Children in the Garden Who Are Not There: Recognizing Dementia With Lewy Bodies in a 74-Year-Old Man, and Why the Antipsychotic Request Had to Be Declined
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University of Phoenix
PMH/501: Neuropsychiatric Disorders
Week 6 Assignment
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[Date]
The patient is a composite written for a model paper.
Mr. J., a 74-year-old retired carpenter, is brought by his wife and daughter. Since early spring he has watched a group of children who are not there, laughing among the tomato plants; he describes them in detail and is not frightened. Some days he is alert and conversational; on others he stares blankly and seems confused for hours. For several years he has shouted and punched in his sleep. He now walks more slowly and has fallen twice. His daughter asks for "something like Haldol for the hallucinations." This paper explains the evaluation.
The Consensus Criteria
The Dementia With Lewy Bodies Consortium's fourth consensus report defines core clinical features: fluctuating cognition with pronounced variations in attention and alertness, recurrent well-formed visual hallucinations, REM sleep behavior disorder, which may precede cognitive decline, and one or more spontaneous cardinal features of parkinsonism (McKeith et al., 2017). Probable dementia with Lewy bodies can be diagnosed with dementia plus two or more core features, or one core feature plus an indicative biomarker.
Applying Them to Mr. J.
His cognitive testing shows a Montreal Cognitive Assessment of 20, with marked deficits in attention, executive function and visuospatial drawing, but relatively preserved memory recall. He has all four core features: fluctuations, well-formed visual hallucinations, dream enactment behavior consistent with REM sleep behavior disorder and parkinsonism, with bradykinesia and mild rigidity on examination. He meets criteria for probable dementia with Lewy bodies.
The children in the garden were not a psychiatric symptom to suppress but a neurological sign to recognize.
Distinguishing It From Other Conditions
Alzheimer disease typically begins with memory loss, with hallucinations appearing later if at all; Mr. J.'s early attention and visuospatial deficits with relatively preserved memory point elsewhere. Delirium causes acute fluctuating attention, but his fluctuations have lasted months without an acute medical cause; I still check for infection, medication effects and metabolic problems. Late-onset psychosis would not explain parkinsonism, dream enactment or cognitive fluctuation. Parkinson disease dementia is diagnosed when dementia develops after well-established Parkinson disease; in Mr. J., cognitive and psychiatric symptoms came first.
Why the Antipsychotic Request Is Declined
McKeith et al. (1992) described severe neuroleptic sensitivity in patients with Lewy body dementia: 81% of those given neuroleptics reacted adversely, over half severely, with increased mortality, compared with only one of 14 patients with Alzheimer disease having a severe reaction. The consensus criteria list severe sensitivity to antipsychotics as a supportive feature and advise avoiding typical antipsychotics such as haloperidol (McKeith et al., 2017). Giving haloperidol could worsen his parkinsonism, confusion and falls, and could be fatal.
What Can Help
Walker et al. (2015) describe management of Lewy body dementias: cholinesterase inhibitors such as rivastigmine or donepezil can improve cognition, fluctuations and hallucinations; nonpharmacological measures, such as reassurance, good lighting and not arguing about hallucinations, reduce distress; and REM sleep behavior disorder may be managed with melatonin and bedroom safety measures. If an antipsychotic becomes essential for severe, distressing psychosis, low-dose quetiapine or clozapine are sometimes used cautiously by specialists.
Addressing the Family's Concern
The hallucinations are not frightening to Mr. J.; they distress his family. I explain that the children he sees are part of the illness, that reassurance and distraction usually work better than correction and that medicines like haloperidol could cause serious harm. We agree to start a cholinesterase inhibitor and reassess.
Safety and Falls
Parkinsonism and fluctuating attention increase fall risk. I refer him for physical therapy and a home safety assessment, and discuss moving sharp objects from the bedside because of dream enactment.
Why Memory Can Look Preserved
Patients with Lewy body dementia often perform relatively well on memory recall early in the illness, while attention, executive function and visuospatial abilities decline. A screening test that relies heavily on memory can miss the diagnosis. Mr. J.'s poor clock drawing and cube copying, contrasted with fair recall, pointed toward Lewy body disease rather than Alzheimer disease.
Fluctuations and How to Ask About Them
Fluctuations are hard to capture in one visit. Asking the family whether there are periods of staring into space, daytime drowsiness despite adequate sleep or episodes of disorganized speech helps. His wife described days when he seemed "switched off" for hours and then returned to himself, a typical description.
Autonomic Symptoms
Orthostatic hypotension, constipation and urinary problems are common in Lewy body disease and contribute to falls. His blood pressure drops 22 points on standing, which adds to his fall risk and argues against medications that lower blood pressure further.
Caregiver Burden
Lewy body dementia places heavy demands on caregivers because of fluctuations, hallucinations and sleep disruption. I screen his wife for stress and depression and connect her with a caregiver support group and respite resources.
Starting the Cholinesterase Inhibitor
Rivastigmine or donepezil is started at a low dose and increased slowly. Side effects include nausea, slow heart rate and vivid dreams, so I check his pulse and ECG first. If hallucinations become distressing despite treatment, the specialist can weigh other options.
Medication Review
I review his other medications for drugs that can worsen confusion or hallucinations, such as anticholinergic bladder drugs or sedatives, and find a pharmacy-bought nighttime pill with diphenhydramine, which he stops.
Sleep Behavior Safety
Because he punches and kicks in his sleep, his wife has been hit twice. I suggest separate beds, padding near the bed and removing objects from the nightstand. Melatonin at bedtime may reduce dream enactment with few side effects (Walker et al., 2015).
Driving
Fluctuating attention and visuospatial deficits make driving unsafe. I discuss this with Mr. J. and his family and recommend that he stop driving, documenting the conversation.
Explaining the Diagnosis to Mr. J.
Mr. J. understands that his mind is playing tricks on him and is relieved to know the cause. I explain in simple terms that his brain has changes that cause the visions and the sleep movements, and that we will treat them with medicines that are safer for him.
Documentation
The note lists each core feature with its evidence, the reasons antipsychotics are avoided and a prominent alert about neuroleptic sensitivity for any future emergency, hospital or nursing home admission, where the risk of an antipsychotic being given for agitation is highest and staff may not know his history.
Referral
I refer him to neurology for confirmation and consideration of supportive tests such as a dopamine transporter scan, and to a memory clinic for ongoing care and caregiver support.
Conclusion
Mr. J.'s visual hallucinations, fluctuating cognition, dream enactment behavior and parkinsonism meet the 2017 consensus criteria for probable dementia with Lewy bodies, a diagnosis that changes treatment fundamentally. Because patients with this condition can react severely and sometimes fatally to antipsychotics, the family's request for haloperidol was declined in favor of a cholinesterase inhibitor, nonpharmacological strategies and fall prevention.
References
McKeith, I., Fairbairn, A., Perry, R., Thompson, P., & Perry, E. (1992). Neuroleptic sensitivity in patients with senile dementia of Lewy body type. BMJ, 305(6855), 673-678. https://doi.org/10.1136/bmj.305.6855.673
McKeith, I. G., Boeve, B. F., Dickson, D. W., Halliday, G., Taylor, J.-P., Weintraub, D., Aarsland, D., Galvin, J., Attems, J., Ballard, C. G., Bayston, A., Beach, T. G., Blanc, F., Bohnen, N., Bonanni, L., Bras, J., Brundin, P., Burn, D., Chen-Plotkin, A., . . . Kosaka, K. (2017). Diagnosis and management of dementia with Lewy bodies: Fourth consensus report of the DLB Consortium. Neurology, 89(1), 88-100. https://doi.org/10.1212/WNL.0000000000004058
Walker, Z., Possin, K. L., Boeve, B. F., & Aarsland, D. (2015). Lewy body dementias. The Lancet, 386(10004), 1683-1697. https://doi.org/10.1016/S0140-6736(15)00462-6
How this PMH 501 Week 6 example is structured
The PMH/501 Week 6 work usually covers neurocognitive disorders, including delirium and dementia. This paper shows how a psychiatric presentation, hallucinations in an older adult, leads to a neurocognitive diagnosis that changes treatment and prevents harm. Students search this week as PMH 501 Week 6, PMH501 Wk 6 or PMH/501 Wk 6; all three are the same assignment.
PMH/501 Week 6 questions, answered
What does PMH/501 Week 6 usually ask for?
Many sections ask students to assess and differentiate neurocognitive disorders such as delirium, Alzheimer disease and other dementias.
What are the core features of dementia with Lewy bodies?
Fluctuating cognition with variations in attention and alertness, recurrent well-formed visual hallucinations, REM sleep behavior disorder and one or more features of parkinsonism.
Why are antipsychotics dangerous in Lewy body dementia?
Many patients have severe sensitivity to antipsychotics, with worsening parkinsonism, confusion, falls and sometimes life-threatening reactions.
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