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14.4 Mild Cognitive Impairment, Dementia & Its Subtypes
ABIM Internal Medicine Exam
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1 Chapter 0: The ABIM Exam, Blueprint & Study Strategy
0.1 Exam Format, Question Types & the 2026 Blueprint 0.2 Eligibility, Registration, Fees & Exam-Day Logistics 0.3 Scoring, the Passing Standard & Score Reports 0.4 Building a Blueprint-Weighted Study Plan
2 Chapter 1: Cardiovascular Disease (14% of Exam)
1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection
3 Chapter 2: Endocrinology, Diabetes & Metabolism (9% of Exam)
2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia
4 Chapter 3: Gastroenterology & Hepatology (9% of Exam)
3.1 Esophageal Disease 3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage 3.3 Inflammatory Bowel Disease 3.4 Celiac Disease & Irritable Bowel Syndrome 3.5 Diverticular Disease & Colorectal Cancer Screening 3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease 3.7 Cirrhosis & the Complications of Portal Hypertension 3.8 Acute Pancreatitis 3.9 Chronic Pancreatitis & Biliary Tract Disease 3.10 Inherited, Autoimmune & Drug-Induced Liver Disease 3.11 Small Intestinal Disease, Ischemia & Gastrointestinal Complications of HIV
5 Chapter 4: Infectious Disease (9% of Exam)
4.1 Lower Respiratory Tract Infections & Sepsis Syndromes 4.2 Viral Respiratory Pathogens & Tuberculosis 4.3 Central Nervous System Infections 4.4 Skin, Soft Tissue, Bone & Joint Infections 4.5 Infective Endocarditis & Cardiovascular Infection 4.6 Clostridioides difficile & Catheter-Related Bloodstream Infection 4.7 HIV Diagnosis, Antiretroviral Therapy & Prevention 4.8 Opportunistic Infections & Sexually Transmitted Infections 4.9 Fever of Unknown Origin, Neutropenic Fever & Toxic Shock 4.10 Travel-Related Illness, Vector-Borne Disease & Outbreaks 4.11 Infection Prevention, Nosocomial Infection & Postexposure Prophylaxis 4.12 Rheumatic Fever, Poststreptococcal Disease, Enteric & Hepatic Infections
6 Chapter 5: Pulmonary Disease (9% of Exam)
5.1 COPD: Diagnosis, GOLD Classification & Initial Pharmacotherapy 5.2 Interventions That Reduce COPD Mortality & Exacerbation Management 5.3 Asthma: Diagnosis, Stepwise Therapy & Status Asthmaticus 5.4 Interstitial Lung Disease & Idiopathic Pulmonary Fibrosis 5.5 Sarcoidosis, Hypersensitivity Pneumonitis & Occupational Lung Disease 5.6 Pulmonary Embolism: Diagnosis, Risk Stratification & Anticoagulation 5.7 Pulmonary Hypertension & Sleep-Disordered Breathing 5.8 Acute Respiratory Distress Syndrome & Mechanical Ventilation 5.9 Pleural Disease, Empyema & Pneumothorax 5.10 Bronchiectasis, Cystic Fibrosis & Restrictive Lung Disease 5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule
7 Chapter 6: Rheumatology & Orthopedics (9% of Exam)
6.1 Rheumatoid Arthritis: Diagnosis & Systemic Manifestations 6.2 Antirheumatic Pharmacotherapy & the Spondyloarthropathies 6.3 Gout: Pathophysiology & Acute Management 6.4 Urate-Lowering Therapy & Calcium Pyrophosphate Deposition Disease 6.5 Osteoarthritis 6.6 Systemic Lupus Erythematosus 6.7 Systemic Sclerosis, Sjogren Syndrome & Inflammatory Myopathies 6.8 The Vasculitides 6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries 6.10 Other Primary Rheumatic Disorders & Mixed Connective Tissue Disease 6.11 Osteonecrosis & Metabolic Bone Disease
8 Chapter 7: Hematology (6% of Exam)
7.1 Approach to Anemia & the Microcytic Anemias 7.2 Macrocytic, Normocytic & Hemolytic Anemias 7.3 Hemoglobinopathies, Thalassemias & Paroxysmal Nocturnal Hemoglobinuria 7.4 Platelet Disorders, Thrombocytopenia & the Bleeding Patient 7.5 Coagulation Factor Disorders, Thrombophilia & Anticoagulant Reversal 7.6 Acute Leukemias, Chronic Leukemias & Myeloproliferative Neoplasms 7.7 Lymphomas & Plasma Cell Disorders 7.8 Myelodysplastic Syndrome, Myeloproliferative Neoplasms & Porphyria 7.9 Transfusion Medicine & Late Complications of Transplantation
9 Chapter 8: Medical Oncology (6% of Exam)
8.1 Breast, Lung, Colorectal & Prostate Cancer 8.2 Oncologic Emergencies 8.3 Genitourinary & Gynecologic Malignancies 8.4 Head and Neck, Bone & Soft Tissue Cancer and Cancer of Unknown Primary 8.5 Complications of Cancer & Its Treatment 8.6 Cancer Prevention, Survivorship & Psychosocial Care
10 Chapter 9: Nephrology & Urology (6% of Exam)
9.1 Acute Kidney Injury: Staging, Etiology & Urine Microscopy 9.2 Glomerular Disorders & Nephrotic Syndrome 9.3 Nephritic Syndromes, RPGN & Indications for Renal Replacement Therapy 9.4 Chronic Kidney Disease: Staging & Progression Retardation 9.5 Complications of Chronic Kidney Disease: Anemia, CKD-MBD & Acidosis 9.6 Hyponatremia, Hypernatremia & Water Balance 9.7 Potassium Disorders & Systematic Acid-Base Analysis 9.8 Renal Tubular Acidosis & Nephrolithiasis 9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions 9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria
11 Chapter 10: Neurology (4% of Exam)
10.1 Acute Ischemic Stroke: Syndromes & Reperfusion 10.2 Transient Ischemic Attack, Secondary Prevention & Hemorrhagic Stroke 10.3 Headache & Facial Pain 10.4 Seizures, Epilepsy & Movement Disorders 10.5 Multiple Sclerosis & Neuromuscular Junction Disorders 10.6 Motor Neuron Disease & Acute Peripheral Neuropathy 10.7 Cranial Neuropathies & Neuro-Ophthalmology 10.8 Peripheral Neuropathies, CNS Tumors & Other Neurologic Disorders
12 Chapter 11: Psychiatry & Behavioral Health (4% of Exam)
11.1 Major Depressive Disorder & Medical Mimics 11.2 Antidepressant Pharmacotherapy & Treatment-Resistant Depression 11.3 Bipolar Disorder, Mood Stabilizers & Lithium Toxicity 11.4 Anxiety, Stress-Related & Obsessive-Compulsive Disorders 11.5 Alcohol Use Disorder & Withdrawal 11.6 Pharmacotherapy for Alcohol & Opioid Use Disorder 11.7 Toxidromes, Psychiatric Emergencies & Suicide Risk Assessment 11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders 11.9 Eating Disorders, Sleep Disorders & Sexual Health
13 Chapter 12: Dermatology (3% of Exam)
12.1 Dermatitis, Papulosquamous & Inflammatory Dermatoses 12.2 Acne, Rosacea & Cutaneous Infections 12.3 Herpes Zoster & Autoimmune Blistering Diseases 12.4 Nodules, Tumors & Cutaneous Oncology 12.5 Dermatologic Emergencies & Severe Cutaneous Adverse Reactions 12.6 Pigment Disorders, Alopecia, Nail Disease & Photosensitivity 12.7 Vascular Dermatoses, Environmental Injury & Cutaneous Signs of Systemic Disease
14 Chapter 13: Obstetrics & Gynecology / Women's Health (3% of Exam)
13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications
15 Chapter 14: Geriatric Syndromes (3% of Exam)
14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings
16 Chapter 15: Allergy & Immunology (2% of Exam)
15.1 Anaphylaxis: Recognition & Emergency Management 15.2 Urticaria & Angioedema 15.3 Drug Allergy, Desensitization & Adult Immunodeficiency 15.4 Food Allergy, Insect Venom Hypersensitivity, Serum Sickness & Contrast Reactions 15.5 Rhinitis, Conjunctivitis, Eosinophilic & Mast Cell Disorders
17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology
16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design
18 Chapter 17: Miscellaneous - Ethics, Patient Safety & Quality Improvement (2% of Exam)
17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity
19 Chapter 18: Perioperative Medicine & Medical Consultation
18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications
20 Chapter 19: Ophthalmology (1% of Exam)
19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease
21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)
20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders
14.4 Mild Cognitive Impairment, Dementia & Its Subtypes
Key Takeaways Explain This Topic AI
Dementia in the elderly is a named Geriatric Syndromes subsection, and dementia also appears under disorders of cerebral function in Neurology.
Evaluation of new cognitive impairment includes thyroid-stimulating hormone, vitamin B12 and structural neuroimaging to exclude reversible causes.
Dementia with Lewy bodies features fluctuating cognition, visual hallucinations, parkinsonism and REM sleep behavior disorder.
Antipsychotics, particularly first-generation agents, can cause severe and potentially fatal sensitivity reactions in dementia with Lewy bodies.
Amyloid-directed monoclonal antibodies require confirmation of amyloid pathology and monitoring for amyloid-related imaging abnormalities.
Last updated: August 2026
Cognitive impairment and palliative care represent core competencies in internal medicine. Clinicians must accurately distinguish insidious neurodegenerative dementias from acute reversible delirium, navigate novel disease-modifying therapies and their safety monitoring, deliver rigorous symptom relief for patients with serious life-limiting illnesses, and uphold patient autonomy through proactive advance care planning.
- 1. Neurocognitive Disorders: MCI vs. Dementia & Reversible Workup
- Diagnostic Distinction: MCI vs. Major Neurocognitive Disorder
Mild Cognitive Impairment (MCI):
Objective cognitive decline in >=1 cognitive domain (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition), typically >=1.5 standard deviations below age- and education-matched norms.
Preserved Functional Independence: The patient remains fully independent in Instrumental Activities of Daily Living (IADLs) (managing finances, taking medications, driving, cooking), although tasks may take more time or require compensatory strategies.
Clinical Course: Converts to dementia at a rate of 10% to 15% per year (compared to 1-2% per year in the general older adult population).
Major Neurocognitive Disorder (Dementia):
Significant cognitive decline in >=1 cognitive domain .
Functional Dependence: Cognitive deficits interfere with independence in everyday activities , requiring assistance with complex IADLs (and eventually basic ADLs).
Deficits do not occur exclusively in the context of delirium and are not better explained by another mental disorder (e.g., major depressive disorder).
Validated Cognitive Screening Instruments
Screening Tool Administration Time Scoring & Clinical Cutoffs Diagnostic Pearls & Limitations
Montreal Cognitive Assessment (MoCA) 10-12 minutes Total score 0-30.; < 26 / 30 indicates cognitive impairment. ; (+1 point if <=12 years formal education). Superior sensitivity (90%) for MCI and early dementia compared to MMSE. Rigorously tests executive function (trail making, clock drawing), visuospatial skills, and abstraction.
Mini-Mental State Examination (MMSE) 8-10 minutes Total score 0-30.; < 24 / 30 indicates cognitive impairment. ; - 20-23: Mild dementia; - 10-19: Moderate dementia; - < 10: Severe dementia Heavily weighted toward orientation and language; insensitive to early MCI and frontal/executive dysfunction; substantial educational and cultural bias. Proprietary copyright restrictions.
Mini-Cog 3 minutes Total score 0-5:; - 3-word registration (0 pts); - Clock Drawing Test (CDT) (normal = 2 pts, abnormal = 0 pts); - 3-word delayed recall (1 pt per word; 0-3 pts); Score 0-2 = Positive screen for dementia. Rapid, highly sensitive bedside screen. Unaffected by educational level or language barriers. Highly effective for initial ambulatory screening.
Mandatory Laboratory & Neuroimaging Workup for Reversible Causes
Before confirming a primary neurodegenerative dementia, secondary and potentially reversible etiologies must be systematically excluded:
Serum Thyroid-Stimulating Hormone (TSH): Excludes clinical hypothyroidism.
Serum Vitamin B12 (Cobalamin): If borderline (200-400 pg/mL), check Serum Methylmalonic Acid (MMA) and Homocysteine; elevated MMA confirms tissue-level B12 deficiency requiring intramuscular cyanocobalamin repletion.
Complete Metabolic Panel (CMP): Evaluates serum calcium (hyperparathyroidism/hypercalcemia), sodium (hyponatremia), renal function (uremia), and liver enzymes (hepatic encephalopathy).
Complete Blood Count (CBC): Evaluates for severe anemia, hematologic malignancies, or occult infection.
Targeted Serologies (When Clinically Indicated): Rapid Plasma Reagin (RPR) / Treponemal antibodies for neurosyphilis; HIV antibody/antigen; toxicological screens.
Structural Brain Neuroimaging (Non-Contrast Head CT or Brain MRI):
Mandatory in all patients with new cognitive decline.
Rules out Normal Pressure Hydrocephalus (NPH) (triad of magnetic / apraxic gait disturbance , urinary urgency/incontinence , and cognitive decline ; ventriculomegaly with Evans index >0.3 out of proportion to sulcal enlargement; treated with large-volume LP tap test and ventriculoperitoneal shunt).
Rules out chronic subdural hematoma , intracranial neoplasms (meningioma, metastasis), multi-infarct vascular lesions, and establishes patterns of regional cortical atrophy (e.g., bilateral hippocampal volume loss in Alzheimer disease).
Loading diagram... Diagnostic Algorithm for Acute vs. Chronic Cognitive Decline
- 2. Dementia Subtypes & Novel Amyloid-Directed Monoclonal Antibodies
- Comparative Overview of Primary Dementias
Dementia Subtype Primary Neuropathology Clinical Hallmark Features First-Line Pharmacotherapy & Key Board Rules
Alzheimer Disease (AD) ; (60-80% of cases) Extracellular Amyloid-beta ( A β 42 A\beta_{42} A β 42 ) plaques and intracellular Neurofibrillary Tangles (NFTs) composed of hyperphosphorylated Tau protein . Begins in entorhinal cortex and hippocampus. Insidious onset with early episodic short-term memory impairment (repeating questions, misplacing items, impaired delayed recall); progresses to executive dysfunction, word-finding difficulty (anomia), visuospatial disorientation, and loss of insight. 1. Cholinesterase Inhibitors ( Donepezil 5-10 mg daily , Rivastigmine 4.6-13.3 mg/24h patch , Galantamine 8-24 mg daily ): Indicated for mild, moderate, and severe AD.; 2. NMDA Receptor Antagonist ( Memantine 5-20 mg daily ): Indicated for moderate-to-severe AD (MMSE <20).; 3. Amyloid Monoclonal Antibodies ( Lecanemab, Donanemab ): Indicated for early symptomatic AD.
Dementia with Lewy Bodies (DLB) ; (15-20% of cases) Intracytoplasmic Lewy bodies composed of aggregated alpha-synuclein in neocortex, limbic structures, and substantia nigra. Core Diagnostic Tetrad: ; 1. Fluctuating cognition and attention (profound day-to-day variations in alertness); 2. Recurrent, detailed, well-formed visual hallucinations (animals, people); 3. REM Sleep Behavior Disorder (RBD) (dream enactment, thrashing during sleep); 4. Spontaneous Parkinsonism (rigidity, bradykinesia, gait changes developing <=1 year of cognitive decline [" 1-year rule "]). Cholinesterase Inhibitors (Donepezil, Rivastigmine) are first-line for cognitive and behavioral symptoms.; CRITICAL BOARD CONTRAINDICATION: Severe Neuroleptic Sensitivity. Typical antipsychotics (Haloperidol) and potent atypicals cause catastrophic rigidity, irreversible parkinsonism, autonomic instability, and increased mortality. If psychosis requires therapy, use low-dose Quetiapine or Pimavanserin (5-HT2A inverse agonist).
Frontotemporal Dementia (FTD / Pick Disease) ; (5-10% of cases) Frontal and temporal lobar degeneration with tau inclusions (Pick bodies) or TDP-43 inclusions. Younger onset (Age 50-65). ; - Behavioral variant (bvFTD): Early, profound personality change, disinhibition (socially inappropriate remarks, shoplifting), apathy , loss of empathy, hyperorality (compulsive carbohydrate craving, binge eating), and repetitive/stereotyped behaviors.; - Language variant (PPA): Progressive loss of speech fluency or word comprehension.; Visuospatial skills and episodic memory are preserved early. Symptomatic only: SSRIs (Sertraline, Citalopram) or Trazodone to manage impulsivity, compulsions, and agitation.; Cholinesterase inhibitors and memantine are INEFFECTIVE and may worsen behavioral agitation.
Vascular Dementia (VaD) ; (10-20% of cases) Large-vessel cortical infarcts, multiple lacunar infarcts, or extensive subcortical ischemic microvascular white matter disease (Binswanger disease). Stepwise / abrupt cognitive deterioration temporally linked to clinical strokes, or insidious executive dysfunction (processing speed, planning, organizing) exceeding memory loss. Accompanied by focal neurologic deficits (pseudobulbar affect, hyperreflexia, hemiparesis, gait apraxia). Aggressive secondary cardiovascular risk reduction: Blood pressure control ( target SBP <130 mmHg per SPRINT-MIND), high-intensity statin ( Atorvastatin 80 mg ), antiplatelet therapy (Aspirin), glycemic control, and smoking cessation.
Prion Disease (Creutzfeldt-Jakob [CJD]) Misfolding of normal cellular prion protein ( P r P C PrP^C P r P C ) into pathological scrapie form ( P r P S c PrP^{Sc} P r P S c ). Rapidly progressive dementia over weeks to months , accompanied by myoclonus (especially startle-induced) , cerebellar ataxia, visual disturbances, and terminal akinetic mutism. Universally fatal (median survival 4-6 months). Palliative care.; Diagnostic Triple: ; 1. Brain MRI (DWI): Cortical ribboning and hockey-stick / pulvinar sign in basal ganglia/thalamus.; 2. CSF RT-QuIC assay (>95% sensitive/specific) and elevated 14-3-3 / tau protein .; 3. EEG: Periodic sharp wave complexes (PSWCs) at 1 Hz.