When Graphnet’s Clinical Workflow Lead Brandon Newman was working as a paramedic, he was once called to support an elderly lady who had been found outside her home. She appeared calm and physically well. But inside the house, there were signs that raised concerns about how she was coping day to day.

The kitchen was filled with repeated purchases of the same food item, around 100 unopened boxes of cornflakes. It was unusual, but it was an important observation, as it suggested there may have been changes in her memory, routines or ability to manage safely at home. Her daughter later confirmed that she had been experiencing memory problems.

This is why dementia care cannot rely on a single snapshot of a person’s condition. For those living with dementia, or caring for someone with dementia, a care plan is only useful if it reflects the person behind the diagnosis and continues to remain relevant as their needs, risks and support network change.

The Alzheimer’s Society reports there to be an estimated 982,000 people living with dementia in the UK, rising to 1.4 million by 2040. As more people live with dementia alongside complex health and care needs, care plans must be shared, flexible and capable of evolving over time. 

This is where Graphnet’s Comprehensive Geriatric Assessment (CGA) can support more coordinated, person-centred care planning.

 

Why dementia care planning needs to be personal

Generic care plan templates can support consistency, but dementia care rarely fits neatly into standardised pathways. Most importantly, good dementia care planning should capture what matters to the person and their loved ones, not only what is clinically wrong.

The experience of dementia varies significantly depending on the type and stage of dementia, alongside a person’s wider health, living circumstances and support network. Two people with the same diagnosis may have very different risks, communication needs and priorities.

A meaningful dementia care plan needs to consider:

• Physical health and comorbidities
• Mobility and falls risk
• Medication and polypharmacy
• Nutrition and hydration
• Communication needs
• Mental wellbeing
• Home environment and safety
• Culture, identity and language
• Family and carer support
• Personal routines, wishes and preferences

NICE guidance highlights the importance of understanding the person as an individual, including their life story, identity, culture and relationships, alongside the needs of family members and carers. 

This wider context matters because dementia care decisions are often shaped as much by environment, support and daily routines as by clinical diagnosis alone.

For example, a person may appear confused or distressed in an unfamiliar environment while functioning relatively well at home with familiar routines and support. Understanding what’s normal for that individual can significantly change how professionals assess risk and decide what support is needed.

 

The limits of static care plan templates

Templates can help create structure and consistency across services. The problem is not the structure itself: the problem is structure without flexibility, visibility or follow-up.

Dementia care planning needs room for nuance because important details are often highly individual. A static care plan template may fail to capture:

• How the person usually communicates distress
• What routines help them feel safe
• Who should be contacted in different scenarios
• What behavioural changes may indicate pain, infection, delirium or environmental stress
• What the family or carer is already managing at home
• What legal or advance care planning arrangements are in place
• What the person’s wishes were when they had capacity to express them

Brandon Newman, now Clinical Workflow Lead at Graphnet Health, describes this in terms of understanding a person’s baseline. In urgent or unfamiliar situations, professionals may only see a snapshot of someone’s condition. Without access to wider context, it becomes much harder to recognise whether behaviour is new, expected or potentially linked to an emerging clinical issue.

This is particularly important in dementia care, where distress or confusion may reflect multiple underlying causes. For example, a change in behaviour could indicate infection, dehydration, pain, medication side effects or environmental triggers rather than progression of dementia itself.

Care plans therefore need to function as living records that support ongoing understanding, not static forms completed once and filed away.

 

Dementia needs change over time, so care plans must evolve too

Dementia care planning must keep pace with change. A person may move from living independently with relatively light-touch support to needing increasing help with medication, nutrition, mobility, personal care or safety. In many cases, these changes happen gradually and may only become visible when information from different services is brought together.

Care plans may need to adapt in response to:

• Emerging falls risk
• Repeated wandering or disorientation
• Changes in nutrition or swallowing
• Carer strain and burnout
• Increasing support needs at home
• Changes in capacity
• Medication risks
• Hospital admissions or transitions into care
• New distress behaviours linked to pain, infection, delirium or environmental factors

NHS England’s dementia guidance specifically highlights the importance of care plans reflecting changing needs over time. This requires regular review alongside clear communication between services, carers and professionals involved in care.

Without continuity in care, there is a risk that small warning signs are missed until a crisis occurs. Repeated falls, weight loss or increasing confusion may each appear manageable in isolation, but together they may indicate growing vulnerability that requires earlier intervention.

A more dynamic approach to care planning can help teams identify those patterns earlier and respond more proactively.

 

Shared information can reduce crisis-driven care

Crisis interventions often happen when professionals are forced to make decisions without enough context. This is especially challenging in dementia care, where the person may not be able to provide an accurate history, describe symptoms clearly or explain what is normal for them.

Brandon Newman reflects on his experience as a paramedic attending incidents involving people found confused, distressed or wandering, without access to their medical history, family context or usual baseline. Those experiences shaped his belief that better information sharing is essential for safer and more proportionate care.

In dementia care, the difference between a crisis response and a proportionate response is often context. A shared care plan helps make that context available at the point of need.

A shared digital care plan helps professionals understand:

• Existing diagnosis and cognitive baseline
• Known risks
• Recent changes
• Medication and relevant reviews
• Capacity and lasting power of attorney information
• Family or carer contacts
• Advance wishes and preferences
• Previous interventions and what worked
• Current plans and follow-up actions

This visibility supports better decision-making across urgent care, primary care, community services, social care and hospital teams. It also helps avoid unnecessary repetition for families and carers, who are often asked to explain the same history multiple times across different services and settings.

 

Supporting families and carers with clearer plans

Families and unpaid carers are often central to dementia care coordination. They may be the people noticing subtle changes in behaviour, managing risks at home, attending appointments, organising medication and communicating with multiple professionals across health and social care services.

This responsibility can become emotionally and practically overwhelming, particularly when information is fragmented between teams.

Better dementia care planning supports carers through:

• Clearer escalation routes
• More consistent information
• Shared visibility of changes and risks
• Earlier recognition of carer strain
• Better involvement in decisions
• Practical support around future planning
• Reduced repetition across services

NICE recommends tailored support for carers of people living with dementia, including education about symptoms and progression, communication support, wellbeing advice and planning for the future.

Brandon Newman also emphasises the emotional dimension of dementia care, describing it as a particularly difficult and complex area for families as well as clinicians. Capturing the person’s story, wishes and support network within the care plan can help professionals make decisions that feel more joined up and person-centred for everyone involved.

 

Why advance planning matters in dementia care

Dementia can affect a person’s ability to make and communicate decisions over time, making early conversations about preferences, future care and legal decision-making especially important.

For dementia care planning, the question is not only “what support is needed now?”, but also “what would this person want if they could not speak for themselves later?” These conversations can be difficult, but they help ensure the person’s wishes remain visible as circumstances change.

NICE recommends early and ongoing opportunities for people living with dementia and those involved in their care to discuss advance care planning. This may include:

• Lasting power of attorney
• Advance statements
• Preferences for future care
• Decisions about treatment and escalation
• Preferred place of care

Brandon highlights the importance of discussing lasting power of attorney early, before decision-making becomes more complex under the Mental Capacity Act. Having clear documentation and agreed plans in place can support families and professionals to make decisions with greater confidence and clarity when capacity changes over time.

Importantly, advance planning should not be viewed solely as a legal exercise. At its core, it is about protecting autonomy, dignity and continuity of care.

 

The role of digital care planning beyond documentation

Digital care planning should not be seen as an administrative exercise. Its value lies in making plans accessible, actionable and updateable across services and care settings.

Effective digital care planning supports:

• Shared access across multidisciplinary teams
• Updates as needs change
• Clear follow-up actions
• Visibility across care settings
• Reduced duplication
• More informed urgent care decisions
• Better continuity for people and carers
• Population-level insight into needs and risks

Graphnet’s CGA solution supports this type of coordinated approach by bringing together assessment domains, clinical scoring, multidisciplinary input and shared care plans within a unified workflow. This enables different professionals to contribute relevant insight over time, helping create a more complete and up-to-date picture of the person’s needs, risks and support arrangements.

Digital care planning does not replace professional judgement or relationships with families, but gives those relationships a stronger foundation by making the right information easier to see, share and act on.

 

Dementia care planning and health inequalities

Dementia care planning also has an important role to play in addressing health inequalities, as people living with dementia often face unequal access to diagnosis, follow-up care and ongoing support.

Risks may be higher for people who:

• Live alone
• Have limited family support
• Experience deprivation or fuel poverty
• Face language or cultural barriers
• Have learning disabilities or sensory impairment
• Are from underserved communities
• Have multiple long-term conditions
• Struggle to access digital or appointment-based services

For health professionals, dementia care planning is not only a clinical workflow, but also a way of making unmet needs more visible.

By combining clinical information with a person's social circumstances and support networks, care planning can help systems identify where additional intervention or targeted support may be needed. This aligns closely with wider NHS priorities around population health management, Core20PLUS5 and reducing avoidable inequalities in access, experience and outcomes.

 

Conclusion: Better plans for changing needs

A dementia care plan should not be a static document created after diagnosis and revisited only when something goes wrong. It should be a shared, evolving plan that reflects the person’s wishes, current needs, support network and risks as they change over time.

For health and care systems, this means moving beyond fragmented records and isolated assessments towards more coordinated, multidisciplinary approaches that support continuity, visibility and proactive decision-making.

Graphnet’s Comprehensive Geriatric Assessment solution supports holistic assessment, shared care planning and multidisciplinary input, helping health and care teams keep dementia care plans visible, actionable and responsive as needs change. Learn more about Graphnet’s CGA solution.