Race, vulnerability and health status shape who receives new Alzheimer’s drugs

The first disease-modifying therapies for Alzheimer’s disease have been hailed as a turning point in neurology, offering patients the possibility of slowing cognitive decline by targeting the amyloid plaques that accumulate in the brain. Yet a new study from Michigan Medicine suggests that the promise of these anti-amyloid drugs is not being distributed evenly. In one of the largest real-world analyses of the new treatment class to date, researchers found that Black and Hispanic adults with mild cognitive impairment or dementia were dramatically less likely than non-Hispanic white adults to receive the medications, even though patients who did start therapy appeared to take it just as faithfully regardless of race or ethnicity.

The findings, published in Neurology, the medical journal of the American Academy of Neurology, arrive at a pivotal moment. Anti-amyloid therapies represent the first approved drugs that modify the underlying biology of Alzheimer’s disease rather than merely managing its symptoms, and their use is expected to expand steadily as diagnostic tools improve and clinical experience grows. But the study’s numbers reveal a stark pattern in who is actually reaching the infusion chair. Black adults had 86 percent lower odds of receiving an anti-amyloid medication compared with non-Hispanic white adults, while Hispanic adults had 79 percent lower odds, after the researchers accounted for other clinical and demographic factors.

“The association we found between race/ethnicity and anti-amyloid medication use raises important questions about how patients are identified, evaluated and ultimately selected for treatment,” said Melissa Elafros, M.D., Ph.D., co-first author of the study and the Andrea and Lawrence A. Wolfe Research Professor at University of Michigan Medical School. “It’s critical that we understand and address the disparities we are seeing today so that as many patients as possible receive benefits.”

To conduct the analysis, the research team drew on a database of more than one million adults diagnosed with mild cognitive impairment or dementia. From that population, they identified 2,427 patients who had received an anti-amyloid medication and compared them with a closely matched group of untreated patients. Because the study was observational, it captures associations rather than proving cause and effect, but the scale of the dataset allowed the investigators to examine how race, ethnicity, comorbid health conditions and social circumstances all intersected with the likelihood of treatment.

Beyond race and ethnicity, the researchers found that social and economic disadvantage played a powerful role. Participants who faced greater disadvantages, measured through factors including income, education, and access to housing and neighborhood resources, were nearly half as likely to receive the latest therapies as their less vulnerable counterparts. Health comorbidities were also strongly associated with whether patients were treated, suggesting that clinicians and health systems may be weighing a complex mix of medical and social considerations when deciding who is a candidate for drugs that require regular infusions, repeated brain imaging and careful monitoring for side effects such as amyloid-related imaging abnormalities.

What the study did not find may be just as consequential as what it did. Once patients began anti-amyloid therapy, adherence was similar across racial and ethnic groups, meaning that the disparities concentrate at the front door of treatment rather than in the day-to-day management of it. “Although race, ethnicity and overall vulnerability are associated with whether patients receive an anti-amyloid medication, we found no differences in initial adherence among those who start treatment,” said Brian C. Callaghan, M.D., M.S., senior author of the study and the Eva L. Feldman, MD, PhD Professor at U-M Medical School. “This suggests that interventions should focus on helping eligible patients start therapy, rather than on adherence after treatment begins.”

That distinction carries significant implications for how the field responds. If patients who begin therapy take the drugs as prescribed at comparable rates, then the bottleneck lies upstream, in the processes that determine who is referred, who undergoes amyloid testing, who is evaluated at specialized memory centers and who is ultimately offered treatment. Anti-amyloid drugs are typically reserved for people with early-stage disease confirmed by biomarkers, a requirement that depends on access to specialists, advanced imaging, lumbar punctures or other diagnostic resources that are unevenly distributed across the health care landscape. Communities that have historically faced barriers to neurologic care may therefore be systematically underrepresented among treatment candidates before any prescribing decision is even made.

The study was funded through a research contract with the American Academy of Neurology, and the authors note that its observational design means unmeasured factors could contribute to the observed differences. Even so, the consistency of the signal across more than two thousand treated patients and a comparable untreated comparison group strengthens the case that the disparities reflect structural patterns rather than random variation. Additional authors on the paper include Lavanya Muthukumar, M.S., and Samuel Terman, M.D., both of the University of Michigan, with further contributors listed in the published article.

For clinicians and policymakers, the message from the Michigan team is that the window for shaping equitable access is open now, while anti-amyloid therapies are still early in their real-world rollout. The researchers argue that understanding and addressing the disparities observed today is essential so that the benefits of a new generation of Alzheimer’s treatments reach as many eligible patients as possible, rather than reproducing the inequities that have long characterized dementia care. As these drugs move from specialized centers into broader clinical practice, the study offers a baseline measurement of who is being left behind, and a warning that without deliberate intervention, the first disease-modifying era of Alzheimer’s medicine could widen existing gaps in brain health.

Subject of Research: Racial, ethnic and socioeconomic disparities in access to anti-amyloid Alzheimer's disease therapies

Article Title: Who gets Alzheimer’s drugs? Race, vulnerability and health status shape access

Article References: Who gets Alzheimer’s drugs? Race, vulnerability and health status shape access. Original publication (Bibliographic details unavailable.)

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Keywords: Alzheimer's disease, anti-amyloid therapy, health disparities, mild cognitive impairment, dementia, Neurology, Michigan Medicine, adherence, social determinants of health, race and ethnicity, amyloid plaques, disease-modifying treatment