Ongoing management and care

This stage addresses the role of ongoing management, care, support and review across the spectrum of services and across care settings such as home, in the community and in residential care (low and high care). Services range from post-diagnosis, addressing fluctuations in needs for care and support services, to more intensive case management and care as the disease progresses. This stage primarily focuses on the community setting.[1]

Consider stage and risk and facilitate timely referral to assessments that help support people living with dementia and their carers to remain living in the community or requiring transition to residential care settings.

Manage physical and psychological co-morbidities and maintain optimal health – be alert to delirium.

Develop a care plan (team management plan) and make follow-up appointments. Regularly review team care arrangements / team management plan.

Assess carers needs on a regular basis and refer to respite care services as appropriate.

Immediate Interventions

Legal issues – Enduring Power of Attorney, Enduring Guardianship, advance care planning

Driving and employment – particularly for licensed machinery operators

Medication for Alzheimer’s if appropriate

Lifestyle – regular exercise, mental stimulation, establish routine

General health – blood pressure, other health conditions [2]

KPMG Dementia services pathways - an essential guide to effective service planning 2011 pg. 23

14 essentials for good dementia care in general practice. Dementia Collaborative Research Centre 2011

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