From Attitudes to Action, Primary Care Alzheimer's Detection: How Knowledge, Confidence, and Clinic Capacity Predict Actual Screening and Referral Behavior

Background: Alzheimer's disease (AD) is one of the most significant and rapidly expanding public health challenges associated with global population aging. Advances in biomarker diagnostics and the development of disease-modifying therapies have increased the clinical importance of detecting cognitive impairment during the earliest stages of disease progression. Early recognition allows for timely care planning, improved management of comorbid conditions, access to emerging therapeutic interventions, and participation in clinical research. Despite these developments, substantial variability persists in Alzheimer's detection within primary care. Historically, limited physician knowledge has been considered a principal barrier to early dementia diagnosis. However, emerging research suggests that structural factors, including diagnostic confidence, clinical workflow integration, and healthcare system capacity may play a more influential role in determining whether cognitive screening and referral occur in routine practice. Objective: This narrative review examines physician-level and system-level determinants that influence whether primary care physicians perform cognitive screening, initiate diagnostic evaluations, or refer patients for specialist assessment when Alzheimer's disease is suspected. Methods: A narrative literature review was conducted using PubMed, Embase, MEDLINE, CINAHL, Web of Science, Scopus, and PsycINFO. Peer-reviewed studies examining dementia detection practices in primary care were included, with emphasis on global research published between 2022 and 2026. Eligible studies evaluated physician knowledge, diagnostic confidence, workflow integration, healthcare system capacity, reimbursement structures, or referral access. Evidence from quantitative, qualitative, mixed-methods, and implementation studies was synthesized using thematic analysis. Results: Findings indicate that most primary care physicians possess adequate conceptual knowledge of Alzheimer's symptoms and commonly used cognitive screening tools. However, knowledge alone does not consistently predict screening behavior. Diagnostic confidence, integration of screening tools into routine workflows, electronic health record decision-support systems, and access to specialist referral networks were more consistent predictors of physician action. Time constraints and competing clinical demands remain significant barriers, although structured workflows and team-based care models substantially improve screening and referral rates.