Quality Indicators for the Care of Dementia in Vulnerable Elders
Quality Indicators for the Care of Dementia in Vulnerable Elders
Denise G. Feil, MD, MPH,wCatherine MacLean, MD, PhD,wz§and David Sultzer, MDw
Key words: dementia; cognitive screening; quality indica-tors; health care
Dementia, defined as an acquired, persistent impairmentin two or more cognitive areas (e.g., frontal executivefunction, language, memory)1is a leading cause of disabil-ity in older adults. Alzheimer’s disease (AD) comprises 55%to 77% of all dementias, whereas vascular dementia (VaD)is the second most common dementia, comprising 15% to25% of all dementias.2Although the prevalence of AD isonly 2% of persons aged 60 to 64, it rises to approximately40% in those aged 80 and older.3The need for dementia care will increase significantly inthe next few decades because of the rapid growth of theoldest age groups in the U.S. population.4The 4.5 millionpersons with AD in 2000 will almost triple, to 13.2 millionby 2050. The cohort aged 85 and older with AD will morethan quadruple, to 8.0 million.5Dementia is the most com-mon reason for placement of older adults in nursing facil-ities, and the demands for nursing home care will also likelyquadruple in this group aged 85 and older.6Furthermore, inCalifornia, the costs of nursing home care for AD are pro-jected to triple by 2040.7A number of quality indicators (QIs) present new op-portunities to forestall cognitive decline and reduce disabil-ity and nursing home admission during the course ofdementia. Early recognition of cognitive impairment anddementia, followed by intervention, can offer patients andcaregivers the opportunity for better quality of life.This article presents a set of indicators to assess thequality of care of patients with dementia. The target patientpopulation is vulnerable elders (VEs), defined as personsaged 65 and older who are at risk for death or functionaldecline.The QIs proposed here do not incorporate exclusionsfor cases of advanced dementia, which is handled in As-sessing Care of Vulnerable Elders (ACOVE) in a uniformfashion across the set of QIs. Refer to ‘‘Application of As-sessing Care of Vulnerable Elders-3 Quality Indicators toPatients with Advanced Dementia and Poor Prognosis’’ forexclusions due to advanced dementia or poor prognosis.METHODSA total of 357 articles were considered in this review: 24identified using a Web search, 94 through reference mining,and 224 through the ACOVE-3 literature searches. Fifteenadditional articles were included after peer review.RESULTSOf the 22 preliminary QIs, the expert panel process judged16 to be valid (see the QIs on pages S464–S487 of thissupplement). Six indicators were rejected, and the expertpanel added one QI. The literature summaries that supporteach of the indicators judged to be valid in the expert panelprocess are described.Cognitive and Functional Screening1. IF a VE is new to a primary care practice or inpatientservice, THEN there should be a documented assessment ofcognitive ability and functional status.2. ALL VEs should be evaluated annually for changes inmemory and function.Supporting EvidenceNo direct evidence was found that screening for dementiaimproves clinical outcomes, although medical,8–11behav-ioral,12and social13interventions early in dementiaimprove clinical outcomes and provide indirect evidencein support of screening. In addition, early diagnosis mayallow patients and families to plan for the future.Cognitive screening tests generally provide better re-sults in populations with a higher risk of dementia, suchas VEs.14,15Examples include the Blessed Orientation-Memory-Concentration Test, which is briefer than theMini-Mental State Examination (MMSE) and performssimilarly. Additional tests that are shorter than the MMSEinclude the 7-Minute Screen, the Memory ImpairmentScreen,14and the Mini-Cog,16which adds a three-itemrecall to the clock drawing task.
Address correspondence to Denise G. Feil, MD, MPH, West Los Angeles VAMedical Center, Bldg. 500 3-South, 116-AE, 11301 Wilshire Boulevard, LosAngeles, CA 90073. E-mail: denise.feil@med.va.gov
DOI: 10.1111/j.1532-5415.2007.01335.x
From theVeterans Affairs Greater Los Angeles Healthcare System,Los Angeles, California;wDavid Geffen School of Medicine, Universityof California at Los Angeles, Los Angeles, California;zRAND Health,Santa Monica, California; and§Programs in Clinical Excellence,WellPoint Inc., Thousand Oaks, California.
JAGS 55:S293–S301, 2007
http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2007.01335.x/epdf
