People living with dementia have a care plan created or reviewed at least once every 12 months.

The Memory Assessment Service, your GP, or a dementia advisor offer you and your carer an appointment to develop a personalised dementia care plan, which is a strength-based document that agrees goals, identifies support needs, develops and implement action plans, and monitors progress. The personalised dementia care plan focusses on ‘What really matters to me’ and those around them affected by dementia.

Your care plan may discuss the following:

  • dementia treatment and review of this
  • what post diagnosis support you may be interested in and what is on offer locally
  • access to psychosocial interventions
  • peer support networks
  • keeping physically active, smoking cessation, reducing alcohol intake, maintain a healthy weight, keep cholesterol and blood pressure at a healthy level
  • advanced care planning
  • finance issues
  • legal issues including planning to undertake lasting powers of attorney (health and welfare, finance)
  • discussion about driving safely and planning ahead in relation to driving assessments
  • other conditions that you may develop and where to obtain support in the future
  • information on delirium
  • contingency planning and preparing for vulnerabilities and risks
You will be asked if the care plan can be shared with other services who provide help and support. You will also be provided with a copy of the care plan and can make amendments if you feel it doesn't reflect the discussion that was held.

Your care plan should be reviewed regularly, at least once a year, but it could every six months or whatever frequency is best for you. You can also request to have your care plan reviewed when your or your carer's needs change.
For extra information, evidence and best practice please scroll down to the bottom of the page.

Regional offerings

Advance statement about your wishes

An advance statement is a written statement that sets down your preferences, wishes, beliefs and values regarding your future care.
The aim is to provide a guide to anyone who might have to make decisions in your best interest if you have lost the ability to make or communicate decisions.

What does it cover?

It can cover any aspect of your future health or social care. This could include:
  • how you want any religious or spiritual beliefs to be reflected in your care
  • where you would like to be cared for, for example at home or in a hospital, a nursing home, or a hospice
  • how you like to do things, for example if you prefer a shower instead of a bath, or like to sleep with the light on
  • practical issues, for example who will look after your dog if you become ill
You can make sure people know about your wishes by talking about them.
By writing your advance statement down, you can help to make things clear to your family, carers and anybody involved in your care.
You can write it with support from relatives, carers, or health and social care professionals.

Is an advance statement the same as an advance decision?

No. An advance decision (also known as a living will, or advance decision to refuse treatment) is a decision you can make now to refuse specific treatments in the future.
An advance decision is legally binding, as long as it meets certain criteria.
Read more about advance decisions to refuse treatment

Who makes an advance statement?

You write an advance statement yourself, as long as you have the mental capacity to make these statements.
Mental capacity is the ability to make decisions. Sometimes, people do not have mental capacity. This can be for a number of reasons, including illness.
Visit GOV.UK to find out about creating a lasting power of attorney, and the Mental Capacity Act.

Is an advance statement legally binding?

No, an advance statement is not legally binding, but anyone who's making decisions about your care must take it into account.

How does an advance statement help?

An advance statement lets everyone involved in your care know about your wishes, feelings and preferences if you're not able to tell them.

Does it need to be signed and witnessed?

You do not have to sign an advance statement, but your signature makes it clear that it is your wishes that have been written down.

Who should see it?

You have the final say in who sees it. Keep it somewhere safe, and tell people where it is, in case they need to find it in the future.
You can keep a copy in your medical notes.

Thinking about your wishes

Dying Matters has information on talking about dying. This includes ideas for starting the conversation, letting people know your wishes, and things to think about.

Find out more about planning ahead

Contact details for Advance Care Planning in each locality in Greater Manchester.

Dementia Wellbeing Plan for Greater Manchester; Dementia United

The Greater Manchester dementia wellbeing plan promotes personalised planning conversations with people living with dementia and carers about their needs and wants. The plan ensures an improved standard of care planning for people living with dementia and also facilitates sharing across the system. It will be available as a standardised plan which can be accessed and shared digitally between practitioners; as well as being available from the website for people affected by dementia to be using when having person centred care plan reviews

Dementia Carers Expert Reference Group (DCERG)

Working with Dementia United to ensure the carers voice is central for influencing policy and commissioning for dementia care and support.


What we did
  • Created a toolkit to support mosques and temples to become dementia friendly
  • Co-produced awareness resources
  • Delivered training sessions for South Asian communities to understand the signs and symptoms of dementia.
The resources were co-produced with local voluntary and community sector groups including: Communities for All, Indian Senior Citizens Group, Bangladeshi Women’s Organisation, North Manchester Black Health Forum, Ethnic Health Forum, Together for Dementia and representatives of temples and mosques; Shree Radha Krishna Mandir Temple, Khizra Mosque, Victoria Mosque and Didsbury Mosque.
We worked with the Alzheimer’s Society to deliver some dementia awareness sessions to local groups who support people from South Asian communities.
We developed a set of ‘Through the eyes of dementia’ videos:
  • A short video for mosques, temples, GP practices and on social media to help people understand some of the signs and symptoms of dementia
  • A longer video for people who’ve been diagnosed with dementia. This video shows real life stories and explains the value of obtaining support from GPs, the Alzheimer’s Society, dementia nurses, social services, mental health trusts and voluntary and community sector organisations
Both videos are available in: English with no subtitles, English subtitles long, English subtitles short. Also the videos are available in  Urdu, Hindi, Gujarati, Bengali, Punjabi, BSL.
For this purpose, we developed leaflets and posters:
  • Provide information about the signs and symptoms of dementia, other causes of memory loss. Specifically, we offer information about the importance of living a healthy life and managing diabetes and other long term illnesses.
  • Promote awareness of support services available in Manchester and tips for carers.
  • Support places of worships to become dementia friendly.
  • Raise awareness of the signs and symptoms of dementia.
Evaluation results
It’s evident that there’s a need to continue engaging with these communities to provide dementia awareness. Additionally, we need to promote the materials created to address and reduce the stigma of dementia in South Asian communities. During the dementia awareness sessions a number of people from the South Asian communities expressed an interest in becoming a dementia champion.
  • Follow up on the interest expressed in becoming a dementia champion with online training sessions being offered in partnership with South Asian voluntary, community and social enterprise organisations.
  • Link in to existing South Asian communications channels (Asian Sound radio, local TV channels and mosques and temples) to promote awareness of symptoms of dementia and cultural support available.
  • Continue to engage with South Asian communities to provide dementia awareness sessions, question and answer sessions and to promote the materials created
  • Consider how culturally appropriate commissioned dementia services are and how they both understand concerns from the BAME community and respond to their needs
  • Develop a communications plan to support the team to continue to share the resources.

National offerings

MSNAP Memory Assessment Service Standards

The Royal College of Psychiatrists have a national accreditation programme for Memory Services against key standards. The website outlines the standards and the process.

NICE Dementia Guidance

This guideline brings together all the research and evidence which covers assessment, diagnosis, treatment and support. It is for people at risk of developing dementia, people who are referred for assessment, people living with dementia as well as being for family and friends and health and social care staff and commissioners. It aims to improve care by making recommendations on standards people should expect to receive from their assessment, care and support as well as on training.
We have provided links to the NICE guideline for dementia and a further link is provided to guidance on how to delay or prevent the onset of dementia.
National Institute for Health and Clinical Excellence (NICE) NG16 (2015) Dementia, disability and frailty in later life – mid-life approaches to delay or prevent onset:
National Institute for Health and Clinical Excellence (NICE) (2019) Dementia: assessment, management and support for people living with dementia and their carers:


Healthwatch is your health and social care champion. If you use GPs and hospitals, dentists, pharmacies, care homes or other support services, we want to hear about your experiences. As an independent statutory body, we have the power to make sure NHS leaders and other decision makers listen to your feedback and improve standards of care. Last year we helped nearly a million people like you to have your say and get the information and advice you need.
Telephone: Call: 03000 683 000 between the hours of 08:30 – 17:30 Monday to Friday

Living with Dementia Toolkit - downloadable guide

Not everyone has access to the internet so we have produced a Guide to the Living with Dementia Toolkit that can be downloaded and printed off. We encourage peers, family members, and health and social care professionals to make use of this.

The Guide is available in English and in Welsh. It introduces the toolkit and the resources available. For the full experience of the toolkit, you need to look at the website. QR codes link you back to the website at various points. There is a 'How to use QR codes' video lower down the page.

This can be downloaded here:

Eating and Drinking well: supporting people living with dementia

This training film is the outcome of a two year research project by Bournemouth University, funded by the Burdett Trust for Nursing. It highlights to carers how to improve their practice and develop their knowledge and skills to provide better eating and drinking for people living with dementia. It is linked with a workbook that is available from Bournemouth University National Centre for Post Qualifying Social Work (

Films can be accessed here:

Universal Principles for Advance Care Planning (ACP)

The Universal Principles for Advance Care Planning has been jointly published by a coalition of the partners listed above, in response to the Care Quality Commission report ‘Protect, Connect, Respect – decisions about living and dying well’ (2021).


ADAPT South Asian Dementia Pathway

ADAPT South Asian Dementia Pathway sets out to create an online toolkit of culturally appropriate assessments and interventions. The toolkit supports people from South Asian communities across the dementia care pathway. Starting in January 2021, the aim of the study is to identify elements of the toolkit that can be drawn upon by commissioners, clinicians and care teams to meet the needs of people from South Asian communities who are living with dementia.
ADAPT South Asian Dementia Pathway toolkit consists of two sections.

1. The dementia care pathway

This section deals with three stages of the dementia care pathway: dementia awarenessdementia diagnosis and assessment; and interventions for people living with dementia and their families. 

2. Working better together

Good dementia care often involves large organisations like the NHS and smaller voluntary or community-based organisations working together. Where these collaborations work well, they enable the resources of health and social care professionals to be used effectively by taking into account the language, spiritual, and cultural needs of different communities. However, we know that it is not always easy for organisations to work together. Formal and voluntary organisations can have very different approaches and priorities, and this can create difficulties and tensions. One aim of our study was to identify what these tensions were, and to find ways of overcoming these. 
Roughly 25,000 people from ethnic minority communities live with dementia in the UK. The largest single grouping are people whose origins are from South Asian countries. People from South Asian communities are at greater risk of developing dementia. However, they are less likely to access all points of the dementia care pathway. They are more likely to present in crisis and/or at a later stage in this community.
There are also differences in how people from south Asian communities use dementia services. People from south Asian communities are more likely to miss or misinterpret their Dementia symptoms .  Moreover, they often have less access to NICE recommended treatments including medication. They are more likely to rely on local, ethnic group-led community organisations for support. All of these differences mean that south Asians with dementia are often disadvantaged compared to their white counterparts.

The UK network of dementia voices - DEEP:

The UK network of dementia voices brings together resources we have produced with DEEP groups, as well as resources they have produced independently.

It also includes resources we have produced for DEEP groups, to help them run more smoothly and more effectively.

Understanding dementia

Understanding dementia Leaflet is also available in alternative formats and additional languages. Please email: or call 0161 213 1750 for more information.
What is dementia? In South Asian communities there is not a single word that describes dementia. Dementia is a set of symptoms that may include problems remembering, speaking and understanding. Dementia is a medical condition and not a natural part of ageing.
There is often a misunderstanding that dementia is a punishment for something that has happened in a past life or as a result of black magic. These beliefs often mean a delay in diagnosis but it is really important to get an early diagnosis so you and help with managing this condition.
Can we prevent dementia? We don’t yet understand dementia well enough to know if it can be prevented and researchers are still investigating how the disease develops. However, there’s good evidence that a healthy lifestyle can help reduce the risk.
Memory assessment If a GP is concerned about the possibility of dementia they may recommend a memory test. If needed they may make a referral to the memory assessment service. Interpreters can be requested for any GP or hospital appointment.
This leaflet is also available in alternative formats and additional languages. Please email: or call 0161 213 1750 for more information.

Dementia risk factors and prevention

Some things can increase your risk of getting dementia, including your age, genes and lifestyle. There are also ways you can reduce your risk.

There are also ways you can reduce your risk.
There are different types of risk factors for dementia, including medical, lifestyle and environmental factors. It is possible to avoid some risk factors, while others cannot be controlled.
Around 1 in 4 people aged 55 years and over has a close birth relative with dementia. Find out what part genes play in dementia and how genetics can affect the risk of developing the condition.
Although getting older is the biggest risk factor for dementia, evidence shows there are things you can do to help reduce your own risk. These include keeping active, eating healthily and exercising your mind.

Air pollution has been a focus of several studies on cognitive impairment and dementia risk. There is evidence that tiny air pollution particles can enter the brain, but at this time we can’t say if they play a role in the development of dementia. There is a strong case for further research into the effect of air pollution on brain health.

Alcohol consumption in excess has well-documented negative effects on both short- and long-term health, one of which is brain damage that can lead to Alzheimer's disease or other forms of dementia.

There are different types of antioxidant, each of which has a slightly different role. We explain the general term 'antioxidants' and provide guidance around their potential benefits in relation to dementia.

Brain training includes activities to challenge the brain, such as crosswords, Sudoku puzzles and bespoke computer games. Here we discuss the evidence and the claims made by commercial game providers.

We explore the effect of caffeine, and by extension coffee, to establish whether there is a link between this and developing dementia.

Research suggests a possible connection between high cholesterol and dementia.

Though studies have been done on the possibility of cinnamon preventing dementia, clinical trials are needed to assess its effect on people with dementia. Cinnamon is not recommended as a prevention or treatment for Alzheimer's disease or dementia as it can be toxic. Some of the extracts of cinnamon may warrant investigation to try and establish new treatments.

The genetics behind Alzheimer's disease and other forms of dementia is complex, and DNA testing kits like 23andme cannot tell the complete story about a person's risk of developing the condition.

Some research does suggest traumatic brain injuries may increase the risk of dementia. However, there is still much more research to be done to understand this complex issue, particularly in relation to contact sports like football (soccer) and rugby.

A lifelong approach to good health is the best way to lower your risk of dementia. Learn more about the effects of high blood pressure and the risk factors of dementia.

Learn about hormones and other reasons women may be more likely to develop dementia than men.

Several infections have been suggested to increase risk of Alzheimer's disease, but the evidence behind it is not clear cut.
Evidence shows that a diet rich in fruit, vegetables and cereals, and low in red meat and sugar could help reduce dementia risks.

The ability of metals from food or cookware to cause Alzheimer's disease is a regular concern in the news. Here's the evidence behind the presence of metals such as copper, zinc, iron and aluminium.
It is often said that fish is 'brain food', and you may have read the speculation that omega-3 in the diet can help reduce your risk of dementia by improving heart and brain health.

Of all the lifestyle changes that have been studied, taking regular physical exercise appears to be one of the best things that you can do to reduce your risk of getting dementia.

People with dementia often have issues with sleep with their memory seemingly worse after a bad night. However, the evidence is unclear on whether poor sleep is a risk factor for dementia.

There is strong evidence that smoking can increase your risk of dementia. Not everyone who smokes will get dementia, but stopping smoking is thought to reduce your risk down to the level of non-smokers.
Turmeric and dementia
There is currently limited evidence from research studies in people to suggest that turmeric, which is a type of spice, can prevent or treat dementia.

What to expect from health and care services

A guide to the support people should get from local services in England if they or someone they know have been diagnosed with dementia.

Guidance : After diagnosis of dementia: what to expect from health and care services


This document is for anyone diagnosed with dementia and the people who care for them. It has details about what support they should get.
It includes information about:
  • what is in a care plan
  • how health care and social care services can help
  • support available to family and friends who are carers
  • how to take part in research
Information to help local health and social care commissioners put the right support in place is on the Social Care Institute for Excellence website.
Published 17 May 2018


NHS England Dementia: Good Personalised Care and Support Planning: "Personalised Care and Support planning is a crucial element in delivering improved care for all people living with dementia, and supporting their families and carers."

Royal College of Psychiatrist (2020) MSNAP Standards for Memory Service #154: "Every patient has a written care plan or care and treatment plan, reflecting their individual needs and preferences. Staff members collaborate with patients and their carers (with patient consent) when developing the care plan."

NHS England (2017) Implementation guide and resource pack for dementia care: "A core component of person-centred dementia care is the support of a named coordinator of care and the presence of a flexible, up-to-date care plan. This person should be allocated based on personal need, and may come from various settings, for example primary care, the voluntary sector or memory assessment services.

Named coordinator of care: key role:

  • Facilitate choice, independence and person-centred care, including, where appropriate, seeking informed decision making and valid consent through use of advance directives and the Mental Capacity Act 2005
  • Signpost people with dementia and their carers to local support services and to ensure continuity of care
  • Jointly develop and review the care plan with the person and their carer, at least every 12 months, to ensure that it is still applicable and effective
  • Ensure the person’s physical and mental health is monitored and that they can access appropriate treatment"

Best Practice Resources

Young onset dementia pathway: Diagnosis and support for people with young onset dementia and their families -,tailored%20to%20meet%20those%20needs.

Dementia Wellbeing Plan: The Greater Manchester dementia wellbeing plan promotes personalised planning conversations with people living with dementia and carers about their needs and wants. The plan ensures an improved standard of care planning for people living with dementia and also facilitates sharing across the system. It will be available as a standardised plan which can be accessed and shared digitally between practitioners. -

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