Today I link to and excerpt from The Curbsiders‘ “#478 Dementia 2.0 with Anna Chodos”.*

*Witt LJ, Heller, M, Chodos A, Williams PN, Watto MF. #478 Dementia 2.0”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast April 7, 2025.

The Curbsiders Internal Medicine Podcast

Transcript available via YouTube

Updates in classification, evaluation, and treatment

Become dexterous with dementia management! We’re talking with Dr. Anna Chodos about cognitive domains, diagnostic criteria, patient and caregiver resources, new antibody therapies, and brain health plans!

Claim CME for this episode at curbsiders.vcuhealth.org!

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Show Segments

• Intro
• Rapid fire questions
• The Terminology of Neurocognitive Disorders
• Cognitive Domains: A Comprehensive Approach
• Physical Examination Insights
• Medical Workup for Dementia
• Imaging and Biomarkers in Dementia Diagnosis
• Referral Considerations for Dementia Patients
• Understanding Dementia Stages and Prognosis
• Implementing Brain Health Plans
• Medications for Dementia Management
• Controversies in Monoclonal Antibody Therapies
• The Importance of Early Detection and Planning
• Outro

Disclosures

Dr. Chodos received remuneration from Novo Nordisk for participating in a task force looking at the feasibility of incorporating biomarkers for Alzheimer’s disease into primary care. The financial relationship has ended. The Curbsiders report no relevant financial disclosures.

The production of this episode was supported by the Penn Geriatrics AGE-SMART Geriatric Workforce Enhancement Grant. This podcast content is solely the responsibility of the authors and does not necessarily represent the official views of the Health Resources and Services Administration or the U.S. Department of Health and Human Services.

Dementia 2.0 Pearls

1. Mild neurocognitive disorder is defined as cognitive changes from baseline in the absence of functional impairment. Major neurocognitive disorder is cognitive impairment causing functional impairment.
2. There are six cognitive domains outlined in the DSM-V diagnostic manual for neurocognitive disorders: memory and learning, language, executive functioning, perceptual/motor, social cognition, and complex attention.
3. Initial diagnostics include testing for reversible causes and, typically, head imaging. MRI is preferred for better structural information.
4. Early detection of dementia is important so that patients and families can plan for the future. It also helps the patient better engage in their care while their disease is still mild.
5. A “brain health plan” is a cornerstone of dementia prevention and intervention. This includes recommendations for physical and social activity, management of cardiovascular risk factors, treatment of hearing/vision impairment, and careful medication review/deprescribing when necessary.
6. The traditional oral/transdermal medication categories for dementia are anticholinesterase inhibitors and NMDA antagonists, which can have some limited  symptomatic benefits but may not have clinical benefit and could come with adverse effects.
7. Newer disease-modifying monoclonal antibody therapies may be offered to patients with early stage Alzheimer’s disease pathology. For eligibility, they require extensive workup, frequent infusions and periodic head imaging to check for ARIA (cerebral hemorrhage or edema) as a side effect. Eligible/interested patients should be referred to neurologists for evaluation.

Diving into Dementia 

Making the diagnosis

The terminology of neurocognitive disorders

The DSM 5 (published in 2013) classification for cognitive impairment is mild neurocognitive disorder (known commonly as mild cognitive impairment) and major neurocognitive disorder (often called dementia). Note: in this episode Dr. Chodos uses the term “minor neurocognitive disorder” instead of “mild neurocognitive disorder.”

What distinguishes the two is function (remember: geriatricians love assessing function)! In both, cognitive decline (from previous level in 1+ cognitive domains) is present and not due to medications, substances, or psychiatric conditions.

• Mild neurocognitive disorder (AKA mild cognitive impairment): cognitive symptoms ARE NOT affecting INDEPENDENT day to day function (see more on function below!). However, the individual may be exerting more effort to accomplish tasks or compensatory strategies (like using maps or calculators more often).
• Major neurocognitive disorder (AKA dementia): cognitive symptoms ARE “interfering with independence” in day to day functioning.

The six cognitive domains

1. Memory and learning: this one gets all the attention and glory, because Alzheimer’s is most common and well-known (and defined early by memory loss). Ask: Are you/they having more trouble remembering conversations, appointments? Trouble recognizing family members?
2. Language: Ask: Are you/they having word finding difficulty? Trouble understanding what people are saying or following conversations?
3. Executive functioning: Ask: Are you/they having difficulty preparing a meal? Planning a trip? Managing finances?
4. Social Cognition (behavior): Ask: Are you/they having changes in mood or personality? Any auditory or visual hallucinations?
5. Perceptual-motor (visuospatial): Ask: Are you/they getting lost or driving in familiar places? Any falls? Are you/they having tremors, falls, trouble swallowing, constipation, or sleep issues?
6. Complex attention (or just attention!). Ask: are you/they having trouble focusing on a task?

Function Function Function

Activities of Daily Living (ADLs) to ask about are bathing, dressing, transferring, toileting, grooming and feeding. Instrumental Activities of Daily Living to evaluate are using the telephone, preparing meals, managing household finances, taking medications, doing laundry/housework, shopping and managing transportation (UCSF, Dementia Care Aware). Remember that this should represent a change in their previous level of functioning (eg if someone never did the laundry, it isn’t a red flag that they aren’t currently doing the laundry!). Additionally, the barriers to function should be related to cognition, not physical function.

If possible, getting collateral information from an informant (like a relative, friend, caregiver, neighbor, etc) is very helpful. Think about the trajectory and severity of symptoms and don’t forget to ask about educational history and a history of an intellectual disability or psychiatric illness.

The MiniCog– an excellent screening tool

A reminder- the Mini-Cog is a three word recall followed by a clock draw (Borson et al 2000). This test makes a great screening tool because it’s very doable in the clinic OR by telehealth (brief and just needs a pen and paper!). It can also translate into many languages and is accessible for patients with varying degrees of education. A positive test indicates a higher posttest probability of having dementia, so if your patient scores less than 3, proceed to next steps for evaluation.

Starting the workup 

Don’t forget the physical exam in addition to your excellent history (Livingston G, et al 2024)! As expected, the neuro exam is one of the most important pieces of your targeted exam. Things to look for include signs of asymmetry (indicating possible prior strokes), Parkinson’s signs (can point to Lewy Body territory), and a gait assessment (Verghese 2022).

Next, check for reversible causes of cognitive impairment. When it comes to lab work, these include vitamin B12, TSH, HIV, and RPR. You can skip the HIV and RPR (or other syphilis testing) in the absence of risk factors.

Head imaging is also generally worth doing in every patient getting a workup for dementia to make sure you’re not missing anything (tumor, metastases, other structural abnormalities). This is especially important for patients with a history of head injury, HIV, on anticoagulation, younger in age, or with rapid onset of symptoms. MRI can be more useful for structural information (Živanović et al 2023), but a CT also works in absence of red flags or if an MRI is not available. On MRI, temporal lobe atrophy can be a sign of possible Alzheimer’s, or age-inappropriate volume loss. The more atrophy seen, the more severe disease is likely. Chronic small vessel disease is a common finding but can sometimes suggest a vascular etiology.

What about biomarkers? While we can make a clinical guess as to the cause of someone’s dementia, newer biomarker testing can look specifically for biomarkers of Alzheimer’s disease (Graff-Radford et al 2021). These include CSF studies looking for amyloid or tau proteins (low amyloid or high tau = suspicious for Alzheimer’s). Blood biomarkers are also available looking for amyloid proteins. There are also amyloid-specific PET scans. Insurance coverage is variable depending on the test and indication. Since these would be used to guide treatments typically in the neurologist’s domain, these tests should be ordered by specialists, as well.

Who should see a geriatrician, neurologist, or other dementia specialist? 

In general, patients with milder disease are more appropriate for specialist care. Patients with more severe disease are unlikely to be able to complete intensive neuropsych testing. Also, patients with milder disease are more appropriate to be evaluated for monoclonal antibody therapies.