Why don’t we have earlier detection of Alzheimer’s disease in primary care? (Guest blog)

When people notice changes in memory or thinking, the first professionals that they consult are often general practitioners (GPs). Therefore, GPs play a pivotal role in assessing and addressing cognitive deficits and potential reasons for the perceived decline. Cognitive impairment may be caused by different conditions, and some of them are treatable, such as depression, side effects of medication, metabolic or nutritional conditions. Other times however, underlying neurodegenerative diseases such as Alzheimer’s disease (AD) are the cause for cognitive decline. The growing availability of biomarkers that target AD can help to increase the accuracy of the diagnosis and prognosis in patients who experience cognitive difficulties [1].

A timely diagnosis of AD at the stage of mild cognitive impairment (MCI) or very mild dementia is often considered beneficial for patients and their families [2,3]. Alzheimer’s organizations promote the value of timely diagnosis to provide adequate time for important decisions about the future, access to education and support as well as to pharmacological and non-pharmacological treatments [4,5]. Latest research has been focusing on early and pre-dementia stages of AD, which are considered promising timeframes for pharmacological and non-pharmacological prevention interventions. Unfortunately, diagnoses are often only made at a late stage of the disease and to this day, dementia remains underdiagnosed [5,6].

As our understanding of the disease has increased considerably, there is now a broad consensus in the scientific community on the need to address the disease at earlier stages. However, the challenges that exist with early diagnosis and treatment remain a barrier to patients and their caregivers receiving the best possible care today. With the increasing relevance of risk reduction strategies and in anticipation of upcoming therapeutic treatments, we need to better understand the obstacles to engagement for early diagnosis and treatment, and implement successful strategies to overcome them.

When we carried out the EU-IMI2 funded MOPEAD (Models of Patient Engagement for Alzheimer’s Disease) project, we worked together closely with GPs from five different European countries. The project aimed to improve detection of “hidden cases” of prodromal AD and mild AD dementia by comparing four different prescreening strategies in different settings [7]. One of those settings focused on primary care with pre-screenings being carried out at the doctors’ offices. When we approached local GPs to present the project and discuss cooperation, the topic of early diagnosis elicited different responses. Previous studies have shown that there are a number of barriers and reasons against early diagnosis, for example the fear of stigmatizing the patient, potentially impeding the physician-patient relationship and the lack of disease-modifying treatment [8–11]. This prompted us to take a closer look and assess GPs’ opinions toward early and pre-dementia diagnosis of AD in these European countries.  

We designed a questionnaire to inquire about general opinion on early AD diagnosis, barriers to early diagnosis, diagnostic procedures, resources and opinions on available and potential future treatment options. The questionnaire was distributed at each MOPEAD site through local GP networks and/or referrers. In total, our questionnaire reached 343 GPs: 97 in Spain, 27 in Sweden, 93 in Germany, 25 in Slovenia and 101 in the Netherlands. Detailed results can be found here [12].

The majority of GPs (74%) already considered an early diagnosis of AD at the stage of MCI or very mild dementia of value, with a larger proportion of GPs indicating that benefits outweigh the risk for relatives compared to patients. In addition, 80% of GPs thought that current pharmacological treatment options for very early dementia had no or low benefit. The proportion of GPs who saw no benefit in pharmacological treatment options was higher in those who did not see value in early diagnosis. The ones who thought that an early diagnosis was of value were more likely to indicate at least medium benefit of pharmacological treatment options. These results support the assumption that the availability of an effective treatment influences the perception of early diagnosis. Indeed, 59% of GPs indicated that they would change their implementation of early diagnosis if a drug was available that could slow down progression of AD.

With regard to non-pharmacological treatment options, 85% of GPs thought that they were beneficial, yet 68% indicated that they were not sufficiently available. A recent Lancet Commission report estimates that about 40% of dementia cases are associated with modifiable risk factors, highlighting the significance of preventive (lifestyle) interventions, especially in the absence of a disease-modifying treatment [13]. Many of the risk factors that have been identified are common responsibilities of GPs, such as management of hypertension, diabetes, obesity or guidance on physical activity and nutrition. In addition, once a disease-modifying treatment is available in Europe, timely diagnosis will be essential to deliver medication to those who need it.

As of now, healthcare systems seem ill-prepared for the growing need of early dementia diagnoses in the face of approaching treatments and prevention interventions in our aging society [5]. To address this challenge, it is important that GPs receive adequate resources to identify patients in early stages of AD and organize postdiagnostic measures. The MOPEAD project recognized GPs as essential for the shift to timely diagnosis and proposed to strengthen the education about prodromal and mild AD dementia, so that GPs would feel confident in diagnosing and caring for their patients.

For further information on the MOPEAD project, please visit our website: Alzheimer's Research Project | MOPEAD


Lena Sannemann

Lena Sannemann, M.Sc. Psychology, is a PhD student at the University of Cologne. In 2017, she joined Prof. Dr....
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