Helping patients and families navigate dementia: The Kootenay Boundary Dementia Roadmaps

Issue: BCMJ, vol. 60, No. 7, September 2018, Page 368 Family Practice Services Committee

As Canada’s population ages, dementia diagnoses are on the rise—there are currently 564 000 Canadians living with dementia,[1] and 25 000 new cases are diagnosed every year.[1] A diagnosis of dementia, known as “the disease of a thousand goodbyes,” is life altering for patients, their families, and their caregivers, and creates a need for support and guidance as they help their loved one navigate their dementia journey.

As a patient’s disease progresses, family members often turn to GPs for information and resources. To ensure doctors are equipped with all the necessary information to support patients and their families through these conversations, the Kootenay Boundary Division of Family Practice created the Dementia Roadmap for Practitioners and the Dementia Roadmap for Families as part of their work on the GPSC Residential Care Initiative.[2]

The Dementia Roadmaps are the brainchild of Dr Trevor Janz, a local physician and member of the Kootenay Boundary Division. Dr Janz theorized that if GPs were able to educate families about signposts (the events and incidents that may occur as a result of symptoms) to look for over the course of their loved one’s dementia journey, they would be better equipped to understand what happens during each stage of the disease, and provide the best care possible as these changes unfold.

Both the family roadmap and the practitioner roadmap split the progression of dementia into four stages:

  • Early dementia
  • Middle dementia
  • Late dementia
  • Actively dying

For each stage, readers are provided with a list of symptoms and impacts that may be displayed by the patient at that stage of disease, followed by a list of potential signposts. The practitioner roadmap then provides a list of questions physicians may ask family members about their loved one’s safety and comfort, and a list of treatments and next steps. The roadmap for families and caregivers provides advice and suggestions for keeping their loved one safe and comfortable.

In the spirit of collaboration, the Kootenay Boundary Division has made the Dementia Roadmaps available for distribution by other divisions and communities. Over 1500 copies have been distributed in communities in Kootenay Boundary and East Kootenay; in the Abbotsford, South Okanagan Similkameen, and Vancouver Divisions of Family Practice; and in the community of Camrose in Alberta.

The Dementia Roadmap for Practitioners and the Dementia Roadmap for Families are available on the Kootenay Boundary Division website at

Divisions and physicians who wish to distribute the Dementia Roadmaps may contact for permission to do so.
—Afsaneh Moradi
Director, Community Partnership and Integration


This article is the opinion of the GPSC and has not been peer reviewed by the BCMJ Editorial Board.


1.    Alzheimer Society Canada. Dementia numbers in Canada. Accessed 11 July 2018.

2.    General Practice Services Committee. Residential Care. Accessed 11 July 2018.

Afsaneh Moradi. Helping patients and families navigate dementia: The Kootenay Boundary Dementia Roadmaps. BCMJ, Vol. 60, No. 7, September, 2018, Page(s) 368 - Family Practice Services Committee.

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