LEWY BODY DEMENTIA

Information for Patients, Families, 

and Professionals

LEARN ABOUT:

• Dementia with Lewy bodies

• Parkinson’s disease dementia

National Institute on Aging

National Institute of Neurological Disorders and Stroke
CONTENTS

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

The Basics of Lewy Body Dementia . . . . . . . . . . . . . . . . . . . . 2

Diagnoses of Lewy Body Dementia . . . . . . . . . . . . . . . . . . . . 5

Causes and Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Common Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Treatment and Management . . . . . . . . . . . . . . . . . . . . . . . . 17

Advice for People Living with Lewy Body Dementia . . . . . . 27

Caring for a Person with Lewy Body Dementia . . . . . . . . . . 30

Research—The Road Ahead . . . . . . . . . . . . . . . . . . . . . . . . 36

Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
1

Introduction

Lewy body dementia (LBD) is a complex and challenging brain disorder. 

It is complex because it affects many parts of the brain in ways that 

scientists are trying to understand more fully. It is challenging because 

its many possible symptoms make it hard to do everyday tasks that once 

came easily. 

Although less known than its “cousins” Alzheimer’s disease and Parkinson’s 

disease, LBD is not a rare disorder. More than 1 million Americans, most 

of them older adults, are affected by its disabling changes in the ability to 

think and move.

As researchers seek better ways to treat LBD—and ultimately to find a 

cure—people with LBD and their families struggle to get an accurate 

diagnosis, find the best treatment, and manage at home. 

This booklet is meant to help people with LBD, their families, and professionals learn more about the disease and resources for coping. It explains 

what is known about the different types of LBD and how they are diagnosed. 

Most importantly, it describes how to treat and manage this difficult disease, 

with practical advice for both people with LBD and their caregivers. A list 

of resources begins on page 37. 
2

The Basics of Lewy Body Dementia

LBD is a disease associated with abnormal deposits of a protein called 

alpha-synuclein in the brain. These deposits, called Lewy bodies, affect 

chemicals in the brain whose changes, in turn, can lead to problems with

thinking, movement, behavior, and mood. LBD is one of the most common 

causes of dementia.

Dementia is a severe loss of thinking abilities that interferes with a person’s 

ability to perform daily activities such as household tasks, personal care, 

and handling finances. Dementia has many possible causes, including 

stroke, brain tumor, depression, and vitamin deficiency, as well as disorders 

such as LBD, Alzheimer’s, frontotemporal dementia, and vascular dementia. 

Diagnosing LBD can be challenging. Early LBD symptoms are often 

confused with similar symptoms found in other brain diseases like 

Alzheimer’s or in psychiatric disorders like schizophrenia. Also, LBD can 

occur alone or along with other brain disorders.

There are two LBD diagnoses—dementia with Lewy bodies and Parkinson’s 

disease dementia. The earliest signs differ but reflect the same biological 

changes in the brain. Over time, people with dementia with Lewy bodies 

or Parkinson’s disease dementia may develop similar symptoms.

Who Is Affected by LBD?

LBD affects more than 1 million individuals in the United States. LBD 

typically begins at age 50 or older, although sometimes younger people 

have it. LBD appears to affect slightly more men than women.

LBD is a progressive disease, meaning symptoms start slowly and worsen 

over time. The disease lasts an average of 5 to 8 years from the time of 

diagnosis to death, but the time span can range from 2 to 20 years. How 

quickly symptoms develop and change varies greatly from person to 

person, depending on overall health, age, and severity of symptoms. 
3

In the early stages of LBD, symptoms can be mild, and people can function 

fairly normally. As the disease advances, people with LBD require more help 

due to a decline in thinking and movement abilities. In the later stages of 

the disease, they often depend entirely on others for assistance and care.

Some LBD symptoms may respond to treatment for a period of time. 

Currently, there is no cure for the disease. Research is improving our 

understanding of this challenging condition, and advances in science may 

one day lead to better diagnosis, improved care, and new treatments.

Understanding Terms

The terms used to describe Lewy body dementia (LBD) can be 

confusing. Doctors and researchers may use different terms to describe 

the same condition. In this booklet, the term Lewy body dementia is 

used to describe all dementias whose primary cause is Lewy bodies in 

the brain. 

LBD may be diagnosed as:

• dementia with Lewy bodies, in which cognitive (thinking) symptoms 

appear within a year of movement problems

• Parkinson’s disease dementia, in which cognitive symptoms develop 

more than a year after the onset of movement problems

As LBD progresses, symptoms of both types of LBD are very similar.
4

What Are Lewy Bodies?

Lewy bodies are named for Dr. Friederich Lewy, a German neurologist. 

In 1912, he discovered abnormal protein deposits that disrupt the brain’s 

normal functioning in people with Parkinson’s disease. These abnormal 

deposits are now called “Lewy bodies.”

Lewy bodies are made of a protein 

called alpha-synuclein. In the healthy 

brain, alpha-synuclein plays a number 

of important roles in neurons (nerve 

cells) in the brain, especially at synapses, 

where brain cells communicate with each 

other. In LBD, alpha-synuclein forms 

into clumps inside neurons, starting in 

areas of the brain that control aspects 

of memory and movement. This process 

causes neurons to work less effectively and, eventually, to die. The activities of 

certain brain chemicals are also affected. The result is widespread damage to 

specific brain regions and a decline in abilities affected by those brain regions.

Lewy bodies affect several different brain regions in LBD:

• the cerebral cortex, which controls many functions, including 

information processing, perception, thought, and language

• the limbic cortex, which plays a major role in emotions and behavior

• the hippocampus, which is essential to forming new memories 

• the midbrain and basal ganglia, which are involved in movement 

• the brain stem, which is important in regulating sleep and maintaining 

alertness

• brain regions important in recognizing smells (olfactory pathways)

Microscopic image of a Lewy body.

Courtesy of Carol F. Lippa, MD, 

Drexel University College of Medicine.
5

Diagnoses of Lewy Body Dementia

Lewy body dementia refers to either of two related diagnoses—dementia 

with Lewy bodies and Parkinson’s disease dementia. Both diagnoses have 

the same underlying changes in the brain and, over time, people with either 

diagnosis develop similar symptoms. The difference lies largely in the timing 

of cognitive (thinking) and movement symptoms. In dementia with Lewy 

bodies, cognitive symptoms develop within a year of parkinsonism—any 

condition that involves the types of movement changes, such as tremor 

or muscle stiffness, seen in Parkinson’s disease. In Parkinson’s disease 

dementia, cognitive symptoms develop more than a year after the onset of 

movement problems. 

Dementia with Lewy Bodies 

People with dementia with Lewy bodies have a decline in thinking ability 

that may look somewhat like Alzheimer’s disease. But over time they also 

develop movement and other 

distinctive symptoms that suggest 

dementia with Lewy bodies. 

Symptoms that distinguish this 

form of dementia from others 

may include:

• visual hallucinations early in 

the course of dementia

• fluctuations in cognitive 

ability, attention, and alertness

• slowness of movement, 

tremor, difficulty walking, or 

rigidity (parkinsonism)

Not-so-sweet dreams

In his mid-60s, Bruce 

started having mild 

confusion and vivid 

dreams in which he 

thrashed around and 

even fell out of bed . 

His neurologist diagnosed REM sleep 

behavior disorder and mild cognitive 

changes . Two years later, Bruce’s 

confusion had progressed to dementia, 

and he had slowness of movement . 

His neurologist referred him for 

neuropsychological testing and, based 

on the results, changed his diagnosis to 

dementia with Lewy bodies .
6

• REM sleep behavior disorder, in which people physically act out their 

dreams by yelling, flailing, punching bed partners, and falling out of bed

• more trouble with mental activities such as multitasking and problem 

solving than with memory early in the course of the disease

Parkinson’s Disease Dementia

Parkinson’s disease dementia starts as a movement disorder, with 

symptoms such as slowed movement, muscle stiffness, tremor, and a 

shuffling walk. These symptoms 

are consistent with a diagnosis 

of Parkinson’s disease. Later on, 

cognitive symptoms of dementia 

and changes in mood and 

behavior may arise.

Not all people with Parkinson’s 

disease develop dementia, and 

it is difficult to predict who 

will. Many older people with 

Parkinson’s develop some degree 

of dementia. 

Parkinson’s progresses

Betty is retired from 

the high school foodservices department 

and is devoted to her 

family, especially her 

three granddaughters . 

At age 73, Betty developed a mild 

tremor in one hand, cramped handwriting, a shuffling gait, and a stooped 

posture . She was diagnosed with 

Parkinson’s disease . When she started 

having hallucinations 3 years later, her 

children became alarmed . Betty soon 

started having problems with confusion 

and visual-spatial orientation . She was 

diagnosed with Parkinson’s disease 

dementia .
7

Causes and Risk Factors

The precise cause of LBD is unknown, 

but scientists are learning more about 

its biology and genetics. For example, 

we know that an accumulation of Lewy 

bodies is associated with a loss of certain 

neurons in the brain that produce two 

important neurotransmitters, chemicals 

that act as messengers between brain cells. 

One of these messengers, acetylcholine, is 

important for memory and learning. The other, dopamine, plays an important 

role in behavior, cognition, movement, motivation, sleep, and mood. 

Scientists are also learning about risk factors for LBD. Age is considered the 

greatest risk factor. Most people who develop the disorder are over age 50.

Other known risk factors for LBD include the following:

• Diseases and health conditions—Certain diseases and health 

conditions, particularly Parkinson’s disease and REM sleep behavior 

disorder, are linked to a higher risk of LBD.

• Genetics—While having a family member with LBD may increase 

a person’s risk, LBD is not normally considered a genetic disease. 

Variants in three genes—APOE, SNCA, and GBA—have been 

associated with an increased risk of dementia with Lewy bodies, but 

in most cases, the cause is unknown. At this time, no genetic test can 

accurately predict whether someone will develop LBD, and genetic 

testing is not usually used in diagnosis. Researchers are looking for 

more genes that may indicate LBD risk.

• Lifestyle—No specific lifestyle factor has been proven to increase one’s 

risk for LBD. 
8

Common Symptoms

People with LBD may not have every LBD symptom, and the severity of 

symptoms can vary greatly from person to person. Throughout the course 

of the disease, any sudden or major change in functional ability or behavior 

should be reported to a doctor.

The most common symptoms include changes in cognition, movement, 

sleep, and behavior. 

Cognitive Symptoms 

LBD causes changes in thinking abilities. These changes may include:

• Dementia—Severe loss of thinking abilities that interferes with a 

person’s capacity to perform daily activities. Dementia is a primary 

symptom in LBD and usually includes trouble with attention, visual 

and spatial abilities (judging distance and depth or misidentifying 

objects), planning, multitasking, problem solving, and reasoning. Unlike 

in Alzheimer’s dementia, memory problems may not be evident at first 

but often arise as LBD progresses. Dementia can also include changes 

in mood and behavior, poor judgment, loss of initiative, confusion 

about time and place, and difficulty with language and numbers. 

• Cognitive fluctuations—Unpredictable changes in concentration, 

attention, alertness, and wakefulness from day to day and sometimes 

throughout the day. A person with LBD may stare into space for 

periods of time, seem drowsy and lethargic, or sleep for several hours 

during the day despite getting enough sleep the night before. His or 

her flow of ideas may be disorganized, unclear, or illogical at times. 

The person may seem better one day, then worse the next day. These 

cognitive fluctuations are common in LBD and help distinguish it 

from Alzheimer’s disease.
Main Characteristics of Lewy Body Dementia

Clinical Symptoms

Core 

Characteristic

Supportive 

Characteristic

Dementia (problems with attention, 

executive function such as problem 

solving and reasoning, visual perception)

X

Movement problems/parkinsonism 

(slowness of movement, muscle rigidity, 

tremor at rest)

X

Cognitive fluctuations (unpredictable 

changes in concentration, attention; 

staring into space)

X

Visual hallucinations X

REM sleep behavior disorder X

Extreme sensitivity to antipsychotic 

medications X

Falls, fainting X

Severe problems with involuntary 

functions (maintaining blood pressure; 

incontinence; constipation; loss of smell)

X

Changes in personality and mood 

(depression, apathy, anxiety) X

Test Results Supporting Diagnosis

PET or SPECT brain scan showing 

Core Characteristic Supportive 

Characteristic

reduced dopamine transporter (DaT) 

uptake in basal ganglia (brain region)

X

Abnormal 123iodine-MIBG myocardial 

scintigraphy showing reduced 

communication of cardiac nerves

X

Sleep study confirming REM sleep behavior 

disorder without loss of muscle tone X

For more information:

McKeith IG, Boeve BF, Dickson DW, et al. Diagnosis and management of dementia with Lewy bodies: 

Fourth consensus report of the DLB Consortium. Neurology. 2017;89(1):88-100.

Lewy Body Dementia Association, www.lbda.org/go/comprehensive-lbd-symptoms-checklist
10

• Hallucinations—Visual hallucinations—seeing things that are not 

present—occur in up to 80 percent of people with LBD, often early 

on. They are typically realistic and detailed, such as images of children 

or animals. Nonvisual hallucinations, such as hearing or smelling 

things that are not present, are less common than visual ones but may 

also occur. Hallucinations that are not disruptive may not require 

treatment. However, if they are frightening or dangerous (for example, 

if the person attempts to fight a perceived intruder), then a doctor may 

prescribe medication.

Movement Symptoms

Some people with LBD may not experience significant movement 

problems for several years. Others may have them early on. At first, 

movement symptoms, such as a change in handwriting, may be very mild 

and easily overlooked. Parkinsonism is seen early on in Parkinson’s disease 

dementia but can also develop later on in dementia with Lewy bodies. 

Specific signs of parkinsonism may include:

• muscle rigidity or stiffness

• shuffling walk, slow movement, or frozen 

stance

• tremor or shaking, most commonly at rest

• balance problems and repeated falls

• stooped posture

• loss of coordination

• smaller handwriting than was usual for 

the person

• reduced facial expression

• difficulty swallowing 

• a weak voice
11

Sleep Disorders

Sleep disorders are common in people with LBD but are often undiagnosed. 

A sleep specialist can help diagnose and treat sleep disorders. Sleep-related 

disorders seen in people with LBD may include:

• REM sleep behavior disorder (RBD)—A condition in which a person 

seems to act out dreams. It may include vivid dreaming, talking in one’s 

sleep, violent movements, or falling out of bed. RBD may be the earliest 

symptom of LBD in some people, appearing many years before other 

LBD symptoms. 

• Excessive daytime sleepiness—Sleeping 2 or more hours during the day. 

• Insomnia—Difficulty falling or staying asleep, or waking up too early.

• Restless leg syndrome—A condition in which a person, while resting, 

feels the urge to move his or her legs to stop unpleasant or unusual 

sensations. Walking or moving usually relieves the discomfort. 

Behavioral and Mood Symptoms

Changes in behavior and mood are possible in LBD and may worsen as 

cognition declines. These changes may include:

• Depression—A persistent feeling of 

sadness, worthlessness, or inability 

to enjoy activities, often with trouble 

sleeping or eating.

• Apathy—A lack of interest in normal 

daily activities or events; less social 

interaction.
12

• Anxiety—Intense apprehension, uncertainty, or fear about a future 

event or situation. A person may ask the same questions over and over 

or be angry or fearful when a loved one is not present. 

• Agitation—Restlessness, as seen by pacing, hand wringing, an inability 

to get settled, constant repeating of words or phrases, or irritability.

• Delusions—Strongly held false beliefs or opinions not based on 

evidence. For example, a person may think his or her spouse is having 

an affair or that relatives long dead are still living. Capgras syndrome, 

in which the person believes a relative or friend has been replaced by an 

imposter, may also appear.

• Paranoia—An extreme, irrational distrust of others, such as suspicion 

that people are taking or hiding things.

Other LBD Symptoms

People with LBD can also experience significant changes in the part of 

the nervous system that regulates automatic functions such as those of the 

heart, glands, and muscles. The person may have:

• changes in body temperature

• problems with blood pressure

• dizziness

• fainting

• frequent falls

• sensitivity to heat and cold

• sexual dysfunction

• urinary incontinence

• constipation

• a poor sense of smell 
13

Diagnosis

It’s important to know which type of LBD a person has, both to tailor 

treatment to particular symptoms and to understand how the disease will 

likely progress. Clinicians and researchers use the “1-year rule” to help make 

a diagnosis. If cognitive symptoms appear at the same time as or at least 

a year before movement problems, the diagnosis is dementia with Lewy 

bodies. If cognitive problems develop more than a year after the onset of 

movement problems, the diagnosis is Parkinson’s disease dementia.

Regardless of the initial symptoms, over time people with LBD often 

develop similar symptoms due to the presence of Lewy bodies in the brain. 

But there are some differences. For example, dementia with Lewy bodies 

may progress more quickly than Parkinson’s disease dementia.

Dementia with Lewy bodies is often hard to diagnose because its early 

symptoms may resemble those of Alzheimer’s or a psychiatric illness. 

As a result, it is often misdiagnosed or missed altogether. As additional 

symptoms appear, it is often easier to make an accurate diagnosis.

The good news is that doctors are increasingly able to diagnose LBD 

earlier and more accurately as researchers identify which symptoms and 

biomarkers (biological signs of disease) help distinguish it from similar 

disorders. 
14

Difficult as it is, getting an accurate diagnosis of LBD early on is important

so that a person:

• gets the right medical care and avoids potentially harmful treatment

• has time to plan medical care and arrange legal and financial affairs

• can build a support team to maximize quality of life

While a diagnosis of LBD can 

be distressing, some people are 

relieved to know the reason for 

their troubling symptoms. It is 

important to allow time to adjust to 

a diagnosis of LBD. Talking about 

it can help people and their families 

focus on developing a care plan. 

Who Can Diagnose LBD?

Many physicians and other 

medical professionals are not 

familiar with LBD, so patients 

may consult several doctors before 

receiving an accurate diagnosis. 

Visiting a family doctor is often 

the first step for people who are 

experiencing changes in thinking, 

movement, or behavior. However, 

neurologists—doctors who 

specialize in disorders of the brain and nervous system—generally have the 

expertise needed to diagnose LBD. Geriatric psychiatrists, neuropsychologists, 

and geriatricians may also be skilled in diagnosing the condition. 

If a specialist cannot be found in your community, ask the neurology department 

of the nearest medical school for a referral. A hospital affiliated with a medical 

What’s going on?

Janet, a 60-year-old 

executive secretary,

began having trouble 

managing the 

accounting, paperwork, and other 

responsibilities of her job. She became 

increasingly irritable, and her daughter 

insisted she see a doctor. Janet was 

diagnosed with depression and stressrelated problems. She was prescribed 

an antidepressant, but her thinking 

and concentration problems worsened.

When she could no longer function at 

work, her doctor diagnosed Alzheimer’s 

disease. A few months later, Janet 

developed a tremor in her right hand.

She was referred to a neurologist, who 

finally diagnosed Lewy body dementia.
15

school may also have a dementia or movement disorders clinic that provides 

expert evaluation. See the “Resources” section at the end of this booklet.

Tests Used to Diagnose LBD

Doctors perform various examinations and tests to distinguish LBD from 

other illnesses. An evaluation may include:

• Medical history and examination—A review of illnesses, medications, 

and symptoms and results of movement and cognitive tests give the 

doctor valuable information.

• Medical tests—Laboratory studies can help rule out other diseases and 

hormonal or vitamin deficiencies that can be associated with cognitive 

changes.

• Brain imaging—Different types of 

brain scans can detect brain shrinkage, 

structural abnormalities, or changes 

in dopamine production. They can 

help rule out other possible causes of 

dementia or movement symptoms. 

• Neuropsychological tests—These 

tests are used to assess memory and 

other cognitive functions and can help identify affected brain regions.

• Other tests—Specific tests, such as a sleep study confirming REM sleep 

behavior disorder without loss of muscle tone, can support a diagnosis of 

dementia with Lewy bodies.

There are no tests that can definitively diagnose LBD. Currently, only a 

brain autopsy after death can confirm a suspected diagnosis. 

However, researchers are studying ways to diagnose LBD earlier and more 

accurately during life. The use of certain imaging, blood, cerebrospinal 

fluid, and genetics tests is being studied.

Magnetic resonance image of the brain.
16

Other Helpful Information

It is important to tell the doctor about any symptoms involving thinking, 

movement, sleep, behavior, or mood. Also, discuss other health problems and 

provide a list of all current medications, including prescriptions, over-thecounter drugs, vitamins, and supplements. Certain medications can worsen 

LBD symptoms.

Caregivers may be reluctant to talk about a person’s symptoms when that 

person is present. Ask to speak with the doctor privately if necessary. The 

more information a doctor has, the more accurate a diagnosis can be. 
17

Treatment and Management

While LBD currently cannot be prevented or cured, some symptoms may 

respond to treatment for a period of time. A comprehensive treatment 

plan may involve medications, physical and other types of therapy, and 

counseling. Changes to make the home safer, equipment to make everyday 

tasks easier, and social support are also important.

A skilled care team often can suggest ways to improve quality of life for 

both people with LBD and their caregivers.

Building a Care Team

After receiving a diagnosis, a person 

with LBD may benefit from seeing a 

neurologist who specializes in dementia 

and/or movement disorders. A doctor 

can work with other types of healthcare 

providers. Depending on an individual’s 

particular symptoms, other professionals 

may be helpful:

• Physical therapists can help with movement problems through 

exercises, gait training, and general physical fitness programs.

• Speech therapists may help with voice volume and projection, and 

swallowing difficulties.

• Occupational therapists help find ways to more easily carry out 

everyday activities, such as eating and bathing. 

• Music or expressive arts therapists may provide meaningful activities 

that can reduce anxiety and improve well-being.

• Mental health counselors can help people with LBD and their 

families learn how to manage difficult emotions and behaviors and 

plan for the future. 
18

Support groups are another valuable resource for people with LBD 

and their caregivers. Sharing experiences and tips with others in the same 

situation can help people find practical solutions to day-to-day challenges 

and get emotional and social support. To find a support group near you, see 

the “Resources” section.

The Role of Palliative Care

The goal of palliative care (comfort care) is to improve a person’s quality 

of life by relieving disease symptoms at any stage of illness. Palliative 

care can help manage LBD symptoms such as constipation, sleep 

disorders, and behavioral problems. Typically, a team of nurses, social 

workers, physical therapists, dieticians, and pharmacists works with 

doctors to:

• relieve troubling symptoms

• assist with medical decisions

• offer emotional and spiritual support

• coordinate care 

To find a palliative medicine specialist, ask a physician or local 

hospital for a referral, or consult CaringInfo, a service of the National 

Hospice and Palliative Care Organization. Visit www.caringinfo.org. 
19

Medications

Several drugs and other treatments are available to treat LBD symptoms. 

It is important to work with a knowledgeable health professional because 

certain medications can make some symptoms worse. Some symptoms can 

improve with nondrug treatments.

Cognitive Symptoms 

Some medications used to treat Alzheimer’s disease also may be used to 

treat the cognitive symptoms of LBD. These drugs, called cholinesterase 

inhibitors, act on a chemical in the brain that is important for memory and 

thinking. They may also improve 

hallucinations, apathy, and 

delusions. (See page 22 for more 

information.) 

The U.S. Food and Drug 

Administration (FDA) has 

approved one Alzheimer’s 

drug, rivastigmine (Exelon®), 

to treat cognitive symptoms in 

Parkinson’s disease dementia. 

Several other drugs are being 

tested as possible treatments for 

LBD symptoms or to disrupt the 

underlying disease process.

Getting treatment

Kamar, a grandfather 

of five, was a highly 

educated executive 

with a background in 

the research, development, and field 

testing of aircraft engines. When he 

retired at age 67, his wife, Manjit, 

noticed that he had problems with 

complex mental activities. He also had 

trouble with tasks involving a sequence 

of steps. His doctor prescribed a medication for the cognitive symptoms,

which was helpful. Manjit credits the 

medication for helping Kamar have a 

better quality of life.
20

Movement Symptoms

LBD-related movement 

symptoms may be treated with 

medications used for Parkinson’s 

disease, called carbidopa-levodopa. 

These drugs can make it easier to 

walk, get out of bed, and move 

around. However, they cannot 

stop or reverse the progress of the 

disease itself. 

Side effects of this medication 

can include hallucinations and 

other psychiatric or behavioral 

problems. Because of this risk, 

physicians may recommend not treating mild movement symptoms with 

medication. If prescribed, carbidopa-levodopa usually begins at a low dose 

and is increased gradually. Other Parkinson’s medications are less commonly 

used in people with LBD due to a higher frequency of side effects. 

A surgical procedure called deep brain stimulation, which can be very 

effective in treating the movement symptoms of Parkinson’s disease, is 

not recommended for people with LBD because it can result in greater 

cognitive impairment. 

People with LBD may benefit from physical therapy and exercise. Talk with 

your doctor about what physical activities are best.

Sleep Disorders

Sleep problems may increase confusion and behavioral problems in people 

with LBD and add to a caregiver’s burden. A physician can order a sleep 

study to identify any underlying sleep disorders such as sleep apnea, restless 

leg syndrome, and REM sleep behavior disorder. 

Trouble with balance

After major surgery 

at age 69, Cliff 

developed balance 

problems, and later 

his movements 

became stiff.

Within a year, Cliff started having 

hallucinations and troubling side effects 

from antipsychotic medications. After 

an initial diagnosis of parkinsonism, he 

developed cognitive problems and was 

diagnosed with Lewy body dementia.

Cliff’s worsening balance problems 

and many falls prompted physical and 

occupational therapy. Cliff’s wife, Kathy, 

discovered that putting his shoes on 

before getting him up helped improve 

his balance. A low dose of medication 

for parkinsonism also helped.
21

REM sleep behavior disorder, 

a common LBD symptom, 

involves acting out one’s dreams, 

leading to lost sleep and even 

injuries to individuals and their 

sleep partners. Clonazepam 

(Klonopin®), a drug used to 

control seizures and relieve panic 

attacks, is often effective for the 

disorder at very low dosages. 

However, it can have side effects 

such as dizziness, unsteadiness, and problems with thinking. Melatonin, a 

naturally occurring hormone used to treat insomnia, may also offer some 

benefit when taken alone or with clonazepam. 

Excessive daytime sleepiness is also common in LBD. If it is severe, a sleep 

specialist may prescribe a stimulant to help the person stay awake during 

the day. 

Some people with LBD have difficulty falling asleep. If trouble sleeping 

at night (insomnia) persists, a physician may recommend a prescription 

medication. It is important to note that treating insomnia and other sleep 

problems in people with LBD has not been extensively studied, and that 

treatments may worsen daytime sleepiness and should be used with caution.

Certain sleep problems can be addressed without medications. Increasing 

daytime exercise or activities and avoiding lengthy or frequent naps can 

promote better sleep. Avoiding alcohol, caffeine, or chocolate late in the 

day can help, too. Some over-the-counter medications can also affect sleep, 

so review all medications and supplements with a physician.

Sleep and dementia 

Lee started having 

bad nightmares in 

his late 60s. Later 

he had problems 

communicating and 

would sit for long 

periods of time staring out the window.

His sleep problems worsened and, 

by age 73, while asleep, Lee talked, 

his limbs jerked, and he thought his 

dreams were real. Upon waking, he 

thought he had been at work or out 

with friends. Medications helped both 

Lee and his wife get more rest.
22

Behavioral and Mood Problems

Behavioral and mood problems in people with LBD can arise from 

hallucinations or delusions, pain, illness, stress, or anxiety. They may also 

be the result of frustration, fear, or feeling overwhelmed. The person may 

resist care or lash out verbally or physically. 

Caregivers can try a variety of strategies to handle such challenging 

behaviors. Some behavioral problems can be managed by making changes 

in the person’s environment and/or treating medical conditions. Other 

problems may require medication.

Medications are appropriate if the behavior interferes with the person’s 

care or the safety of the person or others. If medication is used, then the 

lowest possible dose for the shortest period of time is recommended.

The first step is to visit a doctor to see if a medical condition unrelated to 

LBD is causing the problem. Injuries, fever, urinary tract or pulmonary 

infections, pressure ulcers (bed sores), and constipation can worsen behavioral 

problems and increase confusion. 

Certain medications, such as anticholinergics 

and antihistamines like Benadryl®, may also 

cause behavioral problems. For example, 

some medications for sleep problems, pain, 

bladder control, and LBD-related movement 

symptoms can cause confusion, agitation, 

hallucinations, and delusions. Similarly, some anti-anxiety medicines can 

actually increase anxiety in people with LBD. Review your medications 

with your doctor to determine if any changes are needed.

Not all behavioral problems are caused by illness or medication. A person’s 

surroundings—including levels of stimulation or stress, lighting, daily routines, 

and relationships—can lead to behavior issues. Caregivers can alter the home 

environment to try to minimize anxiety and stress for the person with LBD. 
23

In general, people with LBD benefit from having simple tasks, consistent 

schedules, regular exercise, and adequate sleep. Large crowds or overly 

stimulating environments can increase confusion and anxiety.

Hallucinations and delusions are among the biggest challenges for LBD 

caregivers. The person with LBD may not understand or accept that 

the hallucinations are not real and become agitated or anxious. Instead 

of arguing, caregivers can help by responding to the fears expressed. By 

tuning in to the person’s emotions, caregivers can offer empathy and 

concern, maintain the person’s dignity, and limit further tension. 

Cholinesterase inhibitors may reduce hallucinations and other psychiatric 

symptoms of LBD, but they may have side effects, such as nausea, and 

are not always effective. However, they can be a good first choice to treat 

behavioral symptoms. Cholinesterase inhibitors do not affect behavior 

immediately, so they should be considered part of a long-term strategy. 

Coping with Behavioral Problems

Follow these steps in consultation with a physician to address 

behavioral problems:

• Rule out physical causes, like infection, pain, or other medical 

conditions.

• Review current prescription and over-the-counter medications.

• Look for environmental or social factors that contribute to 

behavioral problems.

• Consider treating with medications if necessary and watch for 

side effects.
24

Antidepressants can be used to treat 

depression and anxiety, which are 

common in LBD. Many of them are 

often well tolerated by people with LBD.

In some cases, antipsychotic medications 

are necessary to treat LBD-related 

behavioral symptoms to improve the 

quality of life and safety of the person with 

LBD and his or her caregiver. These types 

of medications must be used with caution 

because they can cause severe side effects 

and can worsen movement symptoms. 

If antipsychotics are prescribed, many LBD experts prefer quetiapine 

(Seroquel®) or clozapine (Clozaril®, FazaClo®), which are types of 

atypical antipsychotics, to control difficult behavioral symptoms. A newer 

drug, pimavanserin (Nuplazid®), has been approved by the FDA to treat 

hallucinations and delusions associated with Parkinson’s disease psychosis. 

However, a number of serious side effects have been reported, and the 

FDA requires the same black-box warning for Nuplazid® as it requires 

for other antipsychotic drugs in the elderly. We do not know yet whether 

pimavanserin will be helpful in other types of dementia-related psychoses, 

including LBD. Other potential treatments are being tested. 

Typical (or traditional) antipsychotics, such as haloperidol (Haldol®), 

generally should not be prescribed for people with LBD. They can cause 

dangerous side effects. 

Other Treatment Considerations

LBD affects the part of the nervous system that regulates automatic actions 

like blood pressure and digestion. One common symptom is orthostatic 

hypotension, a drop in blood pressure when standing up that can cause 

Seeing things

John, 58, started 

seeing small children 

outside the window 

who were not there.

Eventually, he began 

talking with some of these children, 

whom he thought were visiting the 

house. These hallucinations never 

scared or threatened John, and they 

seemed to give him companionship 

and entertainment. His wife Linda 

consulted a doctor, who said that since 

the hallucinations were not disruptive, 

no medication was needed. He 

advised Linda not to argue with her 

husband about whether or not the 

children were there.
25

dizziness and fainting. Simple measures such as leg elevation, elastic stockings, 

and, when recommended by a doctor, increasing salt and fluid intake can help. 

If these measures are not enough, a doctor may prescribe medication.

Urinary incontinence (loss of bladder control) should be treated cautiously 

because certain medications for this condition may worsen cognition or increase 

confusion. Consider seeing a urologist. Constipation can often be treated by 

exercise and changes in diet, though laxatives, stool softeners, or other treatment 

may be necessary. 

Warning About Antipsychotics 

People with LBD may have severe reactions to or side effects from 

antipsychotics, medications used to treat hallucinations, delusions, or 

agitation. These side effects include increased confusion, worsened 

parkinsonism, extreme sleepiness, and low blood pressure that can 

result in fainting (orthostatic hypotension). Caregivers should contact 

the doctor if these side effects continue after a few days.

Some antipsychotics, including olanzapine (Zyprexa®) and risperidone 

(Risperdal®), should be avoided, if possible, because they are more 

likely than others to cause serious side effects.

In rare cases, a potentially deadly condition called neuroleptic 

malignant syndrome can occur. Symptoms of this condition include 

high fever, muscle rigidity, and muscle tissue breakdown that can lead 

to kidney failure. Report these symptoms to your doctor immediately.

Antipsychotic medications increase the risk of death in all elderly 

people with dementia but can be particularly dangerous in those with 

LBD. Doctors, patients, and family members must weigh the risks of 

antipsychotic use against the risks of physical harm and distress that 

may occur as a result of untreated behavioral symptoms. 
26

People with LBD are often sensitive to prescription and over-the-counter 

medications for other medical conditions. Talk with your doctor about any 

side effects seen in a person with LBD.

If surgery is planned and the person with 

LBD is told to stop taking all medications 

beforehand, ask the doctor to consult the 

person’s neurologist to develop a plan for 

careful withdrawal. In addition, talk with 

the anesthesiologist in advance to discuss 

medication sensitivities and risks unique 

to LBD. People with LBD who receive 

certain anesthetics may become confused 

or delirious and have a sudden, significant 

decline in functional abilities, which may 

become permanent.

Depending on the procedure, possible alternatives to general anesthesia 

may include a spinal or regional block. These methods are less likely to 

result in confusion after surgery. Caregivers should also discuss the use 

of strong pain relievers after surgery, since people with LBD can become 

delirious if these drugs are used too freely.

Vitamins and Supplements

The use of vitamins and supplements to treat LBD symptoms has 

not been studied extensively and is not recommended. Vitamins and 

supplements can be dangerous when taken with other medicines. 

People with LBD should tell their doctors about every medication 

they take, including prescription and over-the-counter medicines, 

vitamins, and supplements.
27

Advice for People Living with 

Lewy Body Dementia

Coping with a diagnosis of LBD and all that follows can be challenging. 

Getting support from family, friends, and professionals is critical to 

ensuring the best possible quality of life. Creating a safe environment and 

preparing for the future are important, too. Take time to focus on your 

strengths, enjoy each day, and make the most of your time with family and 

friends. Here are some ways to live with LBD day to day.

Getting Help

Your family and close friends are likely 

aware of changes in your thinking, 

movement, or behavior. You may want to 

tell others about your diagnosis so they 

can better understand the reason for these 

changes. For example, you could say that 

you have been diagnosed with a brain 

disorder called Lewy body dementia, 

which can affect thinking, movement, and behavior, and that you will need 

more help over time. By sharing your diagnosis, you can build a support 

team to help you manage LBD. 

As LBD progresses, you will likely have more trouble managing everyday 

tasks such as taking medication, paying bills, and driving. You will gradually 

need more assistance from family members, friends, and perhaps professional 

caregivers. Although you may be reluctant to get help, try to let others 

partner with you so you can manage responsibilities together. Remember, 

LBD affects your loved ones, too. You can help reduce their stress when you 

accept their assistance.
28

Finding someone you can talk with about your diagnosis—a trusted friend or 

family member, a mental health professional, or a spiritual advisor—may be 

helpful. See the “Resources” section to find supportive services in your area.

Consider Safety 

The changes in thinking and movement that occur with LBD require 

attention to safety issues. Consider these steps:

• Fill out and carry the LBD Medical Alert Wallet Card (available at 

www.lbda.org/content/lbd-medical-alert-wallet-card) and present it any time 

you are hospitalized, require emergency medical care, or meet with your 

doctors. It contains important information about medication sensitivities.

• Consider subscribing to a medical alert service, in which you push a 

button on a bracelet or necklace to access 911 if you need emergency help. 

• Address safety issues in your home, including areas of fall risk, poor 

lighting, stairs, or cluttered walkways. Think about home modifications 

that may be needed, such as installing grab bars in the bathroom or 

modifying stairs with ramps. Ask your doctor to refer you to a home 

health agency for a home safety evaluation. 

• Talk with your doctor about LBD and driving, and have your driving 

skills evaluated, if needed.

Plan for Your Future

There are many ways to plan ahead. Here are some things to consider: 

• If you are working, consult with a legal and financial expert about 

planning for disability leave or retirement. Symptoms of LBD will 

interfere with work performance over time, and it is essential to plan 

now to obtain benefits you are entitled to. 

• Consult with an attorney who specializes in elder law or estate 

planning to help you write or update a living will, healthcare power of 

attorney, will, and other important documents.
29

• Identify local resources for home care, meals, and other services before

you need them. 

• Explore moving to a retirement or continuing care community where 

activities and varying levels of care can be provided over time, as needed. 

Ask about staff members’ experience caring for people with LBD.

Find Enjoyment Every Day

It is important to focus on living with LBD. Your attitude can help you 

find enjoyment in daily life. Despite the many challenges and adjustments, 

you can have moments of love, humor, tenderness, and gratitude with the 

people closest to you. 

Make a list of events and activities you can still enjoy—then find a way to do 

them! For example, listen to music, exercise, or go out for a meal with family 

and friends. If you can’t find pleasure in daily life, talk with your doctor or 

another healthcare professional about ways to cope. Let your family know if 

you are struggling emotionally so they can offer support.
30

Caring for a Person with 

Lewy Body Dementia

As someone caring for a person with LBD, you will take on many different 

responsibilities over time. You do not have to face these responsibilities 

alone. Many sources of help are available, from adult day centers and respite 

care to online and in-person 

support groups.

Below are some actions you can 

take to adjust to your new roles, be 

realistic about your situation, and 

care for yourself. See the “Resources” 

section for more information.

Educate Others 

About LBD 

Most people, including many 

healthcare professionals, are not 

familiar with LBD. In particular, 

emergency room physicians 

and other hospital workers may 

not know that people with LBD are extremely sensitive to antipsychotic 

medications. Caregivers can educate healthcare professionals and others by:

• Informing hospital staff of the LBD diagnosis and medication 

sensitivities, and requesting that the person’s neurologist be consulted 

before giving any drugs to control behavior problems.

• Sharing educational materials with healthcare professionals who care 

for the person with LBD. Materials are available from the Lewy Body 

Dementia Association (see the “Resources” section).

• Teaching family and friends about LBD so they can better understand 

your situation. 

A peaceful routine 

Susan realized that 

her mother, Estelle, 

could not manage 

a lot of stimulation.

Estelle easily became

agitated and confused, 

so Susan avoided taking her to places 

with large crowds or noisy environments.

Susan found that soothing music

calmed Estelle when she grew anxious.

Establishing a routine with familiar faces 

in smaller groups has allowed Estelle 

to enjoy a better quality of life, despite 

having dementia with Lewy bodies.
31

Prepare for Emergencies

People with LBD may experience sudden declines in functioning 

or unpredictable behaviors that can result in visits to the emergency 

room. Infections, pain, or other medical conditions often cause 

increased confusion or behavioral problems. Caregivers can prepare 

for emergencies by having available:

• a list of the person’s medications and dosages

• a list of the person’s health conditions, including allergies to 

medicines or foods; see the medical alert card at www.lbda.org/

content/lbd-medical-alert-wallet-card

• copies of health insurance card(s)

• copies of healthcare advance directives, such as a living will

• contact information for doctors, family members, and friends

Adjust Expectations 

You will likely experience a wide range of emotions as you care for the person 

with LBD. Sometimes, caregiving will feel loving and rewarding. Other 

times, it will lead to anger, impatience, resentment, or fatigue. Recognize your 

strengths and limitations, especially in light of your past relationship with the 

person. Roles may change between a husband and wife or between a parent 

and adult children. Adjusting expectations can allow you to approach your 

new roles realistically and to seek help as needed.
32

People approach challenges at varied paces. Some people want to learn 

everything possible and be prepared for every scenario, while others 

prefer to take one day at a time. Caring for someone with LBD requires a 

balance. On one hand, you should plan for the future. On the other hand, 

you can also focus on creating enjoyable and meaningful moments. 

Care for Yourself 

As a caregiver, it is critical for you to maintain your own health and 

well-being. You may be at increased risk for poor sleep, depression, or 

illness as a result of your responsibilities. Watch for signs of physical or 

emotional fatigue such as irritability, withdrawal from friends and family, 

and changes in appetite or weight. 

All caregivers need time away from caregiving responsibilities to maintain 

their well-being. Learn to accept help when it’s offered, and learn to ask 

family and friends for help. One option is professional respite care, which 

can be obtained through home care agencies and adult day programs. 

Similarly, friends or family can come to the home or take the person with 

LBD on an outing to give you a break. 
33

Address Family Concerns

Not all family members may understand or accept LBD at the same time, 

and this can create conflict. Some adult children may deny that parents 

have a problem, while others 

may be supportive. It can take 

a while to learn new roles and 

responsibilities.

Family members who visit 

occasionally may not see 

the symptoms that primary 

caregivers see daily and may 

underestimate or minimize 

your responsibilities or stress. 

Professional counselors can 

help provide guidance on how 

families can work together to 

manage LBD. 

Changing relationships

Diane’s husband Jim 

was diagnosed with 

Lewy body dementia 

2 years ago. Their 

son and daughter, 

who live across the 

country, thought that Diane was making 

too much of his illness. She asked them 

to fly out for a family meeting. A counselor who specializes in geriatrics gave 

the children educational materials, 

and the family talked about the kind of 

emotional support Diane needs. They 

are on a better road to teamwork now.
Helping Children and Teens 

Cope with LBD

When someone has Lewy body dementia, it affects the whole 

family, including children and grandchildren. Children notice when 

something “doesn’t seem right.” Telling them in age-appropriate 

language that someone they know or love has been diagnosed with 

a brain disorder can help them make sense of the changes they see. 

Give them enough information to answer questions or provide 

explanations without overwhelming them.

Children and teens may feel a loss of connection with the person 

with LBD who has problems with attention or alertness. They may 

also resent the loss of a parent caregiver’s attention and may need 

special time with him or her. Look for signs of stress in children, 

such as poor grades at school, withdrawal from friendships, or 

unhealthy behaviors at home. Parents may want to notify teachers or 

counselors of the LBD diagnosis in the family so they can watch for 

changes in the young person that warrant attention. 
Here are some other ways parents can help children and teens adjust 

to a family member with LBD:

• Help them keep up with normal activities such as sports, clubs, 

and other hobbies outside the home. Suggest ways for kids to 

engage with the relative with LBD through structured activities 

or play. For example, the child or teen can make a cup of tea for 

the person with LBD. 

• Find online resources for older children and teens so they can 

learn about dementia and LBD. See the “Resources” section for 

more information.

It is important for families to make time for fun. Many challenges 

can be faced when they are balanced with enjoyable times. While 

LBD creates significant changes in family routines, children and 

teens will cope more effectively if the disorder becomes part of, 

but not all of, their lives. 
36

Research—The Road Ahead

There is a great deal to learn about LBD. At a basic level, why does alphasynuclein accumulate into Lewy bodies, and how do Lewy bodies cause 

the symptoms of LBD? LBD represents an important link between 

Alzheimer’s, Parkinson’s, and other brain disorders, and research into 

one disease often contributes to better understanding of the others. 

Many avenues of research focus on 

improving our understanding of LBD. 

Some researchers are working to identify 

the specific differences in the brain 

between dementia with Lewy bodies and 

Parkinson’s disease dementia. Others 

are looking at the disease’s underlying 

biology, genetics, and environmental risk 

factors. Still other scientists are trying to identify biomarkers (biological 

indicators of disease), improve screening tests to aid diagnosis, and 

research new treatments.

Scientists hope that new knowledge about LBD will one day lead to more 

effective treatments and even ways to cure and prevent the disorder. Until 

then, researchers need volunteers with and without LBD for clinical studies.

To find out more about clinical trials, see the Clinical Trials Participation 

section under “Resources” below.
37

Resources

Federal Government

National Institute on Aging

Alzheimer’s and related Dementias Education and Referral 

(ADEAR) Center

1-800-438-4380 (toll-free)

adear@nia.nih.gov

www.alzheimers.gov

National Institute of Neurological Disorders and Stroke

1-800-352-9424 (toll-free)

www.ninds.nih.gov 

MedlinePlus

National Library of Medicine 

www.medlineplus.gov

www.medlineplus.gov/spanish 

General Information 

Lewy Body Dementia Association

1-844-311-0587 (toll-free LBD Caregiver Link)

1-404-975-2322 (national office)

www.lbda.org/contact

www.lbda.org

Michael J. Fox Foundation for Parkinson’s Research

1-800-708-7644 (toll-free)

www.michaeljfox.org

Parkinson’s Foundation

1-800-473-4636 (toll-free helpline)

helpline@parkinson.org

www.parkinson.org
38

Support Services and Resources

Eldercare Locator

This service of the U.S. Administration on Aging connects the public to 

community services for older adults and their families.

1-800-677-1116 (toll-free)

www.eldercare.acl.gov

Family Caregiver Alliance

The Alliance provides information and referral, education, and other 

services to caregivers of people with chronic, disabling health conditions.

1-800-445-8106 (toll-free)

www.caregiver.org

For Children and Teens

Although the following Alzheimer’s organizations are not specific to Lewy 

body dementia, their dementia-related resources and networks may be 

helpful for children and teens.

ADEAR Center Resources for Children and Teens

www.nia.nih.gov/health/resources-children-and-teens-aboutalzheimers-disease

Alzheimer’s Association Kids & Teens

1-800-272-3900 (toll-free)

www.alz.org/living_with_alzheimers_just_for_kids_and_teens.asp

Alzheimer’s Foundation of America (AFA) Teens

1-866-232-8484 (toll-free)

https://alzfdn.org/young-leaders-of-afa/afa-teens/
39

Diagnosis, Treatment, and Research 

The Lewy Body Dementia Association (LBDA) has a network of 24 

Research Centers of Excellence in the United States: www.lbda.org/rcoe.

The Alzheimer’s and related Dementias Education and Referral Center 

maintains a list of research centers funded by the National Institute on 

Aging at NIH where you may find medical specialists in Lewy body 

dementia: www.nia.nih.gov/health/alzheimers-disease-research-centers.

The American Academy of Neurology has a “find a neurologist” page on 

its website: www.brainandlife.org/the-magazine/article/app/9/3/17/find-aneurologist.

The American Association for Geriatric Psychiatry has a physician finder 

on its website: http://gmhfonline.org.

Clinical Trials Participation

NIH and other groups help people learn about clinical trials and studies 

and find research opportunities near them. Visit the following websites 

for details:

National Institute on Aging

www.nia.nih.gov/alzheimers/clinical-trials 

(search using the keyword “Lewy” or the category “Related Dementias”)

Lewy Body Dementia Association

www.lbda.org/participate-in-research

National Institutes of Health

www.clinicaltrials.gov
40

Acknowledgments

The National Institute on Aging and the National Institute of Neurological 

Disorders and Stroke thank the following people for their contributions to the 

vision and creation of this booklet:

Lisa Snyder, MSW, LCSW

Former Director, Quality of Life Programs 

Shiley-Marcos Alzheimer’s Disease Research Center

University of California, San Diego 

Christina Gigliotti, PhD

Manager of Clinical Operations 

Shiley-Marcos Alzheimer’s Disease Research Center

University of California, San Diego

Angela Taylor

Director of Programs

Lewy Body Dementia Association

Scientific and Medical Reviewers from the LBDA 

Scientific Advisory Council

Douglas Galasko, MD

Co-Director, Shiley-Marcos Alzheimer’s Disease Research Center

University of California, San Diego

Howard Hurtig, MD

Emeritus Professor of Neurology

Pennsylvania Hospital

James Leverenz, MD

Director, Cleveland Lou Ruvo Center for Brain Health

Caregiver Reviewers

Nancy Archibald

Kathleen Burr

Paul Smith

Joy Walker
The National Institute on Aging (NIA) and the National Institute of 

Neurological Disorders and Stroke (NINDS) are part of the National 

Institutes of Health, the nation’s medical research agency—supporting 

scientific studies that turn discovery into health. 

NIA leads the federal government effort conducting and supporting 

research on aging and the health and well-being of older people. NIA’s 

Alzheimer’s and related Dementias Education and Referral (ADEAR) 

Center offers information and publications on dementia and caregiving for 

families, caregivers, and professionals. 

NINDS is the nation’s leading funder of research on the brain and nervous 

system. The NINDS mission is to reduce the burden of neurological disease. 

For additional copies of this publication or further information, contact:

National Institute on Aging

Alzheimer’s and related Dementias Education and Referral Center

www.alzheimers.gov

1-800-438-4380

National Institute of Neurological Disorders and Stroke

www.ninds.nih.gov

1-800-352-9424
Publication No. 18-AG-7907

June 2018