Finding out the cause of a patient’s dementia isn’t easy, but it’s important.  Here’s an example of one patient whose diagnosis calls for different treatment considerations than you would have for a patient with the most common cause of dementia: Alzheimer’s disease.  In fact, with the wrong diagnosis he might have been prescribed medications that could have resulted in serious consequences.

A.B.’s wife reported changes in his memory starting 6 years ago, initially with word finding difficulty and now notes progressively worsening confusion with trouble following directions, trouble with calculations, and visuospatial abnormalities.  He started having visual hallucinations 6 months ago and sees his wife sleeping on the couch.  A.B. is drowsier during the day and also has illogical trains of thought and stares into space for periods of time.  He also thrashes in bed at night and acts out his dreams.

A.B. had a full cognitive evaluation of his memory, thinking, and movement at a memory specialty center.   On cognitive testing measures he had difficulty with attention tasks, concentration, executive measures, visuospatial function, learning, and memory.  His neurologic exam was significant for signs of parkinsonism, including slowness in movement, stiffness, and balance problems.

Ultimately, A.B. was diagnosed with Lewy body dementia.

Lewy Body Dementia:  What Home Care Nurses Should Know

What is Lewy body dementia?
Lewy body dementia is a progressive neurodegenerative disease that includes a combination of diagnostic features.  The central feature of this disorder is dementia, with other core features that are often but not always present including fluctuating cognition, recurrent visual hallucinations, and parkinsonsim.  Other suggestive features include REM sleep behavior disorder, sensitivity to certain neuroleptic medications (Haldol, Fluphenazine, etc.), and abnormal imaging results.  Numerous other supportive features may also be present such as autonomic problems (constipation, fainting, change in sweating), delusions, or repeated falls.

Why is this diagnosis important?
Patients with Lewy body dementia can be very sensitive to certain medications.  Traditional antipsychotic medications should be avoided as they can cause sedation, worsening parkinsonism or cognition, or neuroleptic malignant syndrome which can be fatal.

What is the role of the visiting nurse in Lewy body dementia?
Patients with Lewy body dementia require similar interventions as patients with other memory disorders.  The nurse should carefully review all prescription and over the counter medications.  Caregiver education is important including nonpharmacologic interventions for behavior such as distraction and redirection.  Hallucinations are not always disturbing to patients and do not necessarily require medication intervention.  Environmental changes for hallucinations such as reorganizing pillows or furniture is sometimes helpful (i.e. a large couch pillow may be perceived as a person lying on the couch).  Home safety assessments for fall risk factors are also important.

Where can nurses obtain more information or direct caregivers?
Lewy Body Dementia Association:  www.lbda.org
NYU Comprehensive Center on Brain Aging: http://aging.med.nyu.edu/conditions-we-treat/conditions/dementia

Yael Zweig
Nurse Practitioner, Pearl I. Barlow Center for Memory Evaluation and Treatment
Alzheimer’s Disease Center Education Core, Comprehensive Center on Brain Aging
NYU Langone Medical Center