What are the treatment options for dementia with Lewy bodies (DLB)?

Updated: Sep 24, 2018
  • Author: Stephen M Bloomfield, MD; Chief Editor: Selim R Benbadis, MD  more...
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Parkinsonian features may respond somewhat to levodopa therapy in some patients. Hallucinations and confusion are limiting factors.

Pimavanserin (Nuplazid) was approved in April 2016 for treatment of hallucinations and delusions associated with Parkinson disease psychosis. It is the first drug to be approved for this condition. Pimavanserin is a selective serotonin inverse agonists (SSIA) which preferentially targets 5-HT2A receptors, but avoids activity at dopamine and other receptors commonly targeted by antipsychotics. Pimavanserin is not approved for the treatment of patients with dementia-related psychosis unrelated to the hallucinations and delusions associated with Parkinson disease psychosis. Efficacy was shown in a 6-week clinical trial (n=199), where it was shown to be superior to placebo in decreasing the frequency and/or severity of hallucinations and delusions without worsening the primary motor Parkinson disease symptoms (p=0.001). [48]

Other novel neuroleptic medications (eg, quetiapine and clozapine) may be helpful in controlling hallucinations without exacerbating parkinsonian symptoms. However, these agents are not approved for dementia-related psychosis and their prescribing information include a boxed warning. Elderly patients with dementia-related psychosis who are treated with antipsychotic drugs are at increased risk of death, as shown in short-term controlled trials. Deaths in these trials appeared to be either cardiovascular (eg, heart failure, sudden death) or infectious (eg, pneumonia) in nature.

Centrally acting cholinesterase inhibitors (eg, rivastigmine, donepezil, galantamine) partially reverse decreased cortical cholinergic activity and may improve cognition and neuropsychiatric symptoms in DLB. Rivastigmine improves cognition and neuropsychiatric symptoms in patients with DLB without worsening parkinsonian features. Prognosis is poor, as with the other syndromes already described.

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