Ask the Expert: What is the Role of the Geriatric Psychiatrist in LBD?

By Daniel Weintraub, MD, Ian McKeith, MD, FRCPsych, Peter Rabins, MD, MPH

Care of the cognitive, psychiatric and neurologic features of Lewy body dementias (LBD), including dementia with Lewy bodies (DLB) and Parkinson’s disease dementia (PDD), can be provided by individuals with training in several medical specialties, including primary care physicians, geriatric internists, neurologists and geriatric psychiatrists. To some extent the choice is determined by who is available and has the most interest in and experience with the condition. There is no “right specialty” – all have something to contribute. The frequent occurrence in LBD of visual hallucinations, delusions (false, persistent ideas), mood symptoms, and disruptive behaviors, all of which are major contributing factors to poor quality of life and caregiver burden, can benefit particularly from the expertise of a treating psychiatrist.

Because specialists in the management of elderly patients with dementia and behavioral disturbances (generally known in the United States as geriatric psychiatrists or neuropsychiatrists) are not readily available in many clinical settings, initial management of psychiatric symptoms is often managed handled by a non-psychiatrist. Psychiatric referral tends to happen only if this initial management is unsuccessful.

The psychiatrist will usually begin by taking a lengthy history from both patient and family member to confirm the diagnosis and establish precisely what symptoms are present and need treatment. Thereafter, the psychiatrist can provide a range of inputs, including: (1) weighing the pros and cons of psychiatric medication use for psychotic symptoms and agitation; (2) educating caregivers about potential side effects, both minor and severe, that can occur with antipsychotic use in LBD patients; (3) discussing the use of psychiatric medications to treat other neuropsychiatric symptoms that often occur (such as depression and anxiety); (4) assisting with the implementation of non-pharmacologic management strategies; and (5) providing support and education to the patient’s family and caregivers, including regarding disease course and how best to manage the patient’s care and affairs.

Patients with LBD may require hospitalization if the symptoms of psychosis or agitation cannot be safely managed as an outpatient. Providers with expertise in geriatric psychiatry are best equipped to provide such inpatient care. Their expertise includes knowing not to abruptly stop some drugs (for example, carbidopa-levodopa), how to cautiously balance the potential benefits and side effects of newly introduced medications (such as high potency antipsychotics), and the importance of consulting with the family and regular treatment providers when making medication regimen changes.

If the patient requires admission to a medical-surgical unit, then it is helpful to have a psychiatrist (called a consult-liaison psychiatrist) advise on the management of the patient. This will help ensure that informed decisions are made about the risk: benefit ratios of using medications to treat the parkinsonian symptoms and the use of antipsychotic or other psychiatric medications during the hospital stay.