After diagnosis

Care at home, and in care homes

  • Dementia is a long term condition. GPs and primary health care teams should work in partnership with people with dementia, and their carers/families at home, and in care homes,
  • Ensuring that care is planned and future needs are anticipated, to enable people to live well at home, or in a care home, and avoid crises:
    • ensuring patients and their carers/families have a better experience of care;
    • reducing the cost of care by reducing unnecessary admissions to hospital, the frequency of GP attendances, the need for out of hours home visits, and reducing and carer break down.

Useful resources

Regular health checks

Offering regular health checks for people with dementia, by:

  • promoting protective factors
  • improving general health
  • enhancing wellbeing
  • improving quality, reducing costs
Quality and Outcomes Framework for GMS contract 2011/12, DEM 2
  No. Indicator Points Payment stages
DEM2 The percentage of patients diagnosed with dementia whose care has been reviewed in the previous 15 months 15 25-60%

Key checks

  1. General physical health check including blood pressure, pulse (check for new atrial fibrillation). Those with vascular dementia are likely to be on other QOF registers too (eg hypertension, CHD, CVA/TIA) which require other specific checks like cholesterol, taking certain preventative medication etc.
  2. Medication review including cholinesterase (if shared care guideline and GP is issuing not secondary care), co-prescribing of anticholinergics (stop if possible), vascular risk reduction.
  3. Assess falls risk and consider suitable prescribing or referral if high.
  4. Assess for any triggers to behavioural problems over past 12 months and what helped resolved the problems (drug or environmental). Liaise with carer to promote preventative strategies (eg clean urine pot/supply of antibiotics in case of urine infection, regular aperients, analgesia available).
  5. Ensure any care preferences are documented and shared with local agencies (eg out of hours, ambulance provider, care home staff).

Key messages

Staying healthy and living well, encouraging people to:

  • eat a healthy diet, and exercise regularly;
  • keep up with social activities, friendships and networks;
  • make good use of community resources and facilities;
  • ensuring they can access support easily , when needed.

Useful resources