Quality Improvement in Neurology: Dementia Management Quality Measures

Center for Innovative Care in Aging (L.N.G.), Community Public Health, School of Nursing and Department of Psychiatry, Division of Geriatrics and Gerontology, Johns Hopkins University, School of Medicine, Baltimore, MD
Neurology (Impact Factor: 8.29). 09/2013; 81(17). DOI: 10.1212/WNL.0b013e3182a956bf
Source: PubMed


Professional and advocacy organizations have long urged that dementia be recognized and properly diagnosed.(1,2) With the passage of the National Alzheimer's Project Act(3) in 2011, an Advisory Council for Alzheimer's Research, Care, and Services was convened to advise the Department of Health and Human Services. In May 2012, the Council produced the first National Plan to address Alzheimer disease and prominent in its recommendations is a call for quality measures suitable for evaluating and tracking dementia care in clinical settings.(4) Although other efforts have been made to set dementia care quality standards, such as those pioneered by RAND in its series Assessing Care of Vulnerable Elders (ACOVE)(5), implementation has not been widely embraced by practitioners, health care systems, or insurers. In this Executive Summary (full manuscript on, we report on a new measurement set for dementia management developed by an interdisciplinary Dementia Measures Work Group (DWG) representing the major national organizations and advocacy organizations concerned with the care of patients with dementia. This effort was led by the American Academy of Neurology, the American Geriatrics Society, the American Medical Directors Association, the American Psychiatric Association, and the American Medical Association-convened Physician Consortium for Performance Improvement (PCPI). Both the ACOVE measures and the measurement set described here apply to patients whose dementia has already been identified and properly diagnosed. Though similar in concept to ACOVE, the DWG measurement set differs in several important ways: it includes all stages of dementia in a single measure set, calls for the use of functional staging in planning care, prompts the use of validated instruments in patient and caregiver assessment and intervention, highlights the relevance of using palliative care concepts to guide care prior to the advanced stages of illness, and provides evidence-based support for its recommendations and guidance on the selection of instruments useful in tracking patient-centered outcomes. In addition, the DWG measurement set specifies annual reassessment and updating of interventions and care plans for dementia-related problems that affect families and other caregivers as well as patients. Here, we first provide a brief synopsis of why major reforms in health care design and delivery are needed in order to achieve substantive improvements in the quality of care, and then list the final measures approved for publication, dissemination, and implementation.

Download full-text


Available from: Soo Borson, Oct 31, 2014
    • "Additionally, proven programs exist that could improve Mr. Smith's life quality (Gitlin, Hodgson, & Choi, in press) and physician approach, which, in turn, would benefit Mrs. Smith. These include, but are not limited to, the Physician Consortium for Performance Improvement's Dementia Performance Measurement Set recommending routine screening of behavioral symptoms, cognitive and functional abilities , and provision of caregiver education (Odenheimer et al., 2014), practice guidelines and algorithms for systematically addressing behavioral symptoms (Gitlin, Kales, & Lyketsos, 2012; Kales, Gitlin, & Lyketsos, 2014), and collaborative primary care (Callahan et al., 2006) to address dementia patients' comorbidities and caregiver burden. To date, Mrs. Smith, her father, and physician do not have knowledge of or access to these proven programs and approaches. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Over the past 3 decades, more than 200 dementia caregiver interventions have been tested in randomized clinical trials and found to be efficacious. Few programs have been translated for delivery in various service contexts, and they remain inaccessible to the 15+ million dementia family caregivers in the United States. This article examines translational efforts and offers a vision for more rapid advancement in this area. We summarize the evidence for caregiver interventions, review published translational efforts, and recommend future directions to bridge the research-practice fissure in this area. We suggest that as caregiver interventions are tested external to service contexts, a translational phase is required. Yet, this is hampered by evidentiary gaps, lack of theory to understand implementation challenges, insufficient funding and unsupportive payment structures for sustaining programs. We propose ways to advance translational activities and future research with practical applications. © The Author 2015. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail:
    No preview · Article · Apr 2015 · The Gerontologist
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Improving dementia care in health systems requires estimates of need in the population served. We explored whether dementia-specific service needs and gaps for patients and caregivers could be predicted by simple information readily captured in routine care settings. Primary family caregivers (n = 215) rated their own current stress, challenging patient behaviors, and prior-year needs and gaps in 16 medical and psychosocial services. These were evaluated with other patient and caregiver characteristics in multivariate regressions to identify unique predictors of service needs and gaps. Caregiver stress and patient behavior problems together accounted for an average of 24% of the whole-sample variance in total needs and gaps. All other variables combined (comorbid chronic disease, dementia severity, age, caregiver relationship, and residence) accounted for a mean of 3%, with none yielding more than 4% in any equation. We combined stress and behavior problem indicators into a simple screen. In early/mild dementia dyads (n = 111) typical in primary care settings, the screen identified gaps in total (84%) and psychosocial (77%) care services for high stress/high behavior problem dyads vs. 25% and 23%, respectively, of low stress/low behavior problem dyads. Medical care gaps were dramatically higher in high stress/high behavior problem dyads (66%) than all others (12%). The Dementia Services Mini-Screen is a simple tool that could help clinicians and health systems rapidly identify dyads needing enhanced dementia care, track key patient and caregiver outcomes of interventions, and estimate population needs for new service development.
    Full-text · Article · Nov 2013 · The American journal of geriatric psychiatry: official journal of the American Association for Geriatric Psychiatry
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Noncognitive neuropsychiatric symptoms (NPS) of dementia (aggression, agitation, depression, anxiety, delusions, hallucinations, apathy, disinhibition) affect individuals with dementia nearly universally across dementia stages and etiologies. NPS are associated with poor outcomes for individuals with dementia and caregivers, including excess morbidity and mortality, greater healthcare use, and earlier nursing home placement, as well as caregiver stress, depression, and difficulty with employment. Although the Food and Drug Administration has not approved pharmacotherapy for NPS, psychotropic medications are frequently used to manage these symptoms, but in the few cases of proven pharmacological efficacy, significant risk of adverse effects may offset benefits. There is evidence of efficacy and limited potential for adverse effects of nonpharmacological treatments, typically considered first line, but their uptake as preferred treatments remains inadequate in real-world clinical settings. Thus, the field currently finds itself in a predicament in terms of management of these difficult symptoms. It was in this context that the University of Michigan Program for Positive Aging, working in collaboration with the Johns Hopkins Alzheimer's Disease Research Center and Center for Innovative Care in Aging sponsored and convened a multidisciplinary expert panel in Detroit, Michigan, in fall 2011 with three objectives: to define critical elements of care for NPS in dementia; to construct an approach describing the sequential and iterative steps of managing NPS in real-world clinical settings that can be used as a basis for integrating nonpharmacological and pharmacological approaches; and to discuss how the approach generated could be implemented in research and clinical care.
    Full-text · Article · Mar 2014 · Journal of the American Geriatrics Society
Show more