Skip to main content

Study partners should be required in preclinical Alzheimer’s disease trials



In an effort to intervene earlier in Alzheimer’s disease (AD), clinical trials are testing promising candidate therapies in preclinical disease. Preclinical AD trial participants are cognitively normal, functionally independent, and autonomous decision-makers. Yet, like AD dementia trials, preclinical trials require dual enrollment of a participant and a knowledgeable informant, or study partner.

Main text

The requirement of dyadic enrollment is a barrier to recruitment and may present unique ethical challenges. Despite these limitations, the requirement should continue. Study partners may be essential to ensure participant safety and wellbeing, including overcoming distress related to biomarker disclosure and minimizing risk for catastrophic reactions and suicide. The requirement may maximize participant retention and ensure data integrity, including that study partners are the source of data that will ultimately instruct whether a new treatment has a clinical benefit and meaningful impact on the population health burden associated with AD. Finally, study partners are needed to ensure the scientific and clinical value of trials.


Preclinical AD will represent a new model of care, in which persons with no symptoms are informed of probable cognitive decline and eventual dementia. The rationale for early diagnosis in symptomatic AD is equally applicable in preclinical AD—to minimize risk, maximize quality of life, and ensure optimal planning and communication. Family members and other sources of support will likely be essential to the goals of this new model of care for preclinical AD patients and trials must instruct this clinical practice.


In the US and other developed nations, the disability caused by Alzheimer’s disease (AD) dementia exacts tremendous costs on patients and their families, and population aging is increasing these costs [1]. One strategy to address these costs is to discover therapies that slow the onset and progression of disability. This strategy, together with advances in understanding AD biology, has led to trials that enroll volunteers with no cognitive or functional impairments but who have genetic or biomarker evidence that suggests they are at risk of developing AD dementia. These trials are an essential part of validating a new stage of AD called “preclinical AD,” a term that describes the presence of pathophysiology without cognitive or functional impairments [2, 3].

Preclinical AD treatment development faces several challenges. The most immediate are barriers to the efficient conduct of randomized controlled trials. Several design features deter enrollment. These include a long time commitment (typically 3 to 5 years), burdensome procedures (frequent brain imaging), compounds with notable risks (such as brain edema), and the requirement to learn AD genetic or biomarker test results that carry uncertain prognosis and substantial ethical, legal, and social consequences [4,5,6,7]. Finally, all preclinical AD trials require dual enrollment. In addition to the participant, a knowledgeable informant must consent to attend study visits and complete outcome measures. This person is commonly called the “study partner.” Without a study partner, an otherwise eligible subject cannot be enrolled.

In AD dementia clinical trials, caregivers typically serve in the study partner role and are vital to trial success. They drive dementia trial enrollment decisions [8] and ensure informed consent [9], protocol compliance, and study completion [10]. They provide data used to determine treatment efficacy [11]. In contrast, subjects in preclinical AD trials are functionally independent and so able to choose to enroll, provide their own informed consent, and comply with study procedures. They may be unable or unwilling to identify a study partner [12]. Moreover, the primary outcomes in current preclinical AD trials are informant-independent measures of cognition [13, 14]. These points add up to a compelling case. The study partner requirement is a barrier to efficient enrollment and timely study completion that delays the goal of discovering an effective prevention. Why then, should preclinical AD trials require study partners?

The answer to this question has substantial implications not only for the success of trials, but also for the successful translation and dissemination of the preclinical AD diagnosis from research into clinical practice. Although the study partner role in preclinical AD trials is different than in dementia trials and may slow the progress of drug discovery, the role is essential.

In this article, we argue that preclinical AD trials should enroll study subjects and study partners. This “pre-clinical dyad” is both ethically and scientifically necessary to ensure trial success and to instruct future clinical practice. We close by outlining the research essential to instruct investigators and clinicians on how best to work with this novel and important dyad.

The study partner requirement is essential to ensure participant safety and well-being

To minimize cost, maximize efficiency, and understand the clinical impact of knowledge of AD gene or biomarker results, most preclinical AD trials use a “transparent” enrollment design [15]. In transparent designs, the investigator discloses AD genetic or biomarker test results to the subject [16]. Standardized approaches to do this and to monitor participant health and safety after disclosure have been developed [17, 18]. Prospective safety data remain limited, however, as many of the first transparent design studies are ongoing. To date (September 2017), no study has reported a safety concern related to the impact of learning gene or biomarker results.

Data are available from two studies that have investigated the safety of disclosing amyloid positron emission tomography (PET) AD biomarker information to cognitively normal participants [19, 20]. In their randomized preclinical AD trial of physical exercise, Burns and colleagues required disclosure as part of enrollment after excluding participants demonstrating either depression or anxiety [20]. The investigative team disclosed results at a unique study visit, describing the outcome of PET imaging as demonstrating elevated or not elevated amyloid levels. Lim and colleagues made qualitative PET results (described as positive or negative) available to participants’ neurologists as an ancillary study to a preclinical AD trial enrolling older participants with both a family history of AD and subjective memory complaints [19]. Participants had the option to learn their results through their physician. Both studies were relatively small (27 and 4 amyloid-positive individuals in the Burns and Lim studies, respectively) and found that disclosure was largely safe; low rates of psychological adverse events were observed through standardized outcome measures. In both studies, however, participants learning positive amyloid PET results experienced elevations in distress and anxiety at the time of disclosure, which were deemed not clinically significant. In the Burns study [20], participants were required to enroll with a study partner. In the Lim study [19], all participants indicated that they had shared their results with family or friends and reported satisfaction with their support network.

Similar findings of test-related distress exist for the disclosure of AD genetic results. The Risk Evaluation and Education in AD (REVEAL) studies have examined the safety of disclosing apolipoprotein E (APOE) ε4 allele genotypes to cognitively normal middle-aged adults with a first-degree family history of AD. Learning AD genetic risk did not cause clinical anxiety or depression, but individuals who learned that they were ε4 carriers experienced transient test-related distress [21]. Although participants were not required to enroll with a study partner, discussing test results with others was associated with reduced scores on depression and anxiety measures 1 year after APOE disclosure [22]. APOE test results were most commonly shared with spouses or other family members [23].

These data suggest that study partners may play a key role in how participants in preclinical AD trials cope with anxiety and distress, and that enrolling participants who lack a support network could exacerbate the psychological harms of AD risk disclosure. Surveys of the public and of registries of individuals willing to participate in AD research find that 10–12% of individuals wish to gain access to biomarker and/or genetic risk information to instruct suicide planning [24,25,26]. One of these studies found that suicide planning was associated with feelings of non-support and being single [24]. Investigators are ethically bound to minimize risk, maximize benefit, and ensure the safety of those enrolling in trials; enrolling only participants with a satisfactory support network, including at least one individual who can serve as study partner, is a sensible means to achieving this ethical obligation.

The study partner requirement is essential to trial validity

Preclinical AD trials use objective cognitive tests as primary outcomes. Key secondary outcomes, however, assess subjective cognitive and functional performance. It is unclear whether subjects or their informants provide the more accurate assessment of these constructs. Traditional measures of global or functional performance, such as the Clinical Dementia Rating (CDR) scale [27], are being used in preclinical AD trials. These rely on study partner reports. Other scales, such as those developed in the AD Cooperative Study Prevention Instrument (ADCS PI) study [28], include participant and study partner versions, enabling direct comparisons to determine which is optimal for preclinical AD trials.

The ADCS Activities of Daily Living Prevention Instrument (ADCS-ADL-PI) scale [29] examines 15 instrumental ADLs and 5 physical functions. In the ADCS PI study, the participant version demonstrated greater sensitivity to age effects, but also showed an apparent racial bias [29]. Both versions showed modest sensitivity for identifying global and cognitive decline, though only 12-month follow-up data have been reported (the duration of the study was 48 months) [29]. Both versions are used in the Anti-Amyloid treatment in Asymptomatic AD (A4) study [30], and study partners are being asked additional questions about the frequency of functional tasks and the time to complete those tasks. The decision to rely on study partners for these additional items is supported by observations that in mild cognitive impairment (MCI), study partner reporting of functional impairment is more strongly predictive of conversion to dementia than is self-reporting [31].

The Cognitive Function Instrument (CFI) was also developed in the ADCS PI study [32]. The CFI incorporates 14 subjective items assessing cognitive performance and has been proposed as a potential functional outcome measure for preclinical AD trials [33]. In the ADCS PI study, participant self-ratings were more closely related to objective cognitive testing performance than were study partner ratings at baseline. Study partner ratings were better correlated at 48 months [33]. The combination of participant and partner reports was more strongly correlated with cognitive test performance than either report alone [33]. Similar results were observed in the National Alzheimer’s Coordinating Center Uniform Data Set; subjective complaints in both participants and their study partners were associated with greater risk for MCI than were subjective complaints by either the participant or the study partner alone [34]. These results suggest that study partner reporting may be essential to maximize data integrity in preclinical AD trials.

Study partners have key roles in assuring the validity of other aspects of preclinical AD trials. One role is minimizing missing data by preventing drop out. Preclinical AD trials are lengthy and participation can be burdensome, requiring many complex visits. Previous AD prevention trials have incurred greater than expected dropout [35], putting statistical power at risk. In both AD dementia [36] and MCI trials [37], participants lacking a spouse are at increased risk for dropout. As with trials in individuals with cognitive impairment, preclinical AD trial participants who lack a support network such as a study partner may be at increased risk for dropout.

The study partner requirement is essential to ensure the scientific and clinical value of preclinical AD trials

Based on US Food and Drug Administration (FDA) guidance, AD dementia trials assess efficacy using dual primary outcomes—typically a measure of cognitive performance and a measure of global or functional performance. The latter is required to demonstrate the clinical benefit of the cognitive performance. The first AD dementia trials used instruments based only on clinician assessment of the patient to assess clinical meaningfulness [38]. Expert consensus [38] and research demonstrating the benefit of informant reporting [39], however, led to a state of the art in which AD dementia trial co-primary outcomes incorporate or exclusively rely upon study partner reporting.

In preclinical AD, FDA guidance indicates that reducing decline on a single primary outcome measure may be sufficient to achieve approval [40], with post-approval studies to confirm that treatments result in clinically meaningful functional benefit. Though novel approaches to demonstrating clinical benefit should be pursued, such as assessing resource utilization through medical record or claims data [41], long-term extension studies using traditional global or functional outcome measures seem the most probable approach. These outcome measures require a study partner. Study partner-based tools will also be vital to examining the public health implications of preclinical AD treatment, including the time to dementia onset, the number of dementia cases, and the economic burden of disease [42].

Preclinical AD trials will change how society and medicine conceive of what is AD [4]. These trials must instruct not only the use of new therapies, such as drug dosage and safety, but also how to provide care in this new model of AD. In the absence of a drug that halts the onset of cognitive decline across all patients, some patients will suffer cognitive impairment. AD will remain a disease that requires planning, support, and care. No standards exist for this clinical practice in persons who have preclinical AD. Trials should be an essential source of data to develop and refine this practice.

Trial results should instruct the clinical practice of widescale biomarker and genetic testing and disclosure. Truth and honesty in diagnostic disclosure, no different from that recommended in AD dementia [43], includes communicating the prognosis of cognitive decline and functional impairment. Discussing this information will necessarily engender other conversations to make plans to further reduce the risk of cognitive decline, such as exercise and cardiovascular health. Patients will likely begin to consider financial matters such as the timing of retirement and where they will live. Issues of future healthcare decisions will be considered [44]. Such planning will be critical not only to maximize health, but also to minimize the risks associated with early signs of cognitive impairment such as medication errors, driving accidents [45], and financial error and abuse [46].

A sensible means to do all of this is to involve another person in the life of a patient with preclinical AD. This person should be the study partner. Patients should want to have someone, such as a partner, adult child, or close friend, to help them to plan for this future. Patients may need to have someone to watch over them because, in time, as preclinical becomes clinical AD, patients will need the help of someone else to manage their problems. Physicians providing clinical care for persons with preclinical AD will strongly recommend the involvement of such a person in both diagnostic and treatment phases of management. Filling this role, or helping to identify a network that can support these needs, should be part of the role of a study partner.

Areas in need of research

Ensuring that the benefits of preclinical research apply to all older people at risk for AD dementia

Many potentially eligible preclinical AD trial participants lack a person who can fill the study partner role. While this may effectively limit the pool of participants, the requirement may also produce sample bias. Understanding the implications of this bias and ensuring that those who lack the support network needed to enroll in trials can still benefit from the knowledge gained through them will be necessary to maximize the public health impact of preclinical AD research.

Current study partner inclusion criteria do not guarantee knowledgeable informants

The relationship between criteria to serve as study partner and the integrity of informant data has not been established in preclinical AD, or in AD dementia for that matter. In AD dementia, spousal study partners differ from non-spousal study partners in the accuracy of cognitive assessments [47] and in their concordance with patient ratings of quality of life [48]. No study of informant assessment of cognitive function in preclinical AD has explored the qualifications of the study partner and whether some individuals may yield more sensitive identification of participant cognitive decline than others. Requiring study partners will preclude some potentially eligible participants from enrolling. Ensuring that those who are enrolled will provide high-integrity data will be essential to safeguarding trial value and justifying the cost of the requirement.

The study partner requirement may cause unique ethical risks

A critical aspect of preclinical AD trial conduct is to protect participants from unwanted disclosure of genetic or biomarker information through electronic medical records [4]. However, the risk for stigma in the home and in social situations remains in these trials and one open question is how often and with whom do preclinical AD trial participants share their testing results?

In a study of preclinical AD trial enrollment decisions, in which participants were randomly assigned to consider a hypothetical trial that did or did not require biomarker disclosure, we found that the study partner requirement was a more important barrier to enrollment when disclosure was required [12]. The requirement was rated as more important than drug risks in the disclosure arm of this study. These preliminary data suggest that preclinical AD trial participants may be reluctant to share with others that they have biomarker evidence of AD. Some participants may face an unenviable choice: have others potentially learn information about their health they do not want shared, or forego enrolling in a study in which they wish to participate.

Further study will be necessary to instruct optimal means to overcome the study partner requirement as a barrier to enrollment without sacrificing participant privacy and confidentiality. Greater understanding of the frequency and extent of this occurrence are needed. Modifying or improving the disclosure process, which does not currently emphasize the role of the study partner, may improve the willingness of participants to share biomarker information. Ensuring that participants are comfortable and ready to share AD risk information may be critical, as may be education and counseling of others in their support network.

Respecting participant autonomy is an ethical requirement in clinical research. Requiring preclinical AD trial participants to involve another person in the study does not disrespect autonomy. If this requirement does not align with a person’s values of identity, privacy, and authority, he or she can freely choose not to enroll. Among those who do enroll, the requirement may foster their autonomy. These participants are at risk for cognitive and functional impairments. A study partner may become the participant’s trusted advocate to whom the participant can tell how they would like to be cared for and other plans for the future. The advocate can also monitor the participant for signs of impairment. These activities are recognized as a means to maintain autonomy despite the loss of capacity.

Helping study partners become caregivers

A vast scientific literature on the caregiver has informed interventions to improve the lives of patients with AD dementia [49]. Some preclinical AD participants will become clinical AD patients and need a caregiver. Little is known about the implications of who is available to preclinical AD patients for support, to aid with planning, and for assistance with instrumental ADLs with high cognitive demand. The field will ultimately need to know who these people are, if and when they change, and what if any characteristics predict their performance in these roles. Moreover, these individuals will likely need interventions to assist them in these roles, not unlike the interventions to assist dementia caregivers.


The imperative to reduce the public health burden of AD and the field’s growing consensus that early intervention may be essential to slowing disease progression has launched a novel field of investigation, preclinical AD trials. The optimal design features for these trials remain areas of active study and debate, ranging from whether biomarker information can or should be disclosed to participants, to the number and types of outcome measures that should be used to assess drug efficacy. We examined one particular aspect of preclinical AD trial designs that has scientific, regulatory, and ethical implications—the requirement for a study partner (Table 1).

Table 1 Arguments for and against requiring study partners in preclinical Alzheimer’s disease trials

AD is an insight-robbing neurodegenerative disease. Trial participants themselves, therefore, may not be the best judge of clinically important changes in their cognition and function. However, disclosure of AD biomarkers or genes carries risks to participants, such as stigma and discrimination. Together, these points create an ethically complex and unique situation. Whereas other chronic and progressive diseases have similar rationale for earliest possible identification of disease onset, such as genetic and biomarker tests for cancers, these diseases do not generally affect cognition nor are they associated with stigmas such as “loss of self” or “loss of personhood.” Rather, preclinical AD trials are likely to provide important guidance for trials in other neurological conditions in which presymptomatic diagnosis may optimize treatment efficacy [50].

The requirement of dual enrollment of participants and knowledgeable study partners will be essential to ensuring the integrity of preclinical AD trial data, minimizing loss-to-follow-up, and ensuring participant safety. Safety is paramount in trials in this nascent diagnostic construct. Moreover, study partner reporting will be essential for assessing clinical effectiveness and public health outcomes of preclinical treatment.

Further study is needed to understand how the study partner requirement may create challenges to efficient enrollment. The costs of recruiting subjects and their study partners, however, are secondary to the value of knowledge that will discover a novel clinical practice. Trials have a special role to develop and refine this knowledge. Preclinical AD care will surely be more than ordering a biomarker test, prescribing a drug, and scheduling follow-up in some time interval. Patients in the early stages of AD require counseling, planning assistance, and other supportive services. Preclinical AD trials must be designed to instruct this future practice.



Anti-Amyloid treatment in Asymptomatic AD


Alzheimer’s disease


AD Cooperative Study


Activities of daily living


Apolipoprotein E


Clinical Dementia Rating scale


Cognitive Function Instrument


Food and Drug Administration


Mild cognitive impairment


Positron emission tomography


Prevention instrument


Risk Evaluation and Education in AD


  1. Wimo A, Guerchet M, Ali GC, et al. The worldwide costs of dementia 2015 and comparisons with 2010. Alzheimers Dement. 2017;13:1–7.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Sperling RA, Aisen PS, Beckett LA, et al. Toward defining the preclinical stages of Alzheimer's disease: recommendations from the National Institute on Aging-Alzheimer's Association workgroups on diagnostic guidelines for Alzheimer's disease. Alzheimers Dement. 2011;7:280–92.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Dubois B, Hampel H, Feldman HH, et al. Preclinical Alzheimer's disease: definition, natural history, and diagnostic criteria. Alzheimers Dement. 2016;12:292–323.

    Article  PubMed  Google Scholar 

  4. Karlawish J. Addressing the ethical, policy, and social challenges of preclinical Alzheimer disease. Neurology. 2011;77:1487–93.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Arias JJ, Karlawish J. Confidentiality in preclinical Alzheimer disease studies: when research and medical records meet. Neurology. 2014;82:725–9.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Grill JD, Johnson DK, Burns JM. Should we disclose amyloid imaging results to cognitively normal individuals? Neurodegener Dis Manag. 2013;3:9.

    Article  Google Scholar 

  7. Roberts JS, Dunn LB, Rabinovici GD. Amyloid imaging, risk disclosure and Alzheimer's disease: ethical and practical issues. Neurodegener Dis Manag. 2013;3:219–29.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Karlawish JH, Casarett D, Klocinski J, Sankar P. How do AD patients and their caregivers decide whether to enroll in a clinical trial? Neurology. 2001;56:789–92.

    Article  CAS  PubMed  Google Scholar 

  9. Karlawish J, Kim SY, Knopman D, van Dyck CH, James BD, Marson D. The views of Alzheimer disease patients and their study partners on proxy consent for clinical trial enrollment. Am J Geriatr Psychiatr. 2008;16:240–7.

    Article  Google Scholar 

  10. Black BS, Taylor HA, Rabins PV, Karlawish J. Study partners perform essential tasks in dementia research and can experience burdens and benefits in this role. London: Dementia; 2016.

    Google Scholar 

  11. Mohs RC, Kawas C, Carrillo MC. Optimal design of clinical trials for drugs designed to slow the course of Alzheimer's disease. Alzheimers Dement. 2006;2:131–9.

    Article  CAS  PubMed  Google Scholar 

  12. Grill JD, Zhou Y, Elashoff D, Karlawish J. Disclosure of amyloid status is not a barrier to recruitment in preclinical Alzheimer's disease clinical trials. Neurobiol Aging. 2016;39:147–53.

    Article  PubMed  Google Scholar 

  13. Donohue MC, Sperling RA, Salmon DP, et al. The preclinical Alzheimer cognitive composite: measuring amyloid-related decline. JAMA Neurol. 2014;71:961–70.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Langbaum JB, Hendrix SB, Ayutyanont N, et al. An empirically derived composite cognitive test score with improved power to track and evaluate treatments for preclinical Alzheimer's disease. Alzheimers Dement. 2014;10:666–74.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Burns JM, Klunk WE. Predicting positivity for a new era of Alzheimer disease prevention trials. Neurology. 2012;79:1530–1.

    Article  PubMed  Google Scholar 

  16. Kim SY, Karlawish J, Berkman BE. Ethics of genetic and biomarker test disclosures in neurodegenerative disease prevention trials. Neurology. 2015;84(14):1488–94.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Harkins K, Sankar P, Sperling R, et al. Development of a process to disclose amyloid imaging results to cognitively normal older adult research participants. Alzheimers Res Ther. 2015;7:26.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Qian J, Wolters FJ, Beiser A, et al. APOE-related risk of mild cognitive impairment and dementia for prevention trials: an analysis of four cohorts. PLoS Med. 2017;14:e1002254.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Lim YY, Maruff P, Getter C, Snyder PJ. Disclosure of positron emission tomography amyloid imaging results: a preliminary study of safety and tolerability. Alzheimers Dement. 2016;12(4):454–8.

    Article  PubMed  Google Scholar 

  20. Burns JM, Johnson DK, Liebmann EP, Bothwell RJ, Morris JK, Vidoni ED. Safety of disclosing amyloid status in cognitively normal older adults. Alzheimers Dement. 2017;13(9):1024–30.

    Article  PubMed  Google Scholar 

  21. Green RC, Roberts JS, Cupples LA, et al. Disclosure of APOE genotype for risk of Alzheimer's disease. N Engl J Med. 2009;361:245–54.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Ashida S, Koehly LM, Roberts JS, Chen CA, Hiraki S, Green RC. The role of disease perceptions and results sharing in psychological adaptation after genetic susceptibility testing: the REVEAL Study. Eur J Hum Genet. 2010;18:1296–301.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Ashida S, Koehly LM, Roberts JS, Chen CA, Hiraki S, Green RC. Disclosing the disclosure: factors associated with communicating the results of genetic susceptibility testing for Alzheimer's disease. J Health Commun. 2009;14:768–84.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Caselli RJ, Marchant GE, Hunt KS, et al. Predictive testing for Alzheimer's disease: suicidal ideation in healthy participants. Alzheimer Dis Assoc Disord. 2015;29(3):252–4.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Ott BR, Pelosi MA, Tremont G, Snyder PJ. A survey of knowledge and views concerning genetic and amyloid PET status disclosure. Alzheimers Dement (N Y). 2016;2:23–9.

    CAS  Google Scholar 

  26. Caselli RJ, Langbaum J, Marchant GE, et al. Public perceptions of presymptomatic testing for Alzheimer disease. Mayo Clin Proc. 2014;89:1389–96.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Morris JC, Ernesto C, Schafer K, et al. Clinical dementia rating training and reliability in multicenter studies: the Alzheimer's Disease Cooperative Study experience. Neurology. 1997;48:1508–10.

    Article  CAS  PubMed  Google Scholar 

  28. Ferris SH, Aisen PS, Cummings J, et al. ADCS Prevention Instrument Project: overview and initial results. Alzheimer Dis Assoc Disord. 2006;20:S109–23.

    Article  PubMed  Google Scholar 

  29. Galasko D, Bennett DA, Sano M, Marson D, Kaye J, Edland SD. ADCS Prevention Instrument Project: assessment of instrumental activities of daily living for community-dwelling elderly individuals in dementia prevention clinical trials. Alzheimer Dis Assoc Disord. 2006;20:S152–69.

    Article  PubMed  Google Scholar 

  30. Sperling RA, Rentz DM, Johnson KA, et al. The A4 study: stopping AD before symptoms begin? Sci Transl Med. 2014;6:228fs213.

  31. Tabert MH, Albert SM, Borukhova-Milov L, et al. Functional deficits in patients with mild cognitive impairment: prediction of AD. Neurology. 2002;58:758–64.

    Article  CAS  PubMed  Google Scholar 

  32. Walsh SP, Raman R, Jones KB, Aisen PS. ADCS Prevention Instrument Project: the Mail-In Cognitive Function Screening Instrument (MCFSI). Alzheimer Dis Assoc Disord. 2006;20:S170–8.

    Article  PubMed  Google Scholar 

  33. Amariglio RE, Donohue MC, Marshall GA, et al. Tracking early decline in cognitive function in older individuals at risk for Alzheimer disease dementia: the Alzheimer's Disease Cooperative Study Cognitive Function Instrument. JAMA Neurol. 2015;72(4):446–54.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Gifford KA, Liu D, Lu Z, et al. The source of cognitive complaints predicts diagnostic conversion differentially among nondemented older adults. Alzheimers Dement. 2014;10:319–27.

    Article  PubMed  Google Scholar 

  35. Meinert CL, Breitner JC. Chronic disease long-term drug prevention trials: lessons from the Alzheimer's Disease Anti-inflammatory Prevention Trial (ADAPT). Alzheimers Dement. 2008;4:S7–S14.

    Article  CAS  PubMed  Google Scholar 

  36. Grill JD, Raman R, Ernstrom K, Aisen P, Karlawish J. Effect of study partner on the conduct of Alzheimer disease clinical trials. Neurology. 2013;80:282–8.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Edland SD, Emond JA, Aisen PS, Petersen RC. NIA-funded Alzheimer centers are more efficient than commercial clinical recruitment sites for conducting secondary prevention trials of dementia. Alzheimer Dis Assoc Disord. 2010;24:159–64.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Knopman DS. Clinical trial design issues in mild to moderate Alzheimer disease. Cogn Behav Neurol. 2008;21:197–201.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Carr DB, Gray S, Baty J, Morris JC. The value of informant versus individual's complaints of memory impairment in early dementia. Neurology. 2000;55:1724–6.

    Article  CAS  PubMed  Google Scholar 

  40. Kozauer N, Katz R. Regulatory innovation and drug development for early-stage Alzheimer's disease. N Engl J Med. 2013;368(13):1169–71.

    Article  CAS  PubMed  Google Scholar 

  41. Callahan CM, Tu W, Stump TE, Clark DO, Unroe KT, Hendrie HC. Errors in self-reports of health services use: impact on Alzheimer disease clinical trial designs. Alzheimer Dis Assoc Disord. 2015;29:75–81.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Karlawish J, Langa KM. Unfinished business in preventing Alzheimer disease. JAMA Int Med. 2016;176(12):1739–40.

    Article  Google Scholar 

  43. Alzheimer's Association. Telling the Truth in Diagnosis. 2011., Accessed 31 Mar 2014.

    Google Scholar 

  44. Sheffrin M, Stijacic Cenzer I, Steinman MA. Desire for predictive testing for Alzheimer's disease and impact on advance care planning: a cross-sectional study. Alzheimers Res Ther. 2016;8:55.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Ott BR, Jones RN, Noto RB, et al. Brain amyloid in preclinical Alzheimer's disease is associated with increased driving risk. Alzheimers Dement (Amst). 2017;6:136–42.

  46. Sabatino CP. Damage prevention and control for financial incapacity. JAMA. 2011;305:707–8.

    Article  CAS  PubMed  Google Scholar 

  47. Ready RE, Ott BR, Grace J. Validity of informant reports about AD and MCI patients' memory. Alzheimer Dis Assoc Disord. 2004;18:11–6.

    Article  PubMed  Google Scholar 

  48. Conde-Sala JL, Garre-Olmo J, Turro-Garriga O, Vilalta-Franch J, Lopez-Pousa S. Quality of life of patients with Alzheimer's disease: differential perceptions between spouse and adult child caregivers. Dement Geriatr Cogn Disord. 2010;29:97–108.

    Article  CAS  PubMed  Google Scholar 

  49. National Academies of Sciences, Engineering, and Medicine. Families caring for an aging America. Washington, DC; 2016.

  50. Postuma RB, Gagnon JF, Bertrand JA, Genier Marchand D, Montplaisir JY. Parkinson risk in idiopathic REM sleep behavior disorder: preparing for neuroprotective trials. Neurology. 2015;84:1104–13.

    Article  PubMed  PubMed Central  Google Scholar 

Download references


JDG is supported by the National Institute on Aging (NIA grant nos. AG016573 and AG056931) and the National Center for Advancing Translational Science (UL1TR000153). JK is supported by the National Institute on Aging (grant no. AG01024), the Center for Disease Control and Prevention (CDC) Healthy Brain Network supported in part by cooperative agreements from the CSD’s Prevention Research Centers Program (U48 DP 005006, 005002, 005053, 005000, and 005013), and the Diane Eisen Memorial Neurodegenerative Disease Research Fund.


This work was supported by NIA AG AG016573, NIA AG056931, NIA AG01024, CSD U48 DP 005006, 005002, 005053, 005000, and 005013, NCATS UL1TR000153, and the Diane Eisen Memorial Neurodegenerative Disease Research Fund.

Availability of data and materials

Not applicable.

Author information

Authors and Affiliations



JDG and JK were responsible for the concept and design, and drafted the manuscript. Both authors read and approved the final manuscript.

Corresponding author

Correspondence to Joshua D. Grill.

Ethics declarations

Authors’ information

Joshua Grill, PhD, has served as an investigator on studies sponsored by Eli Lilly & Company, Biogen Idec, and the Alzheimer’s Disease Cooperative Study.

Jason Karlawish, MD, is a co-holder of a license of an Integrated NeuroDegenerative Disease Database developed at the University of Pennsylvania. He receives royalties for "Do We Have a Pill for That: Treating Dementia", Johns Hopkins University Press.

Ethics approval and consent to participate

This study does not meet the criteria for human subject research.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Grill, J.D., Karlawish, J. Study partners should be required in preclinical Alzheimer’s disease trials. Alz Res Therapy 9, 93 (2017).

Download citation

  • Published:

  • DOI: