Dementia of Lewy Bodies
Dementia of Lewy Bodies Pathophysiology, Diagnosis, Treatment and Care Plan
NURS751: Neurobiology and Differential Diagnosis of Mental Disorders
Folashade Odedina
May 18, 2025
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Dementia of Lewy Bodies
Abstract
Dementia of Lewy Bodies is an umbrella term used to describe Lewy body dementia and
Parkison’s disease dementia. There are many similarities and differences between Lewy body
dementia and Parkinson’s disease dementia, as well as other dementias. Pathophysiology,
clinical presentation and treatment vary depending on diagnosis of types of dementia. It is an
important role of the advanced registered nurse practitioner to diagnosis, treat and educate
patients experiencing dementia of Lewy bodies.
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Dementia of Lewy Bodies
Dementia of Lewy Bodies Pathophysiology, Diagnosis, Treatment and Care Plan
Dementia is a disease in which cognitive impairment declines from previous levels of
function. This decline often interferes with a person’s daily activities as well as their social and
occupational function (Kaplan & Sadock, 2021). Dementia is not a form of mental retardation,
delirium, or characterized by low intellect. There are several types of dementia and these types
are further classified based on their pathology. Dementia with Lewy bodies (DLB) is the second
most common type of dementia after Alzheimer’s disease (AD) (McFarland, 2024a). DLB
affects nearly 1.4 million Americans and is an umbrella term to include Lewy body dementia
(LBD) along with Parkinson’s disease dementia (PDD) (Galvin et al., 2021).
Pathophysiology
Dementia with Lewy bodies (DLB) was named after alpha-synuclein protein aggregates
(McFarland, 2024a). These aggregates are observed in the brain of an affected individual and
are known as Lewy bodies. Alpha-synuclein is typically involved in synaptic function, but in
DLB these proteins are misshaped which forms Lewy bodies within the neurons. Lewy bodies
are distributed throughout the brain including the cortex, amygdala, hippocampus and brainstem
(McFarland, 2024a). One distinguishing factor of PDD is that the Lewy bodies are initially
located in the brainstem. Typically, these proteins are regulated and it is possible this imbalance
of total protein is a major factor in aggregation and neurotoxic effects on the brain (McFarland,
2024a).
Neurotransmitter deficits are prominent in dementia patients. In DLB a significant loss in
the dopaminergic and cholinergic systems can be observed. Other neurotransmitters that are
affected are serotonin and norepinephrine (McFarland, 2024a). Loss in these neurotransmitters
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Dementia of Lewy Bodies
lead to many of the symptoms related to DLB, such as cognitive impairment, lack of attention
and visual hallucinations.
Clinical Presentation
Clinical presentation of dementia with Lewy bodies can seem like the presentation of
AD. A great distinguishing factor in DLB is often a more rapid onset that displays early
symptoms of impairments in attention and executive and visuospatial function, as opposed to AD
which presents with memory loss as its initial more prominent symptom (McFarland, 2024a).
Dementia with Lewy bodies differs from other forms of dementia in that it often presents with
hallucinations that are vivid, involuntary movements, autonomic features, sleep disturbances
(including daytime sleepiness), neuroleptic sensitivity and cognitive fluctuations (McFarland,
2024a). Early symptoms may present as getting lost or an inability to make concise judgements
in driving or job performance (McFarland, 2024a).
Loss of dopamine can cause rigidity, gate disorders and tremors. Patients diagnosed
with LBD tend to have less severe symptoms than those diagnosed with PDD. Although there is
clinical symptom differentiation such as LBD being milder and more symmetric no specific
feature distinguishes between LBD and PDD.
Dementia of Lewy bodies patients also suffer from a loss of cholinergic neurons which
contributes to a loss of cognitive function, troubles concentrating and visual hallucinations.
According to McFarland (2024) visual hallucinations occur in up to 70 percent of persons
diagnosed with DLB. In addition to visual hallucinations, auditory, olfactory and tactile
hallucinations may be experienced.
Behavioral and psychiatric symptoms that may occur include depression, anxiety, apathy
and delusions (McFarland, 2024). Part of the clinical picture may include Capgrass Syndrome,
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Dementia of Lewy Bodies
which is a delusion where it is believed that a close person has been replaced with an imposter
(Kaplan & Sadock, 2021). The patient often experiences extreme anxiety and mistrust.
Another symptom of DLB is REM sleep behavior disorder (RBD) and hypersomnia
(McFarland, 2024a). Rapid eye movement (REM) sleep behavior disorder can occur in patients
with Lewy Body Dementia as well as Parkinson’s Dementia. RBD is characterized by the loss
of reduced muscle tone that normally occurs during REM sleep (McFarland, 2024a). When this
atonia is lost a patient may experience dream enactment behavior. Those who experience RBD
may experience vocalization or motor skills correlating with their dreams. These symptoms can
range in severity and seem purposeful (McFarland, 2024a).
Postural instability, fall, syncope or transient loss of consciousness are commonly
described in DLB (McFarland, 2024a). Falls can be an early presentation of DLB and can vary
in cause related to parkinsonism, cognitive problems or orthostatic hypotension caused by
autonomic dysfunction. Patients may appear to lose consciousness briefly or stare blankly
(McFarland, 2024a).
Due to autonomic dysfunction, the patient may experience fluctuations in their blood
pressure, problems with their bowels, such as constipation, urinary incontinence or retention and
other gastrointestinal symptoms (McFarland, 2024a). According to Galvin et. al. (2021)
autonomic symptoms may be observed a decade prior to cognitive or motor symptoms.
Autonomic symptoms are more common in LBD rather than PDD (Galvin et al., 2021).
Diagnosis
Dementia of Lewy bodies remains a challenge to diagnose and this leads to delays in
diagnosis and proper care. An initial evaluation for dementia should exclude other causes.
Simple testing that can easily be completed include a cognitive assessment such as a mini-mental
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Dementia of Lewy Bodies
state examination or the Montreal Cognitive Assessment (McFarland, 2024a). Neuroimaging
and lab work can also be helpful in excluding other causes, such as seizure activity or thyroid
disease. Recent developments in diagnostic tools include the Lewy Body Composite Risk Score
(LBCRS) and the Assessment Toolkit for Lewy Body Dementia (known as DIAMOND-Lewy)
(Galvin, et. al., 2021). The LBCRS measures cognition, motor symptoms, function and behavior
and could differentiate between DLB and AD as well as other dementias. The DIAMOND-
Lewy toolkit is available to providers and provides consensus criteria for LBD and PDD (Galvin
et al., 2021).
For proper diagnosis, the patient must have significant cognitive decline as well as an
interference in their social and occupational function (Kaplan & Sadock, 2021). The diagnosis is
determined primarily by clinical criteria which may not be presented by the patient or their
caregivers. Probable DLB includes two core symptoms with or without biomarkers present.
They can also be diagnosed with only one core clinical feature present if they have one or more
indicative biomarkers (McFarland, 2024a). Probable DLB should not be diagnosed based on
biomarkers alone. Possible DLB only requires one core symptom with no biomarker evidence or
in the presence of one or more biomarkers, but no core clinical features (McFarland, 2024a).
Core symptoms include fluctuating levels of attention, recurrent visual hallucinations and
parkinsonian features (Kaplan & Sadock, 2021).
At this time there are not diagnostic biomarkers for DLB, but there are several indirect
measures of Lewy body pathology that support the diagnosis in the context of a proper clinical
exam. Dopamine transporter imaging is considered an indicative biomarker in the diagnosis of
patients with DLB (McFarland, 2024a). The test uses specific ligands for the dopamine
transporter. Both the single-photon emission computed tomography and the positron emission
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Dementia of Lewy Bodies
tomography tests have demonstrated low dopaminergic activity in patients with DLB
(McFarland, 2024a). This finding is found in both PDD and LBD, but not in AD.
Another indicative biomarker that can be observed is cardiac autonomic denervation.
This occurrence can be evaluated using metaiodobenzylguanidine (MIBG) which is a
noradrenaline analogue that binds to postganglionic sympathetic receptor present in the heart
(McFarland, 2024a). This phenomenon occurs in Lewy body disorders (McFarland, 2024a). In
DLB, 123-I-MIBG myocardial scintigraphy presents a low uptake which helps to distinguish
DLB from Alzheimer’s dementia (McFarland, 2024a).
Other supportive test includes imaging. Findings common and nonspecific with dementia
include atrophy and white matter lesions. Magnetic resonance imaging (MRI) can help to better
identify certain regions of atrophy specific to DLB, however these tests are not specific enough
to diagnosis (McFarland, 2024a). These scans can display a more pronounced cortical atrophy in
those with LBD versus PDD. In volumetric analyses of MRI scan atrophy can be noted in DLB
as opposed to AD in the putamen and dorsal mesopontine gray matter (McFarland, 2024a).
Biomarkers testing and radiologic testing are not required if clinical criteria is met, but can aid in
determining a diagnosis.
Treatment and Referrals
Treatment involves care from a multi-disciplinary team. Referrals to neurology as well
as physical and occupational therapy can greatly benefit prognosis. There is not a cure for DLB
rather treatment involves symptom management. Treatment involves medications, lifestyle
changes and therapy. Medications may be poorly tolerated and non-pharmacological strategies
such as modifying stressors in an environment may be more beneficial.
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Dementia of Lewy Bodies
Medications can be used to treat cognitive symptoms, behavioral symptoms, or motor
symptoms. Cholinesterase inhibitors are the treatment of choice for DLB as work to improve
cognitive and behavioral symptoms (McFarland, 2024b). Studies suggest that the use of
cholinesterase inhibitors not only improve cognition, but also improve fluctuations in behavior
and psychotic symptoms noted in DLB. The use of these medications also improved activities of
daily living, reduced caregiver burden, and reduced admissions to nursing homes (McFarland,
2024b). Donepezil and rivastigmine are treatment of choice for DLB and appear to be effective
(McFarland, 2024b). Memantine is occasionally used as monotherapy or in conjunction with
cholinesterase inhibitors. Memantine research in DLB has mixed results and therefore is
considered a second line therapy (McFarland, 2024b).
Antipsychotic drugs should be used cautiously as they can cause severe reactions in DLB
(McFarland, 2024b). These medications should be reserved for severe behavioral symptoms and
only after other non-pharmacological methods of treatment have been attempted to improve
symptoms. Severe sensitivity reactions may occur including exacerbation of DLB symptoms,
confusion and even death (McFarland, 2024b).
Levodopa may be used for motor symptoms. Levodopa seems to be more effective than
dopamine agonists (McFarland, 2024b). In DLB treatment with antiparkinsons medications may
worsen orthostatic low blood pressure or psychotic events. If a worsening of psychotic events
does occur a small dose of atypical antipsychotic may be needed (McFarland, 2024b).
Other non-pharmacological treatments include physical therapy to improve movement, as
well as regular exercise, occupational therapy to assist with activities of daily living, and a
structured routine to reduce confusion (Press, 2025). Being proactive in non-pharmacological
treatment and using a collaborative team helps to best manage a patient’s symptoms. Education,
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Dementia of Lewy Bodies
memory prompts, and behavioral interventions are effective at managing symptoms (Press,
2025). Pain management should also be considered as a source of behavioral problems in a
patient with dementia. Music therapy, pet therapy and aromatherapy have also shown to be
effective in avoiding behavioral outburst (Press, 2025). Other therapeutic methods that have
shown to be effective in PDD include electroconvulsive therapy, deep-brain stimulation, as well
as transcranial magnetic stimulation (Press, 2025).
Teaching and Health Promotion
Patients and families should be educated on the main symptoms and when to notify a
healthcare provider. It is often difficult to distinguish between AD and DLB due to lack of
information being shared by a patient or family member. Symptoms to report should include
difficulties in problems solving or thinking clearly, memory problems, short attention span,
hallucinations, movement problems and difficulty paying attention (Larson, 2025).
Safety is another major issue that must be addressed when teaching. Those suffering
with dementia often do not realize their mental function is impaired and may continue to attempt
daily activities as usual (Larson, 2025). These activities can lead to danger including driving,
managing medications, cooking, wandering or falls (Larson, 2025).
Families and caregivers should be educated on agitation or aggression. Confusion and
disorientation can lead to anger or behavior outburst. Patients may become scared or paranoid
due to hallucinations. Patients may be unable to express they are in pain or feeling depressed.
Caregivers should be encouraged to report if they are experiencing these problems and
understand it is okay to seek help (Larson, 2025).
Patients that experience RBD risk sleep related injury. These injuries could include
falling out of bed or harm to a partner. All patients experiencing RBD should be educated on
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Dementia of Lewy Bodies
ways to modify their sleep environment to prevent injury to themselves or their partner. Many
patients respond well to the use of melatonin or clonazepam (MacFarland, 2024).
Risk
Risk of not seeking help for DLB include depression, loss of interest in activities, anxiety
and suicide. Other concerning risk include safety of the patient as well as their community.
Patients may become violent towards a caregiver. Caregivers should seek assistance to maintain
safety. Patients that are confused may become lost or drive a vehicle with danger. Patients
should consider the risk of falls and modify their homes accordingly by making sure there is
ample lighting and remove trip hazards.
Suicide is not well studied but should be considered when discussing DLB. Factors
contributing to suicide in DLB consist of younger age, white males. Suicide is thought to be a
risk factor in dementia due to the disease, depression, the disability in daily functions,
disconnection from others and means to accomplish suicide (Armstrong et al., 2021). Factors
associated with possible suicide attempts include prior harm, psychiatrics disturbances and recent
diagnosis (Armstrong et al., 2021).
Role of the Advanced Practice Registered Nurse
The role of the advanced practice registered nurse (APRN) is critical in providing care to
patients with DLB. An APRN contributes to the multidisciplinary team by thorough assessment
skills, screening for comorbidities, education, coordination of care, referring the patient to a
specialist. The APRN can also assist in medication management as well as management of non-
pharmacological interventions. Patient and family/caregiver education is important and should
be prioritized by the APRN. Education relating to disease process, symptom management, safety
planning, medication education and future planning should be considered when caring for a
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Dementia of Lewy Bodies
patient diagnosed with DLB. The APRN can also offer support to the caregiver by coordinating
care such as respite care, or advanced care planning. APRNs are often in roles that care for
underserved populations and are key in providing early diagnosis, supportive care and reduction
of complications.
Christian Worldview
A Christian worldview shapes the practice and care of an APRN. The APRN should
integrate biblical principles in all aspects or their care, but specifically those patients that are
vulnerable, such as a patient with dementia. The Bible gives us strength, compassion, and hope
through the challenges of life. As Christians, we trust in God and His strength when faced with
chronic disease. Although patients are faced with chronic disease, as Christians, we understand
that this life is temporary and our hope is in the promise of eternal life. It is also the job of the
Christian APRN to show love and compassion to all patients.
Conclusion
In summary, DLB is a progressive neurodegenerative disease. DLB is characterized by
cognition deficits, behavioral problems and parkinsonism that worsens overtime. Patients should
be evaluated for early diagnosis and treatment of symptoms. Medication management as well as
non-pharmacological methods of treatment should be used to best treat a patient. Educating
families and patients is an important role of the APRN and plays an important role in
maintaining hope and plans for a future.
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