It’s a standout among “senior moment” jokes: A patient goes to the doctor and says, "Doc, I’m really worried. I keep forgetting where I put my keys." The doctor responds “That’s normal at your age. You only need to worry when you find your keys but can't remember what they’re for."
Patients have heard some version of that rejoinder forever. Many family physicians considered memory loss a normal consequence of aging. Doctors lacked the tools to diagnose--let alone treat--memory loss. Under those conditions, even if a patient might be on the path to debilitating dementia, laughter was the best medicine.
But those days are far behind us. My colleagues at the USC Schaeffer Institute and I have been studying the doleful impact of Alzheimer’s disease and other forms of dementia on society for decades, and have never seen a time that is more ripe to push for widespread early detection.
Almost quietly, we have made tremendous scientific progress in cognitive disease. Definitive blood tests are now available, early treatments show promise, and importantly, patients deserve to know what their future holds.
Ideally, all Medicare beneficiaries should be given a cognitive assessment test at each annual wellness visit. Medicare requires such a test, but fewer than one-third of those who have a wellness appointment report undergoing a formal cognitive screening.
If results from the assessment raise concerns, the patient should be a candidate for one of the blood tests approved by the U.S. Food and Drug Administration last year that can indicate the presence of amyloid plaques in the brain, a hallmark sign of Alzheimer's disease. The blood results might trigger further tests, including a neurological exam and a brain scan, that can lead to a diagnosis of Alzheimer’s.
Along the way, the anxious patient and family may receive reassuring news. Maybe the dementia-like symptoms stemmed from issues such as untreated sleep apnea, thyroid problems, or vitamin deficiencies. It also could be side effects from all the medications older patients take today.
At the same time, if the tests result in an early detection of Alzheimer’s, the patient today is in a far better position to chart a positive path forward.
FDA-approved medicines that help symptoms have now been joined by treatments that remove amyloid and have shown significant slowing of the disease. In some cases, treatments applied early enough have proven remarkably restorative.
Clinical trials involving 138 drugs are underway, many eager for participants. For too long, clinical trial recruitment has been a bottleneck to innovation. Medicare should offer modest reimbursement for referral to clinical trials to jump start discovery -- an investment that would likely pay substantial dividends.
Early knowledge provides power to act. For example, perhaps that hoped-for trip to Portugal could be taken sooner rather than later.
Early detection is also the key to reducing the staggering burden of dementia in the U.S. The Schaeffer Center estimates the total cost of dementia to society is around $800 billion, including diminished quality of life for patients and caregivers in addition to medical and informal care. Delaying the onset of Alzheimer’s by five years add about 2.7 years of life for patients. By 2050, a five-year delay in onset results in a 41% lower prevalence of the disease and lowers the overall costs to society by 40%.
Unfortunately, barriers are strewn in the way of early detection. Physicians are not paid well enough--and may not be well enough equipped--to administer cognitive assessments. Medicare does not enforce the requirement for detecting cognitive impairment at annual wellness visits in part because of long held beliefs that diagnosis without a cure is not worthwhile. And patients themselves can be reluctant to seek a diagnosis for a variety of reasons, including stigma, fear, and denial.
Solutions begin with the assessment itself. It should be standardized and brief to alleviate burdens on primary care doctors, and receive a new medical code to ensure adequate reimbursement. Medicare leaders need to recognize the enormous benefit that comes from simply delaying the onset of Alzheimer’s rather than holding out for the gold standard of a cure. Meanwhile, there is a role for public health and thought leaders to normalize conversations about memory health and emphasize that Alzheimer’s is a disease and not a personal failure.
Cardiovascular issues and cancer long ago got doctors’ attention, leading to urgent searches for diagnoses. Screening is now routine and recommended. Memory issues are more than just lost keys, and we need to find a better way.
Dana Goldman is Founding Director of the USC Schaeffer Institute for Public Policy & Government Service.
