Implementing New Dementia Care Models

Care for patients with Alzheimer disease (AD) and related neurodegenerative dementias is undergoing a transformation driven by advances in biomarker diagnostics and disease-modifying therapies. The approval of anti-amyloid monoclonal antibodies (lecanemab, donanemab) has introduced complexities in clinical workflows—from infusion infrastructure and MRI surveillance for amyloid-related imaging abnormalities (ARIA) to genetic counseling and shared decision-making. Sustainable adaptation requires a comprehensive approach at local levels, including clinician and community education, multifaceted stakeholder engagement to optimize infrastructure, and investments in personnel to address existing workforce gaps. This topic reviews practical models for innovation that practices and health care systems can use to implement these new tools while remaining nimble enough to evolve with future developments.

The Specialist Workforce Shortage

Neurodegenerative dementias are among the most common neurologic conditions and a leading cause of death worldwide. Despite this burden, the cognitive and behavioral neurology workforce is severely insufficient. General neurologists, geriatric psychiatrists, internists, and other clinicians must have the training and tools to evaluate and manage common cognitive disorders and understand when subspecialist referral is appropriate. Particularly with the growing availability of blood-based biomarkers for neurodegenerative disease, education on appropriate use and interpretation will be critical to prevent unnecessary patient anxiety and therapeutic mistargeting.

Neurologists with subspecialty expertise have a valuable opportunity to develop and disseminate practically focused domain knowledge with a wider audience through a hub-and-spoke model of dementia care. This model positions subspecialist centers as hubs for complex cases, treatment initiation, and monitoring, while community neurologists and primary care clinicians serve as spokes managing ongoing care with structured decision-support tools.

Practice Models for Dementia Care

Solitary Practitioner Model

Most existing dementia clinics are provider-centric, meaning a patient sees a clinician who then coordinates evaluation and management. The primary clinician establishes a diagnosis and treatment plan, prescribes appropriate therapies, and completes indicated follow-up. Advantages include emphasis on clinician autonomy and retention of longer-term clinician–patient relationships. Limitations include potential for wide practice variation related to differential expertise or viewpoints amid a rapidly evolving knowledge base, which can contribute to disparities in care. Because ARIA and other side effects of new therapies may require brisk action, practices must ensure robust cross-coverage when individual clinicians are unavailable.

Group Practice Model

Group practice models, where clinicians rotate in staffing a clinic analogous to inpatient service structures, offer distinct benefits. Research suggests that group practice models can improve patient access and satisfaction, clinic efficiency and resource use, and clinician job satisfaction and quality of life. Following the availability of anti-amyloid therapies, several centers assembled multidisciplinary committees to review treatment candidacy, modeled on tumor boards and epilepsy surgery boards—settings with high stakes, high complexity, and unknowns.

Downsides include the up-front investment required to change existing clinic structures and the potential for disagreements among colleagues on next steps, requiring established processes, strong interpersonal relationships, and shared objectives.

Anti-Amyloid Therapy Infrastructure Needs

The availability of anti-amyloid monoclonal antibody therapies for early symptomatic AD represents a marked change from prior management options. In cognitive and behavioral neurology, the use of infused medications requiring scheduled safety monitoring is a new paradigm. Practices should recognize that investment in infrastructure now will make future adjustments iterative (akin to incorporating ocrelizumab into a practice already using rituximab) rather than transformative.

Radiology Collaboration and MRI Monitoring

Collaboration with radiologists is integral for emerging dementia therapies. ARIA can present with cerebral edema, microhemorrhages, or superficial siderosis. Certain baseline MRI findings are associated with increased ARIA risk and may be contraindications to therapy. Because exclusionary MRI findings may be among the most common reasons for ineligibility, obtaining imaging early can help prioritize additional testing for patients most likely to be treatment candidates. Consensus recommendations exist regarding the MRI sequences and protocols necessary for adequate ARIA assessment.

ARIA findings can be subtle with significant implications for clinical decision-making. Growth of radiologic expertise and development of AI-assisted image analysis tools for ARIA detection are anticipated to positively impact patient care. Practices should establish proactive partnerships with radiology departments to ensure access, expertise, and bidirectional support.

Biomarker and PET Imaging Considerations

Insurance coverage of amyloid PET for symptomatic AD diagnosis has expanded since lecanemab became clinically available, and some insurers now cover serial amyloid PET for treatment monitoring. Tau PET is mostly used in research at tertiary care centers, though updated clinical guidelines for amyloid and tau PET are in progress. PET tracers for non-AD pathologies—including alpha-synuclein (Lewy body disease) and 4-repeat tau (frontotemporal degenerative disorders)—are in development. Practices using PET modalities should liaise with local radiology departments for rational, impactful, and sustainable use.

Multidisciplinary Team Roles

Neuropsychology

High-value indications for neuropsychological testing in the anti-amyloid era include differentiating subjective cognitive concerns from MCI and gauging impairment severity to discuss therapy use or discontinuation. For most practices, obtaining standard neuropsychological testing on all patients as routine care will not be practical. Development of abbreviated test batteries and innovative approaches such as self-administered digital assessments may facilitate more efficient paths for baseline evaluation and serial monitoring.

Advanced Practice Providers

Emerging treatment complexities provide opportunities for greater integration of nurse practitioners and physician assistants in dementia care through models that support team members practicing to the full extent of their training. Treatment-focused clinic slots and dedicated appointment types can ensure important milestones are completed without monopolizing availability for patients with other conditions.

Social Workers and Care Navigators

Dementia care navigators can help coordinate the patient journey from initial evaluation through long-term management. Roles include managing prior authorizations, scheduling infusions and MRI surveillance, providing contact for routine questions, and assembling medication and testing orders. Integration of social work expertise into workflows addresses financial barriers, advance care planning, and care partner support.

Telehealth and Remote Monitoring

Telehealth expansion offers opportunities to bridge gaps in dementia care access, particularly for patients in rural or underserved areas. Remote cognitive monitoring through self-administered digital assessments may enable more frequent evaluation without requiring in-person visits. However, certain aspects of anti-amyloid therapy management—infusion administration, MRI surveillance, and acute ARIA evaluation—necessarily require in-person infrastructure. A hybrid model integrating telehealth for routine follow-up, patient education, and care coordination with in-person visits for infusions, imaging, and acute assessments represents a practical approach for many practices.

Quality Metrics and Care Coordination

Sustainability of Orders and Scheduling

Anticipatory modeling of patient volumes, testing needs, and treatment and complication rates can help practices safeguard against being overwhelmed. New therapies increase demand for prior authorizations and coverage appeals, which can occupy resources and contribute to burnout. Approaches to mitigate these challenges include training administrative staff to handle prior authorizations, developing letter templates for appeals, and leveraging AI to predict coverage approval likelihood based on historical trends.

For therapies requiring specific follow-up, treatment-focused clinic slots with turnback policies (prioritizing certain visit types while allowing others to fill remaining openings after a time interval) ensure milestones are completed without monopolizing availability. Flexible clinic templates are also advantageous: a visit addressing safety, supervision, and living environment requires more time than an uncomplicated monitoring visit, while a patient with new symptoms concerning for ARIA needs urgent evaluation.

Electronic Health Record Safeguards

Thrombolysis is currently considered contraindicated in patients receiving anti-amyloid monoclonal antibody therapies because of elevated intracerebral hemorrhage risk, including the potential for fatality. Implementing alerts or best practice advisories in the EHR can provide safeguards to prompt investigation—for example, flagging when anticoagulation is being considered for a patient on anti-amyloid therapy who presents with a new pulmonary embolism.

Health Equity in Dementia Care

Disparities in dementia care are complex and demand multipronged interventions. Missed or delayed diagnosis of neurodegenerative dementia is more common in patients from Asian, Hispanic, and non-Hispanic Black populations, in those with low neighborhood socioeconomic status, and in those with atypical clinical syndromes (which are more frequent at younger ages). Demographic representation in the neurology workforce does not reflect the demographic distributions of race and ethnicity in the general US population.

Data from nationally representative studies show that Black and Hispanic older adults with dementia are less likely to have completed an advance care plan compared with non-Hispanic White counterparts. With the complexities of emerging therapies, enhancements to care planning will be critical for optimizing safety and efficacy. Clinical trial enrollment must also broaden—limited inclusion of diverse populations across race, ethnicity, sex, gender, sexuality, neighborhood, and socioeconomic status threatens the generalizability of treatment findings.

Future Models of Dementia Care

Combination Therapy and Flexible Infrastructure

AD and related diseases are pathophysiologically complex. Similar to models applied for HIV and hypertension, neurodegenerative dementia may ultimately require individualized combination therapy targeting multiple mechanisms—amyloid, tau, alpha-synuclein, inflammation, synaptic dysfunction—potentially administered via oral, intravenous, subcutaneous, or intrathecal routes. Clinical practices that are too rigid or built solely to support a single therapy modality will be at a disadvantage. Tau-targeting antisense oligonucleotides (e.g., MAPTRx) are already in Phase 1 trials, and alpha-synuclein PET tracers are in development, signaling the breadth of future diagnostic and therapeutic tools.

AI-Assisted Screening and Decision Support

Artificial intelligence tools are emerging across multiple domains of dementia care: AI-assisted ARIA detection on MRI, predictive models for insurance coverage approval likelihood, digital cognitive assessment platforms, and clinical decision-support systems. These tools may help manage the growing complexity of dementia care without proportional increases in specialist workforce requirements.

Comprehensive Holistic Care

Despite the proliferation of disease-modifying therapies, clinicians must reinforce that care of patients with dementia is not purely pharmacologic. Symptomatic medications, lifestyle modifications, supportive therapies (physical, occupational, and speech therapy), social work, and community-based resources that alleviate care partner burden remain crucial in holistic treatment approaches.

Patient Education and Shared Decision-Making

When new therapies are approved, practices are often flooded with patient inquiries. Templated responses empower nursing and clinical support staff to answer common questions. Frequently asked questions documents and patient-facing brochures can translate complex management concepts for a wide audience. For patients being evaluated for anti-amyloid therapy, APOE genetic testing is recommended because of differential ARIA risk by APOE allele profile. Given the widespread shortage of genetic counselors, collaboration with domain experts can yield scalable patient-facing materials for pretest and posttest counseling.

Nurse education visits can review practical treatment aspects: contact information for routine questions, medication and testing order assembly, and infusion logistics. Medical alert cards serve as an additional precaution for emergency departments in other health systems that may be unaware of ongoing therapy and its implications. Complex new options for dementia diagnosis and management benefit from culturally sensitive shared decision-making to match clinical plans with patient values, preferences, and goals of care.

Policy Implications

Sustainable implementation of new dementia care models requires alignment of health system investment, payer coverage, and regulatory frameworks. Key policy considerations include expanding insurance coverage for biomarker testing and disease-modifying therapies, supporting training pipelines for dementia specialists and advanced practice providers, incentivizing community-based care models that improve access and reduce disparities, and funding research infrastructure for clinical trials that reflect the diversity of affected populations. Fears and stigmas about dementia can contribute to a pervasive sense of futility—centering on an “end-stage” vision or the expectation that nothing can be done. Overcoming these perceptions at both clinical and policy levels will be essential for the field to realize the promise of emerging diagnostics and therapeutics.

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