Clinical Commander

All dossiers
symptom.dementia.v1

Dementia / cognitive impairment

symptomchronicsubacuteadultgeriatricoutpatienttransition
Start encounter →Print handoutPRODUCTION

Phase C shard-3-neuro-sym deepening pass (2026-05-14) — full §5.5 contract depth. Pattern peers: symptom.vertigo.v1 (04bf795f) + symptom.chest_pain.ed_undifferentiated.v1 (be7b7d2f). Engine scope: outpatient cognitive workup — distinguish reversible mimics from neurodegenerative etiologies (AD, vascular, DLB, FTD, PDD, CJD, NPH); stratify anti-amyloid mAb eligibility for early AD; arm caregivers with home + ED + ICU + inpatient + outpatient playbooks. Downstream confirmed diagnoses route to dedicated engines once authored (next-pass targets in depth bundle: dedicated AD / FTD / DLB / vascular dementia engines). Bayesian linkage (LR+, LR−, T_treat, T_test, conditional dependencies, pre-test priors by etiology) and anti-amyloid mAb eligibility decision tree (lecanemab vs donanemab, amyloid PET requirements, APOE stratification, ARIA-E/H monitoring) live in companion depth bundle _briefs/symptom.dementia.v1.depth.md — schema has no first-class likelihood-ratio field. 5 setting playbooks (home, ed, icu, inpatient, outpatient). 13 severity triggers (≥6 per spec): ad_amyloid_positive + vascular_dementia + dlb_phenotype + ftd_phenotype + cjd_rapid_decline + nph_hakim_triad + reversible_b12_or_thyroid + delirium_superimposed_on_dementia + lecanemab_or_donanemab_eligible + aria_e_or_h_on_mab + antipsychotic_initiation_in_dementia + driving_safety_concern + caregiver_burnout_or_abuse_risk. 2 sibling differentiation rows (psych.depression.core.v1 + symptom.falls.v1) — both verified to exist in ALL_DOSSIERS registry. Additional look-alikes (delirium, MCI, normal aging) captured as pivots in depth bundle (no dedicated dossiers yet). Schema-blocked items surfaced (in depth bundle): MoCA codifier, MMSE codifier, FAST stage, CDR (Clinical Dementia Rating), NPI (Neuropsychiatric Inventory), GDS (Geriatric Depression Scale), Hachinski Ischemic Score, Zarit Burden Interview, ARIA grading codifier — none in clinical-tools-registry.ts; cross-shard tickets emitted to shard-0. Modern view captured: anti-amyloid mAb era (lecanemab CLARITY-AD + donanemab TRAILBLAZER-ALZ 2) with strict eligibility + ARIA-E/H monitoring; DLB extreme antipsychotic sensitivity (rivastigmine first-line; avoid risperidone + typicals); FTD ChEI may worsen behaviour (SSRI first-line); BPSD non-pharm DICE first (APA 2024); blood p-tau217 reduces reliance on LP/PET (ALZ-NET 2024-2026). PMIDs (10): NIA-AA 2018 (29653606), CLARITY-AD (36449413), TRAILBLAZER-ALZ 2 (37459141), AAN MCI 2018 (29282327), MMSE (1202204), MoCA (15817019), McKeith DLB 2017 (28592453), Rascovsky bvFTD 2011 (21810890), Zerr CJD 2009 (19773352), CitAD (24549548). All marked NEEDS_SOURCE_REVIEW per shard convention.

Entry points (8)

  • symptom
    Memory or cognitive complaint reported by patient, family, or caregiver (AAN 2018 MCI PMID 29282327)
    cognitive_complaint_patient_or_family
  • symptom
    IADL/ADL decline ≥6 months (NIA-AA 2018 PMID 29653606)
    functional_decline_iadl
  • symptom
    New agitation, apathy, depression, or psychotic features in older adult (APA 2024; AGS Beers 2023)
    behavioural_disturbance
  • symptom
    Behavioural disinhibition / apathy / executive dysfunction in patient <65 — bvFTD or genetic AD (Rascovsky 2011 PMID 21810890)
    personality_or_executive_change_under_65
  • symptom
    Recurrent visual hallucinations OR RBD by partner report — DLB (McKeith 2017 PMID 28592453)
    visual_hallucinations_or_rem_sleep_behaviour
  • symptom
    Hakim triad — magnetic gait + urinary incontinence + cognitive decline — NPH workup (Williams 2019 NPH consensus)
    gait_apraxia_incontinence_cognition
  • lab_abnormality
    MoCA <26 or MMSE <24 in primary care (Nasreddine 2005 PMID 15817019; Folstein 1975 PMID 1202204)
    abnormal_moca_in_primary_care
  • history
    Rapid decline over weeks-months — CJD / autoimmune encephalitis workup (Zerr 2009 PMID 19773352)
    rapid_cognitive_decline

Required inputs (26)

  • agerequired
    demographic • used at CONTEXT
    Age <60 + family history flags genetic AD / FTD; age >85 raises mixed pathology (NIA-AA 2018 PMID 29653606)
  • iadl_adl_functionrequired
    history • used at CONTEXT
    Major vs mild NCD hinges on functional independence (DSM-5; AAN 2018 PMID 29282327)
  • symptom_onset_temporequired
    history • used at FRAME
    Rapid (<1 yr) → CJD / autoimmune (Zerr 2009 PMID 19773352); insidious → AD / FTD; stepwise → vascular
  • vascular_risk_factorsrequired
    history • used at CONTEXT
    HTN / DM / AF / smoking → vascular contribution; Hachinski Ischemic Score discriminates (AAN 2018 PMID 29282327)
  • parkinsonism_or_rem_sleep_behaviorrequired
    history • used at DIFFERENTIAL
    DLB / PDD criteria — REM sleep behaviour disorder (RBD) most specific prodromal marker (McKeith 2017 PMID 28592453)
  • visual_hallucinationsrequired
    history • used at DIFFERENTIAL
    Recurrent well-formed visual hallucinations — DLB core feature (McKeith 2017 PMID 28592453)
  • behavioural_disinhibition_or_apathy
    history • used at DIFFERENTIAL
    bvFTD pivot — early personality change, disinhibition, apathy, stereotypies, hyperorality (Rascovsky 2011 PMID 21810890)
  • language_dysfunction_pattern
    history • used at DIFFERENTIAL
    Primary progressive aphasia (PPA) — semantic / agrammatic / logopenic variants distinct from amnestic AD (Rascovsky 2011 PMID 21810890)
  • cam_4at_for_deliriumrequired
    history • used at RED_FLAGS
    CAM / 4AT screens for delirium — acute fluctuating attention must be excluded before chronic dementia label (Inouye CAM original)
  • depression_screen_phq9_or_gdsrequired
    history • used at CONTEXT
    Depression mimics dementia (pseudodementia) and is treatable; GDS preferred in elderly (AAN 2018 PMID 29282327)
  • current_medsrequired
    medication • used at CONTEXT
    Anticholinergic, benzodiazepine, opioid, sedating antihistamine, long-term PPI, H2-blocker — deprescribe per AGS Beers 2023
  • caregiver_burden_zarit
    history • used at FOLLOWUP
    Caregiver Zarit ≥21 drives institutionalization; assess respite + adult protective services as needed (APA 2024)
  • tshrequired
    lab • used at INITIAL_WORKUP
    Hypothyroid mimic — reversible (AAN 2018 PMID 29282327)
  • b12required
    lab • used at INITIAL_WORKUP
    B12 deficiency — reversible, treat with IM if <200 pg/mL (AAN 2018 PMID 29282327)
  • folate
    lab • used at INITIAL_WORKUP
    Folate deficiency mimic (AAN 2018 PMID 29282327)
  • vitamin_d
    lab • used at INITIAL_WORKUP
    Low vitamin D associated with cognitive decline (NICE 2024 dementia)
  • rpr_or_treponemalrequired
    lab • used at INITIAL_WORKUP
    Neurosyphilis is a reversible dementia (AAN 2018 PMID 29282327)
  • hivrequired
    lab • used at INITIAL_WORKUP
    HIV-associated neurocognitive disorder (HAND) is treatable with ART (AAN 2018 PMID 29282327)
  • hba1c_and_lipidsrequired
    lab • used at INITIAL_WORKUP
    Vascular dementia secondary prevention — DM + dyslipidemia control reduces stepwise progression (AAN 2018; 2025 ACC/AHA HTN; 2026 ACC/AHA Lipid)
  • csf_amyloid_tau_or_blood_ptau217
    lab • used at BRANCHING_WORKUP
    AD biomarker confirmation before anti-amyloid mAb; blood p-tau217 increasingly available (NIA-AA 2018 PMID 29653606; ALZ-NET 2024-2026)
  • apoe_genotype_for_aria_risk
    lab • used at RISK_STRATIFICATION
    APOE e4/e4 homozygote → higher ARIA-E/H risk on anti-amyloid mAb (CLARITY-AD van Dyck NEJM 2023 PMID 36449413)
  • csf_rt_quic_if_cjd_suspected
    lab • used at BRANCHING_WORKUP
    CSF RT-QuIC sens >95% / spec ~100% for sporadic CJD (Zerr 2009 PMID 19773352)
  • mri_brainrequired
    imaging • used at INITIAL_WORKUP
    Atrophy patterns (hippocampal AD, frontal FTD, midbrain PSP), small-vessel ischemic burden, NPH ventriculomegaly + DESH, structural lesions, DWI cortical ribboning + pulvinar sign for CJD (Zerr 2009 PMID 19773352)
  • fdg_pet
    imaging • used at BRANCHING_WORKUP
    FDG hypometabolism patterns — biparietal/temporal AD vs frontotemporal FTD (NIA-AA 2018 PMID 29653606)
  • amyloid_pet
    imaging • used at BRANCHING_WORKUP
    Confirms AD biology before mAb when CSF/blood unavailable (NIA-AA 2018 PMID 29653606)
  • dat_spect_if_dlb_suspected
    imaging • used at BRANCHING_WORKUP
    DAT-SPECT (DaTscan ioflupane) — reduced striatal dopaminergic uptake supports DLB / PDD (McKeith 2017 PMID 28592453)

12-phase flow (12)

  1. 1FRAME
    Confirm cognitive complaint with corroboration; functional decline ≥6 mo defines major NCD vs mild NCD (DSM-5; AAN 2018 PMID 29282327; NIA-AA 2018 PMID 29653606)
    inputs: symptom_onset_tempo, iadl_adl_function
    advance: Cognitive impairment vs subjective complaint clarified; major vs mild NCD assigned (AAN 2018 PMID 29282327)
  2. 2ENTRY
    Patient/family concern, physician noticed decline, abnormal MoCA in primary care, behavioural disturbance, RBD, Hakim triad, rapid decline (AAN 2018 PMID 29282327; McKeith 2017; Williams 2019)
    inputs: age
    advance: Entry pattern recognized
  3. 3CONTEXT
    IADL/ADL, vascular risks, depression PHQ-9/GDS, alcohol AUDIT-C, meds anticholinergic/benzo/opioid, sleep RBD/OSA, hearing, vision, education level (cognitive reserve) (AAN 2018; AGS Beers 2023; NICE 2024 dementia)
    inputs: iadl_adl_function, vascular_risk_factors, depression_screen_phq9_or_gds, current_meds, parkinsonism_or_rem_sleep_behavior, visual_hallucinations
    advance: Full functional + medication + sleep + sensory context complete
  4. 4RED_FLAGS
    Rapid decline (Zerr 2009 PMID 19773352), NPH triad gait/incontinence/cognition (Williams 2019), focal deficit, age <60 + family history, status epilepticus + cognitive change → autoimmune encephalitis (anti-NMDAR / anti-LGI1), DELIRIUM (CAM/4AT) — never call new chronic dementia in acute fluctuating state
    inputs: symptom_onset_tempo, cam_4at_for_delirium
    actions: workup.delirium, workup.anti_nmdar_encephalitis
    advance: Delirium excluded + atypical / urgent etiologies routed
  5. 5INITIAL_WORKUP
    MoCA preferred over MMSE (Nasreddine 2005 PMID 15817019; Folstein 1975 PMID 1202204); PHQ-9 or GDS; CBC, CMP, TSH, B12, folate, vitamin D, HIV, RPR, HbA1c, lipids; MRI brain (AAN 2018 PMID 29282327)
    inputs: tsh, b12, rpr_or_treponemal, hiv, hba1c_and_lipids, mri_brain
    actions: panel.cbc, panel.thyroid, workup.dementia
    advance: Reversible mimics screened + structural imaging done
  6. 6BRANCHING_WORKUP
    CSF Aβ42/40 + p-tau181/217 + t-tau OR blood p-tau217 before mAb (NIA-AA 2018 PMID 29653606); FDG-PET to distinguish FTD vs AD; amyloid-PET; DAT-SPECT for DLB (McKeith 2017 PMID 28592453); EEG + CSF RT-QuIC for CJD (Zerr 2009 PMID 19773352); autoimmune panel (anti-NMDAR / anti-LGI1) for rapid decline + seizures
    inputs: csf_amyloid_tau_or_blood_ptau217, fdg_pet, amyloid_pet, dat_spect_if_dlb_suspected, csf_rt_quic_if_cjd_suspected
    advance: Biomarker / specialist workup as warranted
  7. 7DIFFERENTIAL
    AD (most common) / vascular / DLB / FTD (bvFTD + PPA variants) / PDD / mixed / CJD / NPH / reversible (B12, hypothyroid, neurosyphilis, HIV, depression, medication, autoimmune) / delirium superimposed on dementia (AAN 2018; NIA-AA 2018; McKeith 2017; Rascovsky 2011; Zerr 2009)
    advance: Diagnosis or differential narrowed
  8. 8RISK_STRATIFICATION
    CDR or FAST staging (mild / moderate / severe); ARIA-E/H risk (APOE e4 homozygote, microbleeds, superficial siderosis) before anti-amyloid mAb (CLARITY-AD van Dyck NEJM 2023 PMID 36449413); Hachinski Ischemic Score for vascular vs degenerative; Zarit caregiver burden
    inputs: apoe_genotype_for_aria_risk
    advance: Stage + mAb candidacy + caregiver risk evaluated
  9. 9TREATMENT
    Cognitive enhancer donepezil/rivastigmine/galantamine + memantine (AAN 2018); lecanemab (CLARITY-AD van Dyck NEJM 2023 PMID 36449413) or donanemab (TRAILBLAZER-ALZ 2 Sims JAMA 2023 PMID 37459141) for biomarker-confirmed early AD; behavioural management DICE non-pharm first (APA 2024); SSRI for depression / FTD disinhibition; treat OSA + hearing/vision; deprescribe AGS Beers 2023; advance directives; VP shunt for selected NPH (Williams 2019)
    inputs: csf_amyloid_tau_or_blood_ptau217
    advance: Tailored regimen + non-pharm plan documented
  10. 10DISPOSITION
    Outpatient cognitive clinic; admit if behavioural crisis, superimposed delirium, suspected CJD / autoimmune encephalitis; ICU rarely (refractory status epilepticus from autoimmune encephalitis) (AAN 2018)
    advance: Disposition documented
  11. 11MONITORING
    Annual MoCA / function review; ARIA MRI surveillance before infusions 5/7/14 on mAb (CLARITY-AD PMID 36449413; TRAILBLAZER-ALZ 2 PMID 37459141); AGS Beers 2023 deprescribe sweep q6 mo; antipsychotic taper attempt q3 mo if used
    advance: Monitoring plan documented
  12. 12FOLLOWUP
    Caregiver education + support, dementia care navigator, driving evaluation, capacity assessment, advance care planning + POLST, palliative referral at FAST 7 (NICE 2024 dementia; APA 2024)
    inputs: caregiver_burden_zarit
    advance: Caregiver + advance care plan established