Personalized Goal Attainment in Dementia Care: Measuring what persons with dementia and their caregivers want

Abstract

Background/Objectives

Current outcome measures for Alzheimer’s disease and other dementias do not incorporate personalized health goals, and personalized goal-setting could be used to help patients obtain what is important to them. Little is known about whether goals that persons with dementia and their caregivers value can be elicited and measured in clinical care. We developed a process of goal-setting and measurement of goal attainment in a dementia care management program.

Design

Observational

Setting

Dementia care management program in an urban, academic medical center

Participants

One-hundred one persons with dementia and their caregivers; 5 nurse practitioner dementia care managers

Intervention

Specification of a personalized health goal and action plan and measurement of goal attainment using goal attainment scaling in a clinical care visit

Measurements

Goal attainment at 6 and 12 months; focus groups of 5 dementia care managers

Results

Eighty-four percent of participant goals were nonmedical, 47% were related to quality of life, and 29% were caregiver support goals. Most participants felt the goal they set was meaningful (88%), felt the goal-setting process captured something different from usual care (74%), and found the process helpful in planning for future care (85%). At six months, 74% of dyads had achieved or exceeded their expected level of goal attainment. Dementia care managers expressed that the goal-setting process improved their understanding of what was most important to the patient, helped set expectations about disease progression and care needs, and provided positive reinforcement when goals were accomplished and an opportunity for revision when goals were not met.

Conclusions

Goal setting using goal attainment scaling can be incorporated into the care of persons with dementia to establish and attain patient-centered goals. Research is needed to further develop personalized goal attainment as an outcome measure for dementia care.

INTRODUCTION

Health outcome measures for incurable chronic diseases, including Alzheimer’s disease and related dementias, have focused on survival, condition-specific indicators, symptom control, and general health-related quality of life.¹ These outcomes are “universal” goals that most people with a long life expectancy and who are free of multiple co-morbidities would want. However, these goals may not be possible or desired by persons with dementia. Thus, measures are needed to capture the success or failure in meeting an individual’s health goals when traditional outcomes are not possible or may not address what is most important.

Dementia is usually a long-term disease, with median survival of four to ten years.² During this time, goals and potential to achieve them may change. Early on, the goal may be to preserve function, including the ability to work. As the disease progresses, goals may shift to maintaining mobility, controlling neuropsychiatric symptoms, reducing caregiver strain, and eventually ensuring a dignified death. Thus, medical care decisions should be considered within the context of the stage of the disease and the individual’s goals and preferences and the trade-offs required to achieve them.

Goal attainment scaling (GAS) is one method to specify personal health goals and measure their attainment. Researchers have been using GAS for decades^, to measure the effect of interventions primarily in mental health³ and clinical rehabilitation,^4,5 but also in comprehensive geriatric assessment^6–9 and Alzheimer’s disease.^10,11 The aim of this study was to apply GAS in the clinical care of persons with dementia to elicit, specify, measure attainment of, and revise personalized goals for care. Understanding the feasibility of using GAS in a clinical setting is a first step in improving its application for dementia care quality improvement efforts and research.

METHODS

Overview

We developed and implemented a process of goal setting and measurement of goal attainment using GAS in a dementia care management program. In phase 1, we refined the goal setting process with 32 dyads of persons with dementia and their caregivers and trained 5 nurse practitioner dementia care managers (DCMs) in GAS. In phase 2, DCMs led 101 persons with dementia-caregiver dyads in goal specification using a 5-category goal attainment scale. Goal attainment was measured at 6 and 12 months. Dyads revised goals or set new goals at 6 months, if desired. Structured interviews with dyads and focus groups with DCMs were conducted to explore the process and value of goal setting and measurement using GAS in a dementia clinical care setting.

Setting and Participants

Participants were recruited from the UCLA Alzheimer’s and Dementia Care (ADC) program,¹² a dementia care management program based in an urban academic health system. The program uses nurse practitioners partnered with primary care providers and community-based organizations to address the comprehensive care needs of persons with dementia and their caregivers. Study participants were required to have a diagnosis of dementia and to have family or friend caregiver who was willing to participate in the study and enroll as a dyad. There were no other inclusion criteria.

Phase 1

Goal Inventory Field Testing

We administered a 41-item goal inventory¹³ to 32 dyads to assess feasibility of use and refine the inventory. In six dyads, the person with dementia had early stage disease (MMSE score ≥23). Dyads were asked to rate the importance of each goal over the next 6 months using a 4-category response scale (not at all important to extremely important) and to rank order the three goals most important to them. Dyads were asked to consider both the person with dementia’s and caregiver’s preferences when rating and ranking goals together. If important goals were not included on the inventory, they were asked to write them in.

Goal Attainment Scaling Instrument and Training Dementia Care Managers

Eleven dyads in Phase I completed GAS with their DCM for the one goal they identified as most important to attain over the next 6 months. The goal scaling was reviewed by study investigators (LJ, DR, NW, RH) using the SMART goal criteria (specific, measurable, attainable, relevant, time-bound).¹⁴ Investigators also examined whether the goal scaling represented clinically meaningful change across levels, if scaling was precisely described at each level, and if a baseline performance level was identified.¹⁵ Baseline performance level was defined as the less than expected (−1) outcome for participants who identified a goal to improve the current state (e.g., reduce falls) and was defined as the expected (0) outcome for participants who identified a goal to maintain the current state (e.g., continue to exercise daily). Defining the baseline performance level in this way allowed the scaling to accommodate persons who wished to set goals to improve a current health state as well as those who wanted to maintain a current state. DCMs participated in two one-hour training sessions where they received instruction in using GAS from study investigators (LJ, NW, DR) and role played GAS with clinical scenarios.

Phase 2

Data collection and study visit procedures

In phase 2, DCMs assisted 101 dyads in goal specification using GAS and goal attainment at 6 and 12 months was measured. The primary outcome was goal-attainment at 6 months. Baseline study visits occurred in-person as part of an annual ADC program visit, and 6- and 12-month telephone follow-ups were completed by a research assistant. Follow-up visits were completed within a 1-month window around the 6- or 12-month date.

During the baseline study visit, DCMs reviewed the top three goals identified by the dyad using the goal inventory and completed GAS for the one goal identified by the dyad as most important to attain over the next 6 months. After completing GAS, DCMs were encouraged to add an action plan to assist participants in articulating the steps needed to achieve the goal. The scaled goal and action plan were provided to participants at the conclusion of the visit.

DCMs also rated their perception of how difficult the goal would be to attain using a 4-category response scale (not at all difficult to extremely difficult). Structured interview questions about the goal setting process were also completed with dyads at 6- and 12-month follow-up visits

Eleven new goals proposed by participants during both phases were independently coded by four study investigators (LJ, DR, RH, NW), grouped into goal domains, and added to the inventory (Supplementary Appendix S1). Disagreements in coding were discussed among study investigators and settled by group consensus.

Assessment of Goal Attainment

At 6- and 12-month follow-up visits, participants reviewed the goal identified as most important at the baseline visit and discussed progress toward meeting the goal over the prior 6 months. Dyads were shown their personalized GAS and asked to rate their goal attainment using the 5-category response scale (much less than expected (−2), less than expected (−1), expected level of goal attainment (0), better than expected (+1), much better than expected (+2)).

At 6 months, dyads chose whether they wanted to continue to work on the same goal, revise the scaling of their goal, or choose a different goal to work on for the next 6 months. For dyads who wanted to revise their goal at 6-months, a second telephone visit with their DCM was scheduled to do this.

Statistical analyses

Frequencies or means and standard deviations were used to summarize participant demographic characteristics. The Mini Mental State Exam (MMSE),¹⁶ an inventory of basic activities of daily living (ADLs),¹⁷ Neuropsychiatric Inventory Questionnaire (NPI-Q),¹⁸ and Modified Caregiver Strain Index (MCSI)¹⁹ were also completed with each dyad as part of a routine ADC visit.

Goal attainment at 6 months was first examined as a 5-category ordinal scale and was then dichotomized (yes/no), defined as a score of 0, +1, +2 (yes) versus a score of −1 or −2 (no).

Bivariate statistics (two-sample t-test, chi-square test, and Fisher’s exact test) were used to examine whether goal attainment at 6 months differed by DCM, goal difficulty rating, goal type (caregiver support goals vs. goals in other categories), dementia stage (defined using baseline MMSE score), baseline ADL score, baseline NPI-Q symptom severity score, baseline MCSI score, caregiver relationship, and whether the caregiver lived with the person with dementia. We used the Benjamini-Hochberg procedure²⁰ for multiple comparisons with a false discovery rate of 0.10. Given the small sample sizes, subgroup analyses were not powered for hypothesis testing and thus were considered exploratory.

Qualitative analyses of structured interviews and focus groups

Responses from structured interview questions about the goal setting process completed with dyads at 6- and 12-month follow-up visits were classified as yes/no or into categories. Study investigators (LJ, DR, RH, NW) reviewed any qualitative comments provided by participants during the interviews, supplemented by audio-recordings if clarification was needed. Interview questions are in Table 3.

Table 3:

Dyad Perceptions of the Goal Setting Process

	6 months, N=86	12 months, N=54
	N (%)
	Yes
Was it difficult for you to rate and rank the importance of goals?	34 (40%)	15 (28%)
Was thinking about goals helpful to you in planning for future care?	73 (85%)	45 (83%)
Did the goal-setting process get at something that is different from usual medical care?	64 (74%)	41 (76%)
Do you feel that the goal you set is meaningful?	76 (88%)	50 (93%)
Would you have preferred to work on more than one goal?	41 (48%)	26 (48%)
Was your DCM the right person to discuss your goals with?	82 (95%)	45 (83%)
	About right
Was the time you spent talking about your goal with your DCM too short, too long, or about right?*	73 (85%)	48 (89%)
Was the timeframe of 6 months to attain your goal too long, too short, or about right?**	68 (79%)	39 (72%)
		Yes
Since enrolling in the study, have you discussed your goal with another health care provider?		31 (57%)
Since enrolling in the study, have you discussed your goal with your family or friends?		38 (70%)
Will you continue to work on your goal after the study?		45 (83%)

DCM=Dementia Care Manager

^*Few respondents indicated that time spent talking about their goal with their DCM was too short (N=7 (8%) at 6 months and N=2 (4%) at 12 months. No respondents indicated that the time spent talking about their goal with their DCM was too long at either time point.

^**Few respondents felt 6 months was too short a time to attain their goal, N=4 (5%) at 6 months and N=8 (15%) at 12 months. Similarly, few respondents felt 6 months was too long a time to attain their goal, N=8 (9%) at 6 months and N=2 (4%) at 12 months.

Item level response rates at 6 months range from 93–100% (N=80–86 for each item). Item level response rates at 12 months range from 91–100% (N=49–54 for each item).

We conducted two focus groups with five DCMs to understand the process and clinical value of using GAS to set goals and measure their attainment in a dementia care clinical setting. The first focus group guide was developed from DCM experiences in phase 1. After completing analyses from the first focus group (conducted at the mid-point of Phase 2), the guide for the second focus group (conducted at the study end) was created to allow exploration of emerging themes. (see Supplementary Appendix S2 for focus group guides). Focus groups were approximately 60 minutes, audio-recorded, and transcribed verbatim. Transcripts were independently coded line-by-line by two study investigators (LAJ and DBR) using both deductive (a priori) and inductive (emerging from the data) coding approaches^21–23 to develop a coding scheme. Emerging themes and exemplary texts were discussed among the full study team and any differences in coding were settled by group consensus.

The institutional review board at the University of California, Los Angeles, approved this study (IRB#14–001228).

RESULTS

A total of 133 participants with dementia (Phase 1, n=32 and Phase 2, n=101) ranged in age from 51 to 100 years old, 65% were female, 30% were racial or ethnic minorities, and the mean MMSE score was 15.8 (SD 7.8). Caregivers were largely spouses (32%) or children (57%) and most lived with the patient (70%). The mean MCSI score was 10.2 (SD 6.0, range 0–26), indicating moderate strain on average (Table 1).

Table 1:

Participant Characteristics, N=133

	M (SD) or N (%)
Patient
Age, range 51–100 years	83.4 (9.2)
Female	86 (65%)
Race/Ethnicity, N=101
Hispanic	15 (15%)
Black, non-Hispanic	19 (19%)
White, non-Hispanic	61 (60%)
Asian	3 (3%)
Other	3 (3%)
Primary language not English	20 (15%)
Marital Status, N=112
Married/living with partner	43 (38%)
Widowed	51 (46%)
Divorced/separated/single	18 (16%)
Education, N=112
Some high school or less	25 (22%)
High school graduate	20 (18%)
Some college or college graduate	44 (39%)
Graduate school	23 (21%)
Mini Mental State Exam (MMSE) score, range 0–30, N=112	15.8 (7.8)
Basic Activities of Daily Living (ADLs) performed independently, range 0–6, N=86, Median (IQR)	4 (2, 6)
Neuropsychiatric Inventory - Questionnaire (NPI-Q) symptom severity score, range 0–36, N=99	10.1 (6.4)
Caregiver
Relationship
Spouse	43 (32%)
Child	76 (57%)
Other	14 (11%)
Lives with patient, N=107	75 (70%)
Age, range 37–99 years, N=88	62.3 (13.5)
Female	98 (74%)
NPI-Q caregiver distress score, range 0–60, N=98	11.8 (9.4)
Modified Caregiver Strain Index Score, range 0–26, N=91	10.2 (6.0)

Some ADC programmatic data are incomplete because some forms were not completed during the clinical visit. If the MMSE score was missing (N=29), the prior year’s score was used.

Most goals were nonmedical (n=112, 84%). Goals relating to improving the quality of life of the person with dementia were most commonly selected (by 47%, n=62), followed by caregiver support goals (n=39, 29%). Commonly chosen goals relating to the person with dementia included physical safety (n=20), continuing to live at home (n=11), receiving medical care related to dementia (n=8), avoiding hospitalization (n=7), mental stimulation (n=6), and physical activity (n=6). Commonly chosen caregiver goals included maintaining the caregiver’s own health (n=15), managing stress (n=7), and minimizing family conflict related to dementia caregiving (n=5). There was great diversity of goals with 34 different goals chosen from the inventory. There was no clear pattern to goal selection by cognitive status as assessed by the MMSE.

Examples of goals and how they were scaled by participants in phase 2 (n=101) are presented in Table 2. Eighty-six participants (85%) completed a 6-month follow-up visit, and 54 participants (53%) completed a 12-month follow-up visit. (Figure 1)

Table 2:

Examples of Scaled Goals

Goal Categories	Goal Description	Attainment Levels					Action Plan
		Much less than expected	Somewhat less than expected	Expected	Somewhat better than expected	Much better than expected
Medical Care	Less burdensome medical care. Fewer health care visits and pain better controlled.	Hospital admission	7 health care visits per month and no change in pain level (current state)	4–5 health care visits per month and no change in pain	Reduced pain and 4–5 health care visits per month	Pain-free and 4–5 health care visits per month	Discuss pain management with PCP; refer to pain clinic. Telephone visits with DCM.
Physical Quality of Life	Improve safety by reducing falls.	>4 falls in 6 months or fall with injury	4 falls in last 6 months, no injuries (current state)	2–3 falls in next 6 months, no injuries	1 fall in next 6 months, no injuries	No falls, no injuries in next 6 months	Physical therapy, walker, nightlight, evening caregiver.
Social/ Emotional Quality of Life	Keep Mom’s mind stimulated	Not participating in any activities; stops watching movies.	Watches TV and movies at home. Doesn’t get out. (current state)	1 activity outside home once per week + more in-home activities with caregiver.	Activities outside home >1 day per week + more in-home activities with caregiver.	Activities outside home daily + more in-home activities with caregiver.	Hire caregiver more knowledgeable about dementia who can take Mom to outside activities.
Accessing Services	Legal and financial affairs in order.	Legal or financial problem occurs.	No DPOA established. (current state)	Establish DPOA for finances.	Establish DPOA for finances, have understanding of accounts, taxes, and mortgage.	No legal concerns about finances.	Patient and son will attend legal clinic. DCM provided elder law attorney information.
Caregiver Support	Maintain caregiver’s own health	Unable to maintain daily exercise; cooking at home less (diet worse).	Unable to maintain daily exercise	Daughter walks 1.5 miles daily. (current state)	Add floor exercises to routine and make diet changes.	Walk daily, floor exercises, change diet, and follow-up with own doctor.	Daughter will explore resources provided by DCM to expand hired caregiver hours to use during exercise.

Current state denotes baseline performance level.

PCP=primary care provider; DCM=dementia care manager; DPOA=durable power of attorney

Figure 1. Flow of Participants (Phase 2).

*One participant did not complete a 6-month follow-up visit but did complete a 12-month follow-up visit.

At 6- and 12-months, 74% of participants (n=64 and n=40, respectively) achieved or exceeded their expected level of goal attainment. (Figure 2) Almost all goals selected were rated as extremely (83%) or very important (13%) by the dyad, and most goals were rated as a little (43%) or moderately difficult (32%) by DCMs. Only 11 participants (13%) revised the scaling of their goal or chose a new goal at 6 months.

Figure 2.

Goal Attainment at 6 and 12 months

Baseline median ADL score was higher (more independent) among those who attained goals at 6 months compared to those who did not: 4.0 (IQR 2,6) vs. 2.5 (IQR 1, 4) (Wilcoxon rank-sum, z= −2.33, p=0.02). However, this was not significant after correction for multiple comparisons. Goal attainment did not differ by other participant characteristics, DCM, or goal difficulty or category.

Table 3 shows the perceptions of persons with dementia and their caregivers of the goal setting process using GAS. At six months, 40% of respondents indicated that it was difficult to rate and rank the importance of goals, while fewer reported difficulty at 12 months (28%). At 6 months, most rated the goal setting process as valuable with 85% reporting goal setting was helpful for planning for future care; 74% felt that the process got at something different from usual medical care; and 88% regarded the goals they set as meaningful. About half (48%) would have preferred to work on more than one goal. Participants (95%) felt that the DCM was the right person with whom to discuss goals, and most (79%) felt that a timeframe of six months to obtain their goals was about right. At 12 months, about half (57%) had discussed their goals with another healthcare provider, and most (70%) had discussed goals with family members. Eighty-three percent planned to continue to work on their goal.

In focus groups, DCMs expressed that the goal-setting process improved their understanding of what was most important to their patients and identified goals they might have otherwise missed.

“The times that it was most helpful for me was when I was surprised by their goal. When it was something I didn’t find out in an annual visit…”

“It was valuable for me because it told me what my patient’s goal was and it might have been different from mine. If it (the goal) was in a different direction, maybe I should be looking at their direction more than mine.”

They identified as challenging situations when patients or caregivers chose goals they felt were clinically unrealistic (e.g., drive a car again) or very difficult to achieve (e.g., live at home without caregivers). They also reported that the GAS process helped set expectations about disease progression and care needs for patients and caregivers.

“Sometimes their goal was way off base, in regards to what we can do, and that was helpful to know…her goal was to go to Paris next year and see the Eiffel Tower with her father, but he’s in a nursing home...It was helpful for me to see how much I needed to manage their expectations. It was helpful to have an organized way to get that information.”

DCMs also expressed value in revising goals with patients and caregivers when a goal was not attained.

“If they didn’t quite get what they wanted after 6 months, they were better prepared to have that (goal-setting) conservation at 6 months because they realized that it was a lot harder to make it to support groups, or to go to the gym, or to hire that caregiver than they thought it was going to be. Then their expectations changed, not only of themselves, but also of the situation. I looked at it as valuable instead of looking at it as a failure—for us to see why this didn’t work and then figure out how we can make it more appropriate.”

DCMs thought the GAS process empowered caregivers who did not feel confident in their decision-making and provided positive reinforcement to caregivers and patients who were able to accomplish some part or all of their goals.

“Caregivers have a lot to say and a lot of concerns, and the typical provider is not going to (ask)…’what do you want.’ So they appreciated that… adding goals could be a way to let them know they are being heard.”

“Working through the goal gave the patient or caregiver some feeling of accomplishment and power.”

Some patients and caregivers had difficulty completing the extremes of the GAS scale (much worse or much better than expected), and DCMs suggested a 3-point scale as an alternative for some patients.²⁴

DCMs reported the GAS process added about 15 to 20 minutes to their clinic visit, on average.

DISCUSSION

This study is proof of concept that GAS can be used in the clinical care of persons with dementia to elicit, specify, measure attainment of, and revise personalized goals for care. We used GAS to facilitate the process of making a personalized goal actionable or SMART,¹⁴ and as a measurement tool, allowing the standardized assessment of goal attainment across the study cohort at 6 and 12 months. Most goals identified by persons with dementia and their caregivers were not related to medical care; instead, they focused on broader aspects of quality of life or caregiver support. While most people had attained their goals at follow-up, approximately one-fourth did not, demonstrating that this approach can capture failure as well as success in meeting outcomes. About 10% of participants wanted to revise their goals at follow-up, which is particularly important in dementia as goals may evolve as the disease progresses. Most participants and dementia care managers found the goal setting process valuable and felt it captured something different from usual medical care.

Our findings have important implications for the clinical care of persons with dementia and may be applicable to persons with other advanced illnesses and multiple morbidities. By focusing on goals that are important to patients, the success or failure of health care interventions can be explicitly evaluated. Personalized goal attainment might be used to measure the quality of care provided or to evaluate models of dementia care management or care management for other conditions.²⁵ However, to do so requires the specification of goals and how meeting them would be operationalized.

Many of the goals identified (e.g., low caregiver strain, ensuring safety, living at home) are generally applicable for persons with dementia and their caregivers. However, what it meant to achieve these “universal” outcomes¹ was often very individualized. For example, one caregiver defined safety as avoiding falls while another defined safety as preventing wandering. Goal attainment scaling can accommodate such diverse preferences within the context of achieving an overall goal (e.g., patient safety). Moreover, there were trade-offs even among these commonly desired health outcomes (e.g., a child accepting a more intensive caregiving role to avoid long-term nursing home placement of a parent). While some of the goals identified were similar to existing patient-reported outcome measures (PROMs) (e.g., functional status), other goals were more idiosyncratic and not well captured in existing measures (e.g., attending a family reunion). GAS allows these person-specific goals to be measured as important outcomes.

The goals identified in this study and compiled in the final inventory confirm and extend prior work examining care preferences among persons with dementia and their caregivers.^26–30 The similarity of values articulated across studies underscores the need to measure patient-centered outcomes within these domains.

Although this study was successful at showing proof-of-concept, there are practical barriers to the wider use of GAS in clinical settings. Provider and health system barriers include visit time constraints, a culture of disease-specific outcomes and cure, and a workforce unprepared to use GAS. If the GAS discussion required 20 minutes, based on the national median nurse practitioner salary ($104,000)³¹ plus 40% benefits, the intervention would cost approximately $25 per participant. There are also patient and caregiver barriers to implementation, including unrealistic goals (e.g., reverse cognitive impairment), and situations where the goals of the patient and caregiver do not align (e.g., autonomy vs. safety). This study begins to address some of these limitations by showing that it is feasible to use GAS in an outpatient dementia care setting. We also used a goal-setting process that involved a dyad (the person with dementia and caregiver), as achieving the patient’s goal is often dependent upon caregiver support. The process of goal-setting as a dyad also facilitated discussion between persons with dementia and their caregivers about the person’s values and care preferences, which could be used to guide the caregiver in future decision-making.

While GAS has been widely used in clinical rehabilitation studies,^4,5 there has been less research using GAS in persons with cognitive impairment.^10,11 To further develop goal attainment as a rigorous outcome measure in dementia research,¹⁵ future work should compare goal attainment to other patient-reported outcome measures (PROMs), where available, to examine the construct validity of goal attainment as an outcome. For example, the attainment of a personalized goal to reduce caregiver stress might correspond to a decrease in an index of caregiver burden. The small sample size in this study limited comparisons to PROMs. Future research should also examine whether the process of goal-setting changes care delivery and whether or not care received is aligned with patients’ articulated goals.

When interpreting these findings, the limitations of the study should be considered. This study used GAS in a single dementia care management program in an urban community-dwelling population. Thus, these findings may not be applicable to some other dementia care settings. Additionally, GAS was performed with nurse practitioners and these findings may not translate to other types of care providers such as physicians or social workers. The study also included only a small number of participants with early stage dementia (N=23, 17%); thus, the goal-attainment data largely reflects caregiver input as most participants’ cognitive impairment was too advanced to participate in rating goal-attainment at follow-up. Small sample sizes also limited the robustness of comparisons of goal attainment among different subgroups.

The findings of the study suggest that goal setting and goal attainment scaling can be incorporated into clinical care of persons with dementia and used as an outcome measure. Further research on the use of GAS in dementia cohorts and comparisons with other patient-reported outcome measures should be performed to further develop personalized goal attainment as a useful outcome measure for both clinical care and dementia research.

Impact Statement.

We certify that this work is novel. This work adds to the literature by describing the use of goal attainment scaling in the clinical care of persons with dementia to elicit, specify, measure attainment of, and revise personalized goals for care. The findings of the study are proof of concept that goal setting using goal attainment scaling can be incorporated into the care of persons with dementia to establish and attain patient-centered goals.