Caring for frail, vulnerable elderly patients differs from caring for younger patients and is becoming much more prevalent. The papers in this supplement, derived from the Assessing Care of Vulnerable Elders project, will help all physicians improve our management of the syndromes discussed and evaluate how well we are succeeding.

The Assessing Care of Vulnerable Elders project endeavored to develop a comprehensive set of quality-assessment tools for ill older persons. Because “ill older persons” constitute a heterogeneous cohort that is not easily delineated, we created a system to identify high-risk, community-dwelling individuals and targeted the most important clinical conditions affecting them. The indicators are designed to measure care at the level of the health system or health plan.

This paper describes the methods used to develop the ACOVE quality indicators, including development of process indicators, review of the literature, and review by expert panels.

This table shows all of the quality indicators.

Dementia is a leading cause of disability among older adult patients. Appropriate attention to early identification, the assessment of medications and health conditions that may be contributing to cognitive dysfunction, and the consideration of pharmacotherapy may all contribute to forestalling disability from dementia.

Studies demonstrate inadequate quality of care at the end of life with regard to symptom control, matching of care with patient preferences, and optimal resource use. The quality indicators reported in this paper aim to assess the provision of care to achieve a “good death.“

Falls and mobility problems reduce function, cause considerable morbidity and mortality, and precipitate premature nursing home admissions. Clinicians must use careful and thorough diagnostic approaches to identify the most likely causes, contributing factors, and associated comorbid conditions, many of which will respond to intervention.

Heart failure contributes to substantial morbidity and mortality in elderly persons, and its prevalence increases with age. This review investigates the relationship between processes and outcomes of care and identifies quality indicators that may be applied in evaluating vulnerable elders with heart failure.

Medications are central in the care of elderly patients and are the final common pathway for most therapeutic decisions. While vulnerable elders are particularly likely to require pharmaceutical therapy, they are also at increased risk for drug side effects. In addition, underuse has joined overuse and misuse as indicators for assessing the prescribing of medications to older patients.

Osteoarthritis is the most common chronic condition affecting older persons. Several studies have shown regional and subspecialty variations in the use of pharmacologic, nonpharmacologic, and surgical treatments; indirect evidence suggests that these differences result in variations in outcomes and in quality of care.

Osteoporosis is a major cause of morbidity and death in older persons. For women who are 50 years of age, the estimated lifetime risk for osteoporotic fracture is 54%, and studies suggest that the prevalence of vertebral fractures is similar for men and women. Approximately 4% of patients older than 50 years of age who experience a hip fracture will die while in the hospital, and 24% will die within 1 year of experiencing hip fracture.

Pain occurs frequently with disease and is prevalent in older people. The association of pain with depression, social isolation, sleep disturbance, gait impairment, and increased use of health services with their attendant costs is well documented. Complete relief of chronic pain is often unobtainable, and treatment decisions require that patients and physicians continually weigh the risks against the benefits.

Pneumonia is the most common cause of death from infection in persons 60 years of age and older and is the fourth most common cause of death overall for persons 80 years of age and older. The vulnerable older patient is at even greater risk for death and morbidity from pneumonia, and improving quality of care for this high-risk population may lead to substantial reductions in morbidity and mortality.

Pressure ulcers can lead to pain, disfigurement, and slow recovery from comorbid conditions. They interfere with activities of daily living, predispose to osteomyelitis and septicemia, and are strongly associated with longer hospital stays and mortality.

Urinary incontinence may cause extreme activity limitation and social isolation, and it imposes significant psychosocial distress on family, friends, and caregivers. Urinary incontinence in nursing homes is known to be treatable with assisted toileting programs; however, nursing home residents are older and frailer than community-dwelling elders and have caregivers available 24 hours per day.