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.
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.Simple measures such as monitoring weight and assessing nutritional status regularly can help support the person with dementia to remain physically healthy.
Develop and maintain a care plan (team management plan) and make follow-up appointments. Regularly review team care arrangements / team management plan.
Assess carer’s needs on a regular basis and refer to respite care services as appropriate.
Keep in mind the principles of care:
- Provide person-centred care – identify and respond to the individual needs to the person with dementia, and their carer(s) and family.
- Improve quality of life – maintain function and maximise comfort for people living with dementia throughout the disease trajectory.
- Use appropriate language – use language consistent with the Dementia Language Guidelines and the “Talk to me” communication guide.
1. KPMG Dementia services pathways - an essential guide to effective service planning 2011 pg. 23
2. 14 essentials for good dementia care in general practice. Dementia Collaborative Research Centre 2011
3. Clinical Practice Guidelines for Dementia in Australia: Recommendations 2016