Assessment of Cognitive Complaints Toolkit

As the U.S. population ages, Alzheimer’s disease and other neurodegenerative diseases are becoming more common. Disease-modifying therapies are most effective when started early, underscoring the importance of timely recognition and accurate diagnosis.

Primary care clinicians are often the first to evaluate cognitive and behavioral symptoms, but limited visit time, competing clinical priorities, and variable access to dementia specialists can make assessment challenging.

The Assessment of Cognitive Complaints Toolkit for Alzheimer's Disease (ACCT-AD) provides a practical, evidence-informed approach to evaluating patients with cognitive concerns. Designed for routine primary care workflows, the toolkit supports diagnosis, management, and referral through a structured, team-based approach. Biomarkers can support diagnosis in selected patients, particularly when considering disease-modifying therapies, but they should always be interpreted alongside the patient's history, cognitive assessment, physical examination, and other clinical findings.

Note The Date: The science and care of neurodegeneration are evolving rapidly, including the development of new diagnostic markers and new treatments. The CADCs will regularly update the toolkit to reflect the most recent developments. If the version you are looking at is more than a year old, or if you think there are major developments that do not seem to be addressed in the version you are working with, look to see if there is a more recent version, which should be available on the California Department of Public Health Alzheimer’s Disease Resources page.

Last Toolkit Revision Date: August 1, 2025

What is included

The ACCT-AD supports each stage of the diagnostic evaluation:

1. Identify cognitive concerns
2. Perform a structured assessment
3. Interpret findings
4. Communicate the diagnosis
5. Refer when appropriate

Clinical considerations

The toolkit provides recommendations for situations that may complicate assessments, including:

• No knowledgeable informant: Supplement the history with cognitive testing (for example, MoCA or MMSE).
• Language barriers: Use validated translated assessments when available; otherwise, rely on history and consider referral for neuropsychological evaluation.
• Low literacy or limited education: Adapt testing as appropriate or consider neuropsychological evaluation.
• Major mental illness: Consider specialty referral when psychiatric symptoms may affect assessment.
• Developmental disabilities: Consider referral for patients with developmental disorders, including Down syndrome.

When to refer

Consider referral to a neurologist, geriatrician, psychiatrist, neuropsychologist, or other appropriate specialist when patients have:

• Atypical cognitive or behavioral symptoms
• Early-onset or rapidly progressive decline
• Diagnostic uncertainty after the initial evaluation
• Complex neurological or psychiatric conditions
• Need for advanced diagnostic testing or consideration of disease-modifying therapy

Patients with mild cognitive impairment or dementia that is likely due to Alzheimer’s disease may also benefit from specialty consultation, depending on the diagnostic uncertainty, treatment goals, and availability of local resources.

Why was this toolkit developed?

Primary care clinicians increasingly diagnose and manage patients with cognitive impairment, yet access to dementia specialists remains limited. The ACCT-AD Toolkit was developed by the California Alzheimer’s Disease Centers (CADCs) to provide practical, evidence-informed guidance that supports diagnosis, management, referral, and communication in routine primary care practice.

The toolkit is based on peer-reviewed evidence, best practices, Medicare and Medicaid policy, and reimbursement guidance relevant to primary care. It was developed in response to California Senate Bill 833, which charged the CADCs with improving the detection and diagnosis of Alzheimer's disease in primary care.

What makes this toolkit different?

• Covers the entire diagnostic evaluation—not just screening.
• Supports diagnosis of Alzheimer's disease while helping clinicians recognize alternative causes of cognitive impairment.
• Includes practical guidance for diagnostic disclosure, counseling, referral, and billing.

Why a specific diagnosis matters

A timely and accurate diagnosis can:

• Identify potentially reversible causes of cognitive impairment.
• Improve continuity of care within the primary care practice.
• Support treatment selection, including consideration of disease-modifying therapies when appropriate.
• Guide medication management and reduce the risk of adverse drug effects.
• Inform prognosis, care planning, and counseling for patients and care partners.
• Help identify opportunities for participation in clinical research.

Download the ACCT-AD Toolkit (PDF)

Acknowledgments

The California Alzheimer's Disease Centers gratefully acknowledge the members of the CADCs Task Force for their leadership in developing the ACCT-AD: Loren Alving, MD; Cynthia Barton, GNP; Timothy S. Chang, MD, PhD; John Danner, LCSW; Sarah Dulaney, RN; Sarah Farias, PhD; Diana Ferman, PA-C; Douglas Galasko, MD; Joshua Grill, PhD; David Johnson, MD; Terence Kelley, MS; Sarah Kremen, MD; John Olichney, MD, Aimee Pierce, MD; Howie Rosen, MD; Blake Scanlon, PhD; Freddi Segal-Gidan, PA, PhD; Shirley Sirivong; Maya Slowinska; Karen Stevens, MS; Lon Schneider, MD; Keith Vossel, MD, PhD; Jerry Yesavage, MD.

We also thank Cecilia Alagappan, RN; Alissa Bernstein Sideman, PhD, MPH; and Caroline Prioleau for their significant contributions to the toolkit.

The project was supported by the California Department of Public Health, Alzheimer’s Disease Program.

The Assessment of Cognitive Complaints Toolkit is in the public domain.

About the CADCs

The California Alzheimer’s Disease Centers (CADCs) are a statewide network of ten dementia centers supported by the California Department of Public Health. Since 1984, the CADCs have advanced dementia care through research, clinical services, workforce development, and community education.

The ACCT-AD Toolkit was developed by the CADCs Task Force using peer-reviewed evidence, best practices, and reimbursement guidance to support primary care clinicians evaluating patients with cognitive concerns. It is intended for use by healthcare professionals.

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