Dementia with Lewy Bodies: Therapeutic Opportunities and Pitfalls

Abstract

Increased prudence with the use of neuroleptic agents is essential in DLBs because the use of these agents is associated with physical and cognitive decline and increased mortality. While neuroleptic sensitivity has been reported with the use of both typical and atypical antipsychotic medications, these medications are often necessary for the treatment of psychotic symptoms. Decreases in neuroleptic sensitivity can often be achieved by dose reductions, although neuroleptic discontinuation is sometimes necessary. Cholinesterase inhibitors may be especially useful in the treatment of DLB. Cholinergic deficits are associated with visual hallucinations, and cholinesterase inhibitors often result in resolution of hallucinations, improved cognition, and decreased behavioral disturbances.

A 63-Year-Old Man with Lewy Body Dementia and Multiple Symptoms

“…3,4 Treatment of DLB is challenging. Because dopamine agonists used to treat motor symptoms may precipitate or worsen psychotic symptoms associated with DLB, tapering or discontinuing these agents is a common first consideration.…”

“…Neuroleptic drugs used to treat psychotic symptoms are often ineffective and worsen motor symptoms. 4 Visual hallucinations in patients with DLB are associated with cholinergic deficits, 2 and cholinesterase inhibitors are considered first-line therapy in treating hallucinations and behavioral disturbances in DLB. [3][4][5] Dopaminergic agents are frequently implicated in manifesting psychotic symptoms.…”

“…4 Visual hallucinations in patients with DLB are associated with cholinergic deficits, 2 and cholinesterase inhibitors are considered first-line therapy in treating hallucinations and behavioral disturbances in DLB. [3][4][5] Dopaminergic agents are frequently implicated in manifesting psychotic symptoms. 6 This case illustrates that acetylcholinesterase inhibitors may contribute to visual hallucinations and delusions in susceptible patients, possibly depending on the location and severity of brain lesions from neurodegeneration.…”

Efficacy of donepezil for the treatment of visual and multiple sensory hallucinations in dementia with Lewy bodies

“…Although several studies have demonstrated the efficacy of second-generation antipsychotics and cholinesterase inhibitors for DLB-related psychotic symptoms such as visual hallucinations [6][7][8][9][10][11], few reports have comprehensively reviewed drug therapies for DLB-related psychotic symptoms [5,8]. It is well known that patients with DLB exhibit hypersensitivity to antipsychotics.…”

“…Second-generation antipsychotics, which are less likely to result in extrapyramidal side effects, can be effective for the treatment of DLB-related visual hallucinations [6]. The efficacy of cholinesterase inhibitors, including donepezil, for DLB-related psychotic symptoms has also been reported [3,[7][8][9][10][11]. However, donepezilinduced side effects, including the exacerbation of parkinsonism in patients with DLB, have also been reported [12].…”