What are the diagnostic criteria for individuals greater than 65 years old?

From the Guidelines

Diagnostic criteria for individuals over 65 years old should prioritize comprehensive geriatric assessment tools, including cognitive function tests like the Mini-Mental State Examination or Montreal Cognitive Assessment, as recommended by the most recent guidelines 1. When evaluating older adults, clinicians should consider age-related physiological changes and use a multidomain approach to assessment. This includes evaluating:

• Cognitive function using tests like the Mini-Mental State Examination or Montreal Cognitive Assessment 1
• Functional status through Activities of Daily Living and Instrumental Activities of Daily Living scales
• Mobility using tools like the Timed Up and Go test
• Nutritional status via the Mini Nutritional Assessment
• Medication review to minimize polypharmacy and potential drug interactions Laboratory testing should be tailored to the individual's needs but may include:
• Complete blood count
• Comprehensive metabolic panel
• Thyroid function tests
• Vitamin B12 and folate levels
• Hemoglobin A1c for diabetes screening Imaging studies should be used judiciously, considering radiation exposure and contrast risks. Mental health screening is also crucial and should include depression assessment using the Geriatric Depression Scale. Annual screening for cognitive impairment is indicated for adults 65 years of age or older for early detection of mild cognitive impairment or dementia, as suggested by the 2018 standards of medical care in diabetes 1. These modified diagnostic approaches are necessary because older adults often present with atypical symptoms, have multiple comorbidities, and experience altered drug metabolism. Additionally, normal reference ranges may differ in this population, and the risk-benefit ratio of diagnostic procedures must be carefully considered to avoid unnecessary interventions that could lead to complications.

From the Research

Diagnostic Criteria for Individuals Greater Than 65 Years Old

The diagnostic criteria for individuals greater than 65 years old with dementia involve a combination of clinical evaluation, cognitive assessment, and laboratory tests.

• A history evaluating for cognitive decline and impairment in daily activities, with corroboration from a close friend or family member, is essential 2.
• A thorough mental status examination by a clinician to delineate impairments in memory, language, attention, visuospatial cognition, executive function, and mood is necessary 2.
• Brief cognitive impairment screening questionnaires, such as the Mini-Mental State Examination (MMSE), can assist in initiating and organizing the cognitive assessment 3.
• Neuropsychological testing can help determine whether dementia is present if the assessment is inconclusive 2.
• Physical examination may help identify the etiology of dementia, such as focal neurologic abnormalities suggesting stroke 2.
• Brain neuroimaging may demonstrate structural changes, including focal atrophy, infarcts, and tumor, that may not be identified on physical examination 2.
• Additional evaluation with cerebrospinal fluid assays or genetic testing may be considered in atypical dementia cases 2.

Cognitive Assessment Tools

• The MMSE is a cognitive test commonly used as part of the evaluation for possible dementia, with a pooled accuracy at a cut point of 24 in the community of sensitivity 0.85 and specificity 0.90 3.
• The MMSE contributes to a diagnosis of dementia in low prevalence settings but should not be used in isolation to confirm or exclude disease 3.

Clinical Diagnostic Criteria

• Proposed new diagnostic criteria for Alzheimer disease recognize that nonamnestic presentations with symptoms that predominantly affect language, visuospatial abilities, or executive function may occur, particularly with onset before the age of 65 4.
• Clinical diagnostic criteria for non-Alzheimer dementias are evolving, particularly in areas such as frontotemporal dementia 4.
• Imaging and CSF biomarkers have been proposed in recent diagnostic criteria for Alzheimer disease, although biomarkers for non-Alzheimer dementias are lacking 4.