What to Expect from an AD/ Dementia Assessment/Evaluation

There are at least two good reasons for seeking a diagnostic evaluation. First, the patient or a family member may have noticed problems with memory or other difficulties in thinking that affect daily functioning. A thorough diagnostic evaluation will determine the nature, severity and likely cause of the problem. It may turn out to be a treatable condition, or it might be Alzheimer’s disease (AD) another type dementia. Or it might be mild cognitive impairment (MCI), which is often (but not always) a very early stage of AD. Second, there may be concern about very mild, occasional memory lapses (“senior moments”), perhaps coupled with anxiety because a close relative had Alzheimer’s. A diagnostic evaluation will usually reassure the worried individual that they are merely experiencing the very common effects of “brain aging” (memory almost always declines with age). When the evaluation includes formal memory tests, it also provides a valuable “baseline” for comparison will future evaluations.

What are the essential elements of a thorough evaluation by a dementia specialist (usually a neurologist, psychiatrist or geriatrician)? First, a detailed medical history is obtained, since past and current conditions and treatments can affect the brain. Second, the doctor will interview the patient and family member to document and assess current symptoms, as well as to review the onset and course of these symptoms. This part of the evaluation will include a “mental status” assessment of the patient to determine the pattern and severity of cognitive impairment, functional loss and behavioral symptoms. A more comprehensive cognitive (neuropsychological) test battery may be administered (usually by a psychologist), particularly if the cognitive impairment is mild or uncertain. In order to confirm good health status, the assessments will also include a standard medical evaluation comprised of a physical and neurological exam, electrocardiogram, and standard laboratory tests (blood and urine). If memory or other neurological problems are suspected, an MRI scan of the brain (or a CT scan if MRI is not appropriate) will usually be obtained at a radiology facility. The brain scan is useful to rule out specific brain problems such as strokes or tumors that can cause memory loss and other cognitive problems. If any of these standard medical evaluations have been done recently by another doctor, records can be obtained and they need not be repeated.

When the assessments are completed and the results obtained, the doctor will review all the information and determine a diagnosis. Often the diagnosis is clear, but sometimes it is complicated or uncertain. If there is significant cognitive impairment that affects ability to function in daily life, a dementia diagnosis is likely to be made, provided there are no specific medical, neurological or psychiatric problems that could be causing the impairment. If the pattern of impairment involves memory and at least one other aspect of mental function, and if the symptoms began and have progressed very gradually, Alzheimer’s disease will be the most likely diagnosis. If there is evidence for stroke, a vascular or “mixed” dementia diagnosis may be made. Diagnoses of other, rare types of dementia (frontotemporal dementias, Lewy body dementia, etc.) will depend on specific patterns of cognitive and behavioral symptoms that are somewhat different than usually seen in AD. Finally, when there is very mild impairment with little or no impact on daily functioning, a diagnosis of MCI may be made. While AD and the other types of dementia each have a mild, “pre-diagnosis” MCI stage, MCI can have many causes but it does not always get worse. In fact, some people with MCI actually get better, and may be viewed as “normal” at a subsequent evaluation.

For the “worried well” who seek an evaluation, either by a specialist or most commonly at a research center such as one of the three NIA funded Alzheimer’s Disease Centers in New York City (NYU, Mt. Sinai or Columbia), the most likely outcome is to confirm that there is no significant impairment beyond the typical effects of aging. This conclusion reassures the individual that there is currently no problem, and provides a valuable baseline for comparison with future evaluations.

Those concerned about future cognitive decline can obtain follow-up evaluations every one or two years. Regardless of the results of the diagnostic evaluation — age-related decline, mild cognitive impairment, AD or another dementia — it is important to obtain a definitive diagnosis, particularly because there is promising research on early detection and the development of treatments that may slow or prevent AD.

Steven H. Ferris, Ph.D., is the Friedman Professor and Director of the NIA-supported Alzheimer Disease Center at New York University School of Medicine and Executive Director of the Aging and Dementia Clinical Research Center of NYU’s Silberstein Institute. He has been studying brain aging and Alzheimer’s disease for more than three decades and is a neuropsychologist, psychopharmacologist and gerontologist.

Dr. Ferris expanded initial research that evaluated pharmacologic treatments for Alzheimer’s disease into a comprehensive, multidisciplinary research center studying cognitive decline in aging and dementia. He has now contributed more than 250 scientific publications to the field. Current research interests include clinical trials in brain aging, mild cognitive impairment (MCI) and Alzheimer’s disease; the development of improved diagnostic and outcome measures, particularly neuropsychological techniques for early diagnosis; and the study of psychosocial methods for improving the wellbeing of Alzheimer caregivers. During the past decade he has contributed to the recognition of MCI as a very early stage of Alzheimer’s disease and as an important target for early treatment. He has also focused on the assessment and treatment of brain aging and age-associated memory impairment (AAMI). He is currently directing a national, NIH consortium study designed to improve the efficiency of primary prevention trials for Alzheimer’s disease.

Dr. Ferris formerly served as the Associate Editor in Chief of Alzheimer Disease and Associated Disorders, has served on several NIH peer review panels, has been a member of the FDA Advisory Committee that reviews new drugs for Alzheimer’s disease, and was a member of the Medical and Scientific Affairs Council of the Alzheimer’s Association.

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