Objective: To evaluate the effectiveness of stimulants in reducing cognitive fluctuations in Lewy Body Dementia (LBD).

Background: Lewy Body Dementia (LBD) is the 2nd most common neurodegenerative dementia[1]. Diagnosis is provided when 2 or more core clinical features are present. Core clinical features include cognitive fluctuations (CF), visual hallucinations, REM sleep behavior disorder (RBD), & Parkinsonism[2]. CF occurs in 90% of patients[3] and is defined as spontaneous alterations in cognition, attention, & arousal[4]; not just mere excessive daytime somnolence. 

LBD patients are often misdiagnosed as having TIAs, seizures, delirium, psychosis, parasomnias. One of the factors that contributes to these misdiagnoses is inaccurate identification & assessment of CF[5].

Method: 71-year-old male presented 8 years ago for evaluation of recurrent falls, parkinsonism, & visual hallucinations. Extensive work-up included unremarkable CTA Head/Neck, MRI Brain, & Polysomnograms. EEGs revealed encephalopathy; no seizure activity. He began to have episodes of CF lasting 15-180 mins. Episodes were characterized by aphasia, confusion, disorientation & lack of alertness/arousal. Involuntary eye closure persisted during periods of lucidity. 

He was hospitalized 7 times within 2 years for recurrent falls. CF episodes resulted in extensive workup to exclude TIA, seizure & migraine – all unremarkable. He was placed on antiepileptics with no change in event frequency. 

4 years after initial visit, diagnosis of LBD was made.

Results: Initiated armodafinil 150 mg with continuous EEG monitoring. Patient became more alert, oriented & verbal 3 hours after administration (Table 1). Eyes stayed open & eye contact increased, orientation improved, & patient could complete 2-step commands. EEG showed mild to moderate encephalopathy with no dramatic change despite clinical improvement. 

These improvements were sustained over the next 20 months on daily armodafinil 150 mg. He had fewer episodes of CF & no hospitalizations. Wife felt he was “becoming his old self.”

Conclusion: Cognitive Fluctuations in LBD are not just debilitating for the patient, but their loved ones.. They lead to frequent hospitalizations, unnecessary medical workup, & progressively impair their cognitive abilities, personality, & physical functions. Using stimulants like armodafinil can improve quality of life for the patient & caregiver.

Cognitive Performance Relative to Armodafinil

Cognitive Performance Relative to Armodafinil

Cognitive Performance Relative to Armodafinil

References: 1. Gomperts, S. N. (2016). Lewy body dementias. CONTINUUM: Lifelong Learning in Neurology, 22(2, Dementia), 435–463. https://doi.org/10.1212/con.0000000000000309
2. McKeith, Ian 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. Neurology, 89(1), 88–100. https://doi.org/10.1212/wnl.0000000000004058
3. Escandon, A., Al-Hammadi, N., & Galvin, J. E. (2010). Effect of cognitive fluctuation on neuropsychological performance in aging and dementia. Neurology, 74(3), 210–217. https://doi.org/10.1212/wnl.0b013e3181ca017d
4. McKeith, I. G. (1996). Consensus criteria for the clinical diagnosis of dementia with Lewy bodies (DLB). Dementia with Lewy Bodies, 491–492. https://doi.org/10.1017/cbo9780511601187.044
5. Sanford, A. M. (2018). Lewy body dementia. Clinics in Geriatric Medicine, 34(4), 603–615. https://doi.org/10.1016/j.cger.2018.06.007

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MDS Abstracts - https://www.mdsabstracts.org/abstract/efficacy-of-stimulant-use-for-cognitive-fluctuations-in-lewy-body-dementia-a-case-study/