Integrated Care for Frail Older People Suffering from Dementia and Multi-morbidity

Due to improved living conditions and better health care, life expectancy is expanding very rapidly in many countries (Colombo et al., Help wanted? Providing and paying for long-term care, OECD Health Policy Studies, Paris, 2011). Overall, we consider this as a blessing. But this blessing is to some extent ambiguous. Many people also extend their life with years in which they suffer from multiple chronic diseases, such as dementia, disabilities or frailty. In this chapter we will explore avenues to meeting the multiple health challenges for frail older people, in particular people suffering from dementia and multi-morbidity. We will address how integrated care can be organized for these people. We will apply the construct of the socalled Care Standard and build on principles of person centred care and personalized care. Finally, we will discuss how the organisation of integrated care for frail older people suffering from dementia and/or multiple problems may be built up of similar elements. A community approach combined with a whole person’s point of view is also required.