This short abstract is of a case report by German clinicians who used the antipsychotic Clozaril and levodopa (ie, Sinemet) to treat a DLB patient with "severe neurological and psychopathological symptoms." The full article costs more than I'm willing to pay but, reading between the lines, I think we can figure out some additional details.

Ian McKeith is a UK-based expert on DLB. (He's probably the #1 expert in the world on this disorder.) Based on Dr. McKeith's letter that's in the same journal issue*, it seems that this German patient was probably given a cholinesterase inhibitor (such as Aricept, Razadyne, or Exelon) but this didn't resolve the psychiatric symptoms. Dr. McKeith says "Such patients pose one of the more difficult clinical management problems faced in psychogeriatrics." He points to a recent review of Namenda that showed that it did not relieve psychiatric symptoms though it helped with cognition and globally. (I likely posted here about the Norwegian study of Namenda in June 2009; the lead author is Aarsland.)

Here's what McKeith has to say about anti-psychotics ("neuroleptics"): "Neuroleptics are quite rightly avoided whenever possible and the cautious 'start low/go slow' maxim, which most clinicians apply when neuroleptics have to be used, often turns into a chronic 'stay low/get no (response)' situation."

It would seem seem from McKeith's letter that in the case of the German patient, a high dose of Clozaril was administered but there were motor side effects. To deal with these side effects, levodopa was administered. McKeith describes this as "heroic pharmacotherapy." He seems to be saying "great that it worked in this one case but I'd be reluctant to try this approach myself and would like to hear if any others have used this approach." Well, at least that's my interpretation.

Robin


* You can read the first half of McKeith's letter here:
http://journals.cambridge.org/action/di ... id=7281448


International Psychogeriatrics. 2010 Mar 4:1-2. [Epub ahead of print]

Adjunct treatment with levodopa in a patient with dementia with Lewy bodies, delusions and severe neuroleptic hypersensitivity syndrome.

Majic T, Mell T, Heinz A, Rapp MA.
Department of Psychiatry, Charité - University Medicine Berlin, Berlin, Germany.

We report on the treatment of a patient suffering from dementia with Lewy bodies who initially presented with severe neurological and psychopathological symptoms. After treating the patient with levodopa and clozapine, these symptoms remitted.

PubMed ID#: 20199702 (see pubmed.gov for this very short abstract only)

Well, my husband has been on levodopa [one of three components of Stalevo] for five years and he nonetheless experiences extreme motor meltdown with neuroleptics. The Exelon helped initially and we have to presume it is still somewhat effective after two years. But we would be very reluctant to try another neuroleptic.

My guess is that in the case of this German patient, parkinsonism are not part of the symptoms, and the only reason this patient was prescribed a med to treat parkinsonism symptoms was after seeing side effects from the Clozaril.

I'm unclear as to what percentage of those with LBD take levodopa (in any of its various forms). My guess is that it's about one-third.

It's always a balancing act between the motor problems and the psychiatric problems.

So true, Robin!!! Our first neurologist warned us about this back in 2005 and it has certainly been true for my husband.