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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Author

Howard A Crystal, MD Professor, Departments of Neurology and Pathology, State University of New York Downstate; Consulting Staff, Department of Neurology, University Hospital and Kings County Hospital Center

Howard A Crystal, MD is a member of the following medical societies: American Academy of Neurology, American Neurological Association

Disclosure: Nothing to disclose.

Coauthor(s)

Daniel H Jacobs, MD, FAAN Associate Professor of Neurology, University of Florida College of Medicine; Director for Stroke Services, Orlando Regional Medical Center

Daniel H Jacobs, MD, FAAN is a member of the following medical societies: American Academy of Neurology, American Society of Neurorehabilitation, Society for Neuroscience

Disclosure: Received grant/research funds from Teva Pharmaceutical for consulting; Received grant/research funds from Biogen Idex for independent contractor; Received royalty from Serono EMD for speaking and teaching; Received royalty from Pfizer for speaking and teaching; Received royalty from Berlex for speaking and teaching.

Chief Editor

Jasvinder Chawla, MD, MBA Chief of Neurology, Hines Veterans Affairs Hospital; Professor of Neurology, Loyola University Medical Center

Jasvinder Chawla, MD, MBA is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American Clinical Neurophysiology Society, American Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Robert A Hauser, MD, MBA Professor of Neurology, Molecular Pharmacology and Physiology, Director, Parkinson's Disease and Movement Disorders Center, University of South Florida; Clinical Chair, Signature Interdisciplinary Program in Neuroscience

Robert A Hauser, MD, MBA is a member of the following medical societies: American Academy of Neurology, American Medical Association, American Society of Neuroimaging, and Movement Disorders Society

Disclosure: Adamas Pharmaceuticals Consulting fee Consulting

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment