Skip to main content

Case Series About Territorial Network Setting for Elderly Patients with Dementia

  • Chapter
  • First Online:
Acute Geriatric Care: from Hospital to Territorial Charge


Post-diagnostic support for elderly living with dementia includes a wide variety of both social and health interventions. In the early stage of dementia, it is necessary to ensure memory and driving evaluation, illness education and meaningful activities, support in IADL as medication supervision, skill training in problem-solving and use of compensatory strategy, caregiver education and support, and discussion about advance care planning. In the moderate stage of dementia care, interventions should be focused on behavior management, emotional support, home modifications, caregiver support and skill training, wandering and fall risk management, and structured activities (by occupational therapy) to support ADL. In the severe stage of disease, the people with dementia should have access to palliative care and comfort care where psychosocial models such as sensory-based interventions, environment adaptations, and person-centered care (PCC) should be prevalent. The chapter describes the network of services dedicated to dementia in the Modena county that ensures timely and proper management of people with dementia and their caregivers in conformity with the Italian Dementia National Plan and the recommendations of European Joint Action Alcove (2013–2018). This model of care emphasizes the importance of structure and care organization dedicated to behavioral problems with the final aim of avoiding possible inappropriate emergency hospitalization in generic wards and premature institutionalization. However, to contrast the stigma, it is necessary to implement programs that focus on improving inclusion and quality of life for people with dementia in their communities (Dementia-Friendly Community) where they can contribute and participate in activities that are meaningful for them.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Subscribe and save

Springer+ Basic
$34.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or eBook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
USD 79.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Hardcover Book
USD 99.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions


  1. The Lancet Commission Gill Livingston, et al. Dementia prevention, intervention, and care. Lancet. 2017;390(10113):2673–734.

    Article  Google Scholar 

  2. UNECE (United Nations Economic Commission for Europe)/Working Group on Ageing. Policy brief on ageing, vol. 16, Dignity and non discrimination for person with dementia 2015.

  3. Fabbo A, Capelli O, De Luca ML, De Vreese LP, et al. A model of integrated care for people with dementia in primary care. In: Abstract from 2nd World Congress on Integrated Care, Sydney, November 23–26, 2014; Integrated Journal of Integrated Care, WCIC Conf Suppl. vol. 14, 2014. 10-1-116641.

  4. Fabbo A, De Salvatore L, Rovesta L, De Vreese LP. Chapter 4: The management of dementia in primary care. In: Primary care in practice. Intech Open Science; 2016. p. 69–92.

    Google Scholar 

  5. ALCOVE Project. The European Joint Action on Dementia. Synthesis Report 2013. Alzheimer COoperative Valuation in Europe (ALCOVE); 2013.

    Google Scholar 

  6. Feast A, Moniz-Cook E, Stoner C, Charlesworth G, Orrell M. A systematic review of the relationship between behavioral and psychological symptoms (BPSD) and caregiver well-being. Int Psychogeriatr. 2016;28(11):1761–74.

    Article  PubMed  Google Scholar 

  7. Maki Y, Takao M, Hattori H, Suzuki T. Promoting dementia-friendly communities to improve the well-being of individuals with and without dementia. Geriatr Gerontol Int. 2020;20(6):511–9.

    Article  PubMed  Google Scholar 

  8. Bennett S, Laver K, Voigt-Radloff S, Letts L, Clemson L, Graff M, Wiseman J, Gitlin L. Occupational therapy for people with dementia and their family carers provided at home: a systematic review and meta-analysis. BMJ Open. 2019;9(11):e026308.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Henderson C, Rehill A, Brooker D, Evans SC, Evans SB, Bray J, Saibene FL, Scorolli C, Szcześniak D, d’Arma A, Lion K, Atkinson T, Farina E, Rymaszewska J, Chattat R, Meiland F, Dröes RM, Knapp M. Costs and cost effectiveness of the meeting centres support programme for people living with dementia and carers in Italy, Poland and the UK: the MEETINGDEM study. Health Soc Care Community. 2021;29(6):1756–68. Epub 2016 Jun 27.

    Article  PubMed  Google Scholar 

  10. Kallio EL, Öhman H, Kautiainen H, Hietanen M, Pitkälä K. Cognitive training interventions for patients with Alzheimer’s disease: a systematic review. J Alzheimers Dis. 2017;56(4):1349–72.

    Article  PubMed  Google Scholar 

  11. McDermott O, Charlesworth G, Hogervorst E, Stoner C, Moniz-Cook E, Spector A, Csipke E, Orrell M. Psychosocial interventions for people with dementia: a synthesis of systematic reviews. Aging Ment Health. 2018;23(4):393–403.

    Article  PubMed  Google Scholar 

  12. McLaren AN, Lamantia MA, Callahan CM. Systematic review of non-pharmacologic interventions to delay functional decline in community-dwelling patients with dementia. Aging Ment Health. 2013;17:655–66.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Mossello E, Baccini M, Caramelli F, Biagini CA, Cester A, De Vreese LP, Darvo G, Vampini C, Gotti M, Fabbo A, Marengoni A, Cavallini MC, Gori G, Chattat R, Marini M, Ceron D, Lanzoni A, Pizziolo P, Mati A, Zilli I, Cantini C, Caleri V, Tonon E, Simoni D, Mecocci P, Ungar A, Masotti G, Italian Group on Dementia Day Care Centres. Italian guidance on dementia day care centres: a position paper. Aging Clin Exp Res. 2023;35(4):729–44. Epub 2023 Feb 16.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Piersol CV, Jensen L. Occupational therapy practice guidelines for adults with Alzheimer’s disease and related major neurocognitive disorders. Bethesda, MD: AOTA Press; 2017.

    Book  Google Scholar 

  15. Spector A, Orrell M, Hall L. Systematic review of neuropsychological outcomes in dementia from cognition-based psychological interventions. Dement Geriatr Cogn Disord. 2012;34(3–4):244–55.

    Article  PubMed  Google Scholar 

  16. Kupeli N, Leavey G, Moore K, et al. Context, mechanisms and outcomes in end of life care for people with advanced dementia. BMC Palliat Care. 2016;15:31.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Kales HC, Gitlin LN, Lyketsos CG, Plank E. Assessment and management of behavioral and psychological symptoms of dementia state of the art review. BMJ. 2015;350:h369.

    Article  PubMed  PubMed Central  Google Scholar 

Download references


The authors would like to thank the whole multi-professional team of Cognitive Disorders and Dementia Unit of Health Authority in Modena (Rita Minozzi, Antonella Pellitta, Consiglia Presicce, Carlo Ninivaggi, Angela Mancini, Valentina Guerzoni, Acilia Ottoveggio, Linda Morselli, Alessandro Lanzoni, Glenda Garzetta, Annalisa Baglieri, Giada Giorgi, Alessandra Montanari, Tiziana Muzzioli, Paola Morana, Vincenzo Acchiappati, Lucia Contrucci, Sabatina Coppola, Claudia Zeoli, Michele Fiorani, Salvatore Palumbo, Chiara Galli, Valentina Reda, and Bruna Rodia) who every day ensure the operation of services dedicated to people with dementia and their caregivers.

Author information

Authors and Affiliations


Rights and permissions

Reprints and permissions

Copyright information

© 2023 The Author(s), under exclusive license to Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Vargas, N., Fabbo, A., Esquinas, A.M. (2023). Case Series About Territorial Network Setting for Elderly Patients with Dementia. In: Acute Geriatric Care: from Hospital to Territorial Charge. Springer, Cham.

Download citation

  • DOI:

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-031-48812-2

  • Online ISBN: 978-3-031-48813-9

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics