As the U.S. population ages, the number of people affected by Alzheimer’s disease and other neurodegenerative diseases (NDDs) that cause dementia is increasing. New treatments that target specific causes of dementia are most effective when used early, making a timely and accurate diagnosis essential.

Primary care providers (PCPs) play a key role in early evaluation. Assessment begins with timely attention to cognitive and behavioral changes that arise in their patients, and systematic protocols to elicit complaints in patients that may not bring them up on their own. The 5-Step Brain Health Work-up described on this website outlines a basic approach to this assessment and makes suggestions for implementation. Once a significant cognitive or behavioral change is identified, treatment relies on specifying the cause (step 5). Many PCPs would address the cause by referring to an appropriate specialist, such as a neurologist or a psychiatrist, but the availability of these specialists in the community is limited. Wait times for these consultations can therefore be long.

One solution is for PCPs to expand their role in assessment by performing deeper evaluations to identify the potential cause of cognitive and behavioral changes. However, many PCPs lack confidence in evaluating cognitive and behavioral changes, highlighting the need for more concrete advice and support.

The materials on this page provide specific guidance on performing a thorough cognitive and behavioral assessment that can be implemented without special materials. The approach is based primarily on collecting a careful history, physical examination, and limited cognitive testing using commonly available tools. It provides guidance on the interpretation of the results. While referral will often still be needed, implementation of this process in primary care allows early identification of other medical conditions that need to be addressed (e.g., mood disorders, sleep apnea). It increases the efficiency of specialty evaluation by providing more information to the specialist and clarifying the referral goals. PCPs can find additional support for dementia diagnosis and care through the UCSF Project ECHO for Dementia program.

The Assessment of Cognitive Complaints Toolkit for Alzheimer’s Disease (ACCT-AD)

The California Alzheimer’s Disease Centers developed the ACCT-AD toolkit to guide PCPs on performing a thorough assessment. The toolkit has many components that address various aspects of the diagnostic evaluation. The entire process does not need to be accomplished in a single visit, and not all components need to be performed by the primary provider. Each practice would develop its plan to collect most of the information to ensure accuracy, with the PCP integrating all the information to arrive at a diagnosis and treatment plan.

The toolkit includes:

• Background reading about the major causes of cognitive and behavioral changes in aging
• An approach for the initial identification of potentially concerning symptoms, based on a few questions and limited cognitive testing—this screening would be suitable for an annual wellness check in older patients
• A pre-visit questionnaire designed to streamline a complete cognitive and behavioral assessment by identifying the significant areas of concern
• A set of questions and guidance on the physical exam findings that address the potential causes of cognitive and behavioral complaints
• A concrete interpretation guide that addresses potential responses to questions, exam findings, and laboratory and imaging findings from the assessment
• Decision trees to guide diagnosis and referral
• Scripts to use as examples for diagnostic disclosure
• Billing guidance that covers various scenarios