Role of Neurology in Dementia Evaluation After Primary Care Initiation of Donepezil
Neurology should perform a comprehensive subspecialty evaluation to confirm the diagnosis, characterize the specific cognitive-behavioral syndrome, identify the underlying brain disease causing dementia, and optimize the treatment plan—even when donepezil has already been started in primary care. 1, 2
Why Specialist Referral Remains Essential
Starting donepezil in primary care does not eliminate the need for specialist evaluation. The 2025 Alzheimer's Association guidelines emphasize that many primary care providers lack confidence in dementia diagnosis, with 39% reporting they are "never or only sometimes" comfortable making these diagnoses. 1 Specialist memory clinics can diagnose dementia up to 4 years earlier than primary care services and provide access to multidisciplinary evaluations and clinical trials. 3
What Neurology Will Do Differently
Complete the Three-Step Diagnostic Formulation
Neurology will systematically complete what may have been incompletely assessed in primary care: 1, 2
Cognitive Functional Status: Precise determination of whether the patient has mild cognitive impairment (MCI), mild dementia, moderate dementia, or severe dementia using validated tools beyond basic screening 1
Cognitive-Behavioral Syndrome: Detailed characterization of the specific pattern—amnestic versus non-amnestic presentations (language, visuospatial, executive dysfunction), which is critical for differential diagnosis 1
Underlying Brain Disease: Differentiation between Alzheimer's disease, vascular dementia, Lewy body dementia, frontotemporal dementia, or mixed pathologies—this cannot be reliably done without specialist assessment 1, 2
Advanced Diagnostic Testing
Neurologists will perform or order tests typically unavailable in primary care: 1, 2
Comprehensive neuropsychological testing: This improves diagnostic accuracy beyond brief cognitive screens and is essential for characterizing the specific cognitive profile 1
Advanced brain imaging interpretation: Detailed analysis of MRI patterns to identify specific atrophy patterns (hippocampal atrophy in AD, frontal/temporal atrophy in FTD, preservation of hippocampus in Lewy body disease) 2
Biomarker testing when indicated: CSF analysis or amyloid/tau PET imaging to confirm Alzheimer's pathology, particularly important for atypical presentations or when considering disease-modifying therapies 1
Medication Optimization
Donepezil may not be the optimal medication for all dementia types. 4 For example:
Lewy body dementia shows marked responsiveness to cholinesterase inhibitors, but these patients also require specific management of parkinsonism and may need rivastigmine instead 4
Frontotemporal dementia does not respond to cholinesterase inhibitors and may worsen with these medications 1
Vascular dementia requires aggressive vascular risk factor management in addition to any symptomatic treatment 1
The neurologist will verify that donepezil is appropriate for the specific dementia type and adjust dosing (5 mg versus 10 mg) based on efficacy and tolerability. 1, 5
Specific Situations Requiring Urgent Neurology Referral
Even if donepezil has been started, immediate neurology referral is mandatory for: 2, 6, 3
- Rapidly progressive symptoms (developing over weeks to months rather than years)
- Early-onset dementia (before age 65)
- Atypical presentations: prominent aphasia, apraxia, agnosia, cortical visual abnormalities, movement disorders, or personality changes as the primary feature
- Prominent neuropsychiatric symptoms: severe anxiety, depression, apathy, psychosis, or behavioral changes
- Diagnostic uncertainty about whether symptoms represent true dementia versus delirium, depression, or other conditions
What Happens at the Neurology Visit
The specialist evaluation includes: 1, 2
- Detailed neurological examination to identify focal deficits, movement disorders, or other signs pointing to specific pathologies
- Structured cognitive assessment using validated instruments (MoCA, detailed ADAS-cog, domain-specific testing)
- Functional assessment with standardized tools (FAQ, DAD) to precisely quantify impairment
- Behavioral assessment (NPI-Q, MBI-C) to identify neuropsychiatric symptoms requiring specific management
- Review and interpretation of all prior testing with integration into a comprehensive diagnostic formulation
- Treatment plan refinement including medication adjustments, non-pharmacologic interventions, and caregiver support strategies
Common Pitfalls to Avoid
Do not assume that starting donepezil in primary care completes the diagnostic workup. 2, 3 Critical errors include:
Delaying specialist referral for atypical or rapidly progressive symptoms—this can miss treatable conditions or lead to inappropriate treatment 6, 3
Assuming all dementia is Alzheimer's disease—approximately 30-40% of dementia cases are non-Alzheimer's pathologies requiring different management 1
Failing to obtain detailed informant history—this is essential for accurate diagnosis and cannot be skipped 1, 2
Not assessing caregiver burden—this is a major determinant of hospitalization and nursing home placement and requires specialist attention 3
Ongoing Collaborative Care
After the specialist evaluation, neurology typically establishes: 6, 3
- Regular monitoring schedule (every 6-12 months, more frequently with behavioral symptoms)
- Shared care plan with primary care for tracking cognitive function, functional abilities, behavioral symptoms, and caregiver burden
- Access to specialized resources including support groups, clinical trials, and disease-modifying therapies when appropriate
The key message: Starting donepezil does not replace the need for specialist diagnostic confirmation and comprehensive management planning. 1, 2