How to Handle a Combative Dementia Patient

There are many challenges involved in caring for a patient with dementia. At times these patients may become combative. This is a regular aspect of the disease and may happen even in patients who were not aggressive earlier in their lives. 

How do you deal with combative dementia patients? 

I work as a pharmacist in a geriatric psychiatric unit. We care for these patients when caregivers are unable to. Our goal is to stabilize them and return them into the community.  

This post will give you pointers on what to do when faced with aggression from a dementia patient. 

Be Prepared and Keep Calm

It is essential to be prepared for unusual behaviors from dementia patients. Due to damage occurring in the brain, these patients often display unexpected behaviors.  

Be calm when they become aggressive and speak to them in a soft, comforting tone. Always remember that this is part of the disease process and not a personal attack against you. 

Although your instincts may lead you to retaliate when dealing with an aggressive dementia patient, this can make the situation worse. Try to learn from each situation and keep yourself and the patient safe. 

Try to Identify Possible Causes of the Aggression

There are some basic things to rule out when patients begin to act out. Be sure basic needs are met. These include: 

 Pain – uncontrolled pain can cause individuals to lash out. They often are not able to communicate. It is vital to look for non-verbal signs of distress, including: 

  • Facial grimacing. 
  • Moaning. 
  • Guarding certain areas or withdrawing from touch. 
  • Writhing or constant movement. 
  • Increase in blood pressure or respiratory rate. 


 Constipation-this can make anyone uncomfortable, including dementia patients. Be sure they follow a toileting schedule and pay attention to the frequency of bowel movements. 


Urinary tract infections– These can be a cause of pain and discomfort and are more common in elderly patients. Monitor the patient for smelly, cloudy, or discolored urine. If these signs appear and the patient is acting differently, they should be seen by a medical professional for an evaluation. 

Try to keep the patient comfortable. Maintain a reasonable room temperature and create a good place for the patient to relax.  


Sleep – We all can become grumpy if we don’t get enough sleep.  Follow the basic sleep hygiene guidelines listed below. 


  • Follow a sleep schedule. Try to get the patient to sleep at the same time each night. 
  • Avoid letting the patient take long naps during the day. 
  • Do not give the patient large amounts of fluid close to bedtime. This can increase nighttime awakening. 
  • Be sure the room where the patient sleeps is dark, quiet, cool, and comfortable.  

It is important to note that sleeping pills other than melatonin are not appropriate for dementia patients. Drugs such as diphenhydramine (BenadrylTM) and other sedating antihistamines make dementia worse. Read my blog post on anticholinergics and dementia for more information. 



Calm the Environment

Excessive noise and activity can agitate patients.  

The nurses on our unit are quick to ask staff to quiet down when it becomes noisy or hectic.

Keep music soft, and try to have people speak quietly.

If too many people are around the patient, ask some of them to relocate temporarily. If the patient is starting to act out, try moving them to a different room.

Keep track of what works and doesn’t.

Every patient is different. 



Many times you can calm a dementia patient by merely redirecting them. Read them a story, show them pictures or watch a TV show with them. Avoid activities that demand too much thought or concentration. Most dementia patients will become frustrated if they are asked to participate in activities that are too difficult for them to perform. Find activities that the person enjoys. Redirection is one of the best tools available to you. 

Smile and be Kind

Sometimes a simple smile can do wonders—all of us like people to smile at us.

A gentle touch can also help.

Avoid startling the patient. Approach them from the front so they can easily see you coming.

Show them you care.   

Give Them Time Alone

If nothing seems to be working, consider giving the patient some time alone.

Be sure the patient is safe and keep an eye on them.

They may just need to cool down.

Some alone time in a quiet place may be what is necessary.  

Take Care of Yourself First

If you are taking care of a dementia patient, you will likely be under a lot of stress.

The most important thing for you to do is keep healthy, both physically and mentally.

You will not be an effective caregiver if you get burned out or become sick yourself.  

If you need a break, find help!  

Taking care of these patients often causes one to be up in the middle of the night. Try to find a family member or friend to help when needed.

We all need a break at times. 

Know Your Limits

In some cases, you may be unable to care for the patient yourself.

If the situation becomes unsafe for either you or them, it is time to consider placement into a memory care facility.

This is not a sign of failure on your part. We all have our limits. Memory care facilities are staffed with individuals who know how to care for your loved one. They take care of these patients every day.

Caregivers in these facilities are trained to recognize behaviors that require medication.

Remember, your health and well-being are important too. 

I have spent the last four years working on a unit that cares for geriatric patients with psychiatric issues. Many of these patients have dementia. There are several forms of this disease, but all of these patients become dependent on others for their care eventually.   

Working with these patients has been one of the most rewarding aspects of my pharmacy career. Being involved in the final chapter of a patient’s life has a special meaning to me. 

I hope this post has helped if you are caring for a loved one with dementia. I want you always to remember that there is help out there for you if you are struggling.  

Safety is always the most important goal.   

I have listed some resources below if you need help.  

You can always contact me with questions at [email protected].

If I don’t know the answer to your question, I will find it for you. 



Have a great week, and stay safe. Be sure to read our other blog posts to help you live a happy, healthy life, and please sign up for our newsletter below.   

Michael Brown in Lab Coat with arms crossed

Michael J. Brown, RPh, BCPS, BCPP

Mr. Brown is a Clinical Pharmacist specializing in pharmacotherapy and psychiatry.

Read Michael’s story here.

Feel free to send Michael a message using this link.



Disclosure:  This post may contain affiliate links, meaning, at no additional cost to you, I may earn a commission if you click on, or make a purchase through a third-party link.

Woman in sensory room holding fiber optics

Snoezelen Therapy for Dementia Patients

Woman in sensory room holding fiber optics

Disclosure:  This post may contain affiliate links, meaning, at no additional cost to you, I may earn a commission if you click on, or make a purchase through a third-party link.

The world population is ageing and, because of this, the incidence of dementia has risen.  According to the World Health Organization, approximately 50 million people have dementia worldwide, and 10 million new cases are diagnosed every year.  The incidence of dementia is expected to reach 131 million people by 2050.1

  Dementia has a tremendous impact on both the patient, and the family.    Patients with dementia are unable to remember things, have a difficult time solving problems, and can become easily frustrated.  Their sleep-wake cycle may become reversed and, at times, they may even become violent to the ones they love.  Dementia occurs in older people but is not a normal part of the ageing process.

Dementia patients may reach a point where they need to be hospitalized due to behaviors which are not able to be controlled by their caregivers.  Some of these behaviors include agitation, depression, aggression, and apathy.

I have been working on a unit which cares for dementia patients for three years.  During this time, I have learned a great deal about this condition as well as common and not so common treatments.  I have written other blog posts relating to dementia but this post will concentrate on the use of Snoezelen therapy for these patients.

A Snoezelen room is a controlled multisensory environment (MSE).  Equipment in these rooms cause a variety of stimulation including tactile, auditory, olfactory and visual.  Snoezelen rooms should provide a calm and comfortable environment for the patients.  These rooms can be used for patients with autism, brain injuries, developmental disabilities as well as dementia.  MSE’s are not inexpensive to set up.  Associated costs could run from $10,000 to $30,000 and even more if complex, high-end equipment is used.


Assessing Unmet Needs

The Unmet Needs Model suggests negative behaviors in dementia may result from the inability to communicate one’s needs to caregivers.  There are ways in which we can attempt to learn what these unmet needs are by trial and error.  In the hospital setting, we often talk about the following possibilities that may make the patient uncomfortable.

  • Pain – This one is difficult to assess. There are pain signs such as grimacing.  The patient may also be suffering from a urinary tract infection, or other ailment.
  • Constipation – Keep track of bowel movements. Constipation can be uncomfortable, and is usually easy to treat.
  • Hunger – Offer food. Attempt to learn the patient’s food preferences by speaking to those close to the patient.
  • Thirst – Offer fluids.
  • General Comfort – How the patient is sitting, temperature, clothing, etc.

If these don’t help, the patient may be suffering from boredom.  This is where the Snoezelen room can help.  Always remember, dementia patients are people like us who have a disease and it is important to view them as such.  What works for one patient, may not be effective for another.  Get to know what the patient prefers and keep track of successful interventions.  Always start with the basic needs described above.  If the patient is in pain or uncomfortable due to being constipated, a Snoezelen room experience will likely have little effect on behavior.

Benefits of Multisensory Environments in Dementia Care

Later stage dementia patients are usually unable to seek out enriching and meaningful activities on their own.  In fact, left to their own devises, they would quickly decline.  Most of the time, they are completely dependent on others for their care.  Older people are also less able to perceive sights, sounds, tastes, and smells which increases their risk of sensory deprivation.3

This can have a negative impact on health and wellbeing.4

Some believe that sensory experiences are able to trigger positive memories.  This may promote a feeling of pleasure for the patient.  Think about this in your own life.  I believe we’ve all experienced being taken back in time when we’ve smelled something that triggers a positive time in our lives, or heard a song that takes us back to a happy time.5


The goal of the multisensory environment is to positively effect the dementia patient using sensory channels that are still intact. 

The three main avenues by which a multisensory experience can be achieved are.

  1. Daily care routines such as bathing, feeding, and administering medications 7


  1. Sensory enhancements of the patients living environment. This may include special units in long-term care facilities which provide staff specially trained to care for dementia patients, special activities geared towards these residents and involvement of the family.9

  1. Specially designed rooms or MSEs.10

Studies have shown that MSEs can be beneficial for dementia patients.  Some of these benefits include.

  1. Decreased agitation and disruptive behavior.






I would like to point out that some of the medications utilized to combat aggressive and disruptive behavior can cause agitation.  

  1. Increased alertness14

  1. Increased social interaction, reduced apathy, and better mood.15



  1. Better communication with others.18

  1. Improved functional performance19

These positive attributes of MSEs leads to a more relaxed, engaged patient who gets along better with his or her peers. 

Research also shows caregivers who utilize MSEs for their dementia patients have better job satisfaction and a better relationship with their patients.


This leads to improved patient care and reduced caregiver burnout.

Obstacles to Adding a Snoezelen Room to a Facility

Many facilities do not have the financial resources or space to implement a Snoezelen room.  As mentioned earlier in the post, these spaces can get expensive.  The institutions who have these rooms often under-utilize them.  Another problem is deciding how to design such a space.  There is much debate on exactly what to put into these rooms and research is still being conducted in this area. 

Anti-suicide regulations can also hinder certain facilities from adding a Snoezelen room.  This is especially true of psychiatric facilities where dementia patients may end up due to negative behaviors.

Perspectives of an Expert

I have the pleasure of sharing an office with an occupational therapist.  Kendra Munroe, OTR/L works with our patients daily and was the person who designed our sensory room.  Our main piece of equipment is a Vecta which was purchased from TFH Special needs Toys.  This company specializes in sensory-focused equipment and toys which promote learning and living skills.

The Vecta Full Mobile Sensory Station can turn any room into a relaxing, distracting and empowering multi-sensory room. 

According to Kendra, the sensory room “provides a safe and contained spot where the patients can explore”.  She explains that you want to have different things available to engage their senses.  Some examples include music that is tailored to the specific patients tastes, as well as things they can see or touch.  Kendra also believes it is important to include things related to nature. 

We provide weighted blankets by Salt of the Earth as well as quilts, stuffed animals, robotic pets, and a weighted baby doll to provide a realistic sensory experience.

Munroe stated that certain things are often neglected in sensory rooms, specifically regarding the geriatric population.  She mentioned things that provide proprioceptive and vestibular input in particular. “This is why we put a glider in,” Kendra explains.  We purchased a specific glider that locks in place when the patient attempts to stand.  The Thera-Glide safety glider decreases fall-risk and rocks back and forth which is soothing to the patient.

Kendra does point out that there may be dangers involved with sensory rooms.  She emphasizes that we must be trauma-informed with any of our treatment.  We must be aware that small, enclosed spaces may bother some patients.  We also need to be sure there are no objects or equipment available that the patient may throw due to confusion. 

Dementia patients should never be left alone in a sensory room.  They may become confused because the room is unfamiliar to them.  They may damage the equipment, or injure themselves.

Munroe ended by saying that we really didn’t have many guidelines available to us when setting up our sensory room.  We tried to provide a mixture of adult and pediatric sensory experiences that we believed would be most beneficial to our patient population.

Michael Brown pictured with Final Thought written

I am a big supporter of sensory rooms.  My thought is we should utilize all other treatment modalities prior to resorting to medications for dementia patients.  All drugs come with side effects and currently there are no medications indicated for the behavioral and psychological symptoms of dementia. 

Always try to meet the basic needs of the patient before moving on to other therapies.  Assess for pain, hunger, thirst, constipation and comfort. 

As a society, we have a responsibility to care for our ailing population.  This includes the mentally ill.  Unfortunately, none of us are immune from this debilitation condition.  We can all learn about it, and try to limit our risk of developing dementia.  I will continue to write about this subject as I believe it is very important.

If you have any questions regarding Snoezelen rooms or dementia in general please reach out to me.  I have access to some of the best professionals in this area. 

Please take a look at the Sunshine Store for all of your vitamin and nutritional needs.

Michael Brown in Lab Coat with arms crossed

Michael J. Brown, RPh, BCPS, BCPP

Mr. Brown is a Clinical Pharmacist specializing in pharmacotherapy and psychiatry.

Read Michael’s story here.

Feel free to send Michael a message using this link.



Benadryl And Dementia; Can Anticholinergic Drugs Cause Dementia Or Make It Worse?

Disclosure:  This post may contain affiliate links, meaning, at no additional cost to you, I may earn a commission if you click on, or make a purchase through a third-party link.

Can Benadryl and other anticholinergic drugs give you dementia?

Dementia has become a national health care crisis. This Disease affects not only patients but also families and caregivers. Early signs of dementia include difficulty writing and speaking, misplacing items, confusion, frustration, and memory loss.

Brain failure is an easy way to describe this Disease.

Alzheimer’s Disease, the most common form of dementia, progresses very slowly. Other types, such as vascular dementia may strike immediately after a stroke. Unfortunately, we are all just one stroke away from becoming a potential dementia patient.

Dementia patients will eventually depend on others for their complete care.

For More Information On Lewy Body Dementia, See My Previous Post By Clicking The Box Below:

What is an anticholinergic drug?

An anticholinergic drug is one that blocks acetylcholine. Acetylcholine is one of the neurotransmitters located in the brain and other parts of the body.

It is quickly destroyed by an enzyme called acetylcholinesterase and has a very short duration of action.

Acetylcholine has many functions:

  • Decreases heart rate, acts as a vasodilator, decreases heart muscle contraction.
  • Causes urinary smooth muscle contraction of the bladder.
  • Helps move food through the digestive tract by increasing peristalsis. 
  • Stimulates gland secretion.
  • Causes bronchoconstriction in the lungs.
  • Effects memory and learning

Anticholinergic Burden

There is no single scale available to rate medications for anticholinergic burden.

More than 600 medications have various levels of anticholinergic effects.1 

In my practice, I primarily use the Beers List and two research articles to get this information.

I will list a few examples in each category below. Please reference the following articles if you require an extensive list of agents:




The two articles I utilize currently are:

  1. Mohammed Saji Salahudeen, Stephen B Duffull & Prasad S Nishtala.Anticholinergic burden quantified by anticholinergic risk scales and adverse outcomes in older people: a systemic review. BMC Geriatrics volume 15, Article number: 31 (2015)

   2.  Durán C, Azermai M, Vander Stichele R. Systematic review of anticholinergic risk scales in older adults. European Journal of Clinical Pharmacology. 2013;69(7):1485-1496. doi:10.1007/s00228-013-1499-3.

Anticholinergic medications are used for a variety of indications. Some of these are listed below:


First-generation antihistamines have a high level of anticholinergic activity.

Diphenhydramine (Benadryl) is the most common. This drug is used in its injectable form in hospitals to treat acute allergic reactions along with epinephrine.

It is also used for seasonal allergies, motion sickness, Parkinson’s Disease, and as a sleep aid.

Diphenhydramine is available over the counter (OTC).  Benadryl and memory loss has become a recent study subject.

I tell my patients to steer clear of any OTC medications that end with “PM.”

Most of these products contain diphenhydramine in combination with a pain reliever.

Diphenhydramine is a poor choice to help elderly patients sleep.

Like all anticholinergics, it may lead to blurred vision, dry mouth, and an increased risk of falls.

Antihistamines with high anticholinergic activity:


  • Diphenhydramine (Benadryl)
  • Dimenhydrinate (Dramamine) 
  • Cyproheptadine (Periactin)
  • Hydroxyzine (Atarax, Vistaril)


Antidepressants are primarily used to treat depression and anxiety disorders.

Some antidepressants also possess anticholinergic properties. This is especially true of the older tricyclic antidepressants.

These are rarely used at high doses currently as SSRI’s, such as sertraline (Zoloft) are much safer and have fewer side effects.

Paroxetine (Paxil) is an SSRI that has a higher anticholinergic burden.

It is best to avoid paroxetine in elderly patients.

Antidepressants with high anticholinergic activity:

  • Amitriptyline (Elavil)·
  • Clomipramine (Anafranil)
  • Desipramine (Norpramin)
  • Desipramine (Norpramin)
  • Doxepin (Sinequan)
  • Imipramine (Tofranil)
  • Nortriptyline (Pamelor)
  • Paroxetine (Paxil)


All antipsychotics have some anticholinergic activity. Unfortunately, they are the most effective agents we have for the behavioral and psychological symptoms of dementia, so they are often used in this population.

As with the antidepressants, different agents have various levels of anticholinergic activity. Clozapine (Clozaril) and olanzapine (Zyprexa) are the most anticholinergic atypical antipsychotic agents.

Antipsychotics with high anticholinergic activity:

  • Chlorpromazine (Thorazine)
  • Clozapine (Clozaril)
  • Fluphenazine (Prolixin)
  • Thioridazine (Mellaril)

Urinary antispasmodics

Urinary antispasmodics are indicated for overactive bladder symptoms. The most common is oxybutynin (Ditropan). I have personally witnessed these being used in patients who were incontinent. I believe these drugs should be avoided when possible. These medications should not be used in patients with dementia or delirium. The risk in these cases is likely much higher than the benefit.

GI antispasmodics

Drugs such as dicyclomine are used for irritable bowel syndrome. Many dementia patients are incontinent of bowel as well as urine. These medications should be avoided in this population.

Anticholinergic medications for combating antipsychotic side effects

Benztropine (Cogentin) and trihexyphenidyl (Artane) are used to combat dystonia or pseudo-parkinsonism from antipsychotics.  This is a case where benefit outweighs risk.  These side effects can be debilitating and controlling them is a priority.

Muscle Relaxants

Cyclobenzaprine (Flexeril) and methocarbamol (Robaxin) are used to help with pain and muscle relaxation.

Again, these medications are often necessary for patient comfort.  I suggest using the agent with the lowest anticholinergic burden possible.

Unwanted Side Effects Caused By Anticholinergic Drugs

  • blurred vision
  • dry mouth and eyes
  • constipation
  • dizziness
  • confusion
  • urinary retention
  • Increased risk of falls

Treatment Of Anticholinergic Side Effects

  • Exercise to help relieve constipation.
  • Sugarless candy or gum for dry mouth.
  • Increasing fluid intake for constipation and dry mouth.
  • Saliva substitutes, mouthwashes or fluoride rinses for dry mouth.

Effects Of Aging

As we age, our bodies react differently to medications.

Our liver and kidneys are not as efficient, and we are composed of more fat and less muscle.

We have less protein circulating in our bloodstreams to bind to medications.

We do not excrete drugs as well as a younger person.

All of these factors lead to an increased effect from the medications we ingest.

Dementia patients also have lower acetylcholine levels.2

Anticholinergic medications block a portion of the remaining acetylcholine leading to a further decrease in cognition.

There have been several studies linking anticholinergic medication use to impaired cognitive function in elderly patients.

Clinical Studies On Anticholinergics And Dementia

A clinical review of twenty-seven studies, published in 2009, found all but two discovered an association between the anticholinergic burden of medications and either dementia, delirium, or cognitive impairment.9


A study of 1473 individuals without dementia was conducted over a six-year period to determine whether anticholinergic drugs had an effect on memory decline. 

The subjects in this study were between the ages of sixty to ninety years. Several aspects of cognition were measured. 

Even though only 2% of the subjects used anticholinergic drugs (n=29), the results indicate these medications may lead to a more rapid cognitive decline in older adults without dementia. 10

The final study I would like to discuss was the subject of our journal club luncheon last week. 

This is a new nested case-control study of 58,769 dementia patients and 225,574 controls.  

These patients were from England, and data was obtained via the QResearch primary care database.

The purpose of this study was to determine the association between cumulative anticholinergic drug exposure and the risk of dementia.

This study found an increased risk of dementia in patients who used the following types of anticholinergic agents:

  • Antidepressants
  • Bladder antimuscarinics
  • Antipsychotics
  • Anti-epileptic drugs

We were surprised to discover they found no significant increase in dementia risk for:

  • Antihistamines
  • Gastrointestinal antispasmodics
  • Antimuscarinic bronchodilators
  • Antiarrhythmics
  • Skeletal muscle relaxants


Our journal club group consisting of three psychiatrists, a psychiatric nurse manager and myself.  We discussed the reason for antihistamines not causing a significant increase in dementia risk.  

As a group, we came up with the following possible explanations:

The information obtained was from drugs dispensed. There is no way to determine if the patients ingested the medications.

Patients may not take antihistamines on a consistent basis. Many times they are only utilized for seasonal allergies or to help with insomnia.


Diphenhydramine is available over-the-counter and may not be included in the data obtained by the investigators.

The study also found the link between anticholinergics and dementia was stronger before the age of 80 and in those with vascular dementia as opposed to Alzheimer’s disease.

The increased risk of vascular dementia could be attributed to the anticholinergic agents increasing stroke risk.  

We know that antipsychotics increase the risk of heart disease and stroke as well as diabetes.

I want to point out that this study only looked at medications on the Beers list.

 This list is created by The American Geriatrics Society and lists drugs that should be avoided if possible in geriatric patients.

There are several medications that we often use which are not on this list. Almost all of the antidepressants, with the exception of paroxetine, are rarely used first line.  

Several antipsychotics are also not included. This will undoubtedly affect the study results.

The researchers concluded that there was an almost 50% increase in dementia risk in those who took an equivalent of one single strong anticholinergic medication daily for a three year period.

This leads us to the recommendation that anticholinergic drugs should be avoided when possible, especially in middle-aged and older individuals.

  Physicians and pharmacists should look for alternative agents that have fewer anticholinergic side effects in this patient population.11

I practice as a Clinical Pharmacy Specialist on a psychiatric unit which cares for dementia patients.

As a pharmacist on the unit, one of the first tasks I set out to achieve is to minimize the anticholinergic load of the patient.

I have noticed many patients taking anticholinergic medications unnecessarily.

My suggestion is always to eliminate any medications that are not critical to the patient’s health. This applies to all agents, not only anticholinergics.

There are times when anticholinergic drugs must be used. We can employ the strategies described above to reduce the side effects caused by these agents.

There appears to be an increased risk of developing dementia when taking these medications for an extended period of time.

My recommendation is to use anticholinergic drugs only when clearly indicated.

This applies to all individuals, regardless of age.

Sleep aids and allergy medications should only be used when symptoms are present. This also increases the effectiveness of the agents. The body can become tolerant, especially to sleep aids if used chronically.

The main lesson here is to minimize the use of medications possessing anticholinergic properties.

Michael Brown in Lab Coat with arms crossed

Michael J. Brown, RPh, BCPS, BCPP

Mr. Brown is a Clinical Pharmacist specializing in pharmacotherapy and psychiatry.

Read Michael’s story here.

Feel free to send Michael a message using this link.



Lewy Body Dementia Prognosis, Causes, And Medications To Avoid

I will explore the prognosis, treatment, progression and features of Lewy Body Dementia (LBD). I have extensive experience with this patient population and will share some of what I have learned over the years. LBD is a devastating disease and is very difficult to treat. Family members attempting to care for these patients often become depressed.

Disclosure:  This post may contain affiliate links, meaning, at no additional cost to you, I may earn a commission if you click on, or make a purchase through a third-party link.

What is LBD?

LBD is the second most prevalent type of dementia behind Alzheimer’s Disease. The Lewy Body Dementia Association (LBDA) estimates 1.3 million Americans have LBD.  The other two types of dementia are vascular dementia and frontotemporal lobe dementia (FTD).  All four dementia types have different diagnostic criteria associated with them.

Causes of LBD

Lewy Body Dementia, caused by the deposition of a protein known as alpha-synuclein in the brain (Lewy bodies), generally affects patients over the age of 50. Prevalence is higher in men than woman. Alpha-synuclein is abundant in the brain tissue of healthy individuals. It is found mainly in presynaptic terminals which are specialized structures on the tips of neurons. When this protein builds up, it can kill or damage neurons responsible for producing acetylcholine and dopamine. Movement, thinking, behaviour and mood are affected by this loss.

Diagnosis of LBD

Abuse of alcohol, prescription or illicit drugs can mimic dementia. Metabolic and thyroid imbalances, as well as delirium, can also produce signs similar to LBD. These should be ruled out before making an LBD diagnosis. 

Vascular dementia caused by stroke, frontotemporal dementia, and Alzheimer’s disease are different disease states and are managed differently with regards to medication.

 Lewy bodies cannot be detected in brain tissue while the patient is living.  The disease can only be confirmed after the patient has passed away, and an autopsy performed.

  The symptoms outlined in the next section, specifically Parkinson’s symptoms and visual hallucinations, are used to diagnose a patient with LBD.

Symptoms of LBD


This is progressive confusion. Patients may initially have word-finding difficulties and show some personality changes.  They will misplace items and become easily frustrated.

 Memory loss will become worse over time, and they will be unable to solve problems or learn new skills. During the final stages, they may forget how to eat and drink and will be utterly dependent on others for their care.

REM Sleep Behavior Disorder (RBD)

This is the earliest symptom of LBD in some patients and considered a risk factor for developing it. Dreams, often nightmares, are acted out vocally and physically. Arm and leg movements can be violent during these episodes. 

 The patient may have a difficult time distinguishing dreams from reality when awake.

Parkinson's Disease Symptoms

The classic signs of Parkinson’s disease will likely be present.  These symptoms, along with visual hallucinations, are the core diagnostic criteria which separate Lewy Body Dementia from other dementia types. Parkinson’s symptoms include:


  • Tremor: Usually begins in a limb frequently in hands or fingers.
  • Slowed movement or bradykinesia
  • Rigid muscles
  • Poor posture and balance which may cause falls
  • Changes in speech
  • Writing changes
  • Mask facies, as shown by a blank stare. The patient doesn’t show facial emotions.
  • Changes in gait as evidenced by walking with stiff legs or shuffling

Fluctuations in cognition

The patient may be alert one minute and confused the next. Changes can happen at any time and may go on for hours or days.  These symptoms resemble delirium.



These are most commonly visual and may or may not be disturbing to the patient. The patient may report seeing children or animals. They are often more severe when the patient is confused. Hallucinations occur in approximately 80% of LBD patients.



It is vital to utilize a care team when treating this condition. Cognitive-behavioural therapy (CBT) is used early in the disease process. As the patient progresses, CBT is less beneficial due to a decline in cognition.  LBD cannot be cured or prevented, but the following professionals can help the patient:

Speech Therapist

Can help the patient with difficulty swallowing. The therapist can also help the patient speak more loudly and clearly.


Occupational Therapist

Assists patients with daily activities and mobilization.   Sets up the patients living area to limit frustration and creates a daily routine for the patient to follow.  Can help care-givers with tips on how to manage various behaviours.

Physical Therapist

helps with exercises to strengthen the body and improve gait.

Art and Music Therapists

Dementia patients can often remember and enjoy music and art they experienced in the past. The art and music can help expression, which improves concentration and can ease frustration.

Psychiatrists and Psychiatric Nurses

If the patient becomes aggressive, violent or otherwise hard to manage, there may be a need for hospitalization. These professionals can develop a treatment plan with help from the professionals listed above. Specialized inpatient units exist to treat these patients.

Palliative care Physicians and Nurses

These professionals may be useful during any stage of the disease, and are especially valuable when the patient reaches the final stages. Keeping the patient comfortable becomes the most important goal at this time.

Medication Therapy

Anticholinesterase inhibitors (ACHEI's)

ACHEI’s can be useful in LBD, although Cochrane database reviews have shown mixed results. Rivastigmine is a popular ACHEI choice for these patients, due to its availability as a transdermal patch.  Donepezil may also be used and is often the ACHEI the physician utilizes at the beginning of treatment.  It is important to stress that these medications are not a cure for the disease. They are only useful in slowing its progression.


Memantine has been shown to increase the quality of life scores in LBD patients. Memantine may improve memory and awareness. Memantine has little effect during the final stages of the disease.


It is important to note that antipsychotic medications can make LBD patients worse. The Parkinson’s symptoms present in this disease are due to a decrease in dopamine in the substantia nigra region of the brain. 

Antipsychotics work by blocking dopamine receptors. This blockade creates a further reduction in dopamine and thus makes the movement disorder worse.

Behavioural and Psychological Symptoms of Dementia

Antipsychotic medications are often used in dementia patients to treat behavioural and psychological symptoms of dementia. These are the symptoms that lead to hospitalization and include the following:

  • Apathy: Lacks feeling or emotion.


  • Delusions: Believing something that is not real. They may believe they are an influential person or believe that they are being followed, watched, or poisoned, for example.


  • Aggression: Striking out or yelling at others. Aggression can be new behaviour for these patients.


  • Agitation: Can be restless or appear nervous.


  • Anxiety: Apprehensive or uneasy. May show signs of fear (rapid heart rate, sweating, trembling)


  • Movement disturbances: The patient may pace or move in unnatural ways with no determined purpose. 


  • Irritability: Becomes frustrated or upset quickly.


  • Lability: Patients may experience rapid changes in mood for no apparent reason.They may laugh one minute and cry the next.


  • Sleep/Wake disturbances: Patient may not sleep, or the sleep/wake cycle may be reversed.This can pose a significant problem for care-givers.


  • Depression: the feeling of sadness. The patient may isolate to room.


  • Dysphoria: Dissatisfaction with life in general.


  • Hypersexuality or disinhibition: May touch or try to kiss others. Acts without thoughts of consequences.


  • Sundowning: More common in Alzheimer’s dementia. The patient becomes agitation or aggressive late in the day.


Hallucinations: Visual, auditory, or tactile sensations that are perceived but not real. Visual hallucinations are a diagnostic sign

If antipsychotics are used in LBD patients, quetiapine or clozapine should be utilized due to lower dopamine blocking activity. Haloperidol should NEVER be used in these patients. 


The average lifespan of a patient with LBD is 5 to 8 years after the diagnosis.  Patients can live up to 20 years with the disease, but this is very uncommon.

 Patients become weak near the end of life and may succumb to pneumonia or other opportunistic infections.  They may be unable to swallow, and tube feeding is a poor option for these patients.

Lewy Body Dementia is a devastating condition for the patient, family and care-givers. Below are some helpful hints to keep in mind when caring for these patients.

  • Try not to give the patient tasks or activities that are challenging to complete. Difficult chores can lead to frustration and negative behaviour.
  • Utilize professionals who have experience with this type of patient. 
  • Try to keep the patient’s routine as consistent as possible. Changing practices can cause frustration.
  • Have the patient listen to music they enjoyed in the past or show them pictures of family and friends to help calm them.
  • If the patient becomes aggressive, violent or challenging to manage, get help! Getting burned out does not help the patient or care-giver. Many individuals caring for dementia patients become depressed.  If you are caring for one of these patients, be sure to take care of yourself. Get exercise, eat well, get plenty of sleep and take breaks as needed.  
  • During the final stages, it may be necessary to move the patient to a memory care facility. These facilities specialize in dementia care.

If you have any questions or would like additional information, please feel free to reach out to me using the link below.  If I do not know the answer to your question, I will find it for you. 

Always remember to live a happy, healthy, healing life!

Michael Pharmacist

Michael J. Brown, RPh. BCPS, BCPP

Mr. Brown is a Clinical Pharmacist specializing in pharmacotherapy and psychiatry.
Read Michael’s story here. Feel free to send Michael a message using this link