Dementia diagnostic guidelines: Methodologies, results, and implementation costs

OBJECTIVE: To facilitate the diagnostic process for dementia. Five guidelines and four consensus statements on specific diagnostic,recommendations, specialist referral recommendations, and costs of recommended diagnostic procedures were compared and summarized. DATA SOURCES AND SELECTION: A MEDLINE search from 1984 to 1999 and queries to experts yielded 14 guidelines and consensus statements that addressed the diagnosis of dementia. Only nine documents which had national or international scopes were reviewed. METHODS: Comparisons were made on the specific diagnostic criteria for patient history, clinical examination, functional assessment, laboratory tests, neuroimaging, and other diagnostic tests, as well as specialist referral recommendations and costs for the recommended diagnostic procedures. The first three authors reviewed independently each document and completed a table on specific recommendations in each document. To settle disagreements about specific recommendations, they discussed them until they reached a consensus. To interpret the intent of vague statements, they used their best judgment. RESULTS: The documents differed in content, recommendations, and development methodology. They were based on either expert opinion or scientific evidence, or both. Although the nine documents were nearly unanimous in several recommendations, including assessing the presenting problem, taking a medical history, conducting physical and neurological examinations, and assessing the patient's mental and cognitive status, considerable differences in recommendations were common. Such differences led to large differentials in the estimated costs (range, $190 to $2,001) for recommended diagnostic assessments. CONCLUSIONS: A systematic approach to diagnostic recommendations for dementia may induce greater consistency among guidelines and consensus statements. The current approach leads to considerable variability in recommendations and estimated costs.