Management of DLB and PDD patients should be targeted at the symptoms (motor, cognitive, psychiatric and autonomic) causing most functional disability to the patient. Parkinsonism may be levodopa responsive, but dosing can be limited by psychiatric side effects. Antipsychotics, including atypicals should generally be avoided. A series of case reports and one double-blind placebo RCT suggest that LB disorder patients respond well to cholinesterase inhibitors (CHEI). Psychosis, sleep disorder, apathy and anxiety are the psychiatric / behavioral symptoms most likely to improve. Cognitive effects include improved attention and memory and are significantly greater in DLB patients with visual hallucinations. Treatment effect sizes are generally 2-3 times greater than seen in AD patients of comparable global impairment, with a typical 3-5 point increase in MMSE, a mean 50% reduction in neuropsychiatric symptoms and a similar decrease in caregiver burden. This is consistent with the more severe cholinergic depletion that occurs in PDD and DLB and the relative preservation of post-synaptic cholinoreceptors. CHEI are therefore being increasingly used as first line pharmacological treatments in LB disease avoiding the hazards of prescribing neuroleptics to this vulnerable population. Information about the side effect profile, response predictors and long term outcome of CHEI treatment in these patients is however still very limited. Data will be presented from open label and RCT studies that suggest drug tolerability similar to that in AD apart from an increase in hypersalivation, rhinorrhea and lacrimation. There is no overall increase in parkinsonism on CHEI treatment but a tendency to dose-dependent tremor. All symptoms tend to relapse to baseline within 6 weeks or less of drug withdrawal.
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