Socio-Gerontological Perspectives on Introducing New Alzheimer's Therapies: A Delphi Study Across Central European Care Contexts

1. Introduction

Alzheimer's disease (AD) represents one of the most significant health and social care challenges associated with population ageing. The increasing prevalence of dementia places growing pressure not only on healthcare systems but also on long-term care structures, informal caregiving networks, and wider social support systems (Maestre et al., 2023). Beyond its clinical manifestations, dementia is increasingly recognised as a complex social and ethical phenomenon associated with stigma, dependency, loss of autonomy, and broader societal attitudes toward ageing and cognitive decline (Zimmermann, 2017). In recent years, the emergence of disease-modifying therapies (DMTs) for Alzheimer's disease, particularly anti-amyloid monoclonal antibodies such as Lecanemab, has introduced a significant shift in the therapeutic paradigm of dementia care. Unlike traditional symptomatic therapies, disease-modifying treatments aim to slow disease progression by targeting underlying neuropathological mechanisms, particularly amyloid-β accumulation. Clinical evidence from the CLARITY-AD trial demonstrated that Lecanemab may slow cognitive and functional decline in individuals with early Alzheimer's disease (van Dyck et al., 2023). However, the introduction of disease-modifying therapies also raises broader ethical, organisational, and socioeconomic challenges that extend beyond pharmacological efficacy alone. Unlike conventional symptomatic treatments, DMTs require early diagnosis, biomarker confirmation, longitudinal monitoring, and specialised healthcare infrastructure, including amyloid PET imaging, cerebrospinal fluid analysis, MRI monitoring, infusion services, and genetic testing (Walsh et al., 2024; Cummings et al., 2024). Consequently, implementation of these therapies may place substantial pressure on already strained healthcare systems and intensify inequalities in access to diagnostics and treatment. Several authors have emphasised that the implementation of new Alzheimer's therapies raises important ethical concerns regarding informed consent, prioritisation of treatment eligibility, reimbursement policies, and healthcare equity (Karneboge et al., 2025; Yeo-Teh & Tang, 2023). Furthermore, concerns remain regarding the psychological and social implications of early diagnosis, particularly in environments where dementia continues to be highly stigmatised (Clement et al., 2015; Zimmermann, 2017). Previous research has shown that stigma may negatively influence help-seeking behaviour and delay diagnostic processes, thereby limiting opportunities for timely intervention (Clement et al., 2015). In this context, public awareness and destigmatisation become increasingly important components of successful therapeutic implementation. The anticipated impact of disease-modifying Alzheimer's therapies is also closely connected to the future organisation of long-term care systems. Earlier diagnosis and prolonged management of mild stages of dementia may require a gradual transition from institution-centred models of care toward more flexible, community-based, and person-centred approaches. Previous studies suggest that implementation of DMTs will likely increase demand for specialised consultations, diagnostic pathways, interdisciplinary coordination, caregiver support, and adapted long-term care services (Aye et al., 2025). Consequently, the introduction of these therapies represents not only a biomedical innovation but also a broader socio-gerontological challenge affecting healthcare systems, workforce structures, caregiving models, and social policy. These challenges may be particularly relevant within Central European healthcare and long-term care systems, where considerable differences exist regarding financing models, service organisation, dementia care infrastructure, and cultural attitudes toward ageing and family caregiving. Austria, Slovenia, and Bosnia and Herzegovina represent distinct healthcare and social care contexts characterised by varying levels of preparedness for the implementation of innovative Alzheimer's therapies. While Austria has already initiated certain implementation processes for anti-amyloid therapies (Kunz, 2025), Slovenia and Bosnia and Herzegovina continue to face broader systemic and financial barriers to diagnostic capacity, reimbursement structures, and long-term care adaptation. Despite rapidly growing clinical literature on disease-modifying Alzheimer's therapies, their societal, ethical, and systemic implications within Central European healthcare and long-term care contexts remain insufficiently explored. This study addresses this gap by examining expert perspectives on the anticipated challenges associated with introducing Lecanemab into these care systems. Development and Mechanism of Action of Beta-Amyloid Antagonists such as Lecanemab The development of anti-amyloid monoclonal antibodies such as Lecanemab represents a shift from symptomatic Alzheimer's disease treatment toward disease modification. By targeting soluble amyloid-β protofibrils, Lecanemab aims to slow cognitive and functional decline in the early stages of the disease (van Dyck et al., 2023). Compared with earlier anti-amyloid therapies such as Aducanumab, (sold under the brand name Aduhelm) Lecanemab has been associated with a more favourable balance between efficacy and safety, although concerns regarding implementation, monitoring requirements, and long-term clinical benefit remain under discussion (Cummings et al., 2024; Yeo-Teh & Tang, 2023). Risks and Patient Eligibility Criteria for Lecanemab Treatment Clinical evidence from the CLARITY-AD Phase III trial indicates that Lecanemab may slow cognitive decline in patients with early Alzheimer's disease; however, treatment is associated with potentially serious adverse events, primarily amyloid-related imaging abnormalities (ARIA), which are detected through magnetic resonance imaging and may be symptomatic or asymptomatic (van Dyck et al., 2023). The risk of ARIA is higher among ApoE ε4 carriers, particularly homozygotes, which necessitates genetic testing before treatment initiation to inform risk stratification (Ritchie et al., 2024). Consequently, regulatory recommendations restrict Lecanemab therapy to patients with mild cognitive impairment or mild dementia due to Alzheimer's disease, confirmed through PET imaging or cerebrospinal fluid analysis. Baseline and periodic MRI monitoring are required to detect ARIA and guide treatment decisions (U.S. Food and Drug Administration, 2023). Jönsson et al. (2023) estimate that approximately 5.4 million individuals in the 27 EU countries could potentially be eligible for Lecanemab treatment, with annual treatment costs exceeding 133 billion EUR if priced similarly to the United States. Table 1 provides an overview of estimated annual per-patient costs of Lecanemab across selected healthcare systems.

This study used a modified Delphi design combining qualitative and quantitative elements to systematically collect, refine, and prioritise expert perspectives on the anticipated social, ethical, and systemic implications of introducing disease-modifying therapies for Alzheimer's disease. The Delphi method is a structured, iterative research technique designed to collect and refine expert opinion through multiple rounds of questionnaires and controlled feedback (Hasson et al., 2000; Keeney et al., 2011). Based on the methodological literature, the Delphi approach was selected because it is particularly suitable for research areas in which empirical evidence remains limited, future implementation pathways are uncertain, and multidisciplinary expert judgement is required to inform healthcare policy, clinical practice, and system development (Jorm, 2015). In addition, Delphi methods are widely used in gerontology, nursing, and palliative care research to support the development of operational, organisational, and ethical recommendations (Jünger et al., 2017).

2. Results

Across the three Delphi rounds, experts identified several recurring themes related to the anticipated societal, ethical, and systemic implications of introducing disease-modifying therapies for Alzheimer's disease. The findings demonstrated partial thematic alignment across key priorities, particularly in public awareness, long-term care adaptation, equitable access to treatment, and healthcare system preparedness.

3. Results delphi first round: identification of key themes

In the first Delphi round, experts provided open-ended responses regarding the potential societal, ethical, and systemic implications of introducing new disease-modifying therapies for Alzheimer's disease. The responses addressed three broad areas: societal impacts of new therapies, public awareness and attitudes toward early signs of Alzheimer's disease, and potential effects on long-term care systems. Qualitative analysis of the collected expert statements yielded twenty-nine thematic codes representing the most recurrent concepts identified across responses. These themes were grouped into positive, negative, and neutral categories, as presented in Tables 3-5.

Tables 3-5 summarise the semantic analysis of expert responses. Positive statements emphasised increased public awareness, greater patient autonomy, expectations that scientific progress may improve access to treatment, and the potential for new care models. Negative statements primarily reflected concerns about high medication costs, possible side effects, limited accessibility, and insufficient preparedness of existing health systems. Neutral statements focused on ethical dilemmas, the need for adapted care models, and the continuing role of stigma in delaying early diagnosis and treatment. Among the identified themes, public awareness and destigmatisation emerged as among the most prominent themes. Experts emphasised that early diagnosis and treatment uptake depend strongly on reducing stigma and improving public and professional understanding of Alzheimer's disease. Other recurrent themes included limited accessibility, the need for systematic change, financial barriers, diagnostic complexity, and the adaptation of long-term care services to earlier stages of the disease. Overall, the first Delphi round established a framework of interconnected social, ethical, and systemic issues that informed the subsequent prioritisation process.

4. Results delphi second round: rating and refinement of themes

In the second Delphi round, experts further evaluated the themes identified in the first round. The highest-rated areas were related to public awareness and destigmatisation, long-term care adaptation, and equitable access to innovative Alzheimer's therapies. Statements addressing public and professional education, reducing dementia-related stigma, and preparing care systems for earlier-stage disease management received consistently high ratings. Themes related to diagnostic complexity, financial burden, reimbursement, and organisational preparedness also received high evaluations. These findings indicate that experts viewed the implementation of disease-modifying therapies not only as a clinical innovation but also as a broader health system challenge requiring coordinated diagnostic pathways, professional training, and sustainable financing mechanisms. The second round, therefore, refined the initial qualitative findings into three central thematic clusters: public awareness and destigmatisation; long-term care and system adaptation; and access, equity, and the ethical allocation of medications. These clusters informed the selection of the ten highest-rated statements for final prioritisation in the third Delphi round.

5. Results delphi third round: final prioritisation of themes

In the third Delphi round, the ten highest-rated statements from the previous phase were ranked according to their perceived overall importance for the implementation of disease-modifying therapies for Alzheimer's disease. Table 6 presents the final ranking of statements based on expert evaluations.

As shown in Table 6, the final ranking identified several highly prioritised themes, with mean importance scores ranging from 7.14 to 9.71 on a 10-point scale. Two statements shared the highest rank: ``Raise awareness and educate the public and healthcare professionals'' (M = 9.71) and ``Develop new long-term care tailored to AD patients'' (M = 9.71). These findings indicate the importance that experts attribute to both public and professional education, as well as to the adaptation of long-term care systems to emerging therapeutic developments. The third-ranked statement, ``Faster access to new drugs should be ensured'' (M = 9.43), reflected concerns regarding timely and equitable availability of disease-modifying therapies. Other highly ranked statements emphasised the need to reduce stigma, consider cultural beliefs and healthcare funding, and ensure accessibility despite pricing strategies. Overall, the ranking results suggest three closely interconnected priority areas: increasing awareness and education, adapting care systems to new treatment paradigms, and ensuring equitable access to innovative Alzheimer's therapies.

6. Discussion

The findings of this Delphi study provide insight into how experts perceive the broader societal and systemic implications of introducing disease-modifying therapies for Alzheimer's disease. The results highlight several interconnected themes: public awareness, ethical and structural challenges, and the need to adapt long-term care systems. The following discussion interprets these findings within the context of existing research and considers their implications for health and social care systems in Central Europe.

7. Conclusion

This study suggests that the emergence of disease-modifying therapies for Alzheimer's disease represents both a therapeutic opportunity and a systemic challenge. Rather than demonstrating strong consensus, the findings indicate that three key priority areas emerged from the Delphi process: increasing public and professional awareness, ensuring equitable access to diagnostics and treatment, and adapting long-term care systems to new therapeutic realities. Although these innovations offer potential to delay disease progression and improve quality of life, their integration into practice will require coordinated health system reforms, strengthened diagnostic capacity, and sustained public engagement to reduce stigma. The findings should therefore be understood as shared thematic priorities rather than definitive expert consensus. Ultimately, the promise of new Alzheimer's therapies extends beyond pharmacological advances and calls for a broader societal commitment to transforming dementia care. This study has several limitations. The expert panel was relatively small and geographically limited to Central Europe, which may restrict the generalisability of the findings. Additionally, the Delphi method reflects expert opinion rather than empirical clinical outcomes. The authors declare that they have no known competing financial or non-financial interests that could have influenced the work reported in this paper. This study involved a Delphi survey conducted among expert participants and did not include patients or personal health data. According to applicable institutional and national research regulations, ethical approval was not required. Participation was voluntary, and all experts were informed of the study's purpose. This study was conducted without any financial support or sponsorship. This study did not involve patients or clinical subjects. Explicit written consent was not required for this study. Participation was voluntary, and informed consent was implied by completing and submitting the questionnaires.