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Diagnosis and treatment of dementia: 2. Diagnosis

From the Division of Neurology, Department of Medicine, University of British Columbia, and the University of British Columbia Hospital Clinic for Alzheimer's Disease and Related Disorders (Feldman, Jacova), Vancouver, BC; the Division of Neurology, Department of Medicine (Robillard), Hôpital Maisonneuve-Rosemont and Université de Montréal, Montréal, Que.; the Geriatrics and Neurosciences Centre, Department of Medicine (Garcia), Queen's University, Kingston, Ont.; the Division of Neurology, Department of Medicine, University of Toronto, and the Rotman Research Institute Baycrest Centre for Geriatric Care (Chow), Toronto, Ont.; the Division of Geriatric Medicine, Department of Medicine, University of Western Ontario, and the Aging Brain and Memory Clinic, St. Joseph's Health Care — Parkwood Site (Borrie), London, Ont.; the Departments of Neurology and Neurosurgery and of Medicine (Schipper, Chertkow), McGill University and Sir Mortimer B. Davis–Jewish General Hospital, Montréal, Que.; and the Department of Clinical Neurological Sciences (Blair, Kertesz), University of Western Ontario, London, Ont.

Correspondence to: Dr. Howard H. Feldman, Division of Neurology, University of British Columbia Hospital, S192-2211 Wesbrook Mall, Vancouver BC V6T 2B5; fax 604 822-7703; hfeldman{at}interchange.ubc.ca

Background: Dementia can now be accurately diagnosed through clinical evaluation, cognitive screening, basic laboratory evaluation and structural imaging. A large number of ancillary techniques are also available to aid in diagnosis, but their role in the armamentarium of family physicians remains controversial. In this article, we provide physicians with practical guidance on the diagnosis of dementia based on recommendations from the Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia, held in March 2006.

Methods: We developed evidence-based guidelines using systematic literature searches, with specific criteria for study selection and quality assessment, and a clear and transparent decision-making process. We selected studies published from January 1996 to December 2005 that pertained to key diagnostic issues in dementia. We graded the strength of evidence using the criteria of the Canadian Task Force on Preventive Health Care.

Results: Of the 1591 articles we identified on all aspects of dementia diagnosis, 1095 met our inclusion criteria; 620 were deemed to be of good or fair quality. From a synthesis of the evidence in these studies, we made 32 recommendations related to the diagnosis of dementia. There are clinical criteria for diagnosing most forms of dementia. A standard diagnostic evaluation can be performd by family physicians over multiple visits. It involves a clinical history (from patient and caregiver), a physical examination and brief cognitive testing. A list of core laboratory tests is recommended. Structural imaging with computed tomography or magnetic resonance imaging is recommended in selected cases to rule out treatable causes of dementia or to rule in cerebrovascular disease. There is insufficient evidence to recommend routine functional imaging, measurement of biomarkers or neuropsychologic testing.

Interpretation: The diagnosis of dementia remains clinically integrative based on history, physical examination and brief cognitive testing. A number of core laboratory tests are also recommended. Structural neuroimaging is advised in selected cases. Other diagnostic approaches, including functional neuroimaging, neuropsychological testing and measurement of biomarkers, have shown promise but are not yet recommended for routine use by family physicians.

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