Clinical Diagnosis. Step 1: Dementia or not? Diagnostic criteria for dementia (DSM-IV)

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Reginald Fitzgerald
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1 Step 1: Dementia or not? Diagnostic criteria for dementia (DSM-IV) A. The development of multiple cognitive deficits manifested by both 1 and Memory impairment 2. One (or more) of the following disturbances: (a) Aphasia (b) Apraxia (c) Agnosia (d) Disturbance in executive functioning B. Significant impairment in social or occupational functioning, representing a decline E. Deficits do not occur exclusively during the course of a delirium Dementia or not? 1. Intact 2. Questionable dementia (A.1 and either A.2 OR B but not both) 3. Demented (according to DSM-IV criteria) Criteria for dementia (DSM-III-R) A. Demonstrable evidence of impairment in short- and long-term memory B. At least one of the following: 1. Impairment in abstract thinking 2. Impaired judgment 3. Other disturbances of higher cortical function 4. Personality change C. The disturbance in A and B significantly interferes with work or usual social activities or relationships with others D. Not occurring exclusively during the course of Delirium E. Either 1 or 2: 1. There is evidence from the history, physical examination, or laboratory tests of a specific organic factor (or factors) judged to be etiologically related to the disturbance

2 2 2. In the absence of such evidence, an etiologic organic factor can be presumed if the disturbance cannot be accounted for by any nonorganic mental disorder Criteria for severity of dementia (DSM-III-R) 1. Intact 2. Questionable 3. Mild (Although significantly impaired, the capacity of independent living remains) 4. Moderate (Independent living is hazardous) 5. Severe (Activities of daily living are so impaired that continual supervision is required) Step 2: Type of dementia Dementia of the Alzheimer s Type (DSM-IV) C. The course is characterized by gradual onset and continuing cognitive decline D. The cognitive deficits in A.1. and A.2. are not due to any of the following: 1. Other central nervous system conditions 2. Systemic conditions 3. Substance-induced conditions F. The disturbance is not better accounted for by another Axis I disorder Code based on predominant features: 1. With delirium 2. With delusions 3. With depressed mood 4. Uncomplicated Code based on age of onset: 1. Early onset (age 65 or younger) 2. Late onset (after age 65) Specify if: 1. With behavior disturbance

3 3 Dementia of the Alzheimer s Type (according to DSM-IV criteria) 1. Dementia of the Alzheimer s Type 2. Not dementia of the Alzheimer s Type Vascular dementia (DSM-IV) C. Focal neurological signs and symptoms or laboratory evidence indicative of cerebrovascular disease that are judged to be etiologically related to the disturbance Code based on predominant features 1. With delirium 2. With delusions 3. With depressed mood 4. Uncomplicated Specify if: 1. With behavioral disturbance Vascular dementia (according to DSM-IV criteria) 1. Vascular dementia 2. Not vascular dementia Criteria for clinical diagnosis of Alzheimer s Disease (NINCDS/ADRDA) PROBABLE ALZHEIMER S I Criteria 1. Dementia established by clinical examination 2. Deficits in two or more areas of cognition 3. Progressive worsening of memory 4. No disturbance of consciousness 5. Absence of systemic diseases II. Supported by 1. Progressive deterioration of specific cognitive functions 2. Impaired activities

4 4 III. Consistent with 1. Plateaus in the course of progression of the illness 2. Associated symptoms 3. Other neurological abnormalities in some patients 4. Seizures in advanced disease 5. CT normal for age IV. Unlikely features 1. Sudden, apoplectic onset 2. Focal neurologic findings 3. Seizures or gait disturbances POSSIBLE ALZHEIMER S V. Criteria 1. Dementia syndrome 2. Presence of a second disorder is permitted 3. A single progressive deficit is sufficient Alzheimer s disease (according to NINCDS-ADRDA criteria) 1. Probable AD 2. Possible AD Criteria for the diagnosis of vascular dementia (NINDS-AIREN) PROBABLE VASCULAR I Criteria 1. Dementia (a) Impairment of memory (b) Impairment of two or more cognitive domains (c) Interfere with daily activities not due to physical effects of stroke alone 2. Cerebrovascular disease (a) Focal signs on neurologic examination (b) Evidence of relevant CVD by brain imaging

5 5 3. A relationship between the above two disorders (a) Onset within 3 months of stroke (b) Abrupt deterioration or fluctuating, stepwise II Consistent with 1. Early presence of a gait disturbance 2. History of unprovoked falls 3. Urinary symptoms not explained by urologic disease 4. Pseudobulbar palsy 5. Personality and mood changes III Unlikely features 1. Absence of corresponding focal lesions on brain imaging 2. Absence of focal neurologic signs 3. Absence of cerebrovascular lesions on CT/MRI POSSIBLE VASCULAR VI. Permitted 1. Absence of brain imaging 2. Absence of clear temporal relationship between dementia and stroke 3. Subtle onset and variable course and evidence of relevant CVD Vascular disease (according to NINCDS-AIREN criteria) 1. Probable VaD 2. Possible VaD Criteria for clinical diagnosis of dementia with Lewy Bodies (DLB consortium) I. Criteria 1. Progressive cognitive decline II Two of the following 1. Fluctuating attention and alertness 2. Recurrent visual hallucinations 3. Spontaneous motor features of parkinsonism

6 6 III Supported by 1. Repeated falls 2. Syncope 3. Transient loss of consciousness 4. Neuroleptic sensitivity 5. Systematized delusions 6. Hallucinations in other modalities IV Less Likely 1. Stroke disease 2. Evidence sufficient to account for the clinical picture Dementia due to Lewy Bodies 1. Lewy Body dementia 2. Not Lewy Body dementia Criteria for clinical diagnosis of frontotemporal dementia (modified Lund-Manchester) I Criteria 1. Progressive cognitive decline 2. Gradual onset, continuing cognitive decline Yes No II Consistent with 1. Early loss of personal awareness 2. Early loss of social awareness 3. Early signs of disinhibition 4. Hyperorality 5. Stereotyped and perseverative behavior 6. Early loss of insight into own deficits 7. Amimia/apathy 8. Progressive reduction of speech output 9. Preserved praxis

7 III. Unlikely features 7 1. Abrupt onset 2. Early severe amnesia 3. Early spatial disorientation Frontotemporal dementia 1. Frontotemporal dementia 2. Not Frontotemporal dementia Other Dementia 1. Dementia due to HIV/AIDS 2. Dementia due to head trauma 3. Dementia due to Parkinson s disease 4. Dementia due to Huntington s disease 5. Dementia due to Creutzfeldt-Jakob disease 6. Dementia due to other general medication conditions: (a) Hydrocephalus (b) Progressive supranuclear palsy (c) Tumor (d) Subdural hematoma (e) Anoxia (f) Vitamin B insufficiency (g) Multiple Sclerosis (h) Neurosyphilis (i) Alcoholic dementia (j) Dementia syndrome of depression (k) Other Dementia due to multiple etiologies Check If Applies Indicate the diagnoses 1. 2.

8 Dementia not otherwise specified 8 Check If Applies Indicate diagnostic hypotheses (If one is more likely then put it first) Criteria for diagnosis of Parkinson s disease (CERAD) I. Probable (two or more of the major signs) II. Possible 1. Only one of the four major signs 2. Two or more of the minor signs III. Asymmetric Comment concerning the diagnosis

Dementia. Stephen S. Flitman, MD Medical Director 21st Century Neurology

Dementia. Stephen S. Flitman, MD Medical Director 21st Century Neurology Dementia Stephen S. Flitman, MD Medical Director 21st Century Neurology www.neurozone.org Dementia is a syndrome Progressive memory loss, plus Progressive loss of one or more cognitive functions: Language