Evidence-Based Interventions for Transitions in Care for Individuals Living With Dementia
Abstract
Background and Objectives: Despite numerous, often predictable, transitions in care, little is known about the core elements of successful transitions in care specifically for persons with dementia. The paper examines available evidence-based interventions to improve the care transitions for persons with dementia and their caregivers. Research Design and Methods: A state-of-the-art review was conducted for research published on interventions targeting transitions in care for persons living with dementia and their caregivers through January 2017. Results: Our review revealed seven evidence-based interventions to postpone/prevent or reduce care transitions specific to persons living with dementia. Effective approaches appear to be those that involve the individual and caregiver in establishing goals of care, educate the individual and caregiver about likely transitions in care; provide timely communication of information about the individual, create strong inter professional teams with competencies in dementia care, and implement evidence-based models of practice. Discussion and Implications: Five essential features for consistent and supported care transitions for persons with dementia and their caregivers are recommended. Findings reinforce the need for additional research and adaptation of evidence-based transitions in care interventions.
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Most transitional care interventions have not focused on dementia.
“In the wider literature, most transitional care interventions have not focused on dementia [103]; indeed, patients with dementia or complex care needs are often excluded from transition research [104].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [103]
Research investigating dementia-specific hospital-to-home interventions is in an early stage.
“Research investigating dementia-specific hospital-to-home interventions is in an early stage, and as older adults with MLTCiD have an increased risk of harm during transitions, their inclusion in interventions is important to understand how we can support their needs [103, 104].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [103]
Older adults with MLTCiD have an increased risk of harm during transitions.
“Research investigating dementia-specific hospital-to-home interventions is in an early stage, and as older adults with MLTCiD have an increased risk of harm during transitions, their inclusion in interventions is important to understand how we can support their needs [103, 104].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [103]
Breakdowns in transitions of care between health care providers and settings limit high-quality, comprehensive and/or appropriate dementia care, as evidenced by an increase in emergency room visits and hospitalizations and decreased quality of life.
“Breakdowns in transitions of care between health care providers and settings limit high‐quality, comprehensive and/or appropriate dementia care, as evidenced by an increase in emergency room visits and hospitalizations and decreased quality of life. 975”
From 2024 Alzheimer's disease facts and figures (2024) · cites this paper as [975]
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- Authors
- Hirschman, K. B., & Hodgson, N. A.
- Affiliations
- University of Pennsylvania (US)
- Corresponding author
- Hirschman, Karen B
- Venue
- The Gerontologist
- Publisher
- Oxford University Press (OUP)
- Published
- 2018-01-18
- Volume
- 58
- Issue
- suppl_1
- Pages
- S129-S140
- ISSN
- 0016-9013 (ISSN-L)
- 1758-5341
- OpenAlex
- W2790474892
- Cited by
- 129
- References
- 56
- Citations by year
- 2026: 5 · 2025: 12 · 2024: 25 · 2023: 16 · 2022: 21 · 2021: 24 · 2020: 18 · 2019: 3 · 2018: 3 · 2017: 2
- FWCI
- 1.83
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The Gerontologist (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Alzheimer’s Association
- Topics
- Health Sciences › Medicine › Emergency Medicine › Hospital Admissions and Outcomes
- Health Sciences › Medicine › Psychiatry and Mental health › Dementia and Cognitive Impairment Research
- Health Sciences › Health Professions › Speech and Hearing › Adolescent and Pediatric Healthcare
- Keywords
- dementia, care transitions, evidence-based interventions, caregivers, goals of care, multidisciplinary team, practice models, person-centred care
- MeSH terms
- Aged, Continuity of Patient Care, Dementia, Humans, Patient Transfer, Social Support, Quality Improvement
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