How to Adequately Screen for and Treat Cognitive Decline in Primary Care

Alzheimer disease has historically been a daunting modality of care for clinicians. As its prevalence climbs in an aging population, few direct-targeting therapies beyond last year’s lecanemab have been able to afford patients more than a prolonged suppression of debilitating cognition. Screening additionally remains a difficulty, as physician and caregiver shortages potentially cap how adequately a patient can be diagnosed early into the disease course and facilitated to necessary care.

That said, the current limitations in Alzheimer’s screening and initial care are at least well-understood—and on their way to being better addressed in the coming years.

In the second segment of an interview with HCPLive during the American Academy of Physician Associates (AAPA) 2024 Conference & Expo in Houston, TX, this week, James R. Kilgore, DMSc, PhD, PA-C, associate professor of PA Medicine at the University of Lynchburg, discussed the efforts in place to streamline cognitive decline screening to initiated care, as well as the development of treatment strategies for Alzheimer disease and dementia.

Beginning with screening, Kilgore noted that primary care and neurology workforces alike face caregiver shortages today; it’s necessary primary care providers find time-efficient resources that reliably identify cognitive decline risk that which can be referred to neurologists with fuller clinical context. One such toolkit, developed by the AAPA in conjunction with the Davos Alzheimer's Collaborative, could adequately compensate for primary care’s limited training in cognitive decline testing.

“And the toolkit that AAPA is providing to these providers actually gives you sheets that you can walk through: here's the questions you need to ask, here's the test you need to do,” Kilgore said. “So, if we do reach out to neurology, we say, 'Here's what I've got, here's where the patient is, here's my findings,' then they can help direct as a team in a collaborative effort: 'What do we need to do with this patient?' I think working collaboratively with the neurologists are very important, but they need information from us.”

In the meanwhile, the drug landscape is “changing dramatically,” Kilgore noted; while there’s reasonable hope that breakthroughs with targeted drugs like lecanemab may lead to cognitive decline-reversing therapy options, there are already proven treatments to address cardiovascular and metabolic disease—a pair of comorbidities that commonly exacerbate cognitive decline in aging patients.

“We're getting there,” Kilgore said. “Most of our drugs available to us will stabilize a patient. That's why we want to catch them early and do the screening early, so that we can intervene early and hopefully stabilize them, so they don't get any worse over the next decade or 2 of their lives.”

Other key intervention strategies include addressing patient lifestyle and behaviors in a timely fashion: promoting healthy eating and exercise habits. Kilgore also stressed involvement from family members who may be tasked with aiding patients with cognitive decline: valuing their input on the condition’s progression, getting feedback on the patient’s response to care. Of course, these intervention strategies can only be optimized if efforts are made to address the fact that approximately three-fourths of patients are not diagnosed with cognitive decline until the later stages of the condition.

“It's all of a package of making sure the patient's healthy, they’re giving good information, the family’s stable, and we make sure there's no other problems that are ongoing,” Kilgore said. “But does the future look better? Absolutely. I think we've got a bright future. But screening has to be a portion of this.”

References

1. ^{Meglio M. FDA Grants Traditional Approval to Lecanemab as Therapy for Early-Stage Alzheimer Disease. NeurologyLive. Published July 6, 2023. https://www.neurologylive.com/view/fda-grants-traditional-approval-lecanemab-as-therapy-for-early-stage-alzheimer-disease}
2. ^{Davos Alzheimer’s Collaborative. The Davos Alzheimer’s Collaborative Healthcare System Preparedness (DAC-SP) Early Detection Blueprint. Web page. Accessed May 20, 2024. https://www.dacblueprint.org/}