eMedicine Specialties > Neurology > Behavioral Neurology and Dementia
Dementia With Lewy Bodies: Treatment & Medication
Updated: Dec 23, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
- Double-blinded, placebo-controlled studies have demonstrated that rivastigmine may decrease psychiatric symptoms associated with dementia with Lewy bodies (DLB), particularly apathy, anxiety, hallucinations, and delusions.15,16 These studies also demonstrate that patients with DLB treated with cholinesterase inhibitors do better on neuropsychological tests than subjects treated with placebo. Open-label studies suggest that donepezil and galantamine also are effective.
- For the treatment of agitation and hallucinations associated with DLB, acetylcholinesterase inhibitors should be tried first in most instances.
- In a small minority of patients, motor features are worsened with cholinesterase inhibitors.
- Levodopa/carbidopa may improve motor function in some patients with DLB; however, in many patients this combination has no effect and may exacerbate psychiatric symptoms or confusion.
- Hallucinations and agitation are especially troublesome in DLB. When these symptoms are mild, no medical treatment may be necessary.
- Acetylcholinesterase inhibitors should usually be tried first.
- Most experts recommend atypical neuroleptics such as clozapine, quetiapine, or aripiprazole when cholinesterase inhibitors are ineffective.
- Avoid standard neuroleptics such as haloperidol because of neuroleptic sensitivity.
- Depression is frequent in DLB patients and may result from damage in the dorsal raphe and locus ceruleus and/or as a psychological response to impaired function. Selective serotonin reuptake inhibitors are the drugs of choice.
- Some experts try antiepileptic drugs to treat agitation and hallucinations, but clinical data supporting their use is lacking.
Consultations
Spouses, family members, and caregivers of patients with DLB frequently realize that the patient with DLB behaves differently than typical patients with Alzheimer's disease. Primary caregivers (or neurologists not specializing in dementia) frequently are unable to adequately explain these differences. In such situations, referral to a dementia specialist can be helpful.
Diet
No dietary restrictions are indicated except for patients with severe disease who have swallowing impairment.
Activity
Physical therapy and exercise classes can be useful to maintain mobility. Additionally, advise families of potential problems faced by patients with DLB who drive.
Medication
As yet, no compelling data indicate that medications can decrease the rate of cognitive decline. Medication can be used to treat agitation and hallucinations, treat depression, and improve cognition and/or alertness.
Regarding nonspecific partial glutamate antagonists, in the United States, memantine (Namenda) is approved for the treatment of moderate-to-severe Alzheimer's disease. It is not approved for the treatment of Parkinson's disease or DLB. A recent double-blind, placebo-controlled, multicenter trial of memantine in 72 patients with DLB or Parkinson's disease dementia found that after 24 weeks of treatment, patients taking memantine had better Clinical Global Impression of Change scores than those taking placebo (mean difference 0.7, 95% confidence index 0.04–1.39; p=0.03).17 A few case reports have noted that memantine may exacerbate fluctuations.
Although clonazepam has been considered the treatment of choice for rapid eye movement sleep behavior disorder in patients with DLB, melatonin may be beneficial, either alone or in combination with clonazepam. Melatonin may be administered at 3 mg hs.18
For further discussion of possible treatment of motor features, see Parkinson Disease.
Centrally acting acetylcholinesterase inhibitors
Ach concentrations are decreased in the brains of patients with DLB. Patients with DLB are more likely than patients with AD to improve with cholinesterase inhibitor therapy. Fluctuations in cognition may decrease, alertness may increase, and memory may improve.
Donepezil (Aricept)
Noncompetitively inhibits centrally active acetylcholinesterase, which may increase concentrations of ACh available for synaptic transmission in CNS.
Adult
5 mg PO qhs (with snack) for 6 wk; if tolerated, can be increased to 10 mg qhs
Pediatric
Not established
Increases effects of succinylcholine, cholinesterase inhibitors, or cholinergic agonists; may counteract effects of anticholinergics used for bladder control (anticholinergics should not be used in DLB)
Documented hypersensitivity; theoretic concerns about worsening COPD and peptic ulcer disease because of increased cholinergic tone not clinically observed; case reports, but not systematic studies, describe worsening of motor features of PD, but most studies indicate no exacerbation of PD motor signs; bradycardia may be exacerbated in patients with sick sinus syndrome, but clinical data are lacking
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in seizures, asthma, sick sinus syndrome, or other supraventricular conduction abnormalities
Rivastigmine (Exelon)
Competitive and reversible inhibitor of acetylcholinesterase. Although mechanism of action unknown, may reversibly inhibit cholinesterase, which may, in turn, increase concentrations of ACh available for synaptic transmission in CNS and enhance cholinergic function. Effect may lessen as disease process advances and fewer cholinergic neurons remain functionally intact. No evidence indicates that acetylcholinesterase inhibitors alter the course of underlying dementia.
Adult
1.5 mg PO bid; increase by 1.5 mg q2wk as tolerated; take with food; therapeutic dose range usually 3-6 mg PO bid
Pediatric
Not established
May reduce effects of anticholinergics (anticholinergics should not be used in DLB); increases effects of cholinergic agonists and neuromuscular blockers; risk of bradycardia increases when administered concurrently with beta-blockers without ISA, calcium channel blockers (ie, diltiazem, verapamil), or digoxin
Documented hypersensitivity
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May cause significant nausea, vomiting, anorexia, and weight loss (occurs frequently in women and during titration phase); if significant adverse effects occur, patient should discontinue treatment for several doses, then restart at same or next lower dose; if treatment stopped for several days, initiate treatment at lowest daily dose; caution in history of peptic ulcer disease, concurrent NSAID use, sick sinus syndrome, urinary obstruction, pulmonary conditions (eg, COPD, asthma), and bradycardia or supraventricular conduction conditions; theoretical concerns about worsening COPD and peptic ulcer disease because of increase in cholinergic tone not observed in clinical use; case reports, but not systematic studies, have described worsening of motor features of PD, but most studies indicate no exacerbation of PD motor signs; bradycardia may be exacerbated in sick sinus syndrome, but clinical data are lacking
Galantamine (Razadyne [previously called Reminyl])
Competitive and reversible inhibitor of acetylcholinesterase. Although mechanism of action unknown, may reversibly inhibit cholinesterase, which may, in turn, increase concentrations of ACh available for synaptic transmission in CNS and enhance cholinergic function. Effect may lessen as disease process advances and fewer cholinergic neurons remain functionally intact. No evidence indicates that acetylcholinesterase inhibitors alter the course of underlying dementia.
Available in ER daily dosing and in IR form.
Adult
8 mg PO qd for 4 wk; increase by 8 mg q4wk, not to exceed 24 mg/d
Pediatric
Not established
Coadministration with other cholinesterase inhibitors (eg, succinylcholine) may increase toxicity; CYP2D6 or CYP3A4 inhibitors (eg, cimetidine, ketoconazole, ritonavir, paroxetine, erythromycin) may decrease elimination and increase serum levels; may counteract effects of anticholinergics used for bladder control (anticholinergics should not be used in DLB)
Documented hypersensitivity; severe renal dysfunction (ie, <10 mL/min CrCl)
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Decrease dose in moderate renal insufficiency or moderate-to-severe hepatic impairment; caution in asthma; may cause bradycardia or AV block; syncope may occur with doses >24 mg/d; caution in sick sinus syndrome or other supraventricular conduction; theoretical concerns about worsening COPD and peptic ulcer disease because of increase in cholinergic tone not observed in clinical use; case reports, but not systematic studies, have described worsening of motor features of PD, but most studies indicate no exacerbation of PD motor signs; bradycardia may be exacerbated in sick sinus syndrome, but clinical data are lacking
Rivastigmine transdermal patch (Exelon patch)
Competitive and reversible acetylcholinesterase inhibitor. While mechanism of action unknown, may reversibly inhibit cholinesterase, which may, in turn, increase concentrations of acetylcholine available for synaptic transmission in CNS and thereby enhance cholinergic function. Effect may lessen as disease process advances and fewer cholinergic neurons remain functionally intact.
Available as 5-cm2 patch containing 9 mg (releases 4.6 mg/24 h) and 10-cm2 patch containing 18 mg (releases 9.5 mg/24 h). Indicated for dementia of Alzheimer disease and for dementia associated with Parkinson disease.
Adult
Apply patch to upper or lower back, upper arm, or chest
Initiating patch therapy (not switching from oral therapy): 4.6 mg/24 h patch (5 cm2) applied qd initially; if well tolerated and after minimum of 4 wk, increase to 9.5 mg/24 h patch (10 cm2) applied qd
Switching from oral administration to patch therapy:
Apply first patch on day following last oral dose
Total daily oral dose <6 mg/d: Switch to 4.6 mg/24 h patch
Total daily oral dose 6-12 mg/d: Switch to 9.5 mg/24 h patch
Pediatric
Not indicated
May reduce effects of anticholinergics; increases effects of cholinergic agonists and neuromuscular blockers; risk of bradycardia increases when administered concurrently with beta-blockers without ISA, the calcium channel blockers diltiazem or verapamil, and digoxin
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Apply patch to clean, dry, and hairless area of back, upper arm, or chest; area where patch is applied must be free of powder, oil, moisturizer, lotion, or other substances that would keep patch from adhering properly to skin; also, apply to areas free of cuts, rashes, or other irritation; may cause significant nausea, vomiting, anorexia, and weight loss if taken in doses higher than recommended; if significant adverse effects occur, patient should discontinue treatment for several doses, then restart at lowest dose; extrapyramidal symptoms may occur or be exacerbated (especially tremor); caution in history of peptic ulcer disease, sick sinus syndrome, urinary obstruction, pulmonary conditions (eg, COPD, asthma), and bradycardia or supraventricular conduction conditions
Atypical neuroleptics
Patients with DLB frequently have hallucinations that can cause them to engage in unsafe behavior. Thus, they require treatment. Standard neuroleptics exacerbate parkinsonian motor features and, therefore, are contraindicated.
Clozapine (Clozaril)
Associated with risk of agranulocytosis when used at doses required for treatment of schizophrenia with symptoms refractory to standard neuroleptics; in the United States, weekly dosing and weekly CBC counts required to dispense; discontinuing therapy at first sign of leukopenia decreases but does not eliminate risk of agranulocytosis; whether agranulocytosis is associated with low doses in treating elderly patients and those with dementia not clear.
Adult
25 mg tab, half the tab PO qd; may be increased to half the tab bid after 1-2 wk; dosage can be gradually increased further
Pediatric
Not established
Epinephrine and phenytoin may decrease effects; TCAs, neuroleptics, CNS depressants, guanabenz, and anticholinergics may increase effects
Documented hypersensitivity, WBC count <3500 cells/µL before or during therapy
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May cause serious agranulocytosis; may worsen confusion and EPS; may increase lethargy and cause tachycardia, dizziness, and increased sweating; do not stop abruptly; perform WBC testing q2wk for duration of therapy
Quetiapine (Seroquel)
Atypical neuroleptic that may act by antagonizing dopamine and serotonin effects. Also used to treat insomnia.
Adult
Hallucinations: 25 mg PO bid; can be increased very gradually
Insomnia: 12.5 mg PO hs
Pediatric
Not established
May antagonize levodopa and dopamine agonists; phenytoin, thioridazine, and other liver enzyme inducers may reduce levels; CYP450 3A inhibitors (eg, ketoconazole, fluconazole, erythromycin) increase serum concentrations
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May induce orthostatic hypotension associated with dizziness, tachycardia, and syncope; neuroleptic malignant syndrome and tardive dyskinesia have been associated with treatment; hyperglycemia may occur and, in some cases, be extreme, resulting in ketoacidosis, hyperosmolar coma, or death; caution in hepatic impairment (decrease dose)
Aripiprazole (Abilify)
Improves positive and negative schizophrenic symptoms. Mechanism of action unknown, but is hypothesized to work differently than other antipsychotics. Thought to be partial dopamine (D2) and serotonin (5HT1A) agonist and to antagonize serotonin (5HT2A). Additionally, no QTc interval prolongation noted in clinical trials. Available as tab, orally disintegrating tab, or oral solution.
Adult
10-15 mg PO qd; if needed, may increase dose gradually q2wk, not to exceed 30 mg/d
Pediatric
Not established
CYP450 3A4 and 2D6 isoenzyme substrate, thus, inhibitors (ie, ketoconazole, quinidine, fluoxetine, paroxetine) or inducers (ie, carbamazepine) may increase or decrease serum levels, respectively
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Common adverse effects include headache, anxiety, somnolence, or insomnia; rare reports of tardive dyskinesia and neuroleptic malignant syndrome; may cause orthostatic hypotension, seizure, dysphagia, or suicidal ideation; hyperglycemia may occur and, in some cases, be extreme, resulting in ketoacidosis, hyperosmolar coma, or death
Antidepressants
Depression is frequent in DLB. Antidepressants with little or no anticholinergic activity are desirable.
Venlafaxine (Effexor)
May treat depression by inhibiting neuronal serotonin and norepinephrine reuptake; in addition, causes beta-receptor down-regulation.
Adult
IR: 75 mg/d PO divided bid/tid with food; increase in 75-mg/d increments q4d to 225-375 mg/d
ER: 75 mg/d PO with food; increase in 75-mg/d increments q4d to 225 mg/d
Pediatric
Not established
Cimetidine, MAOIs, sertraline, fluoxetine, class IC antiarrhythmics, TCAs, and phenothiazine may increase effects
Documented hypersensitivity; MAOIs within 14 d
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Patients may experience hypertension; fatal reaction may occur if taken concurrently with an MAOI; caution in patients with cardiovascular disorders
Paroxetine (Paxil)
Selectively inhibits presynaptic serotonin reuptake with minimal or no effect in reuptake of norepinephrine or dopamine.
Adult
10 mg/d PO initially; increase in 10-mg/d increments prn; dose changes should occur at intervals of at least 1 wk; usual dose range is 10-60 mg/d; not to exceed 60 mg/d
Pediatric
Not established
Phenobarbital and phenytoin decrease effects; alcohol, cimetidine, sertraline, phenothiazines, and warfarin increase toxicity
Increases toxicity of diazepam and trazodone by decreasing their clearance; increases toxicity of highly protein-bound drugs
Documented hypersensitivity; MAOIs within 14 d
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution with history of seizures, mania, renal disease, cardiac disease, or hepatic impairment; discontinue MAOIs at least 14 d before initiating therapy
Sertraline (Zoloft)
Selectively inhibits presynaptic serotonin reuptake.
Adult
50 mg tab, half the tab PO qd; gradually increase dose, not to exceed 200 mg (however, in most patients with DLB, not to exceed 100 mg)
Pediatric
Not established
Increases toxicity of MAOIs, diazepam, tolbutamide, and warfarin
Documented hypersensitivity, concurrent MAOIs
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May increase confusion and agitation; may increase sleepiness or conversely cause insomnia; may be associated with weight gain or weight loss; discontinue MAOIs at least 14 d before initiating therapy
Fluoxetine (Prozac)
Selectively inhibits presynaptic serotonin reuptake with minimal or no effect in the reuptake of norepinephrine or dopamine.
May cause more gastrointestinal adverse effects than other SSRIs now currently available, which is the reason it is not recommended as a first choice. May be given as a liquid and a capsule.
May give as 1 dose or divided doses. Presence of food does not appreciably alter levels of the medication. May take up to 4-6 weeks to achieve steady state levels of the medication as it has longest half-life (72 h).
Long half-life is both an advantage and a drawback. If it works well, an occasional missed dose is not a problem; if problems occur, eliminating all active metabolites takes a long time. The choice depends on adverse effects and drug interactions. Adverse effects of SSRIs seem to be quite idiosyncratic; thus, relatively few reasons exist to prefer one over another at this point if dosing is started at a conservative level and advanced as tolerated.
Adult
20 mg/d PO qam; increase after several wk by 20 mg/d; not to exceed 80 mg/d
Pediatric
<18 years: Not established
Inhibits CYP450 isoenzymes 2C9, 2C19, 2D6, and 3A4; increases toxicity of diazepam and trazodone by decreasing clearance; also increases toxicity of MAO inhibitors, and highly protein bound drugs; serotonin syndrome (ie, myoclonus, rigidity, confusion, nausea, hyperthermia, autonomic instability, coma, eventual death) occurs with simultaneous use of other serotonergic agents (eg, anorectic agents, tramadol, buspirone, trazodone, clomipramine, nefazodone, tryptophan), discontinue other serotonergic agents at least 2 wk prior to SSRIs
Documented hypersensitivity; concurrently taking MAO inhibitors or took them in the last 2 wk; coadministration with thioridazine
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Known or suspected history of mania or hypomania; caution in hepatic impairment and history of seizures; MAO inhibitors should be discontinued at least 14 d before initiating fluoxetine therapy
Benzodiazepines
By binding to specific receptor-sites, these agents appear to potentiate the effects of GABA and facilitate inhibitory GABA neurotransmission and other inhibitory transmitters.
Clonazepam (Klonopin)
Long-acting benzodiazepine that increases presynaptic GABA inhibition and reduces monosynaptic and polysynaptic reflexes. Suppresses muscle contractions by facilitating inhibitory GABA neurotransmission and other inhibitory transmitters. Has multiple indications, including suppression of myoclonic, akinetic, or petit mal seizure activity and focal or generalized dystonias (eg, tardive dystonia). Reaches peak plasma concentration at 2-4 h after oral or rectal administration.
In patients who are dependent, used in a manner similar to phenobarbital to smoothly wean patients from short-acting benzodiazepines. General principle is that sedatives with longer half-lives have less severe withdrawal symptoms. Various schemes are used to individualize dose to the patient. If symptoms are severe enough to require inpatient treatment, intravenous lorazepam or diazepam is used.
Adult
0.25 mg PO hs
Pediatric
Not established
Phenytoin and barbiturates may reduce effects; coadministration of CNS depressants increases toxicity
Documented hypersensitivity; severe liver disease and acute narrow-angle glaucoma
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in chronic respiratory disease or impaired renal function; withdrawal symptoms can result from abrupt discontinuation
Dopamine precursors
Patients with DLB have impaired dopaminergic tone due to disease in the substantia nigra and possibly other dopaminergic nuclei. Efficacy of the treatment of motor features in DLB depends on where the patient is on the PD-DLB spectrum. Whether or not levodopa influences cognition positively or negatively remains controversial, and its effect on cognition is probably modest.
Levodopa and carbidopa (Sinemet)
Large neutral amino acid absorbed in proximal small intestine by saturable carrier-mediated transport system; absorption decreased by meals that include other large neutral amino acids (but only patients with meaningful motor fluctuations need consider low-protein or protein-redistributed diet); half-life approximately 2 h.
Provide at least 70-100 mg/d carbidopa; if more is required, substitute 25/100 tab for each 10/100 tab; when more levodopa is required, substitute 25/250 tab for 25/100 or 10/100 tab; CR formulation absorbed more slowly and provides more sustained levodopa levels than IR form; when initially required, CR form is as effective as IR form and may be more convenient; patients with dissipating motor fluctuations and no dyskinesia often benefit from prolongation of short-duration response when switched from IR to CR form; patients with meaningful fluctuations and dyskinesia often have increased dyskinesia when switched to CR form; doses and intervals for CR form may be increased or decreased to response.
Most patients adequately treated with 2-8 tab/d in doses divided q4-8h when awake; >12 tab/d and 3 d between dose adjustments; may be administered as whole or half tab, which should not be crushed or chewed; motor symptoms and signs may or may not improve.
Adult
25/100 tab initially; half the tab PO bid; can be increased gradually; greater consistency of absorption when taken 1 h or longer after meals; some start with CR form
Pediatric
Not established
Hydantoins, pyridoxine, phenothiazine, and hypotensive agents may decrease effects; toxicity increases when administered concurrently with antacids or MAOIs
Documented hypersensitivity, narrow-angle glaucoma, malignant melanoma, or undiagnosed skin lesions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May increase agitation, lethargy, dyskinesias, postural hypotension, hallucination, and confusion; psychiatric symptoms (eg, hallucinations) may be exacerbated; most common acute adverse effects are nausea, hypotension, and hallucinations; nausea often reduced if taken immediately after meals; patients with nausea may benefit from additional carbidopa in doses of 200 mg/d; long-term adverse effects include motor fluctuations and dyskinesia (chorea)
More on Dementia With Lewy Bodies |
| Overview: Dementia With Lewy Bodies |
| Differential Diagnoses & Workup: Dementia With Lewy Bodies |
 Treatment & Medication: Dementia With Lewy Bodies |
| Follow-up: Dementia With Lewy Bodies |
| References |
| « Previous Page | Next Page » |
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Further Reading
Keywords
Lewy body dementia, DLB, LB, Lewy body variant of Alzheimer disease, diffuse Lewy body disease, senile dementia of the Lewy body type, idiopathic Parkinson disease, Parkinson's disease, Parkinson disease with dementia, PD with dementia, parkinsonian dementias, Alzheimer disease, Alzheimer's disease, dementia with Lewy bodies, dementia with LBs
progressive degenerative dementia, nonvisual hallucinations, neuroleptic sensitivity, unexplained syncope, delusions, rapid eye movement sleepdisorder, myoclonus, apolipoprotein genotype E subtype 4, apoE4 genotype
