Cited by 1,051Dementia and Cognitive Impairment ResearchAlzheimer's disease research and treatmentsCancer-related cognitive impairment studies

The DOI matches its Crossref record; 117 of the 119 references it cites were found in a registry or an index; 5 of the 67 sources its claims cite were checked for support.

Clinical diagnosis of Alzheimer’s disease: Recommendations of the International Working Group

Open access

Abstract

In 2018, the National Institute of Aging and the Alzheimer Association proposed a purely biological definition of Alzheimer’s disease (AD) relying on biomarkers. While the intended use of the framework was for research purposes, it has engendered debate and challenges regarding its application in everyday clinical practice. For instance, cognitively unimpaired individuals may have biomarker evidence of both amyloid and tau pathology, but may never develop clinical manifestations in their lifetime. Furthermore, a positive AD pattern may be observed in other brain diseases where AD pathology is present as co‐pathology. In this presentation, the international Working Group (IWG) presents what we consider to be the current limitations of biomarkers in the diagnosis of AD, and on the basis of this evidence we propose recommendations for how biomarkers should and should not be used for diagnosis of AD in a clinical setting. We recommend that AD diagnosis be restricted to the occurrence of positive biomarkers together with specific AD phenotypes, whereas biomarker positive cognitively unimpaired individuals should be considered only at‐risk for progression to AD.

Overview

AI snapshot

Written from the paper’s full text.

TL;DR

The International Working Group argues that a purely biological ATN definition of Alzheimer’s disease is not ready for clinical diagnosis and recommends restricting Alzheimer’s disease diagnosis to people with both a specific Alzheimer’s disease clinical phenotype and positive amyloid and tau biomarkers. Biomarker-positive cognitively unimpaired individuals should be considered at-risk for progression, not clinically diagnosed with Alzheimer’s disease.

Key findings

  • The IWG recommends a clinical–biological diagnosis: a specific Alzheimer’s disease phenotype plus amyloid-positive and tau-positive biomarker evidence; biomarker-positive cognitively unimpaired people should be classified as at-risk, not as having Alzheimer’s disease.
  • A purely biological definition has low predictive accuracy: cognitively unimpaired biomarker-positive individuals often do not progress, and best current estimates of lifetime dementia risk range from 5% to 42%.
  • Alzheimer’s pathology is commonly mixed: pure Alzheimer’s disease pathology is found in 3–30% of neuropathological series of people with dementia of the Alzheimer type, and 50–60% of Alzheimer’s-type dementia is estimated to be attributable to copathologies such as α-synucleinopathy, vascular pathology, non-Alzheimer’s tauopathies, and TDP-43 pathology.
  • Practical biomarker limitations include artificial thresholds, limited generalisability, and accessibility; Cochrane reviews could not recommend routine CSF or amyloid PET use in clinical practice, plasma biomarkers are not currently recommended, and biomarker investigation in cognitively unimpaired individuals is not recommended.

Methods

  • Design: a Personal View and consensus recommendations from the International Working Group, not a primary empirical study.
  • Data or sample: no new primary sample is reported; the paper synthesises prior diagnostic frameworks, biomarker literature, neuropathology evidence, Cochrane reviews, and cohort findings.
  • Analysis: narrative evidence synthesis leading to expert recommendations, including proposed diagnostic criteria, biomarker measures, and a risk-stratification proposal for cognitively unimpaired biomarker-positive individuals.

Limitations

  • The paper states that a purely biological definition risks confusion between Alzheimer’s disease lesions and Alzheimer’s disease, has low predictive accuracy, is complicated by copathologies, and faces uncertain pathogenesis, threshold, generalisability, accessibility, and ethical problems.
  • The paper states that current individualised prediction models do not work sufficiently well in cognitively unimpaired people compared with people in the prodromal stage, and that disclosing individual patient-level risk would be premature and is to be avoided.
  • Evident from the text: as a Personal View, the recommendations are expert consensus rather than a systematic review or meta-analysis; the proposed risk stratification is a starting point for research and requires validation studies on large cohorts with long follow-up, as the paper itself notes.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1016/s1474-4422(21)00066-1

Cites

117 of 117 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Verification

Claims the paper makes

31 Not checked yet · 13 Own interpretation · 2 Partly supported · 1 Supported · 1 No basis given · accuracy not yet measured

Verify all 62 references — free account

Show all 25 claims

  • It may state two separate claims as one. 19
  • Probably not a substantial claim. 7
23 of 23
  • The paper relies on this without support.

    A specific clinical phenotype of Alzheimer’s disease can be reliably identified in clinical practice.

    “It requires the presence of both a specific clinical phenotype of Alzheimer’s disease (phenotype positive) and biomarker evidence of Alzheimer’s disease pathology (amyloid-positive and tau positive).”
  • The paper relies on this without support.

    Biomarkers are currently unavailable for the pathological changes that underlie the non-Alzheimer’s neurodegenerative diseases often found in people with dementia.

    “Unfortunately, biomarkers are currently unavailable for the pathological changes that underlie the non-Alzheimer’s neurodegenerative diseases often found in people with dementia, and disentangling Alzheimer’s disease from other neurodegenerative diseases continues to depend on phenotype or postmortem examination.”
  • The paper relies on this without support.

    In some complex cases, only post-mortem evaluation will provide definitive information about whether Alzheimer's disease is the primary pathology or a copathology.

    “In some complex cases, only post-mortem evaluation will provide definitive information.”
  • The paper relies on this without support.

    Biomarker investigations can be limited by the availability, cost, and health-care payment coverage of biomarkers across countries, centres, and clinical situations.

    “Biomarker investigations can also be limited by the availability, cost, and health-care payment coverage of biomarkers across countries, centres, and clinical situations.”
4 of 4

Claims other papers make about this one

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Citations

Cites

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Metadata

Authors
Dubois, B., Villain, N., Frisoni, G. B., Rabinovici, G. D., Sabbagh, M., Cappa, S., Bejanin, A., Bombois, S., Epelbaum, S., Teichmann, M., Habert, M.-O., Nordberg, A., Blennow, K., Galasko, D., Stern, Y., Rowe, C. C., Salloway, S., Schneider, L. S., Cummings, J. L., & Feldman, H. H.
Affiliations
  • Sorbonne Université (FR)
  • University of Geneva (CH)
  • University of California, San Francisco (US)
  • Cleveland Clinic (US)
  • Istituto Universitario di Studi Superiori di Pavia (IT)
  • Universitat Autònoma de Barcelona (ES)
  • Inserm (FR)
  • Institut national de recherche en sciences et technologies du numérique (FR)
  • Centre National de la Recherche Scientifique (FR)
  • Karolinska University Hospital (SE)
  • Sahlgrenska University Hospital (SE)
  • University of California San Diego (US)
  • Columbia University (US)
  • The University of Melbourne (AU)
  • Brown University (US)
  • University of Southern California (US)
Corresponding author
Dubois, Bruno
Venue
The Lancet Neurology
Publisher
Elsevier BV
Published
2021-06
Volume
20
Issue
6
Pages
484-496
ISSN
1474-4422 (ISSN-L)
OpenAlex
W3159530258
Cited by
1,051
References
119
Citations by year
2026: 146 · 2025: 272 · 2024: 237 · 2023: 209 · 2022: 153 · 2021: 33
FWCI
28.16
Type
journal article
Language
en
Open access
Locations
  • The Lancet Neurology (acceptedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
  • HAL (submittedVersion, other-oa)
  • HAL (submittedVersion)
  • eScholarship (California Digital Library) (submittedVersion)
  • Oskar-Bordeaux (Universite de Bordeaux) (submittedVersion)
  • Archive ouverte UNIGE (University of Geneva) (submittedVersion, cc-by)
Funders
  • National Institutes of Health
  • Merck
  • Rainwater Charitable Foundation
  • U.S. Department of Defense
  • Novartis
  • National Health and Medical Research Council
  • National Institute on Aging
  • Roche
  • Eisai
  • National Institute of General Medical Sciences
  • Medtronic
  • Adamas Pharmaceuticals
  • Johnson and Johnson
  • UCB Pharma
  • Abbott Laboratories
  • American College of Radiology
  • Alzheimer's Drug Discovery Foundation
  • ACADIA Pharmaceuticals
  • Eli Lilly and Company
  • Avid Radiopharmaceuticals
  • Genentech
  • Merz Pharmaceuticals
  • Biogen
  • Sorbonne Université
  • Alzheimer's Association
  • GE Healthcare
  • National Institute of Neurological Disorders and Stroke
Topics
  • Health Sciences › Medicine › Psychiatry and Mental health › Dementia and Cognitive Impairment Research
  • Life Sciences › Neuroscience › Cellular and Molecular Neuroscience › Alzheimer's disease research and treatments
  • Health Sciences › Medicine › Oncology › Cancer-related cognitive impairment studies
Keywords
Alzheimer's disease, diagnosis, biomarkers, amyloid-beta, tau pathology, NIA-AA criteria, cognitively unimpaired individuals, prodromal Alzheimer's disease, at-risk individuals, comorbidities, diagnostic recommendations
MeSH terms
Alzheimer Disease, Humans, Phenotype, Biomarkers, Amyloid beta-Peptides, tau Proteins, Disease Progression, Cognitive Dysfunction

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