Treatment and Management of Lewy Body Dementia
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While Lewy body dementia (LBD) currently cannot be prevented or cured, some symptoms may respond to treatment for a period of time. A comprehensive treatment plan may involve medications, physical and other types of therapy, and counseling. Changes to make the home safer, equipment to make everyday tasks easier, and social support are also important.
A skilled care team often can suggest ways to improve quality of life for both people with LBD and their caregivers.
After receiving a diagnosis, a person with LBD may benefit from seeing a neurologist who specializes in dementia and/or movement disorders. A doctor can work with other types of healthcare providers. Depending on an individual's particular symptoms, other professionals may also be helpful:
- Physical therapists can help with movement problems through exercises, gait training, and general physical fitness programs.
- Speech therapists may help with voice volume and projection, and swallowing difficulties.
- Occupational therapists help find ways to more easily carry out everyday activities, such as eating and bathing.
- Music or expressive arts therapists may provide meaningful activities that can reduce anxiety and improve well-being.
- Mental health counselors can help people with LBD and their families learn how to manage difficult emotions and behaviors and plan for the future.
- Palliative care specialists can help improve a person's quality of life by relieving disease symptoms at any stage of illness.
Support groups are another valuable resource for people with LBD and their caregivers. Sharing experiences and tips with others in the same situation can help people find practical solutions to day-to-day challenges and get emotional and social support.
Several drugs and other treatments are available to treat LBD symptoms. It is important to work with a knowledgeable health professional because certain medications can make some symptoms worse. Some symptoms can improve with nondrug treatments.
Some medications used to treat Alzheimer's disease also may be used to treat the cognitive symptoms of LBD. These drugs, called cholinesterase inhibitors, act on a chemical in the brain that is important for memory and thinking. They may also improve hallucinations, apathy, and delusions.
The U.S. Food and Drug Administration (FDA) has approved one Alzheimer's drug, rivastigmine (Exelon®), to treat cognitive symptoms in Parkinson's disease dementia. Several other drugs are being tested as possible treatments for LBD symptoms or to disrupt the underlying disease process.
LBD-related movement symptoms may be treated with medications used for Parkinson's disease, called carbidopa-levodopa (Sinemet®, Parcopa®, Stalevo®). These drugs can help make it easier to walk, get out of bed, and move around. However, they cannot stop or reverse the disease itself.
Side effects of this medication can include hallucinations and other psychiatric or behavioral problems. Because of this risk, physicians may recommend not treating mild movement symptoms with medication. If prescribed, carbidopa-levodopa usually begins at a low dose and is increased gradually. Other Parkinson's medications are less commonly used in people with LBD due to a higher frequency of side effects.
A surgical procedure called deep brain stimulation, which can be very effective in treating the movement symptoms of Parkinson's disease, is not recommended for people with LBD because it can result in greater cognitive impairment.
People with LBD may benefit from physical therapy and exercise. Talk with your doctor about what physical activities are best.
Sleep problems may increase confusion and behavioral problems in people with LBD and add to a caregiver's burden. A physician can order a sleep study to identify any underlying sleep disorders such as sleep apnea, restless leg syndrome, and REM sleep behavior disorder.
REM sleep behavior disorder, a common LBD symptom, involves acting out one's dreams, leading to lost sleep and even injuries to individuals and their sleep partners. Clonazepam (Klonopin®), a drug used to control seizures and relieve panic attacks, is often effective for the disorder at very low dosages. However, it can have side effects such as dizziness, unsteadiness, and problems with thinking. Melatonin, a naturally occurring hormone used to treat insomnia, may also offer some benefit when taken alone or with clonazepam.
Excessive daytime sleepiness is also common in LBD. If it is severe, a sleep specialist may prescribe a stimulant to help the person stay awake during the day.
Some people with LBD have difficulty falling asleep. If trouble sleeping at night (insomnia) persists, a physician may recommend a prescription medication. It is important to note that treating insomnia and other sleep problems in people with LBD has not been extensively studied, and that treatments may worsen daytime sleepiness and should be used with caution.
Certain sleep problems can be addressed without medications. Increasing daytime exercise or activities and avoiding lengthy or frequent naps can promote better sleep. Avoiding alcohol, caffeine, or chocolate late in the day can help, too. Some over-the-counter medications can also affect sleep, so review all medications and supplements with a physician.
Behavioral and Mood Problems
Behavioral and mood problems in people with LBD can arise from hallucinations, delusions, pain, illness, stress, or anxiety. They may also be the result of frustration, fear, or feeling overwhelmed. The person may resist care or lash out verbally or physically.
Caregivers can try a variety of strategies to handle such challenging behaviors. Some behavioral problems can be managed by making changes in the person's environment and/or treating medical conditions. Other problems may require medication.
Medications are appropriate if the behavior interferes with the person's care or the safety of the person or others. If medication is used, then the lowest possible dose for the shortest period of time is recommended.
The first step is to visit a doctor to see if a medical condition unrelated to LBD is causing the problem. Injuries, fever, urinary tract or pulmonary infections, pressure ulcers (bed sores), and constipation can worsen behavioral problems and increase confusion.
Certain medications, such as anticholingerics and antihistamines like Benadryl®, may also cause behavioral problems. For example, some medications for sleep problems, pain, bladder control, and LBD-related movement symptoms can cause confusion, agitation, hallucinations, and delusions. Similarly, some anti-anxiety medicines can actually increase anxiety in people with LBD. Review your medications with your doctor to determine if any changes are needed.
Not all behavioral problems are caused by illness or medication. A person's surroundings—including levels of stimulation or stress, lighting, daily routines, and relationships—can lead to behavior issues. Caregivers can alter the home environment to try to minimize anxiety and stress for the person with LBD. In general, people with LBD benefit from having simple tasks, consistent schedules, regular exercise, and adequate sleep. Large crowds or overly stimulating environments can increase confusion and anxiety.
Hallucinations and delusions are among the biggest challenges for LBD caregivers. The person with LBD may not understand or accept that the hallucinations are not real and become agitated or anxious. Instead of arguing, caregivers can help by responding to the fears expressed. By tuning in to the person's emotions, caregivers can offer empathy and concern, maintain the person's dignity, and limit further tension.
Cholinesterase inhibitors may reduce hallucinations and other psychiatric symptoms of LBD, but they may have side effects, such as nausea, and are not always effective. However, they can be a good first choice to treat behavioral symptoms. Cholinesterase inhibitors do not affect behavior immediately, so they should be considered part of a long-term strategy.
In some cases, antipsychotic medications are necessary to treat LBD-related behavioral symptoms to improve the quality of life and safety of the person with LBD and his or her caregiver. These types of medications must be used with caution because they can cause severe side effects and can worsen movement symptoms.
If antipsychotics are prescribed, many experts prefer quetiapine (Seroquel®) or clozapine (Clozaril®, FazaClo®), which are types of atypical antipsychotics, to control difficult behavioral symptoms. A newer drug, pimavanserin (Nuplazid®), has been approved by the FDA to treat hallucinations and delusions associated with Parkinson's disease psychosis. However, a number of serious side effects have been reported, and the FDA requires the same black-box warning for Nuplazid® as it requires for other antipsychotic drugs in the elderly. We do not know yet whether pimavanserin will be helpful in other types of dementia-related psychoses, including LBD. Other potential treatments are being tested.
Typical (or traditional) antipsychotics, such as haloperidol (Haldol®), generally should not be prescribed for people with LBD. They can cause dangerous side effects.
LBD affects the part of the nervous system that regulates automatic actions like blood pressure and digestion. One common symptom is orthostatic hypotension, a drop in blood pressure when standing up that can cause dizziness and fainting. Simple measures such as leg elevation, elastic stockings, and, when recommended by a doctor, increasing salt and fluid intake can help. If these measures are not enough, a doctor may prescribe medication.
Urinary incontinence (loss of bladder control) should be treated cautiously because certain medications for this condition may worsen cognition or increase confusion. Consider seeing a urologist. Constipation can usually be treated by exercise and changes in diet, though laxatives, stool softeners, or other treatment may be necessary.
People with LBD are often sensitive to prescription and over-the-counter medications for other medical conditions. Talk with your doctor about any side effects seen in a person with LBD.
If surgery is planned and the person with LBD is told to stop taking all medications beforehand, ask the doctor to consult the person's neurologist to develop a plan for careful withdrawal. In addition, talk with the anesthesiologist in advance to discuss medication sensitivities and risks unique to LBD. People with LBD who receive certain anesthetics may become confused or delirious and have a sudden, significant decline in functional abilities, which may become permanent.
Depending on the procedure, possible alternatives to general anesthesia may include a spinal or regional block. These methods are less likely to result in confusion after surgery. Caregivers should also discuss the use of strong pain relievers after surgery, since people with LBD can become delirious if these drugs are used too freely.
For More Information About Treating and Managing LBD
NIA Alzheimer’s and related Dementias Education and Referral (ADEAR) Center
The National Institute on Aging’s ADEAR Center offers information and free print publications about Alzheimer’s disease and related dementias for families, caregivers, and health professionals. ADEAR Center staff answer telephone, email, and written requests and make referrals to local and national resources.
Lewy Body Dementia Association
1-844-311-0587 (toll-free LBD Caregiver Link)
Content reviewed: June 28, 2018