A 72-year-old man with Lewy Body Dementia (LBD) develops agitation. His physician considers prescribing haloperidol. What is the critical contraindication specific to LBD?

• A Haloperidol causes metabolic syndrome in LBD patients
• B Haloperidol is contraindicated because it worsens cholinesterase inhibitor levels
• C Haloperidol invariably causes tardive dyskinesia within weeks in LBD
• D LBD patients have neuroleptic sensitivity reactions with conventional antipsychotics, risking severe EPS, autonomic dysfunction, and 2–3× increased mortality ✓

Explanation

Neuroleptic hypersensitivity is a defining feature of Dementia with Lewy Bodies. Up to 50% of LBD patients treated with conventional (and some atypical) antipsychotics develop severe reactions including worsening parkinsonism, confusion, autonomic instability, and a neuroleptic malignant-like syndrome with 2–3-fold increased short-term mortality. This sensitivity is due to the underlying dopaminergic depletion in the striatum (synuclein pathology). Quetiapine (low D2 affinity) and clozapine are preferred if antipsychotics are truly needed. Rivastigmine (ChEI) is beneficial and also helps with hallucinations.

Reference: Kaplan & Sadock's Synopsis of Psychiatry, 11th ed.

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