Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

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all patients

1st line – supportive care

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all patients
1st line – 

supportive care

Providing support and information is an essential part of care for patients with dementia.

Following diagnosis, education, support, and resources should be provided to the patient, their family, and other carers, focusing on the key behavioural and psychological symptoms of DLB and how these translate to care needs.[38] Planning should focus on meeting current needs and anticipating future problems. Family and carers should be empowered to assist the patient in making decisions regarding health and property, managing finances, taking medications, cooking meals, etc. Discussion of advanced directives and end-of-life care that may be anticipated requires sensitivity, based on a good patient-provider and family-provider relationship.[38][39][40] Legal counsel may be needed in cases requiring guardianship and the handling of finances, especially because DLB affects executive functions that are key to making responsible financial decisions. A social worker, psychologist, or other mental health professional should be made available to provide emotional support and psychosocial input. Discussion of driving is an emotional topic, frequently bound up with a patient’s desire for maintaining autonomy. Driving privileges, especially in patients with visual hallucinations, should be recommended to be restricted. American Academy of Neurology guidelines suggest that patients with dementia are not accurate at judging their own abilities, and that on-road driving tests are to be utilised to best assess abilities.[41]

Special attention should be directed to maintaining patient safety at home, particularly for those living alone or whose family can provide limited support. A home safety evaluation should be undertaken by an occupational therapist, as well as an assessment of transport, driving, and self-care needs. Falls, in particular, may be limiting and changes may be required to assure home safety. Physiotherapy and occupational therapy consultations may provide useful strategies to prevent injuries. A safe sleeping environment should be ensured for patients with rapid eye movement (REM) sleep behaviour disorder.[42]

Adherence to medications should be monitored at home, and medication lists reviewed at every visit.

Guiding and supporting carers is an integral part of the care plan for any patient with dementia. There is evidence that carers find the depression, apathy, cognitive fluctuation, and especially the psychotic symptoms associated with DLB particularly difficult to cope with.[43] Carers should be advised about coping techniques, and about local and national support organisations such as the Lewy Body Dementia Association: Lewy Body Dementia Association Opens in new window The Savvy Caregiver Program is a validated psycho-educational programme for carers, which has been adapted for racially and ethnically diverse communities as an online 'tele-savvy' programme.[44][45][46]

Many patients require professional help in the home to provide respite to the family, as well as supervision and assistance to the patient. Daycare services can offer respite to carers and patients, and may be used in combination with in-home care. In many cases, continued home care is no longer possible due to the nature of the care situation (e.g., a spouse who cannot retire) or to problem behaviours. Patients who require residential care should be cared for in a specialist dementia unit.

Late-/end-stage care includes palliative measures, end-of-life choices, and discussing goals of care with the family.[38][39][40] The preferences of the patient and family regarding end-of-life interventions - including treatment, resuscitation, and prolonging life when treatable conditions arise - should be discussed early in the course of the illness. End-of-life care is generally focused on providing comfort and basic needs (e.g., help with feeding and cleanliness, adequate pain control, good skin care, and prevention of injury through falls or misadventure). Overly aggressive care, such as enteral tube feeding, can worsen morbidity with no evidence of improvement in quality of life, survival, or carer outcomes.[69]

Plus – cholinesterase inhibitor or memantine

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all patients
Plus – 

cholinesterase inhibitor or memantine

Treatment recommended for ALL patients in selected patient group

Similar to Alzheimer's disease, first-line pharmacological treatment for cognitive impairment and behavioural symptoms in DLB is a cholinesterase inhibitor.[1][53][54] [ Cochrane Clinical Answers logo ]

The three commonly used cholinesterase inhibitors are donepezil, rivastigmine, and galantamine. Donepezil and rivastigmine have been shown to improve both cognition and behavioural symptoms without significant exacerbation of motor symptoms in most cases; evidence for the efficacy of galantamine is limited.[32][36][37] However, nausea, vomiting, hypersalivation, vivid dreams, sleepiness, orthostatic hypotension, and syncope may occur.[55] Adverse effects of chronic cholinesterase inhibitor use include weight loss, runny nose, and muscle cramps.

The N-methyl-D-aspartic acid (NMDA) receptor antagonist memantine is well tolerated, although evidence for effectiveness in DLB (either as monotherapy or combined with a cholinesterase inhibitor) is mixed and limited.[32][36][53][56][57]

Donepezil is available as a 23 mg/day dosage formulation. This may provide limited extra benefit but has not been studied in DLB.

Rivastigmine is available as a transdermal patch, and adverse effects are more common in patients with a low body weight. The patient may require the carer to apply patch and monitor adherence.

Primary options

donepezil: 5 mg orally once daily initially, increase to 10 mg/day after 4-6 weeks according to response, may increase to 23 mg/day after 3 months according to response

OR

rivastigmine: 1.5 mg orally twice daily initially, increase by 3 mg/day increments (given in 2 divided doses) every 2-4 weeks if tolerated, maximum 12 mg/day

OR

rivastigmine transdermal: 4.6 mg/24 hours patch once daily initially, increase to 9.5 mg/24 hours patch after 4 weeks according to response, may increase to 13.3 mg/24 hours patch if necessary; consult specialist for guidance on dose if converting from oral therapy or changing cholinesterase inhibitors

OR

galantamine: 4 mg orally (immediate-release) twice daily for 4 weeks, increase by 8 mg/day increments (given in 2 divided doses) every 4 weeks according to response, maximum 24 mg/day; 8 mg orally (extended-release) once daily initially, increase by 8 mg/day increments every 4 weeks according to response, maximum 24 mg/day

Secondary options

memantine: 5 mg orally (immediate-release) once daily initially, increase by 5 mg/day increments (given in 2 divided doses) no more frequently than once weekly according to response, maximum 20 mg/day; 7 mg orally (extended-release) once daily initially, increase by 7 mg/day increments no more frequently than once weekly according to response, maximum 28 mg/day

Consider – non-pharmacological and behavioural interventions

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all patients
Consider – 

non-pharmacological and behavioural interventions

Additional treatment recommended for SOME patients in selected patient group

Evidence for the effectiveness of non-pharmacological and behavioural interventions for patients with DLB is limited due to a lack of suitable trials. However, such interventions have been shown to be of value in other types of dementia (e.g., Alzheimer's disease) and for psychosis.[47]

Psychological interventions (e.g., cognitive behavioural therapy and cognitive training) may improve cognition and behavioural disturbance, and reduce symptoms of anxiety and depression in people with dementia.[48][49][50]​​ [ Cochrane Clinical Answers logo ]

Exercise may improve cognitive decline, activities of daily living, and motor disturbances in people with dementia.[47]

Multifactorial interventions, including physical activity, occupational therapy, and music therapy, may be effective for psychosis in dementia.[47]

Music-based interventions were reported to moderately improve symptoms of depression, and possibly behaviour, emotional wellbeing, and anxiety, in patients with dementia, but with little or no effect on cognition, agitation, or aggression.[50][51]

Massage therapy, animal-assisted interventions, and personally tailored interventions may reduce agitation in dementia.[52]

Plus – non-pharmacological approaches

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all patients
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with psychotic symptoms or acute behavioural disturbance
Plus – 

non-pharmacological approaches

Treatment recommended for ALL patients in selected patient group

It is important to identify and adequately manage potential precipitating factors for psychosis or acutely disturbed behaviour; for example, underlying infection, polypharmacy, sleep deprivation, dehydration, severe pain. Addressing secondary causes usually alleviates the associated behavioral disturbances.

Non-pharmacological approaches are first-line treatment for psychosis in dementia. These include providing a comfortable environment with adequate lighting, correcting vision, and decreasing visual triggers. Increasing social engagement and ongoing activities may help mask psychotic symptoms.

Consider – atypical antipsychotic

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all patients
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with psychotic symptoms or acute behavioural disturbance
Consider – 

atypical antipsychotic

Additional treatment recommended for SOME patients in selected patient group

The use of antipsychotic drugs should be avoided as far as possible because of the risk of increased adverse effects and mortality.[1][32] Possible complications include increased rigidity, immobility, confusion, sedation, postural falls, weight gain, diabetes, and increased mortality risk.[55] Severe antipsychotic sensitivity reactions have been reported in up to 50% of patients with DLB.[1][32] 

The American Psychiatric Association recommends reserving antipsychotics for symptoms that are considered severe, dangerous, and/or cause significant distress, and assessing efficacy and adverse effects to continuously balance the risk-benefit ratio in each individual patient.[58] The use of antipsychotics in patients with dementia is not a registered indication of the US Food and Drug Administration or similar regulatory agencies.

Low-dose atypical antipsychotics may be considered in the following situations if a balanced decision is made that benefits outweigh risks: for severe psychotic symptoms that do not respond to other treatments (non-pharmacological treatments and cholinesterase inhibitors); or for severe acute primary behavioural changes (e.g., mania-like behaviour with severe aggression).[1][32] Typical antipsychotics should not be used because of their tendency to worsen parkinsonism. The patient and family should be involved in decision making before starting an antipsychotic. Specialist advice should be sought about drug choice and dosage, and drugs titrated in very small increments. Screening for cardiac disease and a baseline ECG are recommended. 

There is no evidence supporting the use of particular atypical antipsychotics in patients with DLB.[1][32][59] Quetiapine is well tolerated and does not worsen motor function, but evidence for efficacy is lacking. Clozapine has been shown to be effective for treating psychosis associated with Parkinson's disease, but efficacy and tolerability in DLB are not established. Risperidone may improve agitation in dementia but is associated with extra-pyramidal symptoms. Pimavanserin (an antipsychotic medication with a specific inverse agonism and antagonism for the 5-HT2A receptor) has shown antipsychotic effects in patients with psychosis associated with Parkinson's disease or dementia.[1][32][60]

A mood stabiliser such as valproate may also be considered alongside psychotropic medications to help alleviate aggression.[66]

Severe psychosis or affective disorders may require inpatient hospitalisation, but most psychiatric comorbidities can be handled on an outpatient basis.

Plus – non-pharmacological interventions and/or pharmacotherapy

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all patients
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with comorbid depression
Plus – 

non-pharmacological interventions and/or pharmacotherapy

Treatment recommended for ALL patients in selected patient group

Depression is common in patients with DLB. Non-pharmacological interventions (e.g., psychological treatments, music-based interventions) should be considered.[48][62]

Although there are no controlled studies specific to the drug treatment of depression in patients with DLB, options include selective serotonin-reuptake inhibitors (SSRIs) such as sertraline or citalopram, serotonin-noradrenaline reuptake inhibitors such as venlafaxine, and mirtazapine because of their limited adverse-effect profile and favourable pharmacokinetics. Treatment should be guided by individual patient tolerability and response.[1] [ Cochrane Clinical Answers logo ] Antidepressants with anticholinergic activity (e.g., tricyclics) should be avoided. Long-acting fluoxetine (an SSRI) may be appropriate in some cases where daily dosing is impractical. Patients with advanced dementia may need liquid preparations.

Primary options

sertraline: 50 mg orally once daily initially, increase gradually according to response, maximum 200 mg/day

OR

citalopram: 10-20 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day (20 mg/day in patients >60 years of age)

OR

mirtazapine: 15 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day

OR

venlafaxine: 75 mg/day orally (immediate-release) initially given in 2-3 divided doses, increase gradually according to response, maximum 375 mg/day; 37.5 to 75 mg orally (extended-release) once daily, increase gradually according to response, maximum 225 mg/day

Secondary options

fluoxetine: 90 mg orally (delayed-release) once weekly

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Plus – non-pharmacological interventions and/or pharmacotherapy

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all patients
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with comorbid anxiety
Plus – 

non-pharmacological interventions and/or pharmacotherapy

Treatment recommended for ALL patients in selected patient group

Anxiety is common in patients with DLB. Non-pharmacological interventions (e.g., psychological treatments, music-based interventions) should be considered.[48][62]

Anxiolytics (e.g., buspirone) may be useful. Cholinesterase inhibitors or memantine may have some efficacy in this regard.[63][64] Benzodiazepines may cause daytime sedation, and paroxysmal reactions may occur when new medications are started. Alprazolam may be used for anxiety control but can cause sedation, and withdrawal seizures have been reported.[65]

Primary options

buspirone: 7.5 mg orally twice daily initially, increase gradually according to response, maximum 60 mg/day (given in 2-3 divided doses)

OR

alprazolam: 0.25 mg orally twice to three times daily initially, increase gradually according to response, maximum 4 mg/day

Plus – clonazepam or melatonin

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all patients
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with rapid eye movement (REM) sleep behaviour disorder
Plus – 

clonazepam or melatonin

Treatment recommended for ALL patients in selected patient group

REM sleep behaviour disturbance often accompanies DLB. Clonazepam is an established treatment for RBD, and should be given in low doses.[1][22][23][32][42]​​ About 90% of patients respond to treatment when given 30 minutes before bedtime; no tolerance has been noted.[61] Abrupt withdrawal must be avoided.

Immediate-release melatonin has also been advocated as a first-line treatment, although evidence for efficacy is mixed. Melatonin may be safer than clonazepam for older patients, as clonazepam may be slowly metabolised, as well as increasing the risk of worsening cognition, gait impairment, and falls.[1][22][23][42]​​

Primary options

clonazepam: 0.25 mg orally once daily initially, increase by 0.25 mg/day increments every 3 days according to response, maximum 2 mg/day

OR

melatonin: 3 mg orally (immediate-release) once daily at night 30 minutes before bedtime, increase gradually according to response, maximum 15 mg/day

Plus – carbidopa/levodopa

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with severe motor symptoms
Plus – 

carbidopa/levodopa

Treatment recommended for ALL patients in selected patient group

Because of potential adverse effects, motor symptoms should be treated with medication only if they are severe and interfere with activities of daily living. If needed, dopaminergic agents, typically levodopa, should be given in a small initial dose and titrated slowly.[1][32] Few controlled trials are available, and caution should be exercised due to possible worsening of cognition, hallucinations, and behaviour. A significant motor response is seen in approximately one third of patients, with younger patients responding better. A limited duration of response is often seen.[67][68]

Primary options

carbidopa/levodopa: 25/100 mg orally (immediate-release) twice daily initially, increase to 25/100 mg three times daily according to response, may increase further if tolerated, maximum 200 mg carbidopa/day

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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