Her early dementia is picked up by the practice nurse during care and support planning for her diabetes when she confides her worries about losing her memory.
She is referred to the memory clinic where the diagnosis is confirmed (added to the GP register) and she is put in touch with a dementia advisor (Megan) from the Alzheimer's Society who is based in the practice.
Personal care and support planning focused around her new diagnosis is now initiated, and linked to other health conditions.
Life gets harder for Kathy
Three years later, Kathy meets the criteria for Integrated Personal Commissioning and is eligible for a personal budget when day to day life becomes harder and she is admitted to hospital after a fall with a urinary tract infection.
Kathy has lost weight and her blood sugar is sometimes too low. A dementia volunteer worker has been visiting every four- six months and has reported that Kathy has decided to give up her day job and directly supervising the evening swimming classes and instead is involved in the admin of the swimming club, maintaining equipment and the scheduling.
Sue has reported to the practice team that Kathy is getting much more forgetful and she notices the house is not quite so ship shape as it was.