The purpose of this paper is to synthesize and critically evaluate the current literature that explains the use and non-use of formal community-based long-term care services by caregivers of persons with dementia. There are four issues related to formal community service use by caregivers: reluctance to initiate formal services; under-utilization of available services; delayed utilization of services; and inappropriate utilization of services. Despite substantial research efforts to understand these issues, the reasons for low rates of community service use by this population remains unclear. Common methodological problems and limitations in the underlying theoretical assumptions in the literature, as they relate to caregivers of persons with dementia, have limited the usefulness of the current research for informing practice and policy. A conflict-theory model of decision-making is proposed as an alternative theoretical framework for understanding the particularity and complexity of the decision-making process leading up to the initiation of formal service use. Utilization of formal services is a result of a complex and subjective decision-making process that is unrelated to objective circumstances. The proposed conflict theory model of decision-making can inform policy and practice regarding the development of appropriate, timely and individualized interventions to facilitate the use of formal services by caregivers of persons with dementia.