For the management of cognitive symptoms in Dementia with Lewy Bodies (DLB), acetylcholinesterase (AChE) inhibitors are recommended NICE CKS,NICE NG97. Specifically, donepezil or rivastigmine are recommended as first-line options for people with mild to moderate DLB NICE CKS,NICE NG97. Galantamine may be considered if donepezil and rivastigmine are not tolerated NICE CKS,NICE NG97. For severe DLB, donepezil or rivastigmine are also recommended NICE CKS,NICE NG97. Memantine, an N-methyl-D-aspartic acid receptor antagonist, may be considered if AChE inhibitors are not tolerated or are contraindicated NICE NG97. It is important to note that the use of AChE inhibitors or memantine for non-Alzheimer's dementia, including DLB, is unlicensed, but they may be prescribed by a specialist NICE CKS,NICE NG97.
Regarding behavioral symptoms, non-pharmacological (psychosocial) approaches are recommended as first-line management NICE CKS,NICE NG97. Before considering pharmacological measures, people with dementia should be assessed for possible clinical causes of challenging behaviour, such as pain, delirium, or discomfort, and these underlying causes should be addressed NICE CKS,NICE NG97.
Antipsychotics should only be offered for people with dementia who are at risk of harming themselves or others, or who are experiencing agitation, hallucinations, or delusions that are causing severe distress NICE CKS,NICE NG97. However, it is crucial to be aware that in people with DLB, antipsychotics can worsen motor features of the condition and, in some cases, cause severe antipsychotic sensitivity reactions NICE CKS,NICE NG97. If antipsychotics are used, they should be initiated under specialist supervision, at the lowest effective dose, and for the shortest possible time NICE CKS,NICE NG97. Treatment should be reassessed at least every six weeks, and stopped if there is no clear ongoing benefit NICE NG97. Risperidone and haloperidol are the only antipsychotics licensed for treating non-cognitive symptoms of dementia, though others may be prescribed off-label NICE CKS. Discussion of benefits and harms with the person and their family or carers should occur before starting antipsychotics NICE NG97.