{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,30]],"date-time":"2026-10-30T00:34:03Z","timestamp":1793320443079,"version":"4.5.0"},"reference-count":107,"publisher":"Oxford University Press (OUP)","issue":"1","license":[{"start":{"date-parts":[[2025,11,25]],"date-time":"2025-11-25T00:00:00Z","timestamp":1764028800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"enAble Institute"},{"name":"National Health and Medical Research Council (NHMRC) Investigator Grant for Associate Professor Burton","award":["GNT1174739"],"award-info":[{"award-number":["GNT1174739"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,1,7]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background and Objectives<\/jats:title>\n                    <jats:p>Care transitions for people living with dementia are critical periods requiring coordinated, person-centered support. Effective transitions can reduce caregiver burden, prevent adverse outcomes, and improve care quality. However, the barriers, facilitators, and lived experiences during transitions remain poorly understood. This systematic review synthesizes evidence on these factors from the perspectives of people with dementia and their informal caregivers.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Research Design and Methods<\/jats:title>\n                    <jats:p>A comprehensive search across MEDLINE, CINAHL, PsycINFO, ProQuest, and Web of Science identified 67 eligible English-language studies published from 2018 to 2023. Quality appraisal used Joanna Briggs Institute tools. The protocol was registered on PROSPERO: CRD42023452669.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Four themes captured the barriers, facilitators, and experiences shaping care transitions for people with dementia and their caregivers. Systemic influences included fragmented governance, funding and policy inconsistencies, and structural challenges in care coordination and delivery, mitigated by proactive planning and integrated care. Health and social care workforce factors highlighted gaps in dementia training, staffing, and communication, with empathetic, informed staff improving transitions. Emotions and decision making reflected caregiver burden, uncertainty, and advocacy, eased by early guidance and peer support. Cultural, social and situational influences showed how values, socioeconomic status, and rurality affected transition choices, underscoring the need for culturally sensitive, person-centered support.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Discussion and Implications<\/jats:title>\n                    <jats:p>Care transitions remain complex, shaped by systemic, workforce, emotional, and cultural factors. Addressing inequities and coordination gaps is critical for more integrated transitional care. Strengthening dementia-specific training, home-based care models, and culturally responsive communication may improve continuity, person-centeredness, and caregiver support.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/geront\/gnaf275","type":"journal-article","created":{"date-parts":[[2025,11,24]],"date-time":"2025-11-24T12:35:23Z","timestamp":1763987723000},"source":"Crossref","is-referenced-by-count":12,"title":["Mind the gap: a systematic review of barriers, facilitators, and experiences of care transitions for people living with dementia and their informal caregivers"],"prefix":"10.1093","volume":"66","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5383-4362","authenticated-orcid":false,"given":"Leanne","family":"Greene","sequence":"first","affiliation":[{"name":"Curtin enAble Institute, Faculty of Health Sciences, Curtin University , Bentley, Perth, Western Australia,","place":["Australia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jacob","family":"Brain","sequence":"additional","affiliation":[{"name":"Institute of Mental Health, School of Medicine, University of Nottingham , Nottingham,","place":["United Kingdom"]},{"name":"Freemasons Foundation Centre for Men\u2019s Health, Discipline of Medicine, School of Psychology, The University of Adelaide , Adelaide, South Australia,","place":["Australia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paige","family":"Watkins","sequence":"additional","affiliation":[{"name":"Curtin enAble Institute, Faculty of Health Sciences, Curtin University , Bentley, Perth, Western Australia,","place":["Australia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aysegul Humeyra","family":"Kafadar","sequence":"additional","affiliation":[{"name":"Institute of Mental Health, School of Medicine, University of Nottingham , Nottingham,","place":["United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3618-6949","authenticated-orcid":false,"given":"Serena","family":"Sabatini","sequence":"additional","affiliation":[{"name":"Curtin enAble Institute, Faculty of Health Sciences, Curtin University , Bentley, Perth, Western Australia,","place":["Australia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Barbara","family":"Blundell","sequence":"additional","affiliation":[{"name":"Curtin enAble Institute, Faculty of Health Sciences, Curtin University , Bentley, Perth, Western Australia,","place":["Australia"]},{"name":"Curtin School of Allied Health, Curtin University , Bentley, Perth, Western Australia,","place":["Australia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ellen","family":"Bothe","sequence":"additional","affiliation":[{"name":"Curtin enAble Institute, Faculty of Health Sciences, Curtin University , Bentley, Perth, Western Australia,","place":["Australia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kristie","family":"Harper","sequence":"additional","affiliation":[{"name":"Curtin enAble Institute, Faculty of Health Sciences, Curtin University , Bentley, Perth, Western Australia,","place":["Australia"]},{"name":"Curtin School of Allied Health, Curtin University , Bentley, Perth, Western Australia,","place":["Australia"]},{"name":"Sir Charles Gairdner Osborne Park Health Care Group, Occupational Therapy , Nedlands, Perth, Western Australia,","place":["Australia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Deborah","family":"Hersh","sequence":"additional","affiliation":[{"name":"Curtin enAble Institute, Faculty of Health Sciences, Curtin University , Bentley, Perth, Western Australia,","place":["Australia"]},{"name":"Curtin School of Allied Health, Curtin University , Bentley, Perth, Western Australia,","place":["Australia"]},{"name":"School of Allied Health Science and Practice, University of Adelaide , Adelaide, South Australia,","place":["Australia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Claire","family":"Morrisby","sequence":"additional","affiliation":[{"name":"Curtin enAble Institute, Faculty of Health Sciences, Curtin University , Bentley, Perth, Western Australia,","place":["Australia"]},{"name":"Curtin School of Allied Health, Curtin University , Bentley, Perth, Western Australia,","place":["Australia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bronwyn","family":"Myers","sequence":"additional","affiliation":[{"name":"Curtin enAble Institute, Faculty of Health Sciences, Curtin University , Bentley, Perth, Western Australia,","place":["Australia"]},{"name":"West Australian Country Health Service (WACHS)-Curtin University Research and Innovation Alliance, Curtin University , Perth, Western Australia,","place":["Australia"]},{"name":"Mental Health, Alcohol, Substance Use and Tobacco Research Unit, South African Medical Research Council , Tygerberg,","place":["South Africa"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrew","family":"Stafford","sequence":"additional","affiliation":[{"name":"Curtin enAble Institute, Faculty of Health Sciences, Curtin University , Bentley, Perth, Western Australia,","place":["Australia"]},{"name":"Curtin Medical School, Curtin University , Bentley, Perth, Western Australia,","place":["Australia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eugene Y H","family":"Tang","sequence":"additional","affiliation":[{"name":"Population Health Sciences Institute, Newcastle University , Newcastle,","place":["United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Blossom C M","family":"Stephan","sequence":"additional","affiliation":[{"name":"Curtin enAble Institute, Faculty of Health Sciences, Curtin University , Bentley, Perth, Western Australia,","place":["Australia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elissa","family":"Burton","sequence":"additional","affiliation":[{"name":"Curtin enAble Institute, Faculty of Health Sciences, Curtin University , Bentley, Perth, Western Australia,","place":["Australia"]},{"name":"Curtin School of Allied Health, Curtin University , Bentley, Perth, Western Australia,","place":["Australia"]},{"name":"Brightwater Research Centre, Brightwater Care Group , Inglewood, Perth, Western Australia,","place":["Australia"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2025,11,25]]},"reference":[{"key":"2026050621430616100_gnaf275-B1","doi-asserted-by":"publisher","first-page":"643","DOI":"10.1016\/j.jamda.2014.04.018","article-title":"Burdensome transitions at the end of life among long-term care residents with dementia","volume":"15","author":"Aaltonen","year":"2014","journal-title":"Journal of the American Medical Directors Association"},{"key":"2026050621430616100_gnaf275-B2","doi-asserted-by":"crossref","DOI":"10.1176\/appi.books.9780890425596","volume-title":"Diagnostic and statistical manual of mental disorders: DSM-5","author":"American Psychiatric Association","year":"2013"},{"key":"2026050621430616100_gnaf275-B3","doi-asserted-by":"publisher","first-page":"728","DOI":"10.1177\/1049909119897241","article-title":"Caregiver-reported barriers to quality end-of-life care in dementia with Lewy bodies: A qualitative analysis","volume":"37","author":"Armstrong","year":"2020","journal-title":"The American Journal of Hospice & Palliative Care"},{"key":"2026050621430616100_gnaf275-B4","doi-asserted-by":"publisher","first-page":"285","DOI":"10.1186\/s12877-021-02235-5","article-title":"Health care transitions for persons living with dementia and their caregivers","volume":"21","author":"Ashbourne","year":"2021","journal-title":"BMC Geriatrics"},{"key":"2026050621430616100_gnaf275-B5","doi-asserted-by":"publisher","first-page":"2117","DOI":"10.1177\/14713012221112234","article-title":"Informal dementia care: The carer\u2019s lived experience at the divides between policy and practice","volume":"21","author":"Britton","year":"2022","journal-title":"Dementia (London, England)"},{"key":"2026050621430616100_gnaf275-B6","doi-asserted-by":"publisher","first-page":"334","DOI":"10.1016\/j.colegn.2019.10.006","article-title":"The effect of a purpose-built memory support unit on the transition to high level dementia care; Perspectives of multiple participants","volume":"27","author":"Broadbent","year":"2020","journal-title":"Collegian"},{"key":"2026050621430616100_gnaf275-B7","author":"Bronfenbrenner","year":"1998"},{"key":"2026050621430616100_gnaf275-B8","doi-asserted-by":"publisher","first-page":"1130","DOI":"10.1080\/07317115.2021.1988023","article-title":"Pilot study of the residential care transition module to support Australian spouses of people with dementia","volume":"45","author":"Brooks","year":"2022","journal-title":"Clinical Gerontologist"},{"key":"2026050621430616100_gnaf275-B9","doi-asserted-by":"publisher","first-page":"794","DOI":"10.1177\/14713012211056461","article-title":"Long-term care placement: The transitional support needs and preferences of spousal dementia caregivers","volume":"21","author":"Brooks","year":"2022","journal-title":"Dementia (London, England)"},{"key":"2026050621430616100_gnaf275-B10","doi-asserted-by":"publisher","first-page":"1495","DOI":"10.1111\/jgs.13540","article-title":"Transitions in care in a nationally representative sample of older Americans with dementia","volume":"63","author":"Callahan","year":"2015","journal-title":"Journal of the American Geriatrics Society"},{"key":"2026050621430616100_gnaf275-B11","doi-asserted-by":"publisher","first-page":"122","DOI":"10.1186\/s12904-020-00627-9","article-title":"Palliative care for nursing home patients with dementia: Service evaluation and risk factors of mortality","volume":"19","author":"Chu","year":"2020","journal-title":"BMC Palliative Care"},{"key":"2026050621430616100_gnaf275-B12","author":"Clarivate","year":"2013"},{"key":"2026050621430616100_gnaf275-B13","doi-asserted-by":"publisher","first-page":"227","DOI":"10.1080\/13607863.2018.1531369","article-title":"Using focus groups to explore caregiver transitions and needs after placement of family members living with dementia in 24-hour care homes","volume":"24","author":"Cottrell","year":"2020","journal-title":"Aging & Mental Health"},{"key":"2026050621430616100_gnaf275-B14","doi-asserted-by":"publisher","first-page":"168","DOI":"10.1111\/scs.12442","article-title":"They are still the same\u2014family members\u2019 stories about their relatives with dementia disorders as residents in a nursing home","volume":"32","author":"Cronfalk","year":"2018","journal-title":"Scandinavian Journal of Caring Sciences"},{"key":"2026050621430616100_gnaf275-B15","doi-asserted-by":"publisher","first-page":"138","DOI":"10.1159\/000509169","article-title":"Effects of a psychoeducational program on caregivers of patients with dementia","volume":"49","author":"Damien","year":"2020","journal-title":"Dementia and Geriatric Cognitive Disorders"},{"key":"2026050621430616100_gnaf275-B16","doi-asserted-by":"publisher","first-page":"3901","DOI":"10.1111\/jocn.14978","article-title":"Adjusting to life in a residential aged care facility: Perspectives of people with dementia, family members and facility care staff","volume":"28","author":"Davison","year":"2019","journal-title":"Journal of Clinical Nursing"},{"key":"2026050621430616100_gnaf275-B17","doi-asserted-by":"publisher","first-page":"36","DOI":"10.1177\/1471301216656097","article-title":"And so I took up residence\u2019: The experiences of family members of people with dementia during admission to an acute hospital unit","volume":"18","author":"de Vries","year":"2019","journal-title":"Dementia (London, England)"},{"key":"2026050621430616100_gnaf275-B18","doi-asserted-by":"publisher","first-page":"e91","DOI":"10.3399\/bjgp.2021.0413","article-title":"Continuity of GP care for patients with dementia: Impact on prescribing and the health of patients","volume":"72","author":"Delgado","year":"2022","journal-title":"The British Journal of General Practice: The Journal of the Royal College of General Practitioners"},{"key":"2026050621430616100_gnaf275-B19","doi-asserted-by":"publisher","first-page":"691","DOI":"10.1111\/j.1468-0009.2005.00397.x","article-title":"Evaluating the quality of medical care","volume":"83","author":"Donabedian","year":"2005","journal-title":"The Milbank Quarterly"},{"key":"2026050621430616100_gnaf275-B20","volume-title":"Excellence in dementia care: Research into practice","author":"Downs","year":"2014"},{"key":"2026050621430616100_gnaf275-B21","author":"European Commission","year":"2021"},{"key":"2026050621430616100_gnaf275-B22","doi-asserted-by":"publisher","first-page":"613","DOI":"10.1186\/s12913-021-06634-7","article-title":"Associations of GP practice characteristics with the rate of ambulatory care sensitive conditions in people living with dementia in England: An ecological analysis of routine data","volume":"21","author":"Eyles","year":"2021","journal-title":"BMC Health Services Research"},{"key":"2026050621430616100_gnaf275-B23","doi-asserted-by":"publisher","first-page":"1284","DOI":"10.1111\/jonm.13267","article-title":"A qualitative study of family members\u2019 experiences of their loved one developing dementia and their subsequent placement in a nursing home","volume":"29","author":"Fekonja","year":"2021","journal-title":"Journal of Nursing Management"},{"key":"2026050621430616100_gnaf275-B24","doi-asserted-by":"publisher","first-page":"287","DOI":"10.1080\/0312407X.2018.1536155","article-title":"Dementia patients\u2019 transition to residential aged care: Carers\u2019 and social workers\u2019 experiences","volume":"72","author":"Fitzpatrick","year":"2019","journal-title":"Australian Social Work"},{"key":"2026050621430616100_gnaf275-B25","doi-asserted-by":"publisher","first-page":"1177","DOI":"10.1002\/gps.4919","article-title":"Hospital outcomes of older people with cognitive impairment: An integrative review","volume":"33","author":"Fogg","year":"2018","journal-title":"International Journal of Geriatric Psychiatry"},{"key":"2026050621430616100_gnaf275-B26","doi-asserted-by":"publisher","first-page":"1169","DOI":"10.3233\/jad-215403","article-title":"Virtual behavioural medicine program: A novel model of care for neuropsychiatric symptoms in dementia","volume":"86","author":"Freedman","year":"2022","journal-title":"Journal of Alzheimer\u2019s Disease"},{"key":"2026050621430616100_gnaf275-B27","doi-asserted-by":"publisher","first-page":"788","DOI":"10.1186\/s12877-024-05388-1","article-title":"Caregivers\u2019 burden of care during emergency department care transitions among older adults: A mixed methods cohort study","volume":"24","author":"Germain","year":"2024","journal-title":"BMC Geriatrics"},{"key":"2026050621430616100_gnaf275-B28","doi-asserted-by":"publisher","first-page":"100051","DOI":"10.1016\/j.inpsyc.2025.100051","article-title":"Geographical inequalities in dementia diagnosis and care: A systematic review","volume":"37","author":"Giebel","year":"2025","journal-title":"International Psychogeriatrics"},{"key":"2026050621430616100_gnaf275-B29","doi-asserted-by":"publisher","first-page":"12233","DOI":"10.3390\/ijerph182212233","article-title":"\"Nobody seems to know where to even turn to\": Barriers in accessing and utilising dementia care services in England and The Netherlands","volume":"18","author":"Giebel","year":"2021","journal-title":"International Journal of Environmental Research and Public Health"},{"key":"2026050621430616100_gnaf275-B30","doi-asserted-by":"publisher","first-page":"378","DOI":"10.1177\/0891988720944245","article-title":"Discharge communication of dementia-related neuropsychiatric symptoms and care management strategies during hospital to skilled nursing facility transitions","volume":"34","author":"Gilmore-Bykovskyi","year":"2021","journal-title":"Journal of Geriatric Psychiatry and Neurology"},{"key":"2026050621430616100_gnaf275-B31","doi-asserted-by":"publisher","first-page":"1089","DOI":"10.3233\/jad-200741","article-title":"Evaluation and effectiveness of dementia staff training programs in general hospital settings: A narrative synthesis with Holton\u2019s three-level model applied","volume":"78","author":"Gkioka","year":"2020","journal-title":"Journal of Alzheimer\u2019s Disease"},{"key":"2026050621430616100_gnaf275-B32","doi-asserted-by":"publisher","first-page":"1208","DOI":"10.1111\/jgs.17049","article-title":"Primary care continuity and potentially avoidable hospitalization in persons with dementia","volume":"69","author":"Godard-Sebillotte","year":"2021","journal-title":"Journal of the American Geriatrics Society"},{"key":"2026050621430616100_gnaf275-B33","doi-asserted-by":"publisher","first-page":"1697","DOI":"10.1017\/s1041610218000686","article-title":"The Going to Stay at Home program: Combining dementia caregiver training and residential respite care","volume":"30","author":"Gresham","year":"2018","journal-title":"International Psychogeriatrics"},{"key":"2026050621430616100_gnaf275-B34","doi-asserted-by":"publisher","first-page":"afab241","DOI":"10.1093\/ageing\/afab241","article-title":"The paradoxes experienced by informal caregivers of people with dementia during the transition from home to a nursing home","volume":"51","author":"Groenvynck","year":"2022","journal-title":"Age and Ageing"},{"key":"2026050621430616100_gnaf275-B35","doi-asserted-by":"publisher","first-page":"7","DOI":"10.3390\/pharmacy6010007","article-title":"Effects of pharmacists\u2019 interventions on inappropriate drug use and drug-related readmissions in people with dementia-A secondary analysis of a randomized controlled trial","volume":"6","author":"Gustafsson","year":"2018","journal-title":"Pharmacy (Basel, Switzerland)"},{"key":"2026050621430616100_gnaf275-B36","doi-asserted-by":"publisher","first-page":"101","DOI":"10.1080\/13607863.2021.2022598","article-title":"Effects of nursing home placement on the mental health trajectories of family caregivers of people with dementia: Findings from the Tele.TAnDem intervention study","volume":"27","author":"H\u00e4hnel","year":"2023","journal-title":"Aging & Mental Health"},{"key":"2026050621430616100_gnaf275-B37","doi-asserted-by":"publisher","first-page":"10","DOI":"10.1016\/j.jpainsymman.2018.10.494","article-title":"Triggered palliative care for late-stage dementia: A pilot randomized trial","volume":"57","author":"Hanson","year":"2019","journal-title":"Journal of Pain and Symptom Management"},{"key":"2026050621430616100_gnaf275-B38","doi-asserted-by":"publisher","first-page":"344","DOI":"10.1177\/09697330211015339","article-title":"Pre-decision regret before transition of dependents with severe dementia to long-term care","volume":"29","author":"Hanssen","year":"2022","journal-title":"Nursing Ethics"},{"key":"2026050621430616100_gnaf275-B39","doi-asserted-by":"publisher","first-page":"2047","DOI":"10.1177\/0969733018791342","article-title":"The influence of individualistic and collectivistic morality on dementia care choices","volume":"26","author":"Hanssen","year":"2019","journal-title":"Nursing Ethics"},{"key":"2026050621430616100_gnaf275-B40","doi-asserted-by":"publisher","first-page":"850","DOI":"10.1111\/hsc.12916","article-title":"Perspectives of Australian family carers of people with dementia on the \u2018cottage\u2019 model of respite: Compared to traditional models of residential respite provided in aged care facilities","volume":"28","author":"Harkin","year":"2020","journal-title":"Health & Social Care in the Community"},{"key":"2026050621430616100_gnaf275-B41","doi-asserted-by":"publisher","first-page":"e2322520","DOI":"10.1001\/jamanetworkopen.2023.22520","article-title":"Changes in nursing home use following Medicaid-supported expanded access to home- and community-based services for older adults with dementia","volume":"6","author":"Harrison","year":"2023","journal-title":"JAMA Network Open"},{"key":"2026050621430616100_gnaf275-B42","doi-asserted-by":"publisher","first-page":"S129","DOI":"10.1093\/geront\/gnx152","article-title":"Evidence-based interventions for transitions in care for individuals living with dementia","volume":"58","author":"Hirschman","year":"2018","journal-title":"Gerontologist"},{"key":"2026050621430616100_gnaf275-B43","doi-asserted-by":"publisher","first-page":"e12391","DOI":"10.1002\/trc2.12391","article-title":"An integrative review of measures of transitions and care coordination for persons living with dementia and their caregivers","volume":"9","author":"Hirschman","year":"2023","journal-title":"Alzheimer\u2019s & Dementia (New York, N. Y.)"},{"key":"2026050621430616100_gnaf275-B44","doi-asserted-by":"publisher","first-page":"afad033","DOI":"10.1093\/ageing\/afad033","article-title":"Freedom and loneliness: Dementia caregiver experiences of the nursing home transition","volume":"52","author":"Holton","year":"2023","journal-title":"Age and Ageing"},{"key":"2026050621430616100_gnaf275-B45","doi-asserted-by":"publisher","first-page":"957","DOI":"10.1177\/14713012211066661","article-title":"Stressors and coping strategies in Chinese family caregivers of people with dementia in long-term care facilities: A qualitative descriptive study","volume":"21","author":"Hui","year":"2022","journal-title":"Dementia (London, England)"},{"key":"2026050621430616100_gnaf275-B46","doi-asserted-by":"publisher","first-page":"2500","DOI":"10.1111\/jgs.16667","article-title":"The effects of dementia care co-management on acute care, hospice, and long-term care utilization","volume":"68","author":"Jennings","year":"2020","journal-title":"Journal of the American Geriatrics Society"},{"key":"2026050621430616100_gnaf275-B47","doi-asserted-by":"publisher","first-page":"479","DOI":"10.2147\/jmdh.S208424","article-title":"Coping with transitions in life: A four-year longitudinal narrative study of single younger people with dementia","volume":"12","author":"Johannessen","year":"2019","journal-title":"Journal of Multidisciplinary Healthcare"},{"key":"2026050621430616100_gnaf275-B48","doi-asserted-by":"publisher","first-page":"8","DOI":"10.3390\/healthcare7010008","article-title":"Comparison of potentially inappropriate medications for people with dementia at admission and discharge during an unplanned admission to hospital: Results from the SMS dementia study","volume":"7","author":"Kable","year":"2019","journal-title":"Healthcare (Basel, Switzerland)"},{"key":"2026050621430616100_gnaf275-B49","doi-asserted-by":"publisher","first-page":"e20597","DOI":"10.1097\/md.0000000000020597","article-title":"The impact of exercise on patients with dementia: A 2-year follow-up","volume":"99","author":"Ke-Hau","year":"2020","journal-title":"Medicine"},{"key":"2026050621430616100_gnaf275-B50","doi-asserted-by":"publisher","first-page":"3119","DOI":"10.1111\/jgs.19105","article-title":"Gaps in the coordination of care for people living with dementia","volume":"72","author":"Kern","year":"2024","journal-title":"Journal of the American Geriatrics Society"},{"key":"2026050621430616100_gnaf275-B51","doi-asserted-by":"publisher","first-page":"1890","DOI":"10.1177\/14713012221098259","article-title":"Interprofessional collaboration in palliative dementia care through the eyes of informal caregivers","volume":"21","author":"Khemai","year":"2022","journal-title":"Dementia (London, England)"},{"key":"2026050621430616100_gnaf275-B52","doi-asserted-by":"publisher","first-page":"87","DOI":"10.1186\/s12904-019-0467-9","article-title":"Context, mechanisms and outcomes in end-of-life care for people with advanced dementia: Family carers perspective","volume":"18","author":"Kupeli","year":"2019","journal-title":"BMC Palliative Care"},{"key":"2026050621430616100_gnaf275-B53","doi-asserted-by":"publisher","first-page":"2038","DOI":"10.1177\/1471301218814641","article-title":"Family caregivers\u2019 involvement in decision-making processes regarding admission of persons with dementia to nursing homes","volume":"19","author":"Larsen","year":"2020","journal-title":"Dementia (London, England)"},{"key":"2026050621430616100_gnaf275-B54","doi-asserted-by":"publisher","first-page":"e78","DOI":"10.1093\/geront\/gnx202","article-title":"Falls and hospitalizations among persons with dementia and associated caregiver emotional difficulties","volume":"58","author":"Leggett","year":"2018","journal-title":"Gerontologist"},{"key":"2026050621430616100_gnaf275-B55","doi-asserted-by":"publisher","first-page":"988","DOI":"10.1097\/mlr.0000000000001386","article-title":"Can continuity of care reduce hospitalization among community-dwelling older adult veterans living with dementia?","volume":"58","author":"Lei","year":"2020","journal-title":"Medical Care"},{"key":"2026050621430616100_gnaf275-B56","doi-asserted-by":"publisher","first-page":"e1285","DOI":"10.1002\/cl2.1285","article-title":"Protocol: Home-based care for people with dementia: A systematic review","volume":"18","author":"Li","year":"2022","journal-title":"Campbell Systematic Reviews"},{"key":"2026050621430616100_gnaf275-B57","doi-asserted-by":"publisher","first-page":"872","DOI":"10.1177\/0733464819888838","article-title":"Patient and caregiver outcomes and experiences with team-based memory care: A mixed methods study","volume":"40","author":"Liu","year":"2021","journal-title":"Journal of Applied Gerontology: The Official Journal of the Southern Gerontological Society"},{"key":"2026050621430616100_gnaf275-B58","volume-title":"World Alzheimer Report 2023: Reducing dementia risk: never too early, never too late","author":"Long","year":"2023"},{"key":"2026050621430616100_gnaf275-B59","author":"QSR International Pty Ltd. (2020"},{"key":"2026050621430616100_gnaf275-B60","doi-asserted-by":"publisher","first-page":"2115","DOI":"10.1016\/j.jamda.2021.07.002","article-title":"Association between dementia care programs in assisted living facilities and transitions to nursing homes in Ontario, Canada: A population-based cohort study","volume":"22","author":"Manis","year":"2021","journal-title":"Journal of the American Medical Directors Association"},{"key":"2026050621430616100_gnaf275-B61","doi-asserted-by":"publisher","first-page":"1440","DOI":"10.1177\/14713012231183394","article-title":"Film as cooperative endeavour: The promises for people living with dementia, their relatives, caregivers and aged care staff","volume":"22","author":"Marsh","year":"2023","journal-title":"Dementia (London, England)"},{"key":"2026050621430616100_gnaf275-B62","doi-asserted-by":"publisher","first-page":"2135","DOI":"10.1177\/1471301218816250","article-title":"A scoping review of gaps and priorities in dementia care in Europe","volume":"19","author":"Martin","year":"2020","journal-title":"Dementia (London, England)"},{"key":"2026050621430616100_gnaf275-B63","doi-asserted-by":"publisher","first-page":"1520","DOI":"10.1186\/s12913-024-12020-w","article-title":"Transition for people with dementia from day respite services to permanent residential care: A realist synthesis","volume":"24","author":"Meyer","year":"2024","journal-title":"BMC Health Services Research"},{"key":"2026050621430616100_gnaf275-B64","doi-asserted-by":"publisher","first-page":"976","DOI":"10.1177\/02692163221092624","article-title":"Health and social care services for people with dementia at home at the end of life: A qualitative study of bereaved informal caregivers\u2019 experiences","volume":"36","author":"Mogan","year":"2022","journal-title":"Palliative Medicine"},{"key":"2026050621430616100_gnaf275-B65","doi-asserted-by":"publisher","first-page":"58","DOI":"10.1097\/01.NAJ.0000336420.34946.3a","article-title":"Transitional care","volume":"108","author":"Naylor","year":"2008","journal-title":"The American Journal of Nursing"},{"key":"2026050621430616100_gnaf275-B66","doi-asserted-by":"publisher","first-page":"1136","DOI":"10.1111\/jgs.17627","article-title":"A mixed-methods evaluation of home-based primary care in dementia within an integrated system","volume":"70","author":"Nguyen","year":"2022","journal-title":"Journal of the American Geriatrics Society"},{"key":"2026050621430616100_gnaf275-B67","doi-asserted-by":"crossref","first-page":"e105","DOI":"10.1016\/S2468-2667(21)00249-8","article-title":"Estimation of the global prevalence of dementia in 2019 and forecasted prevalence in 2050: An analysis for the Global Burden of Disease Study 2019","volume":"7","author":"Nichols","year":"2022","journal-title":"The Lancet Public Health"},{"key":"2026050621430616100_gnaf275-B68","author":"North West Coast Strategic Clinical Network","year":"2018"},{"key":"2026050621430616100_gnaf275-B69","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1155\/2023\/8858773","article-title":"Mapping collaboration and coordination of health and care services for older people with dementia: A scoping review","volume":"2023","author":"\u00d6sterholm","year":"2023","journal-title":"Health & Social Care in the Community"},{"key":"2026050621430616100_gnaf275-B70","doi-asserted-by":"publisher","first-page":"n71","DOI":"10.1136\/bmj.n71","article-title":"The PRISMA 2020 statement: An updated guideline for reporting systematic reviews","volume":"372","author":"Page","year":"2021","journal-title":"BMJ (Clinical Research ed.)"},{"key":"2026050621430616100_gnaf275-B71","doi-asserted-by":"publisher","first-page":"3634","DOI":"10.1111\/jocn.15885","article-title":"Analysis of discharge documentation for older adults living with dementia: A cohort study","volume":"30","author":"Parker","year":"2021","journal-title":"Journal of Clinical Nursing"},{"key":"2026050621430616100_gnaf275-B72","doi-asserted-by":"publisher","first-page":"165","DOI":"10.1001\/jama.2011.1964","article-title":"Association of incident dementia with hospitalizations","volume":"307","author":"Phelan","year":"2012","journal-title":"JAMA"},{"key":"2026050621430616100_gnaf275-B73","doi-asserted-by":"publisher","first-page":"10","DOI":"10.29045\/14784726.2018.03.2.4.10","article-title":"A clinical audit of the electronic data capture of dementia in ambulance service patient records","volume":"2","author":"Pocock","year":"2018","journal-title":"British Paramedic Journal"},{"key":"2026050621430616100_gnaf275-B74","doi-asserted-by":"publisher","first-page":"1764","DOI":"10.1177\/1471301217728845","article-title":"An evaluation of discharge documentation for people with dementia discharged home from hospital\u2014A cross-sectional pilot study","volume":"18","author":"Pond","year":"2019","journal-title":"Dementia"},{"key":"2026050621430616100_gnaf275-B75","doi-asserted-by":"publisher","first-page":"14","DOI":"10.1177\/2053434520908122","article-title":"Understanding transitional care provided to older adults with and without dementia: A mixed methods study","volume":"23","author":"Prusaczyk","year":"2020","journal-title":"International Journal of Care Coordination"},{"key":"2026050621430616100_gnaf275-B76","doi-asserted-by":"publisher","first-page":"15","DOI":"10.3928\/00989134-20190530-02","article-title":"Differences in transitional care provided to patients with and without dementia","volume":"45","author":"Prusaczyk","year":"2019","journal-title":"Journal of Gerontological Nursing"},{"key":"2026050621430616100_gnaf275-B77","doi-asserted-by":"publisher","first-page":"1310","DOI":"10.1177\/10499091231155601","article-title":"Care setting transitions for people with dementia: Qualitative perspectives of current and former care partners","volume":"40","author":"Radcliffe","year":"2023","journal-title":"The American Journal of Hospice & Palliative Care"},{"key":"2026050621430616100_gnaf275-B78","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1016\/j.socscimed.2018.04.014","article-title":"The impact of institution use on the wellbeing of Alzheimer\u2019s disease patients and their caregivers","volume":"207","author":"Rapp","year":"2018","journal-title":"Social Science & Medicine (1982)"},{"key":"2026050621430616100_gnaf275-B79","doi-asserted-by":"publisher","first-page":"1733","DOI":"10.1111\/jocn.15208","article-title":"Behavioural disturbances in patients with frontotemporal lobe degeneration focusing on caregiver burden at home and in nursing homes","volume":"29","author":"Rognstad","year":"2020","journal-title":"Journal of Clinical Nursing"},{"key":"2026050621430616100_gnaf275-B80","doi-asserted-by":"publisher","first-page":"261","DOI":"10.1192\/bjb.2020.24","article-title":"Efficacy of a dementia intensive support (DIS) service at preventing admissions to medical and psychiatric wards: Qualitative and quantitative evaluation","volume":"44","author":"Rubinsztein","year":"2020","journal-title":"BJPsych Bulletin"},{"key":"2026050621430616100_gnaf275-B81","doi-asserted-by":"publisher","first-page":"534","DOI":"10.1177\/0733464821999225","article-title":"Clinical and demographic profiles of home care patients with Alzheimer\u2019s disease and related dementias: Implications for information transfer across care settings","volume":"41","author":"Ryvicker","year":"2022","journal-title":"Journal of Applied Gerontology: The Official Journal of the Southern Gerontological Society"},{"key":"2026050621430616100_gnaf275-B82","doi-asserted-by":"publisher","first-page":"153","DOI":"10.1177\/14713012211031779","article-title":"Using meta-ethnography to understand the care transition experience of people with dementia and their caregivers","volume":"21","author":"Saragosa","year":"2022","journal-title":"Dementia (London, England)"},{"key":"2026050621430616100_gnaf275-B83","doi-asserted-by":"publisher","first-page":"101132","DOI":"10.1016\/j.jaging.2023.101132","article-title":"\"Seeing the day-to-day situation\": A grounded theory of how persons living with dementia and their family caregivers experience the hospital to home transition and beyond","volume":"65","author":"Saragosa","year":"2023","journal-title":"Journal of Aging Studies"},{"key":"2026050621430616100_gnaf275-B84","doi-asserted-by":"publisher","first-page":"1252","DOI":"10.1111\/jep.13551","article-title":"Caregivers\u2019 experiences of medication management advice for people living with dementia at discharge","volume":"27","author":"Sawan","year":"2021","journal-title":"Journal of Evaluation in Clinical Practice"},{"key":"2026050621430616100_gnaf275-B85","doi-asserted-by":"publisher","first-page":"2027","DOI":"10.1111\/jgs.16521","article-title":"Characteristics and outcomes of dementia patients who receive inpatient palliative care consultation","volume":"68","author":"Sharda","year":"2020","journal-title":"Journal of the American Geriatrics Society"},{"key":"2026050621430616100_gnaf275-B86","doi-asserted-by":"publisher","first-page":"1873","DOI":"10.1177\/14713012221097237","article-title":"Using Journey Mapping to support staff, family members and allies of people with dementia to think and act differently during a care transition: The benefits and limits of care imagination","volume":"21","author":"Smith","year":"2022","journal-title":"Dementia (London, England)"},{"key":"2026050621430616100_gnaf275-B87","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1017\/S0144686X2100043X","article-title":"Re-imagining care transitions for people with dementia and complex support needs in residential aged care: Using co-designed sensory objects and a focused ethnography to recognise micro transitions","volume":"43","author":"Smith","year":"2023","journal-title":"Ageing and Society"},{"key":"2026050621430616100_gnaf275-B88","doi-asserted-by":"publisher","first-page":"104471","DOI":"10.1016\/j.archger.2021.104471","article-title":"Integrated dementia care: A qualitative evidence synthesis of the experiences of people living with dementia, informal carers and healthcare professionals","volume":"97","author":"Smith","year":"2021","journal-title":"Archives of Gerontology and Geriatrics"},{"key":"2026050621430616100_gnaf275-B89","doi-asserted-by":"publisher","first-page":"300","DOI":"10.1037\/cfp0000150","article-title":"\"We moved her too soon\": Navigating guilt among adult child and spousal caregivers of persons living with dementia following a move into residential long-term care","volume":"11","author":"Statz","year":"2022","journal-title":"Couple & Family Psychology"},{"key":"2026050621430616100_gnaf275-B90","doi-asserted-by":"publisher","first-page":"512","DOI":"10.1186\/s12913-020-05382-4","article-title":"The barriers and facilitators to implementing dementia education and training in health and social care services: A mixed-methods study","volume":"20","author":"Surr","year":"2020","journal-title":"BMC Health Services Research"},{"key":"2026050621430616100_gnaf275-B91","doi-asserted-by":"publisher","first-page":"28","DOI":"10.1186\/s40814-024-01455-x","article-title":"Caring for caregivers and persons living with dementia under home-based primary care: Protocol for an interventional clinical trial","volume":"10","author":"Sy","year":"2024","journal-title":"Pilot and Feasibility Studies"},{"key":"2026050621430616100_gnaf275-B92","doi-asserted-by":"publisher","first-page":"45","DOI":"10.1186\/1471-2288-8-45","article-title":"Methods for the thematic synthesis of qualitative research in systematic reviews","volume":"8","author":"Thomas","year":"2008","journal-title":"BMC Medical Research Methodology"},{"key":"2026050621430616100_gnaf275-B93","doi-asserted-by":"publisher","first-page":"1486","DOI":"10.1016\/j.jamda.2022.06.021","article-title":"Unique care needs of people with dementia and their caregivers during transitions from skilled nursing facilities to home and assisted living: A qualitative study","volume":"23","author":"Toles","year":"2022","journal-title":"Journal of the American Medical Directors Association"},{"key":"2026050621430616100_gnaf275-B94","doi-asserted-by":"publisher","first-page":"197","DOI":"10.1016\/j.gerinurse.2022.09.016","article-title":"Adapting the connect-home transitional care intervention for the unique needs of people with dementia and their caregivers: A feasibility study","volume":"48","author":"Toles","year":"2022","journal-title":"Geriatric Nursing (New York, N.Y.)"},{"key":"2026050621430616100_gnaf275-B95","doi-asserted-by":"publisher","first-page":"127","DOI":"10.1186\/s12877-022-02809-x","article-title":"Evaluation of IMproving Palliative care Education and Training Using Simulation in Dementia (IMPETUS-D) a staff simulation training intervention to improve palliative care of people with advanced dementia living in nursing homes: A cluster randomised controlled trial","volume":"22","author":"Tropea","year":"2022","journal-title":"BMC Geriatrics"},{"key":"2026050621430616100_gnaf275-B96","doi-asserted-by":"publisher","first-page":"1186","DOI":"10.1093\/geronb\/gbaa204","article-title":"How transitions in dementia care trajectories affect health problems in partners: A longitudinal analysis with linked health and administrative data","volume":"76","author":"van der Heide","year":"2021","journal-title":"The Journals of Gerontology. Series B, Psychological Sciences and Social Sciences"},{"key":"2026050621430616100_gnaf275-B97","author":"Veritas Health Innovation","year":"2014"},{"key":"2026050621430616100_gnaf275-B98","doi-asserted-by":"publisher","first-page":"107223","DOI":"10.1016\/j.ypmed.2022.107223","article-title":"Rural and urban disparities in potentially preventable hospitalizations among US patients with Alzheimer\u2019s disease and related dementias: Evidence of hospital-based telehealth and enabling services","volume":"163","author":"Wang","year":"2022","journal-title":"Preventive Medicine"},{"key":"2026050621430616100_gnaf275-B99","doi-asserted-by":"publisher","first-page":"2148","DOI":"10.1177\/07334648221102402","article-title":"The national partnership to improve dementia care and hospital readmission among skilled nursing facility residents","volume":"41","author":"Wang","year":"2022","journal-title":"Journal of Applied Gerontology: The Official Journal of the Southern Gerontological Society"},{"key":"2026050621430616100_gnaf275-B100","doi-asserted-by":"crossref","first-page":"13405","DOI":"10.3390\/ijerph182413405","article-title":"The Impact of demographic, socio-economic and geographic factors on mortality risk among people living with dementia in England (2002\u20132016)","volume":"18","author":"Watson","year":"2021","journal-title":"International Journal of Environmental Research and Public Health"},{"key":"2026050621430616100_gnaf275-B101","doi-asserted-by":"publisher","first-page":"105001","DOI":"10.1016\/j.jamda.2024.03.112","article-title":"A scoping review of dementia interventions in home-based primary care","volume":"25","author":"Weiner","year":"2024","journal-title":"Journal of the American Medical Directors Association"},{"key":"2026050621430616100_gnaf275-B102","doi-asserted-by":"publisher","first-page":"103576","DOI":"10.1016\/j.ijnurstu.2020.103576","article-title":"Advance care planning for people living with dementia: An umbrella review of effectiveness and experiences","volume":"107","author":"Wendrich-van Dael","year":"2020","journal-title":"International Journal of Nursing Studies"},{"key":"2026050621430616100_gnaf275-B103","volume-title":"International classification of diseases: [9th] ninth revision, Basic tabulation list with alphabetic index","author":"World Health Organization","year":"1978"},{"key":"2026050621430616100_gnaf275-B104","author":"World Health Organization","year":"2020"},{"key":"2026050621430616100_gnaf275-B105","author":"World Health Organization","year":"2023"},{"key":"2026050621430616100_gnaf275-B106","doi-asserted-by":"publisher","first-page":"627","DOI":"10.1332\/239788221X16819168412272","article-title":"Carers\u2019 experiences of the transition of people with dementia into residential aged care: A narrative analysis","volume":"8","author":"Wright","year":"2024","journal-title":"International Journal of Care and Caring"},{"key":"2026050621430616100_gnaf275-B107","doi-asserted-by":"publisher","first-page":"133","DOI":"10.1177\/0898264320963588","article-title":"Transitioning to long-term care: Family caregiver experiences of dementia, communities, and counseling","volume":"33","author":"Zmora","year":"2021","journal-title":"Journal of Aging and Health"}],"container-title":["The Gerontologist"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/gerontologist\/advance-article-pdf\/doi\/10.1093\/geront\/gnaf275\/65500585\/gnaf275.pdf","content-type":"application\/pdf","content-version":"am","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/gerontologist\/article-pdf\/66\/1\/gnaf275\/65500585\/gnaf275.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/gerontologist\/article-pdf\/66\/1\/gnaf275\/65500585\/gnaf275.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,7]],"date-time":"2026-05-07T01:43:16Z","timestamp":1778118196000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/gerontologist\/article\/doi\/10.1093\/geront\/gnaf275\/8342458"}},"subtitle":[],"editor":[{"given":"Patricia C","family":"Heyn","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2025,11,25]]},"references-count":107,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2026,1,7]]}},"URL":"https:\/\/doi.org\/10.1093\/geront\/gnaf275","relation":{},"ISSN":["0016-9013","1758-5341"],"issn-type":[{"value":"0016-9013","type":"print"},{"value":"1758-5341","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2026,1]]},"published":{"date-parts":[[2025,11,25]]},"article-number":"gnaf275"}}