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Clinical diagnosis of Lewy body dementia

  • Ajenthan Surendranathan (a1), Joseph P. M. Kane (a2), Allison Bentley (a3), Sally A. H. Barker (a4), John-Paul Taylor (a5), Alan J. Thomas (a4), Louise M. Allan (a6), Richard J. McNally (a7), Peter W. James (a7), Ian G. McKeith (a4), David J. Burn (a8) and John T. O'Brien (a3)...

Abstract

Background

Lewy body dementia, consisting of both dementia with Lewy bodies (DLB) and Parkinson's disease dementia (PDD), is considerably under-recognised clinically compared with its frequency in autopsy series.

Aims

This study investigated the clinical diagnostic pathways of patients with Lewy body dementia to assess if difficulties in diagnosis may be contributing to these differences.

Method

We reviewed the medical notes of 74 people with DLB and 72 with non-DLB dementia matched for age, gender and cognitive performance, together with 38 people with PDD and 35 with Parkinson's disease, matched for age and gender, from two geographically distinct UK regions.

Results

The cases of individuals with DLB took longer to reach a final diagnosis (1.2 v. 0.6 years, P = 0.017), underwent more scans (1.7 v. 1.2, P = 0.002) and had more alternative prior diagnoses (0.8 v. 0.4, P = 0.002), than the cases of those with non-DLB dementia. Individuals diagnosed in one region of the UK had significantly more core features (2.1 v. 1.5, P = 0.007) than those in the other region, and were less likely to have dopamine transporter imaging (P < 0.001). For patients with PDD, more than 1.4 years prior to receiving a dementia diagnosis: 46% (12 of 26) had documented impaired activities of daily living because of cognitive impairment, 57% (16 of 28) had cognitive impairment in multiple domains, with 38% (6 of 16) having both, and 39% (9 of 23) already receiving anti-dementia drugs.

Conclusions

Our results show the pathway to diagnosis of DLB is longer and more complex than for non-DLB dementia. There were also marked differences between regions in the thresholds clinicians adopt for diagnosing DLB and also in the use of dopamine transporter imaging. For PDD, a diagnosis of dementia was delayed well beyond symptom onset and even treatment.

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Copyright

This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.

Corresponding author

Correspondence: Ajenthan Surendranathan. Email: as2489@medschl.cam.ac.uk

References

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Clinical diagnosis of Lewy body dementia

  • Ajenthan Surendranathan (a1), Joseph P. M. Kane (a2), Allison Bentley (a3), Sally A. H. Barker (a4), John-Paul Taylor (a5), Alan J. Thomas (a4), Louise M. Allan (a6), Richard J. McNally (a7), Peter W. James (a7), Ian G. McKeith (a4), David J. Burn (a8) and John T. O'Brien (a3)...

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Clinical diagnosis of Lewy body dementia

  • Ajenthan Surendranathan (a1), Joseph P. M. Kane (a2), Allison Bentley (a3), Sally A. H. Barker (a4), John-Paul Taylor (a5), Alan J. Thomas (a4), Louise M. Allan (a6), Richard J. McNally (a7), Peter W. James (a7), Ian G. McKeith (a4), David J. Burn (a8) and John T. O'Brien (a3)...
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eLetters

Title – separating DLB only of academic interest?

Prasanna de silva, Consultant Old Age Psychiatrist, CNTW NHS Trust
09 July 2020



My concern about this article is the lack of attention to cost of imaging. The article suggests more effort is needed to diagnose LBD. The currently available LBD consensus guideline (1), in my opinion, is more than adequate for diagnostic purposes without having to resort to a DAT scan (costing a minimum of £500 each time). In any case a false negative rate of up to 20% is assumed (2).

Furthermore, for jobbing clinicians, differentiating between DLB and AD is ‘of academic interest’, as we tend to use the same memory enhancing medications for both, and avoid atypical antipsychotics in both if at all possible. It is arguably more important to separate out ‘pure’ vascular dementia, although post mortem studies often suggest a mixed pathology in most patients with a dementia syndrome.

1. McKeith, I.G., Dickson, D.W., Lowe, J. et.al. Diagnosis and management of dementia with Lewy Bodies. Third report of the DLB consortium. Neurology. 2005; Vol 65: 1863 – 1872

2. Surendranathan, A., O’Brian, J.T. Clinical imaging in dementia with Lewy Bodies. Evidence based mental health. 2018; Vol 21 (2): 61 - 65

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Conflict of interest: None declared

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