Alzheimer's disease care has entered a new phase. For the first time, therapies are available that target the underlying biology of the disease and can slow its progression. However, these therapies are stage-dependent, and their effectiveness relies heavily on timing.
The central challenge is no longer whether treatment exists, but whether patients are identified early enough to benefit. Primary care plays the most important role in solving this problem.
The Core Principle: This Is a Timing Problem
Alzheimer's disease begins years before symptoms become obvious. By the time patients present with clear functional impairment, much of the underlying biology is already established. This means:
Waiting for diagnostic certainty often means waiting too long.
The goal in primary care is not to definitively diagnose Alzheimer's disease. The goal is to recognize early change and initiate the referral pathway.
Who Should Raise Concern
Patients appropriate for early evaluation typically share a common pattern:
- New or progressive cognitive concerns
- Family or caregiver noticing change
- Subtle decline in memory, language, or executive function
- Maintained independence, but with increasing inefficiency or reliance on support
- Mild Cognitive Impairment (MCI) or early-stage dementia
- Elevated risk (e.g., strong family history)
A useful clinical heuristic:
If a patient is still living independently but is clearly declining, this is the window.
What Primary Care Should Do
The role of primary care is intentionally simple and focused. It can be summarized in four steps:
1. Recognize Concern
Trust patient and family reports. Early symptoms are often subtle and may not be fully captured on initial testing.
2. Perform Brief Cognitive Screening
- MoCA or equivalent tool
- Focus on establishing a baseline and identifying deviation from prior function
This does not need to be exhaustive—it is a screen, not a diagnosis.
3. Consider Blood-Based Biomarkers (Optional but Helpful)
- Plasma p-tau181 or p-tau217
These can:
- Increase diagnostic confidence
- Help triage patients more efficiently
- Accelerate downstream evaluation
Importantly:
Testing is helpful—but not required to refer.
4. Refer Early
Referral should be based on concern, not certainty.
If you are thinking about referring, you are likely correct.
Do not wait for:
- Clear dementia
- Functional dependence
- Advanced imaging findings
What Our Program Handles
Once referred, our program assumes responsibility for the full diagnostic and treatment pathway:
- Comprehensive neurocognitive evaluation
- Biomarker confirmation (PET, CSF, or other modalities as appropriate)
- Risk stratification, including ARIA and cerebrovascular considerations
- Determination of treatment eligibility
- Therapy initiation, infusion, and structured monitoring
- Longitudinal care coordination
Primary care does not need to manage these components—we function as an extension of your care team.
What You Do Not Need to Do
To reduce hesitation, it is equally important to clarify what is not required prior to referral:
- You do not need to establish a definitive Alzheimer's diagnosis
- You do not need advanced imaging
- You do not need to determine treatment eligibility
- You do not need to manage therapy
Your role is to recognize early change and initiate the process.
Why This Matters
The effectiveness of anti-amyloid therapies is greatest in patients with:
- Early-stage disease
- Lower tau burden
- Preserved functional independence
Delays in referral reduce the likelihood that patients will qualify or benefit.