Management

Psychosis is often the most troublesome problem when managing a patient with dementia with Lewy bodies (DLB). Most patients are intolerant of the usual antipsychotics because of exquisite sensitivity to the side effects of these drugs. Antidepressants and small doses of benzodiazepines may be tried but are often of little benefit.

The mainstay of management is ensuring that the environment is as safe and non-threatening as possible. Carers should be supported and motivated.

There is some evidence that the acetylcholinesterase drugs such as rivastigmine may be beneficial in DLB, although this is not currently a licensed indication

• NICE have stated (1):
  • donepezil or rivastigmine should be offered to people with mild to moderate dementia with Lewy bodies
    
    
  • only consider galantamine for people with mild to moderate dementia with Lewy bodies if donepezil and rivastigmine are not tolerated
    
    
  • donepezil or rivastigmine should be considered for people with severe dementia with Lewy bodies
    
    
  • consider memantine for people with dementia with Lewy bodies if AChE inhibitors are not tolerated or are contraindicated

With respect to agitation, aggression, distress and psychosis (1)

• antipsychotics should only be offered for people living with dementia who are either:
  • at risk of harming themselves or others or
  • experiencing agitation, hallucinations or delusions that are causing them severe distress
    
    
• be aware that for people with dementia with Lewy bodies or Parkinson's disease dementia, antipsychotics can worsen the motor features of the condition, and in some cases cause severe antipsychotic sensitivity reactions
  
  
• when using antipsychotics:
  • use the lowest effective dose and use them for the shortest possible time
  • reassess the person at least every 6 weeks, to check whether they still need medication

Reference:

1. NICE (June 2018). Dementia