Dementia Evaluation¶

DIAGNOSIS: Dementia Evaluation ICD-10: G31.9 (Degenerative disease of nervous system, unspecified); R41.81 (Age-related cognitive decline); F03.90 (Unspecified dementia without behavioral disturbance) SCOPE: Comprehensive evaluation for cognitive impairment, identification of reversible causes, dementia subtype diagnosis, and symptomatic management. Covers Alzheimer's disease, vascular dementia, frontotemporal dementia, and dementia with Lewy bodies.

STATUS: Draft - Pending Review

PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting

SECTION A: ACTION ITEMS¶

1. LABORATORY WORKUP¶

1A. Essential/Core Labs (Reversible Causes Screen)¶

Test	Rationale	Target Finding	ED	HOSP	OPD	ICU
CBC with differential	Infection, anemia, malignancy contributing to cognitive changes	Normal	STAT	STAT	ROUTINE	-
BMP	Hyponatremia, uremia, hypercalcemia as causes	Normal electrolytes, BUN, Cr	STAT	STAT	ROUTINE	-
TSH	Hypothyroidism is reversible cause of cognitive impairment	0.4-4.0 mIU/L	URGENT	ROUTINE	ROUTINE	-
Vitamin B12	Deficiency causes reversible dementia	>300 pg/mL (>400 optimal)	URGENT	ROUTINE	ROUTINE	-
Folate	Deficiency contributes to cognitive impairment	>3 ng/mL	-	ROUTINE	ROUTINE	-
Glucose (fasting)	Diabetes management affects cognition	70-100 mg/dL	STAT	ROUTINE	ROUTINE	-
Hepatic panel (LFTs, albumin)	Hepatic encephalopathy; nutritional status	Normal	-	ROUTINE	ROUTINE	-
Urinalysis	UTI common cause of acute confusion in elderly	Negative for infection	STAT	STAT	ROUTINE	-

1B. Extended Workup (Second-line)¶

Test	Rationale	Target Finding	ED	HOSP	OPD	ICU
Vitamin D, 25-hydroxy	Deficiency associated with cognitive decline	>30 ng/mL	-	ROUTINE	ROUTINE	-
Hemoglobin A1c	Chronic glucose control affects cognition	<7%	-	ROUTINE	ROUTINE	-
Lipid panel	Vascular risk factor for vascular dementia	LDL <100 mg/dL	-	ROUTINE	ROUTINE	-
Homocysteine	Elevated levels associated with AD and vascular dementia	<15 μmol/L	-	ROUTINE	ROUTINE	-
RPR or VDRL	Neurosyphilis (rare but treatable)	Nonreactive	-	ROUTINE	ROUTINE	-
HIV testing	HIV-associated neurocognitive disorder	Negative	-	ROUTINE	ROUTINE	-
ESR, CRP	Inflammatory/autoimmune causes	Normal	-	ROUTINE	ROUTINE	-

1C. Rare/Specialized (Refractory or Atypical)¶

Test	Rationale	Target Finding	ED	HOSP	OPD	ICU
Heavy metal panel (lead, mercury, arsenic)	Toxic exposure history	Normal	-	-	EXT	-
Copper, ceruloplasmin	Wilson's disease if age <50	Normal	-	EXT	EXT	-
Paraneoplastic antibody panel	Autoimmune dementia; occult malignancy	Negative	-	EXT	EXT	-
Anti-neuronal antibodies (NMDA-R, LGI1, CASPR2, GABA-B, AMPA-R)	Autoimmune encephalitis	Negative	-	EXT	EXT	-
Genetic testing (APOE, PSEN1, PSEN2, APP)	Family history early-onset AD; prognostic	Variable	-	-	EXT	-
Prion protein gene testing	Suspected CJD with family history	No mutation	-	-	EXT	-

2. DIAGNOSTIC IMAGING & STUDIES¶

2A. Essential/First-line¶

Study	Timing	Target Finding	Contraindications	ED	HOSP	OPD	ICU
MRI Brain without contrast	At initial evaluation	Assess atrophy pattern; rule out structural causes (tumor, SDH, NPH)	MRI-incompatible devices	URGENT	ROUTINE	ROUTINE	-
CT Head non-contrast	If MRI unavailable or contraindicated	Rule out mass, hemorrhage, hydrocephalus	None	STAT	STAT	ROUTINE	-

2B. Extended¶

Study	Timing	Target Finding	Contraindications	ED	HOSP	OPD	ICU
MRI Brain volumetrics	Disease monitoring; clinical trials	Hippocampal and whole brain atrophy quantification	MRI contraindications	-	-	ROUTINE	-
FDG-PET Brain	Differentiate AD from FTD; atypical presentations	AD: temporoparietal hypometabolism; FTD: frontal/temporal hypometabolism	None	-	-	ROUTINE	-
Amyloid PET (florbetapir, florbetaben, flutemetamol)	Atypical age/presentation; clinical trial eligibility	Positive: amyloid deposition; negative rules out AD	None	-	-	EXT	-
Tau PET (flortaucipir)	Research; staging AD pathology	Pattern correlates with clinical phenotype	None	-	-	EXT	-
DaTscan (ioflupane I-123)	Differentiate DLB from AD	Reduced: DLB/PDD; Normal: AD	Iodine hypersensitivity	-	-	ROUTINE	-
EEG	Encephalopathy; CJD; seizures	AD: mild slowing; CJD: periodic sharp wave complexes	None	URGENT	ROUTINE	ROUTINE	-
Sleep study (polysomnography)	Sleep apnea contributing to cognition; RBD suggesting DLB	Assess AHI; REM without atonia	None	-	-	ROUTINE	-

2C. Rare/Specialized¶

Study	Timing	Target Finding	Contraindications	ED	HOSP	OPD	ICU
SPECT (perfusion)	Alternative to PET if unavailable	Regional hypoperfusion patterns	None	-	-	EXT	-
MRI with SWI/GRE sequences	Cerebral amyloid angiopathy; microbleeds	Lobar microbleeds pattern	MRI contraindications	-	ROUTINE	ROUTINE	-
Whole body PET-CT	Paraneoplastic workup	Identify occult malignancy	None	-	EXT	EXT	-

LUMBAR PUNCTURE¶

Indication: Rapid progression, early-onset (<65), atypical presentation, suspected autoimmune or infectious etiology, clinical trial eligibility Timing: ROUTINE for diagnosis clarification; URGENT if autoimmune/infectious suspected Volume Required: 10-15 mL (standard diagnostic); additional for research biomarkers

Study	Rationale	Target Finding	ED	HOSP	OPD	ICU
Cell count, protein, glucose	Rule out infection, inflammation	WBC <5, protein <45 mg/dL, glucose >60% serum	URGENT	ROUTINE	ROUTINE	-
CSF Aβ42 (amyloid beta 1-42)	Low in Alzheimer's disease	<600 pg/mL suggests AD	-	ROUTINE	ROUTINE	-
CSF total tau	Elevated in neurodegeneration	<400 pg/mL normal; elevated in AD	-	ROUTINE	ROUTINE	-
CSF p-tau (phosphorylated tau 181)	Specific for AD pathology	Elevated in AD; Aβ42/p-tau ratio most predictive	-	ROUTINE	ROUTINE	-
CSF Aβ42/Aβ40 ratio	More accurate than Aβ42 alone	<0.05-0.08 suggests AD (assay-dependent)	-	ROUTINE	ROUTINE	-
14-3-3 protein	Creutzfeldt-Jakob disease	Positive in CJD (not specific)	-	ROUTINE	ROUTINE	-
RT-QuIC	Prion disease confirmation	Positive indicates CJD	-	ROUTINE	ROUTINE	-
Autoimmune encephalitis panel	Autoimmune dementia	Negative	-	EXT	EXT	-
VDRL	Neurosyphilis	Nonreactive	-	ROUTINE	ROUTINE	-

Special Handling: CSF biomarkers require specialized handling; send to reference lab; freeze within 1 hour Contraindications: Coagulopathy (INR >1.5, platelets <50k); posterior fossa mass; skin infection at site

3. TREATMENT¶

3A. Acute/Emergent¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Treat reversible causes	Various	Identified metabolic/infectious etiology	Per cause :: Various :: :: Correct hyponatremia, treat UTI, replace B12, treat hypothyroidism	Depends on intervention	Cognitive reassessment after treatment	STAT	STAT	ROUTINE	-
Thiamine (if nutritional risk)	IV/PO	Suspected Wernicke's; alcoholism; malnutrition	500 mg IV TID x 3 days; 100 mg PO daily :: IV/PO :: :: 500 mg IV TID x 3 days if Wernicke suspected; then 100 mg PO daily	None	Clinical improvement	STAT	STAT	ROUTINE	-
Vitamin B12	IM/PO	B12 deficiency	1000 mcg IM daily x 7 days; 1000 mcg IM weekly x 4; 1000-2000 mcg PO daily :: IM/PO :: :: 1000 mcg IM daily x 7d, then weekly x 4wk, then monthly; or high-dose oral 1000-2000 mcg daily	None	B12 level, MMA; neuro improvement over months	-	ROUTINE	ROUTINE	-

3B. Symptomatic Treatments (Behavioral)¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Citalopram	PO	Depression; agitation in dementia	10 mg daily; 20 mg daily :: PO :: :: Start 10 mg daily; max 20 mg in elderly (QT risk)	QT prolongation; concurrent QT-prolonging drugs	QTc (especially >20 mg)	-	ROUTINE	ROUTINE	-
Sertraline	PO	Depression; anxiety in dementia	25 mg daily; 50 mg daily; 100 mg daily :: PO :: :: Start 25 mg daily; titrate by 25 mg q1-2wk; typical 50-100 mg	MAOIs	GI upset initially	-	ROUTINE	ROUTINE	-
Mirtazapine	PO	Depression with poor appetite and insomnia	7.5 mg qHS; 15 mg qHS; 30 mg qHS :: PO :: :: Start 7.5-15 mg qHS; may increase to 30 mg qHS	MAOIs	Weight gain, sedation	-	ROUTINE	ROUTINE	-
Trazodone	PO	Insomnia; sundowning; agitation	25 mg qHS; 50 mg qHS; 100 mg qHS :: PO :: :: Start 25-50 mg qHS; titrate by 25-50 mg; typical 50-150 mg qHS	Concurrent MAOIs; QT prolongation	Orthostatic hypotension, priapism (rare)	-	ROUTINE	ROUTINE	-
Quetiapine	PO	Severe agitation/psychosis when non-pharmacologic fails	12.5 mg qHS; 25 mg BID; 50 mg BID :: PO :: :: Start 12.5-25 mg qHS; titrate slowly; keep dose as low as possible	Black box: increased mortality in dementia	Metabolic effects, sedation, QTc	-	EXT	ROUTINE	-
Risperidone	PO	Severe aggression/psychosis (short-term use only)	0.25 mg BID; 0.5 mg BID :: PO :: :: Start 0.25 mg BID; max 1 mg BID; short-term use only	Black box: increased mortality in dementia	EPS, metabolic, stroke risk	-	EXT	ROUTINE	-
Haloperidol	IM/IV/PO	Acute severe agitation in delirium (not chronic)	0.5 mg IM; 1 mg IM; 2 mg IM :: IM/IV/PO :: :: 0.5-2 mg IM/IV q4-6h PRN; short-term only; avoid chronic use	QT prolongation; Parkinson's; DLB	QTc, EPS	STAT	EXT	-	-
Melatonin	PO	Sleep disturbance; sundowning	3 mg qHS; 6 mg qHS; 9 mg qHS :: PO :: :: Start 3 mg qHS; may increase to 9 mg; give 30 min before bed	None	Daytime sedation	-	ROUTINE	ROUTINE	-

3C. Cognitive Enhancers¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Donepezil	PO	Mild-moderate AD; vascular dementia; DLB	5 mg qHS; 10 mg qHS; 23 mg daily :: PO :: :: Start 5 mg qHS x 4-6 weeks; increase to 10 mg qHS; 23 mg for moderate-severe	Sick sinus syndrome; GI bleeding; COPD exacerbation	Bradycardia, GI symptoms, vivid dreams	-	ROUTINE	ROUTINE	-
Rivastigmine oral	PO	Mild-moderate AD; Parkinson's dementia; DLB	1.5 mg BID; 3 mg BID; 4.5 mg BID; 6 mg BID :: PO :: :: Start 1.5 mg BID; increase by 1.5 mg BID q2wk; target 6 mg BID	Same as donepezil; severe hepatic impairment	GI symptoms, weight loss	-	ROUTINE	ROUTINE	-
Rivastigmine patch	TD	Mild-moderate AD; better GI tolerability	4.6 mg/24hr; 9.5 mg/24hr; 13.3 mg/24hr :: TD :: :: Start 4.6 mg/24hr patch; increase q4wk; target 9.5-13.3 mg/24hr	Same as oral	Skin irritation, GI symptoms	-	ROUTINE	ROUTINE	-
Galantamine	PO	Mild-moderate AD	4 mg BID; 8 mg BID; 12 mg BID :: PO :: :: Start 4 mg BID x 4wk; increase to 8 mg BID x 4wk; target 8-12 mg BID	Same as donepezil; severe renal/hepatic	GI symptoms, bradycardia	-	ROUTINE	ROUTINE	-
Galantamine ER	PO	Once daily option	8 mg daily; 16 mg daily; 24 mg daily :: PO :: :: Start 8 mg daily x 4wk; increase q4wk; target 16-24 mg daily	Same as IR	Same as IR	-	ROUTINE	ROUTINE	-
Memantine	PO	Moderate-severe AD; add to cholinesterase inhibitor	5 mg daily; 5 mg BID; 10 mg BID :: PO :: :: Start 5 mg daily; increase by 5 mg/wk; target 10 mg BID	Severe renal impairment (dose adjust CrCl <30)	Confusion, dizziness, constipation	-	ROUTINE	ROUTINE	-
Memantine XR	PO	Once daily option	7 mg daily; 14 mg daily; 21 mg daily; 28 mg daily :: PO :: :: Start 7 mg daily; increase by 7 mg/wk; target 28 mg daily	Same as IR	Same as IR	-	ROUTINE	ROUTINE	-
Memantine + Donepezil (Namzaric)	PO	Moderate-severe AD on both medications	28/10 mg daily :: PO :: :: 28 mg memantine XR + 10 mg donepezil; take qHS	Same as individual drugs	Same as individual drugs	-	-	ROUTINE	-

3D. Disease-Modifying Therapies (Anti-Amyloid)¶

Treatment	Route	Indication	Dosing	Pre-Treatment Requirements	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Lecanemab (Leqembi)	IV	Early AD with confirmed amyloid pathology (MCI or mild dementia)	10 mg/kg IV q2wk :: IV :: :: 10 mg/kg IV every 2 weeks; infuse over 1 hour	Amyloid PET or CSF confirming amyloid; MRI baseline; APOE genotyping recommended	ARIA risk with anticoagulation; >4 microbleeds on MRI; recent stroke/TIA	MRI at baseline, weeks 14, 52, 78; monitor for ARIA-E/H	-	-	ROUTINE	-
Donanemab (Kisunla)	IV	Early AD with confirmed amyloid and tau pathology	700 mg IV q4wk x 3; 1400 mg IV q4wk :: IV :: :: 700 mg q4wk x 3 doses, then 1400 mg q4wk until amyloid cleared	Amyloid PET positive; tau PET intermediate/high	Similar to lecanemab; higher ARIA risk with APOE4 homozygotes	MRI at baseline, weeks 16, 24, 52, 76; ARIA monitoring	-	-	EXT	-
Aducanumab (Aduhelm)	IV	Early AD with confirmed amyloid (limited use)	Titration to 10 mg/kg IV q4wk :: IV :: :: Slow titration: 1→3→6→10 mg/kg monthly	Same as lecanemab	Same as lecanemab; limited clinical adoption	MRI for ARIA monitoring	-	-	EXT	-

ARIA Monitoring Notes: - ARIA-E (edema): Usually asymptomatic; may cause headache, confusion - ARIA-H (hemorrhage): Microbleeds, superficial siderosis - Hold infusion for symptomatic ARIA; resume after resolution per protocol - APOE4 homozygotes have higher ARIA risk; requires informed consent discussion

4. OTHER RECOMMENDATIONS¶

4A. Referrals & Consults¶

Recommendation	ED	HOSP	OPD	ICU
Neurology/Cognitive neurology for diagnosis confirmation, subtype classification, and treatment planning	-	ROUTINE	ROUTINE	-
Neuropsychology for comprehensive cognitive testing to establish baseline and guide diagnosis	-	-	ROUTINE	-
Geriatric psychiatry for behavioral symptoms, medication management, and capacity evaluation	-	ROUTINE	ROUTINE	-
Occupational therapy for ADL assessment, cognitive strategies, and home safety evaluation	-	ROUTINE	ROUTINE	-
Speech therapy for communication strategies and swallowing evaluation if dysphagia present	-	ROUTINE	ROUTINE	-
Social work for caregiver support, community resources, and long-term care planning	-	ROUTINE	ROUTINE	-
Palliative care for advanced dementia symptom management and goals of care discussions	-	ROUTINE	ROUTINE	-
Legal/Elder law attorney for advance directives, healthcare proxy, and financial planning while patient has capacity	-	-	ROUTINE	-
Genetics counseling if familial/early-onset AD for family members	-	-	ROUTINE	-

4B. Patient Instructions¶

Recommendation	ED	HOSP	OPD
Return immediately if sudden confusion worsens which may indicate stroke, infection, or medication effect	STAT	STAT	ROUTINE
Complete advance directives while patient has capacity to document wishes for future care	-	ROUTINE	ROUTINE
Establish healthcare proxy/power of attorney for future decision-making	-	ROUTINE	ROUTINE
Do not drive if cognitive impairment affects judgment or reaction time (formal driving evaluation may be needed)	-	ROUTINE	ROUTINE
Take all medications as prescribed and use pill organizers or reminders to ensure adherence	-	ROUTINE	ROUTINE
Keep a consistent daily routine which helps with orientation and reduces confusion	-	ROUTINE	ROUTINE
Engage in mentally stimulating activities (reading, puzzles, social interaction) to support cognitive reserve	-	ROUTINE	ROUTINE

4C. Lifestyle & Prevention¶

Recommendation	ED	HOSP	OPD
Regular physical exercise (150 min/week moderate aerobic) may slow cognitive decline	-	ROUTINE	ROUTINE
Mediterranean or MIND diet emphasizing vegetables, berries, fish, nuts, and olive oil	-	ROUTINE	ROUTINE
Adequate sleep (7-8 hours) and treat sleep disorders (sleep apnea assessment)	-	ROUTINE	ROUTINE
Social engagement and cognitive stimulation through activities, hobbies, and relationships	-	ROUTINE	ROUTINE
Cardiovascular risk factor control (BP <130/80, diabetes control, cholesterol management) reduces vascular contribution	-	ROUTINE	ROUTINE
Hearing loss correction with hearing aids as untreated hearing loss is modifiable dementia risk factor	-	-	ROUTINE
Limit alcohol to ≤1 drink daily as excess alcohol accelerates cognitive decline	-	ROUTINE	ROUTINE
Fall prevention with home modifications as dementia increases fall and injury risk	-	ROUTINE	ROUTINE

SECTION B: REFERENCE¶

5. DIFFERENTIAL DIAGNOSIS¶

Alternative Diagnosis	Key Distinguishing Features	Tests to Differentiate
Delirium	Acute onset; fluctuating attention; identifiable cause (infection, medication, metabolic)	Resolve cause; reassess cognition when clear
Depression (pseudodementia)	Prominent mood symptoms; often aware of deficits; improves with antidepressants	GDS, PHQ-9; trial of antidepressant
Alzheimer's disease	Insidious onset; short-term memory most affected; language and visuospatial later	MRI hippocampal atrophy; amyloid/tau PET or CSF biomarkers
Vascular dementia	Stepwise decline; focal findings; executive dysfunction; vascular risk factors	MRI with significant white matter disease, strategic infarcts
Dementia with Lewy bodies	Visual hallucinations; parkinsonism; REM sleep behavior disorder; fluctuating cognition	DaTscan; clinical criteria
Frontotemporal dementia (behavioral)	Personality change; disinhibition; apathy; hyperorality; age <65 often	FDG-PET frontal hypometabolism; genetics
Primary progressive aphasia	Language predominates; word-finding, grammar, or comprehension primarily affected	Neuropsychological testing; FDG-PET language areas
Creutzfeldt-Jakob disease	Rapid progression (weeks-months); myoclonus; periodic sharp waves on EEG	EEG, MRI DWI cortical ribboning, CSF RT-QuIC
Normal pressure hydrocephalus	Gait disturbance prominent; urinary incontinence; dementia triad	MRI ventriculomegaly; LP with gait improvement test
Autoimmune encephalitis	Subacute onset; seizures; psychiatric features; often younger	Autoantibody panel (serum/CSF); MRI

6. MONITORING PARAMETERS¶

Parameter	Frequency	Target/Threshold	Action if Abnormal	ED	HOSP	OPD	ICU
MMSE or MoCA	Every 6-12 months	Establish baseline; track trajectory	Adjust treatment; reassess diagnosis if unexpected decline	-	ROUTINE	ROUTINE	-
ADL/IADL function (FAQ, DAD)	Every 6-12 months	Document functional status for staging	Increase support services; OT referral	-	ROUTINE	ROUTINE	-
Behavioral symptoms (NPI)	Each visit	Identify and track BPSD	Behavioral interventions; consider medications	-	ROUTINE	ROUTINE	-
Weight	Each visit	Stable weight	Nutritional assessment; speech therapy for swallowing	-	ROUTINE	ROUTINE	-
Caregiver burden (Zarit scale)	Every 6-12 months	Early identification of burnout	Support resources; respite care; social work	-	-	ROUTINE	-
MRI (ARIA monitoring if on anti-amyloid)	Per protocol	No ARIA-E or ARIA-H	Hold infusion; follow protocol for resumption	-	-	ROUTINE	-
ECG (if on donepezil or citalopram)	Baseline; if dose increased	Normal QTc	Reduce dose or switch agent	-	ROUTINE	ROUTINE	-
Metabolic panel	Annually	Normal	Adjust medications	-	ROUTINE	ROUTINE	-

7. DISPOSITION CRITERIA¶

Disposition	Criteria
Discharge home	Reversible causes treated; safe environment; caregiver support; follow-up arranged
Admit to floor	Acute delirium requiring workup; behavioral crisis unsafe for home; aspiration pneumonia
Admit to psychiatry	Severe behavioral disturbance requiring specialized psychiatric management
Outpatient follow-up	Neurology/geriatrics 1-3 months after diagnosis; then every 6-12 months
Long-term care	Progressive decline; caregiver unable to manage; safety concerns; 24-hour supervision needed

8. EVIDENCE & REFERENCES¶

Recommendation	Evidence Level	Source
Cholinesterase inhibitors for mild-moderate AD	Class I, Level A	Birks J. Cochrane 2006
Memantine for moderate-severe AD	Class I, Level A	Reisberg et al. NEJM 2003
Combination therapy (ChEI + memantine)	Class I, Level A	Tariot et al. JAMA 2004
Lecanemab slows cognitive decline in early AD	Class I, Level A	van Dyck et al. NEJM 2023 (Clarity AD)
Donanemab slows cognitive decline	Class I, Level A	Sims et al. JAMA 2023 (TRAILBLAZER-ALZ 2)
CSF biomarkers accurate for AD diagnosis	Class I, Level A	Hansson et al. Lancet Neurol 2018
Mediterranean diet associated with lower dementia risk	Class II, Level B	Scarmeas et al. Ann Neurol 2006
Physical exercise may slow cognitive decline	Class II, Level B	Livingston et al. Lancet 2020 (Lancet Commission)
Avoid antipsychotics long-term (mortality risk)	Class I, Level A	Schneider et al. JAMA 2005
B12 supplementation reverses deficiency-related cognitive impairment	Class II, Level B	Smith et al. PLoS One 2010

CHANGE LOG¶

v1.0 (January 27, 2026) - Initial template creation - Comprehensive workup for reversible causes - Includes new anti-amyloid therapies (lecanemab, donanemab) - CSF biomarkers section included - Structured dosing format for order sentence generation