How Do We Make Alzheimer’s Diagnosis and Treatment More Equitable?

A series of new drugs that show progress in slowing down early-stage Alzheimer’s symptoms have emerged on the market. One such medication, Lecanemab — approved by the FDA in 2023 — is an infusion therapy that targets amyloid plaques in the brain, which are one of the classic pathological findings of Alzheimer’s disease. Though this new therapy brought a lot of much-needed hope for patients living with the neurodegenerative disorder and their loved ones, there are still debates and unanswered questions, including how to ensure that the medications are equitably accessed by eligible patients.

One of the points of tension in an equitable rollout is that Lecanemab slows progression of Alzheimer’s disease, but it does not reverse any symptoms that have already developed, so it’s best used for people with early-stage disease. Black patients are at higher risk for Alzheimer’s disease and often diagnosed later — at which time their symptoms may be too severe to qualify for treatment.

Another challenge is helping all patients and their caregivers understand that this drug will only slow down symptoms — it will not cure disease — and then help them weigh the choice to use this medication against the potential risks. It’s a conversation that can be difficult, and even more complex for patients with lower levels of education, health literacy, and language barriers.

Boston Medical Center’s Geriatrics and Neurology departments are thinking critically about how to equitably and inclusively roll out this new Alzheimer’s treatment plan at BMC, New England’s largest safety-net hospital. We spoke with Hollis Day, MD, MS, MHPE, BMC’s Chief of Geriatrics and BMC neurologists Steve Lenio, MD, and Sanford Auerbach, MD, to hear more about making this drug accessible to BMC’s patient population — including moving upstream to ensure patients are diagnosed accurately at earlier stages in their disease progression.

HealthCity: With this new drug on the market, how is BMC thinking about an equitable rollout?

Hollis Day, MD, MS, MHPE:  First, we must determine if a patient is at the stage of their cognition where we know that these drugs work. It’s important to remember that every treatment has the potential for side effects — and with these new treatments, there is potential for some very serious side effects — so that’s something we’re not taking lightly.

The equity piece of this is that we are planning to have something that’s akin to a tumor board, which is where a group of experts review each case to determine — regardless of what your background is — are you appropriate for this treatment and are you going to be able to meet all the requirements? No one who fits the criteria should be afraid that they’re not going to get the treatment based on economic status or any other characteristic other than the criteria needed to take the medication.

Steven Lenio, MD: One of the reasons I wanted to work at BMC is because of our patient population, and I want to make sure that any new Alzheimer’s treatments are available to anyone that could benefit. The team at BMC is cognizant of issues related to cost and access and is working really hard to try to overcome these barriers.

Alzheimer’s disease is complicated and the benefits and risks of Lecanemab are not straightforward. A lot of our energy is going to be directed at making sure we can effectively communicate with our patients and their caregivers. We will make sure that any patient educational information about Lecanemab that we provide in the clinic  is available in multiple languages and can be easily understood regardless of health literacy. And we’re going to slow down and have really frank conversations with patients and their families about what this drug can and can’t do. It’s a new drug that showed promise in slowing down disease progression. It’s not a cure and it carries risks, and we want to be really mindful about communicating that.

Sanford Auerbach, MD: As Hollis [Day] and Steve [Lenio] mentioned, there are a lot of tests associated with prepping a patient for this drug. A lot of our prep work is ensuring we have systems in place here to make these tests accessible and to diagnose patients sooner. It can be challenging to diagnose any patient with dementia, especially when age is a factor. We often associate memory loss with aging, but we need to work on decoupling these things. Some memory loss is normal, but we need to work on some of those interventions that help catch Alzheimer’s early — like more robust screening and bringing in Neurology and Geriatrics earlier.

But for the patients who we are catching, it’s really heartening that we can now offer them something. We’re offering it just like any of the other institutions are to their patient populations. I think that it’s important, especially given all the challenges our patients face.

HC: What are the benefits and challenges to rolling out this Alzheimer’s medication equitably at an essential hospital like Boston Medical Center?

SA: We want to make sure that we’re taking care of the patients that have a lot of social needs. For example, what happens if a patient lives alone or doesn’t have a caregiver — like so many of our patients? We’re thinking through carefully how to address those issues in collaboration with the Alzheimer’s Association, which has been very helpful in terms of strategizing and connecting us with resources to help address some of these issues.

We are excited to be able to offer this to our patients. And even more importantly, we’re setting up the platform because everybody is confident that there’ll be other kinds of medications in that same class that will have more benefit and fewer side effects.

HD: When we think about the patients who seek care from an essential hospital, often these are patients who have many illnesses or many comorbidities because of a lifelong lack of access to healthcare or a lack of access to education. Where you live, the access to food that you have, the kind of childhood that you had impacts you now at the age of 80. One of the things that BMC is working toward is diagnosing our patients earlier.

This diagnosis is often in the primary care setting, which provides challenges: patients come with many other comorbidities, and they have very short visits. But we’re working on integrating [dementia screening] into primary care more easily so that it can be done efficiently. Across our system, we’re rolling out Medicare annual wellness visits in primary care, a requirement of which is cognitive testing. We are working to truly use a patient’s entire healthcare team to help diagnose cognitive impairment.

SL: We need to start evaluating and diagnosing our patients earlier in their course of Alzheimer’s disease. We know that many within our patient population that struggle with access to healthcare — especially our Black patients, do not receive dementia diagnoses until later in the course of the disease when symptoms are more severe.  And at that point, they may no longer qualify for this medication. While in the past the management may not have been that different between patients that were diagnosed earlier or later in the course of their disease, the approval of Lecanemab has really emphasized the importance of earlier diagnosis.

The time spent thinking about how we’re going to implement Lecanemab here will ultimately lay the groundwork for any new therapies on the horizon. It will also help position us to advocate for our patient population to be included in future research and hopefully limit health inequity surrounding future therapies for Alzheimer’s disease.

We need to make sure that everybody has a voice when it comes to developing, testing, and implementing future treatments, and we’re working hard to ensure that our patients have access to the latest advances in dementia care.

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This story is also running concurrently on the platform Doximity.