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Rethinking Cognitive Care: Why Brain Health Belongs in Every Exam Room

PAs Should Proactively Address Brain Health with Patients

October 23, 2025

By AAPA Research

Cognitive decline and dementia can creep up subtly, yet by the time memory lapses become obvious, valuable time for intervention may have passed. That’s why clinicians are increasingly treating brain health like any other vital sign, such as blood pressure and A1c levels. In this case, it is measured via cognitive assessments. It is something to monitor and discuss early and proactively, not just reactively in a crisis.

What is “Brain Health” and Why Talk About It Now?
Brain health isn’t just an empty buzzword. It is an encompassing term for maintaining cognitive function over time, much like “heart health” is for the cardiovascular system. It means taking into account the myriad factors that affect our cognition: from lifestyle habits and cardiovascular risk factors to the brain’s own resilience and how it changes with age. In other words, brain health is about “keeping your wits about you” as you grow older, supported by good diet, exercise, and blood pressure control, while recognizing that some decline is normal with aging. It also involves being aware of how well a person can function day-to-day, and acknowledging the gap that sometimes grows between what they want to do and what they actually can do as cognitive or physical limitations emerge.

A key concept is “brain reserve,” essentially the brain’s backup capacity to withstand damage before clinical symptoms appear. People with more brain reserve (thanks to factors like education, cognitive stimulation, or just genetic luck) might delay the onset of dementia symptoms even if underlying disease is present. However, brain reserve declines with age. This makes it crucial to start building and preserving that reserve early on, through healthy habits, engaging the brain, and identifying any emerging issues sooner rather than later.1

As frontline providers, physician associates should start conversations about brain health with patients now, proactively. Simply put, early detection and prevention are becoming more feasible and more important than ever. Many clinicians discuss cognition only after clear red flags are triggered, such as when a patient has a bad fall, shows noticeable memory lapses, or a worried family member expresses concern. Some also bring it up during an annual wellness exam or if a patient fails to recall parts of their medical history.

With an aging population and Alzheimer’s cases expected to close to double by 2050, from seven million to 13 million cases, there’s growing urgency to address this concern early.2 Emerging evidence shows that what we do early on can make a real difference. For example, a large two-year clinical trial (the U.S. POINTER study) just demonstrated that a structured lifestyle intervention improved cognition in older adults at risk for decline, effectively protecting them from normal age-related cognitive loss for the duration of the study. Participants who followed a program of exercise, healthy diet (MIND diet), cognitive challenges, and regular health coaching showed better global cognition over time. Even a less intensive, self-guided lifestyle change plan yielded cognitive benefits, though the coached program did better.3

In short, there’s much to gain by talking about brain health sooner. PAs can encourage lifestyle modifications that build brain reserve, set a baseline for cognitive function, and destigmatize cognitive concerns by making them a routine part of wellness conversations.

The Use of Blood-Based Biomarkers in Early Screening for Alzheimer’s Disease
Fortunately, discussing and screening for cognitive impairment doesn’t mean jumping straight to expensive scans or lengthy exams. New blood tests are available that measure Alzheimer’s disease (AD) proteins (abnormal tau and beta-amyloid) in the plasma. These blood biomarkers are designed to indicate the presence of Alzheimer’s pathology in the brains of patients with mild cognitive impairment or mild dementia due to Alzheimer’s disease. Compared to traditional PET scans and cerebrospinal fluid (CSF) testing, blood-based biomarkers are generally more affordable, easier to access, and more comfortable for patients. However, current guidelines stress that these tests are not a replacement for a full clinical evaluation; rather, they should be ordered and interpreted by a qualified healthcare professional as part of a broader diagnostic process.3 Moreover, cognitive symptoms must be present along with indication of cognitive impairment as measured by validated cognitive assessment and proof of amyloid pathology.

A group of 11 healthcare professionals, including neurologists, geriatricians, NPs, PAs, and other experts, came together under the Alzheimer’s Association to take a deep dive into the evidence around blood-based biomarkers. Their goal was to determine how these tests can best support the diagnosis of patients with clear signs of cognitive impairment, like mild cognitive impairment (MCI) or dementia. They reviewed the research, gathered public feedback, and even included insights from individuals living with early-stage Alzheimer’s through the Association’s National Early-Stage Advisory Group. In the end, the panel issued two formal recommendations and one Good Practice Statement to guide how BBM tests should be used in specialized care settings:

Recommendation 1 — In patients with objective cognitive impairment presenting for specialized memory-care, the panel suggests using a high-sensitivity BBM test as a triaging test in the diagnostic workup of Alzheimer’s disease.

Recommendation 2 — In patients with objective cognitive impairment presenting for specialized memory care, the panel suggests using a high-sensitivity and high-specificity BBM test as a confirmatory test in the diagnostic workup of Alzheimer’s disease.

Good Practice Statement — A BBM test should not be obtained before a comprehensive clinical evaluation by a health care professional, and test results should always be interpreted within the clinical context. The panel urges clinicians to consider the pre-test probability of Alzheimer’s disease pathology for each patient when deciding whether or not to use a BBM test.

Clinicians are cautioned that not all tests on the market are created equal. Many don’t yet meet the ≥90% sensitivity/specificity benchmark are recommended. But the take-home message is that blood tests for Alzheimer’s are here, and they’re moving rapidly into clinical practice. They are cheaper, more accessible, and far less cumbersome than PET scans or spinal taps. For clinicians, this means that in the coming years, we might routinely order an “Alzheimer’s blood panel” when a patient in their 60s starts showing signs of memory loss—much like we order a TSH to rule out thyroid issues or B12 levels to rule out cobalamin deficiency. It’s a paradigm shift toward accessible early diagnostics.4

Emerging Treatments
We are in a new era for Alzheimer’s therapy. For the first time, treatments that can slow the progression of Alzheimer’s disease are available, and more are in development. These are largely monoclonal antibody infusions that target amyloid plaques in the brain (the hallmark protein that accumulates in AD). Until recently, options were limited to symptom-management drugs (like donepezil or memantine). But now drugs such as donanemab (Kisunla, by Eli Lilly) and lecanemab (Leqembi, by Eisai) have shown they can significantly slow cognitive decline in early Alzheimer’s.

In a Phase 3 trial, donanemab slowed patients’ decline over 18 months, and an extension study found that over three years of treatment, the benefit continued to grow compared to those not on the drug.5 What’s truly striking is the difference made by timing: Participants who started on the drug earlier had markedly better outcomes than those who started later. Early starters reduced their risk of progressing to the next stage of disease by 27% compared to those whose treatment was delayed. In practice this could mean, for example, holding someone in the mild cognitive impairment stage due to Alzheimer’s disease longer before they convert to the next state of dementia due to Alzheimer’s disease. Moreover, over 75% of treated patients achieved a reduction of amyloid plaque from their brains within the first one and a half years, which is something unprecedented in Alzheimer’s care. 5

What Can PAs Do to Make a Difference?
A recent survey of PAs indicated that there are barriers that they need to overcome to ensure that the best outcomes for patients with dementia are achieved. More than one third of surveyed PAs indicated the following factors as having a high and somewhat high impact on their ability to achieve the best outcomes for their patients with AD and other forms of dementia:

  • Lack of access to specialists (55.3%),
  • Limited time for patient education (54.3%),
  • Lack of resources to deal with psychosocial issues impacting ability to adhere (49.5%),
  • Large patient load (42.8%),
  • Lack of resources available to manage patients with AD and other forms of dementia (39.1%),
  • Coordinating care with other services/providers (38.5%),
  • Treatment cost to patients (38.3%), and
  • Cost of medications (36.9%).6

So what can PAs do right now?

About This Project
This research was sponsored by Lilly. The research is the work of AAPA, including the focus group and the conclusions drawn.

Noël Smith is AAPA’s Senior Director of PA and Industry Research and Analysis. She can be reached at [email protected].  

References

  1. Stern Y, Barnes CA, Grady C, Jones RN, Raz N. Brain reserve, cognitive reserve, compensation, and maintenance: operationalization, validity, and mechanisms of cognitive resilience. Neurobiol Aging. 2019;83:124-129. doi:10.1016/j.neurobiolaging.2019.03.022
  2. Alzheimer’s Association. Alzheimer’s Disease Facts and Figures. Alzheimer’s Disease and Dementia. Published 2025. https://www.alz.org/alzheimers-dementia/facts-figures
  3. U.S. POINTER Study | Alzheimer’s Association. U.S. POINTER. https://www.alz.org/us-pointer/home.asp
  4. Alzheimer’s Association releases its first clinical practice guideline for blood‐based biomarker tests. Alzheimers Dement. 2025;21(9):e70701. Published 2025 Sep 24. doi:10.1002/alz.70701
  5. Mirasol F. Lilly’s Kisunla Demonstrates Growing Benefit in Treating Early Alzheimer’s Disease. PharmTech. Published August 5, 2025. Accessed October 2, 2025. https://www.pharmtech.com/view/lilly-s-kisunla-demonstrates-growing-benefit-in-treating-early-alzheimer-s-disease
  6. PA’s Role in, and Barriers to, Managing Patients with Alzheimer’s Disease and Other Forms of Dementia. 2025. American Academy of Physician Associates. Alexandria, VA. https://sb1.aapa.org/download/151144/?tmstv=1759436624.

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