By Dr. Brent Forester, MD, MSc
Psychiatrist-in-Chief and Chair, Department of Psychiatry, Tufts Medical Center
Director of Behavioral Health, Tufts Medicine
Professor and Dr. Frances S. Arkin Chair of Psychiatry, Tufts University School of Medicine
Dr. Brent Forester is a collaborator and contributor with EPOCH Senior Living. He is the author of this article.
This article is part of the Dementia Care Pathway, a series exploring what good dementia care can look like over time, from diagnosis and treatment to caregiver support, planning, and living well.
Before I became a geriatric psychiatrist, I thought seriously about becoming a family practice physician.
What appealed to me was the opportunity to care for people over time. I liked the idea of getting to know patients and their families, understanding their health in the context of their lives.
In many ways, that is exactly what good dementia care requires.
When someone begins experiencing changes in memory or thinking, primary care is often the logical place to start.
So, can a primary care doctor diagnose dementia?
Yes. In many cases, they can.
Primary care clinicians can evaluate cognitive concerns, diagnose many typical cases of dementia, identify a likely cause, and manage important aspects of care after diagnosis.
That doesn’t mean every case should remain in primary care. Dementia medicine is becoming more complex, and some people will need specialist expertise or more advanced testing.
The question, then, is not whether primary care or specialty care should “own” dementia. It is how primary care can do what it is particularly well positioned to do, while bringing in additional expertise when needed.
What Role Does Primary Care Play in Dementia Care?
Primary care has one enormous advantage when it comes to dementia:
The primary care clinician often knows the whole person.
Dementia doesn’t develop in isolation from everything else happening in someone’s life or health.
A patient may also be managing high blood pressure or diabetes. They may have experienced depression, or perhaps their hearing has deteriorated. Their spouse may mention that they have stopped doing something they once managed easily (like handling all the bills or attending a social club once a week).
A specialist meeting that person for the first time can gather this information, but it may not be at their fingertips. A primary care physician typically has years of context and personal insights to draw upon.
That can be extremely valuable because evaluating dementia involves identifying change. We want to understand how someone is functioning now compared with how they functioned previously.
Primary care is also where many of the factors that influence brain health are already being managed. This makes the primary care office a natural place to identify cognitive concerns, begin an evaluation, and work out what happens next.
There’s tension here, though.
Primary care clinicians are caring for increasingly complex patients, often during relatively short appointments. At the same time, dementia has become one of the fastest-moving areas of medicine.
Blood-based biomarkers are entering clinical practice. New Alzheimer’s treatments require careful evaluation and monitoring, while our understanding of different forms of dementia continues to develop.
The answer cannot be to simply add all of that responsibility to an already busy primary care appointment and a likely overworked PCP. They aren’t automatic repositories of the latest and greatest in dementia care research, and it would be unfair to expect them to be.
That’s where primary care clinicians need better tools and connections to specialist care to fill gaps.
Can Your Primary Care Doctor Diagnose Dementia?
A common misconception is that someone experiencing memory problems needs to go directly to a neurologist or some kind of specialized memory clinic to receive a dementia diagnosis.
The Alzheimer’s Association’s current clinical guideline states that you can sometimes initiate and complete an evaluation for dementia within primary care. But we should know this involves more than giving someone a quick memory test.
There are several things we need to understand.
First, has there actually been a change?
The clinician needs to hear from the person experiencing symptoms and, whenever possible, someone who knows them well.
- What has changed?
- When did these changes begin?
- Is it getting worse?
A caregiver may notice things the person themselves has not recognized. That outside perspective is often critical.
Second, is there measurable cognitive impairment?
A primary care clinician can use a validated cognitive assessment to look at areas such as memory, attention, language, reasoning, and other thinking skills.
But we should never interpret one test score in isolation. It’s never a clear-cut verdict.
Third, how are these changes affecting life?
Someone may have measurable cognitive changes but still manage their everyday responsibilities independently. That may point toward mild cognitive impairment rather than dementia.
That’s why we doctors are always keen to know more than how someone performs during an office test.
- Can they still manage their medications?
- Are they paying bills correctly?
- Are they getting lost?
- Can they safely carry out the activities they previously managed?
If the answer to any of these questions becomes no, a dementia diagnosis becomes more likely.
Fourth, perform a mood and behavioral symptom assessment
The neuropsychiatric symptoms of dementia are nearly universal over the course of the disease, and new-onset behavioral and mood symptoms may be the first warning sign of an underlying neurodegenerative disorder.
So, performing this assessment represents a key part of the puzzle for a primary care physician.
Finally, what is causing the change?
The clinician brings together the history, cognitive assessment, physical and neurologic examination, medication review, and appropriate diagnostic testing. No one part alone is enough to tell us, “This person has dementia.”
Blood work can help identify medical conditions that may be contributing to cognitive symptoms. Brain imaging may also be part of the evaluation.
In a typical case, that may be enough for a primary care clinician to diagnose dementia and identify Alzheimer’s disease or another condition as the likely cause.
There’s a reason that Arthur Conan Doyle, creator of Sherlock Holmes, was also a trained medical doctor. Medicine and detective work have more in common than we sometimes realize. We gather clues, look for patterns, and rule things out through deductive reasoning. Then we try to build the clearest possible explanation from the evidence in front of us.
For some patients, the picture is still unclear, even with multiple data sources and the best Holmes-like powers of deduction. That’s when clinicians ask for help.
How Is Dementia Diagnosis Changing?
Dementia diagnosis is an area where I think primary care will look very different over the next several years.
For decades, some of our more sophisticated Alzheimer’s diagnostic tools have largely existed in specialty settings, but that’s changing.
Blood-based biomarkers are increasingly entering clinical practice. In 2025, the FDA cleared the first blood test designed specifically for use in primary care to help rule out Alzheimer’s-related amyloid pathology in people with cognitive symptoms. Other FDA-cleared blood tests can also help clinicians assess whether Alzheimer’s-related brain changes may be present.
In short, this brings the first line of early detection right into the primary care office – all they have to do is draw some blood.
These are important developments, but we should be cautious about their promises.
A blood test isn’t a replacement for listening to the patient, performing a comprehensive cognitive, functional and behavioral assessment, and considering other aspects of their health.
Alzheimer’s diagnosis remains a multi-step clinical process.
What blood biomarkers may eventually do is give primary care another useful, accessible tool. They may help clinicians decide which patients are unlikely to have Alzheimer’s pathology and which patients need additional evaluation.
It could also make the relationship between primary care and specialty care much more efficient.
What Can Primary Care Manage After a Diagnosis?
In many ways, primary care’s greatest strength becomes apparent after a diagnosis.
Dementia doesn’t replace all the other reasons somebody needs a doctor.
A person living with dementia still needs management of their cardiovascular health. They still experience pain and infections. They need medication reviews, vaccines, hearing and vision care, and all the other things anyone can expect to be asked about at a typical appointment.
And guess what? All these things can influence how someone with dementia functions, too. So, it follows that primary care is best placed to monitor the change we have been so keen to highlight.
The key point here, and what a PCP is best placed to monitor, is that a sudden decline doesn’t always mean dementia itself has progressed. Other medical problems can temporarily worsen cognition or behavior, so the PCP’s job is often to ask:
What else might be affecting this person today?
That might mean checking:
- whether medications are still appropriate
- whether everyday activities are becoming more difficult
- whether new safety concerns have emerged
- whether mood, sleep, or behavior has changed
- whether the caregiver is seeing something new
After checking for change, the PCP can determine what to do. The goal is for the primary care clinician to understand what they can manage well (can they change medication, offer access to a resource, or manage depression, etc.)
Sometimes, they will recognize when the situation has moved beyond their scope. Then, the PCP can organize the best next step.
When Should Primary Care Refer to a Dementia Specialist?
There are situations where a primary care clinician should be honest and say:
I need another set of eyes on this.
They could need specialist involvement if the symptoms are unusual or the evaluation requires expertise or testing that’s not readily available to them.
Typical cases for referral:
- cognitive symptoms begin at an unusually young age
- symptoms progress very quickly
- the pattern of symptoms is atypical
- the diagnosis remains unclear after an initial evaluation
- more detailed neuropsychological testing is needed
- specialized biomarkers or disease-modifying treatment are being considered
Rapid changes deserve particular attention.
A progressive decline over several years looks very different from cognitive changes developing over weeks. Such progression always needs urgent evaluation, particularly if the individual is experiencing delirium.
But the appropriate specialist depends on the problem.
A neurologist may help clarify an atypical cognitive syndrome. A geriatric psychiatrist, like myself, may become particularly valuable when mood, psychosis, agitation, or other behavioral symptoms are complicating dementia care.
A neuropsychologist can provide much more detailed cognitive testing when a brief office assessment doesn’t give us enough information.
What I don’t want families to take away is that being referred means the primary care doctor’s job is finished.
Referral should expand the care team, not transfer the entire problem somewhere else.
The person’s primary care clinician still has an important role as coordinator and monitor.
How Can Primary Care Help Coordinate the Care Team?
This brings us to what I think is one of the biggest opportunities in dementia care.
Someone living with dementia may see a primary care physician, neurologist, psychiatrist, therapist, geriatrician and several other professionals over time.
Each may be doing excellent work, but who sees the whole picture?
Too often, that job falls to the family. Caregivers carry information between offices, explain what one clinician told another, and try to work out who they should call when something changes. That’s quite the burden on already overwhelmed people. I don’t think they should have to act as the healthcare system’s communication network.
We need a closed-loop system of dementia care.
Primary care can identify a concern and begin the evaluation. A specialist can add expertise when needed. Recommendations then come back to primary care, and everyone involved continues to have access to the information they need as the person’s condition changes.
If a neurologist recommends a new treatment, the primary care clinician should know about it. If the PCP identifies a medical problem that may be worsening cognition, the dementia specialist should know about that, too. That two-way street element is so important for effective care.
And throughout the process, there should be clarity around one very simple question:
Who is responsible for what?
That closed loop also needs to extend beyond physicians. Care navigators, social workers, therapists, community programs, and caregiver support can all become part of the system when needed.
Models such as GUIDE (Guiding an Improved Dementia Experience) are beginning to build more of that infrastructure around dementia care, recognizing that coordination takes time and can’t simply be added to an already busy physician’s workload.
We’re not quite there yet in many areas.
Primary care clinicians still face limited time, and access to specialists varies. Traditional fee-for-service medicine isn’t particularly good at paying for all that ‘extra’ work. Health systems don’t always communicate as well as they should, either.
But I think the direction is clear.
The future depends on giving primary care the tools and support to do what it’s particularly well positioned to do: know the person, recognize change, manage the bigger picture, and bring in additional expertise when needed.
That’s why I was tempted by family medicine in the first place. The clinician gets to know the person and the family, not simply the disease.
And when we are caring for someone with dementia, that perspective is more important than ever.
Continue Exploring Dementia Care
Primary care can be an important starting point, but dementia care may involve several professionals over time. Learn what a geriatric psychiatrist can contribute to dementia care, particularly when changes in mood, behavior, or perception become difficult to manage. Families can also explore what happens after a dementia diagnosis and how ongoing care can be coordinated.
These topics are part of the wider Dementia Care Pathway. You can also browse additional dementia resources or find upcoming educational programs and caregiver support groups from Bridges® by EPOCH.
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