Negotiations are underway in medical literature and clinics as to who should diagnose dementia, in light of new anti-amyloid monoclonal antibodies — lecanemab (Leqembi) and donanemab (Kisunla) — for early Alzheimer’s disease, new developments in biomarkers, and an anticipated increase in the number of cognitively impaired elderly adults.
The new Alzheimer’s drugs have likely increased pressure on primary care to evaluate cognitive changes so eligible people can be diagnosed sooner, noted geriatrician Nathaniel Chin, MD, of the University of Wisconsin in Madison.
“The treatments may have expanded the role of primary care to now discuss the new therapies to some degree, and to help explain who may or may not be eligible and the risks of taking the medications, particularly ARIA,” Chin told MedPage Today. (ARIA — amyloid-related imaging abnormalities — can be a serious risk associated with Alzheimer’s monoclonal antibody therapy; both lecanemab and donanemab carry a boxed warning for it.)
“I believe primary care is perfectly situated to identify the initial thinking changes of patients, evaluate for reversible causes, and then express concern for cognitive impairment,” Chin said.
“From here, I believe primary care can then make the best referral to specialists so they can confirm a syndromic diagnosis of mild cognitive impairment or dementia and evaluate further for the etiology, such as Alzheimer’s, through the use of neuropsychological testing and biomarkers,” he added. “Specialists can then initiate novel therapies, when appropriate.”
The role of primary care in Alzheimer’s also was a topic at the 2024 American Geriatrics Society meeting, where experts discussed the ongoing problem of delayed dementia diagnoses.
In 2023, researchers led by Alissa Bernstein Sideman, PhD, MPH, MA, of the University of California, San Francisco, published the results of a qualitative interview study with 39 primary care practitioners (PCPs) across California — a group that was 64% female, 41% Asian, 36% white, and 8% Black. About half had been in practice for less than 5 years, and 20% were in practice for 16 years or more. Most (85%) were physicians; 15% were nurse practitioners.
In JAMA Network Open, Sideman and co-authors identified six themes from their interview transcripts.
PCPs saw themselves as the first people in the health care system to identify cognitive problems, and that they “should be responsible for parts of the dementia evaluation and treatment, such as conducting a cognitive assessment, laboratory workup, seeking to delay the worsening of symptoms, and providing medications,” Sideman and colleagues wrote.
Second, third, and fourth themes addressed trust built through ongoing relationships, dementia care as part of a broader responsibility to care for the whole person in context, and work that involves the patient’s family.
“These factors made PCPs feel uniquely positioned to understand dementia within the broader context of patient’s lives,” the researchers noted. Overall primary care goals were consistent with an approach that involved both patients and caregivers, like the Six Domains of Health framework, they added.
The specialist role was a fifth theme. PCPs thought a neurologist was helpful in diagnosis, and in managing atypical dementia types when bandwidth constraints of their own practices were limiting and when they felt patients would receive better care and resources. They contrasted one-time specialist visits with primary care’s greater accessibility, established bond with patients, and knowledge of patient contexts.
Finally, the interviews identified a mismatch between PCP values and reality. Nearly all PCPs desired to be better prepared to provide dementia care and described how systemic realities affected their ability to provide care they wanted to offer.
“Although there is a body of literature spanning multiple decades developed to guide PCPs on how to diagnose and manage dementia, PCPs we interviewed reported limited training in dementia,” Sideman and co-authors said. Ways to address training gaps could include AD-ECHO, a hub-and-spoke education and consultation model, they added.
Other impediments included short appointment times, poor reimbursement and funding, and lack of staff support and resources that constrained the ability to provide comprehensive dementia care. Some PCPs believed systemic change — including making dementia care a priority, or boosting institutional support for primary care — was needed.
Chin offered a similar view, arguing that no specialty is better suited than primary care for syndromic identification and diagnosis.
In a recent essay in the New England Journal of Medicine, he and co-author Claire Erickson, PhD, MPA, of the University of Pennsylvania in Philadelphia, echoed the call for additional resources.
Dementia care needs cannot be met in the current health care system, they said, noting that appropriate care would need to involve more social workers and nurses, allowing PCPs to take more time with each patient.
Revised payment models may help, Chin and Erickson suggested. For example, CMS is testing the GUIDE model, which financially supports a team-based approach to dementia care and addresses unpaid caregivers’ needs, partly by adding a patient care navigator to the clinical team.
“The recent advancements in therapy, specifically anti-amyloid monoclonal treatments, have reduced some of the stigma of Alzheimer’s, which is great,” Chin said. “This has led to more people talking openly with their PCPs about cognitive changes.”
Building confidence in diagnosing mild cognitive impairment and dementia in primary care is necessary, he observed. “Now is a great opportunity for PCPs to become confident in evaluating for reversible causes, such as sleep apnea, depression, thyroid issues, medication side effects, vitamin deficiencies, and poorly controlled chronic conditions,” he added.
“Not all cognitive change is due to Alzheimer’s and so primary care can characterize the symptoms, address brain health, and then make the appropriate referral when Alzheimer’s, or another neurodegenerative disease, is actually suspected,” Chin pointed out. “Primary care and specialty care need to come together for the betterment of patients and the healthcare system needs to facilitate this.”
Disclosures
Chin reported relationships with NewAmsterdam Pharma, the Wisconsin Alzheimer’s Association, and the Alzheimer’s Foundation of America.
Sideman reported relationships with the California Department of Public Health’s Alzheimer’s disease program, the California Department of Health Care Services, the Health Resources and Services Administration, and the NIH.
Please enable JavaScript to view the