Creating A Dementia Care Plan: What To Expect

Today, millions of people worldwide live with Alzheimer's or dementia, and the number will continue to grow as baby boomers reach senior citizenship. Studies have revealed that Alzheimer’s affects 68% of seniors over 65, with dementia being the primary type. Dementia is a general term used to describe a variety of neurological disorders that affect the brain, causing changes in cognition and behavior. 

While it can take many forms, dementia typically affects memory, judgment, and reasoning abilities. People with dementia may also experience changes in mood or personality, as well as problems communicating or performing everyday tasks.

Dementia care costs are estimated at $13 billion annually for in-home care and $41 billion annually for nursing home care. These estimates don’t reflect the human costs due to this devastating disease.

As the dementia population grows, we must modify our world to accommodate its members' needs and experiences, ultimately nurturing a Dementia Capable Society — a rich landscape that empowers people with dementia to engage in meaningful activities and maintain a meaningful life, as well as a landscape that supports loved ones as they journey through the disease.

Indeed, the Alzheimer's Association states in Dementia Care Practice Recommendations for Assisted Living Residences and Nursing Homes that “engagement in meaningful activities is one of the critical elements of good dementia care.” This emphasizes that such opportunities can help residents maintain functional abilities and improve their overall quality of life.

To that aim, the organization establishes three fundamental objectives around which the document's proposals for social engagement are based:

  • Providing a consistent context filled with personal meaning, a sense of community, options, and enjoyment
  • Creating activities to perform with a resident rather than to or for a person
  • Respecting the resident's preferences, even if it means recognizing his or her tendency for isolation

Creating such experiences is critical for promoting the well-being of all parties affected by today's dementia care environment, from those living with the disease to their caregivers and healthcare providers, who may face physical, emotional, and financial strain due to their various relationships with the disease.

What Are The Best Practices In Dementia Care Planning?

Dementia Care Plan

However, creating holistic dementia living and care settings takes time. It demands a strong, persistent, yet adaptable approach that the entire dementia care team can embrace. A critical component of developing such a thorough dementia care offering is establishing underlying best practices based on current research, generating quantifiable data, and being malleable enough to meet each resident’s unique needs — all of which are necessary factors in facilitating consistent positive outcomes.

This article summarizes the fundamental ideas of dementia care best practices and demonstrates strategies for integrating the components into a successful, sustainable, and universal care system.

Dementia care planning can be frustrating and stressful. Dementia symptoms may worsen over time, as do their difficult behaviors. As your loved one's sickness worsens, the level of care they require will increase. While you cannot change your parent's diagnosis, you may plan ahead to ensure their health and safety.

Understanding the early, middle, and late stages of dementia and the types of care are required. Recognizing what to expect will assist you in developing a dementia care plan that enables you to make informed decisions in advance.

Understanding Core Principles

When developing a dementia care standard that will be implemented across the nursing home, it is critical to establish principles that are based on objective, quantifiable goals for residents, such as the following:

  • Optimizing the quality of life, functional independence, health, and safety of each individual
  • Advising and assisting family members and caregivers
  • Reducing hospitalizations and the use of psychotropic medications

While providers must establish their own goals and principles based on the unique circumstances of their resident population, many of today's leading dementia care experts, including the Alzheimer's Association and the American Occupational Therapy Society, have agreed on certain general principles that serve as the foundation for virtually any Alzheimer's or dementia best practice. When successfully implemented, these factors work in unison to create person-centered and abilities-focused care. Let’s look into the key attributes of these sister philosophies.

Person-Centered Care

The term "person-centered care" has a number of roots, one of which is Dr. Thomas Kitwood's social psychology. It entails offering treatments and actions motivated by the information we discover about each patient. Choice, respect, purposeful living, dignity, and self-determination are among the values that guide this contemporary approach, particularly when applied to dementia care. The key areas of emphasis are placing the person ahead of the task or sickness and framing care around the recipient's goals and needs.

Abilities-Focused Care

This is another notion with disparate origins, though two of its key motivations are Claudia Kay Allen's work as an eminent occupational therapist and developer of a ground-breaking rehabilitation paradigm for people with cognitive disorders, as well as the occupational therapy profession itself. According to these sources, it is vital to focus on how a person with chronic, progressive cognitive impairment (such as that associated with Alzheimer's or dementia) can still perform rather than on the abilities he or she has lost. Assisting individuals in regaining access to these retained capacities at any stage of sickness and in any environment of care can help ensure that positive outcomes continue.

If you wish to know more about the different stages of dementia for elderly individuals, check out this Senior Strong article today.

What Is Dementia Care Mapping?

Dementia Care Mapping

One method of integrating person-centered care is Dementia Care Mapping (DCM). It entails observing people with dementia and the care they receive regularly. Dementia Care Mappers keep track of their observations to help persons informal care settings like nursing homes and hospitals.

It provides a holistic picture of a family's requirements and allows the care team to understand how each of these elements interacts. The University of Bradford's School of Dementia Studies offers formal DCM training programs and has a training manual. Read on to learn how to incorporate dementia care mapping into your elderly loved one's care plan.

What To Know About Dementia Care Mapping

Professor Tom Kitwood and Dr. Kathleen Bredin developed DCM at the University of Bradford in the late 1980s. A demand arose for dementia care evaluation tools that focused on the person with dementia's perspective, as no such tool existed. 

DCM can be used to "enhance well-being and quality of life for people living with dementia at a personal level. Small items that bring delight or discomfort are highlighted throughout the mapping process. This may be expanded upon to ensure that people have more opportunities to experience happiness throughout their day.

There are five stages to the DCM process:

  • Briefing and preparation
  • Observation
  • Analysis
  • Reaction (both written report and verbal feedback)
  • Action preparation

Who Will Benefit From Dementia Care Mapping?

All people with dementia, especially with concerns about the quality of care being provided and everyone engaged in the person's care, including staff, family members, and visitors, can benefit from DCM. 

It allows everyone to reflect on and analyze the care they are providing and collaborate to achieve the best possible quality of life for the person in question. DCM isn't just for hospitals, nursing homes, and hospices; it may also be used in memory care settings and as a supervisory framework for home care workers.

Finding the right approach to a difficult situation like dementia can be tough for your elderly loved ones. Taking the initiative to prepare them and your family for the massive adjustment is the first step. 

Incorporating the Dementia Care Mapping with your chosen dementia care facility is a good way to keep everyone involved in your loved one's care. 

Dementia Care Plan Based on PLST Model

The PLST (Progressively Lowered Stress Threshold) dementia care model relies on dementia patients' need to exist in an environment modified according to their declining cognitive and functional abilities. These modifications will lower stressors to help them cope and reduce their anxiety and agitation. 

In a PLST-based dementia care plan, caregivers observe the following:

  • Improved competence in managing problematic behavioral symptoms
  • Reduced environmental stress stimuli
  • Delayed institutionalization of the ADRD patient

By reducing the impact of external stimuli on the dementia patient, cognitive processing abilities receive lesser demand. Patients can retain functional abilities like grooming and engage in more family interactions.

Dementia Care Plan For Early Stages

Most people can act independently during the early stages of dementia. Your loved ones may be able to continue engaging in many things they have previously enjoyed, such as driving, volunteering, and attending social gatherings.

You may be unaware of how much assistance your parent needs during the early stages of dementia. While most people can do basic activities of daily living (ADLs), more complicated tasks — like maintaining a budget or learning how to utilize new technology — may be more challenging. Additionally, memory problems and cognitive impairment may become more severe. Establishing a dementia care plan might assist in anticipating challenges that may arise.

You can help your parent during the early stages of dementia by:

  • Offering emotional support
  • Helping your parent stay organized
  • Proactively assessing safety

Dementia Care Plan For Middle Stages

As your loved one's disease worsens, developing a dementia care plan becomes even more critical. The symptoms of middle-stage dementia intensify as the brain cells continue to be damaged.

Your parent with middle-stage dementia may require assistance with the following:

  • Daily care needs
  • Controlling difficult behaviors
  • Problematic emotions and mental health conditions
  • Expressing thoughts and responding to conversations 
  • Driving
  • Maintaining safe hygiene

Dementia Care Planning Options For Middle Stages Dementia

If you live with someone in the middle stages of dementia, you have probably assumed increased responsibility for their care. At this point, assessing whether you require more assistance to safeguard your loved one's health and safety may be necessary. It's also critical to evaluate your own physical and mental health, the financial costs of caregiving, and the impact on your family, social, and professional lives.

You may wish to consider the following care and support options:

Dementia Care Plan For Last Stages 

The symptoms of late-stage dementia continue to worsen as the disease develops. At this point, leaving your loved one alone is no longer safe; they will require 24-hour help and supervision.

Along with full-time assistance with daily care, your parent may:

  • Have difficulties swallowing or eating
  • Incapable of speaking or expressing thoughts coherently
  • Experiencing problems with walking and mobility
  • Increased susceptibility to illnesses such as pneumonia

This is a challenging moment for caregivers and family members, who frequently must make care decisions while also coping with sadness and grief. Preserving a person's quality of life is critical for people who have end-stage dementia. Hospice care might be beneficial for families at this time.

Hospice care is available at home, in hospice facilities, nursing homes, and hospitals, and frequently in assisted living or memory care communities. It focuses on ensuring the comfort of your loved one with dementia while supporting the family.

If you wish to know how seniors cope with dementia, check out Senior Strong’s article for a brief overview of the sickness.

Examples Of How To Write A Care Plan For Dementia

Anyone looking for companion care jobs should know how to write a dementia care plan. These are samples of a dementia care plan that you can use for inspiration when creating one for your patient. For more examples, check out this website.

Care Plan For Elderly With Dementia Sample 1

Nursing Diagnosis: Disturbed Thought Process evidenced by coordination and motor difficulties, confusion, disorientation, and difficulties handling complex tasks.

Desired Outcome: Patient to maintain appropriate mental and physical functions as long as possible. 

Care Plan For Elderly With Dementia Sample 2

Nursing Diagnosis: Fatigue evidenced by tremors, muscle rigidity, generalized weakness, and verbalized overwhelming tiredness.

Desired Outcome: Patient to demonstrate active participation in essential and desired activities.

Care Plan For Elderly With Dementia Sample 3

Nursing Diagnosis: Impaired physical mobility evidenced by coordination and motor problems and inability to perform basic tasks of daily living.

Desired Outcome: Patient to perform activities of daily living within the limits of the disease.

Recommended Resources For Creating Memory Care Plan

To help you deliver the best dementia care plan, check out these resources:

Easy to use and complete. This book is ideal for creating customized and effective nursing care plans.

The official and definitive guide that’s approved by NANDA-I for nursing diagnoses. It comes with an updated version featuring the latest NANDA-I updates.

A quick-reference tool so you can quickly identify the correct diagnosis to create a better care plan.

Useful guide to help you create care plans specific for mental and psychiatric patients.

An all-in-one resource with over 100 care plans covering various nursing topics.

Best Memory Care Facilities In The US

Maybe dementia home care is expensive or impossible in your situation, and you need professional help. Then, you should be looking for the “best memory care facilities near me.” To know more about the “best dementia nursing homes near me” or the “best dementia care homes near me,” check out these memory care facilities rated as the best in the U.S.:

Frequently Asked Questions (FAQs)

Below are the frequently asked questions about dementia care plans:

Who is eligible to receive services under the CPT code 99483?

Anyone who is cognitively impaired, whether clinically diagnosed or judged by a clinician, can receive services under CPT code 99483. This includes patients with Alzheimer’s, dementia, or mild cognitive impairment.

What are the requirements needed to receive care under CPT code 99483?

In order to fully assess the patient, the following are required:
-Cognition-focused exam
-A family member or caregiver interview

Depending on the severity of the patient’s condition, multiple visits may be required to complete nine assessments which include Mini-Cog Early Dementia Detection, MoCa Cognitive Assessment, Key Elements of Cognition Evaluation, and Katz Index of Independence in Activities of Daily Living.

Wrapping Up

Dementia remains a complex and little-understood condition affecting millions of people worldwide. The causes of dementia are not entirely understood, but certain risk factors are known to increase a person's chances of developing dementia. These risk factors include age, family history, diet, lifestyle choices, and certain medical conditions like diabetes or cardiovascular disease. 

Treatment for dementia typically involves a dementia care plan that includes regular monitoring and close management by healthcare professionals. Patients can take advantage of CPT code 99483, which allows for reimbursements of clinical visits that result in a comprehensive dementia care plan. Any cognitively impaired individual is eligible to receive support from this code. 

Dementia can be a tough disease, but those living with it can still lead full and meaningful lives with proper care and support. If you wish to identify depression in dementia patients, check out this Senior Strong blog for detailed information.

Need more resources for caring for dementia patients? Check out our article about it today to learn more.

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William Rivers is an editor with a master’s degree in Human Services Counseling at Maine State University. He has more than 20 years of experience working in the senior healthcare industry.
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