Dementia, bizarre creatures, and a white knight to the rescue
Ms. L, age 78, experiences visual and tactile hallucinations of bizarre creatures in her home that are related to dementia with Lewy bodies. How would you treat her?
SSRIs and other antidepressants have not been shown to improve neuropsychiatric symptoms, and often are poorly tolerated.32
One study found efficacy with electroconvulsive therapy and transcranial magnetic stimulation in treatment-resistant patients.33
In addition to these treatments, nonpharmaceutical interventions should be employed from the earliest stages of diagnosis and treatment (Table 2). See the Figure for an algorithm for treating DLB. These include educational and behavioral interventions, social support, psychological interventions, and environmental therapies and modifications.
OUTCOME New friends
The creatures return from time to time, Ms. L reports, but are no longer upsetting because the white knight (a sort of mental deus ex machina) leads the once-terrifying things away. She describes the hallucination as a kind of zoological observation, refers to the creatures that once horrified her as “her friends,” and chuckles as she observes their natural history. This new, far more benign hallucination becomes a mainstay of her symptoms, and she is discharged to the care of her husband and family.
Soon after her discharge, her hallucinations resolved completely, but returned briefly when Ms. L resumed smoking cigarettes because smoking is known to lower clozapine serum levels.34
Bottom Line
Consider a low dosage of a neuroleptic when a patient suffers significant distress and behavioral disturbance related to psychotic symptoms in dementia with Lewy bodies and those problems are not relieved by other agents. Low-dose clozapine is an option for refractory psychotic symptoms or in patients with severe extrapyramidal sensitivity. Start low, and go slow.
Related Resources
- Bishnoi RJ, Grossberg GT, Manepalli J. Differentiating Alzheimer’s disease from dementia with Lewy bodies. Current Psychiatry. 2012;11(11):22-27.
- McKeith I, Emre M. Management of Parkinson’s disease dementia and dementia with Lewy bodies. In: Emre M, ed. Cognitive impairment and dementia in Parkinson’s disease. Oxford, United Kingdom: Oxford University Press; 2010:245-256.
Drug Brand Names
Aripiprazole • Abilify Mirtazapine • Remeron
Clozapine • Clozaril Olanzapine • Zyprexa
Donepezil • Aricept Quetiapine • Seroquel
Haloperidol • Haldol Risperidone • Risperdal
Memantine • Namenda Rivastigmine • Exelon
Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
