When is the term “Unspecified” appropriate?

• Insufficient diagnostic information (e.g., pending investigations or unavailable collateral history).
• Atypical or mixed clinical features that do not fit a single known syndrome.
• Acute medical instability requiring urgent management before full aetiological workup.
• When withholding a specific label reduces risk of harm or mismanagement while allowing symptomatic care.

Clinical features prompting the diagnosis

• Documented decline in cognition from a previous level in one or more domains (memory, attention, executive function, language, visuospatial skills).
• Functional impairment may be mild to moderate; degree influences provisional severity (mild vs major).
• Unclear temporal profile (acute vs insidious) or lack of corroborating records/collateral.

Assessment priorities — immediate and follow-up

1. Immediate safety and reversible causes: screen for delirium, infection, metabolic derangements, hypoxia and medication effects.
2. Gather collateral: family, caregivers, primary care and hospital records — establish baseline and timeline.
3. Basic cognitive screening: MoCA or MMSE to document impairment and inform next steps.
4. Medication review: identify anticholinergics, sedatives, opioids, polypharmacy that may worsen cognition.
5. Plan targeted investigations: bloodwork, neuroimaging, EEG/CSF as clinically indicated; prioritise based on likely reversible causes.
6. Arrange specialist input: neurology, geriatrics or psychiatry when diagnosis remains uncertain or complex.

Investigations — pragmatic approach

• Urgent blood tests: CBC, electrolytes, renal & liver function, glucose, TFTs, B12, folate.
• Toxicology and medication levels where relevant (e.g., lithium, valproate).
• Neuroimaging: non-contrast CT if acute, MRI brain for structural assessment when feasible.
• EEG when fluctuating consciousness, seizures or encephalopathy suspected.
• CSF analysis when infection or autoimmune encephalitis is in the differential.

Management principles — treating symptoms while investigating

Use a stepwise, safety-first plan: treat reversible contributors, stabilise behaviour and function, support caregivers, and continue diagnostic clarification.

Immediate measures

• Treat delirium and reversible metabolic/infectious causes urgently.
• Reduce polypharmacy and stop offending agents where safe.
• Ensure safety: supervision, fall risk reduction, secure medications and finances if needed.

Short-term management

• Symptom management for agitation, psychosis or mood disturbance (prefer low anticholinergic burden medications and lowest effective doses).
• Begin occupational therapy for compensatory strategies and ADL support.
• Provide caregiver education and contact arrangement for changes in status.

Long-term plan

• Complete aetiological workup and revise diagnosis when sufficient evidence is available (e.g., specify Alzheimer’s disease, vascular NCD, etc.).
• Regular follow-up with cognitive testing and functional assessments to monitor progression.
• Develop care plans addressing capacity, driving, legal and financial affairs as clarity emerges.

Key takeaways

• Use the “unspecified” label sparingly and document reasons and planned follow-up.
• Prioritise reversible causes and patient safety while investigations proceed.
• Engage collateral sources early and arrange specialist input if diagnosis remains unclear.
• Revise diagnosis when sufficient evidence becomes available and plan long-term care accordingly.