Today I review, link to, and excerpt from “American College of Radiology ACR Appropriateness Criteria® Dementia” Revised 2024.
All that follows is from the above outstanding 36 page PDF.
There are 10 variant charts on pp. 1 – 5.
- Variant 1: Adult. Mild cognitive impairment not meeting criteria for dementia. Initial imaging.
- Variant 2: Adult. Cognitive impairment with memory deficits. Suspect Alzheimer disease with typical clinical presentation. Initial imaging.
- Variant 3: Adult. Cognitive impairment with memory deficits. Suspect Alzheimer disease with atypical clinical presentation. Initial imaging.
- Variant 4: Adult. Known Alzheimer disease considering therapy with antiamyloid monoclonal antibodies. Pretreatment imaging.
- Variant 5: Adult. Known Alzheimer disease undergoing therapy with antiamyloid monoclonal antibodies. Posttreatment imaging.
- Variant 6: Adult. Cognitive impairment with behavioral abnormalities or progressive aphasia. Suspect frontotemporal dementia. Initial imaging.
- Variant 7: Adult. Cognitive impairment with visual hallucinations or Parkinsonian symptoms. Suspect dementia with Lewy bodies. Initial imaging.
- Variant 8: Adult. Cognitive impairment with recent stroke or stepwise decline. Suspect vascular dementia. Initial imaging.
- Variant 9: Adult. Cognitive impairment with gait disturbance or urinary incontinence. Suspect normal pressure hydrocephalus. Initial imaging.
- Variant 10: Adult. Rapidly progressive dementia. Initial imaging.
There is an outstanding discussion of procedures for each of the above variants on pp. 7 – 29.
Summary of Literature Review
Introduction/Background
Dementia is a common chronic syndrome in adults, affects up to 47 million people worldwide, and is expected to affect 131 million people by the year 2050 [1]. In the United States, the prevalence of dementia is 15% in people >68 years of age and constitutes the fifth leading cause of death in patients >65 years of age [1]. Complications of dementia can lead to great morbidity and mortality and can pose a diagnostic and management challenge for patients, their families, and clinicians. Dementia is defined by chronic and acquired significant impairment in a single domain or loss of two or more cognitive functions by brain disease or brain injury [1].
The core clinical criteria for all-cause dementia include cognitive or behavioral/neuropsychiatric symptoms—which
interfere with the ability to function at work or usual activities, represent a decline from a previous level of function and performance, and are not explained by delirium or a major psychiatric disorder—and that cognitive impairment is detected and diagnosed through a combination of thorough clinical history and objective cognitive assessment. Furthermore, the cognitive or behavioral impairment must involve impairment of a minimum of two of the following domains: the ability to acquire and remember new information, reasoning and judgement, visuospatial abilities, impaired language, or changes in personality or behavior [2]. Patients with mild cognitive impairment (MCI) have impairment in one or several cognitive domains but of a mild degree, interfering minimally with daily living and functioning [2].Multiple etiologies of dementia exist and are primarily caused by neurodegenerative diseases such as Alzheimer disease (AD), frontotemporal dementia (FTD), and dementia with Lewy bodies (DLB) as well as other diseases such as vascular dementia (VaD) and normal pressure hydrocephalus (NPH). Rapidly progressive dementias (RPD) can be the result of a wide variety of etiologies, to include prion diseases, atypical or rapid onset of neurodegenerative diseases, infectious/inflammatory conditions, neoplastic and paraneoplastic conditions, vascular
conditions, and toxic/nutritional and metabolic disorders. Imaging plays a central role in the diagnosis of various
dementias, and now also plays a key role in the selection and monitoring of patients with AD undergoing targeted
antiamyloid monoclonal antibody (MAB) therapy.Initial Imaging Definition
Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the
variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:
- There are procedures that are equivalent alternatives (ie, only one procedure will be ordered to
provide the clinical information to effectively manage the patient’s care) OR- There are complementary procedures (ie, more than one procedure is ordered as a set or simultaneously where each procedure provides unique clinical information to effectively managethe patient’s care).
