Panelists discuss how to craft future policies for early biomarker detection to use developing therapies that target underlying pathophysiology.
Neil Minkoff, MD: We have touched at length on hypertension as a proxy and knowing what managing comorbidities does for overall health, vascular health, and brain health. To go along with access, I’m going to pick on Dr Cantor here for a secondly, it sounds like we would need cogent policies about lumbar punctures, biomarkers, functional MRI scans, and so on. You are one of those unlucky people who got to do it from both sides. What would you say would be a way to start approaching that? I do not think that we are going to answer it, but what would be a way to approach it?
Michael Cantor, MD: I would say there are 3 things that are important. No. 1, measure the functional status of the person. It is my job as a geriatrician in every discussion I participate in to mention functional status at some point in that conversation. I am saying it because it matters. You can get MRIs that look terrible in terms of plaques and tangles, but the person is functionally fine. You can also get MRIs that look fine, but people are seriously cognitively impaired. My guess is that this will continue for a while. When you look at the biomarkers and other things, there will always be false positives, negatives, and the rest of it.
Even functional status is imperfect: we have good days and bad days, we all know that. Let’s begin with understanding that person’s reality. What can they do? What can they not do? What are their deficits? What are their strengths? Let’s play to the strengths, and let’s minimize the deficits. Begin with functional testing. If there is 1 thing that I would follow, that is what I would follow: cognitive function. The test that Richard mentioned in terms of being able to use computer-based testing would mean you could do it inexpensively and at scale. Unlike neuropsychological testing, which is expensive, hard to find, and difficult to get in certain parts of the country, I would start focusing on function, which tends to be less expensive than the higher tech metrics.
The second thing I would say is this: let’s think about bringing it closer to home. Instead of having to go see the doctor for all of this, let’s continue to use telehealth when possible. Let’s use computer-based diagnostics. Let’s do everything we can to make it more accessible because you are right, Neil: it is all about access. Let’s make it more accessible by bringing the care to the patient instead of bringing the patient to the care. Let’s make this something that, for patients, their caregivers, and their communities, we bring it home for them. Let’s focus on figuring out what the role of drug therapy is, not just in modifying certain biomarkers, but making people’s functional status better and making their families’ lives better. Let’s measure that as well.
The final thing I would say is that we are going to use technologies that are just now in their infancy to help with some of this. We see, for example, that there are dementia therapies in Japan and here in the US [United States] as well. We have robotic pets that people can buy to keep people with cognitive impairment company. It makes them less depressed, and it reduces their behavioral symptoms. We are going to see a lot more growth of those kinds of devices, and we are going to have better communication devices in the future.
The advent of the Internet of Things in the home will make it possible for us to measure functional status in a completely different way than how we manage it today, not just on a paper and pencil test or a computerized test. “How much walking around am I doing? Am I falling down? Am I leaving the refrigerator door open? Am I leaving the water running?” All of that can be measured today using sensors. We do not pay for it. We do not invest in it. As those sensors get cheaper and as the value of supporting people in the community, especially as the number of people in the community who have this issue grows and grows, we are going to see more technology.
Thinking about measuring function, bringing care to the home, and using technology to make it less expensive to scale that, if we do that, then payers will begin to look at not just the diagnostic tests or the medications that are important to making a difference. They will start understanding, getting at this bigger picture of how we do this at scale and create better access and greater outcomes measurement because it is more ubiquitous.
Transcript edited for clarity.