Clinical Commander

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geriatrics.dementia-alzheimer.core.v1

Alzheimer disease dementia

general_internal_medicinechronicgeriatricadultoutpatientinpatient
Start encounter →Print handoutPRODUCTION

Manifest points at the shared real placeholder prisma/seed/manifests/neuro.dementia.core.v1.ts — no dedicated geriatrics.dementia-alzheimer manifest or problem-package folder yet (deferred; tracked in design brief Open gaps). No rxcui on any RegimenDrug — all pharmacologic ChEI/memantine/anti-amyloid/antipsychotic entries are name-only pending RxNav validation (Stage-A); diagnostic/non-pharm/deprescribing/monitoring actions carry non_pharm:true. Sibling engine ids geriatrics.delirium.core.v1 and geriatrics.dementia-lewy-body.core.v1 are referenced by id; on-disk siblings currently exist as neuro.delirium.v1 / neuro.vascular-dementia.v1 / symptom.dementia.v1 — id reconciliation deferred. Anti-amyloid pathway encodes biomarker-gated eligibility + protocolized ARIA-E/H MRI surveillance; calc.moca + calc.acb_scale + calc.gds_15 used (no calc.cdr/calc.fast adapter in registry yet).

Entry points (4)

  • symptom
    Insidious progressive episodic memory loss with functional decline (informant-corroborated)
    progressive_memory_loss
  • problem_list
    Established MCI on surveillance — amnestic phenotype progressing toward dementia
    mild_cognitive_impairment
  • history
    Caregiver reports IADL decline (finances, medications, driving, cooking)
    caregiver_concern_iadl_decline
  • demographic
    Age >=65 presenting with cognitive concern at routine or wellness visit (NICE NG97)
    age_65_plus_cognitive_concern

Required inputs (14)

  • agerequired
    demographic • used at FRAME
    Sporadic AD risk rises with age; early-onset (<65) prompts atypical/genetic workup (AAN 2018)
  • cognitive_symptom_timelinerequired
    history • used at ENTRY
    Insidious months-to-years onset distinguishes AD from rapidly progressive dementia and delirium (AAN 2018)
  • informant_historyrequired
    history • used at CONTEXT
    Informant/collateral required — patient anosognosia underestimates deficits; defines functional decline (NICE NG97)
  • functional_status_adl_iadlrequired
    history • used at CONTEXT
    IADL-then-ADL decline defines dementia vs MCI and drives staging (CDR/FAST) (AA AUR 2021)
  • cognitive_domain_patternrequired
    history • used at DIFFERENTIAL
    Amnestic-predominant with later executive/visuospatial/language vs early behavioral/language/visual (FTD/DLB pivots) (AAN 2018)
  • current_medsrequired
    medication • used at CONTEXT
    Anticholinergic/sedative burden is a reversible contributor; informs deprescribing and ChEI bradycardia risk (AGS Beers 2023)
  • vascular_risk_factorsrequired
    history • used at CONTEXT
    HTN/DM/AF/smoking modify trajectory; mixed AD-vascular pathology common; anticoagulation gates anti-amyloid (NICE NG97)
  • depression_screenrequired
    history • used at INITIAL_WORKUP
    Depression (pseudodementia) is reversible and mimics amnestic decline; GDS-15 screen (NICE NG97)
  • b12required
    lab • used at INITIAL_WORKUP
    B12 deficiency is a reversible/contributing cause — mandatory exclusion before attributing to AD (AAN 2018)
  • tshrequired
    lab • used at INITIAL_WORKUP
    Hypothyroidism is a reversible/contributing cause — mandatory exclusion (AAN 2018)
  • structural_brain_mrirequired
    imaging • used at INITIAL_WORKUP
    MRI (or CT) excludes NPH, subdural, tumor, strategic infarct; hippocampal/medial-temporal atrophy supports AD (NICE NG97)
  • ad_biomarker_status
    history • used at BRANCHING_WORKUP
    Amyloid PET / CSF Aβ42:40 + p-tau / plasma p-tau217 — biomarker confirmation REQUIRED before anti-amyloid therapy (AA AUR 2021)
  • apoe_genotype
    history • used at RISK_STRATIFICATION
    APOE ε4 (esp. homozygote) markedly increases ARIA-E/H risk on anti-amyloid mAbs — required before initiation (CLARITY-AD)
  • caregiver_and_capacityrequired
    history • used at CONTEXT
    Caregiver availability/burden and decision-making capacity drive ACP, driving, finances, and disposition (NICE NG97)

12-phase flow (12)

  1. 1FRAME
    Confirm scope: chronic insidious progressive cognitive decline in an older adult; not acute confusion (delirium) or rapidly progressive (<1-2y) dementia (AAN 2018)
    inputs: age, cognitive_symptom_timeline
    advance: Chronic progressive cognitive complaint established; acute/rapid course excluded or pivoted (AAN 2018)
  2. 2ENTRY
    Capture trigger: progressive episodic memory loss, MCI under surveillance, caregiver-reported IADL decline, or cognitive concern at wellness visit (NICE NG97)
    inputs: cognitive_symptom_timeline
    advance: Entry trigger documented with onset and tempo (NICE NG97)
  3. 3CONTEXT
    Informant history, ADL/IADL baseline, full medication review (anticholinergic/sedative burden), vascular risk factors, alcohol/sleep, education/literacy, caregiver availability and decision-making capacity (NICE NG97)
    inputs: informant_history, functional_status_adl_iadl, current_meds, vascular_risk_factors, caregiver_and_capacity
    actions: workup.cga, workup.beers_screen
    advance: Informant-corroborated functional baseline and contributory-factor context established (NICE NG97)
  4. 4RED_FLAGS
    Rapid progression (<1-2y → CJD/autoimmune/paraneoplastic), early prominent behavioral/language (FTD), early visual hallucinations/parkinsonism/REM-sleep-behavior (DLB — antipsychotic hypersensitivity), early gait/incontinence (NPH/vascular), focal deficits, superimposed delirium (AAN 2018)
    inputs: cognitive_symptom_timeline, cognitive_domain_pattern
    actions: workup.delirium
    advance: No red flag, or red flag pivots case to the appropriate engine/rapid workup (AAN 2018)
  5. 5INITIAL_WORKUP
    Objective cognitive testing (MoCA/MMSE), functional assessment, depression screen (GDS-15), anticholinergic burden (ACB); reversible-cause labs B12/TSH + CMP/CBC; structural MRI (or CT) to exclude NPH/subdural/tumor/strategic infarct (AAN 2018)
    inputs: depression_screen, b12, tsh, structural_brain_mri, functional_status_adl_iadl
    actions: workup.dementia, calc.moca, calc.gds_15, calc.acb_scale, panel.metabolic, panel.cmp, panel.cbc, panel.tsh
    advance: Cognitive/functional profile quantified; reversible/contributing causes excluded or treated; structural imaging reviewed (AAN 2018)
  6. 6BRANCHING_WORKUP
    AD biomarker confirmation when diagnosis uncertain or anti-amyloid therapy considered: amyloid PET, CSF Aβ42/40 + p-tau181, or plasma p-tau217; ATN/AD-continuum framing; targeted workup if rapid (CJD: MRI DWI, CSF RT-QuIC, EEG; autoimmune/paraneoplastic panel) (AA AUR 2021)
    inputs: ad_biomarker_status, cognitive_domain_pattern
    advance: Biomarker status resolved (amyloid-positive AD vs alternative) or rapid-dementia workup launched (AA AUR 2021)
  7. 7DIFFERENTIAL
    AD (amnestic-onset, amyloid+) vs vascular (stepwise, executive, infarct burden), DLB (early visual hallucinations/parkinsonism/RBD/fluctuation, antipsychotic hypersensitivity), FTD (early behavioral/language, younger), NPH (gait+incontinence+cognition triad), pseudodementia (depression), reversible (B12/TSH/meds), delirium (acute fluctuating inattention) (AAN 2018)
    inputs: cognitive_domain_pattern, ad_biomarker_status
    advance: Most-likely terminal diagnosis assigned with phenotype/biomarker support; siblings differentiated (AAN 2018)
  8. 8RISK_STRATIFICATION
    Stage severity — MCI vs mild vs moderate vs severe via CDR/FAST and MoCA/MMSE trajectory; anticholinergic cognitive burden (ACB); for anti-amyloid candidacy: early AD (MCI/mild), amyloid-confirmed, APOE ε4 status (ARIA risk), anticoagulation/bleeding risk, baseline MRI microhemorrhage burden (CLARITY-AD; AA AUR 2021)
    inputs: functional_status_adl_iadl, apoe_genotype
    actions: calc.moca, calc.acb_scale
    advance: Stage assigned; anti-amyloid eligibility and ARIA risk stratified (AA AUR 2021)
  9. 9TREATMENT
    Non-pharm cornerstone (cognitive/behavioral support, structured routine, caregiver education/support/respite, exercise, vascular-risk + sensory optimization, deprescribe anticholinergics/sedatives, advance care planning + capacity/driving/finances early); symptomatic ChEI by stage ± memantine moderate-severe; disease-modifying anti-amyloid mAb (lecanemab/donanemab) only for amyloid-confirmed early AD with eligibility met + ARIA MRI surveillance; BPSD — treat triggers (pain/infection/environment) and non-pharm FIRST, time-limited low-dose antipsychotic only for severe danger/distress (boxed mortality; AVOID in DLB), avoid benzodiazepines (NICE NG97; AA AUR 2021)
    inputs: functional_status_adl_iadl, current_meds, ad_biomarker_status, caregiver_and_capacity
    advance: Non-pharm plan + caregiver support + ACP in place; stage-appropriate pharmacotherapy and (if eligible) anti-amyloid pathway initiated (NICE NG97)
  10. 10DISPOSITION
    Predominantly outpatient with memory-clinic/geriatrics/neurology co-management; inpatient only for superimposed delirium, BPSD crisis with danger, ARIA-E/H, or caregiver breakdown; infusion-center logistics for anti-amyloid; long-term-care planning in advanced disease (NICE NG97)
    inputs: caregiver_and_capacity
    advance: Care setting and multidisciplinary referrals (memory clinic, social work, caregiver support) confirmed (NICE NG97)
  11. 11MONITORING
    Cognitive/functional re-assessment (MoCA/MMSE + ADL/IADL) every 6-12 months; ChEI tolerability (GI, bradycardia/syncope, weight); on anti-amyloid — protocolized surveillance MRI for ARIA-E/H (before doses 5/7/14 per label and if symptomatic); caregiver burden screening at each visit; deprescribing follow-through (AA AUR 2021)
    inputs: functional_status_adl_iadl, current_meds
    actions: calc.moca, calc.acb_scale
    advance: Monitoring cadence set; no untreated ARIA, intolerable ChEI ADR, or caregiver crisis (AA AUR 2021)
  12. 12FOLLOWUP
    Advance care planning revisited at each transition; driving/finances/capacity reviewed; caregiver respite and support referral; vascular-risk and sensory optimization maintained; palliative/end-of-life planning and ChEI/memantine deprescribing decision in advanced (severe) disease (NICE NG97)
    inputs: caregiver_and_capacity
    advance: ACP documented; caregiver support arranged; next cognitive review and goals-of-care interval scheduled (NICE NG97)