Dementia Evaluation¶

VERSION: 1.0 CREATED: January 29, 2026 REVISED: January 29, 2026 STATUS: Approved

DIAGNOSIS: Dementia Evaluation / Cognitive Impairment Workup

ICD-10: R41.81 (Age-related cognitive decline), F03.90 (Unspecified dementia without behavioral disturbance), G30.9 (Alzheimer's disease, unspecified), F01.50 (Vascular dementia without behavioral disturbance), G31.83 (Dementia with Lewy bodies), G31.09 (Other frontotemporal dementia), G31.84 (Mild cognitive impairment)

CPT CODES: 85025 (CBC), 80053 (CMP), 84443 (TSH), 82607 (Vitamin B12), 82746 (Folate), 81003 (Urinalysis), 86592 (RPR/VDRL), 87389 (HIV), 84425 (Thiamine (Vitamin B1)), 82306 (Vitamin D), 83090 (Homocysteine), 83036 (HbA1c), 80061 (Lipid panel), 85652 (ESR), 86235 (ANA), 82390 (Serum ceruloplasmin), 83655 (Heavy metals: lead), 89051 (Cell count (tubes 1 and 4)), 84157 (Protein), 82945 (Glucose), 83519 (Aβ42, total tau, phospho-tau), 83916 (Oligoclonal bands), 70551 (MRI brain without contrast), 70450 (CT head without contrast), 70552 (MRI brain with contrast), 78608 (FDG-PET brain), 78811 (Amyloid PET), 78830 (DaTscan), 95816 (EEG), 95810 (Polysomnography), 96116 (Bedside cognitive screen (MoCA, MMSE)), 96132 (Formal neuropsychological testing), 96374 (Thiamine (Wernicke-Korsakoff)), 96365 (Lecanemab (Leqembi))

SYNONYMS: Dementia, cognitive impairment, memory loss, cognitive decline, major neurocognitive disorder, mild neurocognitive disorder, senility, organic brain syndrome, dementia workup, neurodegenerative disease, Alzheimer's, AD

SCOPE: Systematic evaluation of cognitive impairment and dementia in adults. Covers comprehensive workup to identify reversible causes and establish etiology. Includes initiation of symptomatic treatment. Excludes pediatric intellectual disability, acute delirium (separate entity), and rapidly progressive dementia (separate template for urgent workup).

DEFINITIONS: - Dementia (Major Neurocognitive Disorder): Significant cognitive decline from prior level in ≥1 cognitive domains (memory, language, executive function, attention, perceptual-motor, social cognition) that interferes with independence in everyday activities - Mild Cognitive Impairment (MCI): Modest cognitive decline that does NOT interfere with independence; intermediate stage between normal aging and dementia - Reversible Dementia: Cognitive impairment due to treatable conditions (B12 deficiency, hypothyroidism, NPH, depression, medication effects)

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

1. LABORATORY WORKUP¶

1A. Essential/Core Labs (All Patients)¶

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
CBC (CPT 85025)	URGENT	ROUTINE	ROUTINE	-	Anemia, infection, hematologic disease	Normal
CMP (CPT 80053)	URGENT	ROUTINE	ROUTINE	-	Metabolic encephalopathy, hepatic/renal failure, glucose	Normal
TSH (CPT 84443)	URGENT	ROUTINE	ROUTINE	-	Hypothyroidism is reversible cause	Normal (0.4-4.0 mIU/L)
Vitamin B12 (CPT 82607)	URGENT	ROUTINE	ROUTINE	-	B12 deficiency is reversible cause	>400 pg/mL (>300 per some guidelines)
Folate (CPT 82746)	-	ROUTINE	ROUTINE	-	Folate deficiency can contribute	Normal
Ammonia	URGENT	ROUTINE	-	-	Hepatic encephalopathy if liver disease	<35 μmol/L
Urinalysis (CPT 81003)	URGENT	ROUTINE	ROUTINE	-	UTI common cause of delirium/worsening	Negative

1B. Extended Workup (Second-line)¶

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
RPR/VDRL (CPT 86592)	-	ROUTINE	ROUTINE	-	Neurosyphilis in differential	Negative
HIV (CPT 87389)	-	ROUTINE	ROUTINE	-	HIV-associated neurocognitive disorder (HAND)	Negative
Thiamine (Vitamin B1) (CPT 84425)	URGENT	ROUTINE	ROUTINE	-	Wernicke-Korsakoff if alcohol history	Normal
Vitamin D (CPT 82306)	-	ROUTINE	ROUTINE	-	Deficiency associated with cognitive decline	>30 ng/mL
Homocysteine (CPT 83090)	-	ROUTINE	ROUTINE	-	Elevated levels associated with dementia risk	<15 μmol/L
HbA1c (CPT 83036)	-	ROUTINE	ROUTINE	-	Diabetes and cognitive impairment	<7% ideally
Lipid panel (CPT 80061)	-	ROUTINE	ROUTINE	-	Vascular risk factors	Per guidelines
ESR (CPT 85652)/CRP (CPT 86140)	-	ROUTINE	ROUTINE	-	Inflammatory/vasculitic cause	Normal
ANA (CPT 86235)	-	ROUTINE	ROUTINE	-	CNS lupus, autoimmune	Negative

1C. Specialized Testing (Selected Patients)¶

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
Serum ceruloplasmin (CPT 82390), copper (CPT 82390)	-	EXT	EXT	-	Wilson disease if <50 years	Normal
Heavy metals: lead (CPT 83655), mercury (CPT 83825), arsenic (CPT 82175)	-	EXT	EXT	-	Occupational/environmental exposure	Negative
Paraneoplastic panel	-	EXT	EXT	-	Subacute onset, smoking history, cancer history	Negative
Autoimmune encephalitis panel (serum)	-	URGENT	ROUTINE	-	Subacute onset, psychiatric features, seizures	Negative
Lyme serology	-	ROUTINE	ROUTINE	-	Endemic areas, tick exposure	Negative
West Nile serology	-	EXT	EXT	-	Endemic areas, summer/fall onset	Negative
Genetic testing (APOE, APP, PSEN1/2)	-	-	EXT	-	Strong family history, early onset	Risk assessment

LUMBAR PUNCTURE¶

Indication: Atypical presentation, rapid progression, young onset (<65), suspected CNS infection, inflammatory condition, or when AD biomarkers desired

Study	ED	HOSP	OPD	ICU	Rationale	Target Finding
Opening pressure	URGENT	URGENT	-	-	NPH evaluation	10-20 cm H2O
Cell count (tubes 1 and 4) (CPT 89051)	URGENT	URGENT	-	-	Infection, inflammation	WBC <5
Protein (CPT 84157)	URGENT	URGENT	-	-	Infection, inflammation	15-45 mg/dL
Glucose (CPT 82945)	URGENT	URGENT	-	-	Infection	>60% serum
VDRL	-	ROUTINE	-	-	Neurosyphilis	Negative
CSF meningitis panel	-	URGENT	-	-	Infectious etiology	Negative
Aβ42, total tau, phospho-tau (CPT 83519)	-	ROUTINE	ROUTINE	-	AD biomarkers (AT profile)	Aβ42↓, tau↑, p-tau↑ in AD
RT-QuIC (CPT 86235)	-	URGENT	-	-	CJD if rapid progression	Negative
14-3-3 protein (CPT 83519)	-	URGENT	-	-	CJD if rapid progression	Negative
Oligoclonal bands (CPT 83916)	-	ROUTINE	-	-	MS, inflammatory conditions	Negative
Cytology	-	ROUTINE	-	-	Carcinomatous meningitis	Negative
Autoimmune encephalitis panel (CSF)	-	URGENT	ROUTINE	-	If autoimmune suspected	Negative

2. DIAGNOSTIC IMAGING & STUDIES¶

2A. Essential/First-line¶

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
MRI brain without contrast (CPT 70551)	-	ROUTINE	ROUTINE	-	Initial workup	Atrophy pattern, vascular changes, masses, NPH	Pacemaker, metal
CT head without contrast (CPT 70450)	STAT	STAT	-	STAT	If MRI unavailable or contraindicated	Masses, hemorrhage, hydrocephalus	None

2B. Extended¶

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
MRI brain with contrast (CPT 70552)	-	ROUTINE	ROUTINE	-	If mass, infection, or inflammation suspected	Enhancing lesions	Contrast allergy, renal disease
FDG-PET brain (CPT 78608)	-	-	ROUTINE	-	Distinguish AD from FTD; atypical presentations	AD: temporoparietal hypometabolism; FTD: frontal hypometabolism	Per PET
Amyloid PET (CPT 78811)	-	-	ROUTINE	-	Diagnostic uncertainty; young onset	Positive in AD and preclinical AD	Per PET
Tau PET (Tauvid)	-	-	EXT	-	AD staging, atypical presentations	Pattern correlates with symptoms	Per PET
DaTscan (CPT 78830)	-	-	ROUTINE	-	If parkinsonian features; DLB vs AD	Reduced in DLB; normal in AD	Pregnancy, iodine allergy
EEG (CPT 95816)	-	ROUTINE	ROUTINE	-	Subclinical seizures, CJD (triphasic waves), delirium	Normal or diffuse slowing	None
Polysomnography (CPT 95810)	-	-	ROUTINE	-	If REM sleep behavior disorder suspected (DLB)	Confirm RBD	None

Neuropsychological Testing¶

Study	ED	HOSP	OPD	ICU	Timing	Indication	Findings
Bedside cognitive screen (MoCA, MMSE) (CPT 96116)	-	ROUTINE	ROUTINE	-	All patients	Screening	MoCA <26 or MMSE <24 suggests impairment
Formal neuropsychological testing (CPT 96132)	-	-	ROUTINE	-	Diagnostic uncertainty, MCI vs dementia, baseline, disability evaluation	Gold standard	Domain-specific deficits; pattern suggests etiology

3. TREATMENT¶

3A. Reversible Causes - Treatment¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Vitamin B12 replacement	IM	-	1000 mcg :: IM :: daily :: 1000 mcg IM daily × 7 days, then weekly × 4, then monthly; OR oral 1000-2000 mcg daily	None	B12 levels	URGENT	STAT	ROUTINE	-
Levothyroxine (hypothyroidism)	-	-	25-50 mcg :: PO :: daily :: Start 25-50 mcg daily; titrate per TSH	CAD (start low)	TSH q6-8 weeks	-	ROUTINE	ROUTINE	-
Thiamine (Wernicke-Korsakoff) (CPT 96374)	IV	-	500 mg :: IV :: TID :: 500 mg IV TID × 3 days, then 250 mg IV daily × 5 days, then 100 mg PO daily	None	Clinical response	STAT	STAT	ROUTINE	STAT
NPH treatment (large volume LP)	-	-	30-50 mL :: - :: - :: Diagnostic LP removing 30-50 mL CSF; assess gait before/after	Per LP	Gait improvement suggests shunt candidacy	-	ROUTINE	-	-
VP shunt (NPH)	-	-	N/A :: - :: once :: Neurosurgical placement	Coagulopathy, infection	Shunt complications	-	-	EXT	-
Treat depression (pseudodementia)	PO	-	25-50 mg :: PO :: - :: SSRI (sertraline 25-50 mg, escitalopram 5-10 mg)	Per agent	Mood, cognition	-	ROUTINE	ROUTINE	-
Discontinue offending medications	-	-	N/A :: - :: per protocol :: Stop anticholinergics, sedatives, opioids	N/A	Cognitive reassessment	URGENT	URGENT	ROUTINE	URGENT

3B. Alzheimer's Disease - Cholinesterase Inhibitors¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Donepezil (Aricept)	-	-	5 mg :: PO :: QHS :: Start 5 mg QHS × 4-6 weeks, then increase to 10 mg QHS; 23 mg available for moderate-severe	Bradycardia, sick sinus, GI bleeding	Bradycardia, GI upset, nightmares	-	ROUTINE	ROUTINE	-
Rivastigmine patch (Exelon)	Transdermal	-	4.6 mg :: PO :: monthly :: Start 4.6 mg/24h patch; increase monthly to 9.5-13.3 mg/24h	Same; skin reactions	Skin irritation, GI, bradycardia	-	ROUTINE	ROUTINE	-
Rivastigmine oral	PO	-	1.5 mg :: PO :: BID :: Start 1.5 mg BID with food; titrate to 6 mg BID	Same	GI side effects more common than patch	-	ROUTINE	ROUTINE	-
Galantamine (Razadyne)	PO	-	4 mg :: PO :: BID :: Start 4 mg BID with food × 4 weeks; titrate to 8-12 mg BID; ER: 8 mg daily to 24 mg daily	Same	Same	-	ROUTINE	ROUTINE	-

3C. Alzheimer's Disease - NMDA Antagonist¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Memantine (Namenda)	PO	-	5 mg :: PO :: daily :: Start 5 mg daily; increase by 5 mg/week to 10 mg BID	Severe renal impairment	Confusion, dizziness, constipation	-	ROUTINE	ROUTINE	-
Memantine XR (Namenda XR)	PO	-	7 mg :: PO :: daily :: Start 7 mg daily; increase weekly to 28 mg daily	Same	Same	-	ROUTINE	ROUTINE	-
Donepezil/Memantine XR (Namzaric)	-	-	10 mg :: - :: daily :: For patients on both; 7/10 mg to 28/10 mg daily	Per components	Per components	-	-	ROUTINE	-

3D. Alzheimer's Disease - Disease-Modifying Therapy (Amyloid-Targeted)¶

Treatment	Route	Indication	Dosing	Pre-Treatment Requirements	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Lecanemab (Leqembi) (CPT 96365)	IV	-	10 mg/kg :: IV :: - :: 10 mg/kg IV q2 weeks; confirm amyloid-positive before starting	-	Anticoagulation (relative), ARIA risk factors	MRI at baseline, week 6, 12; ARIA monitoring	-	-	ROUTINE	-
Donanemab (Kisunla) (CPT 96365)	IV	-	700 mg :: IV :: - :: 700 mg IV q4 weeks × 3, then 1400 mg q4 weeks until amyloid clearance; discontinue when cleared	-	Same	Same; discontinue at clearance	-	-	ROUTINE	-
Aducanumab (Aduhelm) (CPT 96365)	IV	-	1-10 mg/kg :: IV :: - :: Titration from 1-10 mg/kg IV q4 weeks; limited use	-	Same	MRI monitoring for ARIA	-	-	EXT	-

ARIA (Amyloid-Related Imaging Abnormalities) Management: - ARIA-E (edema): Usually asymptomatic; hold treatment, repeat MRI in 4-8 weeks - ARIA-H (hemorrhage): Microhemorrhages or superficial siderosis; assess severity - Symptomatic ARIA: Hold treatment, consider corticosteroids, MRI monitoring

3E. Behavioral and Psychological Symptoms of Dementia (BPSD)¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Non-pharmacologic interventions	-	-	N/A :: - :: per protocol :: Music therapy, validation therapy, redirection, environmental modification	None	First-line for all BPSD	STAT	STAT	ROUTINE	-
Sertraline (depression, anxiety)	PO	-	25 mg :: PO :: daily :: Start 25 mg daily; target 50-100 mg	Bleeding risk, QT prolongation	GI bleeding, hyponatremia	-	ROUTINE	ROUTINE	-
Citalopram (agitation)	PO	-	10 mg :: PO :: daily :: Start 10 mg daily; max 20 mg (QT risk at higher doses)	QT prolongation	QTc, hyponatremia	-	ROUTINE	ROUTINE	-
Trazodone (sleep, agitation)	PO	-	25-100 mg :: PO :: QHS :: 25-100 mg QHS	Orthostasis	Sedation, falls	-	ROUTINE	ROUTINE	-
Mirtazapine (sleep, appetite, mood)	PO	-	7.5-15 mg :: PO :: QHS :: 7.5-15 mg QHS	None significant	Weight gain, sedation	-	ROUTINE	ROUTINE	-
Quetiapine (psychosis, agitation)	-	-	12.5-100 mg :: - :: QHS :: 12.5-100 mg QHS; lowest effective dose	QT prolongation, metabolic syndrome	Black box: increased mortality in dementia	-	ROUTINE	ROUTINE	-
Risperidone (psychosis, aggression)	-	-	0.25-1 mg :: - :: BID :: 0.25-1 mg BID; lowest effective dose	Same; EPS	Same; EPS higher than quetiapine	-	ROUTINE	ROUTINE	-
Pimavanserin (DLB psychosis)	PO	-	34 mg :: PO :: daily :: 34 mg daily	QT prolongation	QTc	-	-	ROUTINE	-
Dextromethorphan/Quinidine (Nuedexta)	-	-	1 caps :: - :: BID :: 1 capsule daily × 7 days, then BID; for pseudobulbar affect	QT prolongation, CYP2D6 interactions	QTc	-	ROUTINE	ROUTINE	-
Carbamazepine (aggression)	PO	-	100-400 mg :: PO :: BID :: 100-400 mg BID	Aplastic anemia risk, drug interactions	CBC, LFTs, drug levels	-	EXT	EXT	-

3F. Other Dementia-Specific Treatments¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Aspirin (vascular dementia)	PO	-	81 mg :: PO :: daily :: 81 mg daily; secondary prevention	Bleeding	Bleeding	-	ROUTINE	ROUTINE	-
Statin (vascular dementia)	-	-	N/A :: - :: per protocol :: Per cardiovascular guidelines	Hepatic disease	LFTs, myopathy	-	ROUTINE	ROUTINE	-
BP control (vascular dementia)	-	-	N/A :: - :: per protocol :: Target <130/80 per guidelines	Per agent	BP	-	ROUTINE	ROUTINE	-
Carbidopa/Levodopa (DLB, PDD)	-	-	N/A :: - :: TID :: Start low 25/100 TID; titrate cautiously	May worsen psychosis	Hallucinations, dyskinesia	-	ROUTINE	ROUTINE	-
Avoid anticholinergics (DLB)	-	-	N/A :: - :: N/A :: Contraindicated in DLB due to severe sensitivity	N/A	N/A	STAT	STAT	ROUTINE	-
Avoid antipsychotics (DLB)	-	-	N/A :: - :: N/A :: Can cause severe parkinsonism, NMS-like reaction; if needed, quetiapine safest	Relative contraindication	Severe reactions	STAT	STAT	ROUTINE	-

4. OTHER RECOMMENDATIONS¶

4A. Referrals & Consults¶

Recommendation	ED	HOSP	OPD	ICU	Indication
Neurology/Memory specialist	-	ROUTINE	ROUTINE	-	All patients with dementia for diagnosis confirmation and management
Neuropsychology	-	-	ROUTINE	-	MCI vs dementia distinction, pattern analysis, baseline assessment
Geriatric psychiatry	-	ROUTINE	ROUTINE	-	BPSD, depression, complex behavioral management
Social work	-	ROUTINE	ROUTINE	-	Resources, placement, caregiver support
Physical therapy	-	ROUTINE	ROUTINE	-	Mobility, fall prevention
Occupational therapy	-	ROUTINE	ROUTINE	-	ADL assessment, home safety evaluation
Speech therapy	-	ROUTINE	ROUTINE	-	Swallowing evaluation, communication strategies
Palliative care	-	-	ROUTINE	-	Goals of care, symptom management in advanced dementia
Elder law attorney	-	-	ROUTINE	-	Power of attorney, healthcare proxy, estate planning
Driving evaluation	-	-	ROUTINE	-	Driving safety assessment

4B. Patient/Family Instructions¶

Recommendation	ED	HOSP	OPD
Dementia is a progressive condition; treatments can help symptoms but not cure	-	ROUTINE	ROUTINE
Establish healthcare proxy and advance directives early while patient can participate	-	ROUTINE	ROUTINE
Home safety: remove rugs, improve lighting, stove safety, medication management	-	ROUTINE	ROUTINE
Driving assessment needed; may need to stop driving	-	ROUTINE	ROUTINE
Caregiver support is essential; respite care, support groups (Alzheimer's Association)	-	ROUTINE	ROUTINE
Medical alert bracelet, GPS tracking if wandering risk	-	ROUTINE	ROUTINE
Maintain routines, social engagement, cognitive stimulation	-	ROUTINE	ROUTINE
Return to ED if: sudden worsening, new weakness, fever, falls, inability to care for self	ROUTINE	ROUTINE	ROUTINE

4C. Lifestyle & Prevention¶

Recommendation	ED	HOSP	OPD
Regular physical exercise (30 min, 5 days/week)	-	ROUTINE	ROUTINE
Cognitive engagement (puzzles, reading, social activities)	-	ROUTINE	ROUTINE
Mediterranean or MIND diet	-	-	ROUTINE
Cardiovascular risk factor management (BP, diabetes, cholesterol)	-	ROUTINE	ROUTINE
Hearing aids if hearing impaired (hearing loss increases dementia risk)	-	-	ROUTINE
Adequate sleep (treat sleep apnea)	-	ROUTINE	ROUTINE
Avoid excessive alcohol	-	ROUTINE	ROUTINE
Social engagement and purpose	-	ROUTINE	ROUTINE

5. DIFFERENTIAL DIAGNOSIS¶

Alternative Diagnosis	Key Distinguishing Features	Tests to Differentiate
Delirium	Acute onset, fluctuating, inattention, often reversible cause	Duration, attention testing, underlying cause
Depression (pseudodementia)	Depressed mood, "I don't know" responses, rapid onset, prior psychiatric history	Depression screening, response to antidepressants
Normal aging	Mild forgetfulness, no functional impairment	Neuropsychological testing; MCI vs normal
B12 deficiency	Macrocytic anemia, neuropathy, subacute combined degeneration	B12 level, MMA, MRI spine
Hypothyroidism	Fatigue, weight gain, cold intolerance	TSH
Normal pressure hydrocephalus	Gait apraxia, urinary incontinence, dementia (triad)	MRI (ventriculomegaly), large volume LP response
Medication effects	Anticholinergics, sedatives, opioids	Medication review; improvement after discontinuation
Wernicke-Korsakoff	Alcohol history, confabulation, ataxia, ophthalmoplegia	History, thiamine trial, MRI (mammillary body changes)
Creutzfeldt-Jakob disease	Rapid progression, myoclonus, MRI changes	MRI (cortical ribboning), EEG (periodic complexes), CSF RT-QuIC
Autoimmune encephalitis	Subacute, psychiatric symptoms, seizures	Antibody panels, MRI, EEG
CNS lymphoma/tumor	Focal deficits, headache, progressive	MRI with contrast

6. MONITORING PARAMETERS¶

Parameter	ED	HOSP	OPD	ICU	Frequency	Target/Threshold	Action if Abnormal
Cognitive testing (MoCA, MMSE)	-	ROUTINE	ROUTINE	-	q6-12 months	Stable or slow decline	Adjust medications, reassess diagnosis
Functional status (ADL/IADL)	-	ROUTINE	ROUTINE	-	q6-12 months	Maintaining independence	OT, increase support
BPSD assessment (NPI)	-	ROUTINE	ROUTINE	-	Each visit	Stable or improved	Behavioral interventions, medications
Caregiver stress (Zarit Burden)	-	-	ROUTINE	-	q6-12 months	Manageable	Respite, support services
Weight	-	ROUTINE	ROUTINE	-	Each visit	Stable	Nutrition, dysphagia evaluation
Falls assessment	-	ROUTINE	ROUTINE	-	Each visit	None	PT, home safety
Driving safety	-	-	ROUTINE	-	Annually or with decline	Safe to drive	Driving evaluation, cessation
Medication reconciliation	-	ROUTINE	ROUTINE	-	Each visit	No inappropriate medications	D/C anticholinergics, sedatives
MRI (if on anti-amyloid therapy)	-	-	ROUTINE	-	Per protocol	No ARIA	Hold therapy if ARIA

7. DISPOSITION CRITERIA¶

Disposition	Criteria
Outpatient workup	Most patients; mild-moderate symptoms, safe home environment, caregiver present
Admit to hospital	Acute behavioral crisis, unable to care for self, unsafe home environment, need for IV therapies, rapid progression needing urgent workup
Discharge from hospital	Reversible causes treated, behavior stable, safe disposition, follow-up arranged
Memory care/Assisted living	Unable to live independently, unsafe with current support level
Skilled nursing facility	Advanced dementia, 24-hour care needs, complex medical needs
Hospice	End-stage dementia, FAST stage 7, goals of care focused on comfort

8. EVIDENCE & REFERENCES¶

Recommendation	Evidence Level	Source
MRI recommended in dementia workup	Class I, Level A	AAN Practice Parameters (Knopman et al., Neurology 2001)
B12, TSH, metabolic panel in all patients	Class I, Level A	AAN Practice Parameters (Knopman et al., Neurology 2001)
Cholinesterase inhibitors for mild-moderate AD	Class I, Level A	Cochrane Reviews
Memantine for moderate-severe AD	Class I, Level A	Cochrane Reviews
Combination ChEI + memantine	Class I, Level A	DOMINO trial (Howard et al., NEJM 2012)
Lecanemab slows cognitive decline in early AD	Class I, Level A	Clarity AD trial (van Dyck et al., NEJM 2023); FDA approved 2023
Donanemab slows decline in early AD	Class I, Level A	TRAILBLAZER-ALZ 2 (Sims et al., JAMA 2023); FDA approved 2024
Non-pharmacologic interventions for BPSD first-line	Class I, Level A	APA Guidelines
Antipsychotics increase mortality in dementia	Class I, Level A	FDA black box warning
CSF biomarkers (Aβ42, tau, p-tau) support AD diagnosis	Class II, Level A	AT(N) framework
Amyloid PET useful for diagnostic uncertainty	Class II, Level B	Appropriate Use Criteria
Exercise may slow cognitive decline	Class II, Level B	Multiple RCTs

NOTES¶

Dementia is a clinical diagnosis; workup identifies etiology and reversible causes
"Reversible dementia" accounts for ~10% of cases; always screen for B12, thyroid, medications
Cholinesterase inhibitors provide modest symptomatic benefit; do not alter disease course
Anti-amyloid therapies (lecanemab, donanemab) are disease-modifying but modest effect; require amyloid confirmation, MRI monitoring for ARIA
DLB patients extremely sensitive to antipsychotics - avoid or use quetiapine cautiously
Involve family/caregivers in all visits; caregiver burnout is common
Advance care planning should occur early while patient can participate
"No anticholinergics" in dementia patients - review all medications

CHANGE LOG¶

v1.0 (January 29, 2026) - Initial template creation - Comprehensive laboratory and imaging workup - Included disease-modifying therapies (lecanemab, donanemab) - BPSD management section - Dementia-specific treatments by etiology