Figure 4 Clinical course and pharmacological management. The timeline illustrates the temporal correlation between medication adjustments and clinical symptom evolution. Yellow boxes represent findings suggestive of probable DLB, while green boxes indicate findings suggestive of amyloid pathology. Throughout the clinical course, pre-existing clonazepam (0.5 mg/day) for RBD was maintained, while melatonin was initiated at 2 mg/day and titrated to 4 mg/day to safely manage persistent sleep disturbances. Regarding the management of acute neuropsychiatric deterioration: Initially, levetiracetam (1000 mg/day) was initiated for GTCS 1 month prior to admission. Notably, its initiation was closely followed by acute agitation and disorientation. To manage these worsening behavioral symptoms and nocturnal agitation, quetiapine (50 mg/day) and haloperidol (1.5 mg/day) were sequentially introduced. However, contrary to their intended effects, these medications coincided with a significant decline in cognitive clarity and independent ambulation, suggesting severe neuroleptic sensitivity. Upon admission, haloperidol was discontinued. On admission day 6, levetiracetam was tapered and switched to valproic acid (500 mg/day) due to persistent fluctuating mentation and disorganized behavior. Concurrently, quetiapine (50 mg/day) was discontinued for similar reasons. Immediately following the diagnosis of probable DLB, rivastigmine (6 mg/day) and memantine (10 mg/day) were initiated, leading to gradual cognitive restoration. Regarding motor symptom management: Upon admission, pre-existing pramipexole was discontinued and replaced with levodopa (75 mg/day) for parkinsonism. However, following discharge, the patient independently trialed low-dose pramipexole (0.125 mg/day) for residual gait disturbance, which led to a dramatic improvement. Consequently, considering clinical efficacy and patient preference, pramipexole was reintroduced and carefully titrated up to 1.5 mg/day, while levodopa was discontinued. Adm, admission; CMBs, cerebral microbleeds; DLB, dementia with Lewy bodies; F/U, follow-up; GTCS, generalized tonic-clonic seizure; HD, hospital day; ICH, intracerebral hemorrhage; LEV, levetiracetam; mos, months; OPD, outpatient department; RBD, REM sleep behavior disorder; VPA, valproic acid; wks, weeks; yrs, years).