Perceptions of Peruvian neurologists toward the implementation of anti-amyloid drugs for early Alzheimer's disease in the departments of neurology

Objective

There is little information on neurologists’ preferences leading to specific diagnostic choices and treatment in early AD patients, especially exploring professional profile, clinical settings, and the organization of Neurology Services. In this study, we aimed to explore the perceptions of Peruvian neurologists regarding the changes needed to implement the use of monoclonal antibodies in alignment with the clinical practice guidelines.

Study design and setting

A cross-sectional study was designed to explore the perceptions of neurologists regarding anti-amyloid drugs for AD. The study took place between December 2024 and January 2025 in Peru.

Participants

Neurologists from various regions of the country working in tertiary-level hospitals were selected as Key Informants (KI). The KI were neurologists without a subspecialty in cognitive neurology, as such training is not available in the country. A comprehensive list was compiled of all tertiary-level healthcare institutions in Peru, including those under the public health system (Seguro Integral de Salud – SIS), the social security system (ESSALUD), and police and armed forces hospitals. At least one neurologist from each institution was contacted. The selection of tertiary-level hospitals was based on the complexity associated with administering anti-amyloid drugs, as only this level of care is expected to have the necessary infrastructure and specialists required for their proper implementation.

Although geriatricians and psychiatrists may prescribe symptomatic treatments for probable AD, the administration of anti-amyloid therapies requires a definitive diagnosis confirmed by positive biomarkers in CSF or PET, the latter of which is not available in Peru. Consequently, lumbar punctures to obtain CSF, an essential step for confirming eligibility for these treatments, are performed exclusively by neurologists under approval from local ethics committees. For this reason, only neurologists were included as KIs. Neurologists from private sector clinics were not included, as the high cost and resource requirements of anti-amyloid therapies make their provision largely unfeasible outside the public healthcare system.

The KI methodology, defined as “reliance on a small number of knowledgeable participants who observe and articulate social relationships for the researcher,” originates from ethnographic anthropology. ¹⁶ It has since been integrated into both qualitative and quantitative data collection strategies. A fundamental aspect of this approach is the use of purposive sampling to identify KI, individuals who possess relevant expertise or experience on the topic of interest. ¹⁷

Once the KI were identified, they were contacted and informed about the study. Those who provided informed consent received a link to the online questionnaire via email. Participation was entirely voluntary, and no incentives were offered to participants.

Instrument

The questionnaire used in this study was adapted from a previously published survey conducted in Spain, which pursued the same research objective. ¹⁸ The original version of the instrument comprised 113 questions across seven sections: (1) General questions regarding changes in the organization and operation of neurology services due to the introduction of anti-amyloid drugs; (2) Questions on patient diagnosis and care; (3) Questions on diagnostic and therapeutic techniques; (4) Questions on public information, families, and patients; (5) Specific questions about the organization of neurology services; (6) Questions about resources required by neurology services; (7) Questions related to neurological research. ¹⁸ For the purposes of the present study, the questionnaire was culturally adapted to the Peruvian context. A total of 42 questions were removed because they did not apply to the structure and resources of the local health system. Specifically, 21 items referred to distinctions between hospitals with and without dementia units, which do not exist in Peru; 11 addressed diagnostic technologies such as PET imaging and biomarker testing that are not routinely available in the country; and the remaining 10 were either redundant across sections or deemed not relevant to the Peruvian context. While some individual questions were removed, none of the original seven thematic sections were deleted, and the final version consisted of 71 questions.

Each item was rated using a five-point Likert scale, ranging from “strongly disagree” (1) to “strongly agree” (5). At the end of each section, an open-ended comment field was included to allow participants to provide additional insights or feedback related to that section.

Data analysis

Statistical analysis was performed using StataCorp: Stata version 18. Descriptive statistics and frequency distributions were utilized.

For analytical purposes, responses were grouped into three categories: “agree” (scores 4 and 5), “disagree” (scores 1 and 2), and “neutral” (score 3). Consensus among participants was considered to be reached when 75% or more of the responses fell within either the “agree” or “disagree” categories.

Ethical considerations

This study adhered to the Helsinki Declaration for research ethics. Ethical approval was obtained from the Ethical Board of the “Hospital Nacional Docente Madre Niño San Bartolomé” (16013-23) in Lima, Peru. All participants provided informed consent prior to completing the questionnaire.

General questions

KIs reached consensus that the introduction of anti-amyloid drugs will require modifications to the neurology curriculum in medical schools (82%), in order to enhance students’ knowledge of dementia. In addition, 20 KIs (71%) agreed that the implementation of anti-amyloid therapies will have an impact on the operation of neurology services. However, there was no consensus regarding whether the introduction of these medications will increase the difficulty of neurologists’ clinical tasks (21% agreed, 32% were neutral, and 46% disagreed).

Diagnosis and patient care

Overall, KIs agreed that the introduction of anti-amyloid therapies would lead to changes in both the diagnosis and care of patients. There was consensus on the usefulness of implementing brief cognitive screening tools, both in primary care settings (93%) and in tertiary-level hospitals (86%). KIs also agreed that neurology services should adopt a more systematic approach in order to preselect patients eligible for this type of treatment (89%). Regarding patient care, KIs concurred that once anti-amyloid treatment is initiated, periodic assessments should be conducted to monitor the patient's emotional well-being, with particular attention to depression and behavioral disorders (89%). Furthermore, 93% of respondents agreed that quality of life should also be assessed regularly. Finally, there was consensus not only on the need to include new patient assessment scales, but also on incorporating caregiver-specific instruments to evaluate caregiver burden (93%).

Diagnostic and therapeutic techniques

KIs agreed that the indication for diagnostic testing would shift in patients with suspected AD, with increased use of MRI (75%), brief cognitive batteries (82%), and CSF biomarkers (82%). However, no consensus was reached regarding the increased use of CT scans (25% agreed, 18% neutral, and 57% disagreed). Additionally, 75% of informants considered the introduction of computerized cognitive batteries ideal for diagnosing these patients. A large majority (89%) also emphasized the need to reconsider the therapeutic strategy for patients already diagnosed with AD who may be eligible for anti-amyloid treatment. Most also agreed (86%) on the importance of assessing vascular risk prior to treatment initiation, due to the hemorrhagic risks associated with these drugs.

Regarding patient monitoring, there was strong consensus among neurologists that follow-up visits should become more frequent (93%), that consultation times should be extended (82%), and that control laboratory assessments should be conducted more regularly (82%). However, most informants did not support regular CSF biomarker monitoring (29% agreed, 43% neutral, 29% disagreed). Similarly, no consensus was reached regarding the impact of these drugs on stroke management; only 18% of informants anticipated a reduction in thrombolysis in ischemic stroke, and an increase in mechanical thrombectomies, due to the hemorrhagic risks of anti-amyloid agents.

Public information, families, and patients

Responses in this section were mixed, and consensus was not reached. The first two questions, regarding whether media coverage and patient advocacy groups would increase the demand for neurological services, elicited responses that were mostly in the “agree” and “neutral” categories. The subsequent questions focused on whether the need for caregiver accompaniment would limit patient access to treatment administration and follow-up visits; 57% of informants agreed this would pose a challenge.

Organization of neurology services

KIs reached consensus regarding the organization of neurology services. A large majority (96%) agreed on the need to implement specific clinical guidelines for the use of anti-amyloid therapies. There was strong agreement (93%) on the importance of interdisciplinary teams, particularly the integration of neuropsychologists into neurology departments. In line with this, 96% supported the implementation of a training program in clinical neuropsychology of dementia in the country. Beyond neuropsychology, 86% of informants agreed that neurologists will require sub-specialized training in fields such as cognitive neurology, neuropsychiatry, neuroradiology, etc. Lastly, 79% of informants agreed that due to the high cost of anti-amyloid drugs and complementary evaluations, neurology service budgets would need to increase significantly.

Resources necessary for the departments of neurology

A majority of KIs (86%) agreed that additional resources will be needed for neurology departments, including more neurologists. Furthermore, 89% highlighted the need for increased nursing staff and the incorporation of case management nurses, who would be responsible for coordinating care plans and monitoring medication adherence.

Neurological research

Most informants anticipated that the introduction of anti-amyloid therapies would lead to greater investment in neurology research (82%), as well as an increase in clinical trials for other types of dementia (86%). Moreover, 96% agreed that clinical research in AD would expand, positively impacting research in biomarkers, neuroimaging, and clinical neuropsychology. Finally, over 85% of participants believed that these changes would boost interest in research among neurologists and lead to more publications in high-impact journals.

General preparedness

This study explored the perceptions of Peruvian neurologists regarding the readiness of the healthcare system to implement anti-amyloid therapies for AD, in line with evolving clinical guidelines. More than half of Peruvian KIs (71%) agreed that introducing these therapies will have significant implications for the structure and functioning of neurology services. This proportion is notably lower than in similar studies conducted in Spain (100%) ¹⁸ and Japan (85.7%). ¹⁹ Additionally, marked differences also emerged between Peruvian and Spanish KIs regarding anticipated service needs. While all Spanish informants acknowledged the need to expand neurology consultation capacity, only 64% of Peruvian KI did so. Similarly, a higher proportion of Spanish informants emphasized the necessity of additional infrastructure, such as infusion service spaces, compared to their Peruvian counterparts (81.25% versus 57%). This lower level of agreement among Peruvian KIs may reflect the realities of the local healthcare system, including chronic underinvestment in public infrastructure, limited availability of facilities, and the fragmentation among service providers. Therefore, Peruvian neurologists may perceive these deficiencies as unlikely to be resolved, leading to a cautious outlook regarding the expansion of consultations and infrastructure, whereas Spanish KIs, operating in a more centralized and better-resourced system, anticipate such expansions to be feasible. Interestingly, only 21% of Peruvian neurologists agreed that anti-amyloid therapy would complicate routine clinical practice, compared to 100% in Spain, although there was strong agreement on the need to increase the frequency (93%) and duration (82%) of follow-up visits. These contrasting views may reflect differing clinical baselines, workflow expectations, or resource constraints and warrant further qualitative exploration.

Alignment of diagnostic and clinical pathways

Both the Alzheimer's Association and the International Working Group have emphasized the role of biomarkers in the diagnosis of AD, supporting early intervention based on evidence from PET, CSF, or blood.^5,6 However, Peru lacks access to amyloid PET imaging, ⁷ underscoring the local importance of CSF biomarkers. This is reflected in the strong agreement among Peruvian KIs (82%) on increasing lumbar puncture use, closely aligned with Spain (100%), to compensate for imaging limitations.^7,20

Peruvian and Spanish KIs also agreed on the need to expand the use of brief cognitive screening tools at all levels of care and to adopt a more systematic, protocol-driven approach for patient selection. These findings echo broader calls for harmonized diagnostic frameworks globally, ²¹ especially in LMICs ²² and culturally diverse settings in Latin America.^23,24 Unlike neighboring countries such as Chile, Mexico, Costa Rica, and Puerto Rico, ²⁵ Peru lacks a national dementia plan, which complicates the coordinated rollout of disease-modifying therapies. This absence may also help explain the lack of standardized pathways for cognitive assessment and biomarker access, particularly at the primary care level. Moreover, there was no clear consensus in Peru regarding the implications of anti-amyloid therapy on acute or chronic cerebrovascular disease management, similar to Spain, highlighting the need for more targeted clinical guidance on this issue. ²⁶

Health system infrastructure and equity issues

The perceived lack of infrastructure, including PET scanners, infusion facilities, and trained personnel, was a recurring theme in this study. Moreover, these limitations are compounded by systemic inequities in Peru's fragmented healthcare system, where access to dementia services varies across public (SIS), social security (EsSalud), and military/police health networks. These challenges are consistent with prior findings indicating significant regional disparities and the absence of a national dementia plan, a gap that contrasts with other Latin American countries that have established strategic frameworks for dementia care. The need for equity-driven planning is further underscored by global evidence showing that real-world eligibility for anti-amyloid therapy is often constrained by age-related comorbidities and exclusionary trial criteria.^27,28

Research and workforce development

There was a strong consensus among Peruvian neurologists that the implementation of anti-amyloid therapies will stimulate research in AD and related dementias. The majority (82%) disagreed with the idea that introducing such therapies will reduce the number of randomized clinical trials, closely mirroring Spanish responses (87.5%). This view stands in contrast to recent concerns about contraction in the global AD drug development pipeline, ²⁹ and suggests that clinicians in both countries view these therapies as a catalyst for further scientific inquiry. The study also highlights the need for workforce expansion and training. Peruvian KIs called for the inclusion of dementia-specific content in undergraduate (82%) and postgraduate (68%) neurology curricula, rates higher than those reported in Spain (both 56.2%), as well as increased training and hiring of neuropsychologists and dementia-specialized nursing staff. These educational and human resource gaps have been previously documented in Peru and remain a major barrier to quality dementia care.^30,31

Regional context and implications for Latin America

While there are no previous studies in Latin America directly assessing perceptions of anti-amyloid therapies, a recent global survey explored attitudes and practices in mild cognitive impairment care among 1257 neurology practitioners, including 252 from Latin America. ³² Despite safety concerns, attitudes toward prescribing new anti-amyloid agents were generally similar across all respondents, with 62% indicating they would prescribe such therapies if available. ³² In the Latin American context, donanemab has been approved by Brazil's National Health Surveillance Agency ³³ and lecanemab in Argentina. ³⁴ However, Brazilian specialists have reported significant barriers and challenges related to its incorporation into the public system, reflecting broader structural and resource limitations that may be relevant across the region. ³³ These findings suggest that, while Latin American neurologists may be willing to adopt anti-amyloid therapies, the practical implementation will likely face challenges similar to those observed in our Peruvian survey.

Limitations

This study has several limitations. First, the sample was limited to a select group of KIs and may not represent all neurologists across Peru, particularly those practicing in rural or underserved areas. Second, perceptions may shift over time as more information and local experience with anti-amyloid therapies emerge. Finally, the absence of a national dementia registry or standardized metrics makes it difficult to estimate baseline system capacity or readiness for implementation. Future studies should include a broader range of healthcare professionals, explore patient and caregiver perspectives, and assess implementation feasibility in diverse care settings.

Conclusion

Peruvian neurologists recognize the promise of anti-amyloid therapies for AD but highlight major gaps in infrastructure, training, and care coordination that must be addressed before implementation. The lack of PET imaging, fragmented services, and absence of a national dementia plan pose significant challenges. Still, there is strong professional momentum to adapt clinical pathways, expand biomarker access, and strengthen the workforce. A coordinated national response is urgently needed to ensure equitable access to disease-modifying treatments in Peru.