Letter to the Editor Regarding: Practical Treatment of Lewy Body Disease in the Clinic: Patient and Physician Perspectives.

Introduction

It was a pleasure to read an interesting case of a patient with Lewy body dementia (DLB), published in Neurology and Therapy recently [1]. The author shared an insightful story of how the treatment of this disease affects the patient’s wellbeing and the different pharmacological interventions that he had experienced. Especially interesting was the patient’s account of the progression of DLB, and how the doctors empowered him to feel better about himself, as well as encouraged him to participate in board meetings and take up walking exercises.

Despite numerous publications on the natural history and progression of DLB in the literature, the actual coping mechanisms of the patients with DLB is not very well described. Indeed, most of the already scarce medical literature reports on the caregivers’ or spouses’ experiences in a quantitative manner [2, 3].

Differences in the Literature

Another interesting fact is that the patient’s account was in stark contrast with a previously reported qualitative study [4]. Ducharme et al. described a fear of progressive deterioration and dependence in DLB, and the associated grievances of the loss of function, especially in the work context. The patient featured in the Londos paper, however, seemed to be coping very well with work-related activities and could maintain a leadership position in his company. Indeed, being highly functional in this aspect was a motivating factor in maintaining his self-care regimen. This also eliminated a problem of financial sustainability: a common theme of many patients’ worries.

The patients and their spouses from the Ducharme paper were also very concerned about the future and the uncertainty of DLB progression. This did not emerge in either of the interviews presented by Londos and was not reported as a major issue.

We believe that the reason for these discrepancies lies in the psychological treatment and a positive approach to the outlook, applied by the doctors in Skane University Hospital. The ability to shift the nihilistic paradigm in patients with DLB is a vital clinical skill and, as shown in the paper, could provide for a complete change in the patient’s experience.

Treatment Options

Londos also described different pharmacological treatments used during the disease. A systematic regimen was proposed for introducing and changing drugs to account for changes in the disease states.

Whilst being a useful insight, we believe that the paper lacks the diagnostic considerations connected with DLB. Londos did not describe the process of making the decision and the uncertainty connected with the evaluation of the dementia subtypes. As reported in the literature [2, 3, 5], this could be one of the most stressful experiences and it would be very interesting to learn about how it affected the described patient and his wife.

Indeed, the diagnosis of DLB is very difficult to make. Even with the updated diagnostic criteria [6], the symptoms could easily be in keeping with Parkinson’s disease, Alzheimer’s disease or depressive disorder (Fig. 1). It also worth noting that the pharmacotherapy options reported in this case could be used to treat a whole range of the differential diagnoses of DLB.

Fig. 1

“Worst symptoms” that triggered a change in medication in the patient with DLB, as reported by Londos [1]. The ticks indicate whether a symptom is a common feature of a disease

The medication was changed 14 times between June 2014 and October 2017. All alterations were driven by changes in the “worst symptom”, as per the rule suggested by the author. We wonder whether these changes could reflect the diagnostic uncertainty and different pathophysiological processes that could have contributed to the overall DLB picture in this patient.

Summary

We believe that the paper was a great insight into the positive side of DLB treatment. It made many clinically useful suggestions and showed how the patient’s outlook can be enhanced.

We would suggest, however, that the diagnostic considerations and uncertainties should have been explored in more detail.

We further propose that the changes in the disease and the responsiveness to pharmacotherapy may have been an indicator of the different pathophysiological processes. Considering the low specificity of DLB guidelines [6], more attention should be given to exploring dopaminergic degeneration, serotonin dysregulation, global atrophy or concurrent psychiatric pathologies.