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symptom.dementia.v1PRODUCTION
symptom.dementia.v1

Dementia / cognitive impairment

symptomchronicsubacuteadultgeriatric
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Encounter flow

12/12 authored

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

Current phase

Frame

Detailed

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
2
Actions
0
Advance rule
Set
Advance when

Cognitive impairment vs subjective complaint clarified; major vs mild NCD assigned (AAN 2018 PMID 29282327)

Patient inputs (26)

Age <60 + family history flags genetic AD / FTD; age >85 raises mixed pathology (NIA-AA 2018 PMID 29653606)

Major vs mild NCD hinges on functional independence (DSM-5; AAN 2018 PMID 29282327)

HTN / DM / AF / smoking → vascular contribution; Hachinski Ischemic Score discriminates (AAN 2018 PMID 29282327)

Depression mimics dementia (pseudodementia) and is treatable; GDS preferred in elderly (AAN 2018 PMID 29282327)

Anticholinergic, benzodiazepine, opioid, sedating antihistamine, long-term PPI, H2-blocker — deprescribe per AGS Beers 2023

DLB / PDD criteria — REM sleep behaviour disorder (RBD) most specific prodromal marker (McKeith 2017 PMID 28592453)

Recurrent well-formed visual hallucinations — DLB core feature (McKeith 2017 PMID 28592453)

Rapid (<1 yr) → CJD / autoimmune (Zerr 2009 PMID 19773352); insidious → AD / FTD; stepwise → vascular

Hypothyroid mimic — reversible (AAN 2018 PMID 29282327)

B12 deficiency — reversible, treat with IM if <200 pg/mL (AAN 2018 PMID 29282327)

Neurosyphilis is a reversible dementia (AAN 2018 PMID 29282327)

HIV-associated neurocognitive disorder (HAND) is treatable with ART (AAN 2018 PMID 29282327)

Vascular dementia secondary prevention — DM + dyslipidemia control reduces stepwise progression (AAN 2018; 2025 ACC/AHA HTN; 2026 ACC/AHA Lipid)

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)

CAM / 4AT screens for delirium — acute fluctuating attention must be excluded before chronic dementia label (Inouye CAM original)

AD biomarker confirmation before anti-amyloid mAb; blood p-tau217 increasingly available (NIA-AA 2018 PMID 29653606; ALZ-NET 2024-2026)

CSF RT-QuIC sens >95% / spec ~100% for sporadic CJD (Zerr 2009 PMID 19773352)

FDG hypometabolism patterns — biparietal/temporal AD vs frontotemporal FTD (NIA-AA 2018 PMID 29653606)

Confirms AD biology before mAb when CSF/blood unavailable (NIA-AA 2018 PMID 29653606)

DAT-SPECT (DaTscan ioflupane) — reduced striatal dopaminergic uptake supports DLB / PDD (McKeith 2017 PMID 28592453)

bvFTD pivot — early personality change, disinhibition, apathy, stereotypies, hyperorality (Rascovsky 2011 PMID 21810890)

Primary progressive aphasia (PPA) — semantic / agrammatic / logopenic variants distinct from amnestic AD (Rascovsky 2011 PMID 21810890)

Caregiver Zarit ≥21 drives institutionalization; assess respite + adult protective services as needed (APA 2024)

Folate deficiency mimic (AAN 2018 PMID 29282327)

Low vitamin D associated with cognitive decline (NICE 2024 dementia)

APOE e4/e4 homozygote → higher ARIA-E/H risk on anti-amyloid mAb (CLARITY-AD van Dyck NEJM 2023 PMID 36449413)

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

Severity triggers (13)

13 need judgement
  • informationallife_threateningcjd_rapid_decline
    Rapid cognitive decline <1 year + myoclonus + ataxia + visual disturbance + MRI DWI cortical ribboning + basal ganglia / pulvinar sign + CSF RT-QuIC positive (Zerr 2009 PMID 19773352)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredlb_phenotype
    Fluctuating cognition + recurrent visual hallucinations + REM sleep behaviour disorder + parkinsonism (≥2 of 4 core features = probable DLB per McKeith 2017 PMID 28592453); EXTREME antipsychotic sensitivity flag
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereftd_phenotype
    Behavioural variant FTD — early personality change + disinhibition + apathy + stereotypies + hyperorality (≥3 of Rascovsky 2011 PMID 21810890 criteria) OR primary progressive aphasia (semantic / agrammatic / logopenic); FDG-PET frontal/temporal hypometabolism
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredelirium_superimposed_on_dementia
    Acute fluctuating attentional change + altered consciousness + disorganized thinking in patient with dementia (CAM positive); identify reversible precipitant (infection, medication, retention, dehydration, pain, constipation)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverearia_e_or_h_on_mab
    Vasogenic edema (ARIA-E) or microhemorrhage / superficial siderosis (ARIA-H) on surveillance MRI during anti-amyloid mAb therapy (CLARITY-AD PMID 36449413; TRAILBLAZER-ALZ 2 PMID 37459141)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatead_amyloid_positive
    CSF Aβ42 low + p-tau elevated OR amyloid PET positive OR blood p-tau217 positive — Alzheimer disease biology confirmed (NIA-AA 2018 PMID 29653606)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatevascular_dementia
    Stepwise cognitive decline + Hachinski Ischemic Score ≥7 + small-vessel disease burden on MRI (white matter hyperintensities, lacunes, microbleeds) (AAN 2018 PMID 29282327)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatenph_hakim_triad
    Hakim triad — magnetic / apractic gait + urinary incontinence + cognitive decline + ventriculomegaly Evans ratio >0.3 + DESH (disproportionately enlarged subarachnoid spaces) on MRI (Williams 2019 NPH consensus)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatereversible_b12_or_thyroid
    B12 < 200 pg/mL (with elevated MMA / homocysteine) OR TSH > 10 mU/L with low free T4 OR positive RPR / HIV / autoimmune (anti-LGI1) — reversible mimics
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatelecanemab_or_donanemab_eligible
    Biomarker-confirmed early AD (CSF Aβ low + p-tau elevated OR amyloid PET+ OR blood p-tau217+) + CDR 0.5-1 + MMSE ≥22 + no anticoagulation + no recent stroke / TIA + ≤4 microbleeds + no superficial siderosis + APOE genotype counseled (CLARITY-AD PMID 36449413; TRAILBLAZER-ALZ 2 PMID 37459141)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateantipsychotic_initiation_in_dementia
    Considering antipsychotic initiation for BPSD in any dementia type — FDA black-box mortality warning applies; AGS Beers 2023 strongly cautions
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatedriving_safety_concern
    Caregiver report of unsafe driving OR moderate dementia stage (CDR ≥1) OR getting lost OR motor vehicle incident (AAN 2018 PMID 29282327)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecaregiver_burnout_or_abuse_risk
    Caregiver Zarit Burden Interview ≥21 OR signs of elder abuse / neglect / financial exploitation (NICE 2024 dementia)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

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Recommended regimen

Cholinesterase inhibitor + memantine for AD / DLB / PDD / vascular (AAN 2018; NICE 2024 dementia)
axis: dementia_cognitive_enhancers
Selected axis "Cholinesterase inhibitor + memantine for AD / DLB / PDD / vascular (AAN 2018; NICE 2024 dementia)" by default fallback (first axis)
  • donepezil
    first line
    AChE_inhibitor
    5 mg • PO • once daily at bedtime; titrate to 10 mg after 4-6 wks; 23 mg only for severe AD with caution (max: 23 mg/day (severe AD))
    triggers: AD_mild_to_severe, DLB, PDD
    AAN 2018 PMID 29282327 — modest symptomatic benefit; GI + bradycardia + sleep disturbance ADRs; NICE 2024 dementia
    rxcui 997220
  • rivastigmine
    first line
    AChE_BuChE_inhibitor
    4.6 mg/24h transdermal patch • transdermal • daily; titrate to 9.5 then 13.3 mg/24h q4 wks (max: 13.3 mg/24h patch)
    triggers: DLB_first_line, PDD, AD, donepezil_intolerant
    Patch reduces GI ADRs; FDA-approved for PDD; first-line in DLB per McKeith 2017 PMID 28592453
    rxcui 183379
  • galantamine
    first line
    AChE_inhibitor
    8 mg ER • PO • once daily; titrate to 16 then 24 mg q4 wks (max: 24 mg/day)
    triggers: AD
    Alternative ChEI; weak nicotinic modulation (AAN 2018)
    rxcui 2690627
  • memantine
    add on
    NMDA_antagonist
    5 mg • PO • once daily; titrate to 10 mg BID (max: 20 mg/day)
    triggers: moderate_to_severe_AD_MMSE_le_14, add_on_to_ChEI
    AAN 2018 — modest benefit moderate-severe AD; combination ChEI + memantine in moderate-severe; NICE 2024 dementia
    rxcui 236685

outpatient playbook — drug actions (7)

  1. 1. donepezil
    5 mg PO QHS → 10 mg after 4-6 wks • PO • daily
    trigger: AD / vascular dementia / PDD mild-to-severe
    AAN 2018 PMID 29282327; NICE 2024 dementia
  2. 2. rivastigmine patch
    4.6 → 9.5 → 13.3 mg/24h q4 wks • transdermal • daily
    trigger: DLB first-line OR PDD OR donepezil GI intolerance
    McKeith 2017 PMID 28592453 — DLB first-line; PDD label; patch reduces GI ADRs
  3. 3. memantine
    5 mg PO daily → 10 mg BID over 4 wks • PO • BID
    trigger: Moderate-severe AD MMSE ≤14
    AAN 2018 — add to ChEI for moderate-severe AD
  4. 4. lecanemab or donanemab
    Per anti-amyloid mAb axis • IV • q2 wks (lecanemab) or q4 wks (donanemab)
    trigger: Biomarker-confirmed early AD + CDR 0.5-1 + MMSE ≥22 + no anticoag + no recent stroke + ≤4 microbleeds + APOE risk-counseled
    CLARITY-AD van Dyck NEJM 2023 PMID 36449413 + TRAILBLAZER-ALZ 2 Sims JAMA 2023 PMID 37459141 — ARIA-E/H surveillance per axis
  5. 5. sertraline
    25-100 mg PO daily • PO • daily
    trigger: Comorbid depression / anxiety / FTD disinhibition
    APA 2024 — preferred SSRI; first-line for FTD behavioural symptoms (no ChEI for FTD)
  6. 6. B12 IM if deficient
    1000 mcg IM weekly × 4 then monthly • IM • weekly then monthly
    trigger: B12 < 200 pg/mL or symptomatic with MMA elevated
    Reversible cause (AAN 2018)
  7. 7. levothyroxine if hypothyroid
    25-50 mcg PO daily titrated • PO • daily
    trigger: TSH elevated + free T4 low
    Reversible cause (AAN 2018)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Memory or cognitive complaint reported by patient, family, or caregiver (AAN 2018 MCI PMID 29282327); IADL/ADL decline ≥6 months (NIA-AA 2018 PMID 29653606); New agitation, apathy, depression, or psychotic features in older adult (APA 2024; AGS Beers 2023).

Objective

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

Assessment

**Dementia / cognitive impairment** (symptom.dementia.v1).
Phenotype framing: 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)
Scope: 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)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Cholinesterase inhibitor + memantine for AD / DLB / PDD / vascular (AAN 2018; NICE 2024 dementia)**.
1. donepezil 5 mg PO once daily at bedtime; titrate to 10 mg after 4-6 wks; 23 mg only for severe AD with caution (AChE_inhibitor, first line) — AAN 2018 PMID 29282327 — modest symptomatic benefit; GI + bradycardia + sleep disturbance ADRs; NICE 2024 dementia
2. rivastigmine 4.6 mg/24h transdermal patch transdermal daily; titrate to 9.5 then 13.3 mg/24h q4 wks (AChE_BuChE_inhibitor, first line) — Patch reduces GI ADRs; FDA-approved for PDD; first-line in DLB per McKeith 2017 PMID 28592453
3. galantamine 8 mg ER PO once daily; titrate to 16 then 24 mg q4 wks (AChE_inhibitor, first line) — Alternative ChEI; weak nicotinic modulation (AAN 2018)
4. memantine 5 mg PO once daily; titrate to 10 mg BID (NMDA_antagonist, add on) — AAN 2018 — modest benefit moderate-severe AD; combination ChEI + memantine in moderate-severe; NICE 2024 dementia

Setting playbook (outpatient) — Primary site for dementia care — diagnostic workup (MoCA, labs, MRI, biomarker if AD suspected), ChEI ± memantine titration, anti-amyloid mAb eligibility assessment, behavioural management, BEERS deprescribe, caregiver support, advance care planning (AAN 2018 PMID 29282327; NICE 2024 dementia)
5. donepezil 5 mg PO QHS → 10 mg after 4-6 wks PO daily — AD / vascular dementia / PDD mild-to-severe (AAN 2018 PMID 29282327; NICE 2024 dementia)
6. rivastigmine patch 4.6 → 9.5 → 13.3 mg/24h q4 wks transdermal daily — DLB first-line OR PDD OR donepezil GI intolerance (McKeith 2017 PMID 28592453 — DLB first-line; PDD label; patch reduces GI ADRs)
7. memantine 5 mg PO daily → 10 mg BID over 4 wks PO BID — Moderate-severe AD MMSE ≤14 (AAN 2018 — add to ChEI for moderate-severe AD)
8. lecanemab or donanemab Per anti-amyloid mAb axis IV q2 wks (lecanemab) or q4 wks (donanemab) — Biomarker-confirmed early AD + CDR 0.5-1 + MMSE ≥22 + no anticoag + no recent stroke + ≤4 microbleeds + APOE risk-counseled (CLARITY-AD van Dyck NEJM 2023 PMID 36449413 + TRAILBLAZER-ALZ 2 Sims JAMA 2023 PMID 37459141 — ARIA-E/H surveillance per axis)
9. sertraline 25-100 mg PO daily PO daily — Comorbid depression / anxiety / FTD disinhibition (APA 2024 — preferred SSRI; first-line for FTD behavioural symptoms (no ChEI for FTD))
10. B12 IM if deficient 1000 mcg IM weekly × 4 then monthly IM weekly then monthly — B12 < 200 pg/mL or symptomatic with MMA elevated (Reversible cause (AAN 2018))
11. levothyroxine if hypothyroid 25-50 mcg PO daily titrated PO daily — TSH elevated + free T4 low (Reversible cause (AAN 2018))

Non-pharmacologic actions:
- DICE behavioural framework Describe / Investigate / Create / Evaluate (APA 2024; NICE 2024 dementia)
- Aerobic exercise + Mediterranean / MIND diet — FINGER trial Ngandu Lancet 2015 (NICE 2024 dementia)
- Cognitive engagement + social activity (NICE 2024 dementia)
- Hearing aids if hearing loss (Lancet 2024 dementia commission — modifiable risk factor)
- Cataract surgery / refraction if indicated (NICE 2024 dementia)
- OSA treatment if confirmed (AAN 2018)
- Caregiver support / dementia care navigator / Alzheimer Association resources (NICE 2024 dementia; APA 2024)
- Driving evaluation — formal road test if any concern; DMV reporting per state law (AAN 2018)
- Capacity + advance care planning + POLST + durable power of attorney
- Neurosurgery referral for VP shunt evaluation if Hakim triad + ventriculomegaly + large-volume tap test response (Williams 2019 NPH consensus)

AVOID / contraindication checks:
- ChEI_bradycardia_syncope_risk_check_HR_baseline (AAN 2018)
- ChEI_GI_titrate_with_food (AAN 2018)
- ChEI_avoid_concurrent_anticholinergic (AGS Beers 2023)
- ChEI_avoid_in_FTD_may_worsen_behaviour (Rascovsky 2011 PMID 21810890)
- Memantine_renal_dose_adjust_if_eGFR_lt_30 (AAN 2018)

Monitoring

Regimen monitoring:
- MoCA or MMSE q6 to 12 mo (AAN 2018)
- caregiver function review q3 mo (NICE 2024 dementia)
- HR at each visit for ChEI (AAN 2018)
- BEERS deprescribe sweep q6 mo (AGS Beers 2023)

Setting (outpatient) monitoring:
- MoCA + function q6-12 mo (AAN 2018)
- Caregiver visit q3-6 mo (NICE 2024 dementia)
- ARIA MRI per mAb protocol (CLARITY-AD PMID 36449413; TRAILBLAZER-ALZ 2 PMID 37459141)
- Annual AGS Beers 2023 deprescribe sweep
- Annual fall risk + driving review
- Q6-mo Zarit burden + caregiver depression screen
- Antipsychotic taper attempt q3 mo if any started

Follow-up plan: Caregiver education + support, dementia care navigator, driving evaluation, capacity assessment, advance care planning + POLST, palliative referral at FAST 7 (NICE 2024 dementia; APA 2024)
- Close-out criterion: Caregiver + advance care plan established

Monitoring phase: 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

Disposition

Current setting: outpatient — Primary site for dementia care — diagnostic workup (MoCA, labs, MRI, biomarker if AD suspected), ChEI ± memantine titration, anti-amyloid mAb eligibility assessment, behavioural management, BEERS deprescribe, caregiver support, advance care planning (AAN 2018 PMID 29282327; NICE 2024 dementia)

Disposition criteria:
- Continue current regimen if stable
- Refer cognitive neurology for mAb workup if AD biomarker-confirmed early AD
- Refer geriatric psychiatry for refractory BPSD
- Refer ENT/audiology for sensory optimization
- Refer neurosurgery for NPH VP shunt candidacy
- Hospice referral when FAST 7 for goals-of-care alignment (NICE 2024 dementia)

Escalation triggers (move to higher acuity):
- Behavioural crisis / aggression with safety risk → ED or geriatric psychiatry (APA 2024)
- Superimposed delirium → ED (CAM positive)
- Suspicion of CJD / autoimmune encephalitis → urgent neurology + LP (Zerr 2009 PMID 19773352)
- Rapid decline <1 yr → urgent neurology + biomarkers
- Refractory depression → psychiatry
- ARIA-E/H on mAb surveillance MRI → hold mAb + dementia neurology consult
- Caregiver burnout / abuse concern → adult protective services + respite

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Rapid cognitive decline <1 year + myoclonus + ataxia + visual disturbance + MRI DWI cortical ribboning + basal ganglia / pulvinar sign + CSF RT-QuIC positive (Zerr 2009 PMID 19773352)
- [SEVERE] Fluctuating cognition + recurrent visual hallucinations + REM sleep behaviour disorder + parkinsonism (≥2 of 4 core features = probable DLB per McKeith 2017 PMID 28592453); EXTREME antipsychotic sensitivity flag
- [SEVERE] Behavioural variant FTD — early personality change + disinhibition + apathy + stereotypies + hyperorality (≥3 of Rascovsky 2011 PMID 21810890 criteria) OR primary progressive aphasia (semantic / agrammatic / logopenic); FDG-PET frontal/temporal hypometabolism

Citations

- AAN MCI 2018 (Petersen) + NIA-AA 2018 research framework + AAN/ADRD 2024 anti-amyloid mAb appropriate use + CLARITY-AD (lecanemab) + TRAILBLAZER-ALZ 2 (donanemab) + DLB Consortium 2017 (McKeith) + bvFTD criteria 2011 (Rascovsky) + CJD MRI criteria 2009 (Zerr) + APA Treatment of BPSD 2024 + AGS Beers Criteria 2023 [PMID:29653606](https://pubmed.ncbi.nlm.nih.gov/29653606/)
- 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 29282327) [PMID:29282327](https://pubmed.ncbi.nlm.nih.gov/29282327/)
- Cited evidence (PMID 1202204) [PMID:1202204](https://pubmed.ncbi.nlm.nih.gov/1202204/)

Last reconciled with current guidelines: 2026-05-14.
References
  • AAN MCI 2018 (Petersen) + NIA-AA 2018 research framework + AAN/ADRD 2024 anti-amyloid mAb appropriate use + CLARITY-AD (lecanemab) + TRAILBLAZER-ALZ 2 (donanemab) + DLB Consortium 2017 (McKeith) + bvFTD criteria 2011 (Rascovsky) + CJD MRI criteria 2009 (Zerr) + APA Treatment of BPSD 2024 + AGS Beers Criteria 2023 — PMID:29653606
  • Cited evidence (PMID 36449413) — PMID:36449413
  • Cited evidence (PMID 37459141) — PMID:37459141
  • Cited evidence (PMID 29282327) — PMID:29282327
  • Cited evidence (PMID 1202204) — PMID:1202204