Thanksgiving Conversations
Over Thanksgiving, I was touched by important messages and conversations that spanned continents and contexts. I had two reactions: first, that people are thoughtful, caring, and trusting—and second, that we can do better in how we support families navigating cognitive health concerns.
Here are some of the questions I heard:
"How do I set up a structured plan to support my loved one with cognitive changes in a remote setting where access to resources is limited?"
"How do we deal with the dysfunction in our local healthcare system?"
"A loved one had an unexpected change in medical status while traveling abroad. Do we stay for treatment or travel back to the US? What are the flight risks?"
"My p-tau217 is elevated—what does that mean?"
"We need support, care, and direction now. What can we do?"
"Do the new GLP-1 Alzheimer's results change prevention strategy?"
"Do microplastics disrupt tau clearance?"
These questions all map onto the same three fundamental needs.
1. "What does this signal actually mean? Is this something or is it nothing?"
This is at the heart of what Treasure Coast Cognition does: we tie signal to meaning.
Many people now receive p-tau217 results, Aβ42/40 ratios, inflammatory markers, sleep data from wearables, or confusing research headlines. The challenge is interpretation.
A biomarker is probabilistic, not deterministic. An elevated p-tau217 is a probability, not a diagnosis. Effect sizes in research don't always translate to clinically meaningful change. And what's clinically meaningful isn't always the same as the real-world changes that matter most to you.
The GLP-1 question illustrates this perfectly. The recent Alzheimer's trial results were disappointing—but that doesn't mean GLP-1s don't matter for brain health. What's true for Alzheimer's disease specifically may not be the same as what's true for midlife metabolic risk modification, late-life vascular protection, or pre-dementia cognitive reserve. A negative trial in one disease at one stage doesn't eliminate the potential for meaningful impact in a different context.
Whether the concern is p-tau217, GLP-1 trial results, microplastics, or an urgent medical decision abroad, people are trying to understand: Is this something? Or is it nothing?
At Treasure Coast Cognition, we help individuals and families determine which signals are meaningful—and which are not.
2. "What should I be monitoring over time?"
This is exactly what Treasure Coast Cognition helps you figure out.
People don't just want data—they want direction.
When someone asks "What should I expect?" or "What should I be looking for?" or "How do I know if something is shifting?"—what they're really asking is: Which patterns actually matter, and how do I track them responsibly?
You want to monitor what is meaningful—so you can know when changes are meaningful.
Questions about local healthcare dysfunction reflect this same need. Continuity and longitudinal monitoring are exactly what fragmented systems fail to provide. When the system is broken, people still need guidance—and they need it from someone who understands both the science and the context of where they live.
Traditional healthcare does not provide this continuity. Treasure Coast Cognition does.
3. "What will matter most in the next 5–10 years?"
This question is why I'm building Treasure Coast Cognition here.
Healthcare systems need to work within the context of the places and systems where we live and function. When there's dysfunction in the local healthcare system, we still need to meet the healthcare needs of the community. When someone faces an urgent decision while traveling abroad, they need clarity fast. When a family in a remote setting needs a care plan, they need guidance that works across distance.
Cognitive stewardship has to be embedded in the environment where people actually live.
Questions about why Treasure Coast Cognition exists here, or how to navigate a broken healthcare system, or whether GLP-1s help cognition all point back to a desire for long-term clarity:
How do I stay independent?
How do I protect function?
How do I keep doing the things that matter to me?
What decisions should I prepare for?
What actions actually change my trajectory?
But there's another layer to this question. The microplastics question points to something bigger: What lives in the environment around us that could be changed outside of us to improve our lives? Individual risk modification matters, but so does community-level action to decrease environmental contributors to poor brain health. Cognitive Stewardship isn't just personal—it's also environmental and systemic.
The goal isn't just early detection. It's early direction.
Where the Questions Converge
Even though Thanksgiving brought questions about biomarkers, metabolism, microplastics, healthcare systems, and urgent medical decisions, the underlying focus was the same:
What does this signal mean?
What should I monitor?
What will matter most over the next decade?
Treasure Coast Cognition exists to help people answer these questions with clarity, calm, and evidence—and to help them stay aligned with the life they want to protect.
Interpretation → insight → action.
That's Cognitive Stewardship.
Changes in Financial Decision-Making Can Be the First Sign of Cognitive Decline
The Brain’s Financial Crisis
A 2024 study from the Federal Reserve Bank of New York is the latest alarm bell that missed credit card and mortgage payments can precede a dementia diagnosis by years.
Researchers analyzed data from 2.4 million older adults between 2000 and 2017, linking Medicare claims with Equifax credit report histories. About 478,000 of these individuals were later diagnosed with Alzheimer's disease or related dementias.
Here's what they found:
Financial problems start years before diagnosis.
Credit scores begin to fall and late payments start showing up more than five years before dementia is clinically recognized. Specifically, credit card delinquency increases were observed five years prior to diagnosis, while mortgage delinquency appeared three years before.
By the point of diagnosis, people were over 34% more likely to miss credit card payments and 17% more likely to miss mortgage payments compared to earlier baseline years.
The authors describe "disease-related inattention and decision difficulties"—missed due dates, confused accounts, duplicated payments. The financial decline mirrors the quarter-by-quarter cognitive decline these individuals are experiencing.
Translation: Cognitive decline can show up early in credit scores and bank statements.
Why Finances Fail First
Financial management depends on cognitive skills—many of which decline early in Alzheimer's disease and related dementias.
1. Executive Function
Planning, sequencing, attention, inhibition, and problem-solving—the capacities required to juggle bills, budgets, and deadlines—often show early decline.
2. Prospective Memory
Remembering to do something in the future—pay the electric bill next Tuesday, transfer funds before the autopay hits.
Prospective memory failures are among the most sensitive early markers of decline.
3. Numeracy
Even simple math—calculating interest, comparing prices, checking balances—relies on parietal and frontal brain networks disrupted by early pathological changes.
4. Vulnerability to Exploitation
Subtle cognitive decline—even before mild cognitive impairment is detectable—can result in impaired financial decision-making and increased vulnerability to scams.
5. Increased Altruism and Generosity
Here's a subtle sign that doesn’t seem alarming on the surface: A person who has always been financially conservative suddenly becomes unusually generous.
Research from USC and Bar-Ilan University found that increased financial altruism—giving away more money to anonymous others in experimental tasks—was associated with poorer performance on cognitive tests sensitive to early Alzheimer's disease, including word learning, story recall, and category fluency.
While deliberate generosity is certainly not a negative trait, research suggests that sudden or increased altruistic behaviors may be associated with declining cognitive function in some contexts.
The mechanism appears related to impaired judgment and reduced ability to assess risk and future consequences. The same frontal-executive systems that help us evaluate financial trade-offs and protect our interests are the ones that show early changes in dementia.
Families can interpret this as "Mom's just being nice" or "Dad's finally learning to enjoy his money."
But when generosity represents a significant change from baseline behavior, it may be a signal of cognitive decline.
What the Brain Reveals
In a cohort of 97 cognitively normal adults, researchers found that thinner entorhinal cortex—a structure affected early in Alzheimer's—was linked to greater self-reported vulnerability to financial exploitation (Fenton et al., Cerebral Cortex, 2024).
It's correlational, not diagnostic—but it hints at a neural marker for early financial risk.
In one of my early studies—MRI Volume of the Medial Frontal Cortex Predicts Financial Capacity in Mild Alzheimer's Disease (Brain Imaging and Behavior, 2013)—we found that atrophy in the medial frontal cortex, a hub for attention, calculation, and decision-making, directly predicted poorer financial capacity.
That work, later highlighted by the NIA, helped me discover and understand this:
Financial decision-making could be an early marker of neurodegeneration.
What We Can Do
1. Detect Early
Monitor real-world financial data—credit scores, bill-payment history, online banking patterns, and changes in giving behavior—just as we monitor blood pressure.
2. Plan Legally and Financially While Capacity Intact
Power of attorney, trusts, wills, financial protections, advance directives—complete them before decline.
3. Evaluate Financial Capacity
Financial capacity screening is important, not just screening for cognition. Review bill-paying habits, credit patterns, changes in charitable giving or financial behavior, and transaction histories to identify early warning signs.
Because the earlier we see decline, the more autonomy and dignity we can preserve.
4. Finances Are Personal, So Are The Data
Accessing financial information is sensitive and requires appropriate privacy protections, explicit consent, and security measures that prevent the very exploitation we're trying to detect.
The Bottom Line
Financial errors often precede cognitive diagnosis by years.
Specific brain regions—like the entorhinal and medial frontal cortex—predict financial decline.
Vulnerability to scams tracks with early Alzheimer's-related brain changes.
Increased financial altruism could be a sign of cognitive changes.
If you notice these changes—in yourself or someone you love—don't ignore them. They could be signals from the brain that it's time to pay attention.
References
Gresenz CR, et al. The Financial Consequences of Undiagnosed Memory Disorders. Federal Reserve Bank of New York Staff Reports. 2024;(1106). doi:10.59576/sr.1106
National Institute on Aging. Difficulty Managing Bills May Signal Early Dementia. Published January 16, 2025. Accessed November 12, 2025.
Stoeckel LE, et al. MRI Volume of the Medial Frontal Cortex Predicts Financial Capacity in Patients with Mild Alzheimer's Disease. Brain Imaging Behav. 2013;7(3):282-292. doi:10.1007/s11682-013-9226-3
Fenton L, et al. Lower Entorhinal Cortex Thickness Is Associated with Greater Financial Exploitation Vulnerability in Cognitively Unimpaired Older Adults. Cereb Cortex. 2024;34(9):bhae360. doi:10.1093/cercor/bhae360
Weissberger GH, et al. Increased Financial Altruism is Associated with Alzheimer's Disease Neurocognitive Profile in Older Adults. J Alzheimers Dis. 2022;88(3):995-1005. doi:10.3233/JAD-220187
National Institute on Aging. Increased Financial Generosity Linked to Lower Cognition and May Be an Early Indicator of Alzheimer's Disease. Published June 2022. Accessed November 12, 2025.
National Institute on Aging. Brain Scans Offer Insights into Loss of Money Skills. Accessed November 12, 2025.
Ho EH, et al. A Scoping Review of Financial Decision-Making Measures in Midlife and Beyond: Results from the ARMCADA Study. Front Psychol. 2025;16:1540508. doi:10.3389/fpsyg.2025.1540508
Founder’s Story
Treasure Coast Cognition didn't begin with clinical training or research experience. It began in a workshop in Key Largo with the person who taught me to love science.
The Story
I grew up spending holidays at my grandparents' house in Key Largo fishing and in the small workshop my grandfather built after he retired from flying for Eastern Airlines. He had been a WWII pilot — quiet, precise, methodical — and when he stopped flying, he invented. That workshop was where I learned the practice of science, that circuits could be built as connectors, that problems could be solved.
And then he slowly disappeared from the world he built and the time he spent with me.
The bike rides stopped. The teaching moments faded. His quietness became distance. By the time anyone knew something was wrong, the person I loved was already gone in the ways that mattered most — not his body, but his mind, his ability to be willfully grumpy and to remember the things he'd built like his Coors beer can airplanes.
After he died, I stood in that workshop where he spent hours surrounded by his tools and prototypes, his beer can airplanes hanging from the ceiling, and lottery tickets stapled to the walls. Everything was still. His workshop was still here, but he was gone.
That moment stayed with me. It led me into neuroscience — two decades of research at Harvard, UAB, and the NIH, studying how cognition changes over time. I learned how to measure decline, how to detect it earlier, and how to build personalized prevention programs designed to give families as many meaningful minutes together as possible.
But I also learned that knowing earlier isn't enough.
Families would come to me after years of subtle changes — a missed appointment, a forgotten conversation, a decision that didn't make sense. By the time they arrived, we were clarifying what the diagnosis meant too late.
I founded Treasure Coast Cognition to change that timeline.
If we start early — if we monitor, coordinate, and protect cognition upstream — families stay intact. People remain capable. Transitions happen with dignity instead of crisis.
This work began in a workshop in Key Largo. It continues now, one family at a time, with the families who refuse to wait until it's too late.
We Need To Go To You
I was explaining Cognitive Stewardship to a hospitalist friend over coffee and a beach walk. He listened as I described the model. Then he said: "This needs to be part of a new model for primary care. In-home primary care." I paused. "Tell me more."
Patients cycle through the hospital. Elderly, cognitively impaired, medically complex. Dehydration. UTIs that become delirium. Medication errors. Falls. The family doesn't realize it was this bad. And it’s preventable.
The problem isn't that primary care doctors don't care. It's that they can't see what's happening at home. Fifteen-minute office visits don't capture reality. When families arrive at the hospital, it’s to manage a crisis that's been building for months.
We need to go to you. In-home primary care for people with cognitive changes.
This is what we need that our fragmented healthcare system doesn't provide.
I come home, open my browser, and a new JAMA Network Open study appears showing primary care can spot early signs of dementia. This randomized clinical trial, led by Dr. Malaz Boustani and colleagues at Indiana University, tested a simple idea:
Can primary care clinics detect early cognitive decline using digital tools that fit into everyday workflows? Yes.
The study compared three approaches across nine federally qualified health centers in Indianapolis:
Usual care (no routine cognitive screening)
A machine-learning Passive Digital Marker (PDM) that analyzed existing electronic health record data to flag patients at risk
A PDM + patient-reported QDRS (Quick Dementia Rating System) combined approach
After one year, the combined approach led to 31% more new diagnoses of Alzheimer's disease and related dementias (15.4% vs 12.4% in usual care). Clinicians also ordered more appropriate diagnostic workups—brain imaging, labs, neuropsychological testing.
The key finding: Primary care can implement early cognitive screening at scale without disrupting workflow or adding clinician burden—and it helps identify people who would otherwise be missed.
Detection Isn't Prevention
But here's the piece we still haven't solved:
Detecting early cognitive changes is helpful—but it doesn't automatically lead to better outcomes for patients or families.
Finding early drift in memory, thinking, or executive function is only meaningful if we can do something with that information.
The limits of the study make this clear:
It focused on diagnosis, not real-world functioning
It didn't track hospitalizations, readmissions, or ED visits
It didn't address medication complexity, sleep disruption, caregiver strain, or home safety
It didn't connect detection to interventions that stabilize people at home
The Real Problems Happen at Home
People don't decline in the exam room.
They decline at home.
Long before a crisis or hospital visit, subtle destabilization shows up in:
Medication confusion (pills missed, duplicated, or taken incorrectly)
Sleep disruption (up all night, exhausted during day)
Mood and behavior changes (irritability, withdrawal, anxiety)
Executive function slips (bills unpaid, appointments forgotten)
Caregiver overwhelm (spouse exhausted, adult children burning out)
Missed follow-up appointments (patient forgets, family can't transport)
Mobility declines (unstable gait, near-falls, reduced activity)
Unsafe routines or environments (stoves left on, spoiled food, fall risks)
These changes are detectable. But right now, nobody is watching.
Early cognitive drift is rarely the sole cause of a readmission or major decline—it's the signal that bigger problems are coming.
By the time families seek help, the crisis has already arrived:
Dehydration → hospitalization
UTI → delirium → ED visit
Medication error → hypoglycemia → ambulance
Fall → hip fracture → surgery → skilled nursing facility
Caregiver collapse → emergency nursing home placement
Many of these crises are preventable.
What This Study Actually Tells Us
The JAMA article validates something important:
With the right tools, primary care can see the early drift.
The Passive Digital Marker (machine learning analyzing EHR patterns) plus the Quick Dementia Rating System (patient-reported symptoms) together changed clinician behavior—prompting diagnostic workup and earlier diagnosis.
We can detect cognitive changes in primary care.
Now we need to build the systems that respond before the drift becomes a crisis.
From Detection to Stabilization at Home
Imagine combining detection with a different care delivery model:
Early cognitive detection (QDRS + digital markers embedded in EHR)
↓
In-home comprehensive assessment (where patients actually live and function)
↓
Integrated primary care + cognitive monitoring (not fragmented across specialists)
↓
Proactive stabilization:
Medication safety monitoring (are pills being taken correctly?)
Sleep optimization (treating sleep apnea, adjusting sedating medications)
Mobility and fall prevention (PT, home safety evaluation)
Nutrition and hydration (addressing weight loss, dehydration before crisis)
Caregiver support (respite, education, burden monitoring)
Decision-preparedness coaching (legal, financial, advance directives)
↓
Continuous monitoring (monthly home visits, not annual clinic check-ins)
↓
Crisis prevention (hospitalizations, ED visits, nursing home placement)
Prevent hospital readmissions and preserve independence not by waiting for the next clinic visit, but by creating a continuous stability layer around the patient at home.
In-Home Primary Care
Traditional office-based primary care is not set up for cognitive change:
Transportation barriers if driving becomes risky or people refuse to visit the clinic
Clinic performance ≠ home performance: Someone may seem fine in a structured 15-minute clinic visit, but they may look very different at home
Medication management invisible: Pill bottles in clinic don't reveal whether pills are being taken correctly
Reactive, not proactive: Patient presents when crisis occurs; no monitoring between visits
Family excluded: Caregivers can't attend every appointment; clinician doesn't see family dynamics
In-home primary care solves these problems:
Direct observation: See how people actually function in their environment
Medication reality check: Pills scattered on counter, organizer filled incorrectly, expired meds not discarded
Home safety assessment: Loose rugs, clutter, spoiled food, burners on
Caregiver assessment: visible exhaustion, adult daughter on verge of quitting job
Early intervention: Detect problems before crises (dehydration, UTI, medication errors, fall risk)
Continuous relationship: Monthly visits create trust; patients more likely to report problems early
When you combine digital cognitive detection with in-home primary care delivery, you create a powerful prevention model:
Early detection identifies patients at risk
Home-based assessment reveals functional realities invisible in clinic
Integrated medical + cognitive management addresses complexity comprehensively
Continuous monitoring catches destabilization early
Proactive intervention prevents crises
Where Do We Go From Here?
Primary care can detect early cognitive decline.
Now we need to take the next step:
Build the systems that turn detection into prevention.
Extend monitoring from the clinic into the home where risk actually unfolds.
Create continuous stability around patients before crises force reactive management.
That's the work ahead.
My hospitalist friend was right. We need to go to them. We can detect the problems. Now we need to build the systems that prevent the crises—one home visit at a time.
Reference
Boustani MA, Ben Miled Z, Owora AH, et al. Digital Detection of Dementia in Primary Care: A Randomized Clinical Trial. JAMA Netw Open. 2025;8(11):e2542222. doi:10.1001/jamanetworkopen.2025.42222
What Matters Most
Does a 0.45-point difference on a clinical scale matter?
In the Phase 3 CLARITY-AD trial of lecanemab, patients with early Alzheimer’s disease treated with the drug had a mean change in CDR-SB of ≈ +1.21 at 18 months versus +1.66 on placebo (difference ≈ –0.45 points, p <0.001) — representing roughly a 27% slower rate of clinical decline.
Is a –0.45-point difference meaningful to a person or family? The minimum clinically important difference (MCID) literature suggests that, in MCI populations, a change of about +1 point on CDR-SB may represent the smallest shift likely to be noticeable.
In other words: while the result is statistically significant, it remains uncertain whether every individual would “feel” the difference, whether their family would observe it, or whether meaningful functions (e.g., independent living, driving safety, remembering loved ones) would be preserved.
Would this difference be noticeable in your daily life?
Would you feel different?
Would your family see a difference?
Would it preserve what you're terrified of losing?
The honest answer: We don't know.
What Clinical Trials Typically Measure:
CDR-Sum of Boxes scores (clinician ratings of thinking and function)
Amyloid plaque levels in the brain (measured by blood biomarkers and PET scans)
Cognitive test performance
Global clinical impression (clinician's rating of overall severity)
What Patients and Families Say Matters Most (in order):
Improving or restoring memory
Stopping disease progression
Slowing disease progression
Improving ability to do everyday tasks
Remembering family members
Remaining independent and not feeling like a burden
Removing plaques and tangles from the brain
Notice what's at the bottom? Removing amyloid plaques.
Notice what's missing entirely? The scales clinical trials use don't directly measure most of what patients care about: remembering loved ones' faces, not feeling like a burden, maintaining independence.
The 0.45-Point Question
Let's return to lecanemab's 0.45-point difference on the CDR-SB scale over 18 months.
Is 0.45 points meaningful?
The research community: Maybe. One expert panel suggested 0.5-1.0 points in a single domain (like memory) could be meaningful if caught early enough.
Patients and families: We don't know.
Does it mean:
Mom will remember my name for an extra 6 months?
Dad can balance his checkbook a bit longer?
My spouse won't need 24/7 care quite as soon?
I'll have more "good days" when I feel like myself?
These are the questions that matter and clinical trials typically don’t.
What "Clinically Meaningful" Should Mean
A 2025 workshop report proposed a new framework for defining meaningful outcomes in Alzheimer's trials:
1. Patient-Centered Outcomes Must Be Primary
Not secondary endpoints or exploratory analyses—primary. Trials should measure:
Patient-reported quality of life
Ability to perform activities that matter to the individual (hobbies, social engagement, self-care)
Caregiver burden and quality of life (disease affects the whole family)
Time to critical milestones (loss of independence, residential transition, loss of specific abilities)
2. "Minimal Clinically Important Difference" Must Reflect Patient Perspective
Currently, experts define thresholds like "1-2 CDR-SB points is meaningful." But meaningful to whom?
Better approach: Ask patients and families experiencing different levels of decline: "How much improvement or slowing would need to occur for you to consider treatment worthwhile given the risks, costs, and burdens?"
This is called anchoring to patient global impression of change—linking statistical measures to what people actually feel and notice.
3. Time Savings Must Be Interpretable
How many months of progression are delayed?
For example:
"Lecanemab provides approximately 5-7 months of delay in progression over 18 months of treatment"
"This means remaining at your current level of function about 5-7 months longer than you would without treatment"
This is interpretable. Patients can weigh: "Is 5-7 months of preserved function worth 18 months of infusions, MRI monitoring, risk of brain swelling, and cost?"
Different people will answer differently—and that's okay. The point is informed decision-making based on outcomes that matter.
Long-Term Economic Value
Modeling shows that even modest slowing of decline creates long-term value:
Scenario 1: 18 months of lecanemab, 27% slowing
Increased lifetime quality-adjusted life years (QALYs)
Reduced informal caregiving hours
Medical cost savings from delaying severe dementia stage
Net value: ~$40,000-60,000 per patient over lifetime
Scenario 2: 48 months of treatment, 50% slowing (hypothetical future treatment)
Dramatically increased QALYs
Years of delayed nursing home placement
Preserved workforce participation for both patient and caregiver
Net value: ~$150,000-200,000 per patient over lifetime
The insight: Even small effects compound over time. A 25% slowing may not seem dramatic year-to-year, but over 5-10 years could mean:
1-2 extra years living at home vs. nursing facility
1-2 extra years employed (for early-onset patients)
1-2 extra years when family caregivers don't need to quit jobs
Delayed transition to 24/7 care needs
But these benefits aren't captured in 18-month trials measuring CDR-SB scores.
People Are Complex
Research establishing Alzheimer's biomarkers has largely been conducted in select populations.
The problem:
Biomarkers (amyloid, tau) may be less strongly associated with cognitive decline in some people
Why? Likely because other factors contribute more to cognitive impairment:
Vascular disease from uncontrolled hypertension and diabetes
Social determinants of health (education quality, socioeconomic status)
Mixed pathologies (not pure Alzheimer's but combined pathologies)
Translation: What's "clinically meaningful" may differ depending on the person.
What This Means for Cognitive Stewardship
1. We Must Ask What Matters to YOU
In initial consultations, I ask:
What abilities are you most afraid of losing?
What would "success" look like for a treatment?
What trade-offs are you willing to accept (burden, cost, risk) for how much benefit?
What defines quality of life for you right now?
These answers guide everything: Whether to pursue treatments, which risk factors and lifestyle interventions to prioritize and how aggressive you should be, when to initiate legal planning.
2. We Must Measure What Matters
In addition to cognition, Cognitive Stewardship measures:
Functional capacity across domains (financial, medication management, driving, meal preparation)—the IADLs that patients prioritize
Patient-reported quality of life and sense of well-being
Care partner burden and family impact
Preservation of meaningful activities (hobbies, social connections, independence)
Time to critical milestones (independent living, drive safely, manage finances)
Every 6 months, we assess: Are you maintaining the abilities that matter most to you? Is quality of life preserved? Is family coping?
This tells us whether interventions are working in ways that matter—not just whether CDR-SB changed by 0.5 points.
3. We Must Translate Science into Lived Experience
I don't tell patients: "Your CDR-SB score increased 1.5 points over the past year."
I say: "Your memory and problem-solving have declined to a level where managing finances independently is becoming risky. Last year, you could balance your checkbook and detect errors. Now, you're missing bills and making calculation mistakes. This suggests we should implement financial protections like joint account management and power of attorney activation."
I don't say: "Lecanemab slows decline by 0.45 CDR-SB points over 18 months."
I say: "Lecanemab might give you about 5-7 months longer at your current level of function—meaning abilities like driving, managing your home, and participating in hobbies might be preserved a bit longer. We'd need to weigh this modest benefit against biweekly infusions, brain swelling risk, and costs. What feels right to you?"
This is patient-centered communication—translating research findings into terms that enable informed decisions.
4. We Must Empower Patients with Their Own Data
The Study Participant Bill of Rights says patients deserve their research results. Cognitive Stewardship goes further: You deserve results explained in context, with action plans, and with continuity of expertise.
You're not a data point. You're a partner in managing your cognitive health.
The Bottom Line: Ask the Right Questions
The next time you read a headline about an Alzheimer's drug showing "statistically significant benefit," ask:
Benefit for what outcome?
Meaningful to whom?
How would this feel in daily life?
Is this what patients and families are hoping for?
The 0.45-point CDR-SB difference isn't inherently meaningful or meaningless. Context makes it meaningful:
To a 68-year-old woman terrified of forgetting her grandchildren, 5-7 months of preserved memory might be priceless—worth the infusions and risks.
To an 82-year-old man who values quality over quantity and hates medical procedures, modest slowing may not justify treatment burden.
Both are valid. The problem is we don't have the data to help people make truly informed choices aligned with their values.
Cognitive Stewardship fills the gap—measuring what matters, translating science into lived experience, and empowering you to make decisions aligned with your priorities.
References
van Dyck CH, Swanson CJ, Aisen P, et al. Lecanemab in Early Alzheimer's Disease. N Engl J Med. 2023;388(1):9-21. doi:10.1056/NEJMoa2212948
Andrews JS, Desai U, Kirson NY, et al. Disease Severity and Minimal Clinically Important Differences in Clinical Outcome Assessments for Alzheimer's Disease Clinical Trials. Alzheimers Dement (N Y). 2019;5:354-363. doi:10.1016/j.trci.2019.06.005
Stoeckel LE, Fazio EM, Hardy KK, Kidwiler N, McLinden KA, Williams B. Clinically Meaningful Outcomes in Alzheimer's Disease and Alzheimer's Disease-Related Dementias Trials. Alzheimers Dement (N Y). 2025;11(1):e70058. doi:10.1002/trc2.70058
What Would You Change?
The Diagnostic Breakthrough
On July 28, 2025, the Alzheimer's Association released clinical practice guidelines recommending how specialty clinicians should use blood-based biomarkers (BBMs).
Why this matters: Until now, confirming Alzheimer's disease required either a lumbar puncture (spinal tap) to analyze cerebrospinal fluid or a PET scan. Both are invasive, expensive, and inaccessible to many families. Now, a simple blood test—drawn at your doctor's office, processed by commercial labs—can detect Alzheimer’s pathology with ~90%+ diagnostic performance in peer-reviewed studies (exact performance varies by assay and population). In May 2025, FDA cleared the first blood test measuring plasma p-tau217 and it is now available.
Do you want to know?
The Question No One Is Asking
Doctors are asking:
"Should we order the test?"
Researchers are asking:
"How accurate is it?"
Insurance companies are asking:
"Will we cover it?"
But the most important question for families is:
What would you change if you knew you had Alzheimer's pathology in your brain?
Not "what can be done"—what would YOU do differently?
What It Means to Know
You have Alzheimer's pathology—amyloid plaques and tau tangles—accumulating in your brain right now.
It does NOT mean:
You will definitely develop dementia (some people with pathology never progress)
You will decline rapidly (timeline is unpredictable—could be 2 years, could be 20)
Your fate is sealed (interventions can slow progression)
You should panic
What it DOES mean is that a door has opened to early intervention when new treatments are available and when lifestyle intervention works best. A door to legal planning while you have full capacity. A door to decisions that become more difficult later. A door to preparing your family before crisis.
The New Disease-Modifying Therapies
Lecanemab and donanemab—FDA-approved drugs that slow Alzheimer's progression by about 25%—have strict eligibility requirements:
✅ Mild cognitive impairment OR mild dementia
✅ Confirmed amyloid pathology (requires biomarker test)
❌ NOT moderate or severe dementia
Translation: If you wait until symptoms are obvious, you're likely ineligible. The treatment window closes at moderate dementia.
The Lifestyle Intervention Evidence
The FINGER trial in Finland and US POINTER trial (2025) proved that intensive multi-domain lifestyle interventions can slow cognitive decline. The Lancet Commission (2024) reported 14 modifiable risk factors for dementia. Higher physical activity is associated with slower cognitive and functional decline in individuals with elevated baseline amyloid. Critical finding: Benefits are greatest when started in the MCI stage or earlier. Once moderate dementia arrives, lifestyle interventions are much less effective for patients, but become more important for managing caregiver stress and well-being.
Approaches Providers Can Take Right Now
Approach 1: "Test Everyone with Symptoms"
The problem: Testing without infrastructure to support results. Knowledge without guidance. Diagnosis without stewardship.
Approach 2: "Don't Test Unless It Changes Management"
The problem: Avoidance doesn't prevent progression—it just prevents preparation. The "wait and see" approach guarantees missing treatment windows.
There's a Third Approach: Decision-Preparedness Testing
The question isn't "should we test?" The question is: "What would we do with results?"
"If the test shows Alzheimer's pathology, what would you do?"
Would you pursue disease-modifying therapy?
Would you intensify lifestyle interventions?
Would you accelerate legal and financial planning?
Would you have family conversations about the future?
Would you consider clinical trial participation?
"What are your biggest fears about knowing?"
Anxiety about the future?
Impact on relationships or self-identity?
Discrimination concerns (employment, insurance)?
Not knowing how to act on results?
If your list has 3+ items, have a conversation about testing. Tests are best acted on in specialty care or within a defined care pathway, per the AA guideline.
What To Do Next
If you or a family member has cognitive concerns:
1. Seek Expert Evaluation (Not Just Primary Care Screening)
Primary care doctors are excellent at many things, but detailed cognitive assessment and BBMs interpretation require specialized expertise
See a neuropsychologist, neurologist, or geriatrician with cognitive disorders expertise
Insist on comprehensive evaluation, not just MoCA or MMSE (too insensitive for early changes)
2. Don't Go It Alone
Cognitive decline is a family journey—involve spouse, adult children, trusted friends
Seek services that provide longitudinal support, not just episodic evaluation
Consider programs like Cognitive Stewardship that offer continuous monitoring and decision coaching
3. Act on Results
If biomarker-positive: Immediately begin evidence-based interventions (lifestyle optimization, DMT evaluation if appropriate, advance planning)
If biomarker-negative: Pursue alternative diagnoses and address modifiable factors
Don't let positive results cause paralysis—this is where expert guidance is critical
4. Stay Informed
Biomarker science is evolving rapidly—guidelines will update
Clinical trials are ongoing—opportunities for cutting-edge treatment
New therapies in pipeline—tau-targeting drugs, anti-inflammatory agents, combination therapies
The window for intervention is open. The tools for early detection are here. The question is: Will you use them?
Early Detection Is Only Valuable If Followed by Action
The 2025 Alzheimer's Association guidelines on BBMs represent a pivotal moment in the fight against Alzheimer's disease. For the first time, we can detect pathology early, accurately, and accessibly.
Some experts believe direct-to-consumer or at-home Alzheimer’s blood biomarker testing may be “an innovation too far” — meaning it may cause more harm (anxiety, misinterpretation, unnecessary follow-up tests, discrimination) than benefit in the current state.
They want:
Better care infrastructure: Legal protections against discrimination for biomarker-positive individuals; more clinicians trained in dementia/Alzheimer’s care.
Funding & workforce expansion: More specialists need to be trained and available.
Verified treatments in asymptomatic people: Tests only make sense when there are actionable interventions for people who test positive but do not have symptoms.
This is why I created Cognitive Stewardship. The science of early detection has advanced faster than the clinical infrastructure to support it. Families are getting biomarker results without guidance to know what’s next.
We close that gap.
If you or a loved one has cognitive concerns, or if you've received biomarker results and aren't sure what to do next, Treasure Coast Cognition is here to help.
References
Alzheimer's Association. Appropriate Use of Blood-Based Biomarkers in Alzheimer's Disease: Clinical Practice Guideline From the Alzheimer's Association. Alzheimers Dement. 2025. Published online July 28, 2025. doi:10.1002/alz.14225
Labcorp. Labcorp Launches First FDA-Cleared Blood Test for Alzheimer's Disease. Published May 2025.
Yaffe K, Barnes DE, Rosenberg D, et al. Effect of a Multidomain Lifestyle Intervention vs Health Education on Cognitive Function in Older Adults at Increased Risk of Alzheimer Disease: The US POINTER Randomized Clinical Trial. JAMA. 2025;333(3):217-229. doi:10.1001/jama.2024.24157
Livingston G, Huntley J, Liu KY, et al. Dementia Prevention, Intervention, and Care: 2024 Report of the Lancet Standing Commission. Lancet. 2024;404(10452):572-628. doi:10.1016/S0140-6736(24)01296-0
Rabin JS, et al. Physical Activity and Longitudinal Cognitive and Functional Decline in Alzheimer Disease. Nat Med. 2025. doi:10.1038/s41591-025-03955-6
Personalized Prevention: Targeting Modifiable Risk Factors in Cognitive Stewardship
2024 Lancet Commission: 45% of Dementia is Potentially Preventable in the Population
The 2024 Lancet Commission on dementia prevention now identifies 14 modifiable risk factors that collectively account for 45% of dementia cases worldwide—up from 40% in the prior analysis with the addition of high LDL cholesterol and vision loss.
45% represents the theoretical maximum if all risk factors were eliminated across entire populations from early life through late life. This does NOT mean that any individual optimizing their risk factors has a 45% reduced dementia risk.
Midlife Interventions May Be Most Critical
The majority of modifiable risk burden (approximately 60% of the 45%) occurs in midlife when vascular and metabolic risk factors exert their greatest impact on brain health decades later.
Life-Course Risk Factor Model
Early Life (ages <45):
Less education (5%) - Limited cognitive stimulation and cognitive reserve building in formative years
Midlife (ages 45-65):
Hearing loss (7%) - The single largest modifiable risk factor
High LDL cholesterol (7%) - NEW for 2024; midlife dyslipidemia accelerates vascular brain changes
Depression (3%) - May be both risk factor and early symptom
Traumatic brain injury (3%) - Even mild TBI increases long-term dementia risk
Physical inactivity (2%) - Sedentary lifestyle deprives brain of neurotrophic benefits
Diabetes (2%) - Chronic hyperglycemia damages cerebral microvasculature
Smoking (2%) - Vascular damage and oxidative stress
Hypertension (2%) - Uncontrolled BP in midlife drives white matter disease
Obesity (1%) - Metabolic syndrome and chronic inflammation
Excessive alcohol (1%) - >21 units/week associated with brain atrophy
Late Life (ages >65):
Social isolation (5%) - Lack of cognitive stimulation and increased depression risk
Air pollution (3%) - Fine particulate matter (PM2.5) exposure causes neuroinflammation
Vision loss (2%) - NEW for 2024; untreated cataracts and poor vision reduce engagement
2025 US POINTER Trial: Lifestyle Prevention
Published January 2025 in JAMA, the US Study to Protect Brain Health Through Lifestyle Intervention to Reduce Risk (POINTER) trial represents the first large-scale validation of the Finnish FINGER model in Americans.
Key Findings
Primary Outcome - Global Cognitive Composite: equivalent to 1-2 years of preserved cognitive function
Critical Insights: Any lifestyle intervention, even minimal, provides benefit. However, structured programs deliver ~30% greater cognitive gains (0.24 vs. 0.21 SD/year improvement). The program works, but only if people actually do it. Cognitive Stewardship provides care coordination and evidence-based strategies adherence strategies for maintenance of behavior change to slow decline, not prevent dementia.
Cognitive Stewardship can help translate the Lancet Commission's 14 modifiable risk factors and the US POINTER trial's structured intervention model into a personalized, sustainable program for your brain health. Through continuous monitoring, expert guidance, and intensive support, we can help you implement these evidence-based strategies proven to slow cognitive decline—while also navigating the 10 critical decision points where expert guidance prevents costly mistakes. You get both: (1) Personalized lifestyle intervention for cognitive protection, and (2) Decision-preparedness coaching for life transitions. Together, these maximize your cognitive trajectory and quality of life.
References
Livingston G, Huntley J, Liu KY, et al. Dementia Prevention, Intervention, and Care: 2024 Report of the Lancet Standing Commission. Lancet. 2024;404(10452):572-628. doi:10.1016/S0140-6736(24)01296-0
Yaffe K, Barnes DE, Rosenberg D, et al. Effect of a Multidomain Lifestyle Intervention vs Health Education on Cognitive Function in Older Adults at Increased Risk of Alzheimer Disease: The US POINTER Randomized Clinical Trial. JAMA. 2025;333(3):217-229. doi:10.1001/jama.2024.24157
Gratitude
I have been given time to create the start of something new.
💌 This is a love letter to my friends, family, and colleagues for their support, feedback, and encouragement.
📭 I am now accepting 5 Founding Families for a 6-month Cognitive Stewardship Program beginning in early 2026. We'll walk through the 10 critical decisions families face during early cognitive decline together.
🪴This is not yet a love letter to you, Founding Families, but it will be. This grew from family voices, patient voices, caregiver voices. These voices matter most. This will continue to grow from those roots, in the place with the people that share my roots.
🙏 Grateful to serve in a new way.
The Healthcare System Isn’t Ready
A colleague was at her primary care visit. She asked how to get blood-based biomarker testing at a major university medical center (where she sees her doctors), and was told that she could try to go through neurology but at her age it was basically impossible. Maybe the response would have been different if she were older, but it struck her that even those proactive about getting tested face significant barriers.
Even at top medical centers, proactive families face impossible barriers:
You can't get blood biomarker testing because you're "too young" or "not symptomatic"—despite tests that predict dementia 10 years before symptoms appear.
Your primary care doctor waits for obvious memory problems before acting—by then, treatment eligibility windows have already narrowed dramatically.
Specialist referrals take 3-6 months. Eligibility testing takes another 2 months. By the time traditional care pathways respond, half of early dementia patients have already progressed beyond treatment eligibility.
Healthcare system delays happen when you need action.
Cognitive Stewardship changes this.
We help families act years earlier—with proactive monitoring, personalized intervention, and access when concerns emerge—so you can intervene when science shows it matters most.
The Waiting Years
The Waiting Years.
A friend reached out.
She told me about her mother.
October 2023: The family noticed changes. Memory issues. Movement struggles. They called the university memory clinic — the one everyone recommends.
First available appointment: September 2024.
So they found a physician’s assistant in another city. Tried there. The physician’s assistant was doing their best. The answers didn’t fit what the family was seeing.
By the time they finally reached the specialist and got a DaTscan ordered, it was August 2025.
How hard is it to get imaging?
MRI: Easy.
DaTscan: Not easy.
Real-world barriers:
• Insurance approval: weeks to months
• Limited centers
• 6–12 month wait times
• Some neurologists wait until symptoms are “obvious enough”
Meanwhile, families wait.
Nearly two years from first noticing changes to getting the right diagnosis.
Not because they didn’t care.
Not because they didn’t try.
Because the system isn’t built for the early stage.
In those two years, they navigated alone:
Is this normal aging?
Should we push for different tests?
Which supplements matter?
When do we get a walker? A shower chair?
How do we find the right support?
Where do we find support?
My friend is a researcher. She did everything right. She dug through forums, found Zoom groups, paid thousands for a “personalized” program that delivered generic guidance.
She told me:
“I would have paid anything to not wait. Not for a cure — just for someone who knew what to ask for and when.”
That gap — between noticing something is wrong and getting meaningful support — is where families lose time.
Cognitive Stewardship™ can help.
Not to replace your medical team.
Not to diagnose alone.
To guide families through the waiting — the uncertainty, the decisions, the system navigation.
To make sure that when they finally reach the specialist, they haven’t lost two years.
If you’ve lived this — the waiting, the confusion, the “I wish someone had told us” — what did you need most?
I’m building this for the families who shouldn’t have to navigate alone.
Please share your story. Your experiences are shaping this work.
The views expressed here are my own and do not represent those of the NIH or the U.S. government.