For decades, families facing an Alzheimer’s diagnosis had few treatment options. Medications could help manage symptoms for some patients, but they couldn’t change the disease's underlying cause. The arrival of anti-amyloid drugs like lecanemab and donanemab has started to change that conversation. For the first time, physicians have treatments that can slow cognitive decline in some people with early Alzheimer’s disease.
But getting from “there’s a new treatment” to actually receiving it is much more complicated than headlines about a drug approval might suggest.
As a geriatrician and clinical researcher, Dr. Joel Ross has had a front-row seat to nearly four decades of change in Alzheimer’s treatment. Through the Memory Enhancement Center of America, which he opened in New York and New Jersey in 2000, Ross and his team participated in pivotal research that helped bring currently approved oral and transdermal Alzheimer’s medications to market. Now, a new generation of drugs is changing the treatment conversation again. These medications give physicians another option for treating early Alzheimer’s, but they aren’t right for every patient. Doctors and families still have to weigh the potential benefits against the risks and the demands of treatment itself.
For older adults in particular, treatment decisions can become more complicated as health needs change with age. Just because a medication is available doesn’t necessarily mean it’s the right choice. What matters is whether the potential benefits, risks, and demands of treatment make sense for the individual patient.
Getting From an Alzheimer’s Diagnosis to Treatment
Lecanemab entered routine practice in July 2023, followed by donanemab in July 2024. Both are intravenous antibodies that target amyloid in the brain, and both are intended for people in the early stages of Alzheimer’s disease, either mild cognitive impairment or mild dementia. Lecanemab is generally administered every two weeks, while donanemab is given every four weeks.
Being eligible for one of these drugs, however, involves more than just having an Alzheimer’s diagnosis. Patients need testing to confirm amyloid pathology, and they have to be able to undergo the regular MRI monitoring required during treatment. Other health conditions and medications can also affect whether treatment is appropriate.
Then there are the practical considerations. Regular infusions mean regular appointments, often over an extended period. Patients may need a specialist nearby, reliable transportation, access to an imaging center, and a caregiver or family member to help manage the schedule. For someone who lives far from a major medical center or depends on a working family member for transportation, those requirements can make treatment much harder to pursue.
Early use of the medications reflects some of those limitations. A retrospective study using a large national health system dataset identified roughly 3,400 patients who received either infusion during the first 16 months the medication was available. During the same period, more than 1.9 million patients were taking older oral dementia medications. Patients receiving the newer therapies also tended to be younger, more likely to be white and non-Hispanic, and more likely to have Medicare or commercial insurance than Medicaid.
So while the medications are available nationally, receiving them can still depend heavily on where a patient lives, the medical resources nearby, and how much support they have outside the doctor’s office.
The Treatment Window Can Close Earlier Than Families Expect
Timing is another challenge.
Anti-amyloid drugs aren’t approved for every stage of Alzheimer’s disease. Patients need to be evaluated while their cognitive impairment is still relatively mild, and amyloid pathology has to be confirmed through testing rather than assumed from symptoms alone. Physicians also need to rule out other conditions that could better explain the cognitive changes.
Some families arrive for a memory evaluation expecting to discuss one of the newer medications only to discover that the disease has already progressed beyond the stage at which the drugs are indicated.
Recognizing cognitive changes early can give patients more options.
Throughout his career, Dr. Ross has spoken to hundreds of residents in retirement communities across New York and New Jersey about the difference between ordinary changes associated with aging and signs of more serious memory loss. He has also discussed the types of testing available when someone begins experiencing cognitive changes.
Those conversations can happen long before anyone is talking about an infusion. A patient first has to recognize that something has changed, bring it to a physician’s attention, and reach the appropriate evaluation while treatment is still an option.
Why MRI Monitoring Is Part of the Treatment
For patients who do qualify, the medication is only one part of the process.
The primary safety concern with anti-amyloid therapies is amyloid-related imaging abnormalities, commonly called ARIA. These abnormalities can include brain and small areas of bleeding. Some people develop symptoms, while others feel completely normal, which is why MRI monitoring is necessary even when treatment appears to be going well.
Patients need a baseline MRI before starting therapy and additional scans at scheduled points during treatment. New symptoms can also prompt additional imaging.
Monitoring recommendations have continued to evolve as these medications have moved from clinical trials into wider use. In August 2025, the FDA recommended earlier and additional MRI monitoring for lecanemab after pharmacovigilance identified six fatal cases of ARIA with edema occurring early in treatment, along with roughly 100 serious cases reported through its adverse event system.
The dosing strategy for donanemab has also changed. Its label now includes a modified titration schedule after research found that the approach reduced early ARIA with edema from about 24% to about 14% at 24 weeks. Among patients in the highest-risk APOE4 group, the rate fell from roughly 57% to 19%.
Genetics can therefore enter the treatment conversation. People who carry two copies of the APOE4 variant have a substantially higher risk of complications. That information can shape how physicians and families weigh the risks of moving forward.
Dr. Ross’s clinical research background gives him a familiar frame of reference for this kind of monitoring. He served as a trustee of the Association of Clinical Research Professionals and wrote a nationally recognized primer for principal investigators on conducting high-quality clinical research. Trial protocols depend on careful scheduling and consistent follow-up, and many of those same habits become important when a treatment requiring close monitoring moves into everyday medical practice.
MRI appointments have to happen as scheduled. Results need to be interpreted consistently. Patients and caregivers also need to know which symptoms warrant a call and what to do if something changes between scheduled appointments.
Spending time walking families through the risks and practical demands of treatment can help them understand what they’re agreeing to before the first infusion begins.
What It Really Means to Slow Alzheimer’s
The benefits of these medications can be difficult to explain because “treatment” can mean very different things to different people.
Lecanemab and donanemab can slow cognitive decline in appropriately selected patients. They don’t restore memory or abilities that have already been lost, and they don’t stop Alzheimer’s disease from progressing.
Longer-term findings have provided some encouraging evidence. An open-label extension of the lecanemab trial suggested that benefits continued through 48 months, with treated patients remaining in earlier-stage disease roughly 10 to 13 months longer than matched untreated comparisons. Real-world data presented in mid-2026 also suggested that serious ARIA events remained uncommon and that most patients continued treatment; about one in seven discontinued for reasons that included ARIA, infusion reactions, lack of perceived benefit, patient preference, and logistical difficulties.
What 10 to 13 months means depends on the person.
Someone may want more time living independently at home. Another patient may be thinking about a family milestone, travel, financial planning, or simply preserving familiar routines for as long as possible. Those extra months can carry real value even when the treatment can’t reverse the disease.
Another patient may look at the same potential benefit and decide that repeated infusions, MRI scans, travel, and the possibility of complications aren’t worth it.
Both patients can understand the evidence and still reach different decisions.
For physicians, explaining the potential benefit without overselling it is an important part of the conversation. Families need to know what the medication may offer, but they also need a realistic picture of what it can’t do.
Real Patients Are Often More Complicated Than Trial Participants
Clinical trials require carefully selected participants so researchers can determine whether a treatment works and identify its risks. The patients who eventually show up in a geriatric practice are often much more medically complicated.
An 84-year-old with early Alzheimer’s disease may also have atrial fibrillation, kidney disease, mobility problems, a history of falls, and a long list of medications. Patients with that combination of health concerns weren’t well represented in many trials of the new therapies.
Their physicians still have to decide whether treatment makes sense.
For a patient like that, Alzheimer’s disease can’t be considered separately from everything else affecting their health. A medication that looks reasonable when you consider cognitive decline on its own may look different once frailty, anticoagulation, transportation, fall risk, and other medical conditions enter the picture.
Dr. Ross completed his geriatric medicine fellowship at Mount Sinai Medical Center under Dr. Robert N. Butler, the first director of the National Institute on Aging. His geriatrics training taught him to look beyond a single diagnosis, especially when an older patient is managing several health conditions at the same time.
The question isn’t simply whether there’s a treatment available for a particular diagnosis. Physicians also have to consider how that treatment fits into the patient’s overall health and what the patient wants the next few years of life to look like.
Blood Tests Could Make Earlier Evaluation Easier
Confirming amyloid pathology has traditionally been one of the hurdles patients face before they can be considered for anti-amyloid treatment.
PET imaging can be expensive and isn’t equally accessible everywhere. Testing spinal fluid requires a lumbar puncture, which some older adults may be reluctant to undergo.
Blood-based biomarkers could make that process easier.
Evidence presented in 2026 supported their usefulness in primary care, where many memory concerns first surface. The Alzheimer’s Association, where Dr. Joel Ross has presented his own research, has also published guidance to help primary care clinicians use blood-based biomarker testing appropriately.
A blood test wouldn’t replace every part of an Alzheimer’s evaluation, but it could help physicians determine which patients should move on to more specialized testing or referral.
That could be particularly useful when timing is already working against the patient. If someone showing early signs of cognitive decline can be identified and referred sooner, there’s a better chance of reaching a specialist while treatment options are still available.
What a Practice Needs Before Offering Treatment
Knowing how to prescribe lecanemab or donanemab isn’t enough. A medical practice also needs the systems required to manage treatment safely.
That includes access to amyloid confirmation, dependable MRI scheduling, clinicians who can interpret those scans, infusion services or a partner facility, and participation in the registry connected to Medicare coverage. There also needs to be a clear plan for what happens if a patient develops a concerning symptom between appointments.
Patients and families need to know how the process will work before treatment begins. How often will they need to come in? What monitoring is required? Which symptoms should prompt a phone call? Under what circumstances might treatment need to be paused or stopped?
These details may not get much attention when a new Alzheimer’s drug is approved, but they become very real once someone starts treatment.
The newest therapies have given physicians something they didn’t have before: a way to slow the progression of Alzheimer’s disease in some patients who are identified early enough and can undergo treatment safely. They’ve also made Alzheimer’s care more complicated.
For Dr. Joel Ross, who has watched the field shift from earlier symptom-focused medications to disease-modifying therapies, physicians can now offer patients more. There’s also more to consider before deciding whether one of these treatments belongs in an individual patient’s care.
About Dr. Joel Ross
Dr. Joel Ross is a New Jersey geriatrician, clinical researcher, lecturer, and author with nearly four decades in medical practice. He earned a BA in Biology from Hofstra University and his medical degree from Downstate Medical Center in Brooklyn. After serving as chief resident at Nassau County Medical Center, he completed his fellowship in geriatric medicine at Mount Sinai Medical Center under Dr. Robert N. Butler.
Ross became the first Medical Director of the Anna Alexander Greenwall Geriatric Program at Monmouth Medical Center. He directed New Jersey’s first geriatric fellowship program there and was named Teacher of the Year. He later spent seven years leading the geriatrics section in the Department of Internal Medicine at Jersey Shore Medical Center.
In 2000, he founded the Memory Enhancement Center of America. His multidisciplinary team participated in clinical trials behind the currently approved oral and transdermal Alzheimer’s medications, and Ross has presented Alzheimer’s research at local, regional, national, and international conferences. He has also contributed to peer-reviewed research on neurodegeneration and holds several patents.
Ross is the founder and CEO of J&D Pharmaceuticals LLC in Monmouth, New Jersey. The company is developing JD-004 and JD-005 and has received three FDA Orphan Drug Designations related to the compounds. Both remain investigational and have not been approved by the FDA for treatment use.
He also volunteers at Parker Health Center in Red Bank, where he provides free care, testing, and medications to older patients and gives public lectures on CPR.
