Approach Considerations

Hallucinations and agitation are especially troublesome in dementia with Lewy bodies (DLB). When these symptoms are mild, no medical treatment may be necessary. When medication is used, acetylcholinesterase inhibitors should usually be tried first. For example, double-blinded, placebo-controlled studies have demonstrated that the cholinesterase inhibitor rivastigmine may decrease psychiatric symptoms associated with DLB, particularly apathy, anxiety, hallucinations, and delusions.^[22]

Studies have also shown that patients with DLB treated with cholinesterase inhibitors do better on neuropsychological tests than do subjects treated with placebo.^[23]Cholinesterase inhibitors that may be effective in the treatment of DLB also include donepezil and galantamine. In a small minority of patients, motor features are worsened with cholinesterase inhibitors.

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.

Some experts have tried antiepileptic drugs to treat agitation and hallucinations, but clinical data supporting their use is lacking.

Studies suggest that memantine improves cognitive function and neuropsychiatric features in patients with DLB. A multicenter, double-blinded, placebo-controlled trial revealed significant improvement in 2 important measurement tools in patients who received the drug: the Alzheimer's Disease Cooperative Study clinical global impression of change score (memantine vs placebo, 3.3 vs 3.9) and the Neuropsychiatric Inventory score (memantine vs placebo, -4.3 vs 1.7).^{[24, 25]}

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.

Depression is frequent in patients with DLB; it may occur as a result of damage in the dorsal raphe and locus ceruleus and/or as a psychological response to impaired function. Selective serotonin reuptake inhibitors (SSRIs) are the drugs of choice for treating depression in DLB.

A Cochrane Database review revealed that mild to moderate cognitive stimulation exercises are of benefit for mild and moderate dementia with improvements in memory and quality of life measures.^[26]

Consultations

Spouses, family members, and caregivers of patients with DLB frequently realize that the patient with DLB behaves differently than typical patients with Alzheimer 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 for maintaining the patient’s mobility. Advise families of potential problems faced by patients with DLB who drive.

Medication

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Lewy Body Dementia Treatment & Management

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