DLB and Advanced Dementia
ABSTRACT & COMMENTARY
Source: Ballard C, et al. Neuroloeptic sensitivity in dementia with Lewy bodies and Alzheimer's disease. Lancet 1998; 351:1032-1033.
Dementia with lewy bodies (dlb) has been estimated to be as prevalent as 10% among patients with advanced dementia. Clinical features are accompanied by autopsy identification of Lewy bodies in the brainstem (locus coeruleus, substantia nigra, and nucleus basalis of Meynert) and in the cerebral cortex (McKeith IG, et al. Neurology 1996;47:1113-1124). Most such brains contain various degrees of Alzheimer's disease (AD) as well. The clinical syndrome, however, progresses more rapidly than most AD. Prominent disabilities characteristically include impairments in attention, problem solving, orientation, and visual-spatial relationships. Parkinsonian motor symptoms are prominent. Persistent visual hallucinations and systematized delusions may be disruptive. As might be expected, agitation is almost the rule, but patients with DLB have an excessive sensitivity to neuroleptic medication-sometimes reminiscent of the Neuroleptic Malignant Syndrome.
Against the above background, Ballard and associates compare the potential usage and unwanted side effects of neuroleptics in 40 patients with AD and in 40 with DLB. Age and relative severity were matched, and all patients were ultimately neuropathologically verified. Neuroleptics were supplied to 15 of the AD group and 21 of the DLBs. Seven of the ADs had sensitivity reactions, all of which were mild. Eight DLBs had sensitivity reactions, six of which were severe. In these latter patients, even low dosages of new neuroleptics precipitated severe reactions. All six of the DLB patients with severe reactions died within a year, and five died within an average of 12 weeks. Of the seven AD patients with mild sensitivities to neuroleptics, two lived for 6-12 months and the others survived for more than 12 but less than 30 months.
COMMENTARY
Although McKeith et al (BMJ 1992;305:673-678) emphasized the sensitivity of DLB to neuroleptics several years ago, such patients commonly express so much agitated behavior that many physicians resort to such drugs as a last effort. The natural course of DLB is shorter than that of AD, however, and no satisfactory anti-psychotic has yet been developed, even among the newer agents. Since survival is usually short, strong sedation would seem to be desirable. -FP
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