Historically, diagnosing AD has been difficult, as patients may show mild cognitive impairment (MCI) or subtle behavioral changes that can be mistaken for normal aging or depression.¹ Furthermore, AD shares features with other dementias, such as vascular dementia and Lewy body dementia, complicating the differential diagnosis.^1-5

The updated guidelines were developed through a modifiedDelphi approach by the DETeCD-ADRD Clinical Practice Guideline (CPG) expert workgroup representing primary and specialty care, and a comprehensive review of 7,374 publications, of which 133 met the inclusion criteria.³ This process culminated in a three-step, patient-centered evaluation framework, involving the assessment of cognitive and functional status, identification of cognitive-behavioral syndromes based on specific symptoms, and determination of the underlying brain diseases or conditions causing these symptoms.²

The updated guidelines provide 19 practical recommendations designed to be applicable across various clinical settings.³ These recommendations emphasize the essential components of a high-quality evaluation and diagnostic disclosure process.³ Below is a summary of the key recommendations:³

• Initial assessment: Conduct a multitiered assessment for individuals reporting, or whose care partner or clinician reports, cognitive, behavioral, or functional changes
• Patient-centered communication: Collaborate with the patient and/or their care partner to establish shared goals for the evaluation process while assessing the patient’s ability to engage in goal setting
• Diagnostic formulation: Adopt a tiered approach to assessments and testing, tailored to the individual’s presentation, risk factors, and clinical profile, to determine the level of impairment, cognitive-behavioral syndrome, and likely underlying causes
• History taking: Obtain detailed information from informants regarding changes in cognition, daily functioning, mood, neuropsychiatric symptoms, and sensory or motor functions. Document patient-specific risk factors for cognitive decline
• Examination: Perform a comprehensive evaluation of cognition, mood, behavior, and a dementia-focused neurological assessment using validated tools
• Laboratory testing: Conduct tiered laboratory evaluations, beginning with routine tests for all patients, and expand as necessary based on clinical findings
• Structural imaging: Use structural brain imaging (MRI preferred, CT as an alternative) to assist in identifying potential causes of cognitive impairment
• Ongoing communication: Maintain open and continuous dialogue with the patient and their care partner throughout the diagnostic process to provide guidance and support
• Diagnostic disclosure: Deliver diagnostic findings with honesty and compassion, including information on the identified syndrome, severity, probable cause, prognosis, treatment options, and available support resources
• Specialist referral: Refer patients with atypical, earlyonset, rapidly progressing, or uncertain symptoms to a dementia specialist for further evaluation
• Neuropsychological testing: Employ neuropsychological assessments in cases of diagnostic uncertainty or complex clinical presentations. At a minimum, test cognitive domains such as memory, attention, executive function, visuospatial abilities, and language using normed tools
• Advanced diagnostic testing: For unresolved diagnostic uncertainty, perform additional laboratory evaluations tailored to the individual’s clinical profile
• Molecular imaging: If uncertainty remains following structural imaging, consider molecular imaging, such as fluorodeoxyglucose PET, to enhance diagnostic accuracy in collaboration with a dementia specialist
• CSF biomarker analysis: Utilize cerebrospinal fluid biomarkers to assess amyloid beta and tau protein levels in patients with persistent diagnostic uncertainty
• Amyloid PET imaging: Conduct amyloid PET scans in patients with unresolved diagnostic challenges after completing other assessments
• Genetic counseling and testing: Recommend genetic testing for individuals with strong autosomal dominant family histories, ensuring a genetic counselor is involved in the process

In summary, the Alzheimer’s Association’s updated diagnostic guidelines represent a significant step forward in addressing the complexities of AD evaluation.² By emphasizing comprehensive assessment, the integration of biomarkers, and a multidisciplinary approach, these guidelines aim to improve diagnostic accuracy and enable earlier intervention.² As the prevalence of AD continues to rise globally, adopting these evidence-based practices will be crucial in enhancing patient care and advancing our understanding of this challenging condition.^1,2,6