Quality Statement 1: Comprehensive Assessment - Health Quality Ontario (HQO)

Behavioural Symptoms of Dementia - Clinical Guide

Care for Patients in Hospitals and Residents in Long-Term Care Homes

Click below to see a list of brief quality statements and scroll down for more information.

Quality Statements in Brief

Quality standards are sets of concise statements designed to help health care professionals easily and quickly know what care to provide, based on the best evidence.

See below for the quality statements and click for more detail.

Quality Statement 1: Comprehensive Assessment
People living with dementia and symptoms of agitation or aggression receive a comprehensive interprofessional assessment when symptoms are first identified and after each transition in care.

Quality Statement 2: Individualized Care Plan
People living with dementia and symptoms of agitation or aggression have an individualized care plan that is developed, implemented, and reviewed on a regular basis with caregivers and agreed upon by substitute decision-makers. Ongoing review and update of care plans includes documentation of behavioural symptoms and the person’s responses to interventions.

Quality Statement 3: Individualized Nonpharmacological Interventions
People living with dementia and symptoms of agitation or aggression receive nonpharmacological interventions that are tailored to their specific needs, symptoms, and preferences, as specified in their individualized care plan.

Quality Statement 4: Indications for Psychotropic Medications
People living with dementia are prescribed psychotropic medications to help reduce agitation or aggression only when they pose a risk of harm to themselves or others or are in severe distress.

Quality Statement 5: Titrating and Monitoring Psychotropic Medications
People living with dementia who are prescribed psychotropic medications to help reduce agitation or aggression are started on low dosages, with the dosage increased gradually to reach the minimum effective dosage for each patient, within an appropriate range. Target symptoms for the use of the psychotropic medication are monitored and documented.

Quality Statement 6: Switching Psychotropic Medications
People living with dementia who are prescribed psychotropic medications to help reduce agitation or aggression have their medication discontinued and an alternative psychotropic medication prescribed if symptoms do not improve after a maximum of 8 weeks. Ineffective medications are discontinued to avoid polypharmacy. The reasons for the changes in medication and the consideration of alternative psychotropic medications are documented.

Quality Statement 7: Medication Review for Dosage Reduction or Discontinuation
People living with dementia who are prescribed psychotropic medications to help reduce agitation or aggression receive a documented medication review on a regular basis to consider reducing the dosage or discontinuing the medication.

Quality Statement 8: Mechanical Restraint
People living with dementia are not mechanically restrained to manage agitation or aggression.

Quality Statement 9: Informed Consent
People living with dementia and symptoms of agitation or aggression are advised of the risks and benefits of treatment options, and informed consent is obtained and documented before treatment is initiated. If a person with dementia is incapable of consenting to the proposed treatment, informed consent is obtained from their substitute decision-maker.

Quality Statement 10: Specialized Interprofessional Care Team
People living with dementia and symptoms of agitation or aggression have access to services from an interprofessional team that provides specialized care for the behavioural and psychological symptoms of dementia.

Quality Statement 11: Provider Training and Education
People living with dementia and symptoms of agitation or aggression receive care from providers with training and education in the assessment and management of dementia and its behavioural symptoms.

Quality Statement 12: Caregiver Training and Education
Caregivers of people living with dementia and symptoms of agitation or aggression have access to comprehensive training and education on dementia and its associated behavioural symptoms. This training and education includes management strategies that are consistent with people’s care plans.

Quality Statement 13: Appropriate Care Environment
People living with dementia and symptoms of agitation or aggression whose behavioural symptoms have been successfully treated are transitioned to an appropriate care environment as soon as possible.

Quality Statement 14: Transitions in Care
People living with dementia and symptoms of agitation or aggression who transition between settings have a team or provider who is accountable for coordination and communication. This team or provider ensures the transmission of complete and accurate information to the family, caregivers, and receiving providers prior to the transition.

Resources Quality Statements Advisory Committee About

Comprehensive Assessment

People living with dementia and symptoms of agitation or aggression receive a comprehensive interprofessional assessment when symptoms are first identified and after each transition in care.

Background

A comprehensive assessment ensures an accurate diagnosis and the collection of baseline information. The assessment allows for the identification of potential underlying conditions or issues (e.g., physical, cognitive, functional, psychiatric, psychosocial, and environmental factors) that may be causes of behavioural and psychological symptoms, and thus informs care for people living with dementia with symptoms of agitation or aggression. The patient, family/caregiver, or substitute decision-maker should be included in the assessment. The assessment also provides the opportunity to establish likely factors (or “triggers”) that may contribute to future occurrences of agitation or aggression. Comprehensive assessments should be performed at a person’s initial presentation to a health care setting as well as at transitions between care settings.

What This Quality Statement Means

For Patients

You should receive an examination and full assessment every time you arrive at or leave a hospital or long-term care home. An assessment means that your care team will want to learn more about you to understand how best to help you. It should include questions about your physical health, your medical history, what medications you’re taking, how you spend your time, and how you’re feeling.

For Clinicians

Perform a standardized, comprehensive assessment (as described in the Definitions section of this statement) when people present to a hospital or long-term care home, or when they transition to another care setting.

For Health Services

Ensure hospitals and long-term care homes have comprehensive assessment tools, systems, processes, and resources in place to assess people at presentation and discharge.

Quality Indicators

Process Indicator

Percentage of people living with dementia and symptoms of agitation or aggression who receive a comprehensive assessment at first presentation or after a transition in care

Denominator: total number of people living with dementia and symptoms of agitation or aggression who initially present at a hospital or long-term care home or who transition to another care setting
Numerator: number of people in the denominator who receive a comprehensive assessment
Data sources: local data collection, Resident Assessment Instrument Minimum Data Set (RAI-MDS) in long-term care homes

Definitions Used Within This Quality Statement

Comprehensive interprofessional assessment

This includes, at a minimum, the following components:

Physical health assessment, medical history, and medication review
Cognitive and functional assessments
Psychiatric and behavioural assessments for other conditions (e.g., depression, suicidality, danger to self and others, potential for aggression)
Psychosocial assessment (e.g., for abuse or neglect, inadequate supervision, poor communication, interpersonal conflict, lack of engagement or activities, personal social history)
Physical environment assessment (e.g., for overcrowding, lack of privacy)
Investigation and treatment of potential contributing factors to symptoms of agitation or aggression (e.g., pain, discomfort, delirium)

Interprofessional care team

At least one physician and one other regulated professional who specialize in dementia care are included on the team. Other regulated and unregulated health professionals on the team may include nurses, psychologists, occupational therapists, pharmacists, behavioural support workers, social workers, caregivers, administrative staff, personal support workers, speech-language pathologists, physiotherapists, geriatricians, dietitians, and recreational staff.

Evidence to Improve Care