Lewy Body Dementia

DIAGNOSIS: Dementia with Lewy Bodies (DLB) ICD-10: G31.83 (Dementia with Lewy bodies); F02.80 (Dementia in DLB without behavioral disturbance); F02.81 (Dementia in DLB with behavioral disturbance)

CPT CODES: 85025 (CBC with differential), 80048 (BMP), 84443 (TSH), 82607 (Vitamin B12), 82746 (Folate), 82947 (Glucose (fasting)), 80076 (Hepatic panel (LFTs)), 81001 (Urinalysis), 82306 (Vitamin D, 25-hydroxy), 83036 (Hemoglobin A1c), 80061 (Lipid panel), 86592 (RPR or VDRL), 87389 (HIV testing), 85651 (ESR), 82533 (Cortisol (AM)), 83519 (CSF alpha-synuclein seed amplification assay (SAA)), 88305 (Skin biopsy for phosphorylated alpha-synuclein), 81479 (Genetic testing (GBA, SNCA)), 86235 (Paraneoplastic antibody panel), 86255 (Anti-neuronal antibodies (NMDA-R, LGI1, CASPR2)), 70551 (MRI Brain without contrast), 70450 (CT Head non-contrast), 78607 (DaTscan (ioflupane I-123 SPECT)), 78452 (Cardiac MIBG scintigraphy), 78816 (FDG-PET Brain), 95810 (Polysomnography), 95819 (EEG), 95923 (Autonomic function testing), 70553 (MRI with SWI) SYNONYMS: DLB, Lewy body disease, diffuse Lewy body disease, cortical Lewy body disease, Lewy body dementia, LBD, dementia with Lewy bodies, Parkinson's disease dementia, PDD, Lewy body variant of Alzheimer's disease SCOPE: Diagnosis based on McKeith criteria (2017), biomarker-supported diagnosis (DaTscan, MIBG), symptomatic management of cognitive, motor, behavioral, and autonomic symptoms. Emphasizes neuroleptic sensitivity and safe treatment approaches. Covers both pure DLB and Parkinson's disease dementia (PDD) overlap.

VERSION: 1.1 CREATED: January 27, 2026 REVISED: January 30, 2026 STATUS: Approved

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PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting

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SECTION A: ACTION ITEMS

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1. LABORATORY WORKUP

1A. Essential/Core Labs

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
CBC with differential (CPT 85025)	STAT	STAT	ROUTINE	-	Infection screen; anemia contributing to cognitive changes	Normal
BMP (CPT 80048)	STAT	STAT	ROUTINE	-	Hyponatremia, uremia, hypercalcemia as causes of confusion	Normal electrolytes, BUN, Cr
TSH (CPT 84443)	URGENT	ROUTINE	ROUTINE	-	Hypothyroidism is reversible cause of cognitive impairment	0.4-4.0 mIU/L
Vitamin B12 (CPT 82607)	URGENT	ROUTINE	ROUTINE	-	Deficiency can cause cognitive impairment and parkinsonism	>300 pg/mL (>400 optimal)
Folate (CPT 82746)	-	ROUTINE	ROUTINE	-	Deficiency contributes to cognitive impairment	>3 ng/mL
Glucose (fasting) (CPT 82947)	STAT	ROUTINE	ROUTINE	-	Diabetes affects cognition and autonomic function	70-100 mg/dL
Hepatic panel (LFTs) (CPT 80076)	-	ROUTINE	ROUTINE	-	Baseline before medications; hepatic encephalopathy	Normal
Urinalysis (CPT 81001)	STAT	STAT	ROUTINE	-	UTI common cause of acute confusion in elderly	Negative for infection

1B. Extended Workup (Second-line)

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
Vitamin D, 25-hydroxy (CPT 82306)	-	ROUTINE	ROUTINE	-	Deficiency associated with falls and cognitive decline	>30 ng/mL
Hemoglobin A1c (CPT 83036)	-	ROUTINE	ROUTINE	-	Chronic glucose control affects cognition	<7%
Lipid panel (CPT 80061)	-	ROUTINE	ROUTINE	-	Vascular risk factors	LDL <100 mg/dL
RPR or VDRL (CPT 86592)	-	ROUTINE	ROUTINE	-	Neurosyphilis (rare but treatable)	Nonreactive
HIV testing (CPT 87389)	-	ROUTINE	ROUTINE	-	HIV-associated neurocognitive disorder	Negative
ESR (CPT 85651), CRP (CPT 86140)	-	ROUTINE	ROUTINE	-	Inflammatory/autoimmune causes	Normal
Cortisol (AM) (CPT 82533)	-	ROUTINE	ROUTINE	-	Adrenal insufficiency causing orthostatic hypotension	10-20 mcg/dL

1C. Rare/Specialized (Refractory or Atypical)

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
CSF alpha-synuclein seed amplification assay (SAA) (CPT 83519)	-	-	EXT	-	Confirms synucleinopathy; research/atypical cases	Positive aggregation
Skin biopsy for phosphorylated alpha-synuclein (CPT 88305)	-	-	EXT	-	Peripheral synuclein deposition confirms synucleinopathy	Positive deposits in cutaneous nerves
Genetic testing (GBA, SNCA) (CPT 81479)	-	-	EXT	-	Family history or early-onset; GBA mutations increase DLB risk	Identifies genetic risk
Paraneoplastic antibody panel (CPT 86235)	-	EXT	EXT	-	Autoimmune dementia; rapid progression	Negative
Anti-neuronal antibodies (NMDA-R, LGI1, CASPR2) (CPT 86255)	-	EXT	EXT	-	Autoimmune encephalitis if rapid onset	Negative

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2. DIAGNOSTIC IMAGING & STUDIES

2A. Essential/First-line

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
MRI Brain without contrast (CPT 70551)	URGENT	ROUTINE	ROUTINE	-	At initial evaluation	Relative preservation of medial temporal lobes (vs AD); rule out structural causes	MRI-incompatible devices
CT Head non-contrast (CPT 70450)	STAT	STAT	ROUTINE	-	If MRI unavailable	Rule out mass, hemorrhage, hydrocephalus	None

2B. Extended

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
DaTscan (ioflupane I-123 SPECT) (CPT 78607)	-	EXT	ROUTINE	-	Diagnostic uncertainty; differentiating DLB from AD	Reduced dopamine transporter uptake in putamen (indicative biomarker)	Hypersensitivity to iodine
Cardiac MIBG scintigraphy (CPT 78452)	-	-	ROUTINE	-	Differentiate DLB from AD; supports diagnosis	Reduced cardiac uptake (indicative biomarker)	Recent MI; drugs affecting uptake (labetalol, reserpine)
FDG-PET Brain (CPT 78816)	-	-	ROUTINE	-	Differentiate from AD; atypical presentations	Posterior occipital hypometabolism with cingulate island sign (supportive biomarker)	None
Polysomnography (CPT 95810)	-	-	ROUTINE	-	REM sleep behavior disorder confirmation	REM sleep without atonia (indicative biomarker)	None
EEG (CPT 95819)	URGENT	ROUTINE	ROUTINE	-	Encephalopathy; fluctuating cognition	Posterior slow-wave activity with periodic fluctuations (supportive)	None
Autonomic function testing (CPT 95923)	-	ROUTINE	ROUTINE	-	Dysautonomia assessment	Orthostatic hypotension, abnormal HR variability	None

2C. Rare/Specialized

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
Amyloid PET (CPT 78816)	-	-	EXT	-	Atypical cases; AD co-pathology assessment	May be positive (AD-DLB overlap common)	None
Tau PET (CPT 78816)	-	-	EXT	-	Research; differentiate from AD tauopathy	Less tau deposition than AD for similar dementia severity	None
SPECT perfusion (CPT 78607)	-	-	EXT	-	Alternative to FDG-PET	Posterior hypoperfusion pattern	None
MRI with SWI (CPT 70553)	-	ROUTINE	ROUTINE	-	Microbleeds; cerebral amyloid angiopathy	Lobar microbleed pattern	MRI contraindications

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3. TREATMENT

3A. Acute/Emergent

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
AVOID TYPICAL ANTIPSYCHOTICS	-	CRITICAL SAFETY WARNING	DO NOT USE :: N/A :: N/A :: Haloperidol, chlorpromazine, fluphenazine absolutely contraindicated; risk of severe parkinsonism, NMS, and death	DLB is absolute contraindication	N/A	STAT	STAT	ROUTINE	STAT
AVOID MOST ATYPICAL ANTIPSYCHOTICS	-	CRITICAL SAFETY WARNING	DO NOT USE :: N/A :: N/A :: Risperidone, olanzapine, aripiprazole, ziprasidone contraindicated; 2-3x mortality risk	DLB is relative contraindication	N/A	STAT	STAT	ROUTINE	STAT
Quetiapine (if antipsychotic absolutely needed)	PO	Severe psychosis/agitation when non-pharmacologic fails	12.5 mg :: PO :: qHS :: Start 12.5 mg qHS; increase slowly by 12.5 mg q3-7d; max 50-100 mg; lowest effective dose for shortest time	QT prolongation	Monitor for worsening parkinsonism, sedation	URGENT	URGENT	ROUTINE	-
Treat delirium triggers	Various	Infection, metabolic, medication-induced delirium	Per cause :: Various :: per protocol :: Treat UTI, correct electrolytes, remove offending drugs (especially anticholinergics)	Depends on intervention	Mental status	STAT	STAT	ROUTINE	-

3B. Symptomatic Treatments

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Rivastigmine oral	PO	Cognitive impairment and visual hallucinations (FDA approved for PDD)	1.5 mg :: PO :: BID :: Start 1.5 mg BID with meals; increase by 1.5 mg BID q2-4wk; target 6 mg BID; may improve hallucinations	Sick sinus syndrome; GI bleeding; severe hepatic impairment	Nausea, weight loss, tremor worsening, bradycardia	-	ROUTINE	ROUTINE	-
Rivastigmine patch	TD	Cognitive impairment; better GI tolerability	4.6 mg/24hr :: TD :: daily :: Start 4.6 mg/24hr patch; increase q4wk; target 9.5-13.3 mg/24hr	Sick sinus syndrome; GI bleeding; severe hepatic impairment	Skin irritation, nausea	-	ROUTINE	ROUTINE	-
Donepezil	PO	Cognitive impairment; alternative to rivastigmine	5 mg :: PO :: qHS :: Start 5 mg qHS x 4-6 weeks; may increase to 10 mg qHS	Sick sinus syndrome; GI bleeding; COPD exacerbation	Bradycardia, vivid dreams (may worsen RBD), GI	-	ROUTINE	ROUTINE	-
Galantamine	PO	Cognitive impairment; alternative cholinesterase inhibitor	4 mg :: PO :: BID :: Start 4 mg BID x 4wk; increase to 8 mg BID; target 8-12 mg BID	Sick sinus syndrome; GI bleeding; COPD exacerbation; severe renal/hepatic impairment	GI symptoms, bradycardia	-	ROUTINE	ROUTINE	-
Memantine	PO	Moderate-severe dementia; add to cholinesterase inhibitor	5 mg :: PO :: daily :: Start 5 mg daily; increase by 5 mg/wk; target 10 mg BID	Severe renal impairment (dose adjust CrCl <30)	Confusion, dizziness, constipation	-	ROUTINE	ROUTINE	-
Carbidopa-Levodopa	PO	Motor parkinsonism symptoms	25/100 mg :: PO :: TID :: Start 25/100 mg TID; titrate slowly; use lowest effective dose; may worsen hallucinations	Active psychosis	Dyskinesias, confusion, hallucination worsening	-	ROUTINE	ROUTINE	-
Melatonin	PO	REM sleep behavior disorder (first-line)	3 mg :: PO :: qHS :: Start 3-6 mg 30 min before bed; may increase to 12 mg; first-line for RBD	None	Generally well-tolerated	-	ROUTINE	ROUTINE	-
Clonazepam	PO	REM sleep behavior disorder (second-line)	0.25 mg :: PO :: qHS :: Start 0.25-0.5 mg qHS; typical 0.5-1 mg; use with caution due to sedation and fall risk	Severe sleep apnea; respiratory compromise; dementia (relative)	Sedation, falls, cognitive worsening	-	ROUTINE	ROUTINE	-
Pimavanserin (Nuplazid)	PO	Visual hallucinations and psychosis	34 mg :: PO :: daily :: 34 mg once daily; takes 4-6 weeks for effect; no titration; selective 5-HT2A inverse agonist	Severe hepatic impairment; QT prolongation	QTc at baseline; efficacy assessment 6 weeks	-	ROUTINE	ROUTINE	-
Trazodone	PO	Insomnia; sundowning	25 mg :: PO :: qHS :: Start 25-50 mg qHS; titrate by 25 mg; typical 50-100 mg qHS	MAOIs; QT prolongation	Orthostatic hypotension	-	ROUTINE	ROUTINE	-

3C. Autonomic Dysfunction Treatments

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Midodrine	PO	Orthostatic hypotension	2.5 mg :: PO :: TID :: Start 2.5 mg TID (before arising, lunch, mid-afternoon); titrate by 2.5 mg/dose; max 10 mg TID; last dose by 6 PM	Supine hypertension; urinary retention; severe cardiac disease	Supine BP; avoid lying flat 4 hours after dose	-	ROUTINE	ROUTINE	-
Droxidopa (Northera)	PO	Neurogenic orthostatic hypotension	100 mg :: PO :: TID :: Start 100 mg TID; titrate by 100 mg/dose q24-48h; max 600 mg TID	Supine hypertension	Supine BP, headache	-	ROUTINE	ROUTINE	-
Fludrocortisone	PO	Orthostatic hypotension adjunct	0.1 mg :: PO :: daily :: Start 0.1 mg daily; may increase to 0.2 mg daily	CHF; severe hypertension	K+, edema, supine BP, weight	-	ROUTINE	ROUTINE	-
Polyethylene glycol (MiraLAX)	PO	Constipation	17 g :: PO :: daily :: 17 g (1 capful) in 8 oz liquid daily; may increase to BID	Bowel obstruction	Diarrhea if excessive	-	ROUTINE	ROUTINE	-
Senna + docusate	PO	Constipation stimulant	2 tablets :: PO :: qHS :: 2 tablets qHS; may increase to 4 tablets	Bowel obstruction; undiagnosed abdominal pain	Electrolytes with chronic use	-	ROUTINE	ROUTINE	-
Tamsulosin	PO	Urinary retention	0.4 mg :: PO :: daily :: 0.4 mg once daily 30 min after meal	Known hypersensitivity; concurrent silodosin	Orthostatic hypotension (caution with existing OH)	-	ROUTINE	ROUTINE	-
Oxybutynin	PO	Urinary urgency (use with extreme caution)	2.5 mg :: PO :: BID :: 2.5 mg BID only; avoid higher doses; anticholinergic burden worsens cognition	Narrow-angle glaucoma; urinary retention; dementia (relative)	Cognitive worsening; dry mouth	-	EXT	EXT	-

3D. Depression and Anxiety Treatments

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Sertraline	PO	Depression; anxiety	25 mg :: PO :: daily :: Start 25 mg daily; titrate by 25 mg q1-2wk; typical 50-100 mg	MAOIs	GI upset; may worsen OH	-	ROUTINE	ROUTINE	-
Escitalopram	PO	Depression; anxiety	5 mg :: PO :: daily :: Start 5 mg daily; may increase to 10 mg; max 10 mg in elderly (QT)	MAOIs; QT prolongation	QTc; GI upset	-	ROUTINE	ROUTINE	-
Venlafaxine XR	PO	Depression; anxiety	37.5 mg :: PO :: daily :: Start 37.5 mg daily; titrate q1-2wk; typical 75-150 mg	MAOIs	BP at higher doses	-	ROUTINE	ROUTINE	-
Mirtazapine	PO	Depression with poor appetite and insomnia	7.5 mg :: PO :: qHS :: Start 7.5-15 mg qHS; may increase to 30 mg	MAOIs	Weight gain, sedation	-	ROUTINE	ROUTINE	-

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4. OTHER RECOMMENDATIONS

4A. Referrals & Consults

Recommendation	ED	HOSP	OPD	ICU
Cognitive/behavioral neurology for diagnosis confirmation using McKeith criteria and treatment planning	-	ROUTINE	ROUTINE	-
Movement disorders specialist if motor symptoms prominent or considering dopaminergic therapy	-	ROUTINE	ROUTINE	-
Neuropsychology for comprehensive cognitive testing to establish baseline and differentiate from AD	-	-	ROUTINE	-
Geriatric psychiatry for behavioral symptoms, medication management, and capacity evaluation	-	ROUTINE	ROUTINE	-
Sleep medicine for polysomnography to confirm REM sleep behavior disorder (indicative biomarker)	-	-	ROUTINE	-
Occupational therapy for ADL assessment, cognitive strategies, and home safety evaluation	-	ROUTINE	ROUTINE	-
Physical therapy for gait training, balance exercises, and fall prevention	-	ROUTINE	ROUTINE	-
Speech therapy for communication strategies and swallowing evaluation if dysphagia present	-	ROUTINE	ROUTINE	-
Social work for caregiver support, community resources, and long-term care planning	-	ROUTINE	ROUTINE	-
Palliative care for advanced dementia symptom management and goals of care discussions	-	ROUTINE	ROUTINE	-
Cardiology if orthostatic hypotension refractory to first-line treatment	-	-	ROUTINE	-

4B. Patient Instructions

Recommendation	ED	HOSP	OPD
CRITICAL: Avoid all typical antipsychotics and most atypical antipsychotics - severe sensitivity can cause parkinsonism, rigidity, and death	STAT	STAT	ROUTINE
Carry a medication alert card listing "Lewy Body Dementia - Neuroleptic Sensitivity" for all healthcare encounters	-	ROUTINE	ROUTINE
Report visual hallucinations immediately as these may indicate disease progression or medication effect	-	ROUTINE	ROUTINE
Rise slowly from sitting or lying to prevent falls from orthostatic hypotension	URGENT	ROUTINE	ROUTINE
Implement safety measures for REM sleep behavior disorder: padded bed rails, mattress on floor, remove sharp objects from bedside	-	ROUTINE	ROUTINE
Complete advance directives while patient has capacity to document wishes for future care	-	ROUTINE	ROUTINE
Do not drive due to fluctuating attention, visual-spatial deficits, and hallucinations	-	ROUTINE	ROUTINE
Return immediately if sudden worsening of confusion, falls, or inability to walk (may indicate medication effect or infection)	STAT	STAT	ROUTINE

4C. Lifestyle & Prevention

Recommendation	ED	HOSP	OPD
Fall prevention: remove home hazards, adequate lighting, grab bars, non-slip surfaces due to high fall risk	-	ROUTINE	ROUTINE
AVOID medications that worsen symptoms: anticholinergics, antihistamines (diphenhydramine), sleep aids (Benadryl, Tylenol PM)	URGENT	ROUTINE	ROUTINE
AVOID antiemetics: metoclopramide, prochlorperazine, promethazine (D2 blocking worsens parkinsonism)	URGENT	ROUTINE	ROUTINE
Regular physical exercise as tolerated to maintain mobility and reduce fall risk	-	ROUTINE	ROUTINE
Structured daily routine with consistent sleep-wake times helps with fluctuating cognition	-	ROUTINE	ROUTINE
Adequate lighting and avoid overstimulation which may trigger hallucinations	-	ROUTINE	ROUTINE
Simplify environment and reduce visual clutter to minimize misperceptions	-	ROUTINE	ROUTINE
Caregiver education about fluctuating cognition, which is characteristic and not willful	-	ROUTINE	ROUTINE
Treat sleep apnea if present as it worsens cognition and autonomic dysfunction	-	ROUTINE	ROUTINE

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SECTION B: REFERENCE

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5. DIFFERENTIAL DIAGNOSIS

Alternative Diagnosis	Key Distinguishing Features	Tests to Differentiate
Alzheimer's disease	Memory impairment predominates; no parkinsonism; no visual hallucinations early	DaTscan normal in AD; MRI hippocampal atrophy; amyloid/tau biomarkers
Parkinson's disease dementia (PDD)	Motor symptoms precede dementia by >1 year (vs DLB dementia within 1 year of motor)	Clinical timeline; considered same disease spectrum as DLB
Vascular dementia	Stepwise decline; focal findings; executive dysfunction; vascular risk factors	MRI with significant white matter disease, strategic infarcts
Frontotemporal dementia	Personality change; disinhibition; apathy; hyperorality; younger onset	FDG-PET frontal hypometabolism; preserved posterior metabolism
Progressive supranuclear palsy (PSP)	Vertical gaze palsy; axial rigidity > limb; early falls backward; poor levodopa response	MRI "hummingbird sign"; clinical criteria
Corticobasal syndrome	Asymmetric rigidity; apraxia; alien limb; cortical sensory loss	MRI asymmetric cortical atrophy; clinical criteria
Multiple system atrophy (MSA)	Severe early dysautonomia; cerebellar signs; stridor; poor levodopa response	MRI "hot cross bun" sign; cardiac MIBG preserved (vs reduced in DLB)
Creutzfeldt-Jakob disease	Rapid progression (weeks-months); myoclonus; periodic sharp waves on EEG	EEG PSWCs; MRI DWI cortical ribboning; CSF RT-QuIC positive
Drug-induced parkinsonism	Medication exposure (antipsychotics, metoclopramide); symmetric; no hallucinations	DaTscan normal; medication history; resolves with drug removal
Delirium	Acute onset; fluctuating attention; identifiable cause	Treat cause; reassess cognition when clear
Charles Bonnet syndrome	Visual hallucinations with insight; occurs with visual impairment; no dementia	Ophthalmologic evaluation; cognitive testing normal

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6. MONITORING PARAMETERS

Parameter	Frequency	Target/Threshold	Action if Abnormal	ED	HOSP	OPD	ICU
Cognitive function (MoCA or MMSE)	Every 6 months	Establish baseline; track trajectory	Adjust treatment; reassess diagnosis	-	ROUTINE	ROUTINE	-
Motor function (UPDRS-III)	Every 6 months	Document parkinsonism severity	Adjust levodopa if motor symptoms dominant	-	ROUTINE	ROUTINE	-
Visual hallucinations frequency/severity	Each visit	Document presence and distress level	Adjust cholinesterase inhibitor; add pimavanserin if distressing	-	ROUTINE	ROUTINE	-
Orthostatic blood pressure	Each visit	<20 mmHg systolic drop on standing	Add midodrine or droxidopa	-	ROUTINE	ROUTINE	-
Falls frequency	Each visit	Zero falls	PT referral; medication review; home safety	-	ROUTINE	ROUTINE	-
RBD symptoms	Each visit	Bed partner safety; injury prevention	Adjust melatonin or clonazepam; safety measures	-	ROUTINE	ROUTINE	-
Mood (GDS, PHQ-9)	Every 6 months	Screen negative	Add antidepressant; psychiatry referral	-	ROUTINE	ROUTINE	-
ADL/IADL function	Every 6 months	Document functional decline trajectory	Increase support services; OT referral	-	ROUTINE	ROUTINE	-
Caregiver burden (Zarit scale)	Every 6-12 months	Early identification of burnout	Support resources; respite care; social work	-	-	ROUTINE	-
Weight	Each visit	Stable weight	Nutritional assessment; speech for swallowing	-	ROUTINE	ROUTINE	-
ECG (if on pimavanserin, citalopram)	Baseline; if dose increased	QTc <500 ms	Reduce dose or switch agent	-	ROUTINE	ROUTINE	-

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7. DISPOSITION CRITERIA

Disposition	Criteria
Discharge home	Reversible causes treated; safe environment; caregiver support; no acute behavioral crisis; follow-up arranged
Admit to floor	Acute delirium requiring workup; severe behavioral crisis unsafe for home; falls with injury; medication toxicity
Admit to psychiatry	Severe behavioral disturbance requiring specialized psychiatric management; suicidal ideation
Outpatient follow-up	Neurology/geriatrics 1-2 months after diagnosis; then every 3-6 months
Long-term care	Progressive decline; caregiver unable to manage safely; nocturnal behavioral disturbance; 24-hour supervision needed

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8. EVIDENCE & REFERENCES

Recommendation	Evidence Level	Source
McKeith diagnostic criteria for DLB	Consensus Guidelines	McKeith et al. Neurology 2017
DaTscan indicative biomarker for DLB	Class II, Level B	McKeith et al. Lancet Neurol 2007
Cardiac MIBG indicative biomarker	Class II, Level B	Yoshita et al. Neurology 2015
Rivastigmine for PDD/DLB cognition	Class I, Level A	Emre et al. NEJM 2004
Donepezil for DLB	Class I, Level A	Mori et al. Ann Neurol 2012
Cholinesterase inhibitors reduce visual hallucinations	Class II, Level B	Stinton et al. Int J Geriatr Psychiatry 2015
Neuroleptic sensitivity in DLB	Class II, Level B	McKeith et al. BMJ 1992
Antipsychotic mortality risk in dementia	Class I, Level A	Schneider et al. JAMA 2005
Pimavanserin for PD psychosis	Class I, Level A	Cummings et al. Lancet 2014
Melatonin for REM sleep behavior disorder	Class II, Level B	Kunz et al. Sleep Med 2010
Clonazepam for REM sleep behavior disorder	Class II, Level B	Aurora et al. Sleep 2010
CSF alpha-synuclein SAA for synucleinopathies	Class II, Level B	Siderowf et al. Lancet Neurol 2023

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CHANGE LOG

v1.1 (January 30, 2026) - Reformatted lab tables (1A/1B/1C) to standard column order: Test | ED | HOSP | OPD | ICU | Rationale | Target Finding - Reformatted imaging tables (2A/2B/2C) to standard column order: Study | ED | HOSP | OPD | ICU | Timing | Target Finding | Contraindications - Added inline CPT codes to all lab tests and imaging studies - Fixed structured dosing format: starting dose only in first field across all treatment sections - Expanded cross-references ("Same as donepezil", "Same as SSRIs") with actual content - Added clinical synonyms for searchability - Expanded ICD-10 codes (added F02.80, F02.81) - Added VERSION/CREATED/REVISED header block

v1.0 (January 27, 2026) - Initial template creation - McKeith 2017 diagnostic criteria integrated - Indicative and supportive biomarkers included - Emphasis on neuroleptic sensitivity throughout - Structured dosing format for order sentence generation

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APPENDIX A: McKeith Criteria for DLB (2017)

Essential Feature (Required)

• Dementia defined as progressive cognitive decline sufficient to interfere with normal social or occupational function

Core Clinical Features

1. Fluctuating cognition with pronounced variations in attention and alertness
2. Recurrent visual hallucinations that are typically well-formed and detailed
3. REM sleep behavior disorder (may precede cognitive decline)
4. One or more spontaneous cardinal features of parkinsonism: bradykinesia, rest tremor, rigidity

Indicative Biomarkers

1. Reduced dopamine transporter uptake in basal ganglia (DaTscan)
2. Low uptake on cardiac MIBG scintigraphy
3. Polysomnographic confirmation of REM sleep without atonia

Supportive Biomarkers

1. Relative preservation of medial temporal lobe structures on CT/MRI
2. Generalized low uptake on SPECT/PET perfusion/metabolism scan with reduced occipital activity +/- cingulate island sign on FDG-PET
3. Prominent posterior slow-wave activity on EEG with periodic fluctuations

Supportive Clinical Features

• Severe sensitivity to antipsychotic agents
• Postural instability and repeated falls
• Syncope or other transient episodes of unresponsiveness
• Severe autonomic dysfunction (constipation, orthostatic hypotension, urinary incontinence)
• Hypersomnia
• Hyposmia
• Hallucinations in other modalities
• Systematized delusions
• Apathy, anxiety, and depression

Diagnostic Categories

Probable DLB: - 2+ core clinical features with or without indicative biomarkers, OR - 1 core clinical feature + 1+ indicative biomarkers

Possible DLB: - 1 core clinical feature with no indicative biomarker, OR - 1+ indicative biomarker but no core clinical features

DLB vs PDD

• If dementia occurs before or within 1 year of parkinsonism onset → DLB
• If dementia occurs >1 year after established parkinsonism → PDD
• Both are considered part of the Lewy body disease spectrum

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APPENDIX B: Medications to AVOID in Lewy Body Dementia

Drug Class	Examples	Why to Avoid
Typical antipsychotics	Haloperidol, chlorpromazine, fluphenazine	ABSOLUTE CONTRAINDICATION - severe parkinsonism, NMS, death
Most atypical antipsychotics	Risperidone, olanzapine, aripiprazole, ziprasidone	High D2 blockade; 2-3x mortality risk; severe parkinsonism
Antiemetics (D2 blockers)	Metoclopramide, prochlorperazine, promethazine	Cross BBB; worsen parkinsonism; neuroleptic sensitivity
Anticholinergics	Benztropine, trihexyphenidyl, diphenhydramine, oxybutynin	Worsen cognitive impairment; increase confusion
Sedating antihistamines	Diphenhydramine, hydroxyzine, doxylamine	Anticholinergic effects; worsen cognition
Sleep aids with anticholinergics	Tylenol PM, ZzzQuil	Contains diphenhydramine; contraindicated

Safe Alternatives

Indication	Safe Options
Psychosis/agitation	Quetiapine (lowest effective dose), pimavanserin
Nausea	Ondansetron, domperidone (not US), ginger
Insomnia	Melatonin, trazodone (low dose)
Allergies	Loratadine, cetirizine (less sedating)