On gaps of clinical diagnosis of dementia subtypes: A study of Alzheimer’s disease and Lewy body disease

Abstract

IntroductionAlzheimer’s disease (AD) and Lewy body disease (LBD) are the two most common neurodegenerative dementias and can occur in combination (AD+LBD). Due to overlapping biomarkers and symptoms, clinical differentiation of these subtypes could be difficult. However, it is unclear how the magnitude of diagnostic uncertainty varies across dementia spectra and demographic variables. We aimed to compare clinical diagnosis and post-mortem autopsy-confirmed pathological results to assess the clinical subtype diagnosis quality across these factors.MethodsWe studied data of 1,920 participants recorded by the National Alzheimer’s Coordinating Center from 2005 to 2019. Selection criteria included autopsy-based neuropathological assessments for AD and LBD, and the initial visit with Clinical Dementia Rating (CDR) stage of normal, mild cognitive impairment, or mild dementia. Longitudinally, we analyzed the first visit at each subsequent CDR stage. This analysis included positive predictive values, specificity, sensitivity and false negative rates of clinical diagnosis, as well as disparities by sex, race, age, and education. If autopsy-confirmed AD and/or LBD was missed in the clinic, the alternative clinical diagnosis was analyzed.FindingsIn our findings, clinical diagnosis of AD+LBD had poor sensitivities. Over 61% of participants with autopsy-confirmed AD+LBD were diagnosed clinically as AD. Clinical diagnosis of AD had a low sensitivity at the early dementia stage and low specificities at all stages. Among participants diagnosed as AD in the clinic, over 32% had concurrent LBD neuropathology at autopsy. Among participants diagnosed as LBD, 32% to 54% revealed concurrent autopsy-confirmed AD pathology. When three subtypes were missed by clinicians, “No cognitive impairment” and “primary progressive aphasia or behavioral variant frontotemporal dementia” were the leading primary etiologic clinical diagnoses. With increasing dementia stages, the clinical diagnosis accuracy of black participants became significantly worse than other races, and diagnosis quality significantly improved for males but not females.DiscussionThese findings demonstrate that clinical diagnosis of AD, LBD, and AD+LBD are inaccurate and suffer from significant disparities on race and sex. They provide important implications for clinical management, anticipatory guidance, trial enrollment and applicability of potential therapies for AD, and promote research into better biomarker-based assessment of LBD pathology.

Under-Diagnosis of Dementia with Lewy Bodies in Individuals Racialized as Black: Hypotheses Regarding Potential Contributors

“…But with research suggesting that dementia generally and AD dementia specifically are more commonly diagnosed in Black adults, it remains unclear why DLB would be less frequently identified in this population. It is possible that higher rates of copathology in Black adults with dementia [5,6,20] and symptoms associated with that co-pathology (e.g., AD, vascular disease) obscure the clinical picture that might suggest the presence of Lewy body pathology. It is also possible that clinicians are predisposed to give AD dementia diagnoses to Black individuals based on the research showing high prevalence in this population.…”

“…The prevalence of Lewy body dementia codes was 5.5% in White non-Hispanic adults and 6.1% in Hispanic adults [4]. Multiple studies using the U.S.-based National Alzheimer Coordinating Center (NACC) database identified that fewer Black participants with pathologic Lewy body disease had a clinical suspicion for Lewy body dementia in life compared to White or Hispanic participants [5,6]. Over 96% of participants in clinical trials for Lewy body dementia identify as White [7].…”

Cognitive Impairment in a 64-Year-Old Male: Dilemmas With Differential Diagnosis for Patients With Dementia

“…Risk factors for all-cause dementia include increasing age and female sex, as well as protective factors such as higher education and cognitive or physical activity. Clinical presentation varies greatly with cognitive deficits of memory loss, communication, and language impairments, and in severe cases, aphasia, agnosia, and apraxia [ 4 ]. Dementia is an umbrella term with subtypes of Alzheimer’s dementia (AD), vascular dementia, Lewy body dementia, and frontotemporal dementia.…”