Neurocognitive Disorders

New Guideline Updates Diagnostic Criteria for Alzheimer Disease, ADRD

Meghna Rao
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revised diagnostic criteria for Alzheimer disease
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The Alzheimer's Association released a new clinical practice guideline for clinicians in primary and specialty care on how to diagnose patients with suspected Alzheimer disease (AD) and AD-related dementias.

The Alzheimer’s Association released a new clinical practice guideline for the diagnostic evaluation and testing of Alzheimer disease (AD) and AD-related dementias (ADRD). A list of validated instruments to measure symptoms in daily life and signs of cognitive impairment (CI) have been developed. The full report was published in Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association.

The Alzheimer’s Association convened a working group (Diagnostic Evaluation, Testing, Counseling and Disclosure Clinical Practice Guideline Workgroup [DETeCD-ADRD CPG Workgroup]) to develop a summary of validated instruments for a structured and patient-centered approach in evaluating signs of CI (Table 1), assessing neuropsychiatric symptoms in AD/ADRD (Table 2), and functional impairment in activities of daily living (ADL) in CI (Table 3).

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Ultimately, the evaluation process should lead to a diagnostic formulation that is communicated clearly and compassionately to the patient and care partner, along with a discussion of management and prognosis.

Table 1: Validated instruments for reporting of CI symptoms

InstrumentFunctionMain Features
IQCODEInformant-based questionnaire that measures changes in cognitive function from premorbid levels.Validated for dementia vs other measures of cognitive decline, but less sensitive for mild CI (MCI) cases.
AD8Brief screening interview that helps differentiate between individuals with vs without CI.Validated for dementia vs expert clinical judgement and neuropsychiatric assessments, but not for milder forms of cognitive dysfunction.
QDRS10-item questionnaire to identify types and severity of cognitive and behavioral symptoms and impact on daily function.Screening and staging (not diagnostic) tool to assess changes in cognition, behavior, and function.  
AQPrimary care tool to detect AD-related CI.Quick (approximately 3 mins) assessment of domains of memory, orientation, functional ability, visuospatial, and language.
ECog39-item questionnaire to assess functional ability related to specific cognitive abilities.Validated for distinguishing between patients with dementia vs cognitively healthy individuals, but less sensitivity for MCI cases.
CFI14-item questionnaire, completed by patients or informants, which evaluates cognitive symptoms before dementia diagnosis.Changes in cognitive and functional abilities assessed over a 1-year period, with higher scores indicating greater cognitive dysfunction.
Cognitive Change IndexQuestionnaire that helps determine subjective cognitive decline.Validated tool that assesses patient-reported changes in cognitive function in the previous 5 years, with domains including memory, executive function, and language.
Cambridge Behavioural Inventory45-item informant-based questionnaire to differentially diagnose various forms of dementia.A range of cognitive, mood and behavioral, and daily functional symptoms are assessed with this tool, which may be best used in specialty or general practice settings.
SIST-MInterview format that helps assess history of cognitive and functional impairment symptoms.High reliability against CDR score in patients with MCI and mild dementia.
Abbreviations: IQCODE, Informant Questionnaire on Cognitive Decline in the Elderly; AD8, Eight-item Information Interview to Differentiate Aging and Dementia; CI, cognitive impairment; QDRS, Quick Dementia Rating Scale; AQ, Alzheimer’s Questionnaire; ECog, Everyday Cognition; CFI, Cognitive Function Instrument; SIST-M, Structured Interview and Scoring Tool-Massachusetts Alzheimer’s Disease Research Center; CDR; Clinical Dementia Rating.

Table 2: Validated instruments for assessing neuropsychiatric symptoms

InstrumentFormatConsiderations
NPI-Q12-item informant-based questionnaire on severity and symptom distress.Some of the neuropsychiatric domains included are elusions, hallucinations, agitation/aggression, depression/dysphoria, and anxiety, which helps in detection, tracking, and monitoring of symptoms. This tool also provides information on symptom severity.
BEHAVE-ADQuestionnaire to determine presence of symptoms and effect on patient.Best used in clinical research and specialist settings, covering a broad range of symptoms and behaviors.
MBI-C34-item questionnaire including 5 domains in MBI criteria: decreased motivation, emotional dysregulation, impulse dyscontrol, social inappropriateness, and abnormal perception or thought content.Systematic measurement of behavioral symptoms that may be a precursor to dementia. Overall, the tool has been designed to detect behavioral pre-dementia state in older adults.
GDS15-item screening tool for depressive symptoms and depression in older adults.Applicable for detection in MCI and dementia compared with more advanced and severe dementia, and for monitoring depression.
PHQ-9Patient-administered screening, monitoring, and diagnostic tool for depressive symptoms and depression.Validated for patients with MCI and dementia, with wide usage in primary care.
CSDD19-item questionnaire administered to patients and care partners.Depression and depressive symptoms may be detected, tracked, and monitored in the MCI-dementia spectrum, with higher scores (>11) indicating probable depression.
PSWQ-AAn 8-item anxiety-detection tool typically completed by patients.Screening tool for anxiety and worry symptoms in older adults, with a cutoff score of 17 indicated for significant anxiety in patients with dementia.
GAIPatient self-administered instrument for anxiety symptoms in older adults.A 20-item tool for detection of anxiety symptoms in mild to moderate AD. It is also available as a short form with 5 items.
CMAITool — to measure presence and frequency of 29 agitation and related disruptive behaviors —administered to care partners.Some of the domains that can be assessed are verbal aggression, repetitiveness, screaming, hitting, and sexual advances; however, this tool requires training to administer in specialist and clinical research settings.
Abbreviations: NPI-Q, Neuropsychiatric Inventory-Questionnaire; BEHAVE-AD, Behavioral Pathology in Alzheimer’s Disease Depression Scale; MBI-C, Mild Behavioral Impairment Checklist; GDS, Geriatric Depression Scale; PHQ-9, Patient Health Questionnaire; CSDD, Cornell Scale for Depression in Dementia; PSWQ-A, Penn State Worry Questionnaire Abbreviated; GAI; Geriatric Anxiety Inventory; CMAI; Cohen Mansfield Agitation Index.

Table 3: Validated instruments for functional impairment in ADL in CI

InstrumentFunctionMain Features
FAQAssessment of IADL in older adults with and without CI or mild dementia.The 10-item tool is useful among patients with probable MCI or mild dementia and not useful for tracking of changes beyond this level of dementia severity.
CDRClinician-based measure (interview and examination) to determine presence and severity of cognitive symptoms and their functional impact.A reliable and valid tool that assesses 3 domains of cognitive abilities, including memory, orientation, and judgement, and 3 domains of daily function, including community affairs, home and hobbies, and personal care, in patients with MCI and dementia due to AD.
FASTAssessment of daily function, ranging from no CI to severe dementia.Validated for use in primary and specialty care settings to determine functional status of patients with typical AD dementia.
BALDS20-item tool that determines basic and instrumental ADLs in dementia.Initial assessment and tracking of IADL and BADL in various dementia stages, especially among older populations, and evaluation of eligibility for palliative care.
DAD40-item tool for the measurement of leisure activities and ADL in AD dementia.Initial assessment and tracking of leisure activities and ADL across dementia stages. A modified version (DAD-6) is also available for mild dementia cases.
Lawton and Brody IADL scaleAdministered to older adults to evaluate IADL with or without CI or dementia.It is typically useful for initial assessment of MCI and dementia. Women vs men are scored on a few different areas of function, such as housekeeping and laundry.
A-IADL-SV30-item tool to measure leisure activities and IADL in MCI and mild dementia.Computer-scored against normative distribution.
Abbreviations: FAQ, Functional Activities Questionnaire; IADL, instrumental activities of daily living; CDR, Clinical Dementia Rating; FAST, Functional Assessment Staging Scale; BALDS, Bristol Activities of Daily Living Questionnaire; BADL, basic activities of daily living; DAD, Disability Assessment for Dementia Scale; A-IADL-SV; Amsterdam IADL-short version.

The authors of the report said, “[The recommendations] provide context for primary care and specialty clinicians with regard to how to fit these instruments into the workflow and actions to take when integration of performance on these instruments with clinical profile and clinician judgment support potential cognitive impairment.”

“Ultimately, the evaluation process should lead to a diagnostic formulation that is communicated clearly and compassionately to the patient and care partner, along with a discussion of management and prognosis,” they concluded.

Multiple study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of the authors’ disclosures.

References:

Atri A, Dickerson BC, Clevenger C, et al. The Alzheimer’s Association clinical practice guideline for the diagnostic evaluation, testing, counseling, and disclosure of suspected Alzheimer’s disease and related disorders (DETeCD-ADRD): validated clinical assessment instruments. Alzheimer’s Dement. 2024;1-20. doi:10.1002/alz.14335