Cognitive Concern Identified
Adult. Patient, care partner or clinician reports a change in cognition, behaviour or function
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NeurologyDiagnostic
Dementia and Cognitive Impairment Workup
Dementia and Cognitive Impairment Workup: Cognitive Concern Identified → Acute Onset or Rapid Decline? → Acute or Rapid Change: Urgent Assessment Now.
Pathway Overview
20 steps
Algorithm Steps
20 total
01Start 02Decision Acute Onset or Rapid Decline?
Onset over hours to days, fluctuating attention or alertness, or decline over weeks to months
- Yes: urgent assessment, not this outpatient workup
- No (gradual over months to years): continue workup
- If Yes
03Action Acute or Rapid Change: Urgent Assessment Now
Delirium and rapidly progressive dementia are medical emergencies
- Acute onset or fluctuating attention: treat as delirium until proven otherwise (4AT or CAM)
- Find the cause now: infection, medicines, alcohol or withdrawal, hypoglycaemia, hypoxia, stroke, subdural haematoma, urinary retention
- Decline over weeks to months: urgent neurology review, may need admission (MRI, CSF including RT-QuIC, EEG)
- After delirium resolves: reassess cognition; delirium often unmasks dementia
If No04Action History with an Informant
Gradual change only (delirium and rapid decline excluded). Interview patient and a reliable informant
- Onset, course and first symptoms
- Change in cognition, IADLs and ADLs
- Mood, behaviour, hallucinations, sleep (snoring, apnoea, acting out dreams)
- Hearing, vision, gait, falls, tremor
- Risk factors: vascular, alcohol, head injury, family history
- Medicines: anticholinergics, benzodiazepines, opioids, sedatives
05Action Examination and Cognitive Testing
Neurological examination and a validated cognitive test
- Neurological exam: focal signs, parkinsonism, gait
- MoCA: below 26 abnormal (add 1 point if 12 years or less of education)
- MMSE: 24 or below abnormal; misses mild impairment
- RUDAS for culturally and linguistically diverse patients
- KICA-Cog (or modified KICA) for Aboriginal and Torres Strait Islander people
- A normal score does not exclude dementia
06Decision Level of Impairment?
Use testing plus informant report of daily function
- No objective impairment
- MCI: impairment, daily function preserved
- Dementia: impairment affects daily function (mild, moderate or severe)
- No objective impairment
07Action No Objective Impairment: Subjective Decline
Concern, but normal testing and normal daily function
- Treat contributors: depression, anxiety, sleep, alcohol, medicines, hearing
- Basic blood tests (FBC, UEC, TSH, B12) if not done
- Neuropsychological testing if concern persists
- Reassess in 12 months, or sooner if function changes
- MCI
08Action MCI: Complete the Workup
Impairment beyond normal ageing, daily function intact
- Complete blood tests and brain imaging (next steps)
- Higher risk of dementia; some stay stable or improve
- Treat vascular risk factors, hearing loss, sleep apnoea; physical activity
- Reassess cognition and function over time (for example yearly)
09Action MCI or Dementia: Treatable Contributors
They rarely cause dementia alone but often make it worse
- Depression
- Medicines: anticholinergics, benzodiazepines, opioids
- Alcohol
- Obstructive sleep apnoea
- Hearing and vision loss
- Thyroid, B12, metabolic, infection
- Normal pressure hydrocephalus (gait, urinary symptoms)
10Action Blood Tests
Tier 1 cognitive lab panel for all
- FBC, UEC, LFT, calcium, magnesium, glucose
- TSH, vitamin B12, ESR or CRP
- If indicated: folate, HbA1c, lipids, syphilis serology, HIV, urinalysis
- Sleep study if sleep apnoea or REM sleep behaviour disorder suspected
11Action Structural Brain Imaging
MRI without contrast; CT if MRI is unavailable or contraindicated
- Atrophy pattern (medial temporal, frontal, parietal)
- Vascular disease: infarcts, white matter change, microbleeds
- Exclude tumour, subdural haematoma, hydrocephalus
12Decision Likely Cause?
Use history, examination, tests and imaging
- Alzheimer: amnestic, or logopenic or posterior cortical variants
- Non-Alzheimer: frontotemporal, Lewy body, vascular
- Mixed, atypical, young onset (under 65) or unclear
- AD pattern
13Action Alzheimer Pattern: Consider Biomarkers
Specialist decision; use when the result will change management
- CSF (Aβ42, p-tau) or amyloid PET to confirm amyloid
- Amyloid confirmation is required before anti-amyloid therapy
- Lumbar puncture: check anticoagulants and platelets first
- Blood biomarkers: specialist care only, not alone; use tests with sensitivity 90% or more and specificity 75% or more (triage), 90% or more for both (confirm)
- APOE genotype is not a diagnostic test; test only with counselling before anti-amyloid therapy
14Action Disclose the Diagnosis
Honest, compassionate, structured; with the care partner if the patient agrees
- Name and severity of the syndrome and its likely cause
- What to expect, and treatment options
- Safety concerns
- Written resources and support services
- Plan follow-up
15Warning Drug Safety in Dementia
Check before any drug in the next step
- Lewy body or Parkinson disease dementia: avoid antipsychotics (severe sensitivity reactions)
- Antipsychotics raise stroke and death risk: only for severe distress or risk of harm; lowest dose, shortest time, review within 6 weeks
- Cholinesterase inhibitors: check pulse first; caution in bradycardia, heart block, sick sinus syndrome or syncope
16Action Treatment Plan
Non-drug care first. Start dementia drugs on specialist advice
- AD: cholinesterase inhibitor (donepezil, rivastigmine or galantamine). Lewy body or Parkinson disease dementia: donepezil or rivastigmine (galantamine only if these are not tolerated)
- Moderate to severe AD: memantine, alone or added
- Anti-amyloid (lecanemab, donanemab): specialist centre only; not if APOE4 homozygous; lecanemab not started on anticoagulants; caution with any antithrombotic or thrombolytic
- Not for FTD, MCI, or vascular dementia alone (cholinesterase inhibitors, memantine)
- Anti-amyloid eligibility: MCI or mild dementia due to AD, amyloid confirmed; MRI monitoring for ARIA; ARIA can mimic stroke (caution with thrombolysis)
- Distress or BPSD: look for pain, delirium, unmet needs; non-drug measures first
- Care partner support and education
17Outcome Ongoing Care
Regular review (for example every 6 to 12 months)
- Cognition, function, behaviour, care partner strain
- Review drugs: benefit, side effects, deprescribing
- Palliative care when appropriate
18Action Safety and Legal Planning
Discuss early, while the patient can take part
- Driving: assess fitness to drive; tell the patient they must notify the licensing authority; document this
- Capacity: financial and legal decisions
- Advance care planning and substitute decision-maker
- Home safety, medicines supervision, falls, elder abuse
- Care partner needs and respite
- Path rejoins step 17Shared downstream outcome
- Non-AD pattern
19Action Non-Alzheimer Pattern: Targeted Tests
Specialist review usually needed
- Lewy body: DaT SPECT if diagnosis uncertain
- Frontotemporal: FDG-PET if uncertain; genetic testing only with family history and genetic counselling
- Vascular: stroke risk factor review; vessel imaging if stroke or TIA features
- FDG-PET if the cause is still unclear
- Path rejoins step 14Shared downstream outcome
- Mixed/atypical/unclear
20Action Mixed, Atypical or Unclear: Specialist Referral
Young onset, atypical or uncertain cases need a dementia specialist
- Alzheimer plus vascular disease is common
- Neuropsychological testing if interpretation is unclear
- Treat vascular and other contributors now
- Path rejoins step 14Shared downstream outcome
- Dementia
- Path rejoins step 09Shared downstream outcome
Guideline Source
Alzheimer's Association clinical practice guideline for the Diagnostic Evaluation, Testing, Counseling, and Disclosure of Suspected Alzheimer's Disease and Related Disorders (DETeCD-ADRD): executive summary for primary care (2025)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Not for acute confusion (delirium) or decline over weeks to months: these need urgent assessment
- Blood biomarkers and anti-amyloid therapy are for specialist care only; access and funding vary
- Cognitive tests are less accurate with low education, limited English or sensory loss: use adapted tools
- Young-onset (under 65), atypical and genetic cases need a dementia specialist
Contraindicated Populations
Acute confusion or fluctuating attention: delirium pathwayRapidly progressive decline over weeks to months: urgent specialist referralChildren and adolescentsIntellectual disability: use adapted assessment and a specialist service
Applicable Regions
AUUSEUglobal
AU: Lecanemab (Leqembi) and donanemab (Kisunla) are TGA-registered (2025) for MCI or mild dementia due to AD in APOE4 non-carriers or heterozygotes, with confirmed amyloid, in specialist centres. Use RUDAS for CALD patients and KICA-Cog for Aboriginal and Torres Strait Islander people. Driving: Austroads Assessing Fitness to Drive. Dementia Australia helpline 1800 100 500; My Aged Care 1800 200 422; Carer Gateway 1800 422 737.
EU: Similar approach; biomarker and anti-amyloid availability varies by country.
US: Alzheimer's Association DETeCD-ADRD 2025 guideline and 2025 blood-based biomarker guideline.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Dementia and Cognitive Impairment Workup?
The Dementia and Cognitive Impairment Workup is a diagnostic clinical algorithm for Neurology. It provides a structured decision tree to guide clinical decision-making, based on Alzheimer's Association clinical practice guideline for the Diagnostic Evaluation, Testing, Counseling, and Disclosure of Suspected Alzheimer's Disease and Related Disorders (DETeCD-ADRD): executive summary for primary care (2025).
What guideline is the Dementia and Cognitive Impairment Workup based on?
This algorithm is based on Alzheimer's Association clinical practice guideline for the Diagnostic Evaluation, Testing, Counseling, and Disclosure of Suspected Alzheimer's Disease and Related Disorders (DETeCD-ADRD): executive summary for primary care (2025) (DOI: 10.1002/alz.14333).
What are the limitations of the Dementia and Cognitive Impairment Workup?
Known limitations include: Not for acute confusion (delirium) or decline over weeks to months: these need urgent assessment; Blood biomarkers and anti-amyloid therapy are for specialist care only; access and funding vary; Cognitive tests are less accurate with low education, limited English or sensory loss: use adapted tools; Young-onset (under 65), atypical and genetic cases need a dementia specialist. Individual patient factors may require deviation from these recommendations.
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