Recognition of Dementia in Specific Populations: Dementia with Lewy bodies and Parkinson s Disease Dementia

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1 Recognition of Dementia in Specific Populations: Dementia with Lewy bodies and Parkinson s Disease Dementia Dr John-Paul Taylor Newcastle University john-paul.taylor@ncl.ac.uk

2 Alpha synucleinopathies Multisystem atrophy Pure autonomic failure Lewy body diseases REM sleep behaviour disorder Parkinson's disease Lewy body dementias Up to 80% convert with time PDD DLB

3 Lewy Body Dementia (DLB and PDD) Estimated 4M people affected worldwide Estimated 160,000 people in UK Diagnostic criteria agreed globally for DLB (1996/2005) PDD (2007) LBDs are now included in DSM V (2013) Neurocognitive disorder with Lewy bodies Neurocognitive disorder due to Parkinson s disease

4 Why is DLB important to recognise and treat? DLB causes significantly greater functional disability than Alzheimer s disease (McKeith et al, Am J Ger Psychiat 2006; ) Care costs of DLB are twice those for Alzheimer s disease (Boström et al, 2007 Int J Ger Psychiat. 22: ) Quality of life for people with DLB is significantly worse than for AD with 1 in 4 caregivers rating DLB as worse than death! (Boström et al, 2007 Alz Dis Ass Dis 21: )

5 Dementia with Lewy bodies Presence of dementia plus.. Core and strongly suggestive features REM sleep behaviour (40%) DatSCAN +ve (80%) Visual hallucinations (80%) Cognitive fluctuations (13-85%) Diagnosis of Probable DLB Dementia plus at least two core symptoms or one core symptom plus one strongly suggestive characteristic Neuroleptic Sensitivity (25-50%) Parkinsonism (25-75%) McKeith et al. Neurology 2005

6 Dementia with Lewy bodies Supportive features Falls and syncope Unexplained loss of consciousness Autonomic dysfunction Hallucinations in other modalities Systematized delusions Depression Preserved medial temporal lobe structures on CT/MRI Generalised low uptake on HMPOA SPECT/PET perfusion/metabolism scan with reduced occipital activity Prominent slow wave activity on EEG with temporal lobe transient sharp waves McKeith et al. Neurology 2005

7 Parkinson s disease with dementia Key characteristics Queen Square Brain Bank criteria for Parkinson s disease Dementia with: Impairments in more than one cognitive domain Reduced cognition compared with the premorbid level Deficit related impairments in everyday functioning Associated clinical characteristics Attention & executive impairment Visual-spatial impairment Memory impairment Speech problems, Apathy Personality changes and mood changes Hallucinations & delusions Increased daytime fatigue Emre et al. Movement disorders 2007

8 Parkinson s disease with dementia For diagnosis Probable PDD Dementia & Parkinson s disease Cognitive deficits in 2 of 4 domains (attention, executive, memory and visuo-spatial) At least one behavioural symptom (apathy, depression, hallucinations, delusions, daytime sleepiness) Emre et al. Movement disorders 2007

9 DLB vs PDD: The one year rule Neuropsychiatric features 12 months Parkinsonism DLB PDD Clinically: many similarities in clinical features, cognitive profile and response to treatment (Janvin et al, 2006)

10 DLB vs. PDD DLB PDD Attention Executive function Parkinsonism variable present Visual hallucinations Delusions Responsiveness to levodopa +/- + Nigrostriatal loss Cortical / striatal pathology Amyloid deposition Moderate - high Low

11 Dementia with Lewy bodies Initially described in case studies from Japan (Okazaki et al, 1961; Kosaka et al, 1984) Recognised as common cause of later life dementia in 1990s 15-20% in autopsy samples Lewy bodies in brainstem, limbic areas and cortex McKeith et al. Lancet Neurol. 2004

12 Causes of Dementia Alzheimer s disease 62% Vascular dementia 17% Mixed AD/VaD 10% Dementia with Lewy Bodies 4% Parkinson s disease 2% Other 3% The greatest problem with Lewy body dementia are that we underdiagnose them!

13 Lewy Body Type Pathology The likelihood that the observed neuropathology explains the DLB clinical syndrome is directly related to the severity of Lewy-related pathology, and inversely related to the severity of concurrent AD-type pathology NIA-Reagan Low (Braak stage 0- II) Alzheimer Type Pathology NIA-Reagan Intermediate (Braak stage III- IV) NIA-Reagan High (Braak stage V- VI) Brainstem Predominant Limbic (transitional) Diffuse Neocortical Low Low Low High Intermediate Low High High Intermediate Neuropathological features of DLB Report of 3 rd Consortium Meeting (Neurology 2005)

14 Clinical problems with diagnosing Difficulty recognising / defining cognitive fluctuation DLB Cognitive baseline minute to minute / hour by hour variation time Failure to ask about suggestive and supportive features Early autonomic dysfunction e.g. constipation REM sleep behaviour disorder Transient interruption in awareness Communication difficulties Glazed / switched off

15 Clinical problems with diagnosing DLB Insufficient neuropsychological evaluation Atypical presentations are common Underuse of imaging biomarkers Alzheimer s MMSE 18/30 Orientation 5/10 Short term memory 0/3 DLB MMSE 20/30 Orientation 8/10 Short term memory 2/3

16 Parkinson s Disease Dementia < 50% of those with PDD are currently recognised and diagnosed

17 Parkinson s Disease Dementia Why? Previous perception that Parkinson s disease was primarily a movement disorder Whilst more recent recognition of non-motor, cognitive and neuropsychiatric symptoms movement disorders services traditionally have not tuned into looking for these

18 Parkinson s Disease Dementia Why? Issues of resources / time for detailed assessment in busy geriatric / neurology clinics Cognitive impairment develops insidiously and with other symptoms (e.g. hallucinations) may be put down to medication side effects

19 Parkinson s Disease Dementia Why? Sometimes difficult to clarify ADL decline due to cognitive rather than motor decline Even when cognitive impairment is recognised there is reluctance in disclosing a diagnosis of dementia

20 European study of 40 sites in 10 countries 288 subjects (88 Prob DLB, 56 Poss DLB, 144 non-dlb including 9 VaD) Consensus diagnosis by independent expert panel Primary outcome diagnostic accuracy Prob DLB v non-dlb Sens 78%, Spec 90% Sept 2006 European licence To help differentiate probable dementia with Lewy bodies from Alzheimer s disease Currently seeking FDA approved McKeith, O Brien et al, 2007

21 The future. Things are changing Parkinson s disease with dementia Increasing use of multidisciplinary approaches and cross-referral PD nurses increasingly familiar with cognitive scales e.g. MMSE, MoCA

22 DIAMOND-Lewy Programme UK NIHR 5 year Programme, Improving the DIAgnosis and Management Of Neurodegenerative Dementia of Lewy body type Five work packages (i) and (ii) To improve diagnostic rates (iii) to review evidence and expert practice to develop and (iv) pilot an assessment & management toolkit (v) trial the toolkit against usual care Principal investigator: John O Brien

23 How do we improve recognition of Lewy body dementias in primary care? The suspicious GP

24 Postural blood pressure problems History of repeated unexplained falls Some signs in early DLB History of tremor/loss of facial expression/slowed movements History of shouting out/active movements during sleep

25 Recurrent history of unexplained delirium Unexplained mild/subtle visual disturbances e.g. presence/passage hallucinations, illusions, problems with intermittent double vision + visuospatial issues Some signs in early DLB History of anosmia Longstanding constipation

26 Recognising Parkinson s disease with dementia Parkinson s disease Normal Mild cognitive impairment Dementia PREDICTIVE FACTORS FOR CONVERSION TO DEMENTIA Age Duration of Parkinson s (>10 years) Visual hallucinations Depression & apathy Postural Instability Gait Disorder (Falls/no tremor) Levo-dopa non-responsiveness Attention problems Excessive daytime sleepiness The suspicious GP

27 How do we detect PDD? Get collateral from carers Don t trust sharp as a tack Ask if they d leave their loved one alone overnight and WHY they wouldn t WHY have they taken over the finances? etc

28 Pill Questionnaire (Dubois, oral communication, Chicago 2008) Ability of a patient to verbally describe his/her antiparkinsonian treatment with the time schedule, the nature and dose Correlates with impaired ADL

29 Recognition of Lewy body dementias Primary care services which are alert to potential dementia subtype Specialist services with access to: Diagnostic biomarkers e.g. neuroimaging Detailed neuropsychology for profile of cognitive deficits Physical examination e.g. parkinsonism

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