Neuroleptic Sensitivity in Dementia with Lewy Body and Use of Pimavanserin in an Inpatient Setting: A Case Report

Abstract

Patient: Male, 75-year-old Final Diagnosis: Dementia with Lewy bodies Symptoms: Parkinsonism Medication:— Clinical Procedure: — Specialty: Neurology Objective: Unusual clinical course Background: Antidopaminergic medications, including antipsychotics, are known to worsen motor and neuropsychiatric symptoms, including cognition and psychosis, in patients with dementia with Lewy body (DLB). The intensity of worsened clinical symptoms may vary and can result in mortality in certain situations. There have been some reports supporting clozapine, quetiapine and pimavanserin use in psychosis control in this population. Case Report: We describe the case of 75-year-old man with diagnosis of DLB and the post-treatment outcome with olanzapine for psychosis during hospitalization. He experienced worsened cognitive and motor functions. Discontinuation of olanzapine resulted in resolution of the clinical worsening. Further, re-initiation of Pimavanserin helped treat his hallucinations. He returned back to his baseline during a follow-up visit in the clinic at 1 month after discharge. Further, we incorporated the use of Best Practice Alert (BPA) as a part of the electronic health record (EHR) system to help providers identify patients prone to neuroleptic sensitivity and help select appropriate medications to treat psychosis in this patient population. Conclusions: Administration of antipsychotics in patients with parkinsonism, especially DLB, requires close clinical monitoring and judicious use. Awareness of morbidity and mortality associated with such use is of importance, especially during hospitalization. From our experience, we incorporated use of BPA, which can help providers make judicious choices while treating this patient population. Pimavanserin, which is FDA-approved for psychosis in Parkinson’s disease, could be a potential safe and effective treatment option in this patient population.

Pimavanserin Use in Lewy Body Dementia: A Case Report Demonstrating the Medication’s Efficacy

“…This case adds to the growing body of literature demonstrating a favorable response to pimavanserin in LBD without the adverse effects experienced with other antipsychotics. Interestingly, both our patient and the one presented by Abadir et al showed worsening of symptoms when valproic acid was added for behavioral management [ 13 ]. What is unique about this case report, however, is the utilization of SAPS scoring, which provides invaluable information regarding specific psychotic symptoms and both how and when they responded to pimavanserin treatment.…”

“…Though there are some published randomized controlled studies demonstrating the efficacy of pimavanserin in the treatment of Alzheimer’s disease psychosis [ 11 , 12 ], to the best of the author's knowledge, only one other case report has been published demonstrating the potential benefits of pimavanserin sole use in LBD by Abadir et al [ 13 ]. This case adds to the growing body of literature demonstrating a favorable response to pimavanserin in LBD without the adverse effects experienced with other antipsychotics.…”

Pimavanserin Treatment for Psychosis in Patients with Dementia with Lewy Bodies: A Case Series

“…The extension of these therapies to patients with DLB is thus based on untested assumptions and may lead to efficacy or tolerability issues. For example, while preparing this review, we only found 1 manuscript that specifically focused only on DLB, a case report that described a patient with DLB whose hallucinations responded to pimavanserin but who discontinued it due to financial concerns (ie, the patient had a large copay); that patient subsequently experienced an increase in hallucinations while on clozapine and then returned to his baseline levels of psychosis when clozapine was discontinued and pimavanserin was reinitiated [ 26 ]. In addition, 4 retrospective medical record reviews, 1 case report, and 1 clinical trial included patients with DLB alongside other larger cohorts, but these publications did not report clear histories or specific findings on the patients with DLB.…”

Dementia with Lewy bodies

“…Severe sensitivity to antipsychotic agents. Between 30% and 50% of patients with DLB have a sensitivity to antipsychotic drugs that is not dose-related 35. Antipsychotic medications also may worsen confusion or autonomic dysfunction.…”