Alzheimer's Association clinical practice guideline for the Diagnostic Evaluation, Testing, Counseling, and Disclosure of Suspected Alzheimer's Disease and Related Disorders (DETeCD-ADRD): Executive summary of recommendations for primary care

Abstract

US clinical practice guidelines for the diagnostic evaluation of cognitive impairment due to Alzheimer's disease (AD) or AD and related dementias (ADRD) are decades old and aimed at specialists. This evidence-based guideline was developed to empower all-including primary care-clinicians to implement a structured approach for evaluating a patient with symptoms that may represent clinical AD/ADRD. Through a modified-Delphi approach and guideline-development process (7374 publications were reviewed; 133 met inclusion criteria) an expert workgroup developed recommendations as steps in a patient-centered evaluation process. This summary focuses on recommendations, appropriate for any practice setting, forming core elements of a high-quality, evidence-supported evaluation process aimed at characterizing, diagnosing, and disclosing the patient's cognitive functional status, cognitive-behavioral syndrome, and likely underlying brain disease so that optimal care plans to maximize patient/care partner dyad quality of life can be developed; a companion article summarizes specialist recommendations. If clinicians use this guideline and health-care systems provide adequate resources, outcomes should improve in most patients in most practice settings. Highlights US clinical practice guidelines for the diagnostic evaluation of cognitive impairment due to Alzheimer's disease (AD) or AD and related dementias (ADRD) are decades old and aimed at specialists. This evidence-based guideline was developed to empower all-including primary care-clinicians to implement a structured approach for evaluating a patient with symptoms that may represent clinical AD/ADRD. This summary focuses on recommendations, appropriate for any practice setting, forming core elements of a high-quality, evidence-supported evaluation process aimed at characterizing, diagnosing, and disclosing the patient's cognitive functional status, cognitive-behavioral syndrome, and likely underlying brain disease so that optimal care plans to maximize patient/care partner dyad quality of life can be developed; a companion article summarizes specialist recommendations. If clinicians use this guideline and health-care systems provide adequate resources, outcomes should improve in most patients in most practice settings.

Keywords: Alzheimer's disease; Lewy body dementia; cerebrospinal fluid; dementia; diagnosis; frontotemporal dementia; magnetic resonance imaging; mild cognitive impairment; molecular biomarkers; positron emission tomography; vascular cognitive impairment.

FIGURE 1

For patients who may be exhibiting symptoms and/or signs of cognitive impairment due to AD or ADRD, the three steps of the diagnostic formulation may be accomplished by following a process of seven core elements. AD, Alzheimer's disease; ADRD, Alzheimer's disease and related dementias, Dx, diagnosis; Hx, history.

FIGURE 2

In a primary care setting, this diagram shows the implementation of the seven core elements of the diagnostic evaluation process, illustrating how each clinical practice recommendation fits into the typical workflow, using the first tier of assessments and diagnostic tests. Ultimately, the goal is to evaluate a person with cognitive and/or behavioral symptoms to determine whether they have cognitive impairment and if so its impact on daily function (cognitive functional status), the cognitive–behavioral syndrome, and the likely etiology (‐ies) of the impairment. This diagnostic formulation should then be disclosed clearly and compassionately, and a treatment plan can then be initiated. CBC, complete blood count; CRP, C‐reactive protein; CT, computed tomography; ESR, erythrocyte sedimentation rate; MRI, magnetic resonance imaging; TSH, thyroid‐stimulating hormone.

FIGURE 3

In a specialty care setting (usually general neurology, geriatric psychiatry, or geriatrics), this diagram briefly illustrates how each primary care clinical practice recommendation fits into the typical workflow (see Figure 2 for details). Additional detail is provided on how higher tier assessments and diagnostic tests fit into the specialty care workflow. In some specialty care settings, the assessments and tests illustrated in Figure 4 are performed to arrive at the three‐step diagnostic formulation. This diagnostic formulation should then be disclosed clearly and compassionately, and a treatment plan can then be initiated.

FIGURE 4

In a dementia subspecialty care setting (usually behavioral or geriatric neurology, geriatric or neuropsychiatry, or geriatrics), this diagram briefly illustrates how each primary care or specialty clinical practice recommendation fits into the typical workflow (see Figures 2 and 3 for details). Additional detail is provided on how higher tier assessments and diagnostic tests fit into the subspecialty care workflow to arrive at the three‐step diagnostic formulation. This diagnostic formulation should then be disclosed clearly and compassionately, and a treatment plan can then be initiated. CBC, complete blood count; CRP, C‐reactive protein; CT, computed tomography; DDx, differential diagnosis; Dx, diagnosis; ESR, erythrocyte sedimentation rate; MRI, magnetic resonance imaging; TSH, thyroid‐stimulating hormone.