Revised Criteria for the Clinical Diagnosis of Dementia with Lewy Bodies (DLB)

The Dementia with Lewy Bodies (DLB) Consortium has refined its recommendations about the clinical and pathologic diagnosis of DLB, updating the previous report, which has been in widespread use for the last decade. The revised DLB consensus criteria now distinguish clearly between clinical features and diagnostic biomarkers, and give guidance about optimal methods to establish and interpret these.

Revised criteria for the clinical diagnosis of probable and possible dementia with Lewy bodies (DLB)
Essential for a diagnosis of DLB is dementia, defined as a progressive cognitive decline of sufficient magnitude to interfere with normal social or occupational functions, or with usual daily activities. Prominent or persistent memory impairment may not necessarily occur in the early stages but is usually evident with progression. Deficits on tests of attention, executive function, and visuoperceptual ability may be especially prominent and occur early.
Core clinical features (The first 3 typically occur early and may persist throughout the course)

  • Fluctuating cognition with pronounced variations in attention and alertness.
  • Recurrent visual hallucinations that are typically well formed and detailed.
  • REM sleep behavior disorder, which may precede cognitive decline.
  • One or more spontaneous cardinal features of parkinsonism: these are bradykinesia (defined as slowness of movement and decrement in amplitude or speed), rest tremor, or rigidity.

Supportive clinical features
Severe sensitivity to antipsychotic agents; postural instability; repeated falls; syncope or other transient episodes of unresponsiveness; severe autonomic dysfunction, e.g., constipation, orthostatic hypotension, urinary incontinence; hypersomnia; hyposmia; hallucinations in other modalities; systematized delusions; apathy, anxiety, and depression.

Indicative biomarkers

  • Reduced dopamine transporter uptake in basal ganglia demonstrated by SPECT or PET.
  • Abnormal (low uptake) 123iodine-MIBG myocardial scintigraphy.
  • Polysomnographic confirmation of REM sleep without atonia.

Supportive biomarkers

  • Relative preservation of medial temporal lobe structures on CT/MRI scan.
  • Generalized low uptake on SPECT/PET perfusion/metabolism scan with reduced occipital activity 6 the cingulate island sign on FDG-PET imaging.
  • Prominent posterior slow-wave activity on EEG with periodic fluctuations in the pre-alpha/theta range.

Probable DLB can be diagnosed if:
a. Two or more core clinical features of DLB are present, with or without the presence of
indicative biomarkers, or
b. Only one core clinical feature is present, but with one or more indicative biomarkers.

Probable DLB should not be diagnosed on the basis of biomarkers alone.

Possible DLB can be diagnosed if:
a. Only one core clinical feature of DLB is present, with no indicative biomarker evidence, or
b. One or more indicative biomarkers is present but there are no core clinical features.

DLB is less likely:
a. In the presence of any other physical illness or brain disorder including cerebrovascular disease, sufficient to account in part or in total for the clinical picture, although these do not exclude a DLB diagnosis and may serve to indicate mixed or multiple pathologies contributing to the clinical presentation, or
b. If parkinsonian features are the only core clinical feature and appear for the first time at a stage of severe dementia.

DLB should be diagnosed when dementia occurs before or concurrently with parkinsonism. The term Parkinson disease dementia (PDD) should be used to describe dementia that occurs in the context of well-established Parkinson disease. In a practice setting the term that is most appropriate to the clinical situation should be used and generic terms such as Lewy body disease are often helpful. In research studies in which distinction needs to be made between DLB and PDD, the existing 1-year rule between the onset of dementia and parkinsonism continues to be recommended.

 

References:

  1. McKeith IG, Boeve BF, Dickson DW, Halliday G, Taylor JP, Weintraub D, Aarsland D, Galvin J, Attems J, Ballard CG, Bayston A, Beach TG, Blanc F, Bohnen N, Bonanni L, Bras J, Brundin P, Burn D, Chen-Plotkin A, Duda JE, El-Agnaf O, Feldman H, Ferman TJ, Ffytche D, Fujishiro H, Galasko D, Goldman JG, Gomperts SN, Graff-Radford NR, Honig LS, Iranzo A, Kantarci K, Kaufer D, Kukull W, Lee VMY, Leverenz JB, Lewis S, Lippa C, Lunde A, Masellis M, Masliah E, McLean P, Mollenhauer B, Montine TJ, Moreno E, Mori E, Murray M, O’Brien JT, Orimo S, Postuma RB, Ramaswamy S, Ross OA, Salmon DP, Singleton A, Taylor A, Thomas A, Tiraboschi P, Toledo JB, Trojanowski JQ, Tsuang D, Walker Z, Yamada M, Kosaka K. Diagnosis and management of dementia with Lewy bodies: Fourth consensus report of the DLB Consortium. Neurology. 2017 Jul 4;89(1):88-100. [Medline]
  2. Galasko D. Lewy Body Disorders. Neurol Clin. 2017 May;35(2):325-338. [Medline]

 

 

Created Mar 26, 2018.

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