Dementia (DEM) - QOF indicator

Dementia indicators for 2026/27

The dementia area of QOF centres on reviewing care plans and meeting the changing needs of patients and their carers. For 2026/27, DEM004 carries 14 points for reviews completed in the preceding 12 months; the guidance sets out a broad review covering clinical care, practical support and future care preferences.

Ongoing management

Why dementia is included in QOF

Dementia begins gradually but leads to profound, progressive loss of intellectual abilities across multiple domains. It is a major contributor to disability in later life. Prevalence rises with age, affecting approximately seven per cent of people over 65. Alzheimer’s disease accounts for around 50 to 75 per cent of dementia cases, while vascular dementia accounts for up to 20 per cent.

In the 90-year age group, the annual incidence of Alzheimer’s-type dementia reaches 34.3/100 person years at risk. Dementia is more prevalent among women because they tend to live longer. Less common forms, including dementia with Lewy Bodies and frontotemporal dementia, can also cause substantial distress and disability.

DEM004: care plan reviews

DEM004 is based on NICE IND142.

Establishing and recording a care plan

NICE dementia guidance supports joint care planning with health and social services, with formal reviews at intervals agreed in advance. If neither a care plan nor an advance care plan exists, the practice is expected to create a care plan together with the patient and their carers.

When secondary care has made the diagnosis and prepared the initial plan, the practice should add the diagnosis to the GP record as soon as possible. A patient may enter the indicator denominator before a review is clinically appropriate because their plan was only recently started. In that situation, the practice may use a personalised care adjustment if it considers this appropriate.

What the review should address

Offer an in-person or remote review of the care plan or advance care plan according to the person’s preference. The discussion should support both patient and carer, with repeated reviews allowing care to adapt as their needs change.

The review should address the following, reflecting NHS England’s guide to personalised dementia care and support planning and the objectives of the 10 Year Health Plan for England:

• Assess physical health, mental health and social circumstances.

• Review medicines, including:

• Treatment recommended by NICE: cholinesterase inhibitors (CEIs) for Alzheimer’s disease, dementia with Lewy Bodies or Parkinson’s disease dementia, and consideration of Memantine for moderate or severe Alzheimer’s disease.

• Continuing antipsychotic treatment, taking account of existing or potential adverse effects, including cardiovascular disease, diabetes and falls risk.

• Other prescribed drugs, with particular attention to anticholinergic effects.

• Document:

• Who acts as the named coordinator or key worker, how to contact them, and whether the patient and carer know about and receive all relevant benefits.

• Any legal power of attorney arrangements already established.

• The patient’s wishes for end of life care, and whether patient and carers know how to obtain that care when needed. The GP should consider adding the patient to the palliative care register.

• Check and record which NICE-recommended interventions have been offered, including cognitive stimulation therapy (CST) and psychoeducation for carers.

• Establish who the carer(s) are and, where appropriate:

• Obtain permission for communication with them and share support service details. Tailor information to the stage of dementia and the health or social care needs of both patient and carer.

• Involve them in discussions about the care plan or advance care plan.

• Explore how caring affects them.

• Offer a health check and referrals to services that can support their health and wellbeing. If they are registered elsewhere, explain that they can approach their own practice for advice.

Timing and priorities

All these areas should be covered, but the emphasis should follow what matters most to the patient and carer. Allow 30 minutes as an indicative consultation length, while agreeing the actual appointment duration with the patient. Consider together whether two separate appointments would work better. Aim for the first appointment to take place within six months.

Assessing symptoms and physical health

Research indicates that people with dementia may not mention everyday physical problems, including joint pain and infections. Assessment should therefore take account of:

• The frailty score.

• Reduced mobility and the risk of falls and fractures.

• Difficulties with hearing or vision.

• Physical illness, such as joint pain or intercurrent infection, that may show itself through altered behaviour.

• Dementia-associated psychiatric features, including delusions, hallucinations, depression, anxiety and restlessness.

Information and support for carers

Share information about the diagnosis and available help with patients and carers, while maintaining confidentiality. Evidence indicates that carers’ satisfaction can improve when clinicians recognise their distress and provide information to support them. As dementia advances, the discussion may increasingly need to address respite provision or longer-term care.

Studies provide good evidence for asking carers directly about their caring role and its consequences for them. Men who provide care are less likely to raise difficulties unprompted. The burden of caring relates to how dementia presents — including behaviour and affect — rather than the degree of cognitive impairment alone. If concerns emerge about a carer who is registered elsewhere, the GP can, with appropriate permission, approach the carer’s GP to help arrange further support and treatment.

Coordination between services

As dementia progresses, a growing number of services may become involved. Use the review to check that health services, social care and, where relevant, non-statutory organisations are communicating effectively enough to meet potentially complex needs. Any problems with referrals or information-sharing identified during the review need follow-up.

Further information

The guidance highlights these resources:

• NICE NG97 (2018): dementia guidance.

• NICE QS184 (2019): the dementia quality standard.

• The Forget me not training programme on dementia.

• Department of Health and Social Care (2001): the National Service Framework covering older people.

• NICE PH16 (2008): guidance on mental wellbeing in over 65s, including occupational therapy and physical activity interventions.

• NHS (2025): information on caring for someone with dementia.

DEM004: reporting and verification

The indicator definition in the table sets out the criteria for achievement.

Commissioners may request a random sample of patient records where a review has been documented, to check that the principal areas of care were addressed.