ACCT-AD Reference and Interpretation Manual

Step One: Detecting Cognitive Concerns

It is recommended that patients aged 65 or older be asked about detection questions once a year, unless a cognitive complaint has already been identified and diagnosed.

While ACCT-AD detection questions may be suitable for detecting concerns using pre-visit questionnaires and similar approaches, the ACCT-AD toolkit recommends that a trained medical staff member ask these questions in person, because there is currently not enough data to indicate that these questions are adequately sensitive when self-administered. As detailed below, these questions should be asked of a patient and informant, and if no informant is available, they should be supplemented with a brief cognitive test.

Procedure

• Administer detection questions to both the patient and informant (together or separately) using the ACCT-AD detection questions. The questionnaire can be found in the Patient Assessment Forms section.
• If both the patient and informant do not identify any indeterminate (orange) responses in Part 1, reassure the patient and repeat the ACCT-AD detection questions in one year.
• If the patient or informant identifies any indeterminate (orange) responses in Part 1, proceed to Part 2. If the patient or informant identifies any Yes (yellow) responses in Part 2, proceed to a full assessment or refer to a dementia specialist.
• If the patient does not identify any indeterminate (orange) responses in Part 1 and no informant is available, complete the Mini-Cog© test (see instruction manual) or an alternate test appropriate for non-English speakers and/or individuals with low education to confirm there are no cognitive concerns.
  • If there are no concerns, reassure the patient and repeat the ACCT-AD detection questions in one year.
  • If concerns are identified, proceed to, or arrange, a full assessment, or refer to a dementia specialist.
• Before pursuing a full cognitive evaluation, consider whether the patient has characteristics affected by the Toolkit Limitations. If so, determine whether the evaluation should be modified or whether referral to a dementia specialist is appropriate.

Interpretation Tables: Detection Questions

Patient Component – Part 1

Memory, Language, and Personality Changes

Next Steps

• If there are indications of impairment (Yes responses), continue to the Patient Component – Part 2.
• If there are no indications, continue to the Informant Component – Part 1 to confirm the patient's responses.
• If there are no indications and no informant is available, perform the Mini-Cog©. If the score is normal, end the HRA cognitive questions, reassure the patient, and repeat screening in one year.
• If the patient has any errors on the Mini-Cog©, proceed to a Full Cognitive Evaluation.

Brief Cognitive Test

Mini-Cog©

Using the Mini-Cog©

"The Mini-Cog© is a 3-minute instrument that can increase detection of cognitive impairment in older adults. It can be used effectively after brief training in both healthcare and community settings. It consists of two components, a 3-item recall test for memory and a simply scored clock-drawing test. As a screening test, however, it does not substitute for a complete diagnostic workup."1

Scoring the Mini-Cog©

The Mini-Cog© is scored in two parts:

1. 3-item recall
2. Clock drawing

These are added together for a total score.

Total score = Word Recall score + Clock Draw score.

A cut point of <3 on the Mini-Cog™ has been validated for dementia screening, but many individuals with clinically meaningful cognitive impairment will score higher. When greater sensitivity is desired, a cut point of <4 is recommended, as it may indicate a need for further evaluation of cognitive status.

Resources

• https://mini-cog.com/
• Standardized English Mini-Cog (PDF)

1 Information obtained from mini-cog.com.

Low Literacy and Non-Fluency in English – Brief Cognitive Tests

The toolkit cannot currently recommend appropriate forms of cognitive testing across the wide range of cultural and language contexts encountered in practice. However, the toolkit has identified reasonable approaches for the common contexts in the table below.

In these contexts, the identified test can be used in place of the Mini-Cog© for the detection procedures. The test should be delivered in the patient's native language by a fluent speaker, not through an interpreter. For patients with low levels of education, the cutoff score differs from that used for patients with higher levels of education.

The Spanish version of the Mini-Cog© is available at https://mini-cog.com/. The toolkit also provides:

• A version of the Mini Mental State Exam (MMSE) suitable for low-literacy Spanish-speaking individuals from South and Central America.
• The Brain Health Test (BHT) for Chinese-speaking individuals.

Instructions for administering and scoring the Brain Health Test are included in the Patient Assessment Forms section.

For Chinese speakers, the toolkit recommends the Brain Health Test (BHT) (Tsai PH, et al.), which has been shown to be appropriate for individuals with both lower and higher levels of education.

Some individuals with lower levels of education reported discomfort with the clock drawing task. Developers determined that the test can still be administered without this task. When the clock drawing task is omitted, the maximum score is reduced from 12 to 10, and the cutoff scores should be adjusted accordingly.

Recommended Brief Cognitive Tests by Context

Step Two: Full Cognitive Assessment

Procedure

1. Administer the pre-visit patient questionnaire provided in the Patient Evaluation Forms section.
   1. May be administered as a self-report survey, on paper, online, or in person by clinic staff.
   2. Patient and informant should complete the questionnaire, either separately or together, based on their preference and convenience.
   3. The provider and/or care team should review responses before the evaluation.
   4. Review the Toolkit Limitations to determine whether the evaluation should be modified, referred for specialty evaluation, or completed in primary care.
2. Complete the full cognitive evaluation using the form provided in the Patient Evaluation Forms section.
   1. The patient and informant should attend the appointment to provide an accurate history and evaluation.
   2. Review all questions, including those not endorsed on the pre-visit questionnaire.
   3. Refer to the Reference and Interpretation Manual as needed when interpreting patient and informant responses.
3. Complete an education-level-appropriate standardized cognitive test (such as MoCA, MMSE, 3MS, or SLUMS), using the cutoff scores and interpretation guidance provided in the Reference and Interpretation Manual.
   1. See the Cognitive Testing section of the Instruction Manual for links to standardized cognitive testing tutorials.
4. Complete a physical examination, including a neurological examination.
5. Order laboratory testing and imaging, if indicated.
6. Obtain biomarkers for Alzheimer's disease, if appropriate according to the Decision Tree.
7. Proceed to Step Three: Interpretation, using the Decision Tree to finalize the diagnosis.

Standardized Cognitive Tests

A brief PowerPoint is available upon request to review basic concepts for these cognitive tests. PDF versions of these presentations can be found in Section 3: Patient Assessment Forms.

Reference Chart for Standard Cutoff Scores

This toolkit makes limited use of cognitive testing. It assumes that the clinician will use a relatively short test that provides a single score representing overall cognitive function. The reference scores below assume that the patient has completed at least six years of education and is being tested in their native language using a version of the test developed for that language.

The chart below provides cutoff scores for five commonly used tests. In each case, a cutoff score for normal performance is provided, along with a second cutoff representing the maximum score typically seen in a patient with dementia due to Alzheimer's disease.

The clinician should administer the test of their choice and use the result during final decision-making, as directed in the Decision Tree.

Commonly Used Standardized Cognitive Tests

Standardized Cognitive Testing Limitations

Testing results from patients with a low level of education, those who speak English as a second language, and/or those who are non-English speaking can be difficult to interpret and may result in false positives.

The cutoff scores above apply to patients with six or more years of education. For patients who are not fluent in English or who have lower levels of education, recommendations include relying more heavily on informant information or referring the patient to a dementia specialist. See the following section for additional guidance on testing in specific contexts.

Low Literacy and Non-Fluency in English: Cognitive Tests for Full Assessment

The toolkit cannot currently recommend appropriate forms of cognitive testing for all of the wide varieties of cultural and language contexts encountered in practice. However, the toolkit has identified reasonable approaches for the common contexts described below.

In these situations, the recommended test can be used in place of the tests suggested for the full cognitive evaluation. The test should be administered in the patient's native language by a medical provider who is fluent in that language and not through an interpreter. If an interpreter must be used, they should be professionally trained to administer cognitive testing. When an interpreter is used, the results may be unreliable, and the evaluation should rely more heavily on patient and informant history.

For patients with lower levels of education, cutoff scores differ from those used for patients with higher levels of education.

The Spanish version of the Montreal Cognitive Assessment (MoCA) is available at https://www.mocatest.org/pdf_files/test/MoCA-Test-Spanish.pdf and can be used for patients with more than six years of education. Limited data are available for individuals with fewer than six years of education.

For Spanish-speaking individuals with low literacy, the toolkit provides a simplified Mini Mental State Exam (MMSE) in the Patient Assessment Forms section. Cutoff scores are based on the work of Custodio et al.

The Rowland Universal Dementia Assessment Scale (RUDAS) has been advocated as a cognitive testing tool that can be used across many languages and cultures. Evidence supporting its use in Spanish-speaking individuals with both high and low literacy is available from Custodio et al. Training information is available at https://www.dementia.org.au/resources/rowland-universal-dementia-assessment-scale-rudas.

Several Chinese versions of the MoCA are available. The toolkit includes both the MoCA and MoCA Basic in Chinese within the Patient Assessment Forms section.

Recommended Cognitive Tests by Context

Step Three: Decision Support

Interpretation of Full Assessment Outcomes

Based on the responses to the history, examination (including cognitive testing), and laboratory testing, the full assessment can produce several outcomes. These outcomes and suggested management recommendations are also depicted in the Decision Tree.

Referral Considerations for AD-Spectrum Cases

The decision regarding referral to a dementia specialist depends on the individual clinical scenario.

If the patient has Alzheimer's disease (AD)-type symptoms and:

1. Biomarkers have confirmed that Alzheimer's disease is a likely contributor to symptoms.
2. The patient has a relatively mild degree of impairment, including mild cognitive impairment or mild dementia.

The patient may be eligible for anti-amyloid therapies that are currently administered only in specialized settings.

Considerations for Referral

• The patient's ability to receive frequent infusions at a specialized center and undergo multiple MRI examinations for monitoring potential adverse effects.
• The severity of impairment should remain relatively mild. Although there is no universally accepted definition of mild dementia, many clinicians consider patients who have lost the ability to perform instrumental activities of daily living or who have noticeable impairment in basic activities of daily living to be beyond the mild stage.

Patients with AD-Type Symptoms but Negative Biomarkers

If a patient has symptoms suggestive of Alzheimer's disease but biomarker testing is negative, consider the possibility of a false-negative result.

For example, if a patient has an insidiously progressive syndrome with predominantly memory symptoms, no alternative explanation for the symptoms, and would otherwise be eligible for anti-amyloid treatment, additional testing may be appropriate.

If a blood biomarker such as p-tau217 was used initially, obtaining an amyloid PET scan or cerebrospinal fluid (CSF) Aβ and tau testing may be advisable before finalizing the assessment.

If Referral to a Dementia Specialist Is Planned

Goals for Referral

• Obtain a second opinion regarding the history, examination, and findings.
• Pursue additional diagnostic workup.
• Clarify the diagnosis.
• Obtain treatment recommendations.
• Honor a patient or family request for referral.

Information to Include with the Referral

• A brief summary of the time course and prominent symptoms prompting referral.
• A summary of pertinent medical conditions and current medications.
• Results of cognitive assessments, including cognitive testing results and copies of imaging reports or scan images (CD), if available.

Referral Resources

• State Alzheimer's Disease Centers
• Federal Alzheimer's Disease Research Centers
• American Academy of Neurology – Find a neurologist near you
• Alzheimer's Association – Local chapters can often recommend physicians with expertise in dementia
• Northern California Neuropsychology Forum – Find a neuropsychologist
• American Academy of Clinical Neuropsychology – Search for a clinical neuropsychologist

Diagnostic Decision Tree

The Diagnostic Decision Tree provides a visual workflow for interpreting assessment findings and determining the appropriate next steps in diagnosis, biomarker testing, referral, and management.

Refer to the Diagnostic Decision Tree figure for the complete decision pathway.

Referral Guidance

The Referral Guidance figure summarizes when referral to a dementia specialist is recommended based on clinical presentation, cognitive testing, biomarker results, and diagnostic uncertainty.

Refer to the Referral Guidance figure for the complete referral algorithm.

Step Four: Disclosure and Scripts

Mild Cognitive Impairment

The script below assumes you have identified cognitive difficulties that seem in excess of normal aging, but not severe enough to be labeled as dementia. They may be due to a medical condition that might explain the symptoms (such as depression), or you may not have identified any medical conditions that explain them, making a neurodegenerative disease more likely.

The script addresses how to discuss mild cognitive changes, assessment findings, and plans for management and further evaluation when appropriate.

Key Discussion Points

• Ask the patient and family for their impression of the cause of the problem and their goals for the appointment.
• Explain the dementia syndrome, since many patients believe dementia and Alzheimer's disease are the same.
• Explain the workup used to rule out non-neurodegenerative causes.
• Explain neurodegenerative disease and what the evaluation can and cannot determine.
• Describe the clinical diagnosis and syndrome of Alzheimer's disease.
• Discuss possible blood testing for Alzheimer's disease if appropriate.

Script to Discuss Mild Cognitive Impairment

"Thanks so much for your patience as we have collected all the information we need to assess your complaint. Now that we have gotten a full description of the problem and we have gotten results on the blood tests and brain imaging results [can refer to MRI or CT scan, as appropriate], this is a good time to review what we have found and discuss what is causing these problems."

"Before I tell you what I think about the problems we've been discussing, I think it would be good for you to tell me what you are hoping for in this discussion. Do you have your own theories about what is causing the problem that you would like me to address? Are there specific diseases that you are worried about? Are there other specific questions that you would like me to answer if I can?"

This discussion helps determine whether the patient or family expects to hear about Alzheimer's disease, believes the symptoms are normal aging, or has concerns about other possible causes such as toxins or genetics. Patients often ask about the future, available treatments, or whether they have dementia or Alzheimer's disease.

"These are all great questions. I think our discussion will address some of them today, but we may talk about some of these questions during future visits."

"To start off, the answer to many of these questions starts with trying to establish the cause of the problem. First, it's helpful to talk about terminology..."

Continue by explaining:

• What the term dementia means.
• Medical conditions that can affect cognition.
• Neurodegenerative diseases and how abnormal proteins affect nerve cells.
• How Alzheimer's disease differs from normal aging.
• That the patient's symptoms are greater than expected for normal aging but are not severe enough to meet the definition of dementia.

If a Medical Cause Is Identified

"In your case, we identified XXXXXXXXXX, which can be associated with cognitive complaints. Hopefully, this is the main cause of your problems, and it is not a neurodegenerative disease. So, the first thing we should do is try to address this issue by XXXXXXX (referring, treating as appropriate) and then seeing if your memory or other thinking problems improve."

If No Medical Cause Is Identified

"We did not find any evidence for a specific general medical issue that can explain your complaints..."

Explain that:

• Some people with mild cognitive changes already have proteins associated with neurodegenerative disease.
• Others remain stable or improve over time.
• It is not currently possible to accurately predict which patients will progress.
• Periodic follow-up is necessary to monitor for worsening symptoms.

Management Discussion

Discuss strategies to reduce the risk of further cognitive decline, including:

• Smoking cessation.
• Blood pressure control.
• Diabetes management.
• Weight management.
• Heart-healthy lifestyle changes tailored to the individual patient.

Discussion of Alzheimer's Disease Blood Biomarker Testing

"Another question we should talk about is whether you want to know more about whether you could have a neurodegenerative disease..."

Explain that blood biomarker testing can identify evidence of Alzheimer's disease protein accumulation but does not diagnose every neurodegenerative disease or predict exactly how symptoms will progress.

Discuss how positive results may help with future planning, treatment decisions, and referral to a specialist when appropriate.

Cognitive Changes with Dementia

Begin the discussion by assessing the patient’s and family’s goals and expectations before reviewing the diagnosis.

Key Discussion Points

• Ask the patient and family for their impression of the cause of the problem and their goals for the appointment.
• Explain the dementia syndrome.
• Review the workup completed to rule out non-neurodegenerative causes.
• Describe the clinical diagnosis and syndrome of Alzheimer's disease.
• Discuss possible blood biomarker testing for Alzheimer's disease.

Script to Discuss the Diagnosis of Dementia

"Thanks so much for your patience as we have collected all the information we need to assess your complaint. Now that we have gotten a full description of the problem, and we have gotten results on the blood tests and brain imaging results [can refer to MRI or CT scan, as appropriate], this is a good time to review what we have found and discuss what is causing these problems."

"Before I tell you what I think about the problems we've been discussing, I think it would be good for you to tell me what you are hoping for in this discussion. Do you have your own theories about what is causing the problem that you would like me to address? Are there specific diseases that you are worried about? Are there other specific questions that you would like me to answer if I can?"

This discussion helps determine the patient's and family's expectations, concerns, and questions regarding Alzheimer's disease, dementia, genetics, toxins, prognosis, and treatment options.

"These are all great questions. I think our discussion will address some of them today, but we may talk about some of these questions during future visits."

Continue by explaining:

• The term dementia describes worsening memory or thinking problems that interfere with everyday functioning.
• Dementia is not a diagnosis itself but a description of a syndrome caused by an underlying disease.
• Many medical conditions can contribute to dementia, including metabolic disorders, vitamin deficiencies, infections, strokes, and brain tumors.
• Review that the patient's examination, laboratory testing, and brain imaging did not identify another medical explanation for the symptoms.

Explain that neurodegenerative diseases affect nerve cells over time, causing them to shrink, lose communication with one another, and eventually die. These diseases are associated with abnormal protein accumulation that cannot usually be detected on routine brain imaging.

Explain that Alzheimer's disease is the most common neurodegenerative disease and results from the accumulation of amyloid-beta (Aβ) and tau proteins. Early Alzheimer's disease typically affects memory before progressing to other cognitive functions.

Review how the patient's history, examination, and cognitive testing are consistent with Alzheimer's disease as the most likely explanation for the current symptoms.

"Before we move on to talk about treatments, do you have any questions about the information I gave you? I know it's a lot, and it's very complicated, but if there was anything that didn't make sense to you, please go ahead and ask."

Discussion of Alzheimer's Disease Blood Biomarker Testing

"If you want to know more about the possibility that Alzheimer's disease is causing the problems, we do have a blood test that tells us whether you have the proteins that cause Alzheimer's disease building up in the brain."

Explain that:

• The blood test evaluates only Alzheimer's disease and does not detect other neurodegenerative diseases.
• An abnormal result suggests Alzheimer's disease proteins are present and likely contributing to symptoms.
• A normal result does not exclude other neurodegenerative diseases.
• Biomarker results may help with prognosis, treatment planning, and determining whether referral to a specialist is appropriate.

Medication Treatment for Dementia

This discussion reviews currently available treatment options after a diagnosis of dementia has been established.

Symptomatic medications may improve cognitive symptoms but do not alter the underlying disease process. Disease-modifying therapies may slow progression by targeting Alzheimer's disease proteins.

Topics to Discuss

• Symptomatic medications versus disease-modifying treatments.
• Cholinesterase inhibitors, including expected benefits and possible side effects.
• Memantine, including expected benefits and possible side effects.
• Disease-modifying therapies when appropriate.
• Non-medication approaches such as exercise, social engagement, and cognitive activities.
• Diet and dietary supplements.

Script to Discuss Medication Treatment

"Let's talk about treatment options. There are medications available that can help with symptoms of dementia. While these medications help with the symptoms, it is important to realize that they do not slow down the damage that is happening to the nerve cells. They just adjust the chemistry of the brain to help the brain work better."

Cholinesterase Inhibitors

Common medications include donepezil (Aricept), galantamine (Razadyne), and rivastigmine (Exelon).

Explain that these medications increase acetylcholine levels in the brain and may slow symptom progression, although they do not restore memory or stop disease progression.

Review common side effects, including nausea, diarrhea, bradycardia, dizziness, shortness of breath, chest pain, and nightmares. Advise patients to stop the medication and contact the provider if significant side effects occur.

Memantine

Explain that memantine (Namenda) works through a different mechanism and may be added later in the disease course. It is generally well tolerated and is often introduced after cholinesterase inhibitor therapy has been established.

Disease-Modifying Therapies

Disease-modifying treatments include anti-amyloid infusions, which can slow decline in cognition and function by removing some of the abnormal proteins associated with Alzheimer's disease. These treatments also have potential adverse effects, including amyloid-related imaging abnormalities (ARIA).

Script to Discuss Disease-Modifying Therapies

"There are also drugs that can remove some of the abnormal proteins that build up in the brain with Alzheimer's disease. They can't be used to treat any other neurodegenerative disease. These drugs have to be given into your vein at a special center at least once a month for at least several months. You have to be carefully monitored and get MRIs every few weeks."

"Even these drugs don't completely stop the disease, but they do slow it down, so that your memory would probably be better after a few months of taking the drug than it would have been if you had not been taking the drug."

"These treatments can have serious side effects that can even be life-threatening, but most patients taking the drug don't have these serious side effects. Because of these side effects, the drug is not considered safe for all patients."

"If you are interested, we can refer you to a specialist who can provide more information, determine whether these drugs would be reasonably safe for you, and potentially begin treatment."

If the Patient Is Not a Candidate for Disease-Modifying Therapy

"There are also drugs that can remove some of the abnormal proteins that build up in the brain with Alzheimer's disease. These drugs have to be started early in the disease to have a chance of working, and they can also have very serious side effects, including brain swelling and bleeding."

"In your case, I do not think you are a good candidate for these drugs because [reason]."

Clinical Trials

Patients interested in participating in research may be referred to a tertiary referral center or search for studies independently.

Resources include:

• ClinicalTrials.gov
• Alzheimer's Association

Mental, Physical, and Social Activity

Encourage patients to remain mentally, physically, and socially active whenever possible.

Mental Activity

Although no specific brain exercise has been proven to improve dementia, using the brain regularly may help maintain function. Activities should be enjoyable and appropriate for the patient's abilities.

Examples include:

• Games
• Puzzles
• Word searches
• Computer games
• Discussions with family and friends

Physical Activity

Physical exercise benefits both physical and mental health. Activities should be enjoyable and tailored to the individual's abilities.

Examples include:

• SilverSneakers® programs
• Dancing
• Aquatic aerobics
• Walking with family or friends
• Chair aerobics
• Yoga

Social Engagement

Maintaining contact with family and friends is strongly encouraged. Social interaction may improve mood, communication, and overall well-being. Combining social activities with mental or physical exercise may provide additional benefit.

Diet and Supplements

A healthy diet, particularly a Mediterranean diet, is associated with a lower risk of developing Alzheimer's disease and supports cardiovascular health.

Vitamin deficiencies, such as vitamin B12 deficiency, should be corrected when identified. No other supplements are currently recommended or proven to be beneficial, and some supplements may interfere with prescribed medications or cause harm.

Patients should inform both their healthcare provider and pharmacist about any supplements they take.

Additional information is available from:

• Mayo Clinic: Alzheimer's Disease Diagnosis and Treatment 
• Alzheimer's Association: Medications for Memory 

Dementia-Related Behavioral Symptoms

This discussion introduces dementia-related behavioral symptoms, which can occur across all causes and stages of dementia. Although these symptoms may not be present during the initial evaluation, introducing the topic early can help prepare patients and caregivers should they arise later.

Key Discussion Points

• Behavioral symptoms are caused by changes in the brain and are not intentional.
• Symptoms can range from mildly bothersome to potentially unsafe.
• Non-medication approaches are often more effective and carry fewer risks than medications.
• Medications may reduce the frequency or intensity of symptoms but often require ongoing adjustment.
• Educational programs and caregiver support organizations can help families manage behavioral changes.

Script to Discuss Dementia-Related Behavioral Symptoms

"I wanted to review some of the symptoms that often accompany the memory and thinking symptoms we are most familiar with when we think of dementia. These are changes that tend to affect how someone behaves rather than how they think or remember. They don't occur in everyone, but I want to mention them so you are prepared if you observe them and aren't surprised. Have you heard about these or noticed any of these?"

Tailor the discussion to behaviors already observed or explain that these symptoms may develop over time and that support is available if they occur.

Explain that behavioral changes result from the same brain disease that causes memory impairment and are not intentional. They often reflect confusion, anxiety, or difficulty interpreting the surrounding environment.

Behavioral symptoms may include increased irritability, anger, reduced cooperation, repetitive behaviors, or other changes. While some behaviors may be inconvenient, others may create safety concerns and should be reported promptly.

"Please let us know if you notice behaviors that concern you or affect the safety of you or your loved one. We can help determine what interventions may be appropriate and how urgently they should be addressed."

Non-Medication Approaches

Non-pharmacologic strategies are generally recommended before considering medication.

Examples include:

• Using calm, simple communication techniques.
• Simplifying the environment by reducing clutter, distractions, and background noise.
• Providing consistent routines and uncomplicated schedules.
• Avoiding confrontation over false beliefs or misinterpretations.
• Redirecting attention to another activity when appropriate.
• Participating in caregiver education programs and reviewing expert resources.

Medication Considerations

Explain that medications rarely eliminate behavioral symptoms completely and often provide only partial improvement. Non-medication approaches are preferred whenever possible because they carry fewer risks.

If behaviors become severe or create safety concerns, medications or other treatments may be considered. Multiple medication trials may be necessary to identify an effective treatment while minimizing side effects.

Caregiver Resources

• Alzheimer's Association – Dementia-Related Behaviors 
• Caregiver Resource Center of California 

Discussing Driving Safety

Driving Scripts

The following scripts can be used during the evaluation, before a diagnosis is made, to promote safety when the patient, informant, or clinician has concerns about driving ability.

These discussions are appropriate when cognitive testing is significantly impaired but mandatory reporting is not yet required.

Script Option 1

"As a healthcare provider, my job is to keep my patients healthy and safe. I also have a public health duty to keep others in our community safe. I don't want to see you get hurt or hurt anyone else. At this time, based on what you and your family tell me and/or today's evaluation, I have to advise you that I do not think you should be driving, and I am going to ask you not to drive until the evaluation of your memory and thinking is completed and we know more."

Script Option 2

"I suggest you have an evaluation that shows you are safe to drive. I can refer you to a driver evaluation program, run by an Occupational Therapist who specializes in assessing driving skills and providing adaptations and other assistance to help people continue to drive safely."

"I know that this is a very difficult change to even consider, and I appreciate the challenges that it may present. However, your safety and that of others have to be my primary concern. We will definitely discuss this again. Do you have any questions?"

Additional Guidance

Patients and families may ask about the reporting process. If a diagnosis of dementia is made in the future, explain that reporting requirements may apply depending on state law.

It may also be helpful to explain that an occupational therapist performing a formal driving evaluation may be a mandated reporter to the Department of Motor Vehicles (DMV) if the individual is determined to be unsafe to drive.

Additional Resource

For more information, see the Family Caregiver Alliance resource:

Dementia, Driving, and California State Law 

Billing

Evaluating a Concern

This section provides guidance on planning and billing for the time required to identify a cognitive concern, complete a comprehensive evaluation, and communicate the diagnosis to the patient and family. The shaded rows in the original table represent a typical three-visit process to identify, evaluate, and disclose a diagnosis.

After Diagnosis

This section provides guidance on billing for follow-up visits and ongoing management after a diagnosis has been established.