Dementia diagnostic deserts: workforce and geographic inequities in the diagnostic pathway for cognitive impairment

As disease-modifying therapies for Alzheimer's disease become available, ensuring equitable access to timely and accurate diagnosis of cognitive impairment is critical. This article conceptualizes "dementia diagnostic deserts," defined as geographic areas where rurality, primary care professional shortages, and high social deprivation converge to exacerbate access to the diagnostic continuum, from initial screening and comprehensive evaluation to the appropriate referral for specialist-based diagnostic confirmation. Using a multidimensional framework, we identify "Triple Disadvantage Zones" where these barriers intersect most severely, leading to diagnostic errors, characterized by failure to differentiate subjective complaints from objective impairment. This diagnostic failure produces 2 distinct forms of diagnostic inequity: delayed diagnosis for those with true pathology, and inappropriate over-testing for those who do not meet clinical criteria. Nurse practitioners and physician assistants are frontline providers in these underserved regions but face significant training gaps and practice-level infrastructure barriers. Addressing these disparities requires a multidimensional policy approach that targets the convergence of geographic, workforce, and socioeconomic barriers rather than rurality alone. We propose a coordinated policy agenda focused on comprehensive clinical triage training, appropriate reimbursement for clinician time, financial assistance for diagnostic testing, and investments in practice-level capacity for the entire diagnostic pathway and subsequent care.