Care management and dementia: an evaluation of the Lewisham intensive case management scheme

In the context of an ageing population and with the focus of recent government reforms on meeting the needs of frail people at home within increasingly tight financial constraints, services for older people with dementia will assume greater importance. This may be seen as `one of the greatest challenges to the development of welfare services' (Gilleard, 1992, p. 310). People with dementia are one of the fastest growing disabled groups in the population. This reflects the increasing number of people over 65 and the much faster growing over 85 age group where the prevalence and incidence of dementia are highest (Hofman et al., 1991; Jagger and Lindesay, 1993; Warnes, 1996; Alzheimer’s Disease Society, 1994). The number of people with dementia is expected to increase from 640,000 in 1991 to 900,000 by 2021 (Alzheimer’s Disease Society, 1994). Furthermore, between 1991 and 2011, the percentage of people with dementia living alone is estimated to increase by 59 per cent, from one-quarter to one-third of those people with dementia. These individuals make significant demands on services both in the community and hospital (Cullen et al., 1993). Furthermore, the increased focus on responding to the needs of carers again highlights the specific requirements of people with dementia since their carers of this client group often experience high levels of stress (Gilleard et al., 1984; Levin et al., 1989) and interventions designed to prevent or reduce this are a critical element in continued dementia care in the community (Levin et al., 1989; 1994; Lieberman and Kramer, 1991; Zarit et al., 1985). The unpredictable and deteriorating course of the condition presents a variety of manifestations and difficulties for both clients and carers over a long period. This, coupled with the susceptibility of people with dementia to the quality of care and social environment (Orrell and Bebbington, 1995; Kitwood, 1993), means that providing community care for this client group presents particular challenges to services (ADSS, 1994). This has led to calls for more flexible domiciliary care, to both meet the needs of isolated and confused clients (Alzheimer’s Disease Society, 1994) but also to fit in with the needs and working hours of carers (Joshi, 1995; Philp et al., 1995).