New to the ACCT-AD?
Start here:
- Read this Overview.
- Use the Brief Assessment to determine whether further evaluation is needed.
- Complete the Full Assessment when cognitive concerns are identified.
- Use the Reference and Interpretation Manual to interpret findings and support diagnosis.
The Assessment of Cognitive Complaints Toolkit for Alzheimer's Disease (ACCT-AD) provides a structured approach to evaluating cognitive and behavioral concerns in primary care. Rather than serving as a single test or checklist, the toolkit guides clinicians through the diagnostic process—from identifying patients who need further evaluation to diagnosis, counseling, and referral.
The toolkit is designed to fit into routine primary care workflows. Assessments can be completed over multiple visits, and different members of the care team can complete different components.
Clinical history is the foundation of diagnosis. The toolkit is designed to support—not replace—clinical judgment. The toolkit uses structured history-taking, supported by physical examination, cognitive testing, laboratory evaluation, imaging, and biomarkers, to guide diagnosis and management.
How to use the toolkit
The toolkit follows the same process clinicians use when evaluating patients with cognitive concerns.
Step 1. Detect cognitive or behavioral concerns
Use the Brief Assessment during routine visits, such as the Medicare Annual Wellness Visit, or whenever a patient, family member, or healthcare professional reports changes in memory, thinking, or behavior. Use the forms provided in the Patient Assessment Forms section.
Use brief patient and informant questions to identify concerns that warrant further evaluation. Informant input is particularly important because many patients have limited insight into their symptoms. In some cases, the informant may need to be interviewed separately.
Optional pre-visit questionnaires and interpretation guidance are available in the Patient Assessment Forms and Reference and Interpretation Manual.
Outcome: Determine whether additional evaluation is needed. If concerns are identified, clinicians should proceed to the Full Cognitive Assessment or refer the patient to a specialist.
Step 2. Complete a comprehensive assessment
If concerns are identified, use the Full Assessment to gather the information needed for diagnosis. The full cognitive assessment may be completed over multiple visits if needed.
The assessment includes:
- Comprehensive clinical history from the patient and a knowledgeable informant
- Physical and neurological examination
- Cognitive testing appropriate to the patient's educational and cultural background
- Laboratory testing and brain imaging
Optional pre-visit questionnaires are available in the Patient Assessment Forms and Reference and Interpretation Manual.
Outcome: Determine whether findings are consistent with normal aging, mild cognitive impairment, dementia, or another condition. Based on the assessment, clinicians may establish a diagnosis or identify findings that warrant specialist referral.
Step 3. Interpret the findings
The Reference and Interpretation Manual helps clinicians integrate information from the history, examination, cognitive testing, laboratory studies, imaging, and biomarkers.
Clinical findings generally fall into one of four categories:
- Normal aging
- Alzheimer's disease
- Another neurodegenerative disorder
- An alternative neurological or medical condition requiring additional evaluation
The toolkit's decision support guide and decision tree assist clinicians in integrating findings and developing a plan for disclosure and management.
Step 4. Discuss the diagnosis
The toolkit includes practical guidance and example language for discussing:
- Diagnosis
- Prognosis
- Treatment options
- Driving safety
- Care planning
- Research opportunities
The toolkit provides suggested language for communicating diagnoses and discussing next steps with patients and families. The toolkit also includes guidance for discussing driving safety, which should be addressed with all patients diagnosed with dementia.
Step 5. Refer when appropriate
Patients with atypical presentations, diagnostic uncertainty, or suspected non-Alzheimer neurodegenerative disorders should be referred to an appropriate specialist.
Key principles
The toolkit is built on several important principles.
- Clinical history comes first. Whenever possible, obtain information from both the patient and a knowledgeable informant.
- Detection is not diagnosis. Positive screening results require a comprehensive clinical assessment.
- Biomarkers complement clinical assessment. Interpret biomarker results in the context of the patient's history, examination, and cognitive testing.
- The evaluation is flexible. Different members of the care team can complete different components over multiple visits.
Detection vs. diagnosis
| Detection | Diagnosis |
|---|---|
| Identifies patients who may have cognitive impairment | Determines the underlying cause and severity |
| Uses brief questions and limited cognitive testing | Uses comprehensive history, examination, testing, and interpretation |
| Takes only a few minutes | May require multiple visits |
Toolkit components
| Section | Purpose |
|---|---|
| Brief Assessment | Identify patients who need additional evaluation. |
| Full Assessment | Complete a comprehensive diagnostic evaluation, including history, examination, cognitive testing, laboratory studies, imaging, and biomarkers when appropriate. |
| Diagnostic Disclosure and Counseling | The Reference and Interpretation Manual includes guidance for interpreting findings and supporting diagnostic decision-making. It also provides specific suggestions for communicating the diagnosis, discussing treatment options, and developing a care plan.
|
| Referral Guidance | Determine when specialty evaluation is appropriate. |
When to use the toolkit
Use the ACCT-AD when:
- A patient, family member, or healthcare professional reports cognitive or behavioral concerns.
- Cognitive concerns are identified during routine screening.
- A comprehensive evaluation for mild cognitive impairment or dementia is needed.
Clinical considerations
The toolkit assumes:
- A knowledgeable informant is available whenever possible.
- Cognitive testing is appropriate for the patient's educational background and preferred language.
- The clinician is familiar with the patient's medical history and medications.
The toolkit is intended for typical primary care evaluations. Additional guidance is provided for situations that may require modifying the assessment or referring to a specialist.
Examples of situations that may limit the toolkit's effectiveness include:
- No informant is available, or the informant has limited knowledge of the patient.
- The patient and family have limited English proficiency (see exceptions).
- The patient has limited formal education or literacy (see Cognitive Testing With Low Literacy and Language Constraints for exceptions).
- The patient has a major mental illness.
- The patient has a history of major developmental differences
The toolkit emphasizes clinical history, physical examination, cognitive testing, laboratory studies, imaging, and biomarkers to guide diagnosis.
Ready to begin?
Start with the Brief Assessment to determine whether a patient requires further evaluation, or proceed directly to the Full Assessment if cognitive concerns have already been identified.