ACCT-AD Decision Making and Referrals

Outcomes and suggested management are also depicted in the decision tree:

Green Pathway

No concerning symptoms and normal cognitive testing. The patient and informant report no functional, cognitive, or behavioral changes beyond the types of symptoms that would be encountered with normal aging. The final decisions in this scenario are guided by the cognitive testing.

Suggested action

• If performance on the cognitive test is above the cutoff for normal, the toolkit suggests reassuring the patient and scheduling periodic reassessments every year or two to identify any worsening or new symptoms. Referral is likely unnecessary.
• If performance on the cognitive test is below the cutoff for normal, this indicates that the history or testing may be unreliable. The toolkit would recommend referral in this situation.

Yellow Pathway

Mild Cognitive Impairment (ADLs Preserved)

If several responses fall into the yellow categories, indicating symptoms seen in AD, and the questions about activities of daily living (ADLs) indicate they are not affected, this suggests mild cognitive impairment. The final decisions in this scenario can be guided by the cognitive testing and biomarker results:

Suggested action

1. If performance on the cognitive test is above the dementia cutoff, the clinician can pursue AD biomarker testing. If positive, then the conclusion is that the symptoms are likely due to AD. If negative, the symptoms are not likely to be due to AD. Referral decision depends on the clinician’s goals for management.

2. If performance on the cognitive test is below the cutoff for dementia, this indicates that the history or testing may be unreliable. The toolkit would recommend referral in this situation.

Dementia (ADLs Impaired)

If several responses fall into the yellow categories, indicating symptoms seen in AD, and the questions about activities of daily living (ADLs) indicate they are affected, this suggests dementia. The final decisions in this scenario can be guided by the cognitive testing and biomarker results:

1. Suggested action

   1. If performance on the cognitive test is above the dementia cutoff, this indicates that the history or testing may be unreliable. The toolkit would recommend referral in this situation.

   2. If performance on the cognitive test is below the cutoff for dementia, the clinician can pursue AD biomarker testing. If positive, then the conclusion is that the symptoms are likely due to AD. If negative, the symptoms are not likely to be due to AD. Referral decision depends on the clinician’s goals for management.

Orange/Indeterminate Pathway

Possible non-neurodegenerative contributor affecting cognition, such as a psychiatric disorder, sleep disorder, or other problem. In this case, the problem should be managed, including referral as appropriate. Further decisions would depend on the outcome of that process:

Suggested action

• Treat the contributing condition
• Reassess cognition
  • If the condition is managed and the cognitive or behavioral symptoms resolve, reassure the patient and plan periodic reassessment every year or two using the detection questions.
  • If the condition is managed but the symptoms persist, and the rest of the assessment indicates AD, the clinician should proceed along the path for AD type of symptoms
• Continue evaluation if symptoms persist

Red Pathway

Atypical findings. If one or more responses fall into red categories, it indicates symptoms that are not typical for AD referral to a dementia specialist is warranted.

Suggested action

• Refer to a dementia specialist

When to refer

Consider referral if:

• Symptoms are atypical.
• Diagnosis remains uncertain with AD-type symptoms.
• Biomarkers suggest Alzheimer's disease and disease-modifying therapy may be appropriate.
  • Consider the patient's ability to receive frequent infusions at a specialized center and receive multiple MRIs for monitoring of adverse effects.
  • Determine the degree of impairment. While there is no universally accepted criterion for what constitutes a mild stage of dementia, many expert clinicians would say that if the disease has progressed to the point where a patient has stopped performing any instrumental activities of daily living, cognitive changes, and some changes in performance of basic activities of daily living are apparent, this would not be considered mild.
• Additional diagnostic testing is needed.
• Management is becoming complex.
• The patient or family requests specialist consultation.

In patients who have AD-type symptoms and are AD biomarker negative, it is worth considering whether the biomarker could be a false negative. For example, if a patient has an insidiously progressive syndrome that has predominantly memory symptoms, and there are no other conditions to explain the symptoms, they otherwise might be eligible for anti-amyloid treatment, and a blood biomarker such as p-tau217 was used to assess for AD, then obtaining an amyloid PET scan or CSF Abeta and tau testing might be advisable before finalizing the assessment.

What to include with your referral

• Reason for referral (include one or more):
  • Second opinion about history and/or exam and findings
  • Pursue further workup necessary
  • Clarify diagnosis
  • Offer treatment recommendations
  • Patient and family requested the referral
• Symptom timeline: Brief summary of time course and prominent symptoms prompting referral
• Medications: Summary of medical conditions and medications
• Imaging: Include CD with scan images
• Cognitive testing: Results of any assessments of cognitive problems, including copies of cognitive testing results if available

Referral resources

Resources for identifying dementia specialists and neuropsychologists include:

• State Alzheimer’s Disease Centers – ten academic sites that evaluate cognitive complaints
• Federal Alzheimer’s Disease Research Centers
• American Academy of Neurology – find a neurologist near you
• Alzheimer’s Association – local chapters can often make referrals to an MD with expertise
• Northern California Neuropsychology Forum – find a neuropsychologist
• American Academy of Clinical Neuropsychology – search for a clinical neuropsychologist