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 care team. It improves the quality of life of people with dementia and their carers, reduces behavioural 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

DDiagnostic review Check whether the diagnosis is correct and that the person with dementia and their carers understand it
EEffective carer supportIdentify and assess the carer(s); provide necessary information; provide legal and financial advice; offer participation in research
MMedication reviewCheck for polypharmacy; minimise use of drugs that impair cognition; stop any medication that is not needed
EEvaluation of risksCheck for carer stress, comorbid conditions, problem behaviours, environmental risks
NNew symptoms inquiryInquire whether any new symptoms have occurred
TTreatmentImplement and evaluate pharmacological and non-pharmacological treatments
IIndividualityEnsure that interests, hobbies, social relationships and activities of the person with dementia are maintained
AAdvance care planningEncourage the person with dementia to define what happens when own decision-making capacity is impaired; suggest end-of-life regulations

Example of a treatment plan

Jarek had come for diagnostic evaluation 4 years ago, at the age of 78 years. His MMSE score was 25 points, activities of daily living were minimally impaired. MRI revealed hippocampal atrophy, the CSF evaluation showed low beta amyloid and high tau concentrations. The diagnosis was mild cognitive impairment in Alzheimer’s disease. Treatment was started with donepezil. Over the next 4 years Jarek’s condition gradually deteriorated. At the current visit his MMSE score is 17. He requires assistance with activities of daily living and cannot be left alone in the home. His wife has increasing difficulties handling him. She reports that he makes up stories from the past that never happened. Also, he is occasionally aggressive and refuses to communicate with her. Often he wanders around the home in the night and falls asleep during the day. What might the treatment plan for Jarek look like? 

Jarek’s care plan

DDiagnostic review Jarek’s condition has deteriorated from mild cognitive impairment to moderate dementia. The diagnosis of Alzheimer’s disease is supported by the MRI, typical biomarker profile, gradual cognitive decline and occurrence of behavioural and psychological symptoms.
EEffective carer supportThe neurologist suggested Jarek’s wife to see a social worker or psychologist to develop strategies for coping with the patient’s behaviour and put her in contact with the local Alzheimer’s society which runs carer support group. He also suggested that her children might be more involved in care in order to provide their mother with some respite on weekends. With the aim of reducing carer stress he also arranged regular visits of a day care centre.
MMedication reviewSince Jarek has reached the stage of moderate dementia, memantine was added to donepezil. To reduce Jarek’s occasional aggressiveness and hostility an antipsychotic was tried. To manage the sleep problems daytime activity and a bedtime routine were introduced, and the antidepressant mirtazapine was administered.
EEvaluation of risksThe neurologist made steps toward reducing stress of Jarek’s wife. He checked his co-morbid conditions and initiated treatment for behavioural symptoms combining non-pharmacological and pharmacological interventions.
NNew symptoms inquiryThe newly occurring aggressive and hostile behaviours were adequately addressed.
TTreatmentPharmacological treatment consistent of the antidementia drugs donepezil and memantine in combination, and antipsychotic for aggressive and hostile behaviour, and an antidepressant for nighttime sleep disorder. Non-pharmacological interventions included carer support, daytime activity and bedtime routine, and visits to a day care centre.
IIndividualityPatient- and carer-related therapeutic interventions were chosen in consideration of individual needs and preferences.
AAdvance care planningJarek expressed the wish to be cared at home by his family as long as possible. Jarek’s wife and children received information regarding treatment and care in advanced stages of dementia.