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From the Department of Neurology (Dr. Knopman), Mayo Clinic, Rochester, MN; Departments of Neurology and Psychiatry (Dr. DeKosky), University of Pittsburgh, PA; Departments of Neurology and Psychiatry & Biobehavioral Science (Dr. Cummings), University of California at Los Angeles; Department of Neurology (Dr. Chui), University of Southern California, Los Angeles; Department of Neurosciences (Dr. Corey–Bloom), University of California at San Diego; Department of Neurology and Neuroscience (Dr. Relkin), New York Presbyterian–Weill Cornell Medical College; Neuropsychiatric Institute and Hospital (Dr. Small), University of California at Los Angeles; Department of Neurology (Dr. Miller), University of California at San Francisco; Lutheran Medical Office (Dr. Stevens), Fort Wayne, IN.
OBJECTIVE: To update the 1994 practice parameter for the diagnosis of dementia in the elderly.
BACKGROUND: The AAN previously published a practice parameter on dementia in 1994. New research and clinical developments warrant an update of some aspects of diagnosis.
METHODS: Studies published in English from 1985 through 1999 were identified that addressed four questions: 1) Are the current criteria for the diagnosis of dementia reliable? 2) Are the current diagnostic criteria able to establish a diagnosis for the prevalent dementias in the elderly? 3) Do laboratory tests improve the accuracy of the clinical diagnosis of dementing illness? 4) What comorbidities should be evaluated in elderly patients undergoing an initial assessment for dementia?
RECOMMENDATIONS: Based on evidence in the literature, the following recommendations are made. 1) The DSM-III-R definition of dementia is reliable and should be used (Guideline). 2) The National Institute of Neurologic, Communicative Disorders and Stroke–AD and Related Disorders Association (NINCDS-ADRDA) or the Diagnostic and Statistical Manual, 3rd edition, revised (DSM-IIIR) diagnostic criteria for AD and clinical criteria for Creutzfeldt–Jakob disease (CJD) have sufficient reliability and validity and should be used (Guideline). Diagnostic criteria for vascular dementia, dementia with Lewy bodies, and frontotemporal dementia may be of use in clinical practice (Option) but have imperfect reliability and validity. 3) Structural neuroimaging with either a noncontrast CT or MR scan in the initial evaluation of patients with dementia is appropriate. Because of insufficient data on validity, no other imaging procedure is recommended (Guideline). There are currently no genetic markers recommended for routine diagnostic purposes (Guideline). The CSF 14-3-3 protein is useful for confirming or rejecting the diagnosis of CJD (Guideline). 4) Screening for depression, B12 deficiency, and hypothyroidism should be performed (Guideline). Screening for syphilis in patients with dementia is not justified unless clinical suspicion for neurosyphilis is present (Guideline).
CONCLUSIONS: Diagnostic criteria for dementia have improved since the 1994 practice parameter. Further research is needed to improve clinical definitions of dementia and its subtypes, as well as to determine the utility of various instruments of neuroimaging, biomarkers, and genetic testing in increasing diagnostic accuracy.
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