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Evidence to Improve Care

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 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.

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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.


An individualized care plan is essential to coordinate, document, and ultimately guide the care of people living with dementia. The care plan is developed by and implemented in collaboration with the person living with dementia, caregivers, and providers to ensure consistent and coordinated delivery of care that considers the changing needs, goals, values, and preferences of people living with dementia. Care plans need to be communicated to and accessible to the person living with dementia, members of the interprofessional care team, and caregiver or substitute decision-maker. Ongoing review of the care plan supports revisiting goals of care and allows for the reassessment of evolving needs, preferences and the person’s treatment responses to interventions.

Older adults living with dementia are at high risk for adverse drug events.  Medication optimization is an important aspect of care for people living with dementia.  Considerations include medication adherence, appropriate treatment targets for comorbid conditions (e.g., hypertension, diabetes), appropriate use and monitoring of cognition-enhancing medications (e.g., donepezil, galantamine, rivastigmine, memantine, and optimized use of medications with potentially adverse cognitive effects (e.g., minimizing to the lowest dose necessary or eliminating all inappropriate or unnecessary use of medications including, but not limited to, anticholinergic drugs, benzodiazepines and other sedative-hypnotics, antipsychotics, and opioids). The decision to continue or discontinue a medication should be individualized and based on regular reassessment of both benefits and harms.

For People Living With Dementia

You, your caregivers, and your health care team should create a care plan together that reflects your needs, concerns, and preferences. A care plan is a written document that describes your goals, the care and support services you should receive, and who will provide them. It should be updated regularly, especially if there is a change in your health or situation.


For Clinicians

Work with people living with dementia and their caregivers to create an individualized care plan that documents care and services and responses to interventions. Review and update care plans every 6 to 12 months, or sooner if there is a considerable change in a person’s health or care arrangements.


For Health Services

Ensure there are systems, processes, and resources in place to support clinicians to develop and regularly update individualized care plans, as well as to communicate care plans to others who provide care to the individual. Resources may include standardized care plan templates.

Process Indicators

Percentage of people living with dementia who have an individualized care plan that guides their care

  • Denominator: number of people living with dementia
  • Numerator: number of people in the denominator who have an individualized care plan that guides their care
  • Data source: local data collection

Percentage of people living with dementia who have an individualized care plan that is reviewed annually

  • Denominator: number of people living with dementia who have an individualized care plan
  • Numerator: number of people in the denominator who have an individualized care plan that is reviewed annually
  • Data source: local data collection
Individualized care plan

This is a plan based on an assessment of the life history, social and family circumstances, and preferences and needs of the person living with dementia. It is also based on their physical and mental health needs and current level of functioning and abilities. Developed and reviewed with the person living with dementia and their caregiver, the care plan should be flexible, to accommodate changes in the person’s health status, function and abilities. The plan should include the following components:

  • The results of the comprehensive assessment (see Quality Statement 1)
  • The person’s individual needs, preferences, and goals of care, and those of their caregiver
  • A plan to minimize relocations and retain a familiar living environment for as long as possible
  • Assessment and care-planning advice about activities of daily living and instrumental activities of daily living
  • Details of environmental modifications to help the person function independently and to promote safety; these can include assistive devices and technologies, if available (see Quality Statement 9)
  • A plan for physical exercise, with an assessment and advice from a physiotherapist or occupational therapist, when needed
  • Support for people to participate in meaningful activities at their own pace
  • Individualized nonpharmacological and pharmacological interventions, as indicated
  • A plan for managing behavioural symptoms associated with dementia, if present
  • A nutrition care plan
  • A safety plan, including crisis and emergency management
  • Advance care planning includes the capable person living with dementia confirming a future substitute decision-maker (see Terminology Used in This Quality Standard for a more detailed description) who can communicate their wishes, values, and beliefs about future health care, and make care and treatment decisions when that person is no longer mentally capable of doing this for themself. (For more information on advance care planning, please refer to Health Quality Ontario’s quality standard on palliative care: Palliative Care: Care for Adults with a Progressive, Life-Limiting Illness.
  • At least one named point of contact on the care team—this is the provider who facilitates care coordination and transitions across settings for the person living with dementia (see Quality Statement 4)
Regular basis

The care plan should be reviewed every 6 to 12 months, or sooner according to clinical need. Reviewing the care plan may require a partial or full reassessment, including revisiting the goals of care with the person and caregiver.

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