arXiv:2610.32061v1 Announce Type: new Abstract: Large audio-language models (LALMs) can assess cognitive impairment (CI) from speech, yet their answers reveal neither which internal components control the decision nor how much CI information is accessible in their representations. We investigate both questions through CI-contrast neurons (CICNs), selected by class-contrastive activation frequency in decoder MLPs. Across eight open LALMs and two corpora (Pitt and PROCESS-2), we causally test CICNs against size- and layer-matched random masks and activity-matched controls. In three of the five models that meet our eligibility criteria, ablation of small CICN sets causes large, class-directed prediction shifts; speech-identified masks also control transcript-only decisions, and three of four primary Pitt masks retain specificity on PROCESS-2. Position-restricted interventions locate the influence before the final answer position, most strongly after the speech or transcript evidence under letter-labeled options, largely as a decision-direction shift. Beyond causal localization, supervised linear readouts of frozen CICN activations achieve 0.92--0.97 AUC within Pitt, versus 0.67--0.84 for the models' direct answers. Matched random and all-neuron readouts reach comparable performance; top-ranked CICNs show only an exploratory advantage at very small unit budgets. These results distinguish concentrated causal control over output decisions from broadly distributed diagnostic information for CI detection in LALMs.