Perspectives on the diagnosis and management of functional cognitive disorder: An international Delphi study

Verónica Cabreira; Jane Alty; Sonja Antic; Rui Araújo; Selma Aybek; Harriet A Ball; Gaston Baslet; Rohan Bhome; Jan Coebergh; Bruno Dubois; Mark Edwards; Saša R Filipović; Kristian Steen Frederiksen; Thomas Harbo; Bradleigh Hayhow; Robert Howard; Jonathan Huntley; Jeremy Isaacs; William Curt LaFrance Jr; Andrew J Larner; Francesco Di Lorenzo; James Main; Elizabeth Mallam; Camillo Marra; João Massano; Emer R McGrath; Laura McWhirter; Isabel Portela Moreira; Flavio Nobili; Catherine Pennington; Miguel Tábuas-Pereira; David L Perez; Stoyan Popkirov; Dane Rayment; Martin Rossor; Mirella Russo; Isabel Santana; Jonathan Schott; Emmi P Scott; Ricardo Taipa; Michele Tinazzi; Svetlana Tomic; Sofia Toniolo; Caroline Winther Tørring; Tim Wilkinson; Lisbeth Frostholm; Jon Stone; Alan Carson

doi:10.1111/ene.16318

Perspectives on the diagnosis and management of functional cognitive disorder: An international Delphi study

Eur J Neurol. 2025 Jan;32(1):e16318. doi: 10.1111/ene.16318. Epub 2024 May 3.

Authors

Verónica Cabreira¹, Jane Alty², Sonja Antic³, Rui Araújo^{4

5}, Selma Aybek⁶, Harriet A Ball⁷, Gaston Baslet⁸, Rohan Bhome^{9

10}, Jan Coebergh¹¹, Bruno Dubois¹², Mark Edwards¹³, Saša R Filipović¹⁴, Kristian Steen Frederiksen^{15

16}, Thomas Harbo³, Bradleigh Hayhow^{17

18}, Robert Howard¹⁹, Jonathan Huntley^{19

20}, Jeremy Isaacs¹¹, William Curt LaFrance Jr^{21

22}, Andrew J Larner²³, Francesco Di Lorenzo²⁴, James Main²⁵, Elizabeth Mallam²⁶, Camillo Marra²⁷, João Massano^{4

5}, Emer R McGrath²⁸, Laura McWhirter¹, Isabel Portela Moreira²⁹, Flavio Nobili³⁰, Catherine Pennington^{31

32

33}, Miguel Tábuas-Pereira^{34

35

36}, David L Perez³⁷, Stoyan Popkirov³⁸, Dane Rayment³⁹, Martin Rossor⁹, Mirella Russo⁴⁰, Isabel Santana^{35

36}, Jonathan Schott⁹, Emmi P Scott⁴¹, Ricardo Taipa⁴², Michele Tinazzi⁴³, Svetlana Tomic⁴⁴, Sofia Toniolo⁴⁵, Caroline Winther Tørring³, Tim Wilkinson¹, Lisbeth Frostholm^{46

47}, Jon Stone¹, Alan Carson¹

Affiliations

¹ Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
² Wicking Dementia Research and Education Centre, University of Tasmania, Hobart, Tasmania, Australia.
³ Department of Neurology, Aarhus University Hospital, Aarhus, Denmark.
⁴ Department of Neurology, Centro Hospitalar Universitário São João, Porto, Portugal.
⁵ Department of Clinical Neurosciences and Mental Health, Faculty of Medicine University of Porto, Porto, Portugal.
⁶ Neurology, Faculty of Sciences and Medicine, Fribourg University, Fribourg, Switzerland.
⁷ Population Health Sciences, Bristol Medical School, Bristol, UK.
⁸ Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
⁹ Dementia Research Centre, UCL Queen Square Institute of Neurology, London, UK.
¹⁰ Centre for Medical Image Computing, University College London, London, UK.
¹¹ Department of Neurology, St George's University of London, London, UK.
¹² Department of Neurology, Institut de la mémoire et de la maladie d'Alzheimer (IM2A), AP-HP, Brain Institute, Sorbonne University, Paris, France.
¹³ Department of Basic and Clinical Neurosciences, Institute of Psychiatry Psychology and Neurosciences, Kings College London, London, UK.
¹⁴ University of Belgrade Institute for Medical Research, Belgrade, Serbia.
¹⁵ Clinical Trial Unit, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
¹⁶ Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
¹⁷ Department of Neurology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia.
¹⁸ School of Medicine, University of Notre Dame Australia, Fremantle, Western Australia, Australia.
¹⁹ Division of Psychiatry, University College London, London, UK.
²⁰ Camden and Islington NHS Foundation Trust, London, UK.
²¹ Alpert Medical School, Brown University, Providence, Rhode Island, USA.
²² Neuropsychiatry and Behavioral Neurology, Rhode Island Hospital, Providence, Rhode Island, USA.
²³ Cognitive Function Clinic, Walton Centre for Neurology and Neurosurgery, Liverpool, UK.
²⁴ Department of Clinical and Behavioural Neurology, Santa Lucia Foundation IRCCS, Rome, Italy.
²⁵ Bristol Dementia Wellbeing Service, Devon Partnership NHS Trust, Bristol, UK.
²⁶ Neurology Department, North Bristol NHS Trust, Bristol, UK.
²⁷ Department of Neuroscience, Catholic University of the Sacred Heart, Memory Clinic - Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy.
²⁸ School of Medicine, University of Galway, Galway, Ireland.
²⁹ Neurology Department, Private Hospital of Gaia of the Trofa Saúde Group, Vila Nova de Gaia, Portugal.
³⁰ IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
³¹ Clinical Lecturer, University of Edinburgh, Edinburgh, UK.
³² Neurology Department, NHS Forth Valley, Larbert, UK.
³³ Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK.
³⁴ Neurology Department, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, Coimbra, Portugal.
³⁵ Faculty of Medicine, University of Coimbra, Coimbra, Portugal.
³⁶ Center for Innovative Biomedicine and Biotechnology, University of Coimbra, Coimbra, Portugal.
³⁷ Department of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
³⁸ Department of Neurology, University Hospital Essen, Essen, Germany.
³⁹ Rosa Burden Centre for Neuropsychiatry, Southmead Hospital, Bristol, UK.
⁴⁰ Department of Neuroscience, Imaging and Clinical Sciences G. d'Annunzio University of Chieti-Pescara, Chieti, Italy.
⁴¹ Medical University of South Carolina, Charleston, South Carolina, USA.
⁴² Neuropathology Department, Centro Hospitalar Universitário de Santo António, Porto, Portugal.
⁴³ Department of Neurosciences, Biomedicine and Movement, University of Verona, Verona, Italy.
⁴⁴ Department of Neurology, University Hospital Center Osijek, Medical School on University of Osijek, Osijek, Croatia.
⁴⁵ Cognitive Disorder Clinic, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
⁴⁶ Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.
⁴⁷ Department of Functional Disorders and Psychosomatics, Aarhus University Hospital, Aarhus, Denmark.

Abstract

Background: Current proposed criteria for functional cognitive disorder (FCD) have not been externally validated. We sought to analyse the current perspectives of cognitive specialists in the diagnosis and management of FCD in comparison with neurodegenerative conditions.

Methods: International experts in cognitive disorders were invited to assess seven illustrative clinical vignettes containing history and bedside characteristics alone. Participants assigned a probable diagnosis and selected the appropriate investigation and treatment. Qualitative, quantitative and inter-rater agreement analyses were undertaken.

Results: Eighteen diagnostic terminologies were assigned by 45 cognitive experts from 12 countries with a median of 13 years of experience, across the seven scenarios. Accurate discrimination between FCD and neurodegeneration was observed, independently of background and years of experience: 100% of the neurodegenerative vignettes were correctly classified and 75%-88% of the FCD diagnoses were attributed to non-neurodegenerative causes. There was <50% agreement in the terminology used for FCD, in comparison with 87%-92% agreement for neurodegenerative syndromes. Blood tests and neuropsychological evaluation were the leading diagnostic modalities for FCD. Diagnostic communication, psychotherapy and psychiatry referral were the main suggested management strategies in FCD.

Conclusions: Our study demonstrates the feasibility of distinguishing between FCD and neurodegeneration based on relevant patient characteristics and history details. These characteristics need further validation and operationalisation. Heterogeneous labelling and framing pose clinical and research challenges reflecting a lack of agreement in the field. Careful consideration of FCD diagnosis is advised, particularly in the presence of comorbidities. This study informs future research on diagnostic tools and evidence-based interventions.

Keywords: Alzheimer's disease; Delphi; cognitive disorders; consensus; functional cognitive disorder.

MeSH terms

Adult
Cognition Disorders / diagnosis
Cognition Disorders / therapy
Delphi Technique*
Female
Humans
Male
Middle Aged
Neurodegenerative Diseases / diagnosis
Neurodegenerative Diseases / therapy
Neuropsychological Tests

Grants and funding

956673/European Commission