Post-diagnostic support and dementia care planning

The Australian Dementia Clinical Practice Guidelines recommend that every person with dementia has a care plan. Note there is also a Consumer Companion Guide to support this document.

A comprehensive dementia care plan should be developed with input from the person with dementia and their carer. The plan may be developed by their specialist or primary care team, and ideally has both primary care and specialist input.

Take a proactive approach in supporting function through referral to occupational therapy, physiotherapy, speech pathology and other allied health as needed for rehabilitation. Subsidised allied health services can be accessed through a GP chronic disease management plan. Subsidised psychological support can be obtained through a GP mental health plan.

The care plan should consider the following areas (listed in the Checklist for communicating a diagnosis and care planning.)

Every person with dementia should have a care plan.
Care planning ideally occurs during a follow up appointment, or refer to patient’s GP to develop and implement a chronic disease management plan.
Emphasise that people live full lives with dementia, and treatments and supports are available.
Ensure you understand patient and carer’s goals and concerns.
Medications – donepezil (Aricept), galantamine (Reminyl, Galantyl), rivastigmine (Exelon, Exelon Patch), memantine (Ebixa, APO-Memantine, Memanxa).
- The cholinesterase inhibitors are PBS listed for mild to moderate Alzheimer’s disease and can only be prescribed for people with an MMSE of 10 or more with confirmation of diagnosis by a specialist and stating it is sole subsidised medication.
- Memantine is PBS listed for patients who have a diagnosis of Alzheimer’s Disease made by a specialist physician with a score of 10-14 on MMSE.
- See www.pbs.gov.au for specific guidelines.
Driving – discuss driving safety and driving assessments, your responsibility to report to local driving authority, as well as contingencies if the person stops driving.
Lifestyle recommendations – discuss exercise, staying cognitively and socially active, limit alcohol, stop smoking, ‘Mediterranean’ diet.
General health – management of medications, optimal control of blood pressure, cholesterol and blood glucose.
Psychological support – psychology referral (e.g. through a mental health plan via GP) or Dementia Australia Counselling Service call 1800 100 500.
Support with cognition, communication and function – Refer to occupational therapy, physiotherapy, speech pathology, psychology (e.g. through chronic disease management plan via GP).
Education and information – provide this Forward with Dementia website, and Dementia Australia website as well as the helpline number 1800 100 500.
Managing work or usual activities – discuss issues as relevant.
Legal and financial planning – discuss will, enduring power of attorney, enduring guardianship, advance care directives.
Carer support – refer to local carer support services or to Dementia Australia.