Who Helps After a Dementia Diagnosis? Building Your Care Team — and How to Find a Geriatric Psychiatrist or Social Worker

A dementia diagnosis rarely involves just one clinician. The people who help patients and families navigate diagnosis, treatment, and the transition to more advanced disease span a multidisciplinary team of medical specialists, allied health professionals, care navigators, and community-based support organizations. Knowing who these players are — and when to bring each one in — can make the difference between a fragmented experience and coordinated, person-centered care.

Burns and colleagues recently proposed reorganizing memory clinics away from a “one-size-fits-all” model toward purpose-driven subclinics, each with clearly defined team roles (Figure, Reimagining Care Delivery for Alzheimer Disease, JAMA Neurology, April 2026. Content used under license from the JAMA Network® © American Medical Association). The roles below reflect that same team-based logic.

Medical Specialists

• Primary care physician (PCP): Often the first point of contact and the principal source of referral to memory clinics. PCPs coordinate ongoing medical care, manage comorbidities, and increasingly serve as the hub for dementia care management, particularly through task-shifting models that pair them with specialized case managers. The CMS GUIDE (Guiding an Improved Dementia Experience) Model, launched in 2024, provides a monthly per-beneficiary payment to support comprehensive dementia care coordination within primary care and specialty settings. [2–4]
• Neurologist / Geriatrician: Provides diagnostic evaluation, staging, pharmacologic management (cholinesterase inhibitors, anti-amyloid therapies), and ongoing monitoring. Interdisciplinary models pairing geriatricians, neurologists, and neuropsychologists have demonstrated feasibility and high acceptance. [5]
• Geriatric psychiatrist: Manages behavioral and psychological symptoms of dementia (BPSD), including agitation, psychosis, depression, and sleep disturbances — often the most distressing aspects for families.

Neuropsychologist

Neuropsychological evaluation is a critical component for early and accurate diagnosis, staging, characterizing the clinical profile, assessing trajectory over time, and providing individualized recommendations. [6] The Alzheimer’s Association DETeCD-ADRD guidelines position neuropsychology as integral to both primary care and specialty evaluation pathways. [6]

Genetic Counselor

Particularly relevant for APOE ε4 carriers and families with autosomal dominant dementia histories. The AAN recommends that any patient undergoing genetic testing receive pre- and post-test genetic counseling; where formally trained genetic counselors are unavailable, the ordering neurologist should develop competency in providing such counseling or arrange telemedicine access. [7] Genetic counseling helps families navigate the psychological, ethical, and practical implications of results — including reproductive planning, insurance discrimination concerns (GINA protections), and family conflict around differing coping strategies. [8–9]

Dementia Care Navigator

A rapidly growing role, dementia care navigators are non-clinical staff who serve as a single point of contact, providing person-centered support from the moment of diagnosis onward. [10–11] Their responsibilities include needs assessment and care plan development, dementia education, coordination and referral to services, and ongoing care monitoring. [10] The Alzheimer’s Association Dementia Care Navigation Roundtable has aligned navigator roles with the CMS GUIDE Model, defining duties across care delivery domains. [11]

Social Worker

Social workers help families access community resources, navigate insurance and financial planning, arrange respite care and day programs, address caregiver stress and depression, and facilitate advance care planning (healthcare proxy, power of attorney, living arrangements). [12–13] They are often embedded within interdisciplinary dementia care teams and provide supervision for care navigators. [10]

Occupational Therapist

The American Occupational Therapy Association guidelines recommend OT interventions for adults with AD and related neurocognitive disorders, including cognitive rehabilitation, behavioral interventions, sensory approaches, home safety assessments, and care partner education and training. [14] OT focuses on maximizing functional independence in activities of daily living and adapting the home environment to maintain safety. [15]

Nurse Practitioner / Advanced Practice Provider

NPs increasingly serve as dementia care managers, particularly within GUIDE Model sites. In the Cedars-Sinai C.A.R.E.S. program, NPs managed medication initiation (including dementia-specific drugs and antidepressants), specialty referrals, and behavioral interventions for enrolled patients. [16] The restructured memory clinic model positions APPs as leads for treatment clinics, comprehensive support clinics, and prevention/monitoring clinics, with physician support for escalation. [1]

Community Health Workers (CHWs)

CHWs are trusted community members who can fill gaps throughout the dementia care continuum — improving early detection, providing culturally responsive health education, and helping caregivers navigate daily challenges, particularly in underserved populations (African American, Latino, American Indian/Alaska Native communities). [17]

Caregiver Support Organizations

• Alzheimer’s Association: Provides information, local support services, care consultation, support groups, a 24/7 helpline, and educational resources for patients and families. [13]
• Area Agencies on Aging / Eldercare Locator: Connect families with local services including respite care, adult day programs, and home care. [13]
• Family Caregiver Alliance: Focuses on long-term home caregiving needs with fact sheets, online support groups, and practical resources. [13]

Elder Law Attorney / Financial Planner

While not healthcare professionals, early referral for legal and financial planning is consistently recommended across guidelines — including designation of power of attorney, advance directives, asset allocation, and long-term care insurance — while the patient retains decision-making capacity. [12]

How to Find a Geriatric Psychiatrist

As dementia progresses, behavioral and psychological symptoms — agitation, psychosis, depression, sleep disruption — often become the most distressing part of caregiving, and a geriatric psychiatrist’s expertise becomes increasingly valuable. Practical ways to locate one:

• Ask for a referral first. Your PCP, neurologist, or geriatrician is usually the fastest route — they can refer directly to a geriatric psychiatrist within their health system or affiliated memory clinic.
• American Association for Geriatric Psychiatry (AAGP): A member directory of psychiatrists who specialize in the mental and behavioral health of older adults is available at aagponline.org.
• American Psychiatric Association “Find a Psychiatrist” tool: Available through the APA at psychiatry.org; you can filter by geriatric/older-adult focus.
• Board certification verification: Geriatric psychiatry is an American Board of Psychiatry and Neurology (ABPN) subspecialty. You can verify a psychiatrist’s certification in geriatric psychiatry through the ABPN or the American Board of Medical Specialties (ABMS) certification lookup before scheduling.
• Academic memory disorder centers: University-affiliated Alzheimer’s Disease Research Centers and memory clinics typically have geriatric psychiatry embedded in their interdisciplinary teams and can accept direct referrals.
• Alzheimer’s Association Helpline (1-800-272-3900): Staff can help identify geriatric psychiatry resources and behavioral health referrals in your area, 24/7.

How to Find a Social Worker for Dementia Care Transitions

A social worker becomes especially important as families face transitions — increasing care needs, decisions about in-home care versus assisted living or memory care, financial and legal planning, and caregiver burnout. Ways to locate one:

• Start within the existing care team. Hospitals, memory clinics, and health systems participating in the CMS GUIDE Model typically have a social worker embedded in the dementia care team — ask your PCP, neurologist, or care navigator for an introduction.
• National Association of Social Workers (NASW): Many state and local NASW chapters maintain directories of clinical and geriatric social workers; contact NASW Member Services (800-742-4089) or your state chapter, or visit socialworkers.org, for referrals in your area.
• Aging Life Care Association (ALCA): ALCA’s “Find an Aging Life Care Expert” directory (aginglifecare.org) lets you search by ZIP code for aging life care professionals — many of whom are licensed social workers — who specialize in coordinating complex, long-term dementia care.
• Area Agency on Aging / Eldercare Locator (1-800-677-1116; eldercare.acl.gov): A federally funded, no-cost starting point for connecting with local social workers, respite care, and adult day programs.
• Alzheimer’s Association Care Consultation: Offered through the Alzheimer’s Association helpline and local chapters, this service connects families with social workers for personalized care planning at no cost.
• Hospital or health-system case management department. If your loved one has been hospitalized or seen in an emergency department, the case management or social work department can often make a direct referral for ongoing dementia-specific support.

Would you like a follow-up post exploring the structure and reimbursement mechanisms of the CMS GUIDE Model and how to enroll a patient in a participating practice?

References

1. Reimagining Care Delivery for Alzheimer Disease. JAMA Neurology. 2026. Burns JM, Woodward JL, Morris JK, Townley RA.
2. Primary Care Practitioner Perspectives on the Role of Primary Care in Dementia Diagnosis and Care. JAMA Network Open. 2023. Sideman AB, Ma M, Hernandez de Jesus A, et al.
3. Billing for Comprehensive Dementia Care Services Among Traditional Medicare Beneficiaries: Implications for the GUIDE Model. Journal of the American Geriatrics Society. 2026. Hou Y, Naik AD, Joynt Maddox KE, Johnston KJ.
4. GUIDE and Beyond: Strategies for Comprehensive Dementia Care Integration. Journal of the American Geriatrics Society. 2025. Haggerty KL, Reuben DB, Stoeckle R, et al.
5. Montefiore-Einstein Center for the Aging Brain: Preliminary Data. Journal of the American Geriatrics Society. 2016. Verghese J, Malik R, Zwerling J.
6. The Role of Neuropsychological Assessment in the Evaluation of Patients With Cognitive-Behavioral Change Due to Suspected Alzheimer’s Disease and Other Causes of Cognitive Impairment and Dementia. Alzheimer’s & Dementia. 2025. Shaughnessy LW, Weintraub S.
7. Ethical Considerations in Dementia Diagnosis and Care: AAN Position Statement. Neurology. 2021. Chiong W, Tsou AY, Simmons Z, et al.
8. Genetic Counseling and Testing for Dementia – A Scoping Review of Patient and Relatives Experiences and Outcomes. Patient Education and Counseling. 2025. Chen G, Sexton A.
9. Genetic Testing in Dementia – A Medical Genetics Perspective. International Journal of Geriatric Psychiatry. 2021. Huq AJ, Sexton A, Lacaze P, et al.
10. Dementia Care Navigation: A Systematic Review on Different Service Types and Their Prevalence. International Journal of Geriatric Psychiatry. 2023. Giebel C, Reilly S, Gabbay M, et al.
11. A Framework for Implementing High-Quality Dementia Care Navigation: Recommendations From the Alzheimer’s Association Dementia Care Navigation Roundtable. Alzheimer’s & Dementia. 2026. Daven M, Bass DM, Deaner N, et al.
12. Diagnosis and Management of Dementia: Review. JAMA. 2019. Arvanitakis Z, Shah RC, Bennett DA.
13. Dementia Care: Mental Health Effects, Intervention Strategies, and Clinical Implications. The Lancet Neurology. 2006. Sörensen S, Duberstein P, Gill D, Pinquart M.
14. Occupational Therapy Practice Guidelines for Adults Living With Alzheimer’s Disease and Related Neurocognitive Disorders. The American Journal of Occupational Therapy. 2024. Smallfield S, Metzger L, Green M, Henley L, Rhodus EK.
15. Cognitive Rehabilitation for People With Mild to Moderate Dementia. Cochrane Database of Systematic Reviews. 2023. Kudlicka A, Martyr A, Bahar-Fuchs A, et al.
16. Characteristics of Dementia Care Provided by Nurse Practitioners: Findings From the Cedars-Sinai C.A.R.E.S. Program. Journal of the American Geriatrics Society. 2026. Qureshi N, Hirsch D, Rhinehart D, et al.
17. Community Health Workers: Developing Roles in Public Health Dementia Efforts in the United States. Frontiers in Public Health. 2025. Johnson E, Lewis M, Nordyke A, et al.