From the Guidelines
For treating agitation in Dementia with Lewy Bodies (DLB), a comprehensive approach is recommended that begins with non-pharmacological strategies before considering medications, with cholinesterase inhibitors like rivastigmine or donepezil considered first-line for their ability to improve both cognitive and behavioral symptoms 1. When considering treatment for agitation in DLB, it's crucial to prioritize non-pharmacological interventions, including environmental modifications such as maintaining a consistent routine, reducing stimulation, providing reassurance, and identifying triggers that worsen agitation. The use of antipsychotic medications should be reserved for cases where symptoms are severe, dangerous, and/or cause significant distress to the patient, as recommended by the American Psychiatric Association 1. Key considerations in the management of agitation in DLB include:
- Starting with environmental modifications and non-pharmacological strategies
- Considering cholinesterase inhibitors as first-line treatment for their cognitive and behavioral benefits
- Avoiding traditional antipsychotics and most atypical antipsychotics due to the risk of severe neuroleptic sensitivity reactions
- Using low-dose quetiapine or other cautiously selected antipsychotics for persistent agitation, with careful monitoring for side effects
- Deprescribing cholinesterase inhibitors or memantine should be done gradually, with treatment reinitiated if the individual shows clinically meaningful worsening of symptoms 1.
From the Research
Treatment for Agitation in Dementia with Lewy Bodies (DLB)
- Non-pharmacological interventions, such as exercise-based interventions and environmental interventions, have been studied in LBD, although the evidence supporting their efficacy is not robust 2.
- Pharmacological management of DLB includes the use of cholinesterase inhibitors, such as rivastigmine, galantamine, and donepezil, which have been shown to be effective in managing cognitive and behavioral symptoms, including agitation 3.
- Atypical antipsychistic drugs, such as quetiapine, may be effective in managing agitation associated with DLB, but may not always be helpful as monotherapy 3, 4.
- Low doses of valproic acid can be effective when added as an adjunct to drugs like quetiapine for managing agitation in DLB patients 3.
- Pimavanserin may prove to be a useful treatment for psychosis in DLB patients, but like other antipsychotic drugs, there is a small increased risk of mortality 3.
Non-Pharmacological Interventions
- Deep brain stimulation of the nucleus basalis of Meynert has been reported to confer cognitive benefit in LBD patients 2.
- Electroconvulsive therapy and repetitive transcranial magnetic stimulation have been reported to ameliorate depressive symptoms in LBD patients 2.
- Transcranial direct current stimulation has been observed to improve attention in LBD patients 2.
- Spaced retrieval memory training and environmental intervention for "mirror sign" have also been reported to be beneficial in LBD patients 2.
Pharmacological Management
- Levodopa can treat the parkinsonism of some DLB patients, but the dose is often limited due to the fact that it can cause agitation or worsening of visual hallucinations 3.
- Zonisamide has been shown to be beneficial when added as an adjunct to levodopa for treating DLB parkinsonism 3.
- Melatonin or clonazepam can be used to manage rapid eye movement sleep behavior disorder (RBD), a common core clinical feature of DLB 3.