Background: While the majority of patients with Alzheimer's disease resides in low and middle-income countries, little is known of their preparedness for emerging disease-modifying treatments. We analyze the preparedness of Brazil, one of the most populous middle-income countries, from a capacity and institutional preparedness perspective.Methods: Desk research and 12 interviews for background and capacity data. Markov model to estimate wait times for access to treatment.Findings: Brazil has no national dementia strategy or established pathway for evaluation of cognitive concerns, and dementia is typically diagnosed late if at all. While members of private health plans have ready access to elective specialty care, wait times in the public sector are long. Assuming potentially treatment-eligible patients are referred from primary to specialty care based on a brief cognitive exam and a blood test for the Alzheimer's pathology, available capacity will not be sufficient to match the projected demand. The biggest obstacle is availability of dementia specialist visits, and the effect of population growth and ageing means that the wait list for specialist appointment will continue to grow from around 400,000 in 2022 to over 2.2 million in 2040. We do not project substantial wait times for confirmatory biomarker testing and treatment delivery but note that this is a consequence of patients waiting for their specialist appointments. These queues will result in estimated persistent wait times for treatment of around two years on average with substantial differences between the public and private sectors, as capacity growth is insufficient to keep up with increasing demand.Discussion: Our findings suggest that Brazil is ill-prepared to provide timely access to an Alzheimer's treatment with predicted wait times of about two years, largely because of a limited number of dementia specialists.

BackgroundBlood‐based biomarker tests are critical tools with the potential to change pathways for dementia diagnosis and care. These tests are less invasive than PET scan or lumbar puncture, potentially more affordable, and thus more accessible across more care settings and in more countries. Utilization in primary care settings together with brief cognitive assessments provides a compelling use case that could transform diagnosis, assessment and care.A critical challenge to the widespread adoption of blood‐based biomarker testing is the issue of disclosure. To date, Alzheimer’s Disease and Related Dementias (ADRD) biomarker disclosure recommendations have primarily focused on disclosure in research and/or specialized‐care settings. Primary care clinicians are well situated to conduct biomarker testing, but they are likely to need training and support to develop confidence and capacity to communicate results.MethodReview of literature findings involving biomarker disclosure and input from dementia researchers from six countries reflecting diverse health care systems informed development of a disclosure framework to support the inaugural project of the Davos Alzheimer’s Collaborative’s (DAC) Systems Preparedness (DAC‐SP) initiative. This project seeks to promote routine uptake of cognitive screening among people ≥ age 60 and, when cognitive impairment is identified, blood‐based biomarker testing. The biomarker testing is completed using a commercially available, CLIA‐certified test that measures the likelihood of amyloid pathology when cognitive impairment is identified.ResultThe framework recognizes that biomarker disclosure is part of a comprehensive patient evaluation that includes cognitive assessment and a broader discussion of the patient’s health and wellbeing. It divides disclosure into five phases: pre‐test education; consent for and administration of testing; disclosure of results and discussion of treatment plan; provision of educational materials; and follow up (Table 1). This general framework can be adapted for site‐specific factors such as health literacy, health systems operations, legal structures, and cultural relevance.ConclusionAs part of a pragmatic multisite implementation evaluation of a screening and early detection program including high and middle income countries, the authors have developed a framework to guide biomarker disclosure to patients in primary care settings. This provisional framework represents an important first step towards clinical consensus building on biomarker disclosure.

BackgroundWhile the majority of patients with Alzheimer’s disease resides in low and middle‐income countries, little is known of their preparedness for emerging disease‐modifying treatments. We analyze the preparedness of Brazil, one of the most populous middle‐income countries, from a capacity and institutional preparedness perspective.MethodDesk research and 12 interviews for background and capacity data. Markov model to estimate wait times for access to treatment.ResultBrazil has no national dementia strategy or established pathway for evaluation of cognitive concerns, and dementia is typically diagnosed late if at all. While members of private health plans have ready access to elective specialty care, wait times in the public sector are long. Assuming potentially treatment‐eligible patients are referred from primary to specialty care based on a brief cognitive exam and a blood test for the Alzheimer’s pathology, available capacity will not be sufficient to match the projected demand (Figure 1). The biggest obstacle is availability of dementia specialist visits, and the effect of population growth and ageing means that the wait list for specialist appointment will continue to grow from around 400,000 in 2022 to over 2.2 million in 2040. We do not project substantial wait times for confirmatory biomarker testing and treatment delivery but note that this is a consequence of patients waiting for their specialist appointments. These queues will result in estimated persistent wait times for treatment of around two years on average with substantial differences between the public and private sectors, as capacity growth is insufficient to keep up with increasing demand.ConclusionOur findings suggest that Brazil is ill‐prepared to provide timely access to an Alzheimer’s treatment with predicted wait times of about two years, largely because of a limited number of dementia specialists. Access is likely to be unequal based on socioeconomic status and geographic location. Closing this gap will be challenging because of high public debt and chronic underinvestment, leaving a focus on prevention and on use of scalable technologies, such as digital cognitive and blood tests for Alzheimer’s disease as viable option. A national dementia plan with an implementation strategy would be an important first step.