BACKGROUND Many patients with
dementia with Lewy bodies (DLB) experience
cholinesterase inhibitor- and
antipsychotic-resistant
psychosis. The new second-generation
antipsychotic pimavanserin has been used with some success in the treatment of
psychosis in other forms of
dementia, including
Alzheimer disease and
Parkinson disease dementia. It is possible that
pimavanserin may also be useful in the treatment of
psychosis in DLB. We sought to describe the disease course and treatment of
psychosis in 4 patients with DLB who were prescribed
pimavanserin after other medications failed to reduce the frequency or severity of
hallucinations and delusions. CASE REPORT This is a case series of 4 male patients (ages 56 to 74 at the beginning of the reports) who developed DLB and
psychosis (eg,
visual illusions, visual and
olfactory hallucinations, and paranoid delusions). All 4 patients were prescribed
cholinesterase inhibitors (eg,
donepezil or
rivastigmine) prior to
pimavanserin, and only 1 patient experienced improved
psychosis while on
cholinesterase inhibitors. All 3 patients who were prescribed first-generation
antipsychotics (eg,
haloperidol) or traditional second-generation
antipsychotics (eg,
olanzapine,
risperidone, or
quetiapine) experienced initial or lasting side effects with no improvement of
psychosis. Conversely, all 4 patients tolerated
pimavanserin well, and 3 of the 4 patients experienced significant improvement of
psychosis (eg, fewer
hallucinations, fewer delusions, reduced
paranoia, and/or reduced distress or agitation related to
hallucinations and delusions) when prescribed
pimavanserin. CONCLUSIONS This case series suggests that
pimavanserin is tolerable in older males with DLB and that it may be useful for the reduction of distressful
hallucinations, delusions, and
paranoia in patients with DLB.