Alzheimer's disease (AD) is a neurodegenerative disease and is the most common cause of dementia, accounting for around 60–70% of cases. The most common early symptom is difficulty in remembering recent events. As the disease advances, symptoms can include problems with language, disorientation (including easily getting lost), mood swings, loss of motivation, self-neglect, and behavioral issues. As a person's condition declines, they often withdraw from family and society. Gradually, bodily functions are lost, ultimately leading to death. The median life expectancy following diagnosis of dementia is three to twelve years. Co-occurring movement disorder, also known as extrapyramidal signs, multiplies risk of death by 1.6. The causes of Alzheimer's disease remain poorly understood. There are many environmental and genetic risk factors associated with its development. The strongest genetic risk factor is from an allele of apolipoprotein E, a protein involved in the metabolism of fats in mammals. Other risk factors include a history of head injury, clinical depression, and high blood pressure. The progression of the disease is largely characterised by the accumulation of malformed protein deposits in the cerebral cortex, called amyloid plaques and neurofibrillary tangles. These misfolded protein aggregates interfere with normal cell function, and over time lead to irreversible degeneration of neurons and loss of synaptic connections in the brain. A probable diagnosis is based on the history of the illness and cognitive testing, with medical imaging and blood tests to rule out other possible causes. Initial symptoms are often mistaken for normal brain aging. Examination of brain tissue is the only way to definitively diagnose Alzheimer's, but neuroimaging techniques and fluid biomarkers have made it possible to diagnose probable Alzheimer's disease in vivo. No known treatments can stop or reverse its progression, though some may temporarily improve symptoms. A healthy diet, physical activity, and social engagement are generally beneficial in aging, and may help in reducing the risk of cognitive decline and Alzheimer's. Affected people become increasingly reliant on others for assistance, often placing a burden on caregivers. The pressures can include social, psychological, physical, and economic elements. Exercise programs may be beneficial with respect to activities of daily living and can potentially improve outcomes. Behavioral problems or psychosis due to dementia are sometimes treated with antipsychotics, but this has an increased risk of early death. As of 2020, there were approximately 50 million people worldwide with Alzheimer's disease. It most often begins in people over 65 years of age, although up to 10% of cases are early-onset impacting those in their 30s to mid-60s. It affects about 6% of people 65 years and older, and women more often than men. The disease is named after German psychiatrist and pathologist Alois Alzheimer, who first described it in 1906. Alzheimer's financial burden on society is large, with an estimated global annual cost of US$1 trillion. Alzheimer's and related dementias are ranked as the seventh leading cause of death worldwide. Given the widespread impacts of Alzheimer's disease, both basic-science and health funders in many countries support Alzheimer's research at large scales. For example, the US National Institutes of Health program for Alzheimer's research, the National Plan to Address Alzheimer's Disease, has a budget of US$3.98 billion for fiscal year 2026. In the European Union, the 2020 Horizon Europe research programme awarded over €570 million for dementia-related projects.
Signs and symptoms The course of Alzheimer's is generally described in three stages, with a progressive pattern of cognitive and functional impairment. The three stages are described as early or mild, middle or moderate, and late or severe. The disease is known to target the hippocampus, which is associated with memory, and this is likely to be responsible for the first symptoms of memory impairment. As the disease progresses, so does the degree of memory impairment.
First symptoms
The first symptoms are often mistakenly attributed to aging or stress. Detailed neuropsychological testing can reveal mild cognitive difficulties up to eight years before a person fulfills the clinical criteria for diagnosis of Alzheimer's disease. These early symptoms can affect the most complex activities of daily living. The most noticeable deficit is difficulty in remembering recently learned facts and inability to acquire new information. Subtle problems with the executive functions of attentiveness, planning, flexibility, and abstract thinking, or impairments in semantic memory (memory of meanings and concept relationships) can also be symptomatic of the early stages of Alzheimer's disease. Apathy and depression can be seen at this stage, with apathy remaining as the most persistent symptom throughout the course of the disease. People with objective signs of cognitive impairment, but not more severe symptoms, may be diagnosed with mild cognitive impairment (MCI). If memory loss is the predominant symptom of MCI, it is termed amnestic MCI and is frequently seen as a prodromal or early stage of Alzheimer's disease. Amnestic MCI has a greater than 90% likelihood of being associated with Alzheimer's.
Early stage In people with early stage Alzheimer's disease, there is increasing impairment of learning and memory. In a small percentage, difficulties with language, executive functions, perception (agnosia), or execution of movements (apraxia) are more prominent than memory problems. Alzheimer's disease does not affect all memory capacities equally. Older memories of the person's life (episodic memory), facts learned (semantic memory), and implicit memory (the memory of the body on how to do things, such as using a fork to eat or how to drink from a glass) are affected to a lesser degree than new facts or memories. Language problems are mainly characterised by a shrinking vocabulary and decreased word fluency, leading to a general impoverishment of oral and written language. In this stage, the person with Alzheimer's is usually capable of communicating basic ideas adequately. While performing fine motor tasks such as writing, drawing, or dressing, certain movement coordination and planning difficulties (apraxia) may be present; however, they are commonly unnoticed. As the disease progresses, people with Alzheimer's disease can often continue to perform many tasks independently; however, they may need assistance or supervision with the most cognitively demanding activities.
Middle stage Progressive deterioration eventually hinders independence, with subjects being unable to perform the most common activities of daily living. Speech difficulties become evident due to an inability to recall vocabulary, which leads to frequent incorrect word substitutions (paraphasias). Reading and writing skills are also progressively lost. Complex motor sequences become less coordinated as time passes and Alzheimer's disease progresses, so the risk of falling increases. During this phase, memory problems worsen, and the person may fail to recognise close relatives. Long-term memory, which was previously intact, becomes impaired. Behavioral and neuropsychiatric changes become more prevalent. Common manifestations are wandering, irritability and emotional lability, leading to crying, outbursts of unpremeditated aggression, or resistance to caregiving. Sundowning can also appear. Approximately 30% of people with Alzheimer's disease develop illusionary misidentifications and other delusional symptoms. Subjects also lose insight of their disease process and limitations (anosognosia). Urinary incontinence can develop. These symptoms create stress for relatives and caregivers, which can be reduced by moving the person from home care to other long-term care facilities.
Late stage During the final stage, known as the late-stage or severe stage, there is complete dependence on caregivers. Language is reduced to simple phrases or even single words, eventually leading to complete loss of speech. Despite the loss of verbal language abilities, people can often understand and return emotional signals. Although aggressiveness can still be present, extreme apathy and exhaustion are much more common symptoms. People with Alzheimer's disease will ultimately not be able to perform even the simplest tasks independently; muscle mass and mobility deteriorate to the point where they are bedridden and unable to feed themselves. The cause of death is usually an external factor, such as infection of pressure ulcers or pneumonia, not the disease itself. In some cases, there is a paradoxical lucidity immediately before death, where there is an unexpected recovery of mental clarity.
Causes
Alzheimer's disease is believed to occur when abnormal amounts of amyloid beta (Aβ), accumulating extracellularly as amyloid plaques, or tau proteins, accumulating intracellularly as neurofibrillary tangles, form in the brain, affecting neuronal functioning and connectivity, resulting in a progressive loss of brain function. This altered protein clearance ability is age-related, regulated by brain cholesterol, and associated with other neurodegenerative diseases. Deterministic causes for most Alzheimer's cases are still mostly unknown, except for 1–2% of cases where deterministic genetic differences have been identified. Predisposing causes (also known as "risk factors") such as hearing impairment and smoking are increasingly documented. Several unifying hypotheses attempt to explain underlying causes; the most predominant are the amyloid beta (Aβ) hypothesis, and the tau hypothesis.
Genetic
Late onset Late-onset Alzheimer's is about 70% heritable. Most cases of Alzheimer's are not familial, and so they are termed sporadic Alzheimer's disease. Of the cases of sporadic Alzheimer's disease, most are classified as late onset where they are developed after the age of 65 years. The strongest genetic risk factor for sporadic Alzheimer's disease is APOEε4. APOEε4 is one of the three major alleles of apolipoprotein E (APOE). APOE plays a major role in lipid-binding proteins in lipoprotein particles and the ε4 allele disrupts this function. Between 40% and 80% of people with Alzheimer's disease possess at least one APOEε4 allele. The APOEε4 allele increases the risk of the disease by three times in heterozygotes and by 15 times in homozygotes. Like many human diseases, environmental effects and genetic modifiers result in incomplete penetrance. For example, Nigerian Yoruba people do not show the relationship between the dose of APOEε4 and incidence or age-of-onset for Alzheimer's disease seen in other human populations.
Early onset
Only 1–2% of Alzheimer's cases are inherited due to autosomal dominant mutations, as Alzheimer's disease is substantially polygenic. When autosomal dominant variants cause the disease, it is known as early-onset familial Alzheimer's disease, which is rarer and tends to progress more rapidly. Less than 5% of sporadic Alzheimer's disease have an earlier onset, and early-onset Alzheimer's is about 90% heritable. Familial Alzheimer's disease usually implies two or more persons affected in one or more generations. Early onset familial Alzheimer's disease can be attributed to mutations in one of three genes: those encoding amyloid-beta precursor protein (APP) and presenilins PSEN1 and PSEN2. Most mutations in the APP and presenilin genes increase the production of a small protein called amyloid beta (Aβ)42, which is the main component of amyloid plaques. Some of the mutations merely alter the ratio between Aβ42 and the other major forms—particularly Aβ40—without increasing total Aβ levels in the brain. Two other genes associated with autosomal dominant Alzheimer's disease are ABCA7 and SORL1. Alleles in the TREM2 gene have been associated with a three to five times higher risk of developing Alzheimer's disease. A Japanese pedigree of familial Alzheimer's disease was found to be associated with a deletion mutation of codon 693 of APP. This mutation and its association with Alzheimer's disease was first reported in 2008, and is known as the Osaka mutation. Only homozygotes with this mutation have an increased risk of developing Alzheimer's disease. This mutation accelerates Aβ oligomerization, but the proteins do not form the amyloid fibrils that aggregate into amyloid plaques, suggesting that Aβ oligomerization rather than the fibrils may be the cause of this disease. Mice expressing this mutation have all the usual pathologies of Alzheimer's disease.
Hypotheses
Misfolded protein
Two abnormal proteins define the pathology of Alzheimer's disease: amyloid beta protein (Aβ) in amyloid plaques and tau protein in neurofibrillary tangles. These proteins share two features that promote their ability to cause disease: They both become abnormal by misfolding, that is, by assuming a shape that is rich in beta sheets; and they proliferate in the brain by the prion-like mechanism of seeded protein aggregation. The presence of these abnormal proteins in Alzheimer's disease has spawned two hypotheses of the proteopathic origin of the disease: The amyloid (or Aβ) hypothesis, and the tau hypothesis. The amyloid hypothesis, also known as the "amyloid cascade hypothesis" or "Aβ cascade hypothesis", holds that the accumulation of misfolded Aβ in the brain is the fundamental cause of Alzheimer's disease. In the amyloid cascade, the buildup of abnormal Aβ leads to tauopathy and eventually the complex degenerative changes of advanced Alzheimer's disease. Abnormal Aβ is thought to damage the brain by directly interacting with cells, as well as indirectly, for example by causing oxidative stress and neuroinflammation. The amyloid hypothesis is supported by evidence from genetics and biomarkers. All autosomal dominant genetic causes of Alzheimer's disease affect either the amyloid precursor protein (APP) on chromosome 21 or the enzymes that generate Aβ, known as presenilin 1 and presenilin 2. In addition, people with trisomy 21 (Down syndrome), most of whom have an extra copy of the gene for APP, almost universally develop the symptoms and neuropathology of Alzheimer's disease by 40 years of age. Conversely, people with a rare mutation in the APP gene that reduces the production of Aβ and its tendency to aggregate are protected against Alzheimer's disease. Additionally, a major genetic risk factor for Alzheimer's disease is a specific isoform of apolipoprotein E, APOE4. Of the three major isoforms (APOE2, APOE3 and APOE4), APOE4 is linked to the least efficient removal of Aβ by astrocytes, which promotes the buildup of Aβ in the brain. The most efficient clearance of Aβ is achieved by cells bearing the APOE2 isoform, which protects against Alzheimer's disease. Evidence from tests such as imaging of protein deposits in the brain and measurement of brain-derived substances in cerebrospinal fluid and blood implicates abnormalities of Aβ as the earliest and most robust disease-specific change in Alzheimer's disease. The tau hypothesis proposes that abnormalities of the tau protein initiate the disease cascade, at least in cases of idiopathic Alzheimer's disease. The tau hypothesis is supported by the histopathological findings of Heiko Braak and colleagues that tauopathy can be detected in certain neurons before Aβ plaques are evident. Specifically, Alzheimer's starts with the hyperphosphorylation of tau in specific vulnerable neuronal populations such as the locus coeruleus and projection neurons of the association cortex. There is agreement in the research community that tau contributes strongly to dementia in Alzheimer's disease. Tauopathy occurs in over 30 diseases in addition to Alzheimer's disease. In addition, mutations of the gene for tau (MAPT) cause neurodegenerative disorders known as primary tauopathies, but these diseases occur in the absence of Aβ proteopathy. Current evidence thus favors abnormal Aβ as the prime mover of Alzheimer's disease. However, the Aβ hypothesis and tau hypothesis are not mutually exclusive, in that abnormalities of Aβ initiate the disease and tauopathy is required for its complete expression.
Hormonal Because women have a higher incidence of AD than men, it has been thought that estrogen deficiency during menopause is a risk factor. In a 2025 analysis of the Canadian Longitudinal Study on Aging, earlier age at menopause was linked with lower cognitive performance.
Infection The possibility that infectious agents cause Alzheimer's disease has been considered since the early 20th century, when Oskar Fischer likened amyloid plaques to small masses (called 'Drusen') of a microbe called actinomyces. Since then, at least 15 different agents, including bacteria, viruses, fungi and protozoa, have been proposed to cause Alzheimer's disease. No definitive evidence has been presented that a specific infectious agent is necessary and sufficient to cause Alzheimer's disease. However, it is possible that microbial infections might act as risk factors for the disease. For example, human herpes viruses such as HSV-1, HHV-6, and HHV-7 have been linked to the risk of Alzheimer's disease. In addition, some pathogens have been reported to seed Aβ deposition in the brain, and aggregated Aβ has antimicrobial properties, suggesting that Aβ plaques might form when brain cells generate Aβ to fight infection. Researchers caution that brain infections can cause dementia by mechanisms unrelated to Alzheimer's disease.
DNA damage DNA damage accumulates in affected brains; reactive oxygen species may be the major source of this DNA damage.
Cholinergic The cholinergic hypothesis proposes that the loss of neurons in the basal forebrain, which produce the neurotransmitter acetylcholine, is a key event in the pathogenesis of Alzheimer's disease. These cells supply acetylcholine to synapses in the limbic system and cerebral cortex. The cholinergic hypothesis led to the development of drugs that increase acetylcholine in the brains of Alzheimer patients. The efficacy of these agents is limited, probably because many other neurotransmitter systems degenerate in Alzheimer's disease.
Sleep Sleep disturbances are seen as a possible risk factor for inflammation in Alzheimer's disease. Sleep disruption was previously only seen as a consequence of Alzheimer's disease, but as of 2020, accumulating evidence suggests that this relationship may be bidirectional.
Neuroinflammation, metal toxicity, smoking, and air pollution Systemic markers of the innate immune system are risk factors for late-onset Alzheimer's disease, and misfolded Aβ and tau proteins both are associated with oxidative stress and neuroinflammation. Chronic inflammation also is a feature of other neurodegenerative diseases, including Parkinson's disease, and ALS. The cellular homeostasis of biometals such as ionic copper, iron, and zinc is disrupted in Alzheimer's disease, though it remains unclear whether this is produced by or causes the changes in proteins. Smoking is a significant Alzheimer's disease risk factor. Exposure to air pollution may be a contributing factor to the development of Alzheimer's disease.
Age-related myelin decline Retrogenesis is a medical hypothesis that just as the fetus goes through a process of neurodevelopment beginning with neurulation and ending with myelination, the brains of people with Alzheimer's disease go through a reverse neurodegeneration process starting with demyelination and death of axons (white matter) and ending with the death of grey matter. Likewise the hypothesis is, that as infants go through states of cognitive development, people with Alzheimer's disease go through the reverse process of progressive cognitive impairment. According to one theory, dysfunction of oligodendrocytes and their associated myelin during aging contributes to axon damage, which in turn generates amyloid production and tau hyperphosphorylation. Comorbidities between the demyelinating disease, multiple sclerosis, and Alzheimer's disease have been reported.
Other hypotheses
The association with celiac disease is unclear, with a 2019 study finding no increase in dementia overall in those with celiac disease, while a 2018 review found an association with several types of dementia, including Alzheimer's disease. Some studies have reported a potential link between infection with certain viruses and developing Alzheimer's disease later in life, such as COVID-19 or Herpes simplex virus 1 (HSV-1). Some researchers have proposed that Alzheimer's disease is type 3 diabetes because of a number of correspondences with both type 1 and type 2 diabetes.
Pathophysiology
Neuropathology
The gross (macroscopic) appearance of the brain in Alzheimer's disease is variable. In many cases the cortical sulci are widened and the gyri are shrunken, but the degree of cortical atrophy varies. It can sometimes be difficult to discern, particularly in the very elderly. The areas most affected by atrophy are the medial temporal lobe including the hippocampal formation, the amygdala, the frontal lobe and the parietal lobe; the occipital lobe is relatively unaffected by atrophy. The volume of the ventricles increases in parallel with cortical shrinkage. Studies using MRI and PET have documented reductions in the size of specific brain regions in people with Alzheimer's disease as they progress from mild cognitive impairment to Alzheimer's disease, and in comparison with similar images from healthy older adults. These macroscopic changes in the brain are not specific to Alzheimer's and can occur in other disorders and to some extent in normal aging. At the microscopic level, the defining histopathologic characteristics of Alzheimer's disease are abundant amyloid plaques and neurofibrillary tangles in certain brain regions. Both of these abnormalities are clearly visible by microscopy, and amyloid imaging. In the early stages of disease, tangles are present mainly in the medial temporal lobe and plaques are present mainly in the neocortex, but as the disease progresses the lesions proliferate throughout much of the brain. Although it was once thought that Alzheimer's disease can occur without neurofibrillary tangles in the neocortex, newer methods have shown that dementia in these cases can be linked to a comorbid condition, often Lewy body disease. Aβ plaques are dense, mostly insoluble deposits of amyloid beta peptide and cellular material outside and around neurons. Neurofibrillary tangles are aggregates of the microtubule-associated protein tau which has become hyperphosphorylated and accumulates inside neurons. Although many older individuals develop some plaques and tangles as a consequence of aging, the brains of people with Alzheimer's disease have a greater number of them in specific brain regions.
In addition to plaques and tangles, other neuropathological changes contribute to the clinicopathological features of advanced Alzheimer's disease. These include cerebral Aβ-amyloid angiopathy (CAA), inflammation, and the loss of neurons and synapses. The disappearance of neurons and their synapses is a particularly prominent correlate of dementia, although not all cells are affected equally. Selective vulnerability - that is, why certain neurons and synapses are affected, and others spared - is an important unanswered question. In more than half of the cases examined neuropathologically, and especially in very old people, the pathology of Alzheimer's disease is accompanied by lesions that are characteristic of other brain disorders. The most common of these comorbid conditions are vascular disease, Lewy body disease, and TDP-43 proteinopathy. This mixed pathology can complicate both diagnosis and the evaluation of clinical trials, which often target only one of several potential contributors to dementia.
Biochemistry
Amyloid beta (Aβ) Alzheimer's disease has been identified as a protein misfolding disease, a proteopathy, caused by the accumulation of abnormally folded Aβ protein into amyloid plaques, and tau protein into neurofibrillary tangles in the brain. Plaques are made up of small peptides, 39–43 amino acids in length, called Aβ. Aβ is a fragment derived from the larger Aβ precursor protein (APP), a transmembrane protein that penetrates the cell's membrane. APP is critical to neuronal growth, survival, and post-injury repair. In Alzheimer's disease, the enzymes gamma secretase and beta secretase act together in a proteolytic process that divides APP into smaller fragments. One of these fragments is Aβ, which misfolds and self-assembles into fibrils; these fibrils form clumps that deposit outside neurons in dense formations known as Aβ plaques. Excitatory neurons are known to be major producers of Aβ that contribute to extracellular plaque deposition.
Phosphorylated tau Alzheimer's disease is also considered a tauopathy due to the abnormal aggregation of the tau protein within cells. Every neuron has a cytoskeleton, an internal support structure partly made up of organelles called microtubules. These microtubules act like tracks, guiding nutrients and molecules from the body of the cell to the ends of the axon and back. The tau protein stabilises the microtubules when phosphorylated, and it is therefore called a microtubule-associated protein. In Alzheimer's disease, tau undergoes chemical changes, becoming hyperphosphorylated; it then begins to pair with other threads, creating neurofibrillary tangles and disintegrating the neuron's transport system. Pathogenic tau can also cause neuronal death through transposable element dysregulation. Necroptosis has also been reported as a mechanism of cell death in brain cells affected with tau tangles.
Disease mechanism Exactly how disturbances of production and aggregation of the Aβ peptide give rise to the pathology of Alzheimer's disease is not known. The amyloid hypothesis (also known as the 'amyloid cascade hypothesis') posits that the accumulation of abnormally shaped Aβ peptides is the central event triggering the sequence of changes that eventually lead to neurodegeneration and dementia. Misfolded Aβ accumulates in the brain because it causes normal Aβ molecules to similarly misfold by a prion-like 'seeding' mechanism. The aggregated Aβ takes the form of small oligomers (which are particularly toxic to neurons) and amyloid fibrils, the long polymers that are the main components of Aβ plaques. Some researchers have argued that the amyloid fibrils bind up smaller oligomers and thus protect brain cells from the injurious effects of the oligomers. However, the plaques are not benign inasmuch as they are associated with abnormal neuronal processes and local inflammation. Whatever the relative influence of Aβ oligomers and fibrils, the presence of aggregated Aβ is associated with the disruption of neuronal metabolism and various other changes such as inflammation. Aβ also selectively builds up in mitochondria in the cells of Alzheimer's-affected brains, and it inhibits certain enzyme functions and the utilisation of glucose by neurons. Evidence supports Aβ as playing a central role in the pathogenesis of Alzheimer's disease. As the disease progresses, the brain undergoes a complex assortment of cellular and molecular changes, including (in addition to tauopathy) inflammation, oxidative/nitrative stress, DNA damage, epigenetic changes, excitotoxicity, endosomal/lysosomal failure, dysproteostasis, autophagy failure, lipid dysmetabolism, calcium ion (Ca2+) dyshomeostasis, post-translational protein modifications, neuronal cell cycle re-entry, mitochondrial failure, cytoskeletal disruption, glucose dysmetabolism, vascular or lymphatic impairments, and biometal dyshomeostasis. Iron dyshomeostasis is linked to disease progression in which an iron-dependent form of regulated cell death called ferroptosis could be involved. Products of lipid peroxidation are also elevated in the Alzheimer's brain compared with controls. Various inflammatory processes and cytokines also play a role in the pathology of Alzheimer's disease. Inflammation is a general marker of tissue damage in any disease, and may be either secondary to tissue damage in Alzheimer's disease or a marker of an immunological response. Cells that mediate neuroinflammation in Alzheimer's include microglia, astrocytes, oligodendrocytes, lymphocytes and myeloid cells. There is increasing evidence of a strong interaction between neurons and the immunological mechanisms in the brain. Obesity and systemic inflammation may interfere with immunological processes which promote disease progression. Microglia are especially important actors in the Alzheimer's-related inflammation. Microglia are the principal immunological cells of the central nervous system, serving as the tissue-resident macrophages of the brain; they are capable of recognizing and taking up Aβ through multiple pattern recognition receptors, making them central to amyloid clearance within the brain. However, microglia can also be a major source of pro-inflammatory mediators which can be deleterious to neurological function. Microglia are topographically associated with aberrant deposits of tau and Aβ within the brain, even when each pathologic component occurs in distinct brain regions. Microglial activation has been documented in people with mild cognitive impairment, despite a lack of detectable binding of a PET tracer for Aβ in the brain, suggesting that microglial dysfunction may precede plaque deposition as an inciting event in AD. Alterations in the distribution of different neurotrophic factors and in the expression of their receptors, such as the brain-derived neurotrophic factor (BDNF), have been described in Alzheimer's disease. By the time the symptoms of Alzheimer's first appear, the complex degenerative mechanisms in the brain have been active for many years. The absent or minor effect on cognitive function of monoclonal antibodies that promote Aβ clearance suggests reconsideration of the amyloid cascade hypothesis.
Diagnosis
Alzheimer's disease (AD) can be definitively diagnosed only with histopathological findings; in the absence of autopsy or brain biopsy, clinical diagnoses of AD are "possible" or "probable", based on other findings. Up to 23% of those clinically diagnosed with AD may be misdiagnosed and may have pathology suggestive of another condition with symptoms that mimic those of AD. AD is usually clinically diagnosed based on a person's medical history, observations from friends or relatives, and behavioral changes. The presence of characteristic neuropsychological changes with impairments in at least two cognitive domains that are severe enough to affect a person's functional abilities is required for the diagnosis. Domains that may be impaired include memory (most commonly impaired), language, executive function, visuospatial functioning, or other areas of cognition. The neurocognitive changes must be a decline from a prior level of function, and the diagnosis requires ruling out other common causes of neurocognitive decline. Advanced medical imaging with computed tomography (CT) or magnetic resonance imaging (MRI), and with single-photon emission computed tomography (SPECT) or positron emission tomography (PET), can be used to help exclude other cerebral pathology or subtypes of dementia. On MRI or CT, Alzheimer's disease usually shows a generalised or focal cortical atrophy, which may be asymmetric. Atrophy of the hippocampus is also commonly seen. Brain imaging commonly also shows cerebrovascular disease, most commonly previous strokes (small or large territory strokes), and this is thought to be a contributing cause of many cases of dementia (up to 46% cases of dementia also have cerebrovascular disease on imaging). FDG-PET scan is not required for the diagnosis but it is sometimes used when standard testing is unclear. FDG-PET shows a bilateral, asymmetric, temporal and parietal reduced activity. Advanced imaging may predict conversion from prodromal stages (mild cognitive impairment) to Alzheimer's disease. FDA-approved radiopharmaceutical diagnostic agents used in PET for Alzheimer's disease include three that bind to beta amyloid: florbetapir (2012); flutemetamol (2013); and florbetaben (2014); and one that binds to tau protein, flortaucipir (2020). Because many insurance companies in the United States do not cover this test, its use in clinical practice is largely limited to clinical trials as of 2018. Assessment of intellectual functioning, including memory testing, can further characterise the disease state. Medical organizations have created diagnostic criteria to ease and standardise the diagnostic process for practising physicians. Definitive diagnosis can only be confirmed when brain material is available, usually post-mortem, and can be examined histologically for senile plaques and neurofibrillary tangles.
Criteria There are three sets of criteria for the clinical diagnoses of the spectrum of Alzheimer's disease: the 2013 fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5); the National Institute on Aging-Alzheimer's Association (NIA-AA) definition as revised in 2011; and the International Working Group criteria as revised in 2010. Eight intellectual domains are most commonly impaired in AD—memory, language, perceptual skills, attention, motor skills, orientation, problem solving and executive functional abilities, as listed in the fourth text revision of the DSM (DSM-IV-TR). The DSM-5 defines criteria for probable or possible AD for both major and mild neurocognitive disorders. Major or mild neurocognitive disorder must be present along with at least one cognitive deficit for a diagnosis of either probable or possible AD. For major neurocognitive disorder due to AD, probable Alzheimer's disease can be diagnosed if the individual has genetic evidence of AD or if two or more acquired cognitive deficits, and a functional disability that is not from another disorder, are present. Otherwise, possible AD can be diagnosed as the diagnosis follows an atypical route. For mild neurocognitive disorder due to AD, probable Alzheimer's disease can be diagnosed if there is genetic evidence, whereas possible AD can be met if all of the following are present: no genetic evidence, decline in both learning and memory, two or more cognitive deficits, and a functional disability not from another disorder. The NIA-AA criteria are used mainly in research rather than in clinical assessments. They define AD through three major stages: preclinical, mild cognitive impairment (MCI), and Alzheimer's dementia. Diagnosis in the preclinical stage is complex and focuses on asymptomatic individuals; the latter two stages describe individuals experiencing symptoms, along with biomarkers, predominantly those for neuronal injury (mainly tau-related) and amyloid beta deposition. The core clinical criteria itself rests on the presence of cognitive impairment without the presence of comorbidities. The third stage is divided into probable and possible AD dementia. In probable AD dementia there is steady impairment of cognition over time and a memory-related or non-memory-related cognitive dysfunction. In possible AD dementia, another causal disease such as cerebrovascular disease is present.
Techniques
Neuropsychological tests including cognitive tests such as the mini–mental state examination (MMSE), the Montreal Cognitive Assessment (MoCA) and the Mini-Cog are widely used to aid in diagnosis of the cognitive impairments in AD. These tests may not always be accurate, as they lack sensitivity to mild cognitive impairment, and can be biased by language or attention problems; more comprehensive test arrays are necessary for high reliability of results, particularly in the earliest stages of the disease. Further neurological examinations are crucial in the differential diagnosis of Alzheimer's disease and other diseases. Interviews with family members are used in assessment, and caregivers can supply important information on daily living abilities and on the decrease in the person's mental function. A caregiver's viewpoint is particularly important, since a person with Alzheimer's disease is commonly unaware of their deficits. Many times, families have difficulties in the detection of initial dementia symptoms and may not communicate accurate information to a physician. Supplemental testing can rule out other potentially treatable diagnoses and help avoid misdiagnoses. Common supplemental tests include blood tests, thyroid function tests, as well as tests to assess vitamin B12 levels, rule out neurosyphilis and rule out metabolic problems (including tests for kidney function, electrolyte levels and for diabetes). MRI or CT scans might also be used to rule out other potential causes of the symptoms – including tumors or strokes. Delirium and depression can be common among individuals and are important to rule out. Psychological tests for depression are used, since depression can either be concurrent with AD (see Depression of Alzheimer disease), an early sign of cognitive impairment, or even the cause. Due to low accuracy, the C-PIB-PET scan is not recommended as an early diagnostic tool or for predicting the development of AD when people show signs of mild cognitive impairment (MCI). The use of 18F-FDG PET scans, as a single test, to identify people who may develop Alzheimer's disease is not supported by evidence. In 2025, the US FDA approved a blood test by Fujirebio Diagnostics' Lumipulse G pTau217/ß-Amyloid 1-42 Plasma Ratio diagnostic device for the early detection of amyloid plaques associated with AD in adults aged 55 years and older who are exhibiting signs and symptoms of the disease.
Electrophysiology Electroencephalography (EEG) is not routinely used as a primary test for Alzheimer's disease but may assist in the differential diagnosis of cognitive impairment by helping exclude metabolic encephalopathies, Creutzfeldt–Jakob disease, epileptic disorders, and some atypical dementias. EFNS Quantitative EEG studies consistently demonstrate slowing of the dominant posterior rhythm, increased theta and delta activity, reduced alpha power, and disrupted functional connectivity, changes that correlate with disease severity and cognitive decline. Expert consensus considers resting-state EEG a promising non-invasive test for research, patient stratification, and monitoring in clinical trials, although it is not recommended as a substitute for established imaging or fluid biomarkers. Event-related potentials (ERPs), particularly the P300 component, have also been extensively investigated. Meta-analyses show significantly reduced P300 amplitude in patients with Alzheimer's disease, while prolonged latency has been reported in many studies, reflecting impaired cognitive processing. Despite these findings, variability between recording protocols has limited the routine clinical use of ERP measures, and they remain primarily research tools.
Prevention
There is no disease-modifying treatments proven to cure Alzheimer's disease, and because of this, AD research has focused on interventions to prevent the onset and progression. There is no evidence that supports any particular measure in preventing AD, and studies of measures to prevent the onset or progression have produced inconsistent results. Epidemiological studies have proposed relationships between an individual's likelihood of developing AD and modifiable factors, such as medications, lifestyle, and diet. There are some challenges in determining whether interventions for AD act as a primary prevention method, preventing the disease itself, or a secondary p