Do psychiatrists diagnose dementia or should primary care doctors (PCPs) initiate the diagnostic process?

Primary Care Physicians Should Initiate and Often Complete Dementia Diagnosis

Primary care physicians should initiate the diagnostic evaluation for dementia and can complete the diagnosis in most typical cases, with specialist referral reserved for atypical presentations, early onset, or rapidly progressive symptoms. 1

Who Diagnoses Dementia: A Tiered Approach

Primary Care as the Starting Point

The 2025 Alzheimer's Association guidelines explicitly state that the evaluation process for possible cognitive or behavioral impairment can be initiated and in most cases completed in primary care settings. 1 The practitioner's proficiency with this patient population and the individual patient's profile should guide whether the evaluation stays in primary care or requires specialist input. 1

• Primary care physicians should be vigilant for cognitive symptoms reported by patients, family members, or observed during clinical encounters (missed appointments, difficulty following instructions, medication non-adherence, decline in self-care, or new-onset behavioral changes). 1
• Any middle-aged or older patient with cognitive concerns should undergo evaluation—clinicians should not assume "normal aging" without appropriate assessment, as this constitutes suboptimal care. 1

When Primary Care Can Complete the Diagnosis

For most individuals with typical presentations of Alzheimer's disease dementia, primary care physicians can arrive at a confident clinical diagnosis after completing the structured evaluation process. 1 This includes:

• Obtaining history from both patient and a reliable informant about changes in cognition, function, and behavior 1, 2
• Performing validated cognitive screening (MoCA for mild impairment, MMSE for moderate dementia, or rapid tools like Mini-Cog) 1, 3
• Conducting functional assessment using standardized tools (FAQ, DAD) 2, 3
• Evaluating behavioral symptoms (NPI-Q, MBI-C) 2, 3
• Ordering basic laboratory tests (CBC, thyroid function, B12) 2, 3
• Obtaining structural brain imaging (MRI preferred over CT) when indicated 2, 3

This evaluation typically requires two or more problem-focused visits in primary care, especially when involving an informant and allowing sufficient time for comprehensive assessment. 1

When to Refer to Specialists (Including Psychiatrists)

Specialist referral is indicated for specific clinical scenarios, not as routine practice. 1, 4 Appropriate specialists include geriatricians, neurologists, psychiatrists, and geriatric psychiatrists. 4

Mandatory Referral Situations:

• Atypical presentations: Prominent aphasia, apraxia, agnosia, or cortical visual abnormalities 4
• Early onset dementia: Symptoms beginning before age 65 2, 4
• Rapidly progressive symptoms: Cognitive decline developing over weeks to months (requires urgent evaluation) 2, 4
• Prominent neuropsychiatric symptoms: Severe anxiety, depression, apathy, psychosis, or personality changes that dominate the clinical picture 4
• Movement or gait disorders accompanying cognitive symptoms 4

The Role of Psychiatrists Specifically

Psychiatrists (particularly geriatric psychiatrists) serve as dementia subspecialists for complex cases, not as the primary diagnostic pathway. 4 They are particularly valuable when:

• Behavioral and psychological symptoms are prominent and difficult to manage 4
• Differentiating between primary psychiatric disorders (depression, late-onset psychosis) and dementia is challenging 1
• Complex medication management for neuropsychiatric symptoms is needed

However, psychiatrists do not replace primary care as the initial diagnostic setting—they complement it for specific clinical scenarios. 1

Common Pitfalls to Avoid

• Delaying specialist referral when atypical or rapidly progressive symptoms are present leads to worse outcomes 2, 4
• Failing to obtain informant history results in missed diagnoses due to patient anosognosia (lack of insight) 1, 3, 4
• Assuming all dementia requires specialist diagnosis unnecessarily delays care for typical presentations that primary care can manage 1
• Not using standardized assessment tools reduces diagnostic accuracy and makes longitudinal tracking unreliable 3

The Collaborative Model

The diagnosis of dementia is a shared responsibility between generalist and specialist disciplines, with primary care serving as the entry point and specialists providing consultative input for complex cases. 5 This tiered approach:

• Maximizes access to timely diagnosis for the majority of patients 1
• Reserves specialist resources for cases requiring subspecialty expertise 1, 4
• Allows primary care physicians to maintain longitudinal relationships with patients and families 1
• Enables earlier diagnosis compared to models requiring universal specialist referral 4

Primary care physicians should not reflexively refer all suspected dementia cases to psychiatrists or other specialists—they have the tools and guidelines to diagnose most typical cases independently, referring selectively based on clinical complexity. 1