Alzheimer Disease Referral Pathways Strain Under Push for Early Detection

Earlier detection of Alzheimer disease is outpacing the specialty capacity needed to act on it, and blood tests, online screening, and new therapies may widen gaps for patients who rarely engage with the health system. Those were central concerns raised by clinicians and researchers at The American Journal of Managed Care^®’s Population Health Roundtable in Cleveland, Ohio.

The faculty, drawn from Cleveland Clinic, University Hospitals, Case Western Reserve University, and the Louis Stokes Cleveland Veterans Affairs (VA) Medical Center, described what their organizations are doing to move patients from first concern to diagnosis and care and where those efforts still fall short.

Why Specialty Access Is the Real Bottleneck

Panelists agreed that new disease-modifying therapies have raised the urgency of catching mild cognitive impairment early, but several said identifying patients is no longer the hardest step.

“The roadblock is not diagnosing people,” Martha Sajatovic, MD, of Case Western Reserve University School of Medicine, said. “It's getting them into specialty care."

Rajeet Shrestha, MD, of University Hospitals Cleveland Medical Center, said the wait for his regular cognitive clinic had grown from about 4 months to about 6 months as he carved out time for patients who may be candidates for anti-amyloid monoclonal antibodies. Patients who already present at later stages now wait even longer, he noted.

How Cleveland Systems Are Building Referral Pathways

Several organizations are building structured pathways so the right patients reach the right clinician first. Kaitlin Seibert, MD, of Cleveland Clinic, said her team is developing a screening protocol with general neurology, primary care, and geriatrics and creating education for clinicians who are not yet comfortable ordering and interpreting biomarkers. Within the clinic’s Center for Brain Health, clinicians use the Montreal Cognitive Assessment (MoCA) as a screener, although Seibert said practice remains variable. Many add p-tau217 blood tests or amyloid PET, turning to spinal fluid analysis mainly when insurance is a barrier, and use brain MRI to check for microhemorrhages before anti-amyloid therapy.

At University Hospitals, Shrestha said his team is designing a screening tool for primary care, general neurology, and psychiatry that flags not only cognitive concerns but also whether a patient is likely to be an appropriate candidate for monoclonal antibody treatment, so others can be routed to a geriatrician or general neurologist instead.

"The challenge is going to be, how do we get these very disparate systems to adopt a uniform workflow?" Shrestha said, noting that time pressure in primary care is the biggest obstacle.

The VA takes a different approach. Rather than screening every patient, it uses a dementia warning sign instrument: when a patient, caregiver, or clinician notes a warning sign, it triggers a cascade of cognitive assessment, panelists explained.

Philipp Dines, MD, PhD, of University Hospitals Cleveland Medical Center, said history from family and the patient’s support system remains essential, with any significant functional change, such as new trouble managing finances or making household repairs, serving as a trigger for further workup.

Where Biomarkers and Neuropsychological Testing Fit

Faculty cautioned against letting blood tests replace clinical judgment. One academic researcher noted that assay results can shift with time of day, whether a patient has eaten, and genetic ancestry. "On an individual basis, it's really hard to use those, which is why we're still looking at trying to improve those things," the researcher said.

Sajatovic warned that jumping straight to biomarkers can miss reversible causes such as depression or drug interactions, recalling a patient whose cognitive symptoms resolved after a benzodiazepine was deprescribed.

Seibert argued that neuropsychological testing is more important than ever. Noting that there are only about 500 behavioral neurologists nationwide, she explained that primary care and general neurology will need tools beyond biomarkers if they are to take on more of the diagnostic work.

How Trusted Messengers Can Reach Underserved Patients

Panelists said structural barriers, more than awareness, drive diagnostic disparities. Many Cleveland residents lack home internet or a data plan, which limits online cognitive testing, panelists noted.

Ann Nguyen, PhD, MSW, MS, of Case Western Reserve University, said many people from marginalized or socially isolated communities rarely engage with the health care system at all, so testing must be made more equitable before it is expanded. She added that some wearable devices store data locally for researchers to collect in person, removing the need for home internet or a data plan, and are less invasive than blood draws.

Outreach works best when it runs through community leaders. Sajatovic described an outreach event at a Hispanic church in Lorain, Ohio, where parish leaders, not clinicians, led the program and served a meal so the event did not feel purely transactional. Attendees wanted to know what practical help clinicians offered, such as a physician stepping in when an older family member should stop driving.

"If clergy endorse someone, something, an organization, a treatment, whatever it may be, congregants are more likely to be open to that," Nguyen said. She also pointed to evidence that race-concordant physician-patient pairs are linked with greater trust and adherence, tying disparities to the neurology workforce pipeline.

What Faculty Say a Better System Needs

Asked for their main takeaways, faculty pointed to models that span the full course of the disease rather than a single diagnostic moment.

"I think we should try and use models for other diseases that are successful rather than starting from square one," Sajatovic said, citing Medicare-covered diabetes education and SilverSneakers as examples.

Dines emphasized efficient diagnosis that minimizes unnecessary tests while addressing depression, psychosis, and behavioral symptoms alongside cognition. "So you have to treat the whole patient, all aspects of the problem, and you have to do that in an efficient way," he said.

Shrestha suggested treating dementia as end-organ damage from many diseases and lifestyle factors, approached with the same prevention mindset used for cardiac disease. Nguyen called for an interdisciplinary model that accounts for life-course risk, including education and housing.

Seibert said payment remains the underlying barrier, explaining that without reimbursement models to support multidisciplinary and translational care, access will be a persistent issue.