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Home Care Clinical Care Assess Your Knowledge Organisational SupportResidential Aged Care Assess Your Knowledge Clinical Care Organisational SupportEnd of Life Law Toolkit Capacity and Consent to Medical Treatment Factsheet: Advance Care Directives Futile or Non-Beneficial Treatment Legal Protection for Administering Pain and Symptom Relief Managing Disputes about Medical Treatment Decision-Making Substitute Decision-Making Urgent Medical Treatment Voluntary Assisted Dying Withholding and Withdrawing Life-Sustaining Medical Treatment Overview of End of Life Law in Australia Advance Care DirectivesDementia Clinical Care
- Advance Care Planning
- Recognise End of Life
- Assess Palliative Care Needs
- Provide Palliative Care
- Work Together
- Respond to Deterioration
- Manage Dying
- Bereavement
Home Care Residential Aged Care End of Life Law Toolkit DementiaClinical CareToolkit Education Other ToolkitsAdvance Care Planning Recognise End of Life Assess Palliative Care Needs Provide Palliative Care Work Together Respond to Deterioration Manage Dying BereavementAssess Your Knowledge Practice ExemplarsWork Together
Dementia care involves addressing complex care needs involving physical, cognitive, and emotional issues. Most people with dementia are living with multiple long-term health conditions. In 2023–2024, on average people living with dementia had 6.1 health conditions (including dementia) who completed an aged care needs assessment. [1] The most common health conditions impacting the care needs of all people living with dementia were:
- high blood pressure (51%)
- high cholesterol (31%)
- osteoarthritis (29%). [1]
Due to the complex care needs of a person with dementia, a multidisciplinary approach supporting comprehensive, holistic palliative care is required. Health professionals work as a team to provide integrated care across settings including:
- acute care
- primary care
- home care
- residential aged care
- specialist palliative care.
This may involve health professionals across a range of disciplines and from the same or different organisations, who work together to attend to the needs of the person with dementia. The person with dementia and their family are also essential members of the care team. Family includes people identified by the person as family. This may or may not be people who are biologically related, including chosen family, street family, friends, and pets. [2]
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How to work together in caring for people with dementia
The following strategies provide guidance about how to work effectively with a person with dementia, their families and carers, and across services and sectors of care.
Coordinate care to plan for and respond to the complex needs of people with dementia.
- See the ELDAC Residential Aged Care and Home Care Toolkits for relevant information on working together in those specific care settings. There is information about facilitating case conferences and palliative care needs rounds.
- Review the palliAGED resources on care coordination and case conferences (pdf), to support the provision of palliative care for people with dementia.
- Adopt an informed approach to case conferences involving people with dementia. Support the dignity and rights of people with dementia, aiming to ensure they can remain active participants in their own care and life decisions. Include substitute decision-maker(s), key family members, and multidisciplinary team members. Involve family members in clarifying care goals and planning.
A person with dementia may receive care across a variety of settings. However, 66% of people with dementia were living in the community in 2022. [3] Consider the varied care settings and forms of assistance that may be relevant in these settings for people with dementia, and their family and carers.
The Australian Government has services across the care spectrum:
- The Commonwealth Home Support Program (CHSP) provides entry-level home support for older people who need assistance to keep living independently, as well as respite services to give carers a break. From 1 November 2025, the Support at Home Program replaced the Home Care Packages (HCP) Program and the Short-Term Restorative Care (STRC) Programme. Support at Home is available for older people who require more care than can be provided by the Commonwealth Home Support Programme (CHSP). Support at Home assists older people to stay at home rather than entering residential aged care. The program provides ongoing personal and support services and clinical care. This may include access to an End-of-Life Pathway designed to help people with less than three months to live remain at home during their final months of life.
- The Dementia and Cognition Supplement for home care provides additional funding for people with moderate to severe cognitive impairment. These supplements only apply to people who transitioned from the Home Care Packages Program and were receiving (or were eligible to receive) on 31 October 2025. The supplements are the dementia and cognition supplement or the Extended Aged Care at Home – Dementia (EACH-D) top up supplement.
- Respite programs are available and important for family carers to access for people with dementia who are being cared for at home and require end-of-life care. My Aged care has information on accessing respite or short-term care. Carer Gateway is funded by the Australian Government to support carers and has information on accessing planned and emergency respite.
- For people with dementia who can no longer be cared for at home, residential aged care can provide 24/7 care. More than half of people living in residential aged care have dementia. [4]
The Australian government funds multiple dementia related support services and programs, including:
- Dementia Behaviour Management Advisory Services (DBMAS): This is a mobile workforce provided by Dementia Support Australia (DSA). This service provides on the early on ground support, clinical advice and help for people with living with dementia experiencing change behaviours and their families and carers.
- Severe Behaviour Response Teams (SBRT): This is a mobile workforce provided by DSA to provide support, information, assessment and advice for people living with dementia experiencing severe behaviours and psychological symptoms, and their families and carers.
- Specialist Dementia Care Program (SDCP): This is a tailored program, which funds specialist dementia care units in residential aged care. The units provide specialised care to people with very severe behavioural and psychological symptoms of dementia. The program aims to reduce or stabilise symptoms so people can transition into less intensive care settings.
Providing end-of-life care for people with dementia requires knowledge about the person’s dementia, as well as other health conditions that may cause distress symptoms. Specialist palliative care services may provide support for people living with dementia in the community or residential aged care.
- The Advance Project® provides triage tools for clinicians to identify if the person with dementia requires referrals to specialist palliative care services. There are specific referral triage tools for primary care, home care and residential aged care. Registration is free to access the tools.
- The Nightingale Program created by Dementia Australia is a specialist nurse-led support and palliative care service for people with late dementia, their families and carers. It is available free in South Australia, and some locations across New South Wales. The program involves a collaboration between general practitioners, nurse practitioners, community palliative care teams, existing service providers and allied health. The Nightingale Program can be accessed by calling the National Dementia Helpline on 1800 100 500.
- Contact your local specialist palliative care service to identify what support is available in your local area. Palliative Care Australia (PCA) provides a National Service Directory.
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How to build knowledge, confidence and skills in working together for people with dementia
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- Review the ELDAC educational videos on Working Together for Residential Aged Care or Home Care, which also discuss how to respond to a person who is declining in health.
- Read the ELDAC Case Study on John to see how the multidisciplinary team work together to achieve high-quality care. Explore the ways different members of the team contribute to addressing John’s specific care needs living with dementia.
- Organise workshops, in-services or meetings where team members can learn together and build understanding about each other’s roles in dementia care. Invite professionals from across various disciplines, such as nursing, allied health, and/or medical.
- Explore CareSearch resources that can help nurses to communicate with people, families, and within the care team.
- The Agency for Clinical Innovation has a guide on the many ways allied health professionals can work together and provide interventions for people living with dementia. It includes a section on palliative care and end of life.
- Arrange reflective practice sessions where team members are encouraged to explore and reflect on challenges and successes in working within a multidisciplinary team to provide palliative care for people with dementia.
- Conduct a service mapping exercise to identify relevant programs, community resources and support networks relevant to your care setting to enhance the care of individuals with dementia and their family and carers.
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Information for families and carers
Information for you and your family: Palliative care case conferences (pdf)
palliAGED
This resource explains what a palliative care conference is and why it can be important.
Allied Health Professionals and You: A Guide for People Living with Dementia and Their Carers
Agency for Clinical Innovation
This resource outlines how allied health professionals can work with people living with dementia. There are sections for families and carers, palliative care and the end of life. A downloadable pdf version (2MB pdf) of the guide is also available to give out to families and carers.
HammondCare Staying at Home (pdf)
HammondCare
An overnight wellbeing and respite program for people living with dementia and their families and carers.
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References
- Australian Institute of Health and Welfare. Dementia in Australia Web Report: Aged Care Needs Assessments. Canberra: AIHW. Last updated 5 Dec 2025. [cited 14 Dec 2025].
- Palliative Care Australia. National Palliative Care Standards for Specialist Palliative Care Providers. Canberra (AU): PCA, 2024, 5.1 edition. [cited 6 Nov 2025].
- Australian Institute of Health and Welfare. Dementia in Australia Web Report: Prevalence of Dementia. Canberra: AIHW. Last updated 5 Dec 2025. [cited 14 Dec 2025].
- Australian Institute of Health and Welfare. Dementia in Australia Web Report: Residential Aged Care. Canberra: AIHW. Last updated 12 Sept 2025. [cited 6 Nov 2025].
Page updated 23 September 2026
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