Cognitive Concern Identified
Patient, family, or clinician notes cognitive change
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NeurologyDiagnostic
Dementia and Cognitive Impairment Workup
Dementia and Cognitive Impairment Workup: Cognitive Concern Identified → Comprehensive History → Cognitive Testing → Severity Assessment → Mild Cognitiv...
Pathway Overview
16 steps
Algorithm Steps
16 total
01Start 02Action Comprehensive History
Patient and informant interview
- Timeline of cognitive changes
- Functional decline (IADLs, ADLs)
- Behavioral/psychiatric symptoms
- Risk factors (vascular, family history)
- Medication review (anticholinergics)
03Action Cognitive Testing
Standardized assessment tools
- MoCA (preferred, ≤25 abnormal)
- MMSE (≤24 abnormal)
- Clock drawing test
- Consider neuropsychological testing
- Assess multiple domains
04Decision Severity Assessment
MCI vs Dementia?
- MCI: cognitive impairment, preserved function
- Dementia: impairment affecting daily function
- Mild/Moderate/Severe staging
05Action Mild Cognitive Impairment
Concern beyond normal aging, function intact
- Annual monitoring recommended
- Risk factor modification
- Cognitive engagement
- May progress to dementia (10-15%/year)
06Action Exclude Reversible Causes
Treatable conditions
- Thyroid (TSH)
- B12 deficiency
- Depression (pseudodementia)
- Normal pressure hydrocephalus
- Medications (anticholinergics)
- Infections, metabolic
07Action Laboratory Studies
Standard workup
- CBC, CMP, TSH
- Vitamin B12
- Consider: folate, RPR, HIV
- Glucose/HbA1c
- Lipid panel
08Action Structural Brain Imaging
MRI preferred over CT
- MRI without contrast (preferred)
- CT if MRI contraindicated
- Look for: atrophy pattern, vascular disease
- Exclude: tumor, SDH, NPH
09Decision Clinical Pattern Analysis
Determine likely etiology
- Alzheimer's: memory-predominant
- Frontotemporal: behavior/language
- Lewy body: visual hallucinations, parkinsonism
- Vascular: stepwise, focal signs
10Action Alzheimer's Disease Suspected
Consider biomarker testing
- CSF: Aβ42, p-tau, t-tau
- Amyloid PET if available
- Tau PET (research/specialist)
- Blood biomarkers emerging
11Action Diagnosis Disclosure
Communicate with patient and family
- Private, unhurried setting
- Clear language, avoid jargon
- Discuss prognosis honestly
- Provide written resources
- Plan follow-up
12Action Treatment & Management Plan
Pharmacologic and non-pharmacologic
- AD: cholinesterase inhibitors (donepezil)
- AD: memantine (moderate-severe)
- AD: anti-amyloid therapies if eligible
- Manage BPSD (behavioral symptoms)
- Caregiver support
13Outcome Ongoing Care
Regular follow-up
- Monitor progression (q6-12 months)
- Adjust medications
- Support services
- Palliative care when appropriate
14Action Safety & Legal Planning
Essential discussions
- Driving assessment
- Financial/legal capacity
- Advance directives
- Home safety evaluation
- Caregiver needs
- Path rejoins step 13Shared downstream outcome
15Action Non-AD Dementia Suspected
Further targeted workup
- FTD: genetic testing (C9orf72, etc.)
- LBD: DaTscan if unclear
- Vascular: MRA, echo, cardiac workup
- Prion: CSF 14-3-3, RT-QuIC
- Path rejoins step 11Shared downstream outcome
16Action Mixed/Unclear Etiology
Multiple pathologies common
- AD + vascular very common
- Treat modifiable factors
- Specialist referral
- May need autopsy for definitive
- Path rejoins step 11Shared downstream outcome
- Path rejoins step 06Shared downstream outcome
Guideline Source
Alzheimer's Association Clinical Practice Guideline for Diagnostic Evaluation, Testing, Counseling, and Disclosure (DETeCD-ADRD)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Biomarker testing not available everywhere
- PET imaging requires specialist interpretation
- Genetic testing requires counseling
- Young-onset dementia may need different approach
Applicable Regions
USEUglobal
EU: Similar approach with regional biomarker availability
US: Alzheimer's Association 2024 guidelines
Version 1Next review: 2028-01-01
Next steps
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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 Diagnostic Evaluation, Testing, Counseling, and Disclosure (DETeCD-ADRD).
What guideline is the Dementia and Cognitive Impairment Workup based on?
This algorithm is based on Alzheimer's Association Clinical Practice Guideline for Diagnostic Evaluation, Testing, Counseling, and Disclosure (DETeCD-ADRD) (DOI: 10.1002/alz.14333).
What are the limitations of the Dementia and Cognitive Impairment Workup?
Known limitations include: Biomarker testing not available everywhere; PET imaging requires specialist interpretation; Genetic testing requires counseling; Young-onset dementia may need different approach. Individual patient factors may require deviation from these recommendations.
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