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Evidence to Improve Care

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.


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.

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.

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
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).

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