Office of Healthy Aging

Enhance Public Awareness and Education: Increase understanding of ADRD among the public, especially in high-burden populations, as well as among healthcare providers and professionals. This includes promoting knowledge about risk factors, early detection, and management of dementia.

Teach Youth about Dementia: Help young people to understand and learn the basics of dementia so they can interact respectfully and constructively with those living with dementia.

Promote Primary, Secondary, and Tertiary Prevention: Support efforts to prevent, detect, and manage dementia across its different stages. This involves activities that range from promoting brain health and preventing cognitive decline to improving the quality of care and support for those already living with dementia.

Address Social Determinants of Health (SDOH): Focus on achieving health equity by addressing the social and environmental factors that contribute to disparities in dementia outcomes. This includes improving access to resources and services for populations disproportionately affected by dementia.

Strengthen Community-Clinical Linkages: Enhance the connections between healthcare systems, public health agencies, and community-based organizations to create a more coordinated and comprehensive approach to dementia care. This ensures that individuals and families affected by dementia have access to the support and services they need. See examples in the navigation menu to the left under the tabs for ADRD Advisory Council, Dementia Action Collaborative, and Dementia Navigator.

Expand Public Health Infrastructure: Develop and sustain public health systems and policies that support effective and scalable interventions for dementia. This includes fostering collaborations across sectors and leveraging data to inform public health strategies.

Overall, BOLD funding aims to strengthen the public health infrastructure to effectively address the growing impact of ADRD, with a strong emphasis on health equity and comprehensive care.

TDH’s BOLD activities are aligned with the strategies outlined in the Healthy Brain Initiative (HBI) Road Map. The Road Map is a guide for public health entities to implement strategies that support cognitive health and address dementia. The guide promotes brain health across the lifespan, with an emphasis on middle-aged and older adults who are at a greater risk for cognitive decline and dementia.

Key Elements

• Awareness & Education: Enhance public and professional understanding of cognitive health and dementia.
• Surveillance: Collect and analyze data on cognitive health, Alzheimer’s, and caregiving.Intervention: Encourage early detection and management of cognitive decline.
• Caregiving Support: Provide resources and support for caregivers.
• Public Health Actions: Mobilize communities to take action on brain health.

Data surveillance for dementia involves systematically collecting, analyzing, and interpreting data related to Alzheimer’s disease and related dementias (ADRD). This process helps public health officials, researchers, and policymakers understand the prevalence, risk factors, and impact of dementia on communities.

Key Components of Dementia Data Surveillance

• Prevalence & Incidence: These data points tell us how many people currently have dementia (prevalence) and how many new cases are diagnosed over a specific period (incidence).
• Risk Factors: Data on risk factors, such as age, genetics, lifestyle, and co-existing health conditions, helps identify who is more likely to develop dementia.
• Health Disparities: Analyzing dementia data across different groups—such as by race, ethnicity, gender, income, or geography—reveals disparities in who gets dementia and how they are treated.
• Impact on Healthcare: Data about hospitalizations, emergency room visits, and long-term care admissions related to dementia shows the impact of the disease on the healthcare system.
• Caregiver Burden: Understanding data on the experiences of caregivers, including the physical, emotional, and financial toll, is important for creating support systems for those who care for people with dementia.

*This is not an exhaustive list; however, it serves as a useful starting point.

• Surveillance Systems: Behavioral Risk Factor Surveillance System (BRFSS) is a state-based health survey that collects data on various health-related behaviors, chronic health conditions, and the use of preventive services among Tennessee residents.
  • Cognitive Decline and Caregiving Modules: The Tennessee BRFSS often includes optional modules, such as those related to cognitive decline and caregiving.  
     
• Community Assessment Tools:
  • AARP Livability Index: This tool measures the livability of U.S. communities based on seven categories: housing, neighborhood, transportation, environment, health, engagement, and opportunity. It helps users assess how age-friendly a community is for older adults.
  • Community Health Assessment (CHA): This tool is used by health departments and hospitals to assess the health needs of their communities. It helps identify priority areas for intervention, including issues that affect older adults, like chronic diseases, mental health, and social determinants of health. Learn more about the TN CHA process and priorities, here.
  • U.S. Census Bureau’s American Community Survey (ACS): The ACS provides detailed demographic, social, and economic data that can be used to assess community needs, including those relevant to older adults and aging populations.
     
• Public Health Dashboards: Tools like the:
  • TN Multi-Sector Plan for Aging Data Dashboard: Developed by TennCare and ETSU to support the TN Multi-Sector Plan for Aging, the dashboard illustrates demographics (population trends in age, gender, and geographic distribution), health outcomes for older adults (dementia, chronic diseases, mental health, disabilities), social determinants of health (housing, transportation, social isolation, economic security), public health metrics (healthcare access, preventive services), regional comparisons, and community resources (caregiving support, senior housing, health care facilities).
  • County Health Rankings & Roadmaps: Developed by the Robert Wood Johnson Foundation, this platform ranks the health of counties based on various measures, including health behaviors, clinical care, and social determinants of health.
  • America’s Health Rankings: Created by the United Health Foundation, this dashboard provides annual data on the health of each state, looking at a range of factors like health outcomes, behaviors, and policy changes. Click to view the 2024 Senior Report and learn more about ways to improve Tennessee’s ranking.
  • Healthy People 2030 Data Tracker: The U.S. Department of Health and Human Services provides this dashboard to track the nation's progress toward meeting the Healthy People 2030 objectives, with data on a wide array of health topics including dementia and caregivers.
     
• Partnerships:
  • Alzheimer's Association
  • 2024 Alzheimer’s Disease Facts and Figures: Special Report Mapping a Better Future for Dementia Care Navigation
  • 2024 Alzheimer’s Disease Facts and Figures (U.S.)
  • 2024 TN Alzheimer’s Statistics

Dementia is not a single disease. Dementia does describe a group of symptoms that someone can experience if they are living with a diagnosis of Alzheimer’s disease, vascular dementia, Lewy body dementia, frontotemporal dementia, other dementia, including Huntington’s disease, or a mixture from more than one cause. Dementia symptoms cause a decline in thinking skills, also called cognitive abilities, severe enough to interfere with daily life and independent functioning. It also impacts behavior, emotions, and relationships. Some signs of dementia may include getting lost in a familiar neighborhood, using unusual words to refer to familiar objects, forgetting the name of a close family member or friend, forgetting old memories, and not being able to complete tasks independently. Dementia is progressive and worsens over time. How long this progression takes varies for each person. Some individuals may experience a steady decline for years, while others may lose abilities more rapidly. Your chance of developing dementia increases as you get older, but not everyone will get it. If someone develops dementia before the age of 65, it is called young onset dementia or early-onset dementia.

Learn More

• Center of Disease Control & Prevention (CDC), Alzheimer’s Disease & Healthy Aging
• Alzheimer’s Association, Alzheimer’s and Dementia
• Alzheimer’s Tennessee, Alzheimer’s Disease: The Basics
• U.S. Department of Health & Human Services, National Institute on Aging (NIH)
• National Institute on Aging (NIH), What is Dementia? Symptoms, Types, & Diagnosis
  
• BOLD Public Health Center of Excellence, Early Detection of Dementia

BOLD Public Health Center of Excellence, Dementia 101

• Why detect dementia?
• What is mild cognitive impairment?
• What is dementia?
• What is Alzheimer’s disease?
• What is Lewy body dementia (LBD)?
• What is vascular dementia?
• What is frontotemporal dementia (FTD)?

Dementia is NOT a normal part of aging.

Aging is a natural process where the body and brain experiences gradual changes over time. These changes affect our physical and mental abilities. Genes, lifestyles, and environments in which we grow impact how we age. As we get older about 40% of people have some degree of memory loss, called age-associated memory impairment. While these factors may cause memory problems, they:

• Do not disrupt your daily life.
• Do not affect your ability to complete normal tasks.
• Do not affect your ability to learn or remember new things.
• Are not caused by an underlying medical condition.

Unlike people with normal aging, people with dementia will have memory loss that gets worse over time until they are no longer able to take care of themselves.

Learn More

• Alzheimer’s Tennessee, Dementia vs Normal Aging
• Video: Normal Aging or Dementia? Dr. Monica Crane, Geriatric Medicine

Alzheimer’s is a brain disease that causes changes in memory, thinking, language, and behavior. These changes, or symptoms, get worse over time and will disrupt your daily life.

Alzheimer’s disease is the most common cause of dementia and accounts for 60-80% of dementia diagnosis. Brain changes traditionally associated with Alzheimer’s disease involves amyloid (am-uh-loid) plaques (plak) and neurofibrillary (noor-oh-fib-ril-lary) tangles.

• Amyloid plaques are unusual clumps of protein called beta-amyloid, found outside nerve cells (neurons). This plaque interferes with neuron-to-neuron communication at synapses.
• Neurofibrillary tangles are twisted bundles of protein called tau, found inside nerve cells (neurons). This plaque blocks the transportation of nutrients and other molecules critical for normal function and survival of neurons.

Plaques and tangles, known as Alzheimer’s biomarkers, increase as the disease progresses and ultimately cause cell death (neurodegeneration). Neurodegeneration, along with the biomarkers are key features of Alzheimer’s disease.

Late-Onset Alzheimer's: The most common form, generally develops in people aged 65 and older. It has a more gradual progression and is primarily influenced by age-related factors, genetics, and lifestyle, though its exact cause is still not fully understood.

Early-Onset Alzheimer's: Typically occurs in individuals under the age of 65, often affecting those in their 40s or 50s. It is less common and can sometimes be linked to genetic factors, making it more likely to run in families.

Alzheimer's disease can progress quickly in some people and slowly in others. On average, a person with Alzheimer's lives four to eight (4-8) years after diagnosis, but can live as long as 20 years, depending on other factors. Changes in the brain related to Alzheimer's begin years before any signs of the disease.

There are 10 signs to help identify symptoms that could be related to Alzheimer’s disease and related dementias:

1. Memory loss that disrupts daily life: Forgetting recent events, conversations, or important appointments. 
2. Challenges in planning or solving problems: Difficulty with budgeting, managing bills, or following recipes. 
3. Difficulty completing familiar tasks: Trouble with cooking, driving, or using appliances. 
4. Confusion with time or place: Getting lost in familiar surroundings or forgetting the day of the week. 
5. Trouble understanding visual images and spatial relationships: Misinterpreting distances, getting tripped up, or difficulty with puzzles. 
6. New problems with words in speaking or writing: Using incorrect words, repeating oneself, or struggling to find the right words. 
7. Misplacing things and losing the ability to retrace steps: Losing keys, glasses, or other items frequently.
8. Poor judgment or decision-making: Making impulsive or unusual choices, such as spending excessive money or neglecting personal hygiene. 
9. Withdrawal from work or social activities: Losing interest in hobbies, jobs, or social interactions. 
10. Changes in mood and personality: Exhibiting increased anxiety, depression, or aggression.

If you notice changes in memory, thinking, or behavior in friends, family, or others close to you, it can be challenging to know how to respond. It is normal to feel unsure or anxious about how to offer support, but these changes are serious health concerns. Knowing the 10 Steps to Approach Memory Concerns can help you feel more confident in assessing the situation and taking appropriate action.

Learn More

• Center of Disease Control & Prevention (CDC), Alzheimer’s Disease and Healthy Aging
• Alzheimer’s Association: 10 Early Signs and Symptoms of Alzheimer’s and Dementia
• Alzheimer’s Association: 10 Steps to Approach Memory Concerns in Others

Alzheimer’s disease follows a progressive pattern or moves through three (3) general stages over time including early, middle, and late, sometimes referred to as mild, moderate, and severe. However, the stages do not always fit neatly into these categories, and each person may move through the disease stages in their own way.

Preclinical: Changes in the brain begin years before a person shows any signs of the disease. This period is called preclinical Alzheimer’s disease, and it can last for years.

Early, Mild Stage: At this stage, a person may function independently and experience mild forgetfulness and/or shorter levels of concentration. Signs of this stage may not be obvious to others including family, friends, and doctors.  

Middle, Moderate Stage: This is typically the longest stage, lasting for many years. People in this stage exhibit increased memory loss and confusion, difficulty recognizing people, forgetting names of family and friends, trouble completing tasks with multiple steps, changes in behavior and mood, wandering, and trouble naming common items. As this stage progresses, the person will lose the ability to function independently and will require a higher level of care.

Late, Severe Stage: In the final stage of the disease, the symptoms of dementia become very serious. People lose the ability to respond to their surroundings, communicate, and eventually control their movements including swallowing and incontinence. They may say some words or phrases, but it is hard for them to tell others when they are in pain. As their memory and thinking skills get worse, their personality may change, and individuals need extensive care.

Learn More

• Alzheimer’s Association, Stages of Alzheimer’s
  
• Alzheimer’s Tennessee: Stages of Alzheimer’s Disease

A person’s risk profile for developing Alzheimer’s disease is driven by fixed and modifiable risk factors.

Fixed risk factors, or those that cannot be changed include:

• Increased Age - Older age does not cause Alzheimer’s, but it is the most important known risk factor for the disease.
• Family History - Having a family history of a parent or sibling with the disease does not mean for sure that you will have it too, but it may mean you are more likely to develop it.
• Genetics - Risk genes, including APOE-e4, APOE-e2, and APOE-e3, can increase the chance of diagnosis but it is not guaranteed. Down syndrome, 21 trisomy, increases the risk of a person developing Alzheimer’s starting around age 40. Deterministic genes account for 1% or less of Alzheimer’s diagnosis. It causes familial early-onset forms in which symptoms usually develop in a person’s early 40s and mid-50s.

Modifiable risk factors are parts of your lifestyle or environment that can be changed to lower your risk of developing Alzheimer’s disease. For example:

• Chronic disease management. Managing long-term conditions like diabetes, high blood pressure, and high cholesterol can reduce the risk of dementia. This is especially important in mid-life (45+).
• Preventing other medical conditions. Addressing and managing conditions like hearing loss, depression, mild cognitive impairment (MCI), and traumatic brain injuries (TBI) can reduce the risk of developing dementia. Each of these factors can contribute to cognitive decline, so it's important to seek treatment and support for these issues to help maintain overall brain health.
• Lifestyle factors. Regular exercise, eating a balanced diet, avoiding smoking, limiting alcohol intake, staying socially active and engaged, and participating in activities that challenge your mind can support cognitive function and reduce the risk of dementia.

Learn More

• Centers for Disease Control & Prevention (CDC), Dementia Risk Reduction
• National Association of Chronic Disease Directors (NACDD), Healthy Aging/Healthy Brain
• Centers for Disease Control & Prevention (CDC), Find a Lifestyle Change Program
• Centers for Disease Control & Prevention (CDC), Noise and Hearing Loss
• Alzheimer’s Association, Mild Cognitive Impairment (MCI)

Understanding how common, or prevalent, Alzheimer’s is and who it affects helps Tennessee provide better care and support to everyone, especially those who are most at risk.

In Tennessee

• Alzheimer's is the 7th leading cause of death for Tennesseans.
• 129,900 individuals, aged 65 and above, are diagnosed with Alzheimer's. 
• Women are diagnosed with Alzheimer's at twice the rate as men.

In the United States

• Nearly 7 million Americans live with Alzheimer's.
• More people die from Alzheimer's or other related dementias than breast and prostate cancer combined.
• The lifetime risk for Alzheimer's at age 45 is 1-in-5 for women and 1-in-10 for men.
• Hispanic and African-Americans in the U.S. will see the largest increases in Alzheimer's Disease and related dementias through 2060.

Learn More

• Centers for Disease Control & Prevention (CDC), Minorities and women are at Greater Risk for Alzheimer’s Disease
• Centers for Disease Control & Prevention (CDC), Infographics
• Alzheimer’s Association, Alzheimer’s Disease Facts and Figures (Video and PDF)

A formal diagnosis allows people living with dementia to have access to:

• Treatment: Early diagnosis enables timely interventions with medications, non-pharmacological treatments, and complementary care, helping to manage symptoms, improve quality of life, and slow the progression of the disease.
• Planning for the Future: It enables individuals and caregivers to plan, including legal, financial, and care decisions while the person with Alzheimer’s can participate.
• Lifestyle Adjustments: Early diagnosis provides an opportunity to make lifestyle changes that may help preserve cognitive function, such as improving diet, increasing physical activity, and engaging in mental exercises.
• Access to Support: It allows for early access to support services, resources, and education for both the individual and their caregivers, helping them to better cope with the challenges ahead.
• Participation in Clinical Trials: Individuals diagnosed early may be eligible to participate in clinical trials, contributing to research that could lead to new treatments or a cure.

Learn More

• Centers for Disease Control & Prevention (CDC), Creating a Care Plan
• Alzheimer’s Association, Medications for Memory, Cognition, and Dementia-Related Behaviors

Advancing the TN ADRD State Plan Together Survey

This survey is designed to collect information about activities being implemented across Tennessee that support the goals of the TN ADRD State Plan.

By sharing your work, you help highlight efforts happening statewide—whether in public health, healthcare, aging services, faith-based, or community-based programs. Your input ensures the plan reflects real action on the ground and helps identify opportunities for collaboration, innovation, and continued progress.

The Council meets no less than twice annually and follows the Tennessee Open Meetings Act HB 0023/SB 0027. Meeting dates and times can be found on the Tennessee Department of Health Upcoming Events Calendar.

2024

2025

2026

Several medical conditions and factors can mimic the symptoms of dementia, leading to a misdiagnosis. These conditions often result in cognitive decline, memory loss, and behavioral changes.

Some of the most common conditions include:

• Depression: Depression can cause significant cognitive impairment, including memory problems, difficulty concentrating, and confusion. There is a 10-question, Online Depression Screening available at the TN Department of Mental Health & Substance Abuse Services.
• Delirium: This sudden change in mental status, often due to infections, medications, or metabolic imbalances, can cause confusion, disorientation, and hallucinations, resembling dementia.
• Vitamin Deficiencies: Deficiencies in certain vitamins, particularly B12 and folate, can lead to cognitive decline, memory loss, and other neurological symptoms.
• Thyroid Disorders: Both hyperthyroidism and hypothyroidism can cause cognitive issues, such as memory problems, confusion, and difficulty concentrating.
• Normal Pressure Hydrocephalus (NPH): This condition, caused by an abnormal accumulation of cerebrospinal fluid in the brain, can lead to memory problems, gait disturbances, and urinary incontinence, which are like dementia symptoms.
• Medication Side Effects: Certain medications, especially sedatives, anticholinergics, and some pain relievers, can cause cognitive impairments that resemble dementia.
• Chronic Alcohol Use: Chronic alcohol use can lead to cognitive decline and memory problems. Visit this link to learn more about Treatment & Recovery.
• Infections: Infections such as urinary tract infections (UTIs) or chronic infections like syphilis or HIV can cause cognitive changes and confusion that may be mistaken for dementia. Local health departments offer free and confidential testing.
• Sleep Disorders: Conditions like sleep apnea can cause fatigue, memory issues, and difficulty concentrating, which can mimic dementia.
• Brain Tumors: Tumors in certain areas of the brain can cause cognitive decline, personality changes, and memory loss, like dementia symptoms.
• Chronic Pain or Stress: Persistent pain or high levels of stress can impair cognitive function and memory, leading to symptoms that may be confused with dementia.

It is essential for healthcare providers to thoroughly evaluate and rule out these conditions before diagnosing dementia, as some of them are treatable and reversible.

Sources:

• National Institute on Aging (NIH), What is Dementia? Symptoms, Types, & Diagnosis
• Mayo Clinic, Dementia
• AARP, 6 Medical Problems that Can Mimic Dementia – But Aren’t

ADRD is diagnosed through a complete evaluation process that involves several steps.

There is no single test that can confirm a diagnosis of ADRD, so healthcare providers use a combination of methods to assess cognitive function and rule out other possible causes of symptoms.

• Medical History: The healthcare provider will ask the patient about their symptoms, family history, and any changes in thinking, memory, or behavior. The provider will review all current and past medications to identify and medications that may cause cognitive impairment.
• Physical Exam: A physical check-up will help rule out other conditions that might cause memory problems, like infections, heart disease, or thyroid issues.
• Neurological Exam: This exam will assess reflexes, coordination, muscle tone and strength, eye movement, speech, and sensation to detect any neurological problems.
• Cognitive Exam: Tools like the Mini-Mental State Examination (MMSE) or the Montreal Cognitive Assessment (MoCA) are commonly used to assess memory, attention, language, and other cognitive abilities.
• Lab Tests: Blood tests can check for conditions that might cause symptoms like dementia. In some cases, particularly when there is a strong family history, genetic tests may be requested to look for changes associated with ADRD.
• Brain Imaging: CT or MRI scans detect brain issues like tumors or strokes, while PET scans identify Alzheimer’s disease by revealing amyloid plaques and tau tangles.
• Functional Assessment: This involves evaluating the patient’s ability to perform daily activities, such as managing finances, cook, or personal care.
• Mental Health Assessment: A psychiatric evaluation may be conducted to rule out conditions like depression or anxiety, which can cause symptoms like dementia.
• Monitoring Progression: Because dementia symptoms often develop slowly, the doctor may monitor the patient over time, reassessing cognitive function and daily living abilities.
• Referral to Specialists: The patient may be referred to a neurologist, geriatrician, or neuropsychologist for further evaluation and confirmation of the diagnosis.
• Communication of Diagnosis: The doctor will discuss the diagnosis with the patient and their family, explaining what it means and what to expect. They will also discuss treatment options, care planning, and available support services.
  
  Sources:
• National Institute on Aging (NIH), How is Alzheimer’s Disease Diagnosed?
• Alzheimer’s Association, How is Alzheimer’s Disease Diagnosed?
• Alzheimer’s Association, Medical Tests for Diagnosing Alzheimer’s

After a dementia diagnosis, the next steps are not always straightforward or linear because each person’s situation is unique. Here are some key steps that may help navigate the diagnosis:

Understand the Diagnosis

• National Institute on Aging (NIH), Understanding Different Types of Dementia (English), (Español)
• National Institute on Aging (NIH), Next Steps after an Alzheimer’s Diagnosis
• Alzheimer’s Association, Education Center: Understanding Alzheimer’s and Dementia

Build a Care Team

• Alzheimer’s Association, Building a Care Team

Create a Care Plan

• Center of Disease Control & Prevention (CDC), Creating a Care Plan
• Alzheimer’s Disease Education and Referral (ADEAR) Center; General Information
• National Institute on Aging (NIH), Home Safety Checklist for Alzheimer’s Disease
• Alzheimer’s Association, Safety

Legal & Financial Planning

• National Institute on Aging (NIH), Advance Care Planning
• Honoring Choices TN
• AARP, From Early to Late-Stage: How to Financially Prepare for Alzheimer’s
• TN Division of TennCare, TennCare Medicaid; Apply at Tenncareconnect.tn.gov
• TN Division of TennCare, CHOICES

Support & Resources

• National Institute on Aging (NIH), What are Palliative Care and Hospice Care?
• National Institute on Aging (NIH), Caregiving
• CDC Caring for Yourself When Caring for Another (English), (Español)
• Alzheimer’s Tennessee, Support Groups, 24/7 Helpline 800-259-4283
• Alzheimer’s Association, Help and Support, 24/7 Helpline 800-272-3900
• TN Department of Disability and Aging, National Family Caregiver Support Program (NFCSP)
• U.S. Department of Veterans Affairs, Family and Caregiver Benefits
• AARP, Family Caregiving
• TN Caregiver Coalition
• Alzheimer’s Association, Faith-Based Organizations
• The University of TN Chattanooga, Answering the Call: engAGING Communities

Stay Engaged

• National Institute on Aging (NIH), Adapting Activities for People with Alzheimer’s Disease
• Alzheimer’s Association, Activities
• Tennessee Care Planning Council, Tennessee Senior Centers

There are currently NO known interventions that will CURE dementia.

Medication, supportive therapy, and lifestyle changes are key components in treating dementia. Medications may help manage symptoms and slow the progression of the disease, supportive therapy can help with behavioral and emotional needs, and lifestyle changes promote overall well-being.

Learn More

•  National Institute on Aging (NIH), How is Alzheimer’s Disease Treated?
• Alzheimer’s Association, Treatments for Alzheimer’s
• Alzheimer’s Association, Lecanemab Approved for Treatment of Early Alzheimer’s Disease

A well-coordinated Care Team and comprehensive Care Plan are the most effective supports for the treatment and management of dementia.

A Care Team for someone with dementia typically includes a mix of healthcare professionals, family members, caregivers, and community resources which may include, but is not limited to:

• Primary Care Physician (PCP): Oversees general health, provides regular check-ups, manages medications, and coordinates care with specialists.
• Neurologist/Psychiatrist: Specializes in diagnosing and managing dementia and related cognitive disorders.
• ·Geriatrician: Focuses on the unique health needs of older adults, including those with dementia.
• Nurse or Nurse Practitioner (NP): Provides regular check-ups, manages medications, and monitors health.
• Social Worker/Dementia Navigator: Helps navigate community resources, legal issues, and provides emotional support resources.
• Occupational Therapist (OT): Assists with adapting daily activities and home environments to maintain independence.
• Physical Therapist (PT): Helps with mobility and physical activities to maintain strength and balance.
• Speech Therapist: Supports communication and swallowing issues that may arise with dementia.
• Caregiver: Often a family member or hired help, the caregiver plays a central role in daily support and care.
• Community and Support Services: Include dementia care specialists, support groups, respite care providers, faith and religious communities, and elder care services.

A Care Plan is a personalized roadmap for managing dementia. It is created with input from the Care Team and the individual with dementia (when applicable) including:

• Medical Management: The care plan includes a schedule for medications prescribed to manage symptoms, slow the progression of the disease, or treat co-existing conditions like high blood pressure or diabetes. It details the dosage, timing, and purpose of each medication and any known medication allergies. Regular monitoring is set up to assess the effectiveness of the medications and to watch for any side effects. It also includes a schedule of regular visits to the PCP, neurologist, or other specialists to monitor the progression of dementia. This ensures that any changes in symptoms or overall health are promptly addressed. If the individual has specific needs, such as psychiatric care for mood disorders or physical therapy for mobility issues, these are integrated into the plan.
• Caregiver Details: The plan includes details about current caregivers such as name, contact, and address. The plan includes contacts in case of emergencies when the primary caregiver is unavailable for any reason. Power of attorney documents may be attached or included as part of the care plan to ensure decisions are being made by the appropriate individual.
• Advance Directives or Physician Orders for Scope of Treatment (POST): Advance Directives or POST forms may be attached or included with the care plan to express the healthcare wishes of the individual with dementia when the individual is incapable of making their wishes known. More information about Advance Directives or POST forms can be found here.
• Daily Living Assistance: The care plan includes strategies for helping the individual with activities of daily living (ADLs), such as bathing, dressing, eating, and using the bathroom. It should include required assistive devices such as glasses, hearing aids, dentures, walkers, or canes. It might include home modifications to improve safety, like installing grab bars in the bathroom or removing tripping hazards.
• Cognitive and Physical Activities: To keep the mind active, the care plan includes activities like puzzles, reading, or memory games. These activities are chosen based on the person’s interests and abilities. Physical exercise is also part of the plan, encouraging activities like walking or stretching to maintain physical health. The plan might outline the time of day the individual likes to perform exercise or perform certain activities.
• Emotional and Social Support: The plan includes opportunities for social interaction, such as visits with family and friends or participation in community programs. This helps reduce feelings of isolation and supports emotional well-being. Counseling or therapy may be included to help the individual and their caregivers cope with the emotional challenges of dementia.
• Nutritional Guidance: The care plan includes a balanced diet that meets the nutritional needs of the individual, considering any difficulties with swallowing or specific dietary restrictions. It may also outline meal planning and preparation to ensure that the person is eating regularly and healthily. The plan may indicate the individual's personal preferences and known food allergies.

By addressing both medical and supportive aspects, the complex needs of individuals with dementia and their caregivers can be effectively met.

More information from the CDC - Creating a Care Plan.

Palliative medicine is specialized medical care aimed at providing relief from the symptoms and stress associated with serious illnesses. Palliative care is specialized care for people facing serious illness, focusing on providing relief of suffering (physical, psychosocial, and spiritual), to maximize quality of life for both the patient and family. Within palliative care, serious illness is defined as a health condition that carries a high risk of mortality and:

• Negatively impacts a person’s daily function;
• Negatively impacts a person’s quality of life; and/or,
• Excessively strains the person’s caregiver.

Dementia palliative care focuses on improving the quality of life for people with dementia by addressing their physical, emotional, and spiritual or religious needs. The goal is to provide comfort and support. This type of care often involves symptom management, emotional and psychological support, coordination of care, support for decision-making, and end-of-life care and planning. 

Learn More

• TDH Office of Healthy Aging Palliative Care
• National Institute on Aging (NIH), What are Palliative Care and Hospice Care? (English), (Español)

Sources

• Palliative Care Interventions in Advanced Dementia
• Lewy Body Dementia Association, The Role of Palliative and Hospice Care in Lewy Body Dementia
• World Health Organization, Palliative Care