A dementia care plan is the plan you make with a patient and their caregiver after a diagnosis of dementia or mild cognitive impairment: test results, stage, function, medicines, behavior, safety, support, and who decides if the patient can’t. Copy the free template, see a new mild Alzheimer’s plan and a moderate mixed dementia plan with evening agitation, and check what goes in each part.
Blank dementia care plan template
FreeDEMENTIA CARE PLAN Patient: [Name, date of birth] Visit date: [Date] Visit type: [Cognitive assessment and care planning visit, or plan review] Present: [Patient, caregiver, other family, interpreter] History from: [Patient, caregiver or another informant, records, other clinicians] Clinician: [Name, credentials] DIAGNOSIS AND COGNITIVE TESTING Changes noticed: [What the patient and caregiver have noticed, when it started, and how fast it is changing] Cognitive tests: [Each tool with its score, date, and the patient's years of schooling: MoCA, Mini-Cog, MMSE, or another] Workup: [Blood tests, brain imaging, hearing and vision checks, mood screen, with results] Diagnosis: [Mild cognitive impairment or dementia, and the likely cause: Alzheimer's, vascular, Lewy body, frontotemporal, or mixed] Stage: [Mild, moderate, or severe, and any staging scale used] How it was shared: [Words used, who was there, the patient's reaction and questions] FUNCTION Self-care: [Bathing, dressing, toileting, transfers, continence, eating: on their own, with prompting, or with help] Household tasks: [Money, medicines, meals, shopping, transport, phone, housework: who does each now] Mobility and falls: [Walking aid, falls in the past year, injuries] Hearing and vision: [Aids worn, and checks due] MEDICATIONS Reconciled list: [Each medicine and dose, the source checked, and who manages them at home] Medicines that cloud thinking: [Anticholinergics, sedatives, sleeping pills, opioids: stopped, tapered, or kept, and why] Dementia medicine: [Cholinesterase inhibitor or memantine: started, continued, changed, or not used, and why] Dose steps and side effects: [Starting dose, when to raise it, and what to watch for] Help with medicines: [Blister packs, organizer, reminders, or supervised doses] BEHAVIOR AND MOOD Symptoms: [Low mood, anxiety, apathy, agitation, sleep change, hallucinations, delusions, wandering] Pattern and triggers: [Time of day, how often, what sets it off, what settles it] Causes checked: [Pain, constipation, infection, hearing loss, medicines, sleep, delirium] Non-drug plan: [Routine, activity, light and noise, how the caregiver responds] Medicine for symptoms: [Started or not, the reason, the risks discussed, and the date to review or stop] SAFETY Driving: [Driving, stopped, or referred for a driving assessment, and any report the rules where you practice require] Firearms: [None, locked, or removed, and who holds the key] Wandering: [Episodes, ID bracelet, door alarm, location device] Home and cooking: [Stove, fall hazards, living alone, emergency call system] Money and scams: [Who helps with finances, bank alerts, recent losses] Abuse or neglect: [Asked, with the patient alone where possible; concerns and action] CAREGIVER AND SUPPORTS Main caregiver: [Name, relationship, lives with the patient or not, phone] Caregiver strain: [Sleep, health, work, mood, and any strain scale score] Education given: [Topics covered and materials] Support for the caregiver: [Respite, support group, counseling, their own clinician] Community services: [Alzheimer's organization, day program, home care, meals, transport: referrals and dates] ADVANCE CARE PLANNING Capacity today: [For which decisions, and how you judged it] Decision-maker: [Name, relationship, and how named] Legal documents: [Powers of attorney and advance directive: on file, or steps to complete them] Conversation: [Held today, booked, or recorded in a separate advance care planning note] OTHER CONDITIONS Conditions that affect the plan: [Blood pressure, diabetes, heart disease, stroke, sleep, alcohol, weight, continence, pain] Changes for them: [Targets eased, medicines simplified, tests stopped] FOLLOW-UP Next contact: [Phone call or visit, date, and who] Plan review and retesting: [Date for review and repeat cognitive test] Call sooner if: [Sudden worse confusion, a fall, side effects, or the caregiver can't cope] Copies to: [Patient, caregiver, other clinicians, and services] Signed: [Clinician name, credentials, date]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Family practice, cognitive assessment and care planning visit with her husband
74-year-old woman, retired bank teller, 14 years of schooling. Her husband first noticed 2 years ago that she repeated questions and forgot recent conversations. In the past 6 months she has missed 2 bills, left the stove on twice, and got lost driving to her sister’s house on a road she has used for decades. She says her memory is “not what it was” but feels she copes. Mini-Cog 2 of 5 at her annual visit 6 weeks ago: 2 of 3 words recalled, clock abnormal. MoCA 19 of 30 today, with most points lost on delayed recall, orientation, and the executive tasks. Blood tests: CBC, electrolytes, calcium, glucose, creatinine, TSH, and B12 normal. MRI: atrophy of both hippocampi, mild small vessel change, no stroke or mass. GDS-15 score 2. Mild hearing loss in both ears on a whisper test. Diagnosis: dementia, most likely due to Alzheimer’s disease, given the slow onset, the memory-first pattern, and the MRI. Stage: mild. Shared with her and her husband using the words dementia and Alzheimer’s. She was tearful, then said it was a relief to have a name for it, and asked first about driving.
Self-care: independent in all 6 areas, Katz ADL 6 of 6. Household tasks: Lawton IADL 5 of 8. Her husband now pays the bills and fills a weekly pill organizer. Since the stove incidents she cooks only when he is home. Still shops with a list, does the laundry and housework, and uses the phone. Walks 30 minutes most days; no falls. Reading glasses; no hearing aids.
Reconciled with her pharmacy: amlodipine 5 mg daily, atorvastatin 20 mg daily, vitamin D 1,000 units daily, and an over-the-counter night-time pain reliever with diphenhydramine most nights for 3 years, for sleep. Stop the diphenhydramine product: it is anticholinergic and likely adds to her confusion. Plain acetaminophen if she needs it for pain. Sleep plan instead: the same wake time every day, a morning walk outdoors, and no naps after 2 p.m. Start donepezil 5 mg at bedtime; raise to 10 mg after 6 weeks if she tolerates it, at the slower end of the usual range, to limit nausea. Move it to the morning if she has vivid dreams. Pulse 72 and regular; no fainting; not on a beta-blocker. Side effects to watch for: nausea, diarrhea, poor appetite, vivid dreams, muscle cramps, dizziness, or a slow pulse. Benefit expected to be modest: it may keep her thinking and daily function steadier for a time, and doesn’t stop the disease. Memantine not indicated at this stage. Her husband keeps filling the pill organizer.
Irritable when she can’t find things, a few times a week; settles when her husband helps without quizzing her. No low mood, with a GDS-15 of 2. No apathy, hallucinations, or wandering. Sleeps about 6 hours. Plan: a wall calendar and a notebook by the phone, keys and glasses in one bowl by the door, and keeping up her garden club and walks. Her husband will give clues rather than test her memory.
Driving: lost once on a familiar route, and her husband has seen her hesitate at intersections. Referred for a formal on-road driving assessment. She agreed not to drive until the result, and her husband will drive. Checked the reporting rules for the licensing authority where we practice, and followed them. Firearms: her husband’s hunting rifle is in a locked safe with the ammunition stored apart; she doesn’t know the code. Stove: an automatic shut-off device to be fitted this week. Money: her husband added to her bank account, alerts set for large withdrawals, and both warned about phone and email scams. Wandering: none; location sharing turned on in her phone. Abuse: asked alone, she feels safe and well treated.
Husband, 77, retired electrician, lives with her; his own type 2 diabetes is well controlled. Coping well for now, but worried about what is ahead. Education: what to expect in mild dementia, how to help with memory without testing her, and how to spot donepezil side effects. Referred both of them to the local Alzheimer’s organization’s program for people newly diagnosed and their partners, and its early-stage support group. Their daughter lives an hour away and will join the next visit by video.
Capacity today: she can make her own health care decisions and choose a decision-maker; she explained her choice and her reasons in her own words. She wants her husband to decide for her if she can’t, then her daughter. No powers of attorney or advance directive yet: lawyer appointment for powers of attorney for health care and property within the month. Advance care planning visit booked in 4 weeks with her husband and daughter, to be recorded in its own note.
Blood pressure 134/78 on amlodipine: no change. Hearing loss: audiology referral, since treating it may help her follow conversations. Alcohol: 1 glass of wine a week. Nurse phone call in 2 weeks about side effects and sleep. Visit at 6 weeks to raise donepezil, with pulse and weight. Plan review in 6 months; repeat MoCA at 12 months. Call sooner for fainting, a slow pulse, vomiting, weight loss, or a sudden change in confusion. Copies to her, her husband, and the driving assessment center with the referral.
Primary care, care plan review with his daughter, 3 years after diagnosis
85-year-old man, retired machinist, 10 years of schooling. Mixed Alzheimer’s and vascular dementia diagnosed 3 years ago; MRI then showed widespread small vessel disease and 2 old small strokes. MMSE 14 of 30 today, from 19 a year ago. Stage: moderate. Lives with his daughter, who moved in 18 months ago. Reason for review: 3 months of agitation in the late afternoon and evening, building over weeks. No fever, no change over hours or days, and he was alert and no more muddled than usual today, so delirium is unlikely. Blood tests last month: CBC, electrolytes, calcium, glucose, and creatinine normal.
Katz ADL 3 of 6: needs help choosing clothes and in the shower, and has some leaks at night. Feeds himself and gets to the toilet on his own with prompting. Day-time urgency. Walks with a cane; one fall in the kitchen last month, no injury. His daughter handles all money, medicines, meals, and transport. Wears hearing aids, but often takes them out by late afternoon.
Reconciled with his pharmacy’s blister pack list: donepezil 10 mg at bedtime for 2 years; oxybutynin 5 mg twice daily, started 10 months ago for urgency that began soon after donepezil was raised to 10 mg, a likely prescribing cascade; amlodipine 5 mg, aspirin 81 mg, and atorvastatin 40 mg daily; acetaminophen as needed, rarely given. No sleeping pills or benzodiazepines. Stop oxybutynin: it is anticholinergic, can worsen confusion and constipation, and works against donepezil. Timed toileting every 2 to 3 hours in the day and before bed; pads at night. Start acetaminophen 650 mg three times a day, scheduled, for knee pain, as a 4-week trial. Start polyethylene glycol 17 g daily for constipation. Keep donepezil 10 mg. Memantine discussed and deferred to the 4-week visit, so each change can be judged on its own. Changes sent to his pharmacy today for the blister packs.
From his daughter’s 2-week log: agitation from about 5 to 8 p.m. on 10 of 14 days. He paces, asks to “go home” although he is home, and shouts when she tries to stop him. Twice he tried to leave the house after dark. No hitting. Triggers: waking from a long afternoon nap, the TV news, dusk, a full bladder, and being corrected. He winces getting up and rubs his right knee in the evenings: PAINAD 4 of 10 on standing. Bowels open every 3 to 4 days. Cornell Scale for Depression in Dementia 7, not suggestive of depression. No hallucinations or delusions. Non-drug plan first: a morning walk outdoors; a nap of 30 minutes at most, before 1 p.m.; lights on and curtains closed before dusk; his favorite big band music at 5 p.m. instead of the news; a simple task such as folding towels or sorting screws; the toilet before 5 p.m.; hearing aids kept in until bedtime; and reassure and redirect rather than correct. No antipsychotic: no psychosis and no danger so far. If agitation causes severe distress or a risk of harm despite these steps, discuss one with his daughter, including the higher risk of stroke and death.
Driving: stopped 2 years ago, and his car has been sold. Firearms: none in the home, confirmed with his daughter. Wandering: a chime fitted on the front door; an ID bracelet with his name and her phone number; a recent photo kept for emergencies; and registration with a local missing-person program for people with dementia, where one exists. Home: stove knob covers already in place; occupational therapy home safety visit after the fall, for grab bars, night lights, and a clear path to the bathroom. Money: his daughter holds his power of attorney for property. Abuse or neglect: asked about safety for both of them. No physical harm either way. She has shouted back twice and felt ashamed; discussed as a sign of strain, and addressed below.
Daughter, 56, part-time bookkeeper, his main caregiver; her brother lives in another city and calls weekly. Strain is high: she sleeps about 5 hours, was tearful today, and missed 3 shifts this month. Education: why evenings are harder, how to redirect rather than argue, and what to log. Referrals today: an adult day program 3 days a week, starting in about 2 weeks; home care for 2 showers a week; in-home respite one evening a week; and a caregiver support group through the local Alzheimer’s organization. Her brother will cover one weekend a month. Encouraged her to see her own clinician about her sleep and mood. A short respite stay discussed for when she needs a longer break.
He could say what matters to him, “staying here with my girl, no machines,” but couldn’t weigh treatment choices today. His daughter is his health care decision-maker, named in the power of attorney for health care he signed 5 years ago, with her brother as alternate. Started a conversation about hospital transfer, resuscitation, and comfort; she wants her brother included. Family meeting by video in 3 weeks, to be recorded in a separate advance care planning note, with a portable medical order discussed then.
Blood pressure 126/72 sitting and 122/70 standing, no drop. Old small strokes: aspirin and atorvastatin continued. Knee osteoarthritis: scheduled acetaminophen as above, and physiotherapy for strength and walking. Weight steady at 68 kg (150 lb). Nurse phone call to his daughter in 1 week about bowels, toileting, sleep, and the log. Visit in 4 weeks with the log, for the memantine decision and an acetaminophen review. Plan review in 3 months. Call the same day for a sudden change in confusion, fever, a fall, or if he can’t pass urine; call 911 if anyone is in danger. Copies to his daughter, the day program, home care, and his pharmacy.
What led to the plan: the changes noticed, the test scores, the workup, and the diagnosis and stage, with how you shared it.
Avoid: A score in place of a diagnosis. Dementia means a decline in daily function as well as on testing, so write down the tasks the patient can no longer manage.
What the patient can still do and what they need help with, so the plan matches the help in place.
Avoid: Asking only the patient. People with dementia often rate themselves as more able than they are. Ask the caregiver too, and record both views.
A full review: medicines that make thinking worse, the dementia medicine decision, and who makes sure the doses are taken.
Avoid: Starting a dementia medicine without clearing out the ones that work against it. Bladder pills such as oxybutynin and sleep aids with diphenhydramine are common culprits.
Behavioral and psychological symptoms, the pattern behind them, the causes you checked, and the plan, with non-drug steps first.
Avoid: An antipsychotic as the first step. In people with dementia they raise the risk of stroke and death; keep them for severe distress or danger, at a low dose, with a date to review.
The risks that come with dementia, asked about directly, with what was agreed for each one.
Avoid: Leaving driving and firearms for a later visit. Ask at the diagnosis visit, and write down what the patient and family agreed.
Who provides the care, how they are coping, and the services that help them keep going.
Avoid: A plan that names the caregiver but never asks about them. Strain builds slowly; ask at each visit, and act before a crisis.
Whether the patient can take part in decisions now, who decides when they can’t, and the documents and conversations in place.
Avoid: Waiting until the patient can no longer take part. In mild dementia most people can still name a decision-maker and say what matters to them.
How dementia changes the care of other conditions, and when the plan is looked at again.
Avoid: Calling a sudden change in confusion the dementia getting worse. A change over hours or days is delirium until proven otherwise.
A MoCA of 19 is a result, not a diagnosis. Dementia needs a decline in daily function too, so record what the patient can no longer do, and who told you.
Bladder pills, older antihistamines in sleep aids, some antidepressants, and sedatives all worsen memory. Ask about over-the-counter products, and stop what you can before adding a dementia medicine.
Pain, constipation, infection, a full bladder, and hearing loss all drive agitation. Check them, and try non-drug steps, before any medicine for behavior.
Driving, firearms, the stove, and money are easier to settle at diagnosis than after a crash or a scam. Ask about each, and write down what was agreed.
The caregiver carries out most of the plan. Name them, ask how they are coping, and arrange respite before strain becomes a crisis.
Vero Scribe writes the dementia care plan in your template from the visit, with the patient’s consent, or from your dictation. You review and edit every section, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
The cognitive test scores and diagnosis, the stage, what the patient can and can’t do, a medication review, behavior and mood, safety including driving and firearms, the caregiver and their support, community services, advance care planning and the decision-maker, other conditions, and follow-up, with copies for the patient and caregiver.
Start from the assessment: name each test with its score, then the diagnosis and stage. Ask the patient and caregiver about daily tasks, review every medicine, and go through behavior and each safety risk. Name the caregiver and what they need. End with who decides if the patient can’t, the services you referred to, and dates for the next contact and review.
A chronic care plan covers several long-term conditions through targets and a flare-up action plan. An advance care planning note records the full conversation about future treatment. A dementia care plan is built around cognition: test scores, function, medicines that affect thinking, behavior, safety, and the caregiver. It names the decision-maker and points to the advance care planning note for the details.
Some health plans and insurers pay for a dedicated cognitive assessment and care planning visit. They usually expect the same parts as this template: a cognitive test, function, stage, a medication review, behavior, safety, the caregiver, advance care planning, and a written plan shared with the patient and caregiver. Check the exact requirements where you practice.
Yes, a shorter one. Record the test scores, the treatable causes checked, such as hearing, mood, sleep, medicines, B12, and thyroid, and the risk factors to work on, such as blood pressure and activity. Cover driving and money if they already cause concern, plan ahead while decisions are easy, and retest in about a year. Cholinesterase inhibitors haven’t been shown to help in MCI; anti-amyloid treatment, where available, needs a specialist assessment.
Yes. Copy it, or download it as a Word or text file. No account needed.
The preventive visit: interval history, screening and vaccines due, full exam, and counseling.
The Medicare AWV, G0438 and G0439: health risk assessment, cognition, screening schedule, risk factors, and the prevention plan.
The one-time IPPE, G0402: history, depression and safety review, exam with visual acuity, end-of-life planning, and the written plan.
The standing summary at the front of the chart: problems, history, medications, allergies, immunizations, risks, and reminders, kept current.
Screening, vaccines, and counselling due at an adult periodic health review, by age and sex, with a next due date on every line.
Complex visits, care plans, and caregiver updates, drafted for your review.
How to score the 3-minute screen that often leads to the full assessment.
Form versions, score corrections, and how to record the result.
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