Dementia

Care for People Living in the Community

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 and Diagnosis
People suspected to have mild cognitive impairment or dementia receive a comprehensive assessment when signs are first identified. If diagnosed with either condition, they are then reassessed on a regular basis or when there is a significant change in their condition.

Quality Statement 2: Interprofessional Care Team
People living with dementia have access to community-based dementia care from an interprofessional team with expertise in dementia care, of which the person living with dementia and their caregivers are integral team members.

Quality Statement 3: Individualized Care Plan
People living with dementia have an individualized care plan that guides their care. The plan identifies their individual needs, those of their caregivers, and goals of care. The plan is reviewed and updated on a regular basis, including documentation of changing needs and goals and the person’s response to interventions.

Quality Statement 4: Named Point of Contact
People living with dementia and their caregivers have one or more named providers on the interprofessional care team who serve as a point of contact to facilitate care coordination and transitions across settings.

Quality Statement 5: Education and Training for People Living With Dementia and Their Caregivers
People living with dementia and their caregivers have access to education and training on dementia and available support services.

Quality Statement 6: Education and Training for Health Care Providers
Health care providers delivering care and services to people living with dementia receive education and training in dementia care.

Quality Statement 7: Access to Support Services
People living with dementia and their caregivers have access to support services that are individualized and meet their ongoing goals and needs.

Quality Statement 8: Caregiver Assessment and Support
Caregivers of people living with dementia are assessed on an ongoing basis and offered supports to address their individual needs.

Quality Statement 9: Safe Living Environment
People living with dementia have access to a safe living environment that meets their specific needs, including design modifications and a range of housing options.

Quality Statement 10: Access to Primary Care
People living with mild cognitive impairment or dementia have regular visits with a primary care physician or nurse practitioner who provides effective primary care that meets both their general health care needs and their specific needs related to cognitive impairment or dementia.

Resources Quality Statements Advisory Committee About

Comprehensive Assessment and Diagnosis

People suspected to have mild cognitive impairment or dementia receive a comprehensive assessment when signs are first identified. If diagnosed with either condition, they are then reassessed on a regular basis or when there is a significant change in their condition.

Background

A comprehensive assessment ensures an accurate diagnosis and the collection of baseline information to track changes in a person’s status. Diagnosis should ideally be made by a physician with expertise in diagnosing and treating cognitive disorders such as dementia. An early and accurate diagnosis helps people and their families get timely access to information, advice, and support. It also helps them start treatment earlier, if appropriate, and enables them to plan and make important decisions about their care. If after the comprehensive assessment, the diagnosis still remains unclear, it is important for the physician to organize a plan to arrive at a diagnosis (such as arranging for further testing or referral to a specialist). Clinically indicated care interventions (such as optimizing medications and coordinating necessary supports) should be initiated during this process and not delayed until diagnosis is achieved. Based on the current Canadian clinical practice guideline, structural imaging (e.g., CT and/or MRI) isn’t mandatory in the assessment of a person with cognitive impairment or dementia, but should be obtained if the results would change the clinical management (e.g., if the presence of cerebrovascular disease would result in initiation of specific medications, or where there is suspicion of a mass).

Given the ongoing cognitive decline associated with dementia and the increased risk of people with mild cognitive impairment developing dementia, a comprehensive assessment should be performed when a person first exhibits or experiences changes in cognition, behaviour, mood or function, and on a regular basis afterwards. The person and ideally their family, caregivers, and/or substitute decision-makers should be included in the assessment. The assessment should be culturally appropriate—respectful of diverse cultural, ethnic, and spiritual backgrounds—and in the person’s preferred language.

What This Quality Statement Means

For People Living With Mild Cognitive Impairment or Dementia

When you, your family, or a health care professional first notices changes in your memory or judgment, you should be assessed by a health care professional. This assessment should include questions about your physical health, your medical history, what medications you’re taking, and how you’re feeling. If you are diagnosed with either mild cognitive impairment or dementia, these assessments should be repeated at regular intervals.

For Clinicians

Perform a comprehensive assessment (as described in the Definitions section of this statement) when people first show signs of mild cognitive impairment or dementia. People diagnosed with either condition should be reassessed on a regular basis afterwards.

For Health Services

Ensure there are systems, processes, and resources, including standardized assessment instruments, for clinicians and health care teams to carry out comprehensive assessments of people with suspected or confirmed mild cognitive impairment or dementia.

Quality Indicators

Process Indicators

Percentage of people suspected to have mild cognitive impairment or dementia who receive a comprehensive assessment

Denominator: number of people suspected to have mild cognitive impairment or dementia
Numerator: number of people in the denominator who receive a comprehensive assessment
Data source: local data collection

Percentage of people living with mild cognitive impairment who received a comprehensive reassessment within the past year

Denominator: number of people living with mild cognitive impairment
Numerator: number of people in the denominator who received a comprehensive reassessment within the past year
Data source: local data collection

Percentage of people living with dementia who received a comprehensive reassessment within the past year

Denominator: number of people living with dementia
Numerator: number of people in the denominator who received a comprehensive reassessment within the past year
Data source: local data collection

Definitions Used Within This Quality Statement

Comprehensive assessment

This clinical assessment should be conducted by skilled health care professionals and include, at a minimum, the following components:

Medical history
Medication review (including over-the-counter and alternative medications) and substance use history
Physical and functional status examinations, including diet, nutrition, oral health, pain, sleep, and continence
Cognitive assessment, using a validated instrument
Assessment of potential medical and psychiatric co-morbidities or potential contributing factors (e.g., delirium, depression) to cognitive signs and symptoms
Assessment of behavioural and psychological symptoms of dementia
Assessment of social history and psychosocial functioning
Assessment of safety risks, including driving safety, falls
Relevant laboratory tests

Collateral history from family and caregivers should be obtained.

Regular basis

A person with mild cognitive impairment should receive a comprehensive assessment every year, or sooner according to clinical need.

A person living with dementia should receive a comprehensive assessment every 6 to 12 months, or sooner according to clinical need. The assessment informs the care plan (see Quality Statement 3).

Evidence to Improve Care