Lewy Body Dementia – Causes, Symptoms, Treatment

Lewy Body Dementia/It is a progressive degenerative brain disorder characterized by cognitive decline involving memory and at least 1 of the other domains, including personality, praxis, abstract thinking, language, executive functioning, complex attention, social and visuospatial skills,[rx] dementia, psychosis, and features of parkinsonism. Symptoms fluctuate with time and vary among different individuals. Diagnosis of LBD requires thorough clinical examination as many of its features overlap with other dementia disorders. This activity reviews the cause and presentation of Lewy body dementia and highlights the role of the interprofessional team in its management.

Lewy body dementia (LBD) is a complex and challenging brain disorder. It is complex because it affects many parts of the brain in ways that scientists are trying to understand more fully. It is challenging because its many possible symptoms make it hard to do everyday tasks that once came easily.

Although less known than its cousins Alzheimer’s disease and Parkinson’s disease, LBD is not a rare disorder. More than 1 million Americans, most of them older adults, are affected by its disabling changes in the ability to think and move.

As researchers seek better ways to treat LBD—and ultimately to find a cure—people with LBD and their families struggle day today to get an accurate diagnosis, find the best treatment, and manage at home.

This booklet is meant to help people with LBD, their families, and professionals learn more about the disease and resources for coping. It explains what is known about the different types of LBD and how they are diagnosed. Most importantly, it describes how to treat and manage this difficult disease, with practical advice for both people with LBD and their caregivers.

The Basics of Lewy Body Dementia

LBD is a disease associated with abnormal deposits of a protein called alpha-synuclein in the brain. These deposits, called Lewy bodies, affect chemicals in the brain whose changes, in turn, can lead to problems with thinking, movement, behavior, and mood. LBD is one of the most common causes of dementia, after Alzheimer’s disease and vascular disease.

Dementia is a severe loss of thinking abilities that interferes with a person’s capacity to perform daily activities such as household tasks, personal care, and handling finances. Dementia has many possible causes, including stroke, brain tumor, depression, and vitamin deficiency, as well as disorders such as LBD, Parkinson’s, and Alzheimer’s.

Diagnosing LBD can be challenging for a number of reasons. Early LBD symptoms are often confused with similar symptoms found in other brain diseases like Alzheimer’s. Also, LBD can occur alone or along with Alzheimer’s or Parkinson’s disease.

There are two types of LBD—dementia with Lewy bodies and Parkinson’s disease dementia. The earliest signs of these two diseases differ but reflect the same biological changes in the brain. Over time, people with dementia with Lewy bodies or Parkinson’s disease dementia may develop similar symptoms

Who Is Affected by LBD?

LBD affects more than 1 million individuals in the United States. LBD typically begins at age 50 or older, although sometimes younger people have it. LBD appears to affect slightly more men than women.

LBD is a progressive disease, meaning symptoms start slowly and worsen over time. The disease lasts an average of 5 to 7 years from the time of diagnosis to death, but the time span can range from 2 to 20 years. How quickly symptoms develop and change varies greatly from person to person, depending on overall health, age, and severity of symptoms.

In the early stages of LBD, usually, before a diagnosis is made, symptoms can be mild, and people can function fairly normally. As the disease advances, people with LBD require more and more help due to a decline in thinking and movement abilities. In the later stages of the disease, they may depend entirely on others for assistance and care.

Some LBD symptoms may respond to treatment for a period of time. Currently, there is no cure for the disease. Research is improving our understanding of this challenging condition, and advances in science may one day lead to better diagnosis, improved care, and new treatments.

What Are Lewy Bodies?

Lewy bodies are named for Dr. Friederich Lewy, a German neurologist. In 1912, he discovered abnormal protein deposits that disrupt the brain’s normal functioning in people with Parkinson’s disease. These abnormal deposits are now called “Lewy bodies.”

Lewy bodies are made of a protein called alpha-synuclein. In a healthy brain, alpha-synuclein plays a number of important roles in neurons (nerve cells) in the brain, especially at synapses, where brain cells communicate with each other. In LBD, alpha-synuclein forms into clumps inside neurons, starting in particular regions of the brain. This process causes neurons to work less effectively and, eventually, to die. The activities of brain chemicals important to brain function are also affected. The result is widespread damage to certain parts of the brain and a decline in abilities affected by those brain regions.

Lewy bodies affect several different brain regions in LBD:

• the cerebral cortex, which controls many functions, including information processing, perception, thought, and language
• the limbic cortex, which plays a major role in emotions and behavior
• the hippocampus, which is essential to forming new memories
• the midbrain, including the substantia nigra, which is involved in a movement
• the brain stem, which is important in regulating sleep and maintaining alertness
• brain regions important in recognizing smells (olfactory pathways).

Types of Lewy Body Dementia

Lewy body dementia includes two related conditions—dementia with Lewy bodies and Parkinson’s disease dementia. The difference between them lies largely in the timing of cognitive (thinking) and movement symptoms. In dementia with Lewy bodies, cognitive symptoms are noted within a year of parkinsonism, any condition that involves the types of movement changes, such as tremor or muscle stiffness, seen in Parkinson’s disease. In Parkinson’s disease dementia, movement symptoms are pronounced in the early stages, with cognitive symptoms developing years later.

Dementia with Lewy Bodies

People with dementia with Lewy bodies have a decline in thinking ability that may look somewhat like Alzheimer’s disease. But over time they also develop movement and other distinctive symptoms that suggest dementia with Lewy bodies. Symptoms that distinguish this form of dementia from others may include:

• visual hallucinations early in the course of dementia
• fluctuations in cognitive ability, attention, and alertness
• the slowness of movement, difficulty walking, or rigidity (parkinsonism)
• sensitivity to medications used to treat hallucinations
• REM sleep behavior disorder, in which people physically act out their dreams by yelling, flailing, punching bed partners, and falling out of bed
• more trouble with complex mental activities, such as multitasking, problem-solving, and analytical thinking, than with memory

Parkinson’s Disease Dementia

This type of LBD starts as a movement disorder, with symptoms such as slowed movement, muscle stiffness, tremor, and a shuffling walk. These symptoms are consistent with a diagnosis of Parkinson’s disease. Later on, cognitive symptoms of dementia and changes in mood and behavior may arise. Not all people with Parkinson’s develop dementia, and it is difficult to predict who will. Being diagnosed with Parkinson’s late in life is a risk factor for Parkinson’s disease dementia.

Causes and Risk Factors

The precise cause of LBD is unknown, but scientists are learning more about its biology and genetics. For example, they know that an accumulation of Lewy bodies is associated with a loss of certain neurons in the brain that produces two important neurotransmitters, chemicals that act as messengers between brain cells. One of these messengers, acetylcholine, is important for memory and learning. The other, dopamine, plays an important role in behavior, cognition, movement, motivation, sleep, and mood.

Scientists are also learning about risk factors for LBD. Age is considered the greatest risk factor. Most people who develop the disorder are over age 50.

Other known risk factors for LBD include the following:

• Diseases and health conditions – Certain diseases and health conditions, particularly Parkinson’s disease and REM sleep behavior disorder, are linked to a higher risk of LBD.
• Genetics – While having a family member with LBD may increase a person’s risk, LBD is not normally considered a genetic disease. A small percentage of families with dementia with Lewy bodies has a genetic association, such as a variant of the GBA gene, but in most cases, the cause is unknown. At this time, no genetic test can accurately predict whether someone will develop LBD. Future genetic research may reveal more information about causes and risks.
• Lifestyle – No specific lifestyle factor has been proven to increase one’s risk for LBD. However, some studies suggest that a healthy lifestyle— including regular exercise, mental stimulation, and a healthy diet— might reduce the chance of developing age-associated dementias.

Common Symptoms

People with LBD may not have every LBD symptom, and the severity of symptoms can vary greatly from person to person. Throughout the course of the disease, any sudden or major change in functional ability or behavior should be reported to a doctor.

The most common symptoms include changes in cognition, movement, sleep, and behavior.

Cognitive Symptoms

LBD causes changes in thinking abilities. These changes may include:

• Dementia—Severe loss of thinking abilities that interferes with a person’s capacity to perform daily activities. Dementia is a primary symptom in LBD and usually includes trouble with visual and spatial abilities (judging distance and depth or misidentifying objects), planning, multitasking, problem-solving, and reasoning. Memory problems may not be evident at first but often arise as LBD progresses. Dementia can also include changes in mood and behavior, poor judgment, loss of initiative, confusion about time and place, and difficulty with language and numbers.
• Cognitive fluctuations— Unpredictable changes in concentration, attention, alertness, and wakefulness from day to day and sometimes throughout the day. A person with LBD may stare into space for periods of time, seem drowsy and lethargic, or sleep for several hours during the day despite getting enough sleep the night before. His or her flow of ideas may be disorganized, unclear, or illogical at times. The person may seem better one day, then worse the next day. These cognitive fluctuations are common in LBD but are not always easy for a doctor to identify.
• Hallucinations— Seeing or hearing things that are not present. Visual hallucinations occur in up to 80 percent of people with LBD, often early on. They are typically realistic and detailed, such as images of children or animals. Auditory hallucinations are less common than visual ones but may also occur. Hallucinations that are not disruptive may not require treatment. However, if they are frightening or dangerous (for example, if the person attempts to fight a perceived intruder), then a doctor may prescribe medication.

Movement Symptoms

Some people with LBD may not experience significant movement problems for several years. Others may have them early on. At first, signs of movement problems, such as a change in handwriting, may be very mild and thus overlooked. Parkinsonism is seen early on in Parkinson’s disease dementia but can also develop later on in dementia with Lewy bodies. Specific signs of parkinsonism may include:

• muscle rigidity or stiffness
• shuffling gait, slow movement, or frozen stance
• tremor or shaking, most commonly at rest
• balance problems and falls
• stooped posture
• loss of coordination
• smaller handwriting than was usual for the person
• reduced facial expression
• difficulty swallowing
• a weak voice

Sleep Disorders

Sleep disorders are common in people with LBD but are often undiagnosed. Asleep specialists can play an important role on a treatment team, helping to diagnose and treat sleep disorders. Sleep-related disorders seen in people with

LBD may include:

• REM sleep behavior disorder—A condition in which a person seems to act out dreams. It may include vivid dreaming, talking in one’s sleep, violent movements, or falling out of bed. Sometimes only the bed partner of the person with LBD is aware of these symptoms. REM sleep behavior disorder appears in some people years before other LBD symptoms.
• Excessive daytime sleepiness—Sleeping 2 or more hours during the day.
• Insomnia—Difficulty falling or staying asleep, or waking up too early.
• Restless leg syndrome—A condition in which a person, while resting, feels the urge to move his or her legs to stop unpleasant or unusual sensations. Walking or moving usually relieves the discomfort.

Behavioral and Mood Symptoms

Changes in behavior and mood are possible in LBD. These changes may include:

• Depression—A persistent feeling of sadness, inability to enjoy activities, or trouble with sleeping, eating, and other normal activities.
• Apathy—A lack of interest in normal daily activities or events; less social interaction.
• Anxiety—Intense apprehension, uncertainty, or fear about a future event or situation. A person may ask the same questions over and over or be angry or fearful when a loved one is not present.
• Agitation—Restlessness, as seen by pacing, hand wringing, an inability to get settled, the constant repeating of words or phrases, or irritability.
• Delusions—Strongly held false beliefs or opinions not based on evidence. For example, a person may think his or her spouse is having
  an affair or that relatives long dead are still living. Another delusion that may be seen in people with LBD is Capgras syndrome, in which the person believes a relative or friend has been replaced by an imposter.
• Paranoia—An extreme, irrational distrust of others, such as suspicion that people are taking or hiding things.

Other LBD Symptoms

People with LBD can also experience significant changes in the part of the nervous system that regulates automatic functions such as those of the heart, glands, and muscles. The person may have:

• changes in body temperature
• problems with blood pressure
• dizziness
• fainting
• frequent falls
• sensitivity to heat and cold
• sexual dysfunction
• urinary incontinence
• constipation
• a poor sense of smell

In addition to symptoms of dementia, the following atypical symptoms may be seen in the following conditions

• In patients with LBD, symptoms of well-formed visual hallucinations, delusions, sleep disturbances, and trouble processing visual information can be seen.
• In patients with CJD, symptoms of muscle stiffness, twitches, muscle jerks, visual hallucinations, and double vision may be seen.
• In patients with Huntington’s disease, symptoms of chorea, irritability, and obsessive-compulsive behavior may be seen.
• In patients with vascular dementia, symptoms of imbalance, headache, sensorimotor deficits, and speech difficulties may be seen.
• In patients with FTD, behavior changes, problems with spatial orientation, and speech difficulties may be seen.
• In patients with PDD, symptoms of parkinsonism characterized by muffled speech, slow movement, tremors may be seen. In addition, visual hallucinations and delusions may also be seen, especially in the late stages.

Diagnosis

It’s important to know which type of LBD a person has, both to tailor treatment to particular symptoms and to understand how the disease will likely progress. Clinicians and researchers use the “1-year rule” to diagnose which form of LBD a person has. If cognitive symptoms appear within a year of movement problems, the diagnosis is dementia with Lewy bodies. If cognitive problems develop more than a year after the onset of movement problems, the diagnosis is Parkinson’s disease dementia.

Regardless of the initial symptoms, over time people with LBD often develop similar symptoms due to the presence of Lewy bodies in the brain. But there are some differences. For example, dementia with Lewy bodies may progress more quickly than Parkinson’s disease dementia.

Dementia with Lewy bodies is often hard to diagnose because its early symptoms may resemble those of Alzheimer’s, Parkinson’s disease, or a psychiatric illness. As a result, it is often misdiagnosed or missed altogether. As additional symptoms appear, it is often easier to make an accurate diagnosis.

The good news is that doctors are increasingly able to diagnose LBD earlier and more accurately as researchers identify which symptoms help distinguish it from similar disorders.

No single test, such as a blood test, can be used to diagnose a frontotemporal disorder. A definitive diagnosis can be confirmed only by a genetic test in familial cases or a brain autopsy after a person dies. To diagnose a probable frontotemporal disorder in a living person, a doctor— usually a neurologist, psychiatrist, or psychologist—will

Laboratory tests to be considered in all patients in the evaluation of dementia include complete blood count, urinalysis, metabolic panel, B12, folic acid, Thyroid function tests, serological tests for syphilis. Additional work up to be considered when symptoms are atypical for Alzheimer dementia include erythrocyte sedimentation rate, electroencephalography (EEG), magnetic resonance imaging (MRI) of the brain, lumbar puncture, heavy metal screen, ceruloplasmin levels, Lyme disease titer, human immunodeficiency virus (HIV) screening, serum protein electrophoresis, etc,

Difficult as it is, getting an accurate diagnosis of LBD early on is important so that a person:

• gets the right medical care and avoids potentially harmful treatment
• has time to plan medical care and arrange legal and financial affairs
• can build a support team to stay independent and maximize the quality of life

While a diagnosis of LBD can be distressing, some people are relieved to know the reason for their troubling symptoms. It is important to allow time to adjust to the news. Talking about a diagnosis can help shift the focus toward developing a care plan.

Tests Used to Diagnose LBD

Doctors perform physical and neurological examinations and various tests to distinguish LBD from other illnesses. An evaluation may include:

• Medical history and examination—A review of previous and current illnesses, medications, and current symptoms and tests of movement and memory give the doctor valuable information.
• Medical tests—Laboratory studies can help rule out other diseases and hormonal or vitamin deficiencies that can be associated with cognitive changes.
• Brain imaging—Computed tomography or magnetic resonance imaging can detect brain shrinkage or structural abnormalities and help rule out other possible causes of dementia or movement symptoms.
• Neuropsychological tests—These tests are used to assess memory and other cognitive functions and can help identify affected brain regions.

There are no brain scans or medical tests that can definitively diagnose LBD. Currently, LBD can be diagnosed with certainty only by a brain autopsy after death.

• Positron emission tomography –  and single-photon emission computed tomography—have shown promise in detecting differences between dementia with Lewy bodies and Alzheimer’s disease. These methods may help diagnose certain features of the disorder, such as dopamine deficiencies. Researchers are also investigating the use of lumbar puncture (spinal tap) to measure proteins in cerebrospinal fluid that might distinguish dementia with Lewy bodies from Alzheimer’s disease and other brain disorders.
• Formal neuropsychological testing – can help with the establishment of the diagnosis and social decision-making as the disease advances. These have high sensitivity and specificity. They can help evaluate the extent and severity of cognitive impairment as well as behavioral impairments. They can help differentiate normal aging from mild cognitive impairment and identify the type of dementia.
• Functional brain imaging with PET, SPECT – and fMRI can help in early diagnosis and monitoring of patients with dementia, especially AD. These can also help differentiate the etiology of dementia. These are expensive and routine use in clinical practice is not indicated.
• CJD – The diagnosis of CJD is established by the presence of rapidly progressive dementia and the presence of at least 2 of the 4: myoclonus, akinetic mutism, pyramidal/extrapyramidal signs, and visual/cerebellar signs. CJD has unique abnormalities in diagnostic testing, and these can help in confirming the diagnosis. Periodic sharp-wave complexes at 1 Hz frequency are characteristic EEG findings seen in this condition, though other findings like diffuse slowing and frontal rhythmic delta activity. MRI may show T2 hyperintensity in the basal ganglia, thalamus, and cortex. 14-3-3 is positive in CSF testing.[rx]
• MIBG Myocardial scintigraphy – Cardiac autonomic denervation is found in Lewy body diseases such as PD, DLB, and pure autonomic failure [rx]. Meta-iodobenzylguanidine (MIBG) is a noradrenaline analog that binds to presynaptic cardiac autonomic nerve terminals. MIBG binding in the heart is compared to non-specific binding in the mediastinum. Single-center studies have demonstrated high sensitivity and specificity of MIBG scintigraphy [rx–rx]. The only multicentre study to date found a sensitivity of 69% and specificity of 89% [rx]. The diagnostic accuracy of MIBG in this study improved when compared with clinical diagnosis 3 years after the scan (sensitivity 77%, specificity 97%) [rx].
• A limitation of MIBG scintigraphy – is that comorbid conditions and medications can reduce cardiac MIBG uptake [rx]. As a result, studies have excluded participants with common conditions such as heart failure, ischaemic heart disease, and poorly-controlled diabetes [rx]. Thresholds for abnormality in the H: M ratio differ between centers, due in part to differences in collimators (from 1.60 to 2.20 in the above studies) [rx, rx]. Individual centers should therefore develop local thresholds prior to clinical application.
• Polysomnography – Polysomnography allows for the objective identification of RBD by measuring EEG, eye movements, and muscle movement during sleep. Polysomnography-confirmed RBD has a very high diagnostic specificity of 98% for synucleinopathies (PD, DLB, or MSA) [rx]. It had an 84% sensitivity in post-mortem confirmed DLB cases [rx]. Sensitivity may be limited by the absence of REM sleep in some polysomnography sessions.

Other Helpful Information

It is important for the patient and a close family member or friend to tell the doctor about any symptoms involving thinking, movement, sleep, behavior, or mood. Also, discuss other health problems and provide a list of all current medications, including prescriptions, over-the-counter drugs, vitamins, and supplements. Certain medications can worsen LBD symptoms.

Caregivers may be reluctant to talk about a person’s symptoms when that person is present. Ask to speak with the doctor privately if necessary. The more information a doctor has, the more accurate a diagnosis can be.]

Treatment and Management

While LBD currently cannot be prevented or cured, some symptoms may respond to treatment for a period of time. A comprehensive treatment plan may involve medications, physical and other types of therapy, and counseling. Changes to make the home safer, equipment to make everyday tasks easier, and social support are also very important.

A skilled care team often can provide suggestions to help improve the quality of life for both people with LBD and their caregivers.

Building a Care Team

After receiving a diagnosis, a person with LBD may benefit from seeing a neurologist who specializes in dementia and/or movement disorders. A good place to find an LBD specialist is at dementia or movement disorders clinic in an academic medical center in your community. If such a specialist cannot be found, a general neurologist should be part of the care team. Ask a primary care physician for a referral.

A doctor can work with other types of healthcare providers. Depending on an individual’s particular symptoms, other professionals may be helpful:

• Physical therapists – can help with movement problems through cardiovascular, strengthening, and flexibility exercises, as well as gait
  training and general physical fitness programs.
• Speech therapists – may help with low voice volume, voice projection, and swallowing difficulties.
• Occupational therapists – help identify ways to more easily carry out everyday activities, such as eating and bathing, to promote independence.
• Music or expressive arts therapists – may provide meaningful activities that can reduce anxiety and improve well-being.
• Mental health counselors – can help people with LBD and their families learn how to manage difficult emotions and behaviors and
  plan for the future.

Support groups are another valuable resource for both people with LBD and caregivers. Sharing experiences and tips with others in the same situation can help people identify practical solutions to day-to-day challenges and get emotional and social support. To find a support group near you, see the “Resources” section.

Medications

Several drugs and other treatments are available to treat LBD symptoms. It is important to work with a knowledgeable health professional because certain medications can make some symptoms worse. Some symptoms can improve with nondrug treatments.

Pharmacological Management

• Cholinesterase inhibitors – Used to treat the cognitive symptoms of LBD and are the mainstay of treatment. Initially developed for Alzheimer’s disease treatment, they are probably more effective in patients with LBD. These include rivastigmine, galantamine, and donepezil.
• Carbidopa-Levodopa – Used to treat movement symptoms.; however, it has serious side effects and can lead to delusions, hallucinations, and confusion and practitioners should use them with caution in these patients, and they should start with low doses if required.
• Atypical antipsychotics – Used to treat hallucinations that cause significant distress in patients not responding to standard cholinesterase inhibitors. Commonly used drugs include pimavanserin, clozapine, quetiapine, and aripiprazole. Use with caution due to neuroleptic sensitivity in these patients.
• Clonazepam/melatonin – Used for REM sleep behavior disorder.
• SSRIs – Depression is common in patients with LBD and often requires antidepressant therapy with SSRIs.
• Memantine – has been investigated in clinical trials and may work in patients with early disease.
• Nelotanserin – is a second novel therapeutic undergoing clinical trials as a treatment for DLB. Nelotanserin is an inverse agonist of serotonin receptors of the subtype 5-HT_2A. Randomized clinical trials are ongoing to assess nelotanserin’s safety and tolerance based on the incidence of adverse effects. These ongoing randomized-clinical trials are also observing changes in extrapyramidal symptoms and frequency of visual hallucinations; an open-label study is ongoing as well. Results are not yet available from these studies but prespecified analyses of the DLB patient subset have shown improvement in parkinsonian symptoms [a 4.00-point improvement in the Unified Parkinson’s Disease Rating Schedule (p = 0.041, unadjusted)] when ketanserin was compared with placebo. In patients with a baseline Scale for the Assessment of Positive Symptoms > 8.0, nelotanserin treatment at 40 mg for 2 weeks followed by 80 mg for 2 weeks led to a 1.21 point improvement (p = 0.011, unadjusted). However, this improvement was not observed in the entire evaluable population. Nelotanserin was also generally well-tolerated in the patients involved [rx–rx]
• Stem Cell Therapy – Stem cell therapy has been hypothesized as a treatment modality for DLB. Researchers developed an immune-deficient transgenic DLB murine model that exhibited progressive accumulation of human alpha-synuclein inclusions as well as cognitive and motor impairments, similar to that of patients suffering from DLB. Following grafts of human neural progenitor cells (CNS10-hNPCs), behavior assessments of the experimental murine model were completed at 30 and 90 days. Transplantation of these cells was found to rescue motor and cognitive deficits among the experimental murine model. Restoration of dopaminergic and glutamatergic regulation was additionally observed [rx].

Support and Therapies

Patient and caregiver education regarding symptoms of a disease and their management is necessary. Understanding the disease helps the caregivers cope with everyday challenges. They require home modifications occasionally and individual patient needs should specifically guide them.[rx][rx][rx]

Patients can take part in different therapies to improve their quality of life, including:

• Physiotherapy
• Occupational therapy
• Speech therapy
• Support groups
• Individual and family psychotherapies.
• Exercise

Cognitive Symptoms

Some medications used to treat Alzheimer’s disease also may be used to treat the cognitive symptoms of LBD. These drugs, called cholinesterase inhibitors, act on a chemical in the brain that is important for memory and thinking. They may also improve behavioral symptoms. (See “Behavioral and Mood Problems” on page 22 for more information.) The U.S. Food and Drug Administration (FDA) approves specific drugs for certain uses after rigorous testing and review. The FDA has approved one Alzheimer’s drug, rivastigmine (Exelon®), to treat cognitive symptoms in Parkinson’s disease dementia. This and other Alzheimer’s drugs can have side effects such as nausea and diarrhea.

Movement Symptoms

LBD-related movement symptoms may be treated with a Parkinson’s medication called carbidopa-levodopa (Sinemet, Parcopa, Stalevo). This drug can help improve functioning by making it easier to walk, get out of bed, and move around. However, it cannot stop or reverse the progress of the disease.

Side effects of this medication can include hallucinations and other psychiatric or behavioral problems. Because of this risk, physicians may recommend not treating mild movement symptoms with medication. If prescribed, carbidopa-levodopa usually begins at a low dose and is increased gradually. Other Parkinson’s medications are less commonly used in people with LBD due to a higher frequency of side effects.

A surgical procedure called deep brain stimulation, which can be very effective in treating the movement symptoms of Parkinson’s disease is not recommended for people with LBD because it can result in greater cognitive impairment.

People with LBD may benefit from physical therapy and exercise. Talk with your doctor about what physical activities are best.

Sleep Disorders

Sleep problems may increase confusion and behavioral problems in people with LBD and add to a caregiver’s burden. A physician can order a sleep study to identify any underlying sleep disorders such as sleep apnea, restless leg syndrome, and REM sleep behavior disorder.

REM sleep behavior disorder, a common LBD symptom, involves acting out one’s dreams, leading to lost sleep and even injuries to sleep partners. Clonazepam (Klonopin®), a drug used to control seizures and relieve panic attacks, is often effective for the disorder at very low dosages. However, it can have side effects such as dizziness, unsteadiness, and problems with thinking. Melatonin, a naturally occurring hormone used to treat insomnia, may also offer some benefit when taken alone or with clonazepam.

Excessive daytime sleepiness is also common in LBD. If it is severe, a sleep specialist may prescribe a stimulant to help the person stay awake during the day.

Some people with LBD may have difficulty falling asleep. If trouble sleeping at night (insomnia) persists, a physician may recommend a prescription medication to promote sleep. It is important to note that treating insomnia and other sleep problems in people with LBD has not been extensively studied and that treatments may worsen daytime sleepiness and should be used with caution.

Certain sleep problems can be addressed without medications. Increasing daytime exercise or activities and avoiding lengthy or frequent naps can promote better sleep. Avoiding alcohol, caffeine, or chocolate late in the day can help, too. Some over-the-counter medications can also affect sleep, so review all medications and supplements with a physician.

Behavioral and Mood Problems

Behavioral and mood problems in people with LBD can arise from hallucinations or delusions. They may also be a result of pain, illness, stress or anxiety, and the inability to express frustration, fear or feeling overwhelmed. The person may resist care or lash out verbally or physically. Caregivers must try to be patient and use a variety of strategies to handle such challenging behaviors. Some behavioral problems can be managed by making changes in the person’s environment and/or treating medical conditions. Other problems may require medication.

The first step is to visit a doctor to see if a medical condition unrelated to LBD is causing the problem. Injuries, fever, urinary tract or pulmonary infections, pressure ulcers (bed sores), and constipation can worsen behavioral problems. Increased confusion can also occur.

Certain medications used to treat LBD symptoms or other diseases may also cause behavioral problems. For example, some sleep aids, pain medications, bladder control medications, and drugs used to treat LBD-related movement symptoms can cause confusion, agitation, hallucinations, and delusions. Similarly, some anti-anxiety medicines can actually increase anxiety in people with LBD. Review your medications with your doctor to determine if any changes are needed.

Not all behavioral problems are caused by illness or medication. A person’s surroundings—including levels of stimulation or stress, lighting, daily routines, and relationships—can lead to behavior issues. Caregivers can alter the home environment to try to minimize anxiety and stress for the person with LBD. In general, people with LBD benefit from having simple tasks, consistent schedules, regular exercise, and adequate sleep. Large crowds or overly stimulating environments can increase confusion and anxiety.

Hallucinations and delusions are among the biggest challenges for LBD caregivers. The person with LBD may not understand or accept that the hallucinations are not real and become agitated or anxious. Caregivers can help by responding to the fears expressed instead of arguing or responding factually to comments that may not be true. By tuning in to the person’s emotions, caregivers can offer empathy and concern, maintain the person’s dignity, and limit further tension.

Cholinesterase inhibitors may reduce hallucinations and other psychiatric symptoms of LBD. These medications may have side effects, such as nausea, and are not always effective. However, they can be a good first choice to treat behavioral symptoms. Cholinesterase inhibitors do not affect behavior immediately, so they should be considered part of a long-term strategy.

Antidepressants can be used to treat depression and anxiety, which are common in LBD. Two types of antidepressants called selective serotonin reuptake inhibitors and serotonin and norepinephrine reuptake inhibitors, are often well tolerated by people with LBD.

In some cases, antipsychotic medications are necessary to treat LBD-related behavioral symptoms to improve both the quality of life and safety of the person with LBD and his or her caregiver. These types of medications must be used with caution because they can cause severe side effects and can worsen movement symptoms.

If antipsychotics are prescribed, it is very important to use the newer kind, called atypical antipsychotics. These medications should be used at the lowest dose possible and for the shortest time possible to control symptoms. Many LBD experts prefer quetiapine (Seroquel®) or clozapine (Clozaril®, FazaClo®) to control difficult behavioral symptoms. Typical (or traditional) antipsychotics, such as haloperidol (Haldol®), generally should not be prescribed for people with LBD. They can cause dangerous side effects.

Other Treatment Considerations

LBD affects the part of the nervous system that regulates automatic actions like blood pressure and digestion. One common symptom is orthostatic hypotension, low blood pressure that can cause dizziness and fainting. Simple measures such as leg elevation, elastic stockings, and, when recommended by a doctor, increasing salt and fluid intake can help.

If these measures are not enough, a doctor may prescribe medication. Urinary incontinence (loss of bladder control) should be treated cautiously because certain medications used to treat this condition may worsen cognition or increase confusion. Consider seeing a urologist. Constipation can often be treated by exercise and changes in diet, though laxatives and stool softeners may be necessary.

People with LBD are often sensitive to prescription and over-the-counter medications for other medical conditions. Talk with your doctor about any side effects seen in a person with LBD.

If surgery is planned and the person with LBD is told to stop taking all medications beforehand, ask the doctor to consult the person’s neurologist in developing a plan for careful withdrawal. In addition, be sure to talk with the anesthesiologist in advance to discuss medication sensitivities and risks unique to LBD. People with LBD who receive certain anesthetics may become confused or delirious and have a sudden, significant decline in functional abilities, which may become permanent.

Depending on the procedure, possible alternatives to general anesthesia may include a spinal or regional block. These methods are less likely to result in confusion after surgery. Caregivers should also discuss the use of strong pain relievers after surgery since people with LBD can become delirious if these drugs are used too freely.

Advice for People Living with Lewy Body Dementia

Coping with a diagnosis of LBD and all that follows can be challenging. Getting support from family, friends, and professionals is critical to ensuring the best possible quality of life. Creating a safe environment and preparing for the future is important, too. Take time to focus on your strengths, enjoy each day, and make the most of your time with family and friends. Here are some ways to live with LBD day today.

Getting Help

Your family and close friends are likely aware of changes in your thinking, movement, or behavior. You may want to tell others about your diagnosis so they can better understand the reason for these changes and learn more about LBD. For example, you could say that you have been diagnosed with a brain disorder called Lewy body dementia, which can affect thinking, movement, and behavior. You can say that you will need more help over time. By sharing your diagnosis with those closest to you, you can build a support team to help you manage LBD.

As LBD progresses, you will likely have more trouble managing everyday tasks such as taking medication, paying bills, and driving. You will gradually need more assistance from family members, friends, and perhaps professional caregivers. Although you may be reluctant to get help, try to let others partner with you so you can manage responsibilities together. Remember, LBD affects your loved ones, too. You can help reduce their stress when you accept their assistance.

Finding someone you can talk with about your diagnosis—a trusted friend or family member, a mental health professional, or a spiritual advisor—may be helpful. See the “Resources” section to find supportive services in your area.

Consider Safety

The changes in thinking and movement that occur with LBD require attention to safety issues. Consider these steps:

• Fill out and carry the LBD Medical Alert Wallet Card and present it any time you are hospitalized, require emergency medical care, or meet with your doctors. It contains important information about medication sensitivities.
• Consider subscribing to a medical alert service, in which you push a button on a bracelet or necklace to access 911 if you need emergency help.
• Address safety issues in your home, including areas of fall risk, poor lighting, stairs, or cluttered walkways. Think about home modifications that may be needed, such as installing grab bars in the bathroom or modifying stairs with ramps. Ask your doctor to refer you to a home health agency for a home safety evaluation.
• Talk with your doctor about LBD and driving, and have your driving skills evaluated if needed.

Plan for Your Future

There are many ways to plan ahead. Here are some things to consider:

• If you are working, consult with a legal and financial expert about planning for disability leave or retirement. Symptoms of LBD will
  interfere with work performance over time, and it is essential to plan now to obtain the benefits you are entitled to.
• Consult with an attorney who specializes in elder law or estate planning to help you write or update important documents, such as a
  living will, healthcare power of attorney, and will.
• Identify local resources for home care, meals, and other services before you need them so you know whom to call when the time comes.
• Explore moving to a retirement or continuing care community where activities and varying levels of care can be provided over time, as needed. Ask about staff members’ experience caring for people with LBD.

Find Enjoyment Every Day

It is important to focus on living with LBD. Your attitude can help you find enjoyment in daily life. Despite the many challenges and adjustments, you can have moments of humor, tenderness, and gratitude with the people closest to you.

Make a list of events and activities you can still enjoy—then find a way to do them! For example, listening to music, exercising, or going out for a meal allows you to enjoy time with family and friends. If you can’t find pleasure in daily life, consult your doctor or another healthcare professional to discuss effective ways to cope and move forward. Let your family know if you are struggling emotionally so they can offer support.

Caring for a Person with Lewy Body Dementia

As someone who is caring for a person with LBD, you will take on many different responsibilities over time. You do not have to face these responsibilities alone. Many sources of help are available, from adult day centers and respite care to online and in-person support groups.

Below are some important actions you can take to adjust to your new roles, be realistic about your situation, and care for yourself. See the “Resources” section for more information.

Educate Others About LBD

Most people, including many healthcare professionals, are not familiar with LBD. In particular, emergency room physicians and other hospital workers may not know that people with LBD are extremely sensitive to antipsychotic medications. Caregivers can educate healthcare professionals and others by:

• Informing hospital staff of the LBD diagnosis and medication sensitivities, and requesting that the person’s neurologist be consulted
  before giving any drugs to control behavior problems.
• Sharing educational pamphlets and other materials with doctors, nurses, and other healthcare professionals who care for the person with LBD.
• Teaching family and friends about LBD so they can better understand your situation.

Adjust Expectations

You will likely experience a wide range of emotions as you care for the person with LBD. Sometimes, caregiving will feel loving and rewarding. Other times, it will lead to anger, impatience, resentment, or fatigue. You must recognize your strengths and limitations, especially in light of your past relationship with the person. Roles may change between a husband and wife or between a parent and adult children. Adjusting expectations can allow you to approach your new roles realistically and to seek help as needed.

People approach challenges at varied paces. Some people want to learn everything possible and be prepared for every scenario, while others manage best by taking one day at a time. Caring for someone with LBD requires balance. On one hand, you should plan for the future. On the other hand, you may want to make each day count in personal ways and focus on creating enjoyable and meaningful moments.

Care for Yourself

As a caregiver, you play an essential role in the life of the person with LBD, so it is critical for you to maintain your own health and well-being. You may be at increased risk for poor sleep, depression, or illness as a result of your responsibilities. Watch for signs of physical or emotional fatigue such as irritability, withdrawal from friends and family, and changes in appetite or weight.

All caregivers need time away from caregiving responsibilities to maintain their well-being. Learn to accept help when it’s offered and learn to ask family and friends for help. One option is professional respite care, which can be obtained through home care agencies and adult day programs. Similarly, friends or family can come to the home or take the person with LBD on an outing to give you a break.

Address Family Concerns

Not all family members may understand or accept LBD at the same time, and this can create conflict. Some adult children may deny that parents have a problem, while others may be supportive. It can take a while to learn new roles and responsibilities.

Family members who visit occasionally may not see the symptoms that primary caregivers see daily and may underestimate or minimize your responsibilities or stress. Professional counselors can help with family meetings or provide guidance on how families can work together to manage LBD.

Helping Children and Teens Cope with LBD

When someone has Lewy body dementia, it affects the whole family, including children and grandchildren. Children notice when something “doesn’t seem right.” Telling them in age-appropriate language that someone they know or love has been diagnosed with a brain disorder can help them make sense of the changes they see. Give them enough information to answer questions or provide explanations without overwhelming them.

The organizations listed in the Resources section can help with information about caregiver services and support.

Children and teens may feel a loss of connection with the person with LBD who has problems with attention or alertness. They may also resent the loss of a parent caregiver’s attention and may need special time with him or her. Look for signs of stress in children, such as poor grades at school, withdrawal from friendships, or unhealthy behaviors at home. Parents may want to notify teachers or counselors of the LBD diagnosis in the family so they can watch for changes in the young person that warrant attention.

Here are some other ways parents can help children and teens adjust to a family member with LBD:

• Help them keep up with normal activities such as sports, clubs, and other hobbies outside the home. Suggest ways for kids to engage with the relative with LBD through structured activities or play. For example, the child or teen can make a cup of tea for the person with LBD.
• Find online resources for older children and teens so they can learn about dementia and LBD. See the “Resources” section for more information.

It is important for families to make time for fun. Many challenges can be faced when they are balanced with enjoyable times. While LBD creates significant changes in family routines, children and teens will cope more effectively if the disorder becomes part of, but not all of, their lives.

References

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