Meet Kathy - a person with dementia

Kathy is 59-years-old and lives alone. Her daughter Sue lives in the same town. She works as a swimming teacher, and enjoys walking, gardening and keeping active. Kathy enjoys her own company and knits for charities and watches TV in the evening.

We describe two scenarios for personalised care and support planning. The first follows on from her diagnosis of dementia (scenario 1), the second 3 years later when life is getting harder and she is eligible for a personal budget. (Scenario 2).

What's Important to Kathy

  • Being active , independent and working
  • Being a swimming teacher
  • Gardening

Daily living

  • Managing OK, by keeping notes for herself and around the house.
  • Has forgotten her keys on a number of occasions - but the neighbour has a set
  • Has left the front door open by accident on one occasion when out for the day.
  • Often can't remember if she's taken her tablets or not.
  • As time goes by things are becoming harder

Events, issues and concerns

  • Worried about her job and safety of children when she is in charge.
  • Referred to occupational health at work when diagnosis is made.
  • Not being a burden on Sue

Health concerns and provision

  • Type 2 diabetes - has routine CSP at GP practice
  • Foot complications of diabetes - sees podiatrist 6 weekly
  • Slightly overweight
  • Hypertension
  • Dementia
  • Low mood - difficult to get out of

Resources / Assets

  • Daughter in same town - works full time
  • Friends at work
  • Good organiser - does rotas at work
  • Creative - good at making things
  • Loose connection with local charities
  • Has a small amount of savings


  • Metformin
  • Statin
  • Ramipril
  • Gliclazide

Annual 'health' tests for diabetes

  • Blood tests for glucose, cholesterol and kidney
  • Urine tests for kidneys
  • Blood pressure
  • Foot examination
  • Eye examination