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Visual Hallucinations and Parkinsonism in Dementia
JAMDA xxx (2016) 1
JAMDA journal homepage: www.jamda.com
Letter to the Editor
Visual Hallucinations and Parkinsonism in Dementia To the Editor: We read with interest the article by Zahirovic et al.1 The article is informative; however, the authors’ suggestion that because the setting was a nursing home for patients with dementia, all of the elderly patients fulfilled the basic dementia criterion and, therefore, the addition of specific signs of dementia with Lewy body (DLB) could indicate a diagnosis of DLB1 may not be correct. For DLB, a patient must have 2 of the 3 core clinical features (parkinsonism, visual hallucinations, cognitive fluctuations) at the time of diagnosis of dementia and not after a lapse of months or years. What the authors found in this study may have been the symptom manifestation of Alzheimer disease (AD) and related dementia, instead of a manifestation of DLB. When patients with known AD and related dementia have psychosis, such as visual hallucinations, they should be classified as having psychosis because of dementia and not DLB. In patients with DLB, visual hallucinations are present early in the course of a dementing illness.2 Furthermore, if a patient has Parkinson disease (PD) symptoms and later on develops visual hallucination, the patient may well have dementia because of PD and not DLB. As outlined by the authors, DLB has a shorter survival.1 Therefore, it is equally important to not over diagnose DLB because of its implication on patient/healthcare proxy decision to forgo lifesustaining measures because of a shorter life expectancy with DLB. In clinical practice, it is known that irrespective of the type of dementia, 3 domains (cognition, functional status, behavioral issue) are affected, and usually the more severe the cognitive difficulty, the more dependent the patient will be for functional assistance, and is at more risk of developing behavioral symptoms (ie, irrespective of the type of dementia with the worsening in dementia, patients are anticipated to have behavioral issues). Delusions and hallucinations are very common in AD and predict cognitive and functional decline with the presence of hallucinations also associated with institutionalization and mortality.3 Furthermore, it is not unusual that with the progression in AD dementia patient may have the manifestation of parkinsonism. The major parkinsonism-plus syndromes include progressive supranuclear palsy, multiple system atrophy, corticobasal degeneration, as well as parkinsonism occurring in the context of AD or one of the other primary dementing disorders.4 The frequency and severity of extrapyramidal signs, a common feature of AD, appear to increase over time with disease severity.5 A differentiation between Parkinson’s Disease dementia (PDD) and DLB needs to be made. Dementia is a common feature of PD.6 Cognitive dysfunction is common in PD and exists on a continuum of severity; prevalence increases with the duration of the movement disorder. When severe, dementia often surpasses the motor features of PD as a major cause of disability and mortality.2 In PDD, dementia occurs in the setting of well-established parkinsonism, whereas in DLB, dementia
usually occurs concomitantly with or before the development of parkinsonian signs. If parkinsonism is present for more than 1 year before the onset of dementia, it is officially classified as PDD.2 Visual hallucinations are common in PD with and without dementia and can be identified in as many as 50% of all patients with PD.7 As outlined by the authors, a limitation of this study was having no measure of dementia severity. In the absence of known severity of dementia, it is difficult to reliably attribute visual hallucinations and parkinsonism solely to DLB. We know from clinical practice that the more severe the AD, the more the likelihood of seeing behavioral issues (such as visual hallucinations as well as the potential for parkinsonism) increase. The participants in this study were residents of nursing homes specifically for dementia.1 This raises the possibility that their dementia may have been at moderate to advanced stage and, hence, visual hallucinations and parkinsonism may have been due to severity of dementia rather than DLB. Furthermore, by relying on staff of several nursing homes to identify parkinsonian features (rigidity, stiffness, tremor, rigid posture and walk, weak voice), subjective bias may have increased. This bias would have been minimal if 1 or 2 research staff physicians or midlevel medical providers had assessed parkinsonism features compared with several nursing staff at several facilities. One may also wonder if a 2hour oral presentation is sufficient to provide competency to nursing staff to identify parkinsonian features. If nursing staff had adequately demonstrated the ability to identify parkinsonism following the oral presentation, proper competency may have been assured. The conclusion from this study should be that the combined prevalence of visual hallucination and parkinsonism was 16% to 20%, and not the prevalence of Lewy body as 16% to 20%, as the later implies the new diagnosis of DLB, which in this nursing home study may not be reliably possible because it is not conclusive that these residents had visual hallucination and parkinsonism around the time that they were diagnosed with dementia. References 1. Zahirovic I, Wattmo C, Torisson G, Minthon L. Prevalence of dementia with Lewy Body symptoms: A cross-sectional study in 40 Swedish nursing homes. J Am Med Dir Assoc 2016;17:706e711. 2. Pelak VS. Approach to the patient with visual hallucinations. uptodate.com Accessed September 23, 2016. 3. Scarmeas N, Brandt J, Albert M, et al. Delusions and hallucinations are associated with worse outcome in Alzheimer disease. Arch Neurol 2005;62:1601e1608. 4. Ahlskog JE. Diagnosis and differential diagnosis of Parkinson’s disease and parkinsonism. Parkinsonism Relat Disord 2000;7:63e70. 5. Ellis RJ, Caligiuri M, Galasko D, et al. Extrapyramidal motor signs in clinically diagnosed Alzheimer disease. Alzheimer Dis Assoc Disord 1996;10:103e114. 6. Svenningsson P, Westman E, Ballard C, et al. Cognitive impairment in patients with Parkinson’s disease: Diagnosis, biomarkers, and treatment. Lancet Neurol 2012;11:697e707. 7. Aarsland D, Brønnick K, Ehrt U, et al. Neuropsychiatric symptoms in patients with Parkinson’s disease and dementia: Frequency, profile and associated care giver stress. J Neurol Neurosurg Psychiatry 2007;78:36e42.
http://dx.doi.org/10.1016/j.jamda.2016.09.018 1525-8610/Published by Elsevier Inc. on behalf of AMDA e The Society for Post-Acute and Long-Term Care Medicine.
Abid Iraqi, MD, CMD, FACP, AGSF Terry Lynn Hughes, RN, CS Syracuse VA Medical Center Syracuse, New York
JAMDA journal homepage: www.jamda.com
Letter to the Editor
Visual Hallucinations and Parkinsonism in Dementia To the Editor: We read with interest the article by Zahirovic et al.1 The article is informative; however, the authors’ suggestion that because the setting was a nursing home for patients with dementia, all of the elderly patients fulfilled the basic dementia criterion and, therefore, the addition of specific signs of dementia with Lewy body (DLB) could indicate a diagnosis of DLB1 may not be correct. For DLB, a patient must have 2 of the 3 core clinical features (parkinsonism, visual hallucinations, cognitive fluctuations) at the time of diagnosis of dementia and not after a lapse of months or years. What the authors found in this study may have been the symptom manifestation of Alzheimer disease (AD) and related dementia, instead of a manifestation of DLB. When patients with known AD and related dementia have psychosis, such as visual hallucinations, they should be classified as having psychosis because of dementia and not DLB. In patients with DLB, visual hallucinations are present early in the course of a dementing illness.2 Furthermore, if a patient has Parkinson disease (PD) symptoms and later on develops visual hallucination, the patient may well have dementia because of PD and not DLB. As outlined by the authors, DLB has a shorter survival.1 Therefore, it is equally important to not over diagnose DLB because of its implication on patient/healthcare proxy decision to forgo lifesustaining measures because of a shorter life expectancy with DLB. In clinical practice, it is known that irrespective of the type of dementia, 3 domains (cognition, functional status, behavioral issue) are affected, and usually the more severe the cognitive difficulty, the more dependent the patient will be for functional assistance, and is at more risk of developing behavioral symptoms (ie, irrespective of the type of dementia with the worsening in dementia, patients are anticipated to have behavioral issues). Delusions and hallucinations are very common in AD and predict cognitive and functional decline with the presence of hallucinations also associated with institutionalization and mortality.3 Furthermore, it is not unusual that with the progression in AD dementia patient may have the manifestation of parkinsonism. The major parkinsonism-plus syndromes include progressive supranuclear palsy, multiple system atrophy, corticobasal degeneration, as well as parkinsonism occurring in the context of AD or one of the other primary dementing disorders.4 The frequency and severity of extrapyramidal signs, a common feature of AD, appear to increase over time with disease severity.5 A differentiation between Parkinson’s Disease dementia (PDD) and DLB needs to be made. Dementia is a common feature of PD.6 Cognitive dysfunction is common in PD and exists on a continuum of severity; prevalence increases with the duration of the movement disorder. When severe, dementia often surpasses the motor features of PD as a major cause of disability and mortality.2 In PDD, dementia occurs in the setting of well-established parkinsonism, whereas in DLB, dementia
usually occurs concomitantly with or before the development of parkinsonian signs. If parkinsonism is present for more than 1 year before the onset of dementia, it is officially classified as PDD.2 Visual hallucinations are common in PD with and without dementia and can be identified in as many as 50% of all patients with PD.7 As outlined by the authors, a limitation of this study was having no measure of dementia severity. In the absence of known severity of dementia, it is difficult to reliably attribute visual hallucinations and parkinsonism solely to DLB. We know from clinical practice that the more severe the AD, the more the likelihood of seeing behavioral issues (such as visual hallucinations as well as the potential for parkinsonism) increase. The participants in this study were residents of nursing homes specifically for dementia.1 This raises the possibility that their dementia may have been at moderate to advanced stage and, hence, visual hallucinations and parkinsonism may have been due to severity of dementia rather than DLB. Furthermore, by relying on staff of several nursing homes to identify parkinsonian features (rigidity, stiffness, tremor, rigid posture and walk, weak voice), subjective bias may have increased. This bias would have been minimal if 1 or 2 research staff physicians or midlevel medical providers had assessed parkinsonism features compared with several nursing staff at several facilities. One may also wonder if a 2hour oral presentation is sufficient to provide competency to nursing staff to identify parkinsonian features. If nursing staff had adequately demonstrated the ability to identify parkinsonism following the oral presentation, proper competency may have been assured. The conclusion from this study should be that the combined prevalence of visual hallucination and parkinsonism was 16% to 20%, and not the prevalence of Lewy body as 16% to 20%, as the later implies the new diagnosis of DLB, which in this nursing home study may not be reliably possible because it is not conclusive that these residents had visual hallucination and parkinsonism around the time that they were diagnosed with dementia. References 1. Zahirovic I, Wattmo C, Torisson G, Minthon L. Prevalence of dementia with Lewy Body symptoms: A cross-sectional study in 40 Swedish nursing homes. J Am Med Dir Assoc 2016;17:706e711. 2. Pelak VS. Approach to the patient with visual hallucinations. uptodate.com Accessed September 23, 2016. 3. Scarmeas N, Brandt J, Albert M, et al. Delusions and hallucinations are associated with worse outcome in Alzheimer disease. Arch Neurol 2005;62:1601e1608. 4. Ahlskog JE. Diagnosis and differential diagnosis of Parkinson’s disease and parkinsonism. Parkinsonism Relat Disord 2000;7:63e70. 5. Ellis RJ, Caligiuri M, Galasko D, et al. Extrapyramidal motor signs in clinically diagnosed Alzheimer disease. Alzheimer Dis Assoc Disord 1996;10:103e114. 6. Svenningsson P, Westman E, Ballard C, et al. Cognitive impairment in patients with Parkinson’s disease: Diagnosis, biomarkers, and treatment. Lancet Neurol 2012;11:697e707. 7. Aarsland D, Brønnick K, Ehrt U, et al. Neuropsychiatric symptoms in patients with Parkinson’s disease and dementia: Frequency, profile and associated care giver stress. J Neurol Neurosurg Psychiatry 2007;78:36e42.
http://dx.doi.org/10.1016/j.jamda.2016.09.018 1525-8610/Published by Elsevier Inc. on behalf of AMDA e The Society for Post-Acute and Long-Term Care Medicine.
Abid Iraqi, MD, CMD, FACP, AGSF Terry Lynn Hughes, RN, CS Syracuse VA Medical Center Syracuse, New York