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Alzheimer’s presents with gradual onset and progressive decline. The hallmark is early, prominent memory impairment for recent events. Rule out reversible causes of cognitive decline (delirium, hypothyroidism, B12 deficiency, depression) before diagnosing dementia.
Key Knowledge
● Most common cause of dementia, accounting for 60-70% of cases
● Pathologically characterised by amyloid plaques and neurofibrillary tangles
● Typical onset after age 65 (late-onset); rare early-onset (<65) forms exist, often familial
● Core features: progressive memory impairment, plus other cognitive domains (language, visuospatial, executive function), ACE-III often show deficits in all areas
● Behavioural and psychological symptoms (BPSD) are common—agitation, apathy, depression, psychosis
● Diagnosis is clinical; neuroimaging excludes other causes and can show temporal lobe atrophy (MTA score 0-4); biomarkers are increasingly used in specialist settings
What is Alzheimer’s Disease?
ICD-11 defines dementia due to Alzheimer disease (6D80) as an acquired syndrome characterised by decline in memory and other cognitive domains, sufficiently severe to interfere with personal, social, or occupational functioning. The course is insidious in onset and gradually progressive.
Core clinical features:
● Memory impairment: Difficulty learning and retaining new information. Repetitive questioning, forgetting recent conversations or events. Remote memory is relatively preserved initially.
● Impairment in at least one other cognitive domain:
Language (word-finding difficulties, anomia, reduced fluency)
Visuospatial abilities (getting lost in familiar places, difficulty with spatial tasks)
Executive function (planning, organisation, decision-making, abstract thinking)
● Functional decline: Increasing difficulty with instrumental ADLs (finances, medication management, cooking) progressing to basic ADLs (washing, dressing, eating)
● Behavioural and psychological symptoms of dementia (BPSD):
○ Apathy (most common)
○ Depression and anxiety
○ Agitation and aggression
○ Psychotic symptoms (delusions, often paranoid; hallucinations, usually visual)
○ Sleep disturbance, wandering, sexual disinhibition
Typical progression:
● Mild: Forgetfulness, word-finding difficulty, some functional impairment (managing finances, appointments). Insight is often present initially.
● Moderate: Clear memory loss, disorientation, need for assistance with ADLs, BPSDs are common.
● Severe: Loss of verbal communication, incontinence, complete dependence for care, loss of mobility.
Subtypes:
● Late-onset (most common, >65 years old)
● Early-onset (<65 years old, often more BPSDs, higher genetic component)
Investigations:
● Cognitive testing (ACE-III, MoCA)
● Blood tests to exclude reversible causes (TFTs, B12, calcium, glucose, renal and liver function)
● Neuroimaging (CT/MRI): medial temporal lobe atrophy, generalised atrophy (excludes structural lesions)
● Specialist tests: CSF biomarkers, amyloid PET, genetic testing (in early-onset cases)
Differential Diagnosis for Alzheimer’s Disease
1. Vascular dementia
Key distinctions: Vascular dementia has more abrupt onset, stepwise deterioration, and clear relationship to cerebrovascular events (strokes, TIAs). Focal neurological signs may be present. Neuroimaging shows infarcts or significant white matter disease. Can often present as mixed Alzheimer’s and Vascular Dementia, as they share risk factors.
2. Lewy body dementia (LBD)
Key distinctions: LBD involves prominent visual hallucinations, parkinsonism, REM sleep behaviour disorder, and marked cognitive fluctuations. Memory is relatively preserved early on compared to Alzheimer’s.
3. Frontotemporal dementia (FTD)
Key distinctions: FTD presents with prominent behavioural change (disinhibition, apathy, loss of empathy) or language deficits (progressive aphasia). Memory is relatively preserved until later. Onset typically earlier (50s-60s). Neuroimaging shows frontal and/or temporal atrophy.
4. Depression (pseudodementia)
Key distinctions: In depression, cognitive complaints exceed objective findings. Mood symptoms predominate. Onset is more rapid, and symptoms may improve with antidepressant treatment. Note depression can co-exist with dementia.
5. Mild cognitive impairment (MCI)
Key distinctions: MCI involves cognitive decline greater than expected for age, but without significant functional impairment in daily life. It is a risk state for dementia but not dementia itself.
6. Delirium
Key distinctions: Acute or subacute onset, fluctuating course, identifiable medical precipitant (infection, medication, metabolic). Potentially reversible. Dementia is a risk factor for delirium, and they can coexist.
7. Reversible causes of cognitive impairment
Key distinctions: Hypothyroidism, B12 deficiency, normal pressure hydrocephalus, chronic subdural haematoma, brain tumours, neurosyphilis, iatrogenic (medications). Blood tests and neuroimaging help identify these.
8. Normal ageing
Key distinctions: Normal age-related cognitive changes are subtle and do not impair daily functioning. “Senior moments” (occasional forgetfulness) differ from the progressive, disabling impairment of dementia.
Risk Assessment in Alzheimer’s Disease
As with every risk assessment, you must consider risk to self, to others and from others.
To self:
● Self-neglect – Forgetting to eat, take medications, maintain hygiene, or secure home
● Wandering and getting lost – Disorientation, particularly in moderate-severe stages
● Falls and injury – Poor judgment, balance issues, agitation
● Accidents – Leaving stove on, unsafe driving
● Exploitation – Vulnerability to financial abuse
● Aspiration and choking – Swallowing difficulties in later stages
● Depression and suicide – Particularly early on, when person has insight into decline
To others:
● Generally low
● Agitation or aggression may occur, for example if paranoid due to BPSDs
From others:
● Vulnerability to abuse (physical, financial, emotional) by carers or family
● Caregiver stress and burnout may increase risk of neglect or harm
Communication Tips
Alzheimer’s stations often involve taking a history from a relative. Focus on memory, functional decline, BPSDs, and impact on carers.
Opening (with relative/carer):
● “Thank you for coming in. I’d like to understand what’s been happening with [patient]. Can you tell me what changes you’ve noticed?”
Exploring memory:
● “Have you noticed any problems with their memory?”
● “Do they forget recent conversations or repeat themselves?”
● “Do they forget appointments or important events?”
● “Can they remember things from years ago, for example childhood, their wedding?”
Exploring other cognitive domains:
● “Have they had difficulty finding the right words when speaking?”
● “Do they get lost, even in familiar places?”
● “Have they had trouble managing tasks they used to do easily, like cooking, managing bills, using the phone?”
Timeline and progression:
● “When did you first notice these changes?”
● “Have things got worse gradually or suddenly?”
Exploring functional impairment:
● “How are they managing day-to-day tasks?”
● “Do they need help with washing, dressing, eating, using the toilet?”
● “Can they still manage their medications, finances, and shopping?”
Behavioural and psychological symptoms:
● “Have you noticed any changes in their mood including low mood, anxiety, irritability?”
● “Any changes in behaviour, for example agitation, aggression and restlessness?”
● “Have they seemed less interested in things they used to enjoy?”
● “Do they see or hear things that aren’t there?”
● “Any unfounded suspicions, like thinking someone is stealing from them?”
● “Any sleep problems or wandering at night?”
Risk and impact:
● “Have they had any falls or accidents?”
● “Do they still drive? Any concerns about safety?”
● “Are you worried about them at home on their own?”
● “How are you coping as a carer? Are you getting support?”
Past medical history and medications:
● “Do they have any other medical problems, such as diabetes, heart disease, or a previous stroke?”
● “What medications are they taking?”
● “Have they recently seen the GP for any pain, constipation or infection?”
● “Any recent falls or change in mobility?”
Family history:
● “Does anyone else in the family have dementia or memory problems?”
CASC Station 5: Alzheimer’s Disease
Setting: Memory clinic (outpatient)
Candidate Instructions:
You are the SpR in the memory clinic. You are seeing Mr Robert Chen, a 71-year-old retired accountant, with his wife Margaret. Mr Chen was referred by his GP following Margaret’s concerns about his memory over the past two years. ACE-III score last week was 61/100 (attention 14/18, memory 8/26, fluency 6/14, language 22/26, visuospatial 11/16). MRI brain showed bilateral hippocampal and medial temporal lobe atrophy, generalised cortical atrophy, and mild periventricular white matter changes. Blood tests including TFTs, B12, folate, and glucose were normal.
Please take a collateral history from Margaret regarding her husband’s cognitive and functional decline.
Scenario Summary:
Robert Chen is a 71-year-old man with a two-year history of progressive cognitive decline consistent with Alzheimer’s disease. He has prominent memory impairment for recent events (forgets conversations, repeats himself, misplaces items), mild word-finding difficulties, reduced ability to manage complex tasks (finances, cooking), and gets lost in familiar places. The decline has been gradual and insidious with no sudden step-wise decline. He is still managing basic self-care but requires supervision for ADLs. He is becoming more apathetic and withdrawn, with occasional irritability. There are no hallucinations, parkinsonism, or significant fluctuations. Margaret is his primary carer and is coping but finding it emotionally difficult. Robert has limited insight into the severity of his difficulties.
Actor Brief:
You are Margaret Chen, a 69-year-old retired primary school teacher. You’re here with your husband Robert, who is 71. You’ve been married for 45 years and have two adult children, David (43) who lives in Manchester, and Helen (40) who lives locally. Robert retired five years ago after a long career as an accountant. You live together in a three-bedroom house.
You first noticed something was wrong about two years ago. Robert started forgetting conversations. You’d tell him something and the next day he’d have no memory of it. He’d ask you the same questions repeatedly: “What time is David visiting?” or “Have we got anything planned this weekend?” even though you’d just answered. He’d lose things constantly, including his wallet, his phone, his glasses, and accuse you of moving them. At first, you thought it was just normal aging, but it’s gotten progressively worse.
His memory for things from years ago is still pretty good. He can tell you all about his childhood in Hong Kong, your wedding day, holidays you took decades ago, but he can’t remember what he did yesterday. He forgets appointments constantly. He forgot David’s birthday last month, which really upset him because he’s never done that before. He’ll start telling you a story and then repeat the exact same story an hour later, word for word.
He’s also having trouble finding words. He’ll be mid-sentence and just stop, searching for the word, getting frustrated. Sometimes he’ll substitute the wrong word—he called the kettle “the hot thing” last week. It’s subtle, but it’s there.
About six months ago, he got lost driving to the supermarket, somewhere he’s been hundreds of times. He couldn’t work out how to get home and had to call you, quite distressed. Since then, you don’t let him drive anymore, which he’s unhappy about but accepts. He also got lost walking back from the corner shop two months ago, you found him three roads away, confused and upset.
He can’t manage finances anymore. He used to do all the household accounts, pay bills, manage investments. He was an accountant, so he was brilliant at it. Now he can’t follow bank statements or work out bills. You’ve taken over completely. He also can’t cook anymore. He left a pan on the hob and burned it, and another time he put a metal dish in the microwave. You do all the cooking now.
He’s still managing to wash and dress himself, though sometimes he needs prompting or puts clothes on in the wrong order. He’s still continent. He can make a cup of tea, but you have to remind him. He’s stopped reading; he used to love books, but now he says he can’t follow the plot. He watches TV but doesn’t really engage with it.
His mood has changed. He’s become quite apathetic. He used to be sociable, loved going to his golf club and seeing friends, but now he shows no interest. He’s withdrawn into himself. He’s not depressed exactly, he’s not tearful or saying life’s not worth living, but you feel like he has lost his ‘spark’. He’s also more irritable, snapping at you over small things, which isn’t like him, and this is often worse in the evenings. His sleep is okay. His appetite is normal. He doesn’t drink much, maybe a small glass of wine with dinner. He’s on amlodipine 5mg for blood pressure and aspirin 75mg, which you manage for him.
There’s no family history of dementia that you know of. Robert has always been healthy, he hasn’t had a stroke or head injury, and has no past psychiatric history.
You’re coping, but it’s hard. You’re exhausted from constantly supervising him and repeating yourself. You’ve had to give up your book club and your watercolour class because you don’t feel you can leave him alone for long. Your daughter Helen helps when she can, but she works full-time. David is supportive but far away. You haven’t arranged any formal care yet. You feel that you are managing on your own, but you know that might need to change.
You’re anxious about the diagnosis. You’ve suspected Alzheimer’s for a while, but hearing it confirmed will be devastating. You’re also worried about the future, how quickly he’ll decline, whether he’ll recognise you eventually, whether you’ll be able to cope.
Feedback for Scenario:
Knowledge & Clinical Skills
A good candidate will:
● Elicit the characteristic pattern of Alzheimer’s disease: insidious onset, gradual progression, prominent memory impairment for recent events with relative preservation of remote memory, and additional deficits in language (word-finding), visuospatial function (getting lost), and executive function (managing finances)
● Differentiate Alzheimer’s from other dementias by systematically ruling out features of vascular dementia (stepwise decline, focal neurology), Lewy body dementia (fluctuations, hallucinations, parkinsonism), and frontotemporal dementia (prominent behavioural change or language deficits early on)
● Brief screen for reversible causes (delirium)
● Assess functional impairment comprehensively, distinguishing between instrumental ADLs (finances, cooking, driving, shopping) and basic ADLs (washing, dressing, eating, continence).
● Screen for behavioural and psychological symptoms of dementia (BPSD), including apathy, depression, irritability, agitation, and psychotic symptoms, all of which are common and require specific management.
● Assess carer burden and coping, recognising that the wellbeing of the primary carer is critical to the patient’s ability to remain at home and that carers often neglect their own needs.
● Assess risk – focus on self-neglect, wandering, carer burnout and risk to others.
Communication
A good candidate will:
● Build rapport with the carer by acknowledging the emotional burden of caring for someone with dementia, using phrases like “this must be incredibly difficult for you.”
● Structure the collateral history systematically while remaining flexible and responsive to the carer’s emotional state and need to express grief and frustration.
● Demonstrate sensitivity when exploring potentially distressing topics such as loss of independence (driving, finances) and personality change, framing questions in a way that acknowledges the significance of these losses.
● Can offer reassurance if carer shows distress – “this must be very difficult for you as a family, but there are things we can do to help and support you.”
Authors / Reviewers
Dr Damir Rafi is a psychiatry speciality registrar in forensics, currently working in London.
Dr Leola Foscoe is a is a psychiatry speciality registrar in older adults, currently working in North East of England.
Dr Rebecca Goodall (2nd reviewer) is a is a psychiatry speciality registrar in CAMHS, currently working in London.
References and Resources
● World Health Organization. (2019). International classification of diseases for mortality and morbidity statistics (11th ed.). https://icd.who.int/browse11/l-m/en
● National Institute for Health and Care Excellence. (2018). Dementia: Assessment, management and support for people living with dementia and their carers (NG97). https://www.nice.org.uk/guidance/ng97
● Alzheimer’s Society. (2023). What is Alzheimer’s disease? https://www.alzheimers.org.uk/about-dementia/types-dementia/alzheimers-disease
Disclaimer:
This article is intended for use as a learning resource for doctors training in Psychiatry in the UK. It is not intended for patients. If you are looking for information about mental health conditions, please visit www.rcpsych.ac.uk/mental-health to find readable, user-friendly and evidence-based information on mental health problems, treatments and other topics written by qualified psychiatrists, with help from patients and carers. If you are looking for help for a mental health condition, please visit https://www.mind.org.uk/ for information about where help is available.
The article was written by UK doctors and cross-checked against various published sources (see Reference list). We endeavour to keep information up to date, but it should not be relied on for clinical decision making. Consult local guidelines and senior colleagues whenever you are not sure.