From the Guidelines
A comprehensive dementia workup for diagnosis should include a thorough clinical evaluation, laboratory tests, and neuroimaging, as outlined in the 2021 review and synthesis published in the Journal of Internal Medicine 1. To initiate the diagnostic process, a detailed medical history should be obtained, focusing on cognitive abilities, including the onset of complaint, pace of decline, and nature of cognitive loss, such as short-term memory and instrumental activities of daily living (ADLs) like balancing checkbook, cooking, driving, and manipulation of electronics 1. A neurologic physical examination should be conducted, and risk factors for cognitive decline, such as cerebrovascular risk factors, and medications like anticholinergics or sedative hypnotics, should be assessed 1. Additionally, psychiatric conditions should be evaluated to rule out other potential causes of cognitive impairment. The diagnostic workup should include general laboratory tests, such as thyroid function tests, vitamin B12, homocysteine, complete blood count with differential, complete metabolic panel, erythrocyte sedimentation rate, and C-reactive protein 1. Neuroimaging with MRI is recommended, with head CT as an alternative if MRI is contraindicated, to detect structural abnormalities and patterns of atrophy 1. Key components of the workup include:
- Expanded history focused on cognitive abilities
- Neurologic physical examination
- Assessment of risk factors for cognitive decline and medications
- Evaluation for psychiatric conditions
- General laboratory tests
- Structural brain imaging with MRI or head CT By following this approach, clinicians can accurately diagnose dementia and differentiate between various causes of cognitive decline, ultimately guiding appropriate treatment planning and management.
From the Research
Dementia Diagnosis
Dementia diagnosis requires a comprehensive approach, including:
- A thorough medical history to evaluate cognitive decline and impairment in daily activities, with corroboration from a close friend or family member 2, 3, 4
- A physical examination to identify potential underlying causes of dementia, such as focal neurologic abnormalities suggesting stroke 2, 5
- A mental status examination to delineate impairments in memory, language, attention, visuospatial cognition, executive function, and mood 2, 3
- Brief cognitive impairment screening questionnaires to initiate and organize the cognitive assessment 2
- Neuropsychological testing to determine whether dementia is present if the assessment is inconclusive 2
- Brain neuroimaging to demonstrate structural changes, such as focal atrophy, infarcts, and tumor 2, 6, 3
- Laboratory tests, such as cerebrospinal fluid assays or genetic testing, in atypical dementia cases 2, 3
Diagnostic Evaluation
The diagnostic evaluation of dementia should include:
- A comprehensive evaluation of patient cognitive and functional abilities 4
- Diagnostic laboratory evaluation 4
- Brain imaging 4
- Validated cognitive assessment tools to identify the extent and nature of cognitive deficits and track disease progression over time 4
- Consideration of serum biomarkers, which are showing promise in facilitating an earlier and more accurate diagnosis 4
Physical Examination
A physical examination is essential in the evaluation of dementia, as it can:
- Identify subtle cues from patients and other informants 5
- Differentiate specific subtypes of dementia, including Alzheimer's disease, vascular dementia, Lewy body dementia, and frontotemporal dementia, based on unique physical examination findings 5
- Help exclude and treat other mimics of dementia 5
Screening and Referral
Screening for dementia is recommended in high-risk populations, and can be performed using tools such as the Mini-Cog and AD8 combined 5. Timely referral to dementia specialists is useful in the management of dementia, but all physicians should understand how to make a diagnosis of dementia due to limited access to specialists 5.