From the Guidelines
For agitation and insomnia in Lewy body dementia, non-drug approaches should be tried first, including maintaining a consistent sleep schedule, creating a calm environment, and addressing underlying causes like pain or discomfort. When medications are necessary, low-dose melatonin (1-3mg) at bedtime can help with sleep, as suggested by the American College of Physicians guideline on managing chronic insomnia disorder in adults 1, 2. For more severe symptoms, low-dose atypical antipsychotics like quetiapine (12.5-50mg) or clozapine (6.25-25mg) may be used cautiously, as recommended by the American Psychiatric Association practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia 3. It's also important to consider the use of armodafinil for the treatment of hypersomnia secondary to dementia with Lewy bodies, as suggested by the American Academy of Sleep Medicine clinical practice guideline 4. However, it's crucial to avoid traditional antipsychotics like haloperidol, as they can worsen symptoms due to Lewy body dementia patients' extreme sensitivity to these medications. Cholinesterase inhibitors such as rivastigmine (3-12mg daily) or donepezil (5-10mg daily) may reduce hallucinations and improve cognition. Benzodiazepines should generally be avoided due to increased fall risk and potential cognitive worsening, though in some cases, short-acting options like lorazepam (0.25-0.5mg) might be used for severe agitation. Any medication should be started at the lowest possible dose and increased gradually while monitoring for side effects, as Lewy body dementia patients are particularly sensitive to medications that affect brain function. Some key considerations for treatment include:
- Maintaining a consistent sleep schedule
- Creating a calm environment
- Addressing underlying causes like pain or discomfort
- Using low-dose melatonin for sleep
- Considering low-dose atypical antipsychotics for severe symptoms
- Avoiding traditional antipsychotics and benzodiazepines when possible
- Monitoring for side effects and adjusting medications as needed.
From the Research
Treatment Options for Agitation and Insomnia in Lewy Body Dementia
- Cholinesterase inhibitors such as rivastigmine, galantamine, and donepezil have been shown to be effective in managing cognitive and behavioral symptoms of DLB, including agitation 5.
- Memantine can improve clinical global impression of change in patients with mild to moderate DLB 5.
- Low doses of valproic acid can be effective in managing agitation when added as an adjunct to drugs like quetiapine 5.
- Quetiapine has been shown to be effective in treating psychotic symptoms and aggressive behavior in some patients with DLB 6.
- Melatonin or clonazepam can be used to manage rapid eye movement sleep behavior disorder (RBD), a common core clinical feature of DLB 5.
Management of Agitation
- Agitation is a common symptom in DLB, with a prevalence of around 30% 7.
- The pathophysiological mechanism underlying agitation involves frontal lobe dysfunction and increased sensitivity to noradrenergic signaling 7.
- Factors such as sundown syndrome, hospitalization, and changes in pharmacological regimens can precipitate agitation in patients with DLB 7.
- Identification, prevention, and management of acute and chronic agitation are crucial to reduce the burden on patients, caregivers, and the healthcare system 7.
Impact of Lewy Body Dementia on Patients and Caregivers
- DLB has a significant impact on patients, including limiting potential exposure to medications that may cause adverse outcomes and affecting quality of life 8.
- Caregivers of patients with DLB experience burden and grief associated with disease manifestations, and common concerns include access to care, prevention of hospitalization, and managing behavior 8.