Search Results

Nearly all of us end up in the hospital for something sooner or later. The unique problems of Lewy disorders and medications can challenge hospital care teams. On a related note, some individuals with DLB or PDD may require care in a nursing facility. This may be transient, requiring rehabilitation and stabilization following a hospitalization; in other cases, it is indefinite because of the complex care necessary for DLB and PDD. In this chapter, the focus is on the care teams in these facilities. Although many staff in these settings are familiar with the medications and problems of DLB and PDD, this knowledge is not universal. Little published literature addresses the special needs of those with PDD or DLB admitted to the hospital or living in extended care facilities. It is hoped that this chapter can be an aid in caring for those with PDD or DLB. People with DLB or PDD are, by definition, cognitively impaired. Sometimes this is associated with hallucinations or delusions. Most individuals also have dopamine deficiency states with parkinsonism. Another common component is autonomic nervous system dysfunction. This dysautonomia may be associated with bladder and bowel disorders but, more importantly, with orthostatic hypotension (potential for fainting when ambulating). Some people with PDD or DLB are mildly impaired by these problems, and others are quite compromised. What follows is a summary of crucial knowledge for nursing and paramedical staffs. 1. As with any dementia, novel environments are disorienting. 2. Hallucinations are a frequent component of DLB and PDD. These may be exacerbated by psychoactive medications, including narcotics for pain. 3. Carbidopa/levodopa is the least likely among the potent drugs for parkinsonism to provoke hallucinations. Other Parkinson drugs should generally not be started. 4. People with DLB or PDD commonly experience dream enactment behavior (REM sleep behavior disorder); this should not be misinterpreted as nocturnal hallucinations. 5. Anticholinergic medications for urinary urgency may cross the blood–brain barrier and impair cognition (e.g., oxybutynin). The only drug from this class that cannot get into the brain is trospium (Sanctura).

People with DLB and PDD tend to be middle-aged and older. In this age group, selected general health issues deserve discussion. Comprehensive medical care is beyond the scope of this book, but several general medical topics should be addressed here. People with Lewy disorders commonly experience walking difficulties. The risk of falling may surface early or later in the condition. Fracture risk is also a concern, and preemptive action is wise. Falls can be tolerated if bones are strong; witness athletes who fall on a football field. Over the course of a lifetime, bones tend to lose their strength and become more prone to fractures. When the loss of bone integrity is substantial we categorize this as osteoporosis. There are specific criteria that doctors use to define osteoporosis. While bone integrity is measured in several ways, the most common and accepted measurement is by imaging with a nuclear medicine technique. A quick scan after injection of a radioisotope that is taken up by bones generates a picture and numeric data; these can be compared to those of normal subjects. This analysis is termed a nuclear medicine bone density study and sometimes is called a DEXA scan. Using the numeric measures from a bone density scan, reductions of bone integrity fall into two classes. We have already mentioned that substantial loss of bone strength is termed osteoporosis. A less severe reduction of bone integrity has been defined and termed osteopenia. Restated, mild bone weakening is osteopenia, and marked loss of bone integrity is osteoporosis. Conventionally, osteoporosis is treated with prescription medications, whereas the lesser problem of osteopenia is not. However, if there is a substantial fall risk, some clinicians would advise treating osteopenia with a prescription drug (see below). Who is at risk for osteoporosis? In the general population, advancing age is the major risk factor. Women over age 60 and men over age 70 fall into these risk categories, as well as those with very sedentary lives. In the context of DLB or PDD, osteoporosis is especially important to consider.