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Shanna V. Diaz, DO, is a Sleep Medicine Fellow, Division of Pulmonary and Critical Care, University of New Mexico School of Medicine. Jennifer M. Erickson, DO, is a Fellow in Psychosomatic Medicine, Mt. Sinai Beth Israel Hospital. Swala K. Abrams, MD, is an Associate Professor and an Attending Psychiatrist, University of New Mexico Psychiatric Center; and the Medical Director, University of New Mexico Psychiatric Center COPE Clinic. Frank M. Ralls, MD, is an Associate Professor, Department of Internal Medicine, and the Director, Sleep Medicine Fellowship, University of New Mexico School of Medicine.
Disclosure: The authors have no relevant financial relationships to disclose.
The patient is a 63-year-old man with Lewy body dementia that was diagnosed 7 years prior, who was taking dopamine agonists for severe parkinsonism. His presenting symptoms included obsessive-compulsive behaviors of excessive cleaning, rearranging, and punding (for example, purposely rearranging an organized room of boxes several times). Cognitive deficits became noticeable concomitantly. He exhibited confusion about the nature of his work and his schedule, experienced onset of sleep-wake cycle reversal, and started interacting with visual hallucinations of a little girl. He was forced to retire from his job of several decades as a telecommunications technologist (in 2008, at age 57 years), and became convinced that it was a plot by coworkers to push him out of the company. The onset of tremor in his right hand occurred within 1 year of these cognitive and behavioral changes, and it progressed to a dopamine-responsive diffuse tremor with axial rigidity and freezing episodes.
In addition to continuing treatment with a dopamine agonist for motor symptoms, the patient was started on the cholinesterase inhibitor donepezil in 2011 (at age 60 years). This occurred prior...