Visual Hallucinations, Acting Out Dreams, and Shuffling Feet

In my clinic last week, a family member of one of my new patients told me the following story:

“It started when my wife began having difficulty paying the bills and balancing the checkbook. She would also forget things—including important things like picking up our granddaughter after school. Then she began to wake me up, saying, 'There’s a dog in our bedroom!' I’d turn on the light and we’d look around together and there would never be a dog. Shortly after seeing the dog for the first time, she began to move around while she was sleeping. And not just a little—she would move her arms and legs as if the dog were chasing her! You see, she was acting out her dreams. These problems went on for a while, and then her walking became slow and shuffling, her handwriting got small, and her hands started shaking. None of it was bad, at first, but it was noticeable. We’re now struggling with the basics, like dressing and getting to the bathroom on time.”

By the time he was halfway through the story, I knew what the diagnosis was. More importantly, I knew that I could help.

Two Lewy bodies in a single cell under the microscope.

Source: Andrew Budson/used with permission

Dementia with Lewy bodies is a common cause of dementia. It gets its name because in the brain under the microscope we find Lewy bodies: an abnormal collection of protein that interferes with brain cell function. Lewy bodies are also present in Parkinson’s disease. The difference is that in Parkinson’s disease, the Lewy bodies are found only in a part of the brain related to movement that causes tremor, slowness of movements, shuffling walking, reduced size of letters in writing, and diminished facial expression. In dementia with Lewy bodies, the Lewy bodies have spread throughout the brain and, in addition to the features of Parkinson’s disease, they often cause trouble with vision—including visual hallucinations—and acting out dreams at night. Some people who have been living with Parkinson’s disease for many years will later develop dementia with Lewy bodies. Because it started with Parkinson’s disease, in these individuals it is sometimes called Parkinson’s disease dementia instead of dementia with Lewy bodies.

In pure dementia with Lewy bodies, the primary cognitive difficulty is with vision, attention, and performing complicated activities. There can be difficulty forming and retrieving memories, but once memories are formed, they should not be lost. However, it is very common to have both Lewy body dementia and Alzheimer’s. These individuals have the features of both diseases—including prominent memory problems due to rapidly forgetting information.

Common features of Lewy body disease/dementia and Lewy bodies/Parkinson’s disease dementia

Features of Parkinson’s disease

• Tremor
• Slow, shuffling walking
• Falls
• Slowness of movement
• Difficulty rising from a low chair, car seat, or toilet
• Reduced size of letters in writing
• Diminished facial expression

Visual disturbances

• Visual hallucinations of people or animals
• Difficulty seeing

Acting out dreams

Thinking and memory problems

• Poor attention
• Difficulty with complicated activities
• Difficulty forming and retrieving memories

Dementia with Lewy bodies can be treated using the same memory enhancing medications as Alzheimer’s, such as donepezil (Aricept) or rivastigmine (Exelon), as discussed in a prior post. In fact, not only do these medications help the memory in these patients, but they also reduce the visual hallucinations. Melatonin can help lessen the problem of acting out dreams while sleeping. It is also important to move furniture around and put pillows on the floor so that if one does move around and fall out of bed when acting out dreams, injuries will be less likely.

Key Question:

Q: When waking up or falling asleep, your loved one has had several episodes of seeing a person or animal that isn’t there. Does that mean he or she is going crazy?

A: Not at all. Seeing people or animals that are not there may be a sign of dementia with Lewy bodies. Let the doctor know about these symptoms; there are medications that can help.

© Andrew E. Budson, MD, 2019, all rights reserved.