While there is still no cure for AD, doctors are finding promise in tailored treatment approaches that take into account a patient’s genetics, biomarkers, environmental factors, lifestyle habits and psychosocial support.^1-3 “Precision medicine recognizes the complexity of AD and allows us to understand how each individual may react to a particular treatment,” says Kostas G. Lyketsos, MD, director of the Johns Hopkins Memory and Alzheimer's Treatment Center and founding director of the Richman Family Precision Medicine Center of Excellence in Alzheimer’s Disease in Baltimore. “Only by fully understanding the different subgroups of patients, such as those who have mostly language problems or those with behavioral problems, can we optimize treatments.”

There's a false assumption that AD is a single disease, an idea that persists even though it has been well documented by clinical, imaging, neuropathological and genetic studies that AD is a heterogeneous disease,⁴ according to the Precision Medicine for Alzheimer Disease and Related Disorders Affinity Research Collaborative (ARC) at Boston University. ARC uses the latest data on why individuals respond differently to therapies to guide clinicians toward more targeted and predictive treatments.⁴ “We are increasingly recognizing the heterogeneity of AD, and no two individuals with AD are the same,” says Daniel J. Lee, MD, a neuropsychiatrist at OhioHealth Neuroscience in Columbus. “Symptoms, cerebral localization of pathological burden, genes, behavior and environmental factors vary across a wide spectrum and interact in ways we don’t yet fully understand.”

To incorporate precision medicine into your treatment of patients with AD, consider the following strategies:

Assess a patient’s cognitive profile with neuropsychological testing

For most patients, an AD diagnosis typically begins with neuropsychological testing, which relies on cognitive assessment tools such as the Montreal Cognitive Assessment (MoCA) to evaluate their mental function.² The 30-question MoCA assesses a range of cognitive abilities, including orientation, short-term memory, executive function, language, abstraction, attention, naming and spatial relations. A MoCA score between 18 and 25 typically suggests mild cognitive impairment (MCI), with lower scores indicating more severe impairment.⁵

Other components of a thorough neuropsychological assessment include testing visual, auditory, verbal, memory, language, executive function and other skills to uncover specific areas where a patient needs help, and serve as a baseline for understanding the patient’s current functional state.^2,3

“Understanding a patient’s cognitive profile helps us start to personalize their treatments,” explains Dr. Lyketsos. “For example, if tests reveal that a patient’s primary problem is language instead of delayed recall, then we can tailor their therapies by focusing on speech-language pathology.” 

Look for early signs of AD with neuroimaging

Magnetic resonance imaging (MRI) provides a detailed visualization of brain anatomy, which is critical for detecting the early subtle changes associated with AD and other neurodegenerative conditions that mimic some of the symptoms of AD, such as Parkinson’s disease. Dr. Lee says an MRI is critical in establishing a neurodegenerative diagnosis by providing evidence for an AD diagnosis and eliminating  other potential causes of disease. “Structural lesions, such as strokes or tumors, might suggest a non-neurodegenerative cause of disease,” he says.

Other imaging tests might include fluorodeoxyglucose positron-emission tomography (FDG-PET) to measure the brain’s energy usage by looking at the concentration of glucose in the brain, and an amyloid PET scan to measure the accumulation of abnormal amyloid proteins.² “Metabolic imaging, such as FDG-PET, can disclose regional hypometabolism or a decrease in brain glucose consumption, which is common in neurodegenerative diseases,” says Dr. Lee. “Amyloid PET scanning quantifies the degree of amyloid-beta burden in the brain, suggesting underlying AD.”

Test for the presence of AD biomarkers

Currently, AD biomarkers—molecules that can indicate the presence of disease—are analyzed via a cerebrospinal fluid test and amyloid PET scan, according to experts. Specifically, doctors look for beta-amyloid and tau biomarkers, protein fragments that accumulate in the brain and are visible during tests.⁶

“Biomarkers are fundamental for precision medicine in AD,” says Dr. Lee. “They are critical in establishing a neuropathologic diagnosis, particularly in the earlier stages of the illness.” He notes that emerging plasma markers have shown promise in a research context, but are not yet widely used in the clinical setting.

Biomarkers also have the potential to play a bigger role in individualizing treatment in the future, according to experts. “As science advances, we may identify more biomarkers that will allow us to personalize treatments,” Dr. Lyketsos says. “For example, we can already use an amyloid PET scan and cerebrospinal fluid test to identify patients who have elevated beta-amyloids and who would benefit from taking an anti-amyloid antibody intravenous infusion therapy. In the future, we may be able to link more biomarkers to specific treatments.”

Target treatment with genetic testing

Drs. Lee and Lyketsos say the role of genetic testing for AD remains limited, but that progress continues. Having a family history of AD increases the risk of inheriting the disease, but researchers have identified only three genes (APP, PSEN1, PSEN2) linked to AD, which account for less than 1% of cases.^7,8 “Familial AD is quite rare,” says Dr. Lee, “so testing for these genes is reserved for individuals with very early onset disease and who have an exceptionally conspicuous family history.”

Drs. Lee and Lyketsos both note, however, that genetic testing can predict a patient’s potential response to specific AD therapies. For example, patients who have the APOE-e4 gene have a higher risk of developing amyloid-related imaging abnormalities (ARIA) when treated with anti-amyloid therapy, which is believed to be caused by neuroinflammation or vascular rupture associated with plaque removal.^9,10 ARIA usually is asymptomatic, but in some, it can cause headaches, worsening confusion, dizziness, visual disturbances, nausea and seizures.¹¹ It is most commonly associated with edema (ARIA-E) or hemorrhage (ARIA-H), and either subtype has been reported in about 40% of patients receiving these agents based on imaging tests, with about one-quarter of patients reporting symptoms.^11,12

“With the recent emergence of FDA-approved anti-amyloid therapies, there is a growing role for APOE genotyping to determine an individual’s risk for developing side effects to anti-amyloid drugs,” says Dr. Lee. Experts agree that genetic testing for the APOE-e4 gene is strongly recommended before administering an amyloid-targeting antibody.

Slow progression with anti-amyloid therapies

Research has shed light on the role of the amyloid-beta cascade in creating neuron-damaging tau tangles that spur AD progression. These findings have sparked the development of biological treatments, most notably lecanemab. Currently the only FDA-approved anti-amyloid therapy, it destroys amyloid-beta and slows disease progression in patients with early-stage AD with known amyloid-beta pathology.^1-3,13 “Lecanemab is good at removing amyloids, and it may delay disease progression, but it’s not a cure,” says Dr. Lyketsos. “Patients and families should be made aware of its benefits and risks.”

In addition to anti-amyloid therapies, there are two other classes of FDA-approved medications: cholinesterase inhibitors and glutamate regulators. However, these drugs can only treat the symptoms of the disease.⁶ “Both classes are considered to be symptomatic as they have modest, time-limited effects on cognition and function,” says Dr. Lee.

While none of the current therapies can reverse AD, tailoring available treatments based on the individual patient’s medical history and needs can produce better outcomes. “We know patients with a lot of amyloids in the brain typically also have chronically elevated blood pressure,” says Dr. Lyketsos. “We can personalize treatment by aggressively monitoring and managing each patient’s blood pressure and customizing their treatment accordingly.”

Help delay cognitive decline with lifestyle modifications

Multiple lifestyle factors, such as diet, sleep, exercise and stress, may contribute to or delay disease progression.³ Research also shows that simple lifestyle modifications can help slow the progression of cognitive decline, especially in the early stages.¹⁴ “There is good evidence that certain foods, like those in the Mediterranean diet, can modulate the rate of progression in AD,” says Dr. Lee. “There’s also a strong body of evidence that physical activity, sleep and stress or mood management can each have a tremendous impact in reducing risk and decelerating the rate of progression in AD.” 

Dr. Lyketsos adds:  “I recommend implementing lifestyle changes slowly and focusing on things patients will like, such as adding healthy foods they enjoy or getting them moving by dancing or other exercises that are easy for them. We have to prioritize behavioral changes and start with education.”

Physicians who adopt individualized medicine in their practice through counseling, support, testing and the latest therapies, will join the new frontier for AD treatment. As Dr. Lee explains: “The better we understand an individual patient—their cognitive strengths and weaknesses, the severity of illness, level of functioning, underlying disease, family history, level of psychosocial support and access to healthy food, hobbies and housing—the more we can make a meaningful difference.”  

—by Lana Bandoim

Changes in cognitive function are common in aging patients and can affect a variety of cognitive domains such as memory, learning and decision-making. Unfortunately, some patients and even healthcare professionals have a fatalistic attitude about the effects of aging on the brain, including the belief that dementia is often an inevitable consequence of getting older. However, research shows that simple lifestyle modifications can help slow the progression of cognitive decline, especially in the early stages. “It’s so important for people to be proactive about brain health because, while there are many potential treatments on the horizon, nothing is going to replace taking care of our brain to preserve brain function and reduce the risk of developing mild cognitive impairment (MCI), Alzheimer’s disease, stroke and other brain disease,” says Marie Pasinski, MD, Assistant Professor of Neurology at Harvard Medical School in Cambridge, MA. “The studies are powerful, showing that more than 40% of dementia cases are due to modifiable risk factors.”¹

Assessing modifiable risks

To start, Dr. Pasinski recommends using tools that can identify modifiable risk factors. “Brain health is all about understanding how we are currently caring for our brain and knowing what things we need to focus on,” she explains. When it comes to assessing brain health, she recommends the McCance Brain Care Score, which can be calculated using a short questionnaire developed at the Massachusetts General Hospital McCance Center for Brain Health (available at massgeneral.org). The Brain Care Score was developed to serve as an evidence-based tool to evaluate modifiable risk factors (e.g., hypertension, dyslipidemia, overweight/obesity, etc.) that have been shown to affect brain health, cognitive function and dementia risk. In a study involving nearly 400,000 adults, the Brain Care Score was found to be significantly predictive of risk for future dementia.²

Counseling patients on brain-healthy habits

“It’s never too early or too late to change our brain for the better,” says Dr. Pasinski. To help improve brain function in all patients, including those without brain disease and those with cognitive decline, Dr. Pasinski advocates for addressing modifiable risks outlined in the Brain Care Score. Specifically, counsel patients on adopting these habits:

1. Follow the MIND diet. 

Nutrition plays a key role in the health of the brain, affecting a variety of factors such as inflammation, energy and blood supply. For optimal brain health, Dr. Pasinski recommends the MIND diet (Mediterranean-DASH Diet Intervention for Neurodegenerative Delay). As the name suggests, this is modeled after the Mediterranean diet and Dietary Approaches to Stop Hypertension (DASH) promoted by the National Heart, Lung, and Blood Institute. The DASH diet also incorporates evidence-based recommendations that focus specifically on brain health. 

“What I like about the MIND diet is that it not only provides guidelines for how many servings of specific brain-healthy foods people should be eating per week, but also what unhealthy foods to limit,” explains Dr. Pasinski. For instance, the MIND diet specifically recommends six or more servings of green leafy vegetables per week. Other brain-healthy foods include whole grains, nuts, berries, poultry, fish and olive oil as the primary fat. Sodium should be limited to 1,500 mg per day, and restricting foods such as pastries, sweets, red meat, cheese and butter is recommended.

Rigorous adherence to the MIND diet was shown to lower the risk of Alzheimer’s disease by 53%, while those who followed it moderately reduced their risk by 35%.³ Additional research found that the MIND diet is associated with a lower risk for Alzheimer’s disease and delayed rates of cognitive decline, even among individuals who are considered genetically high risk for Alzheimer’s disease.⁴

2. Limit alcohol consumption.

“We used to think alcohol was part of the brain-healthy diet and red wine is often cited as part of the Mediterranean diet,” explains Dr. Pasinski. “But those studies were confounded by the fact that alcohol is a luxury item. People who can afford alcohol also tend to have access to better healthcare and have lower rates of dementia risk factors. Alcohol is a known neurotoxin to the brain.” She adds, “We recommend limiting it. None is best, and that’s what I advocate for, especially with patients who are experiencing memory problems.”

3. Quit smoking. 

Smoking affects vascular health, which is known to play an important role in the development of Alzheimer’s disease. Research has found that, among older adults (>65 years), smoking increases the risk for dementia by up to 60%. Smoking cessation, on the other hand, has been found to reduce the risk for dementia by up to 10% after at least four years.⁴ Support your patients who smoke by giving them resources to help them kick the habit, such as 1-800-QUIT-NOW or smokefree.gov. 

4. Be physically active—and avoid prolonged sitting. 

For adults, 150 minutes weekly of moderate-intensity physical activity, or 75 minutes of high-intensity physical activity per week, is recommended by most major health organizations. Alongside these recommendations, Dr. Pasinski suggests her patients avoid sitting for long periods. “We know that with prolonged sitting, cortisol levels rise and blood sugar rises,” she explains. “Weaving more physical activity throughout your day, or just getting up for a couple of minutes and walking around, can bring those levels down.”

For added benefits, Dr. Pasinski encourages patients to engage in activities that they enjoy. “When it’s fun, it boosts the benefits in the brain,” she says. She suggests combining physical activity with mental stimulation and socialization by learning a new sport, such as pickleball, or joining a team.

5. Get restorative sleep. 

“We know that sleep is critical for brain health,” says Dr. Pasinski. “During sleep, the brain rejuvenates itself, fortifies synapses, and stores new information learned during the day. It’s also when the toxic plaque-forming beta-amyloid that accumulates in Alzheimer’s disease is cleared from the brain. When we miss out on sleep, we’re missing out on a great chance to boost our brain health.”

Research suggests that insufficient sleep (≤6 hours per night) in adults over the age of 50 is associated with a 30% increased risk for dementia.⁵ To help improve sleep, Dr. Pasinski urges healthcare providers to check patients for underlying sleep disorders, particularly in those who report snoring or poor-quality sleep. Addressing untreated sleep problems can have profound effects on cognitive health. “I’ve had many patients who present with memory problems that turn out to have an untreated sleep disorder like obstructive sleep apnea,” she notes. “And once this is treated, their memory improves.”

6. Stay engaged, control stress and socialize. 

“Mental health is an important component of brain health,” says Dr. Pasinski, adding that research has revealed a significant link between depression and anxiety and the risk of developing Alzheimer’s disease. Similarly, loneliness is also strongly associated with dementia.⁶ In addition to stress management and addressing mental health needs, Dr. Pasinski recommends encouraging patients to nurture social relationships and becoming involved in their community. 

“When we emotionally connect with others, a potent cocktail of feel-good neurotransmitters—including serotonin and dopamine, the brain’s natural antidepressants—is released. Socializing has also been shown to lower cortisol levels, ease anxiety and improve overall health.” Dr. Pasinski adds: “Having a rich social life is not only wonderful for the brain, but it’s also one of the best predictors of happiness, longevity and well-being.”  

—by Morgan Meissner

As cognitive decline progresses from lapses dismissed as “senior moments” to a total loss of independence, in-home care for people with dementia often becomes too challenging for most families or hired caregivers. When this occurs, specialized memory care offered in long-term residential communities, which include assisted living, standalone facilities and skilled nursing homes, might be a good option.¹ “Memory care is about optimizing a person’s remaining abilities and quality of life, and minimizing distress and burden,” says Carolyn Clevenger, DNP, RN, GNP-BC, AGPCNP-BC, FAANP, FGSA, Director of the Emory Healthcare Integrated Memory Care Clinic, and Professor at the Nell Hodgson Woodruff School of Nursing at Emory University in Atlanta. She adds that memory care services can provide dementia-
related personal and therapeutic care in a supportive environment.

“Finding the right fit for a loved one with dementia can feel overwhelming,” says Valerie Cotter, DrNP, AGPCNP-BC, FAANP, FNAP, FAAN. “Each facility is unique, so patients and family members should make more than one visit to several places before making a decision,” says Cotter, Associate Professor at Johns Hopkins School of Nursing and School of Medicine, and a nurse practitioner at Johns Hopkins Memory and Alzheimer’s Treatment Center in Baltimore.

Getting ahead of it.

Families frequently consider memory care centers when their loved ones lose their ability to walk, exhibit anger and agitation or become incontinent, according to Cotter. However, the best time to think about memory care, she says, is before it’s needed. “I see many families trying to hold on as long as they can to support the person themselves or by hiring caregivers,” Cotter says. “But the time often comes when they can’t handle it anymore.”

Cotter adds that medical admission forms for memory care facilities require verification of the dementia diagnosis as well as other health records to help determine the level of care needed, so families should obtain this information from the patient’s medical provider.

Experts explain what to consider when evaluating memory care centers:

How far is the facility?
The availability of memory care facilities varies by region and is the fastest-growing segment of senior housing.  “Families should choose a facility that’s a reasonable distance from them since they will probably want to visit regularly,” Cotter advises. Studies show that the quality of life of patients in memory care life improves when families visit them frequently.²

What are the communication practices?
It’s important to ask staff about their communication practices and expectations for family involvement. Families also should look for facilities that encourage interaction with loved ones and make staying connected to them a priority, Clevenger says. For instance, does the facility send weekly email communications, such as newsletters or videos, and offer family-sponsored events? 

What levels of care do they offer?
Over one-third of assisted living residents have dementia, according to the Alzheimer’s Association.³ But not all assisted-living facilities provide memory care services, and some have only minimal support for dementia residents,⁴ which is why experts recommend family members ask about levels of care available for patients with dementia. To qualify for memory care in assisted living, people must have the ability to be independently mobile, which can include using a walker or wheelchair, and not require 24-hour assistance with daily living activities such as using the bathroom and showering. 

“Assisted living is only suitable for those with early to very moderate stages of dementia,” says Clevenger, “because daily skilled nursing care isn’t part of the package. Memory care in assisted living is essentially housing with supportive services.”

Facilities typically add on fees for residents who need shower or bathroom assistance or reminders to take their medications. The cost for these services is based on how much help from nursing aides is required. Family members should also be aware that assisted living is regulated by each state and that standards can vary widely, particularly when it comes to licensing requirements for dementia-specific training and staff-to-resident ratios.⁵ It’s a good idea to ask the facility director about the staff’s hourly rate and turnover, Clevenger advises. “These are the people who truly make a difference, and it’s important to know if there’s a healthy work culture and that workers are treated well,” she says.

As dementia progresses, patients will likely need to be transferred to a nursing facility. Unlike assisted living, nursing homes are federally regulated and have licensed nursing care and 24-hour supervision of chronically ill patients.⁶ A recent national survey found that 10% to 90% of total nursing home residents have dementia or AD, and facilities where dementia patients are the majority have better outcomes.⁷

Experts advise families to seek facilities that offer a higher level of care to minimize transitions as the disease progresses. They note that changing environments can be triggering and disorienting for those with AD. Standalone memory care facilities that offer a continuum of services in one place are a good option, but are less common than memory care services in campus-like environments that provide an assisted living and skilled nursing facility.¹ 

Is the environment supportive?
Memory care is increasingly delivered in dedicated units, wings or floors that are specially designed to provide a supportive environment, including alarmed doors, as dementia residents can be prone to unsafe elopement.³ Families should look for features such as a centralized nursing station where caregivers can observe residents, easy-to-navigate floor plans and color-coded hallways to help orient residents. They should also have enhanced natural lighting and ways to minimize noise that may overstimulate or distress residents, says Clevenger.

“It’s important for people with dementia to feel safe and loved in their environment,” Cotter says. Doors with photos of family members on them and facts about the resident’s life indicate a friendly environment, Clevenger says. There should also be memory activity programs, including puzzles, games, art and music therapy, as well as outdoor activities like gardening and exercise that keep residents active and social. “Individualized care reflects an understanding of the resident’s unique abilities and interests, personal care, nutritional and medical needs,” Clevenger says. This is information that should also be shared and regularly reviewed with family members, she adds.

What’s the financial picture?
The median national cost of memory care per resident in assisted living is $6,200 per month, according to A Place for Mom, a senior care referral company.⁸ It’s important to know what services are provided in the monthly fee and what are considered additional fees for memory care in assisted living, Cotter says. For example, assisted living memory care add-on fees range from $550 per month extra for a low level of care to over $2,000 a month for higher tiers.⁹

Medicare and Medicare Advantage plans don’t cover memory care in assisted living, except for some services such as physical therapy or outpatient physician visits. Other monthly costs are often shouldered by families. Residents who have purchased long-term care insurance or qualify for Veteran’s Administration benefits may use these sources to help foot the bill.³

“Most families spend down their loved one’s assets to meet eligibility thresholds for Medicaid,” Cotter says. Medicaid generally pays all the costs of a nursing home stay, but doesn’t cover the cost of room and board in an assisted living facility with memory care. However, Medicaid may pay for some assisted living memory care services for eligible patients if the facility is Medicaid-approved.³

Easing the transition.
Some patients in very early stages of dementia may be willing participants in the decision to move to memory care, experts say. But for those with less cognitive function, it’s best to avoid causing “anticipation anxiety” by talking about moving too soon. People eventually adjust because they’re receiving better care, and enjoying a social environment. “Many of my dementia patients do better at a memory care center than at home where they spent much of their time alone watching  TV,” Cotter says.  

—by Linda Keslar

Special thanks to our medical reviewer:

Samuel E. Gandy, MD, PhD, Professor of Alzheimer’s Disease Research and Associate Director of the Alzheimer’s Disease Research Center, Mount Sinai Medical Center, New York City

Maria Lissandrello, Senior Vice President, Editor-In-Chief; Lori Murray, Associate Vice President, Executive Editor; Lindsay Bosslett, Associate Vice President, Managing Editor; Jodie Gould, Senior Editor; Joana Mangune, Editorial Manager; Debra Koch, Senior Copy Editor; Erica Kerber, Vice President, Creative Director; Jennifer Webber, Associate Vice President, Associate Creative Director; Ashley Pinck, Art Director; Sarah Hartstein, Graphic Designer; Rachel Pres, Senior Director, Digital Production

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