One-liner#

Systematic evaluation of memory loss and cognitive decline in older adults—distinguishing normal aging from mild cognitive impairment (MCI) and dementia, identifying reversible causes, and providing diagnosis, prognosis, and care planning for patients and families.

Quick nav#

• Red flags / send to ED
• Key history
• Focused exam
• Differential (quick pattern recognition)
• Workup
• Initial management
• Management by diagnosis
• Follow-up
• Patient instructions
• Smartphrase snippets

Red flags / send to ED#

• Acute onset confusion (hours to days) → This is delirium, not dementia → ED workup
• Rapid progression (weeks to months) → Consider Creutzfeldt-Jakob disease, malignancy, autoimmune encephalitis → Urgent neurology
• New focal neurologic deficits → ED (stroke, mass)
• Severe headache with cognitive changes → ED (hemorrhage, mass)
• Seizures → ED
• Gait disturbance + incontinence + dementia (NPH triad) → Urgent neurology/neurosurgery

Urgent (expedited outpatient):

• Cognitive decline with new gait abnormality
• Rapid decline over weeks
• Young-onset dementia (<65 years)
• Behavioral changes suggesting frontotemporal dementia
• Concern for elder abuse or self-neglect

Key history#

CRITICAL: Interview patient AND informant separately

• Patients often minimize or lack insight into deficits
• Family/caregiver provides essential collateral
• Discrepancy between patient and informant report is itself informative

Characterize the cognitive complaint:

• What specific problems are you/they noticing?
• When did it start? (months, years)
• Is it getting worse? How fast?
• Gradual progression (typical dementia) vs stepwise decline (vascular) vs fluctuating (Lewy body)

Cognitive domains affected:

• Memory: Repeating questions, forgetting appointments, losing things
• Language: Word-finding difficulty, trouble following conversations
• Executive function: Difficulty with planning, multitasking, managing finances, cooking
• Visuospatial: Getting lost in familiar places, difficulty parking, trouble with spatial tasks
• Attention: Easily distracted, can’t follow a movie or book

Functional impact (critical for staging):

• IADLs (instrumental): Managing finances, medications, driving, cooking, shopping, using phone
• BADLs (basic): Bathing, dressing, toileting, eating, transferring
• MCI: Cognitive decline but IADLs preserved
• Dementia: Cognitive decline WITH functional impairment

Behavioral and psychiatric symptoms:

• Depression (common, can mimic or coexist with dementia)
• Anxiety
• Apathy (common in dementia, often mistaken for depression)
• Agitation, irritability
• Hallucinations (visual → think Lewy body; auditory → think psychiatric)
• Delusions (paranoia, theft accusations common in Alzheimer’s)
• Sleep disturbance (REM sleep behavior disorder → Lewy body)
• Personality changes (disinhibition, apathy → frontotemporal)

Medical history (reversible causes):

• Thyroid disease
• B12 deficiency
• Depression
• Sleep apnea
• Hearing loss (contributes to cognitive decline)
• Recent surgery or hospitalization (post-operative cognitive decline)
• Head trauma
• Alcohol use
• Vascular risk factors (HTN, DM, hyperlipidemia, smoking, AF)

Medication review:

• Anticholinergics (diphenhydramine, oxybutynin, TCAs)
• Benzodiazepines
• Opioids
• Anticonvulsants
• Polypharmacy

Family history:

• Dementia (Alzheimer’s has genetic component)
• Parkinson’s disease
• Psychiatric illness
• Age of onset in affected relatives

Social history:

• Education level (affects cognitive reserve and test interpretation)
• Living situation
• Caregiver availability and stress
• Driving status
• Firearms in home
• Advance directives status

Focused exam#

Cognitive testing (essential):

MoCA (Montreal Cognitive Assessment) - Preferred screening tool:

• 30 points; takes 10-15 minutes
• More sensitive than MMSE for MCI
• Tests multiple domains: memory, visuospatial, executive, attention, language, orientation
• Score interpretation:
  • 26-30: Normal
  • 18-25: Mild cognitive impairment
  • 10-17: Moderate impairment
  • <10: Severe impairment
• Add 1 point if education ≤12 years

Mini-Cog (quick screen, 3 minutes):

• 3-word recall + clock draw
• Abnormal: 0-2 words recalled OR abnormal clock
• Good for screening; if abnormal, do full MoCA

MMSE (Mini-Mental State Examination):

• 30 points; less sensitive for MCI than MoCA
• Ceiling effect in educated patients
• 24-30: Normal; 18-23: Mild; 10-17: Moderate; <10: Severe

Depression screening:

• PHQ-2/PHQ-9 or Geriatric Depression Scale (GDS)
• Depression can cause “pseudodementia” and commonly coexists with dementia

Neurologic exam:

• Gait: Shuffling (Parkinson’s, NPH), magnetic gait (NPH), ataxia
• Parkinsonism: Bradykinesia, rigidity, tremor (Lewy body, Parkinson’s dementia)
• Focal deficits: Suggest vascular or mass lesion
• Frontal release signs: Grasp, snout, palmomental (nonspecific but suggest frontal involvement)
• Reflexes: Asymmetry suggests vascular; hyperreflexia suggests myelopathy

General exam:

• Vital signs (HTN as vascular risk factor)
• Thyroid (goiter)
• Cardiovascular (AF, carotid bruits, signs of HF)
• Signs of self-neglect (hygiene, nutrition)

Differential (quick pattern recognition)#

Common/likely (outpatient)#

Can’t-miss / urgent#

Workup#

Initial workup (all patients with cognitive complaint):

Second-tier testing (based on clinical suspicion):

When NOT to order extensive workup:

• Classic Alzheimer’s presentation in elderly patient with gradual progression
• Known dementia with stable course (unless new symptoms)
• Very advanced dementia where results won’t change management

Neuroimaging guidance:

• MRI preferred over CT (better for white matter disease, atrophy patterns, small infarcts)
• CT acceptable if MRI contraindicated or unavailable
• Contrast not routinely needed unless mass suspected

Initial management#

After diagnosis:

1. Disclose diagnosis with sensitivity (patient and family together, unless patient prefers otherwise)
2. Assess and document decision-making capacity
3. Discuss prognosis (general trajectory, not specific timeline)
4. Address safety concerns (driving, firearms, wandering, finances)
5. Identify caregiver and assess caregiver burden
6. Discuss advance care planning
7. Connect with resources (Alzheimer’s Association, support groups)

Safety assessment (every visit):

• Driving:
  • Dementia is a progressive condition that eventually impairs driving
  • Refer for formal driving evaluation if any concern (occupational therapy driving assessment)
  • Many states require physician reporting of dementia diagnosis to DMV
  • Have direct conversation with patient and family; document discussion
  • Consider: getting lost, accidents/near-misses, family concerns, MoCA <20
• Firearms: Recommend removal from home
• Wandering risk: Door alarms, ID bracelet, GPS tracker
• Financial exploitation: Assess for signs; consider POA
• Medication management: Assess ability; consider pill boxes, supervision
• Home safety: Fall risks, stove safety, supervision needs

Anosognosia (lack of insight):

• Common in dementia; patient may deny or minimize problems
• Family report often more accurate than patient report
• Does not mean patient is being dishonest
• Complicates safety discussions (patient may resist giving up driving, etc.)

Caregiver support:

• Assess caregiver stress and burnout
• Provide education about disease progression
• Connect with support groups and respite care
• Screen caregiver for depression

Management by diagnosis#

Alzheimer’s disease#

Education:

• Alzheimer’s is a progressive brain disease affecting memory and thinking
• Medications may help symptoms but don’t cure or stop progression
• Planning ahead while the patient can participate is important
• Average survival after diagnosis is 4-8 years, but varies widely

Treatment - Cholinesterase inhibitors (mild-moderate AD):

Treatment - NMDA receptor antagonist (moderate-severe AD):

Combination therapy: Donepezil + memantine commonly used in moderate-severe AD.

Realistic expectations:

• Cholinesterase inhibitors: Modest symptomatic benefit; may slow decline by ~6 months
• Not disease-modifying; benefit diminishes over time
• ~50% of patients show no measurable response
• Consider discontinuation in severe dementia or if no perceived benefit

New disease-modifying therapies (specialist-initiated):

• Lecanemab, aducanumab: Anti-amyloid monoclonal antibodies
• Require amyloid PET or CSF confirmation
• Modest benefit with significant risks (ARIA—brain edema/hemorrhage)
• Specialist (neurologist/geriatrician) should initiate and monitor
• Not appropriate for all patients; shared decision-making essential

Non-pharmacologic (equally important):

• Cognitive stimulation (puzzles, social engagement, music)
• Physical exercise (reduces behavioral symptoms, may slow decline)
• Structured routine
• Caregiver education and support

Follow-up: Every 3-6 months; assess cognition, function, behavior, caregiver status.

Mild cognitive impairment (MCI)#

Education:

• MCI means memory or thinking problems beyond normal aging, but you can still do daily activities
• Some people with MCI stay stable, some improve, and some progress to dementia
• About 10-15% of people with MCI progress to dementia each year
• Lifestyle factors may help slow progression

Management:

• No FDA-approved medications for MCI
• Cholinesterase inhibitors NOT recommended (no proven benefit, side effects)
• Focus on modifiable risk factors:
  • Cardiovascular risk management (BP, cholesterol, diabetes, smoking)
  • Physical exercise (strongest evidence)
  • Cognitive engagement
  • Social activity
  • Treat depression if present
  • Treat sleep apnea if present
  • Hearing aids if hearing impaired
  • Mediterranean diet

Monitoring:

• Repeat cognitive testing every 6-12 months
• Monitor for functional decline (signals conversion to dementia)
• Reassess driving safety

Follow-up: Every 6-12 months with repeat MoCA.

Vascular dementia#

Education:

• Vascular dementia is caused by reduced blood flow to the brain, often from small strokes
• Controlling vascular risk factors is the most important treatment
• Progression can sometimes be slowed with good risk factor control

Treatment:

• Vascular risk factor management (primary intervention):
  • Blood pressure control (target <130/80 if tolerated)
  • Statin therapy
  • Diabetes management
  • Smoking cessation
  • Antiplatelet therapy (aspirin 81 mg) if ischemic strokes
  • Anticoagulation if AF
• Cholinesterase inhibitors: May have modest benefit; often tried
• Memantine: May have modest benefit in moderate-severe

Follow-up: Every 3-6 months; monitor vascular risk factors and cognition.

Lewy body dementia#

Education:

• Lewy body dementia causes memory problems, visual hallucinations, and movement symptoms
• Symptoms can fluctuate day to day
• Some medications can make symptoms much worse—always check before starting new medications

CRITICAL - Medication sensitivity:

• Avoid typical antipsychotics (haloperidol)—can cause severe parkinsonism, neuroleptic malignant syndrome
• Avoid most atypical antipsychotics—use only quetiapine or clozapine if absolutely necessary
• Avoid anticholinergics—worsen cognition

Treatment:

Referral: Neurology for diagnosis confirmation and management.

Follow-up: Every 3 months given complexity; close monitoring for medication effects.

Frontotemporal dementia#

Education:

• FTD affects the front part of the brain, causing personality and behavior changes
• Memory is often preserved early, unlike Alzheimer’s
• There are no FDA-approved medications; treatment focuses on managing symptoms
• Progression is variable; average survival 6-8 years from symptom onset

Management:

• No disease-modifying treatment
• Cholinesterase inhibitors NOT recommended (may worsen behavior)
• SSRIs for behavioral symptoms (disinhibition, compulsions, depression)
• Trazodone for agitation, sleep
• Avoid antipsychotics if possible
• Behavioral strategies and caregiver education
• Speech therapy for language variants

Referral: Neurology for diagnosis and management.

Follow-up: Every 3-6 months; focus on behavioral management and caregiver support.

Depression with cognitive symptoms (“pseudodementia”)#

Education:

• Depression can cause memory and concentration problems that look like dementia
• Treating the depression often improves thinking
• Sometimes depression and dementia occur together

Treatment:

Avoid in elderly: TCAs (anticholinergic), paroxetine (anticholinergic)

Follow-up: 4-6 weeks to assess mood response; repeat cognitive testing after depression treated (wait 3+ months).

Normal pressure hydrocephalus (NPH)#

Education:

• NPH is caused by fluid buildup in the brain that can be treated
• The classic symptoms are walking problems, memory problems, and bladder control problems
• A procedure to drain fluid can help determine if surgery would work

Recognition: Triad of gait apraxia (magnetic gait), dementia, urinary incontinence

Management:

• MRI brain (enlarged ventricles out of proportion to atrophy)
• Neurology/neurosurgery referral
• Large-volume lumbar puncture (30-50 mL) as diagnostic/therapeutic trial
• If improvement after LP: Consider VP shunt placement

Follow-up: Per neurosurgery; gait often improves most, cognition variable.

Follow-up#

Frequency:

• MCI: Every 6-12 months
• Mild dementia: Every 3-6 months
• Moderate-severe dementia: Every 3 months or as needed

What to reassess:

• Cognitive status (repeat MoCA annually or if change noted)
• Functional status (ADLs, IADLs)
• Behavioral symptoms
• Safety (driving, wandering, firearms, finances)
• Medication tolerance and adherence
• Caregiver burden and health
• Advance care planning status

Advance care planning:

• Discuss early while patient can participate
• Healthcare proxy/POA
• Living will/advance directive
• Goals of care (hospitalization, feeding tubes, CPR)
• Revisit as disease progresses

Patient instructions#

For patient (early stage) and family/caregiver:

• Memory and thinking problems can have many causes. We’re doing tests to find out what’s causing yours and whether it can be treated.
• Some causes of memory problems can be improved with treatment (like thyroid problems, vitamin deficiencies, or depression).
• If you have Alzheimer’s disease or another type of dementia, medications may help with symptoms, but there is no cure yet.
• Staying physically active, socially engaged, and mentally stimulated may help maintain function.
• It’s important to plan ahead while you can make decisions. This includes choosing someone to make medical and financial decisions if needed, and discussing your wishes for future care.
• Safety is important. We’ll talk about driving, managing medications, and home safety.
• Caregivers need support too. The Alzheimer’s Association (1-800-272-3900, alz.org) has resources for patients and families.
• Keep a list of all medications and bring it to every appointment. Some medications can worsen memory—always check before starting something new.
• Call us if you notice sudden changes in thinking or behavior, new symptoms like weakness or trouble walking, or if you’re struggling to manage at home.

Smartphrase snippets#

.COGNITIVEEVAL Cognitive evaluation in [age]-year-old. Chief complaint: [memory loss / family concern / functional decline]. Duration [X months/years]. Progression: [gradual / stepwise / rapid]. Domains affected: [memory / language / executive / visuospatial]. Functional status: IADLs [intact / impaired - specify]; BADLs [intact / impaired]. Behavioral symptoms: [none / depression / anxiety / hallucinations / agitation]. MoCA score: [X]/30. PHQ-9: [X]. Neurologic exam: [normal / findings]. Labs: [pending / results]. Assessment: [MCI / probable Alzheimer’s / vascular dementia / other]. Plan: [Labs / imaging / referral / medication / safety assessment / advance care planning discussion]. Follow-up in [X weeks/months].

.DEMENTIADIAGNOSIS Diagnosis of [Alzheimer’s disease / vascular dementia / mixed dementia] discussed with patient and [family member]. Explained that this is a progressive condition affecting memory and thinking. Discussed that medications may help symptoms but do not cure or stop progression. Reviewed safety concerns: [driving / firearms / wandering / finances / medication management]. Advance care planning discussed; [patient has / will complete] healthcare proxy and advance directive. Caregiver [name] present; provided Alzheimer’s Association resources. Started [donepezil 5 mg daily / other]. Follow-up in [4-6 weeks] to assess tolerance, then [3-6 months] ongoing.

.MCIFOLLOW MCI follow-up. Patient reports [stable / worsening] symptoms. Functional status: IADLs remain [intact / specify changes]. MoCA today: [X]/30 (previous [X]). No new safety concerns. Reinforced lifestyle recommendations: exercise, cognitive engagement, social activity, cardiovascular risk management. Not starting cholinesterase inhibitor at this time (not indicated for MCI). Will repeat cognitive testing in [6-12 months]. Return sooner if functional decline or new symptoms.

Related pages#

• Dementia (problem) — ongoing management of diagnosed dementia
• Delirium — acute confusion vs chronic decline
• Depression — pseudodementia vs dementia
• Falls (geriatric) — cognitive impairment increases fall risk
• Polypharmacy — medication-induced cognitive impairment
• Frailty (problem) — cognitive frailty and functional decline

Coding/billing notes#

• G31.84: Mild cognitive impairment
• G30.9: Alzheimer’s disease, unspecified
• G30.0: Alzheimer’s disease with early onset (<65)
• G30.1: Alzheimer’s disease with late onset (≥65)
• F01.50: Vascular dementia without behavioral disturbance
• F01.51: Vascular dementia with behavioral disturbance
• G31.83: Lewy body dementia
• G31.09: Frontotemporal dementia
• G91.2: Normal pressure hydrocephalus
• F32.9: Major depressive disorder (if depression causing cognitive symptoms)
• R41.81: Age-related cognitive decline (normal aging)

Annual Wellness Visit cognitive assessment:

• Required component of Medicare AWV
• Document structured assessment performed
• Can use any validated tool (Mini-Cog, MoCA, etc.)

Advance care planning billing:

• 99497: First 30 minutes of ACP discussion
• 99498: Each additional 30 minutes
• Document time spent and topics discussed