Quality Indicators for the Care of Dementia in Vulnerable Elders

Dementia, defined as an acquired, persistent impairment in two or more cognitive areas (e.g., frontal executive function, language, memory) is a leading cause of disability 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% to 25% of all dementias. Although the prevalence of AD is only 2% of persons aged 60 to 64, it rises to approximately 40% in those aged 80 and older. The need for dementia care will increase significantly in the next few decades because of the rapid growth of the oldest age groups in the U.S. population. The 4.5 million persons with AD in 2000 will almost triple, to 13.2 million by 2050. The cohort aged 85 and older with AD will more than quadruple, to 8.0 million. Dementia is the most common reason for placement of older adults in nursing facilities, and the demands for nursing home care will also likely quadruple in this group aged 85 and older. Furthermore, in California, the costs of nursing home care for AD are projected to triple by 2040. A number of quality indicators (QIs) present new opportunities to forestall cognitive decline and reduce disability and nursing home admission during the course of dementia. Early recognition of cognitive impairment and dementia, followed by intervention, can offer patients and caregivers the opportunity for better quality of life. This article presents a set of indicators to assess the quality of care of patients with dementia. The target patient population is vulnerable elders (VEs), defined as persons aged 65 and older who are at risk for death or functional decline. The QIs proposed here do not incorporate exclusions for cases of advanced dementia, which is handled in Assessing Care of Vulnerable Elders (ACOVE) in a uniform fashion across the set of QIs. Refer to Application of Assessing Care of Vulnerable Elders-3 Quality Indicators to Patients with Advanced Dementia and Poor Prognosis for exclusions due to advanced dementia or poor prognosis. METHODS: A total of 357 articles were considered in this review: 24 identified using a Web search, 94 through reference mining, and 224 through the ACOVE-3 literature searches. Fifteen additional articles were included after peer review. RESULTS: Of the 22 preliminary QIs, the expert panel process judged 16 to be valid. Six indicators were rejected, and the expert panel added one QI. The literature summaries that support each of the indicators judged to be valid in the expert panel process are described.