Planned and proactive management

What is a care plan?

A care plan is a written plan which is clear, simple and precise. It must explain what care the person is having, contain contingency plans for the future and include arrangements for review. It is an agreement that helps therapists and patients make positive change toward problem-solving. The care plan encourages professionals, people with dementia and their carers to work together. They agree goals, identify support needs, develop and implement action plans, and monitor progress. This is a continuous process, not a one-off event. The care plan should be written from a person-centred perspective, including the views and needs of carers. The information must be recorded in a way that it is accessible to the person with dementia, using a language that is recognized. The care plan should be personalized for each individual patient. Physicians should plan patient visits for each 3-4 months if pharmacotherapy is used. Monitoring should include the assessment of the patient’s cognition, activities of daily living, behaviour, medical status, home modifications, community support services and decisions concerning institutional care if applicable.

Why is care planning important?

Dementia is a complex health condition that requires complex management. It usually involves professionals of different occupations (e.g. general physicians, specialist physicians, psychologists, nurses, social workers, occupational therapists, physical therapists, speech and language therapists, pharmacists). The activities of these actors must be planned. Care planning is a crucial element in delivering high quality care for people living with dementia, and supporting their families and carers.

When should care planning take place

Care planning should take place as soon as possible after diagnosis. The care plan should be reviewed at least annually involving the person with dementia and their family or carers to consider changes in needs and wishes.

What are the benefits of care planning?

Care planning provides a number of advantages people with dementia, carers, and the interprofessional team. It improves the quality of life of people with dementia and their carergivers, reduces behavioral changes, enhances quality of care and adherence to treatment guidelines, promotes referral for non-pharmacological interventions, lowers the rate of institutionalization, increases the use of community services and enhances the detection of comorbid medical conditions.

Core elements of a care plan

Mnemonic Element Description
D Diagnostic review  Check whether the diagnosis is correct and that the person with dementia and their carers understand it
E Effective carer support Identify and assess the carer(s); provide necessary information; provide legal and financial advice; offer participation in research
M Medication review Check for polypharmacy; minimise use of drugs that impair cognition; stop any medication that is not needed
E Evaluation of risks Check for carer stress, comorbid conditions, problem behaviours, environmental risks
N New symptoms inquiry Inquire whether any new symptoms have occurred
T Treatment Implement and evaluate pharmacological and non-pharmacological treatments
I Individuality Ensure that interests, hobbies, social relationships and activities of the person with dementia are maintained
A Advance care planning Encourage the person with dementia to define what happens when own decision-making capacity is impaired; suggest end-of-life regulations


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  • Ledgerd R, Hoe J, Hoare Z, Devine M, Toot S, Challis D, & Orrell M. Identifying the causes, prevention and management of crises in dementia. An online survey of stakeholders. Int J Geriatr  Psychiatry 31: 638–647, 2016
  • MacNeil Vroomen J, Bosmans JE, van Hout HPJ, de Rooij SE. Reviewing the definition of crisis in dementia care. BMC Geriatr 13, 10, 2013