleep behavior disorder Difficulty with complex mental activities Fluctuation – good days and bad days Day-time sleepiness Medication sensitivity Vivid hallucinations/Delusions Motor dysfunction Autonomic dysfunction Abnormal brain imaging
  19. 19. Autonomic Dysfunction REM sleep behavior disorder Difficulty with complex mental activities Fluctuation – good days and bad days Day-time sleepiness Medication sensitivity Vivid hallucinations/Delusions Motor dysfunction Autonomic dysfunction Abnormal brain imaging
  20. 20. Putting it All Together LEWY BODY DEMENTIA Visual hallucinations and/or sensitivity to neuroleptics Acting out dreams (REM Sleep Behavior Disorder) and/or other sleep disturbances Motor dysfunction (may look like Parkinson’s) Autonomic dysfunction Cognitive dysfunction (may look like AD) Fluctuating levels of attention (may mimic delirium)
  21. 21. Taxonomy is somewhat arbitrary • No major clinical differences, both, DLB and PDD are LBD • ICD-9 codes are the same – 331.82 Is it DLB, PDD, or LBD? 12 months PDD DLB BY CONSENSUS: IF
  22. 22. Poll • What is one medication that should always be avoided in DLB? • Aricept • Valium • Seroquel • Haldol • Prozac
  23. 23. Treating Behavior LBD Disturbances Always evaluate for physical problem. • Is it delirium? Avoid or reduce medications. •Benzodiazepines, bladder Avoid traditional antipsychotics •Hallucinations and psychotic behaviors appear to be related to cholinergic deficits. •Try: • Donepezil, Rivastigmine, and Galantamine – a long term “fix.” • If urgent, try Quetiapine or Clozapine. • Note “black box” warnings to family. Use for shortest duration •Educate patient/family
  24. 24. Research Needed: Racial and Socioeconomic Disparities Parkinson’s Disease African Americans Whites Disease prevalence may be higher X Seek care earlier at specialty clinic X Greater disability X Greater disease severity X More likely to be prescribed dopaminergic medications, especially newer ones X More likely to be prescribed antipsychotics X
  25. 25. Importance of an Early Diagnosis • These patients respond differently to: • Neuroleptic medications • Anti-cholinesterase inhibitors • Parkinson’s medications • Different progression than Alzheimer’s • Shorter prognosis • Need advance planning • More family support needed • New research emerging at rapid rate
  26. 26. Poll • Do you work with or know someone who has LBD? • Yes • No
  27. 27. Quality of Life Matters • Comprehensive care of LBD symptoms improves quality of life and reduces caregiver burden • Coordinate treatment with patient’s other doctors to avoid exacerbating symptoms • Consider referrals to Physical Therapist, Occupational Therapist and Speech Therapist
  28. 28. Caregiver burden • Treat the primary caregiver as a second patient • Burden is associated with cognitive, behavioral or affective symptoms • Especially disturbances in mood and sleep • Caregivers should expect crises, especially trips to the emergency room
  29. 29. Poll – open ended question • Name some of the signs of caregiver burnout Please use your Questions tab to enter such signs (separated by commas)
  30. 30. Meal services Senior transportation Caregiver support groups Geriatric case manager Home health aides Adult day programs Long term care providers Helpful Community Services
  31. 31. Caregiving Tips to Share • Focus more on the individual than the disorder • Maintain a sense of humor • Limit noise and distractions • Simplify questions and expectations • Keep a regular routine • Address underlying emotions instead of behavior. • Stay flexible to fluctuating symptoms • Don’t accept sudden changes as a “normal” progression
  32. 32. Poll – open ended question • What would you do if you suspect a client has undiagnosed LBD or is possibly misdiagnosed with another disorder?
  33. 33. Help Relieve Caregiver Burden • If you or the family suspects LBD – urge a second opinion at a specialty clinic • Encourage learning about LBD and talking with other caregivers • LBD is likely to overstress and burden families. • Encourage them to accept help • Remind caregivers their well-being is equal to patient well-being • Recommend community-based services and resources • Watch for grieving
  34. 34. Help is Available Outreach EducationResearch Family Services LBD Caregiver Link (800) LEWY SOS (800) 539-9767 Caregiver support groups An active online community
  35. 35. Download free diagnostic and comprehensive symptom checklists from LBDA.org Order print copies of this 40 page booklet from NIA’s Alzheimer’s Disease Education and Referral Center Educational Resources
  36. 36. Stay Informed with LBDA • Visit our homepage, www.lbda.org and click this image: • Or visit: http://www.lbda.org/content/sign-lewy-body- digest-0

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