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geriatrics.dementia-alzheimer.core.v1PRODUCTION
geriatrics.dementia-alzheimer.core.v1

Alzheimer disease dementia

general_internal_medicinechronicgeriatricadult
Hard-required inputs
0 / 12
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm scope: chronic insidious progressive cognitive decline in an older adult; not acute confusion (delirium) or rapidly progressive (<1-2y) dementia (AAN 2018)

Inputs
2
Actions
0
Advance rule
Set
Advance when

Chronic progressive cognitive complaint established; acute/rapid course excluded or pivoted (AAN 2018)

Patient inputs (14)

Informant/collateral required — patient anosognosia underestimates deficits; defines functional decline (NICE NG97)

IADL-then-ADL decline defines dementia vs MCI and drives staging (CDR/FAST) (AA AUR 2021)

Anticholinergic/sedative burden is a reversible contributor; informs deprescribing and ChEI bradycardia risk (AGS Beers 2023)

HTN/DM/AF/smoking modify trajectory; mixed AD-vascular pathology common; anticoagulation gates anti-amyloid (NICE NG97)

Caregiver availability/burden and decision-making capacity drive ACP, driving, finances, and disposition (NICE NG97)

Amnestic-predominant with later executive/visuospatial/language vs early behavioral/language/visual (FTD/DLB pivots) (AAN 2018)

Insidious months-to-years onset distinguishes AD from rapidly progressive dementia and delirium (AAN 2018)

Sporadic AD risk rises with age; early-onset (<65) prompts atypical/genetic workup (AAN 2018)

Depression (pseudodementia) is reversible and mimics amnestic decline; GDS-15 screen (NICE NG97)

B12 deficiency is a reversible/contributing cause — mandatory exclusion before attributing to AD (AAN 2018)

Hypothyroidism is a reversible/contributing cause — mandatory exclusion (AAN 2018)

MRI (or CT) excludes NPH, subdural, tumor, strategic infarct; hippocampal/medial-temporal atrophy supports AD (NICE NG97)

Amyloid PET / CSF Aβ42:40 + p-tau / plasma p-tau217 — biomarker confirmation REQUIRED before anti-amyloid therapy (AA AUR 2021)

APOE ε4 (esp. homozygote) markedly increases ARIA-E/H risk on anti-amyloid mAbs — required before initiation (CLARITY-AD)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningdelirium_superimposed_on_dementia
    Acute fluctuating inattention/altered consciousness superimposed on baseline dementia (NICE NG97)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningantipsychotic_in_suspected_lewy_body
    Antipsychotic considered/given in a patient with early visual hallucinations, parkinsonism, fluctuation, or RBD (suspected DLB) (NICE NG97)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningaria_e_h_on_anti_amyloid
    ARIA-E (vasogenic edema) or ARIA-H (microhemorrhage/superficial siderosis/macrohemorrhage) on anti-amyloid mAb, symptomatic or significant on surveillance MRI (AA AUR 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererapidly_progressive_dementia
    Cognitive decline progressing to dementia over <1-2 years (or weeks-months) — atypical for AD (AAN 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebpsd_danger_to_self_or_others
    Behavioral & psychological symptoms with danger to self/others or severe unrelievable distress (NICE NG97)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatereversible_cause_identified
    Significant B12 deficiency, hypothyroidism, NPH triad, or anticholinergic/sedative-driven decline identified (AAN 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

INITIAL_WORKUPrequiredDrives screening
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Recommended regimen

Alzheimer disease care ladder — exclude reversible → non-pharm/caregiver/ACP → ChEI by stage → memantine → anti-amyloid → BPSD → deprescribe
axis: ad_care_ladderstep 1 - Step 1 — Exclude reversible/contributing causes + biomarker confirmation
Selected step "Step 1 — Exclude reversible/contributing causes + biomarker confirmation" — Any patient before attributing decline to AD or starting AD-directed therapy
  • reversible_cause_workup
    first line
    diagnostic_action
    triggers: cognitive_decline_new
    AAN 2018 — B12, TSH, depression (GDS-15), medication/anticholinergic burden, structural MRI (NPH/subdural/tumor) excluded/treated before AD attribution
  • ad_biomarker_testing
    first line
    diagnostic_action
    triggers: diagnosis_uncertain, anti_amyloid_considered
    AA AUR 2021 — amyloid PET or CSF Aβ42/40 + p-tau181 (or plasma p-tau217); amyloid confirmation REQUIRED before any anti-amyloid mAb

outpatient playbook — drug actions (6)

  1. 1. reversible-cause workup + biomarker confirmation
    n/a • n/a • at diagnosis
    trigger: New cognitive decline
    AAN 2018 — exclude B12/TSH/depression/meds/NPH before AD attribution; amyloid confirmation gates anti-amyloid
  2. 2. non-pharm + caregiver education/respite + ACP
    n/a • n/a • ongoing from diagnosis
    trigger: AD confirmed
    NICE NG97 — cornerstone; ACP/capacity/driving/finances addressed early
  3. 3. donepezil (or rivastigmine/galantamine)
    donepezil 5 mg, up-titrate to 10 mg after 4-6 wk • PO • once daily
    trigger: Mild-moderate (or severe for donepezil/rivastigmine)
    NICE NG97 — first-line symptomatic; counsel modest benefit
  4. 4. memantine
    5 mg titrate to 10 mg BID • PO • daily→BID
    trigger: Moderate-severe (MMSE ~<=20)
    NICE NG97 — add-on or monotherapy if ChEI intolerant
  5. 5. lecanemab (or donanemab)
    lecanemab 10 mg/kg • IV infusion • q2 weeks (donanemab q4 weeks)
    trigger: Amyloid-confirmed early AD, eligibility met, ARIA MRI surveillance in place
    CLARITY-AD / TRAILBLAZER-ALZ 2 — modest disease modification; biomarker-gated
  6. 6. risperidone (BPSD, last resort)
    0.25-0.5 mg lowest effective, time-limited • PO • once-twice daily, review 6-12 wk
    trigger: Severe agitation/psychosis with danger, non-pharm failed, NOT DLB
    NICE NG97 — boxed mortality; trigger search + non-pharm FIRST

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Insidious progressive episodic memory loss with functional decline (informant-corroborated); Established MCI on surveillance — amnestic phenotype progressing toward dementia; Caregiver reports IADL decline (finances, medications, driving, cooking).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Alzheimer disease dementia** (geriatrics.dementia-alzheimer.core.v1).
Phenotype framing: 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)
Scope: Confirm scope: chronic insidious progressive cognitive decline in an older adult; not acute confusion (delirium) or rapidly progressive (<1-2y) dementia (AAN 2018)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Alzheimer disease care ladder — exclude reversible → non-pharm/caregiver/ACP → ChEI by stage → memantine → anti-amyloid → BPSD → deprescribe** — step "Step 1 — Exclude reversible/contributing causes + biomarker confirmation".
1. reversible_cause_workup (diagnostic_action, first line) — AAN 2018 — B12, TSH, depression (GDS-15), medication/anticholinergic burden, structural MRI (NPH/subdural/tumor) excluded/treated before AD attribution
2. ad_biomarker_testing (diagnostic_action, first line) — AA AUR 2021 — amyloid PET or CSF Aβ42/40 + p-tau181 (or plasma p-tau217); amyloid confirmation REQUIRED before any anti-amyloid mAb

Setting playbook (outpatient) — Diagnose and stage AD, exclude reversible causes, establish non-pharm/caregiver/ACP cornerstone, initiate stage-appropriate therapy, run anti-amyloid pathway with ARIA surveillance when eligible
3. reversible-cause workup + biomarker confirmation n/a n/a at diagnosis — New cognitive decline (AAN 2018 — exclude B12/TSH/depression/meds/NPH before AD attribution; amyloid confirmation gates anti-amyloid)
4. non-pharm + caregiver education/respite + ACP n/a n/a ongoing from diagnosis — AD confirmed (NICE NG97 — cornerstone; ACP/capacity/driving/finances addressed early)
5. donepezil (or rivastigmine/galantamine) donepezil 5 mg, up-titrate to 10 mg after 4-6 wk PO once daily — Mild-moderate (or severe for donepezil/rivastigmine) (NICE NG97 — first-line symptomatic; counsel modest benefit)
6. memantine 5 mg titrate to 10 mg BID PO daily→BID — Moderate-severe (MMSE ~<=20) (NICE NG97 — add-on or monotherapy if ChEI intolerant)
7. lecanemab (or donanemab) lecanemab 10 mg/kg IV infusion q2 weeks (donanemab q4 weeks) — Amyloid-confirmed early AD, eligibility met, ARIA MRI surveillance in place (CLARITY-AD / TRAILBLAZER-ALZ 2 — modest disease modification; biomarker-gated)
8. risperidone (BPSD, last resort) 0.25-0.5 mg lowest effective, time-limited PO once-twice daily, review 6-12 wk — Severe agitation/psychosis with danger, non-pharm failed, NOT DLB (NICE NG97 — boxed mortality; trigger search + non-pharm FIRST)

Non-pharmacologic actions:
- Cognitive stimulation, structured routine, orientation aids, environmental modification
- Caregiver education, skills training, support groups, respite referral
- Advance care planning, surrogate, driving assessment, financial/legal capacity early
- Exercise program; vascular-risk and hearing/vision optimization
- Deprescribe anticholinergics/sedatives; minimize benzodiazepines
- BPSD: trigger search (pain, infection, constipation, environment) and non-pharm before any drug

AVOID / contraindication checks:
- Antipsychotic_boxed_increased_mortality_and_stroke_in_dementia_lowest_dose_time_limited (NICE NG97)
- Avoid_antipsychotic_in_dementia_with_lewy_bodies_severe_hypersensitivity (NICE NG97)
- Avoid_benzodiazepines_in_dementia_delirium_falls_paradoxical_agitation (AGS Beers 2023)
- Anti_amyloid_mab_anticoagulation_and_APOE_e4_homozygote_raise_ARIA_H_macrohemorrhage_risk_discuss (CLARITY AD)
- Anti_amyloid_mab_requires_amyloid_confirmation_and_protocolized_ARIA_MRI_surveillance (AA AUR 2023)
- Cholinesterase_inhibitor_bradycardia_syncope_GI_caution_baseline_HR_and_cardiac_history (NICE NG97)
- Avoid_abrupt_anticholinergic_or_benzodiazepine_withdrawal_taper_gradually (AGS Beers 2023)

Monitoring

Regimen monitoring:
- cognitive and functional MoCA MMSE ADL IADL q6-12mo (AA AUR 2021)
- cholinesterase inhibitor tolerability GI HR syncope weight at each titration (NICE NG97)
- memantine renal dose check CrCl (NICE NG97)
- ARIA surveillance MRI before 5th 7th 14th infusion and if symptomatic on anti amyloid mAb (AA AUR 2023)
- caregiver burden screen each visit (NICE NG97)
- anticholinergic burden ACB reassessment after deprescribing (AGS Beers 2023)

Setting (outpatient) monitoring:
- MoCA/MMSE + ADL/IADL q6-12mo (AA AUR 2021)
- ChEI tolerability — GI, HR/syncope, weight at each titration (NICE NG97)
- ARIA surveillance MRI per label on anti-amyloid mAb (AA AUR 2023)
- Caregiver burden screen each visit (NICE NG97)

Follow-up plan: 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)
- Close-out criterion: ACP documented; caregiver support arranged; next cognitive review and goals-of-care interval scheduled (NICE NG97)

Monitoring phase: 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)

Disposition

Current setting: outpatient — Diagnose and stage AD, exclude reversible causes, establish non-pharm/caregiver/ACP cornerstone, initiate stage-appropriate therapy, run anti-amyloid pathway with ARIA surveillance when eligible

Disposition criteria:
- Continue outpatient memory-clinic/geriatrics/neurology co-management when stable (NICE NG97)
- Refer long-term care/placement planning as disease advances and caregiver capacity is exceeded (NICE NG97)

Escalation triggers (move to higher acuity):
- Superimposed delirium or acute deterioration → inpatient workup (NICE NG97)
- BPSD with danger to self/others not controllable in clinic → inpatient/urgent (NICE NG97)
- ARIA-E/H symptomatic or significant on surveillance MRI → pause mAb + neurology (AA AUR 2023)
- Rapid progression (<1-2y) → rapid-dementia workup (CJD/autoimmune/paraneoplastic) (AAN 2018)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Acute fluctuating inattention/altered consciousness superimposed on baseline dementia (NICE NG97)
- [LIFE_THREATENING] Antipsychotic considered/given in a patient with early visual hallucinations, parkinsonism, fluctuation, or RBD (suspected DLB) (NICE NG97)
- [LIFE_THREATENING] ARIA-E (vasogenic edema) or ARIA-H (microhemorrhage/superficial siderosis/macrohemorrhage) on anti-amyloid mAb, symptomatic or significant on surveillance MRI (AA AUR 2023)

Citations

- 2018 AAN MCI Practice Guideline + 2021 Alzheimer's Association Appropriate Use Recommendations + 2023-2025 AD anti-amyloid appropriate-use (lecanemab CLARITY-AD, donanemab TRAILBLAZER-ALZ 2) + NICE NG97 Dementia [PMID:29282327](https://pubmed.ncbi.nlm.nih.gov/29282327/)
- Cited evidence (PMID 36449413) [PMID:36449413](https://pubmed.ncbi.nlm.nih.gov/36449413/)
- Cited evidence (PMID 37459141) [PMID:37459141](https://pubmed.ncbi.nlm.nih.gov/37459141/)
- Cited evidence (PMID 29653606) [PMID:29653606](https://pubmed.ncbi.nlm.nih.gov/29653606/)
- Cited evidence (PMID 34114333) [PMID:34114333](https://pubmed.ncbi.nlm.nih.gov/34114333/)

Last reconciled with current guidelines: 2026-05-16.
References
  • 2018 AAN MCI Practice Guideline + 2021 Alzheimer's Association Appropriate Use Recommendations + 2023-2025 AD anti-amyloid appropriate-use (lecanemab CLARITY-AD, donanemab TRAILBLAZER-ALZ 2) + NICE NG97 Dementia — PMID:29282327
  • Cited evidence (PMID 36449413) — PMID:36449413
  • Cited evidence (PMID 37459141) — PMID:37459141
  • Cited evidence (PMID 29653606) — PMID:29653606
  • Cited evidence (PMID 34114333) — PMID:34114333