Integrating research, education, care and lived expertise at The Royal

MRI
Dr. Tim Lau, psychiatrist and clinical lead of the Geriatric Psychiatry Inpatient Unit, The Royal. Photo by Shane Francescut
Editor's Note

Dementia with Lewy Bodies (DLB) is a complex neurodegenerative disease that is oftentimes difficult to diagnose and treat. Characterized by progressive cognitive decline, executive dysfunction, visual hallucinations, fluctuating cognition, and Parkinsonism, DLB is often underdiagnosed, or more so, mistaken for other types of neurodegenerative diseases and sub-types of dementia. Making a clinical diagnosis of DLB remains an ongoing and challenging issue for psychiatrists.

DLB is also unique when compared to other neurodegenerative diseases, as many people with DLB are unable to take antipsychotic medications due to a sensitivity that puts them at a significantly higher risk for severe autonomic dysfunction. 

Electroconvulsive therapy (ECT) has been described as a potential treatment for neuropsychiatric symptoms associated with DLB; however the studies are limited to very small case reports, so this form of treatment is still novel in clinical care.

Studies have shown that medical imaging offers new opportunities to narrow the differential diagnosis in many neurodegenerative diseases including the dementia subtypes. Magnetic resonance imaging (MRI) can be used to show specific patterns of atrophy in the brain and can also eliminate other pathologies. Positron emission tomography (PET) coupled with an imaging tracer called 18F-fluorodeoxyglucose (FDG) can be used to examine regional patterns of glucose utilization, where distinct utilization patterns are directly associated to different subtypes of neurodegenerative dementia.

While clinical MRI is provincially funded in Ontario, there is no comparable mechanism for access to FDG-PET for neurodegenerative dementia. Access to FDG-PET specifically for the diagnosis of dementia is only accessible through hospital-led clinical trials.

Dr. Tim Lau, psychiatrist and clinical lead of the Geriatric Psychiatry Inpatient Unit at The Royal, was treating one of his geriatric patients with suspected Dementia with Lewy Bodies (DLB), when he made an interesting discovery. 

Dr. Lau’s patient had been receiving ECT for neuropsychiatric symptoms of depression, anxiety and visual hallucinations. Through her ECT treatment, Dr. Lau began to notice a significant improvement in her DLB neuropsychiatric symptoms. 

This was the moment that Dr. Lau knew a collaboration with his research colleagues at The Royal’s Institute of Mental Health Research (IMHR) was required. Dr. Lau and Dr. Lauri Tuominen, Emerging Research Innovators in Mental Health (eRIMh) scientist and PET expert, partnered to delve further into what was going on inside their patient’s brain.

Dr. Lau, Dr. Tuominen, the Geriatric Psychiatry department and the research team at the Brain Imaging Centre (BIC) led by Katie Dinelle, manager of the BIC, developed a personalized clinical case study for this one patient. 

“One of The Royal’s strategic goals is to integrate research and care for the benefit of our patients,” says Dr. Lau. “This collaboration is enabling us, for the first time, to open our BIC to patients for imaging that can directly impact individual diagnosis and personalized treatment planning. Even for specialists in the field, much uncertainty exists for clinical diagnosis. Until recently the brain has been a black box into which we could not explore much aside from its structural appearance. Tools like PET-MRI not only show what something looks like but also how it works. In this particular case we were able to study not only how things work but also what was improving as a person clinically improved.”

They used neuroimaging modalities of PET and MRI in order to get a better look at the patient’s brain, specifically to see if they could use diagnostic PET-MRI to confirm the suspected diagnosis of DLB.

The use of FDG-PET imaging provided the ability to confirm a differential diagnosis of Dementia with Lewy bodies (DLB) – as distinct from other dementia sub-types and depression – and therefore to tailor treatment approaches. 

“The scan helped confirm the diagnosis, which was unclear prior to this case study,” says Dr. Lau. “Four different nuclear medicine specialists all agreed on the pattern.”

The results and success of this case study demonstrate the collaborative capabilities of our clinical and research teams at The Royal and have fostered future collaborations between research and care.

“The future of research at The Royal is about research-informed care and vice-versa,” says Dr. Florence Dzierszinski, IMHR president and VP research, The Royal. “Our inter-professional teams composed of patients and families, clinicians, program leaders, and scientists are co-designing studies that are clinically impactful, and provide access to care through research.” 

Dr. Lau and Dr. Tuominen have received funding through the Translation of Research into Care (TRIC) grant to conduct a larger study at The Royal that will potentially improve care and dementia diagnosis for patients in the Geritric Unit. 

“This case study was our first step towards the long term goal of improving access to diagnostic imaging for clients of The Royal via research,” says Dinelle. “Longer term we hope to add imaging tracers that would allow us to visualize beta amyloid plaques [deposits that form plaques around brain cells] into our studies, which are a hallmark of Alzheimer’s disease.”

The feedback received from the patient’s family was all positive and everyone involved is motivated to build on the success of this experience. 

“My patient benefited greatly from the scan and from the treatments she is receiving,” says Dr. Lau. “She is still receiving ECT as an outpatient and her daughter, who is her substitute decision maker, is very appreciative of the research-informed care she has received. Access to research offers the hope and promise of a better future. The scans offered something my patient’s daughter did not have before, and that is certainty of diagnosis.”