Pharmacological therapy for cognitive impairment in dementia with Lewy bodies
Manage dementia with Lewy bodies in consultation with a specialist.
Drug treatments for dementia with Lewy bodies are not curative and do not modify disease progression.
The acetylcholinesterase inhibitors, donepezil and rivastigmine, modestly improve or stabilise cognition, alertness and function, and reduce hallucination frequency. Donepezil and rivastigmine appear to have similar efficacy for dementia with Lewy bodies. Their modest benefits must be weighed against their significant adverse effects, which include prominent gastrointestinal adverse effects (particularly nausea, vomiting and anorexia), weight loss, vivid dreams, urinary incontinence, tremor, cramps, bradycardia, dizziness and drowsiness. Because of these adverse effects, the benefit–harm profile of acetylcholinesterase inhibitors varies depending on patient factors. Before starting an acetylcholinesterase inhibitor, perform an ECG, record the patient’s weight and assess their falls risk. Most adverse effects are dose-related; the regimens below aim to minimise adverse effects by starting treatment with a low dose and slowly increasing.
Donepezil and rivastigmine transdermal patches are easier to use than oral rivastigmine because they are dosed once daily and can be more easily titrated. The rivastigmine transdermal patch is better tolerated than the oral formulation.
Before starting pharmacotherapy for cognitive impairment in dementia with Lewy bodies, discuss potential benefits and harms with the patient or their substitute decision maker—consider their goals of care and create a plan for when to stop therapy (see Modification and duration of pharmacological therapy for cognitive impairment in dementia).
If an acetylcholinesterase inhibitor is considered appropriate to treat cognitive symptoms of dementia with Lewy bodies and the patient has undergone an ECG, a falls risk assessment and had their baseline weight recorded, use:
1 donepezil 5 mg orally, at night for 4 weeks, then increase to 10 mg at night, if tolerated; see Modification and duration of pharmacological therapy for cognitive impairment in dementia dementia (lewy body) donepezil donepezil donepezil
OR
1 rivastigmine 4.6 mg transdermally, replaced daily for 4 weeks, then increase to 9.5 mg, replaced daily, if tolerated. If needed and tolerated, after at least 4 additional weeks, increase to 13.3 mg, replaced daily; see Modification and duration of pharmacological therapy for cognitive impairment in dementia1 dementia (lewy body) rivastigmine rivastigmine rivastigmine
OR
2 rivastigmine 1.5 mg orally, twice daily for 2 weeks, then, if tolerated, increase by 1.5 mg twice daily every 2 weeks up to a maximum of 6 mg twice daily. See Modification and duration of pharmacological therapy for cognitive impairment in dementia. rivastigmine rivastigmine rivastigmine
The evidence for memantine for dementia with Lewy bodies is equivocal. If a patient cannot take donepezil or rivastigmine, consider using the memantine regimen for Alzheimer dementia.