The approval of Leqembi by the Food and Drug Administration marks an exciting turning point for Alzheimer’s disease. For the first time, we have a medication that can change the course of an illness that affects one in every third American 85 years of age and older. While not a cure, Leqembi has been shown to slow early-stage disease progression by up to 27%.
There are big questions around costs, access, risk and efficacy in certain populations (e.g., women, Black, Hispanic, etc.). However, the most urgent, overarching question is: How can we find patients who will benefit from the drug before their condition progresses outside of the treatment window?
Alzheimer’s care today
The Alzheimer’s Association reports 6.7 million patients in the U.S. are diagnosed with Alzheimer’s. The true number, however, is much higher as many individuals with early indicators will not receive a timely diagnosis, and 12% to 18% of adults 60+ are living with mild cognitive impairment (MCI). Everyone who develops dementia due to Alzheimer’s first experiences MCI, even if that early stage is unrecognized. Progression from MCI to dementia can be delayed, and even prevented, with early diagnosis and intervention. That is also the stage when Leqembi is likely to be most effective.
I see several new dementia patients every week. When most patients finally arrive in my (or another specialist’s) office, their condition has gone on for 10 to 20 years and it’s often too late for drugs or lifestyle interventions to make an impact. While none of those patients will benefit from this new drug, there is still hope for those yet to be diagnosed—but only with early screening and detection.
Screening is key
It is more challenging to reverse cognitive function loss than it is to protect remaining function and slow disease progression, which is why better screening is needed to accelerate detection and treatment. Current methods, which rely on specialists for diagnosis, are often conducted with blunt tests not sensitive enough to catch early signs and usually when symptoms are already present. Today, dementia care is reactive. We wait for the patient or their family to raise a concern to their PCP and then get a referral, wait months to see an overbooked neurologist or specialist, and then get a diagnosis or treatment recommendation. These inefficient practices, which can take months or even years, are one reason that up to 2,000 people progress outside of the treatment window per day.
According to a recent patient survey of adults 65+, only 23% had been tested for dementia and only 12% regularly discuss cognitive health with their PCPs. Why is routine screening not commonplace or standardized? One factor is a lack of awareness in healthcare and the general public that treatments and lifestyle interventions can make a difference. In fact, that same survey found 25% of respondents believed dementia is genetic and there’s nothing anyone can do about it, and less than half were aware that factors like alcohol consumption, sleep, and social connection impact cognitive health.
Leqembi must catalyze change
Leqembi is only approved to target early-stage disease, so catching early disease indicators is essential for empowering individuals to make the best decisions. The next wave of drugs behind Leqembi, like donanemab, share similarly promising results of targeting early-stage decline, so early screening will continue to be valuable. Early diagnosis also enables lifestyle modifications, such as sleep, diet, and socialization, which can prevent disease progression by 40%-plus (even more significantly than Leqembi) and help the many people ineligible for the drug.
To capitalize on this moment, we must look to primary care and the U.S. Preventive Services Task Force to drive change home. Primary care is the critical juncture in the care pathway to add proactive screening practices. With greater education and awareness around catching early-stage Alzheimer’s, and with the right tools and processes, primary care providers could spot early signs and even diagnose the disease. The Task Force can also shift cognitive care from reactive to proactive by recommending annual screenings starting at age 55. Cognitive screenings could become as routine as annual colon cancer screenings or mammograms, or even as getting a blood pressure reading at every visit.
Moving forward
Dementia is not a disease of old age but one that starts in middle age, even if it does not manifest until later. If we equip primary care with sensitive, efficient, and reliable assessments and make check-ups for the brain routine, we will help people in their 30s, 40s, and 50s who aren’t yet thinking about their Alzheimer’s risk but—if they show early warning signs that healthcare is equipped to catch—will at least have a chance to beat the disease.
Alvaro Pascual-Leone, M.D., Ph.D., is a Professor of Neurology at Harvard Medical School, Senior Scientist at the Hinda and Arthur Marcus Institute for Aging Research, Medical Director of the Deanna and Sidney Wolk Center for Memory Health at Hebrew SeniorLife, and co-founder and Chief Medical Officer of Linus Health.