Advancing Early Detection and Equitable Access in Alzheimer Disease Care

Am J Manag Care. 2025;31(Spec. No. 15):SP1163

At an Institute for Value-Based Medicine^® roundtable held by The American Journal of Managed Care^® in Boston, Massachusetts, on November 3, 2025, a multidisciplinary panel of neurologists, geriatricians, and researchers examined how early identification, equitable access, and value-based models could reshape Alzheimer disease care. Moderator Andrew Budson, MD, head of cognitive behavioral neurology in the Memory Disorders Clinic at the Veterans Affairs Boston Healthcare System and associate director of the Boston University Alzheimer’s Disease Research Center, set the stage for the discussion of how to improve early identification of impairment and disease, the barriers and the enablers to patients receiving new amyloid-targeting treatments, and the use of value-based and population health approaches to improve access to “therapies and care coordination for everybody, not just for the few people that have the resources to be able to do it.”

Early Identification: System Challenges and Innovations

Panelists agreed that Alzheimer disease, which is the fifth leading cause of death in patients 65 years and older,¹ remains underrecognized as a public health priority. Michael Stanley, MD, a cognitive neurologist at Tufts Medical Center and an assistant professor at Tufts University School of Medicine, said national investment still falls short, perhaps because lawmakers don’t see Alzheimer disease as an imminent threat. “The recognition is relatively small,” Stanley said. “I just think there are other priorities.”

Within health systems, support and prioritization remain inconsistent. Some health systems still don’t see dementia and cognitive disorders as a population health priority, said Alexandra Stillman, MD, director of concussion, traumatic brain injury, and neurorehabilitation; director of clinical education in the Cognitive Neurology Division; and director of diversity for the Neurology Department at Beth Israel Deaconess Medical Center (BIDMC). However, she said, “I think there is a growing appreciation by health care systems that this is an important condition to address proactively, and then if you wait, things will just get worse. If you wait until the caregiver is unduly stressed, if you wait until the patient is not taking their diabetes medicines because they don’t understand how to take them anymore, if you wait until they can no longer understand how to take their diuretic for their heart failure, you’re not helping anybody. So, my general sense is there is a growing appreciation and recognition by health care systems about the importance of addressing and attending to cognitive disorders.”

Even when health systems recognize the importance, frontline clinicians often lack resources. “If I don’t have access to a social worker, a pharmacist, or a community resource specialist, it’s very difficult for me to [treat] a patient, even without the behavioral issues or the caregiver support,” said Medha Munshi, MD, a geriatrician and diabetologist at BIDMC. Sanford Auerbach, MD, a behavioral neurologist at Boston Medical Center and associate professor of neurology and psychiatry at Boston University’s Chobanian & Avedisian School of Medicine, agreed, noting that primary care doctors often are so overburdened that they lack the time to prospectively identify patients who are soon to worsen. The solution to “getting people into the system,” he said, “is not by having enough PET scans or CT scans. It’s first by identifying the problem.”

The advantages of early diagnosis of Alzheimer disease are numerous. For the patient, these include timely access to disease-modifying therapies, and for the health care system, it can reduce crisis-driven utilization. However, the panelists agreed that the complexity of diagnosis and logistical barriers to health care mean that diagnosis is often delayed. Clinical readiness is also a factor, with 40% of primary care providers (PCPs) reporting discomfort with diagnosing Alzheimer disease and 50% feeling unprepared to care for patients with the diagnosis.²

Technology and AI Offer Promise—but Also Gaps

Artificial intelligence (AI) and digital tools emerged as potential allies in early detection. Vijaya Kolachalama, PhD, an associate professor of computer science and medicine at Boston University, described his laboratory’s work with 2 primary care networks to integrate AI into electronic health record systems, identify risk of Alzheimer disease, and “flag those individuals, because we don’t want AI to make a diagnosis,” allowing PCPs to follow up.

Brad Dickerson, MD, professor of neurology at Harvard Medical School and director of the Frontotemporal Disorders Unit at Massachusetts General Hospital, noted that validated cognitive surveys could help close information gaps, “which could easily be done outside the context of the appointment through the email prompts that we always get before appointments to fill out forms.”

Stillman shared results from a similar pilot initiative at BIDMC: “When patients come in, they do a quick 3-minute cognitive screening program on an iPad. It’s really simple—anyone would be able to do it with access to an iPad.”

Michael Erkkinen, MD, a cognitive neurologist and codirector of the Alzheimer’s Therapeutics Program at Brigham and Women’s Hospital, predicted that as app technology and on-demand blood testing evolve, “we need to be prepared for people come to us with a lot of extra data that we didn’t order, that we need to be able to handle and then be able to integrate into a diagnosis.”

Balancing Innovation With Equity and Safety

Yet the panel warned against relying too heavily on at-home blood-based biomarker tests or AI-based tools. Stillman suggested that gaps in care could widen if patients without support or literacy skills cannot access home-based testing: “I worry that with some of these new opportunities, those disparities are only going to escalate.”Christine Ritchie, MD, MPH, a professor of medicine at Harvard Medical School who directs the Dementia Care Collaborative at Mass General Brigham, raised concerns about the ramifications of at-home testing: “If that discovery occurs alone, without any context or community, I do worry that people will jump to conclusions that could be problematic for them, especially if they have a gun in the home.”

Munshi proposed a middle layer of assessment, in which PCPs can flag problems, but there is a midlevel assessment step between identification and full neurology referral. The panel also discussed the consistency of screening efforts done by different clinicians: “I just have a worry about the gap between providers. How good are we at really testing people?” asked Pamela Woo Williams, MSN, ANP-BC, ACHPN, a palliative care nurse practitioner in the Massachusetts General Hospital Home-Based Palliative Care Program.

Confronting Stigma and Fear

Panelists described how fear of cognitive decline discourages patients and clinicians alike from seeking or making a diagnosis. Many people don’t want to know if they have Alzheimer disease, said Vanny McLean, NP, an adult-gerontology nurse practitioner at Boston University. “That’s another dynamic that we have to think about from a community education perspective, that there are opportunities to actually live a good life with this chronic illness and to change the frame around it,” McLean said, “because for most people, that frame is not a positive frame.” Erkkinen agreed that at-home testing options might appeal to patients who want privacy until they’re ready to seek care.

Expanding Access to Disease-Modifying Therapies

The discussion shifted to treatment of Alzheimer disease, which is divided into symptom-relieving drugs and disease-modifying therapies. The 2 disease-modifying drugs now approved by the FDA, lecanemab (Leqembi) and donanemab (Kisunla), clear the amyloid tangles in the brain that characterize Alzheimer disease, leading to a 25% to 35% slowing in cognitive decline for those with mild dementia.^3,4 These antiamyloid drugs also require a rethinking of care delivery to ensure access.

Brigham has a triage process in place to focus on patients being considered for these therapies, Erkkinen said, and “the nurse practitioner team has really upped our access quite a bit” at Mass General, Dickerson added. However, capacity in limited infusion sites presents a problem considering the high demand, with Stillman reporting a 250-person waitlist at her center.

Equity-driven solutions are emerging. Ritchie described how she and colleagues “realized that we were not getting our more minoritized patients in fast enough to see dementia specialists,” so they created a telehealth program where a geriatrician at a community health center connects a patient with the main center at Brigham.

Infrastructure is also an important target for improvement. Erkkinen noted that whereas new imaging technology can be bought, “it just takes too long to grow a cognitive neurologist.” To address the infusion seat shortage, Ritchie proposed creative alternatives such as mobile infusion vans, similar to mobile cardiac catheterization labs, to bring care to patients.

The panelists agreed that the advent of disease-modifying therapies, increasing knowledge around early prevention of Alzheimer disease, growing capabilities of AI, and attention to both pharmacological and nonpharmacological prevention and treatment strategies together offer the potential to reach a larger population than ever before. “I think this is a very exciting time and there’s a lot of optimism that sometime in the future, Alzheimer disease will look very differently than it does now,” Erkkinen said.

Author Information: Ms Mattina is an employee of MJH Life Sciences^®, the parent company of the publisher of Population Health, Equity & Outcomes.

REFERENCES

1. 2024 Alzheimer’s disease facts and figures. Alzheimers Dement. 2024;20(5):3708-3821. doi:10.1002/alz.13809
2. American perspectives on early detection of Alzheimer’s disease in the era of treatment. Alzheimer’s Association. 2025. Accessed November 7, 2025. https://www.alz.org/getmedia/3d226bf2-0690-48d0-98ac-d790384f4ec2/alzheimers-facts-and-figures-special-report.pdf
3. van Dyck CH, Swanson CJ, Aisen P, et al. Lecanemab in early Alzheimer’s disease. N Engl J Med. 2023;388(1):9-21. doi:10.1056/NEJMoa2212948
4. Mintun MA, Lo AC, Duggan Evans C, et al. Donanemab in early Alzheimer’s disease. N Engl J Med. 2021;384(18):1691-1704. doi:10.1056/NEJMoa2100708