Howard Fillit, MD: Physician Burden in Treating Patients with Alzheimer's Disease

Howard Fillit, MD, the founding executive director and chief scientific officer at the Alzheimer's Drug Discovery Foundation, sat down with MD Magazine to discuss the burden faced by physicians that treat patients with Alzheimer's Disease (AD).

As many patients—and their caretakers—require hours of care, education, and testing, there is a burden placed on physicians who provide those services, both in their ability to give so much care in limited time and in their reimbursement for it due to complications with the health care system.

Fillit has been working with patients with AD for almost 40 years, and with the Alzheimer's Drug Discovery Foundation, he helps fund clinical trials for much-needed therapies for the debilitating condition—as many trials fail before they start due to a lack of funding.

Howard Fillit, MD, founding executive director and chief scientific officer of the Alzheimer's Drug Discovery Foundation:

When you're treating a person with Alzheimer's, you're also treating their caregiver. There is always a diad of the caregiver—the spouse, the daughter, the son, a home aide—there is almost always a caregiver [because] it is very hard for a person with Alzheimer's to live alone and not have any services.

There is no magic bullet. We can write prescriptions like we can for hypertension, but we do not have an easy biomarker like cholesterol or hemoglobin A1c. [We cannot say] "Oh your hemoglobin A1c is 7.2, I'm going to give you this drug, come back and see me in a month. OK, now it is 6.8, everything is wonderful." We are measuring cognition as the primary outcome and function, and it is hard—there is no number. So it takes an interview or a mini-mental exam or some kind of gestalt about how a patient is doing.

They need education and counseling. That takes a long time. There are reimbursement problems for payment for a physician to spend an hour with a patient, and literally end up after taxes and overhead and rent, to come home with $30 to $40 because all these people have Medicare. So there are a lot of disincentives for doctors to spend time with education and counseling and arranging services and long-term care. When really, as a geriatrician, for example, if that is all I did, I would not be able to pay the rent.

I really think that the problem is sort of structural. I hope that with the way that medicine is changing that maybe the financial incentives can change so that doctors can take better care of Alzheimer's patients. But right now, I get patients referred to me who are seeing neurologists and primary care doctors at some of the major academic medical centers—they are just not getting care.

I like to quote Hippocrates, and he said: "the role of the physician is sometimes to treat, and often to relieve pain, but always to comfort." These patients are suffering. Most of them are not having a good time. It is a long day. Caregivers need, really, a lot of education and counseling on how to deal with the thing because these are people—caregivers are often 75, 80 years old taking care of someone who is totally dependent or keeps asking them 5 times every minute, "where are we going later?" and that drives you crazy.

The challenges are enormous. I think for physicians, this is a very, very difficult illness and we have not figured out the right paradigm for care at this point.