Clinical Guideline Briefing
AS
Alzheimer's Disease And Related Dementias
2024
Published May 18, 2026
10 min read
Alzheimer's Association launches 2024 guideline for Alzheimer's disease and related dementias
New guidance empowers primary care clinicians with a structured, patient-centered approach to diagnostic evaluation, testing, counseling, and disclosure for suspected cognitive impairment.
Headline change
The guideline significantly expands the role of primary care in the structured, multi-tiered diagnostic evaluation of cognitive impairment, moving beyond traditional specialist-centric models.
Bedside action
For patients presenting with cognitive or behavioral changes, initiate a multi-tiered evaluation, including a comprehensive history from both patient and informant, a dementia-focused exam, and routine Tier 1 lab tests and structural brain imaging.
The Alzheimer's Association has released its 2024 clinical practice guideline for the Diagnostic Evaluation, Testing, Counseling, and Disclosure of Suspected Alzheimer's Disease and Related Disorders (DETeCD-ADRD). This comprehensive, evidence-based document aims to standardize and improve the diagnostic process for all clinicians, particularly in primary care, addressing long-standing gaps in timely and accurate diagnosis. The core takeaway emphasizes a tiered, patient-centered evaluation integrating history, physical exam, validated tools, and appropriate diagnostics, with a strong focus on shared decision-making and clear communication.
How It Compares Across Societies
This 2024 Alzheimer's Association guideline offers a more contemporary and comprehensive approach to dementia diagnosis, particularly in its emphasis on multi-tiered evaluation and the role of advanced biomarkers, compared to earlier guidelines like the 2001 AAN parameter.
AAN 2001
AAN 2001
The AAN 2001 guideline recommended screening for depression, B12 deficiency, and hypothyroidism, but stated that "no laboratory tests have yet emerged that are appropriate for routine use in the clinical evaluation of patients with suspected AD."
This guideline
This guideline recommends a multi-tiered approach to laboratory testing, starting with routine Tier 1 labs (CBC, metabolic panel, TSH, B12, homocysteine, CRP, ESR) for all patients, with subsequent tiers for specialized tests (e.g., ANA, HgbA1c, CSF, molecular imaging) based on individual risk and diagnostic uncertainty.
Why they differThe 2024 guideline reflects significant advancements in diagnostic capabilities and understanding of contributing factors to cognitive decline over the past two decades, leading to a more structured and comprehensive approach to laboratory evaluation.
For the clinicianClinicians should now routinely order a broader panel of Tier 1 laboratory tests beyond just B12 and TSH, and be prepared to consider higher-tier tests like CSF and molecular imaging in specialist settings when diagnostic uncertainty persists.
AAN 2001
AAN 2001
The AAN 2001 guideline stated that "Structural neuroimaging with either a noncontrast CT or MR scan in the initial evaluation of patients with dementia is appropriate," but also noted that "Because of insufficient data on validity, no other imaging procedure is recommended."
This guideline
The 2024 guideline strongly recommends structural brain imaging (MRI or CT if MRI is contraindicated) in almost all patients being evaluated for a cognitive-behavioral syndrome to aid in establishing causes and detecting atrophy patterns.
Why they differAdvances in neuroimaging interpretation and understanding of atrophy patterns have increased the diagnostic utility of structural imaging beyond merely excluding non-neurodegenerative causes, allowing for more specific diagnostic insights.
For the clinicianStructural brain imaging is now considered a fundamental Tier 1 diagnostic tool, with interpretation focusing not only on excluding other pathologies but also on identifying atrophy patterns consistent with specific neurodegenerative diseases.
AAN 2001
AAN 2001
The AAN 2001 guideline explicitly stated that "PET imaging is not recommended for routine use in the diagnostic evaluation of dementia at this time" and that "There are no CSF or other biomarkers recommended for routine use in determining the diagnosis of AD at this time."
This guideline
This guideline recommends molecular imaging with FDG PET, CSF Aβ42 and tau/p-tau analysis, and amyloid PET scans in specialist settings when diagnostic uncertainty persists after initial evaluations and structural imaging.
Why they differThe 2024 guideline incorporates the significant evolution of molecular biomarkers (PET, CSF) for Alzheimer's disease diagnosis, which have become increasingly validated and accessible, especially with the advent of disease-modifying therapies.
For the clinicianSpecialists now have a clear pathway to utilize advanced molecular imaging and CSF biomarkers to improve diagnostic accuracy in complex cases, particularly when considering new disease-modifying therapies.
AAN 2001
AAN 2001
The AAN 2001 guideline stated that "Genetic testing of patients with suspected DLB and CJD is not recommended" and "Routine use of APOE genotyping in patients with suspected AD is not recommended at this time."
This guideline
The 2024 guideline recommends considering genetic testing for patients with an established cognitive-behavioral syndrome and a likely autosomal dominant family history, with genetic counselor involvement.
Why they differUnderstanding of genetic contributions to dementia has advanced, particularly for autosomal dominant forms, making genetic testing relevant in specific clinical scenarios, always with appropriate counseling.
For the clinicianWhile not for routine screening, genetic testing is now a consideration in specialist settings for patients with strong family histories of autosomal dominant dementia, emphasizing the need for genetic counseling.
Where they agree
- Both guidelines emphasize the importance of using validated clinical criteria for diagnosing dementia and its subtypes.
- Both guidelines acknowledge the role of screening for depression as a common comorbidity in patients with dementia.
- Both guidelines highlight the need for further research to improve diagnostic accuracy and the utility of emerging biomarkers.
Practice Notes
Key considerations for integrating the new Alzheimer's Association guideline into your daily practice.
Do not miss
Always involve a care partner or informant in the evaluation process.
Patient awareness of illness (anosognosia) and capacity impairments are common in cognitive-behavioral syndromes, making collateral history from someone who knows the patient well critical for accurate diagnosis and goal-setting.
Implementation
Adopt a multi-tiered, individualized approach to assessments and tests.
Start with foundational Tier 1 evaluations (history, exam, basic labs, structural imaging) and only proceed to higher tiers (e.g., neuropsychological evaluation, molecular imaging) if diagnostic uncertainty persists or atypical features are present.
Caution
Do not attribute cognitive symptoms solely to 'normal aging' without a thorough evaluation.
This guideline explicitly states that assuming 'normality' without appropriate evaluation constitutes suboptimal care, underscoring the importance of initiating a diagnostic process for any reported cognitive changes.
Shared decision point
Establish a continuous dialogue with the patient and care partner about their understanding of the syndrome.
This ongoing communication guides education, diagnostic disclosure, and ensures that information is tailored to their capacity and needs, fostering a patient-centered approach throughout the process.
Red flag
Expeditiously refer patients with atypical findings, diagnostic uncertainty, or suspected early-onset/rapidly progressive conditions to a specialist.
These presentations often require complex evaluations beyond primary care scope and may indicate urgent medical problems or less common forms of dementia that benefit from specialized expertise.
Monitoring
Counsel middle-aged and older adults on 'brain-healthy behaviors' and assess dementia risk factors.
Primary care clinicians should proactively assess modifiable risk factors (e.g., hypertension, diabetes, physical inactivity) and provide counseling, even in cognitively normal individuals, to promote brain health and potentially mitigate future decline.
Key Recommendations
The Alzheimer's Association's 2024 guideline provides a structured, patient-centered framework for evaluating suspected Alzheimer's disease and related dementias. These key recommendations outline the essential steps for primary care clinicians, from initial assessment to advanced diagnostics and compassionate disclosure, ensuring a comprehensive and timely approach to cognitive impairment.
Key recommendations15 highlighted
01
In patients who self-report or whose care partner/clinician report cognitive, behavioral, or functional changes., initiate a multi-tiered evaluation focused on the problem.
StrengthStrength of Recommendation A
EvidenceThe guideline emphasizes that timely evaluation of cognitive or behavioral symptoms is best medical practice, supported by evidence indicating benefits of early diagnosis. It explicitly states that not evaluating these changes and attributing them to 'normal aging' is suboptimal care.
For practiceDo not dismiss reported cognitive changes; begin a structured evaluation promptly.
02
In patients being evaluated for cognitive/behavioral symptoms and their care partners., use patient-centered communication to partner with the patient and/or care partner to establish shared goals and assess capacity for the evaluation process.
StrengthStrength of Recommendation A
EvidenceCompetent and ethical medicine relies on open communication and patient autonomy. Given potential impairments in patient awareness (anosognosia) and capacity in cognitive-behavioral syndromes, engaging a care partner from the outset is crucial for accurate information gathering and shared decision-making.
For practiceIntegrate the care partner into discussions from the start, assessing patient capacity and tailoring communication accordingly.
CaveatRelationship dynamics between patient and care partner can be complex and may require separate communication streams.
03
In patients being evaluated for cognitive or behavioral symptoms., utilize tiered assessments and tests, individualized to the patient, to establish a diagnostic formulation covering impairment level, cognitive-behavioral syndrome, and likely causes/contributing factors.
StrengthStrength of Recommendation A
EvidenceA structured yet personalized diagnostic evaluation balances effectiveness and efficiency, ensuring essential information is collected while allowing for clinical judgment. This approach helps delineate functional status, characterize the clinical syndrome, and narrow the differential diagnosis of underlying brain diseases.
For practiceFollow a systematic, step-wise evaluation process, tailoring tests to the individual patient's presentation and risk factors.
04
In patients being evaluated for cognitive or behavioral symptoms., obtain reliable information from an informant about changes in cognition, ADLs/IADLs, mood/neuropsychiatric symptoms, and sensory/motor function, ideally using structured instruments.
StrengthStrength of Recommendation A
EvidenceThe history of present illness is foundational. Informants provide crucial, reliable information often missed or under-reported by patients due to cognitive impairments. Structured instruments ensure comprehensive and sensitive detection of changes across key domains.
For practiceAlways seek collateral history from a knowledgeable informant, using structured questions or tools.
CaveatEnsure privacy for the informant to provide the most honest history.
05
In patients being evaluated for cognitive or behavioral symptoms., obtain reliable information about individualized risk factors for cognitive decline during history taking.
StrengthStrength of Recommendation A
EvidenceEach person has a unique profile of modifiable and non-modifiable risk factors for brain diseases. Systematically collecting this information helps contextualize symptoms, estimate likelihood of specific etiologies, and inform care plans, including 'brain-healthy behaviors'.
For practiceThoroughly explore the patient's medical, social, and family history for all known dementia risk factors.
CaveatRisk factors may include multiple neuropathological changes and contributing conditions in older individuals.
06
In patients being evaluated for cognitive or behavioral symptoms., perform a mental status exam (cognition, mood, behavior) and a dementia-focused neurologic examination to diagnose the cognitive-behavioral syndrome.
StrengthStrength of Recommendation A
EvidenceA structured examination helps characterize the cognitive-behavioral syndrome and generate hypotheses about the differential diagnosis. It can identify signs of neurological or psychiatric impairment suggesting atypical syndromes that may warrant specialist referral.
For practiceConduct a focused mental status and neurological exam to identify specific patterns of impairment.
07
In patients being evaluated for cognitive or behavioral symptoms., use validated tools to assess cognition.
StrengthStrength of Recommendation A
EvidenceValidated cognitive assessment instruments are invaluable for detecting clinically significant impairment. Interpretation should integrate the score profile with the patient's overall risk, history, and other findings, not just a cutoff score.
For practiceIncorporate validated brief cognitive tests into the evaluation, interpreting results in the context of the full clinical picture.
CaveatIf office-based tools are not sufficiently informative (e.g., extremes of age/education), consider referral to a neuropsychologist.
08
In all patients being evaluated for cognitive or behavioral symptoms., obtain routine Tier 1 laboratory studies (CBC, metabolic panel, TSH, B12, homocysteine, CRP, ESR).
StrengthStrength of Recommendation A
EvidenceRoutine Tier 1 labs are relatively inexpensive and widely available, aiding in the recognition and treatment of common comorbid conditions (e.g., B12 deficiency, hypothyroidism) that may contribute to or exacerbate cognitive symptoms, even if rarely the primary cause of a progressive syndrome.
For practiceOrder a standard 'cognitive lab panel' as a first-line diagnostic test for all patients with suspected cognitive impairment.
CaveatA 'shotgun approach' to lab testing is not recommended; focus on a judicious, stepwise approach.
09
In patients being evaluated for a cognitive-behavioral syndrome., obtain structural brain imaging (MRI or CT if MRI is unavailable/contraindicated).
StrengthStrength of Recommendation A
EvidenceStructural brain imaging is crucial for excluding non-AD/ADRD conditions (e.g., tumors, hydrocephalus) and for identifying atrophy patterns consistent with neurodegenerative diseases (e.g., medial temporal lobe atrophy in AD). MRI is preferred for its detail.
For practiceOrder structural brain imaging as part of Tier 1 testing to rule out other causes and identify disease-specific patterns.
CaveatInterpretation must consider patient age and the clinical context; 'age-related' changes should not be assumed without correlation.
10
In patients and care partners during the evaluation process for cognitive-behavioral syndrome., establish a dialogue about understanding and appreciation of the syndrome to guide education and disclosure.
StrengthStrength of Recommendation A
EvidenceEthical medicine requires open communication. Clinicians must assess the patient's and care partner's knowledge and appreciation of the illness to tailor information, timing, and content of diagnostic disclosure, especially given potential capacity impairments.
For practiceContinuously engage in dialogue with both patient and care partner, adapting communication to their evolving understanding.
CaveatThe timing and content of information shared should be guided by the patient's awareness and capacity.
11
In patients and care partners receiving diagnostic findings for cognitive-behavioral syndrome., honestly and compassionately inform the patient and care partner of the syndrome's name, characteristics, severity, likely disease cause(s), stage, prognosis, treatment options, safety concerns, and resources.
StrengthStrength of Recommendation A
EvidenceStructured diagnostic disclosure ensures comprehensive and compassionate communication, empowering patients and care partners to exercise autonomy and make informed decisions about care. It addresses the illness, prognosis, treatment, and available support.
For practiceDeliver a structured, empathetic diagnostic disclosure, covering all key aspects of the diagnosis and available support.
CaveatDisclosure must be tailored to the individual patient's capacity; different methods may be needed for the patient versus care partner.
12
In patients with atypical findings, diagnostic uncertainty, or suspected early-onset/rapidly progressive cognitive-behavioral conditions., further evaluate expeditiously, usually including referral to a specialist.
StrengthStrength of Recommendation A
EvidenceAtypical presentations (e.g., early-onset, rapid progression, prominent focal deficits) pose unique diagnostic and care challenges, often requiring a broader differential and comprehensive evaluation best performed by specialists to avoid delays and potential harm.
For practicePromptly refer complex or unusual cases to a dementia specialist or neuropsychologist.
CaveatDelirium and rapidly progressive dementia are urgent medical problems requiring rapid evaluation.
13
In patients where office-based cognitive assessment is not sufficiently informative., conduct neuropsychological evaluation, including normed testing of learning/memory, attention, executive function, visuospatial function, and language.
StrengthStrength of Recommendation A
EvidenceNeuropsychological evaluation can detect subtle but clinically important cognitive impairment missed by brief office tests, delineate complex cognitive-behavioral syndromes, and help differentiate neurodegenerative disorders from other conditions, informing further studies and care plans.
For practiceRefer for neuropsychological testing when initial cognitive assessments are inconclusive or the clinical picture is complex.
CaveatThe referring clinician should provide a clear consultation question to guide the evaluation.
14
In patients with an established cognitive-behavioral syndrome and continued diagnostic uncertainty after structural imaging (with or without FDG PET)., a dementia specialist can obtain CSF for Aβ42 and tau/p-tau analysis to evaluate for AD neuropathologic changes, following appropriate use criteria.
StrengthStrength of Recommendation B
EvidenceCSF biomarkers (Aβ42, tau/p-tau) can improve diagnostic accuracy for AD neuropathologic changes, especially when structural imaging is inconclusive. This is particularly relevant for considering new disease-modifying therapies that require biomarker confirmation.
For practiceConsider CSF biomarker analysis in specialist settings for diagnostic refinement, especially for potential disease-modifying therapies.
CaveatThis recommendation applies to dementia specialist settings and should follow appropriate use criteria.
15
In any middle-aged or older adult., primary care clinicians should perform a personalized assessment of dementia risk factors and provide counseling on “brain-healthy behaviors.”
EvidenceAccruing evidence indicates several potentially modifiable risk factors for dementia (e.g., hearing loss, hypertension, obesity, smoking, physical inactivity, diabetes). Counseling on 'brain-healthy behaviors' can reduce risk and benefit patients even after symptoms emerge.
For practiceIntegrate dementia risk factor assessment and 'brain-healthy behavior' counseling into routine primary care for middle-aged and older adults.
CaveatThis is a proactive measure for prevention and risk mitigation, not a diagnostic step.
