Alzheimer’s disease may cost the United States alone more than $1.3 trillion by 2050, but early diagnosis could be one way to mitigate at least some of that increase, a special report released by the Alzheimer’s Association says.

An improved clinical scenario, with 88% of patients diagnosed in the early stage of mild cognitive impairment (MCI), could save $231.4 billion in direct treatment and long-term care costs by that time, according to the report, contained in the 2018 Alzheimer’s Disease Facts and Figures. Extrapolated out to the full lifespan of everyone now alive in the United States, the 88% diagnostic scenario could reap $7 trillion in savings, the report noted. This benefit would comprise $3.3 trillion in Medicare savings, $2.3 trillion in Medicaid savings, and $1.4 trillion in other areas of spending, including out-of-pocket expenses and private insurance.

“The results of this model underscore the economic benefits – to the government, to individuals, and to the medical and long-term care systems overall – of an early and accurate diagnosis of Alzheimer’s,” the report said. “Furthermore, they suggest that diagnosing all individuals who have Alzheimer’s is not necessary to achieve large cost savings, and that savings can be achieved with a realistic diagnosis rate goal.”

The improved clinical diagnosis picture could manifest if diagnoses were based solely on biomarkers rather than the current method, which relies largely on symptoms and performance on cognitive tests, without biomarker confirmation. The biomarker-based diagnostic algorithm has been proposed for research cohorts, but not for clinical care.

The diagnostic workup currently employed, which is most often not confirmed with biomarkers, “means that many people who are diagnosed with Alzheimer’s may in reality have MCI or dementia due to other causes,” the report noted. Studies consistently show that up to 30% of patients diagnosed with apparent Alzheimer’s actually have another source of cognitive dysfunction. The misdiagnosis gap haunts clinical trialists and makes a strong case for incorporating biomarkers, including amyloid imaging, into the diagnostic workup – something the Alzheimer’s Association is pushing for with its IDEAS study .

Diagnostic reliance on symptoms and cognitive test performance without the additional information provided by biomarkers can affect the confidence clinicians have in making a diagnosis and thereby delay a diagnosis, dementia specialist Marwan N. Sabbagh, MD , said when asked to comment on the report.

“The report by the Alzheimer’s Association underscores the fact that early diagnosis of dementia or MCI due to Alzheimer’s disease is important not only because it is good health care but because net savings can be realized. The simple fact is that physicians have been taught to approach a diagnosis of dementia as a diagnosis of exclusion and they have been told that a diagnosis can be absolutely attained only by biopsy or autopsy. The consequence of these messages is that there is a lack of confidence in the clinic diagnosis and a subsequent delay in making a diagnosis,” said Dr. Sabbagh, the Karsten Solheim Chair for Dementia, professor of neurology, and director of the Alzheimer’s and memory disorders division at the Barrow Neurological Institute, Phoenix. “The deployment of in vivo biomarkers will transform the diagnosis from one of exclusion to one of inclusion. The up front costs will be saved later in the course.”

Earlier diagnosis is also associated with greater per-person savings, the report noted. “Under the current status quo, an individual with Alzheimer’s has total projected health and long-term care costs of $424,000 (present value of future costs) from the year before MCI until death. Under the partial early diagnosis scenario, the average per-person cost for an individual with Alzheimer’s is projected to be $360,000, saving $64,000 per individual.”

The economic modeling study employed The Health Economics Medical Innovation Simulation ( THEMIS ), which uses data from the Health and Retirement Study ( HRS ), a nationally representative sample of adults aged 50 and older.

The simulated population included everyone alive in the United States in 2018 and assumed cognitive assessment beginning at age 50. The model did not assume that biomarkers would be used in the diagnostic process.

It included three scenarios:

• The current situation, in which many people never receive a diagnosis or receive it later in the disease.

• A partial early-diagnosis scenario, with 88% of Alzheimer’s patients diagnosed in the MCI stage.

• A full early diagnosis scenario, in which all Alzheimer’s patients receive an early MCI diagnosis.

The current situation of inaccurate or late diagnosis remains the most expensive scenario. The model projected a total expenditure of $47.1 trillion over the lifetime of everyone alive in the United States in 2018 ($23.1 trillion in Medicare costs, $11.8 trillion in Medicaid costs, and $12.1 trillion in other costs). The report also noted that this total doesn’t include the current expense of caring for everyone in the United States who has Alzheimer’s now.

The partial early diagnosis scenario assumes that everyone with Alzheimer’s has a 70% chance of being diagnosed with MCI every 2 years; this would yield a total diagnostic rate of 88%.

Under this scenario, the model projected a total care cost of $40.1 trillion – a $7 trillion benefit composed of $3.3 trillion in Medicare savings, $2.3 trillion in Medicaid savings, and $1.4 trillion in other savings.

“Thus, nearly all of the potential savings of early diagnosis can be realized under the partial early diagnosis scenario,” the report noted.

These savings would be realized over a long period, but there could be massive shorter-term benefits as well, the report said. Savings under the partial early-diagnosis scenario could be $31.8 billion in 2025 and $231.4 billion in 2050.

That would be good financial news, especially in light of the report’s current cost analysis. In 2018, the cost of caring for Alzheimer’s patients and those with other dementias is on track to exceed $277 billion, which is $18 billion more than the United States paid out last year. If the current diagnostic scenario and incidence rates continue unabated, the report projected an annual expense of $1.35 trillion for care in 2050.

msullivan@mdedge.com

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