This is an interesting English-language abstract of a German article on medications used in DLB and PDD. This article notes that in Germany:

* standard treatment for psychosis in PD and DLB is low-dose clozapine

* other atypical antipsychotics (besides clozapine) are not licensed to use in those with dementia. (At least that's what I understood from the abstract. The authors do talk about the use of quetiapine, however.)

* "risperdone is contraindicated in DLB [by the] manufacturer's notice" and is not well-tolerated in DLB and PD.

The authors give the following "preliminary" recommendation for treating psychosis (hallucinations and delusions) in DLB and PDD:

"Stop all anticholinergic medication and reduce levodopa and other antiparkinsonian medication to the tolerated minimum. Levodopa alone is preferred. Treat with cholinesterase inhibitors to the maximum tolerated dose. If there is no adequate response regarding psychotic symptoms, add quetiapine. If this approach fails, replace quetiapine by low-dose clozapine. If behavioural disturbances are due to depression, anxiety, or irritability, treatment with an antidepressant, preferably citalopram, is an option."

Probably US clinicians would agree with this approach except they are unlikely to use clozapine (despite the better research evidence for it) in favor of quetiapine, and I doubt there would be consensus on the use of citalopram.

Robin



Medizinische Monatsschrift fur Pharmazeuten. 2011 Feb;34(2):47-52; quiz 53-4.

[Drug treatment of dementia with Lewy bodies and Parkinson's disease dementia--common features and differences].
[Article in German]

Drach LM.
Klinik für Alterspsychiatrie, HELIOS-Kliniken Schwerin, Carl-Friedrich-Flemming-Klinik, Schwerin.

Abstract
Dementia with Lewy-bodies (DLB) and Parkinson's disease dementia (PDD) are no rare causes of dementia. Both have neuropathologically, clinically, and neurochemically much in common.

In the course of both conditions frequently psychotic symptoms occur, often induced by antiparkinsonian medication. Treatment of psychotic features with conventional antipsychotics is not tolerated in many cases. Therefore low-dose clozapine treatment is acknowledged usual practise for psychosis in Parkinson's disease and a case report indicates efficacy for psychosis in DLB, too.

All other atypical antipsychotics except risperidone are not licensed for dementia in Germany, but risperidone is contraindicated in DLB due to manufacturer's notice and usually not well tolerated in DLB and Parkinson's disease.

Open trials indicate safety for treatment of psychosis in DLB and PDD with quetiapine. Randomized controlled trials indicate, that quetiapine is less effective than clozapine against psychotic symptoms in both conditions, although comparatively safe.

Cholinesterase inhibitors, especially rivastigmine, are a therapeutic alternative for treating both psychotic and cognitive symptoms in both conditions.

Parkinsonism in DLB-patients responds worse to levodopa compared to patient with Parkinson's disease.

Anticholinergic drugs often induce delirium in demented patients and therefore should be avoided.

The same problem is associated with dopamine agonists in PDD and DLB.

Amantadine, a NMDA-receptor antagonist like memantine, potentially bears the same risk of worsening psychotic symptoms.

The following preliminary recommendation for drug treatment of PDD and DLB can be given: Stop all anticholinergic medication and reduce levodopa and other antiparkinsonian medication to the tolerated minimum. Levodopa alone is preferred. Treat with cholinesterase inhibitors to the maximum tolerated dose. If there is no adequate response regarding psychotic symptoms, add quetiapine. If this approach fails, replace quetiapine by low-dose clozapine. If behavioural disturbances are due to depression, anxiety, or irritability, treatment with an antidepressant, preferably citalopram, is an option.

PubMed ID#: 2142801 (see pubmed.gov for this abstract only)


clozapine = Clozaril
risperidone = Risperdal
quetiapine = Seroquel
rivastigmine = Exelon
citalopram = Celexa

Thank you for posting this Robin.

My sister just called me today to ask about citalopram. We are constantly being asked about various medications by my mother's GP who visits her at the ALF. She doesn't know a lot about DLB. I have found this list, and your posts especially, helpful in finding primary research sources to look at. Thank you so much for your posts.

Liz

Thanks, Robin!
I just emailed the author to see if I can get a copy of the full article. (Our university doesn't subscribe to this journal, probably because it's in German.) My spoken and written German have lost some fluency over the years but I figure I'll be able to read it just fine if he is able to send me an electronic copy. It sounds like it might be quite interesting.
Laurel