Create a Dementia-Friendly Care Plan

Imagine stepping into the world of someone living with dementia, where familiar faces and routines bring comfort amidst the confusion. For families navigating this journey, understanding and recording the person’s unique story becomes their guiding light. This post explores how crafting a dementia-friendly care plan centred on personal routines and preferences safeguards dignity and eases the caregiving path.

The Heart of Dementia Care: Understanding the Individual

At the centre of quality dementia care is a simple but powerful truth: care succeeds when it’s focused on the person, not just the symptoms or diagnosis. Every person living with dementia is unique, with their own life story, routines, and preferences. Recognising and respecting this individuality is the foundation of person-centred care—and it’s the key to preserving comfort, dignity, and emotional wellbeing throughout the dementia journey.

Beyond the Diagnosis: Knowing the Person Behind Dementia

While medical needs are important, the real heart of dementia care lies in understanding who the person is. This means looking beyond clinical tasks and connecting with the individual’s history, personality, and what matters most to them. When carers—whether family or professionals—know the person’s favourite foods, cherished hobbies, and daily routines, they can provide support that feels familiar and reassuring.

“Person-centred assessment forms the foundation of effective dementia care plans, focusing on the individual’s story, preferences, and challenges.”

Building a Personal Profile: The “This Is Me” Document

A practical way to capture what makes someone unique is through a “This Is Me” or personal profile document. This tool helps carers understand the person’s background, routines, and triggers, guiding daily care and reducing confusion or distress. Here’s a simple framework for creating a meaningful profile:

Life Story: Include details about their career, hobbies, important relationships, and cultural background. For example, knowing someone was a keen gardener or loved classical music can inspire meaningful activities.
Routines & Preferences: Document their typical daily routine, favourite foods and drinks, preferred music, how they like to be addressed, and what helps them feel calm. Small details—like enjoying a cup of tea at 10am or being called by a nickname—can make a big difference.
Dislikes & Triggers: Note anything that causes agitation or distress, such as loud noises, certain foods, or unfamiliar environments. Understanding these triggers helps carers avoid situations that might upset the person.

Why Personal Profiles Matter for Quality Dementia Care

When all carers have access to a personal profile, they can deliver consistent, respectful care that honours the person’s identity. This approach reduces behavioural and psychological symptoms, as routines and preferences are maintained even when the person can no longer communicate them. For example, playing a favourite song may soothe agitation, while offering a familiar meal can encourage eating and comfort.

Emotional wellbeing is just as important as physical health. Taking time to connect through shared memories or meaningful activities can ease anxiety and foster a sense of belonging. This is especially vital in the middle and later stages of dementia, when words may fade but feelings remain strong.

In today’s digital world, tools like Evaheld make it easier than ever to keep a living record of the person’s identity. Evaheld acts as a digital “This Is Me” document, allowing families to update and instantly share the profile with any new carer, respite home, or health professional. This ensures that person-centred care continues, and the individual’s wishes for comfort and dignity are always at the forefront—no matter who is providing support.

By focusing on the person behind dementia, families and carers can create care plans that truly reflect the individual, supporting both their physical and emotional wellbeing every step of the way.

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Crafting the Personal Profile: The “This Is Me” Document Explained

High-quality dementia care is built on truly knowing the person, not just managing their symptoms. A person-centred care plan recognises that every individual has a unique story, set of preferences, and personal routines that shape their comfort and dignity. The “This Is Me” document, or personal profile, is a practical tool that captures these details—ensuring that care remains respectful, familiar, and adaptive as dementia progresses.

Why Personal Profiles Matter in Dementia Care Plans

When care providers understand a person’s life story, routines, and what matters most to them, they can use adaptive strategies such as memory aids, simplified tasks, and familiar environments. This approach not only enhances quality of life but also helps reduce confusion, anxiety, and behavioural symptoms. The “This Is Me” document becomes the heart of a dementia care plan, guiding every carer—whether family, professional, or respite staff—to deliver consistent, compassionate support.

Core Components of the “This Is Me” Document

Life Story: This section covers the person’s background—career, hobbies, important relationships, and cultural heritage. For example, noting that someone was a teacher, enjoyed gardening, or has strong ties to a particular community can inform meaningful conversations and activities. Understanding cultural background is especially important, as it influences food preferences, religious practices, and comfort items.
Routines & Preferences: Documenting the person’s typical day—when they like to wake up, favourite meals, preferred drinks, and how they take their tea or coffee—helps maintain a sense of normalcy. Include details like favourite music, TV shows, or calming activities. Even noting how they like to be addressed (e.g., “Mrs Smith” instead of “Joan”) can make a big difference in how respected and secure they feel.
Dislikes & Triggers: Identifying things that cause distress or agitation is vital for emotional safety. This might include loud noises, certain foods, or specific topics of conversation. By recording these triggers, carers can avoid unnecessary stress and reduce the risk of behavioural symptoms, supporting a calmer environment.

The real power of a personal profile lies in its ability to travel with the person. It should be shared with all those involved in care—family members, professional carers, and staff at respite or residential homes. This ensures that everyone is working from the same understanding, providing consistent, person-centred care no matter where the person is or who is supporting them.

“When my mum moved into respite care, her ‘This Is Me’ profile meant the staff knew she loved classical music and hated being called by her first name. It made her transition so much smoother.” — Family carer

Evaheld: The Living “This Is Me” Document

Traditionally, these profiles were paper-based and easily lost or outdated. Evaheld transforms the “This Is Me” document into a living, digital profile. Families can update routines, preferences, and triggers as needs change, and instantly share the latest version with any new carer or health professional. This means the person’s identity and wishes always guide their care—even when they can no longer communicate them directly. Evaheld ensures that quality dementia care is always tailored, dignified, and truly person-centred.

Using Evaheld for Dynamic Dementia Care Coordination

High-quality dementia care is about more than just managing symptoms—it’s about truly knowing the person behind the diagnosis. For families planning for the middle and later stages of dementia, documenting a loved one’s personal routines, preferences, and life story is essential to preserving their comfort and dignity. This is where Evaheld steps in, offering a modern, digital approach to care coordination that keeps the person’s identity at the heart of every decision.

Evaheld: The Living ‘This Is Me’ Document

Evaheld acts as a living, digital version of the traditional ‘This Is Me’ document. Unlike paper profiles that can quickly become outdated or misplaced, Evaheld’s digital care plan allows families and carers to:

Update the profile in real time as needs and preferences change
Instantly share the profile with new carers, health professionals, or respite services
Ensure that every care provider, from family members to professional staff, has access to the same up-to-date information

This dynamic approach supports caregiver support and adaptive strategies by making sure everyone involved in care is on the same page, no matter where care is delivered.

Creating a Comprehensive Digital Care Plan

Evaheld’s digital profile is designed to capture the full picture of the person with dementia, going beyond medical needs to include the details that make them unique. Families are encouraged to build a profile that covers:

Life Story: Document important milestones, career highlights, favourite hobbies, cultural background, and key relationships. This helps carers connect on a personal level and offer meaningful engagement.
Routines & Preferences: Record daily routines, preferred foods, music, how the person likes to be addressed, and what brings them comfort. These details help maintain familiar patterns and reduce anxiety.
Dislikes & Triggers: List anything that may cause distress or agitation, such as loud noises, certain environments, or specific topics. This enables carers to avoid unnecessary triggers and respond sensitively to behavioural cues.

By capturing this information, Evaheld empowers carers to deliver person-centred dementia care that respects individual dignity, even as communication abilities decline.

Facilitating Consistent, Identity-Centred Care

One of the biggest challenges in dementia care is ensuring consistency—especially during transitions between home, respite, and residential services. Evaheld’s digital sharing capabilities mean that the person’s care plan travels with them, reducing confusion and helping new carers quickly understand what matters most.

“Evaheld bridges the gap between family and professional carers, making sure the person’s identity and preferences guide every aspect of their care—even when they can no longer express them.”

This approach mirrors the CMS GUIDE Model, which highlights the importance of care coordination, regular assessments, and caregiver support. By uniting healthcare professionals and family carers around a single, up-to-date profile, Evaheld supports an interdisciplinary approach that adapts as the person’s needs evolve.

Supporting Emotional and Behavioural Understanding

Dementia can affect how a person communicates, making it difficult for new carers to interpret emotional or behavioural cues. With Evaheld, carers have immediate access to insights about what soothes, motivates, or upsets the person. This knowledge helps prevent misunderstandings, minimises distress, and fosters a sense of safety and respect.

Swift onboarding: New carers can get up to speed quickly, reducing anxiety for both the person with dementia and their family.
Continuity of care: The digital profile ensures that care remains consistent, even as the care team changes or expands.

In summary, Evaheld’s digital care plan is a powerful tool for dynamic dementia care coordination. It ensures that the person’s story, preferences, and dignity remain central—no matter where they are on their dementia journey.

Balancing Comfort and Dignity in Daily Dementia Care

High-quality dementia care goes far beyond managing symptoms—it’s about truly knowing the person behind the diagnosis. When families and carers focus on the individual’s unique story, routines, and preferences, they lay the foundation for care that preserves both comfort and dignity. This person-centred approach not only improves emotional wellbeing but also helps reduce behavioural and psychological symptoms that can arise during the middle and later stages of dementia.

Respecting Personal Preferences: The Heart of Quality Dementia Care

Every person with dementia has a rich history and a set of personal preferences that shape their sense of self. Respecting these preferences is key to their emotional wellbeing and overall quality of life. Small gestures—like playing a favourite song, preparing a beloved meal, or using a preferred nickname—can make a world of difference. These acts remind the person that they are valued, not just as a patient, but as an individual with a life story worth honouring.

Building a “This Is Me” Personal Profile

One of the most effective adaptive strategies for maintaining comfort and dignity is creating a detailed personal profile, often called a “This Is Me” document. This living record captures the essence of the person and guides all carers in providing consistent, respectful support. Key elements to include are:

Life Story: Document their career, hobbies, important relationships, and cultural background. This helps carers connect and engage meaningfully.
Routines & Preferences: Note their typical daily routine, favourite foods, music, preferred forms of address, and what helps them feel calm or happy.
Dislikes & Triggers: List anything that causes agitation or distress—such as loud noises, certain foods, or unfamiliar environments—so these can be avoided.

Family carers are often the best source of this information, offering insights into what soothes or upsets their loved one. Their knowledge is invaluable in shaping personalised comfort strategies that truly work.

Adaptive Strategies for Everyday Comfort

Personalised care plans enhance quality of life through adaptive strategies tailored to the individual. Examples include:

Memory Aids: Using photos, labels, or familiar objects to support independence and reduce confusion.
Music Therapy: Playing familiar tunes to evoke positive memories and calm anxiety.
Simplified Tasks: Breaking down activities into manageable steps to promote success and maintain dignity.
Familiar Environments: Surrounding the person with recognisable items and layouts to foster a sense of security.

These adaptive strategies, when informed by the “This Is Me” profile, help ensure care is always respectful and responsive to the person’s changing needs and moods.

To maintain dignity and comfort, it’s essential that every carer—whether a family member, professional support worker, or respite provider—has access to the personal profile. This ensures that care remains consistent, even as circumstances or carers change. The digital platform Evaheld acts as a living “This Is Me” document, allowing families to easily update and instantly share their loved one’s preferences, routines, and triggers with any new carer or health professional. Evaheld ensures that the person’s identity and wishes continue to guide their care, even when they can no longer communicate them directly.

“Dignity is maintained when care is respectful and responsive to mood changes. Family carers’ insights are invaluable for personalised comfort strategies.”

By focusing on routines, preferences, dislikes, and triggers, families and carers can create a dementia-friendly care plan that truly balances comfort and dignity—ensuring every day is lived with meaning and respect.

Wild Card: A Hypothetical Scenario – When Routines Change

High-quality dementia care is not just about managing symptoms—it’s about truly knowing the person behind the diagnosis. Adaptive strategies and person-centred care planning are essential, especially when routines shift unexpectedly. Let’s explore a scenario that highlights the importance of flexibility and the role of a living “This Is Me” document, like Evaheld, in guiding care with dignity and comfort.

Scenario: When a Favourite Routine No Longer Fits

Imagine Margaret, a retired teacher living with moderate dementia. For years, her family has known that a cup of tea and a slice of banana bread at 3pm is her cherished daily ritual. One afternoon, Margaret suddenly refuses her snack, pushing the plate away and turning her head. She appears unsettled, and her daughter feels a pang of worry and sadness. This is a moment many families face: a beloved routine, once a source of comfort, is now a source of distress.

Adapting with Dignity: The Role of “This Is Me”

When routines change, it’s natural for carers to feel uncertain. The key is to adapt while preserving the person’s dignity and sense of self. A well-prepared “This Is Me” document—like Evaheld’s digital profile—offers a framework for understanding and responding to these changes. It includes:

Life Story: Margaret’s career as a teacher, her love of gardening, her close relationship with her sister, and her Irish heritage.
Routines & Preferences: Her usual afternoon tea, favourite music (Irish folk songs), and preference for being called “Maggie.”
Dislikes & Triggers: Loud noises, strong perfumes, and being rushed.

With this information at hand, caregivers can quickly look for alternative comfort options. If banana bread is no longer appealing, perhaps a gentle walk in the garden or listening to her favourite music might offer the same sense of security and joy. The digital nature of Evaheld means updates can be made instantly, ensuring all carers—family, professionals, or respite staff—are on the same page.

The Emotional Impact: Navigating Change Together

Routine changes can be emotionally challenging for both the person with dementia and their family. For Margaret, refusing her afternoon tea might be a sign of changing tastes, discomfort, or simply a need for something different. For her daughter, it’s a reminder that dementia is progressing, and familiar connections are shifting. It’s important to acknowledge these feelings and seek support when needed. Adaptive strategies in dementia care are not just about practical solutions—they’re about maintaining trust and emotional connection.

Strategies to Manage Distress and Maintain Trust

Stay Calm and Observant: Notice what might be causing distress. Is Margaret in pain? Is the room too noisy?
Offer Alternatives: Use the “This Is Me” profile to suggest other activities or snacks she has enjoyed in the past.
Communicate Changes: Update the care plan in Evaheld so all carers know about the new preferences or triggers.
Involve the Person: Whenever possible, involve Margaret in choices, even if they’re small. This preserves her dignity and autonomy.

Reflection: The Need for Flexibility in Care Planning

Routine changes are a normal part of dementia’s progression. Regular evaluation and adaptation of care plans, with input from the person and their family, ensures care remains person-centred and respectful. Tools like Evaheld’s living profile make it easier to respond to these “wild card” moments, so that comfort and dignity are never left behind, even when routines change.

The Role of Family Carers in Person-Centred Dementia Care

Family carers are at the heart of person-centred dementia care. They are more than just helpers—they are the primary advocates and knowledge holders of their loved one’s unique preferences, routines, and life story. High-quality dementia care is not just about managing symptoms; it’s about recognising the person behind the diagnosis and ensuring their comfort and dignity are always respected.

Knowing the Person: The Foundation of Person-Centred Care

Person-centred care plans rely on understanding the individual’s history, values, and daily habits. Family carers are best placed to provide this insight, having shared years of experiences and memories. Their observations are essential for updating care plans as dementia progresses, ensuring that care remains tailored and respectful.

Creating a “This Is Me” Personal Profile

A practical tool for supporting person-centred care is the “This Is Me” document—a personal profile that captures what matters most to the person with dementia. This living document should include:

Life Story: Key details such as career, hobbies, favourite activities, important relationships, and cultural or spiritual background.
Routines & Preferences: Usual daily routines, favourite foods and drinks, music or TV shows they enjoy, preferred ways of being addressed, and what helps them feel calm and safe.
Dislikes & Triggers: Things that may cause distress, such as loud noises, certain foods, or unfamiliar environments.

This profile is not static—it should be updated as needs and preferences change. Family carers play a crucial role in observing and recording these updates, ensuring the care plan evolves alongside the person’s journey.

Consistent, respectful care depends on everyone involved having access to the same information. Sharing the “This Is Me” profile with all care providers—including professional carers, respite services, and community resources—reduces confusion and helps prevent behavioural and psychological symptoms. It ensures that even when the person can no longer communicate their wishes, their identity and preferences continue to guide their care.

Evaheld offers a digital solution for this need. As a living “This Is Me” document, Evaheld allows family carers to create, update, and instantly share a detailed profile with any new carer or health professional. This ensures the person’s story, routines, and preferences are always at the centre of their care, no matter where they are or who is supporting them.

Supporting Family Carers: Education, Community, and Emotional Wellbeing

Providing person-centred dementia care can be rewarding, but it is also demanding. Research shows that caregiver support and education are vital for sustaining high-quality care and reducing burnout. Family carers benefit from:

Education: Training in person-centred care builds confidence and skills, helping carers respond to changing needs.
Community Resources: Access to support groups, respite care, and local dementia services provides practical help and emotional relief.
Emotional Support: Connecting with others who understand the journey improves resilience and overall wellbeing.

With burnout rates among family carers remaining high, robust support systems are essential. Carers bridge the gap between the person with dementia and professional care, making their role—and their need for support—central to any effective care plan.

Concluding Thoughts: Weaving Identity into Every Care Moment

At the heart of quality dementia care lies a simple, powerful truth: every person is more than their diagnosis. Behind every care plan is a unique individual with a rich life story, cherished routines, and deeply held preferences. As dementia progresses, the risk is that these personal details fade into the background. Yet, it is precisely these details that must remain front and centre. A truly person-centred care approach recognises that comfort and dignity are not just clinical goals—they are deeply personal, woven from the threads of identity, history, and connection.

A dementia-friendly care plan is not a static document. It evolves alongside the person, adapting to new needs and circumstances. This is why creating and regularly updating a personal profile—sometimes called a “This Is Me” document—is so important. This living record captures the essence of the person: their career, hobbies, important relationships, and cultural background. It details daily routines, favourite meals, preferred music, and the little things that bring joy or calm. It also notes dislikes and triggers, helping carers avoid distress and reduce behavioural symptoms.

The value of this approach is echoed in the Dementia Care Action Plan, which calls for strengths-based, adaptive care that draws on interdisciplinary expertise. The GUIDE Model further supports comprehensive dementia care, highlighting the need for caregiver support and a focus on health equity. Both frameworks agree: knowing the person behind dementia is the foundation of effective care planning.

But knowing the person is only the first step. To ensure consistent, respectful care, this knowledge must be shared—across family members, professional carers, respite homes, and health professionals. This is where digital tools like Evaheld make a real difference. Evaheld acts as a living, digital “This Is Me” document. It allows families to easily update and instantly share the person’s profile with anyone involved in their care. As needs change, so too can the care plan—ensuring that the person’s identity continues to guide every care moment, even when they can no longer communicate it themselves.

This digital coordination is more than just convenience. It is a safeguard for dignity and comfort. When everyone caring for a person with dementia has access to the same, up-to-date information, the risk of distressing misunderstandings is reduced. Routines are respected, preferences are honoured, and triggers are avoided. The result is a calmer, more supportive environment—one where the person’s strengths and individuality are celebrated, not overlooked.

Family carers are the backbone of this process. Your insight, love, and advocacy are invaluable in shaping and adapting care. By documenting routines, sharing stories, and updating preferences, you help ensure that care remains truly person-centred, no matter where or by whom it is delivered. Open communication with professionals and other carers is key, and digital tools can make this easier than ever.

As dementia care continues to evolve, models like GUIDE point towards a future where comprehensive, equity-focused care is the norm. By weaving identity into every care moment, we move closer to a world where people with dementia are seen, heard, and valued at every stage. Comfort and dignity are not just possible—they are achievable, with the right planning, tools, and teamwork. For families and carers, this is a message of hope and empowerment: you have the power to ensure that the person you love is always at the centre of their care.

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TL;DR: A dementia-friendly care plan rooted in personal history, daily preferences, and clear communication creates a compassionate, consistent care environment that enhances quality of life and supports carers.

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How to Create a Personalised, Dementia-Friendly Care Plan