Table 1. Stepwise Approach to Diagnosing and Assessing Alzheimer Disease in Primary Care
StagePurposeTools to Use/Information to Obtain
Step 1: Prediagnostic testsDifferential diagnosis and determination of coexisting disordersRisk factors, including age, female sex, apolipoprotein E4 gene, prior head injury, low education, and family history of AD; stroke, obesity, hypertension, hyperlipidemia, hyperhomocysteinemia, diabetes, hyperinsulinemia, and smoking10,65,66
Medical history:
  • Other ailments that mimic dementia include normal age-associated memory changes, depression, delirium, drug reactions, vision and hearing problems1

Key questions to ask:
  • Has the patient had any recent illnesses?

  • Has the patient used any new prescription or over-the-counter medications that could cause memory loss, such as benzodiazepines, anticholinergic drugs for urinary incontinence

  • Has the patient used or been exposed to illicit drugs?

  • Has there been any exposure to environmental toxins, eg, fuels or solvents?

  • Has the patient had any head injuries recently?

  • Is there any history of epilepsy?

Laboratory/medical tests:
  • Complete blood cell count (to ascertain presence of anemia/infection), glucose and thyroid function tests, serum electrolytes, serum B12 levels (to identify vitamin deficiencies), liver function tests, renal function tests, and urinalysis, if appropriate1

  • Patients with AD frequently have comorbid medical conditions, eg, cardiovascular disease, infection, pulmonary, renal insufficiency, and arthritis.13

Early warning signs of preclinical dementia:
  • Increased frequency of patient visits to the PCP prior to diagnosis, over a period up to 5 years prior to the diagnosis34,35

  • Accelerated weight loss,36 late-life depression, gait disturbances, and physical frailty37

Step 2: Assess performanceCognitive assessments that help screen for/diagnose ADCognitive tests:*
  • MMSE12,13

  • Mini-Cog39,40,42,67

  • MoCA68

Informant-rated tool:*
  • AD863

Step 3: Assess daily functioningDetermine level of independence and degree of disabilityDaily function assessment tool:*
  • IADL48,49

Step 4: Assess behavioral symptomsDetermine presence and degree of behavioral symptomsBehavioral assessment tool:*
  • NPI-Q57

Assess the patient for drug toxicity and medical psychiatric, psychosocial, or environmental problems that may underlie behavioral changes.13
Step 5: Identify caregiver and assess needsIdentify the primary caregiver and assess adequacy of family and other support systemsIdentify primary carers and establish collaboration:
  • Family caregivers are central to the PCP's assessment and care of the patient.59

  • Establish and maintain collaboration with caregivers.59,60

  • Routinely incorporate caregivers' reports of patients' changes in daily routine, mood, behavior, and sleeping patterns.

Assess health of primary caregiver:
  • Regularly monitor the physical and emotional health of the primary caregiver as well as that of the patient.13

  • The PCP should assess the caregiver themselves or refer them to a psychologist, social worker, or other member of the health care delivery team.

Special considerationsIdentify culture, language, and literacy of patient and caregiverCulture:
  • Recognize the caregiving patterns of ethnic minority groups, eg, African American and Hispanic families distribute care among several family members, rather than one primary carer.

  • Ethnic minority groups may place different interpretations on memory and behavioral problems.

  • Be aware of the preferred language of the patient and family.69

  • Recognize that paper-and-pencil tests and forms may not work well with diverse patient populations if basic literacy is not present, even when such forms are in the person's native language.

  • Some experts suggest that patients be tested only on what they reasonably may be expected to know,70 eg, a person with little schooling may not know how to do the serial sevens on the MMSE, but may be competent at applying simple math, such as subtraction, when handling monetary transactions.

  • The initial assessment of cognitive and functional abilities is important to determine a baseline to which future deficits may be compared. Reassessment of the patient every 6 months is recommended, and more often in cases of sudden changes in behavior or increased rate of decline.13

  • * Refer to Table 2 for further details.

  • AD, Alzheimer disease; AD8, 8-item Ascertain Dementia tool; IADL, instrumental (or intermediate) activities of daily living; MMSE, Mini-Mental State Examination; Mini-Cog, Mini Cognitive Assessment Instrument; MoCA, Montreal Cognitive Assessment; NPI-Q, Neuropsychiatric Inventory Questionnaire; PCP, primary care physician.