From the Guidelines
The workup for dementia should start with a comprehensive history, physical examination, and basic diagnostic assessments, including laboratory tests and structural brain imaging with MRI, as recommended by the most recent guidelines 1. The initial evaluation should focus on obtaining an expanded history of cognitive abilities, including onset of complaint, pace of decline, and nature of cognitive loss, as well as assessing risk factors for cognitive decline and medications that may contribute to cognitive impairment 1. Key components of the workup include:
- Conducting a neurologic physical examination
- Assessing for psychiatric conditions
- Requesting general labs, such as thyroid function tests, vitamin B12, homocysteine, complete blood count with differential, and complete metabolic panel
- Performing structural brain imaging with MRI, or head CT if MRI is contraindicated 1 Additionally, monitoring cognitive function and fully evaluating the patient when impairment is noted is crucial, and a comprehensive medical history and examination focusing on cognitive function, behavior, and medical comorbidities should be obtained 1. Neuropsychological evaluation can be considered to establish the extent and severity of cognitive impairment, and patients should be monitored serially with subspecialty consultation as needed 1.
From the Research
Workup for Dementia
The workup for dementia typically involves a combination of clinical evaluation, cognitive screening, laboratory testing, and neuroimaging. The following steps are commonly taken:
- Clinical history: evaluating for cognitive decline and impairment in daily activities, with corroboration from a close friend or family member 2, 3, 4
- Physical examination: to identify the etiology of dementia, such as focal neurologic abnormalities suggesting stroke 2, 3
- Brief cognitive impairment screening questionnaires: to initiate and organize the cognitive assessment, such as the Mini-Mental State Examination (MMSE) 4, 5
- Neuropsychological testing: to determine the extent of cognitive impairment, especially in situations where screening tests are normal or equivocal 2, 4, 6
- Laboratory testing: to rule out treatable causes of dementia, such as thyroid-stimulating hormone and vitamin B12 levels 3, 4
- Neuroimaging: structural imaging with computed tomography or magnetic resonance imaging to demonstrate structural changes, such as focal atrophy, infarcts, and tumor 2, 3, 4
Additional Evaluation
In atypical dementia cases, such as age of onset younger than 65 years, rapid symptom onset, and/or impairment in multiple cognitive domains but not episodic memory, additional evaluation with:
- Cerebrospinal fluid assays 2
- Genetic testing 2
- Functional neuroimaging, measurement of biomarkers, or neuropsychologic testing may be considered, although their role in routine diagnosis is still controversial 3, 5
Diagnostic Criteria
Clinical criteria for diagnosing most forms of dementia are available, and a standard diagnostic evaluation can be performed by family physicians over multiple visits 3. The diagnosis of dementia remains clinically integrative based on history, physical examination, and brief cognitive testing 3.