What is the initial step in a dementia workup?

Initial Dementia Workup Protocol

The initial step in a dementia workup should include a thorough medical history, cognitive assessment with standardized tools, laboratory testing for reversible causes, and structural neuroimaging. 1, 2

Step 1: Comprehensive History and Cognitive Assessment

• Obtain detailed history focusing on cognitive abilities, including onset and nature of cognitive loss 3
• Collect corroborative history from a reliable informant about changes in cognition, function, and behavior using structured tools like AD8 or Alzheimer's Questionnaire 1, 4
• Perform standardized cognitive screening using validated tools such as Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment (MoCA) 2, 4
• Include Clock Drawing Test as a useful supplementary screening tool 4
• Document baseline functioning and compare with current functioning to establish decline 1
• Assess specific cognitive domains: memory, executive function, visuospatial abilities, language functions, and personality/behavior changes 4, 3

Step 2: Laboratory Testing for Reversible Causes

• Complete blood count with differential to rule out anemia 3, 5
• Comprehensive metabolic panel including electrolytes, calcium, magnesium, and liver function tests 2, 5
• Thyroid function tests (TSH, free T4) 1, 5
• Vitamin B12 and folate levels 1, 5
• Consider additional tests based on clinical suspicion:
  • Syphilis serology if risk factors present 5
  • Inflammatory markers (ESR, CRP) if inflammatory condition suspected 3
  • HIV testing if risk factors present 1

Step 3: Structural Neuroimaging

• MRI is preferred over CT, especially for detecting vascular lesions 1, 4
• Neuroimaging is particularly important with:
  • Onset of cognitive symptoms within past 2 years 4, 3
  • Unexpected decline in cognition/function 4
  • Recent significant head trauma 4
  • Unexplained neurological manifestations 4
  • Significant vascular risk factors 4, 3

Step 4: Assess for Common Contributors to Cognitive Impairment

• Review medications, especially anticholinergics or sedative hypnotics that can contribute to cognitive symptoms 3
• Screen for depression and anxiety, which can manifest as or exacerbate cognitive symptoms 3
• Evaluate for sleep disorders, particularly sleep apnea 1
• Assess sensory deficits (hearing loss, vision loss) that may impact cognitive testing 1
• Evaluate for pain and mobility problems that may affect function 1

Step 5: Diagnostic Formulation

• Integrate information about risk profile, history of symptoms, and examination findings 1
• Determine whether cognitive-behavioral syndrome is present 1
• Consider referral to specialist (neurologist, geriatrician, geriatric psychiatrist) for complex cases 3
• Consider additional biomarker testing in atypical cases (e.g., early onset, rapid progression) 3, 6

Common Pitfalls to Avoid

• Failing to obtain corroborative history from an informant 3
• Attributing cognitive changes to normal aging without proper assessment 7
• Overlooking potentially reversible causes of dementia 5, 8
• Neglecting to assess impact on instrumental activities of daily living 4
• Overlooking medical conditions that can influence biomarker interpretation 1

Follow-up Planning

• Schedule follow-up visits every 6-12 months to track disease progression 4, 3
• Use a multi-dimensional approach to monitor cognition, functional autonomy, behavioral symptoms, and caregiver burden 4
• Provide information on dementia prevention strategies including physical activity, social engagement, and cognitive stimulation 4