This series takes a detailed look at the domains of the Decision Support Tool. This week we examine the descriptors in the Psychological & Emotional Needs domain, to help you assess your or your relative’s “level of need” in this important domain.

Catch up on parts one to eleven of this series below!

Get Help Breaking Down The Decision Support Tool: An Overview

Get Help Breaking Down the Decision Support Tool: Breathing Part 1

Get Help Breaking Down the Decision Support Tool: Breathing Part 2

Get Help Breaking Down the Decision Support Tool: Nutrition Part 1

Get Help Breaking Down the Decision Support Tool: Nutrition Part 2

Get Help Breaking Down the Decision Support Tool: Continence

Get Help Breaking Down the Decision Support Tool: Skin (including tissue viability), Part 1

Get Help Breaking Down the Decision Support Tool: Skin (including tissue viability), Part 2

Get Help Breaking Down the Decision Support Tool: Mobility, Part 1

Get Help Breaking Down the Decision Support Tool: Mobility, Part 2

Get Help Breaking Down the Decision Support Tool: Communication

Following the 2018 revisions of the DST, Psychological & Emotional Needs – often abbreviated as “P.E.N.” – moved from domain number three to domain number seven. It now follows Communication and precedes Cognition, highlighting the common interaction between these domains. The assessed levels of need in the P.E.N. domain range from ‘No Needs’ to ‘High’ needs. There is no descriptor for ‘Severe’ or ‘Priority’ needs in this domain, indicating that psychological & emotional needs are unlikely to present an immediate risk to life, or amount to a primary health need in and of themselves. Needs in the P.E.N. domain are important because of their impact on the overall health and wellbeing of the individual and on other domains of the DST, particularly Nutrition, Behaviour and Medications. This interrelation should always be carefully considered in the analysis of the four Key Characteristics.

In our experience, it is relatively unusual to see a ‘High’ level of need in this domain outside a specialist mental health setting. Of course, such cases do exist, but they are rare. Families often underestimate the degree of intervention required to support an assessment of ‘High’ level needs in this domain.

The following clinical factors are relevant to the assessment of needs in this domain:

• Does the person have a history of poor mental health?
• Do they continue to present with psychological symptoms – anxiety, depression, hallucinations, tearfulness, low mood, withdrawal etc?
• Are they prescribed any psychotropic medications – antidepressants, sedatives, antipsychotics etc?
• Are these medications prescribed routinely, or on an as-required basis (PRN)?
• Is the person under the care of the Community Mental Health Team (CMHT)?
• Do they require regular review by a Community Psychiatric Nurse (CPN)?
• Is a Psychiatrist involved in their care?
• When episodes of psychological distress occur, can these be assuaged by staff intervention (distraction, reassurance, comfort, medication)?
• How long do these interventions take to be effective?
• As a result of their psychological state, has the person withdrawn from life?*
• Do the person’s psychological needs have an impact on their physical health (weight loss, lack of enjoyment, inability to perform everyday tasks)?

*REMEMBER – this part of the descriptor does not relate to cognitive ability. A person with a ‘Severe’ level of need in Cognition may be unable to engage with everyday activities owing to the degree of their cognitive impairment, rather than their psychological & emotional presentation.

The DST provides the following advice to those assessing needs in the Psychological & Emotional Needs domain:

There should be evidence of considering psychological needs and their impact on the individual’s health and well-being, irrespective of their underlying condition. Use this domain to record the individual’s psychological and emotional needs and how they contribute to the overall care needs, noting the underlying causes. Where the individual is unable to express their psychological/emotional needs (even with appropriate support) due to the nature of their overall needs (which may include cognitive impairment), this should be recorded and a professional judgement made based on the overall evidence and knowledge of the individual. It could be argued that everyone has psychological and emotional needs, but this domain is focused on whether and how such needs are having an impact on the individual’s health and well-being, and the degree of support required. If an individual has a severe level of need in the cognition domain they may not be able to consciously withdraw from any attempts to engage them in care planning, but careful consideration will need to be given to any evidence of psychological or emotional needs that are having an impact on their health and well-being.

Now that we’ve outlined the type of things the MDT will be considering in this domain, let’s take a look at the descriptors for the respective levels of need. For each level of need, we provide a case study to give you a better understanding of how the descriptors might be applied at your or your relative’s assessment.

NO NEEDS

Psychological and emotional needs are not having an impact on their health and well-being.

Key Factors No evidence of distress psychological and/or emotional symptoms.

CASE STUDY – NO NEEDS

Mrs. X.is a cheerful lady who, despite her poor physical health, remains positive about life and continues to enjoy her hobbies – knitting, puzzles, simple tasks in the garden. She participates in the activities in the home and has made some good friends with whom she enjoys a cup of tea and a chat.

Mrs. X told me she was very happy at the care home and enjoys the company of the staff and other residents after living alone for some years.

Mrs. X is not under the care of the mental health team and is not prescribed any medications to manage psychological symptoms.

Mrs. X presents with ‘No Needs’ as psychological and emotional needs are not having an impact on their health and well-being.

LOW

Mood disturbance, hallucinations or anxiety symptoms, or periods of distress, which are having an impact on their health and/or well-being but respond to prompts, distraction and/or reassurance. OR Requires prompts to motivate self towards activity and to engage them in care planning, support, and/or daily activities.

Key Factors Evidence of some psychological and/or emotional symptoms (low mood, tearfulness, anxiety, worry, frustration). Low-dose psychotropic medication routinely prescribed. No ongoing involvement by Community Mental Health Team. Responds to attempts to assuage distress. May need some prompts to engage in daily life.

CASE STUDY – LOW

Mr. X has a diagnosis of Mixed Dementia. He presents with a disturbed sleep pattern and often wanders around the home. Zopiclone has been trialled but was not found to be particularly effective and has now been discontinued due to concerns about falls. Mr. X is subject to a Deprivation of Liberty Safeguards assessment (DOLS ) which notes his sleep pattern is disturbed. Mr. X does ask to go home but is easily distracted by carers.

Mr. X’s family describe him as a sociable gentleman prior to his dementia diagnosis.

Mr. X’s Care Plans note he has poor concentration which impacts his ability to engage in activities, although he will usually join-in with support from staff. Mr. X is noted to watch the television and enjoy some of the entertainment.

Mr. X presents as restless and unsettled at times and this appears to have increased following his move to the nursing home. Staff use distraction and reassurance, which are usually effective in resolving episodes of distress.

Mr. X is not prescribed any mood enhancing medication.

Mr. X presents with a ‘Low’ level of need as he presents with mood disturbance, hallucinations or anxiety symptoms, or periods of distress, which are having an impact on his health and/or well-being but respond to prompts, distraction and/or reassurance.

AND

He requires prompts to motivate self towards activity and to engage him in care planning, support, and/or daily activities.

MODERATE

Mood disturbance, hallucinations or anxiety symptoms, or periods of distress, which do not readily respond to prompts, distraction and/or reassurance and have an increasing impact on the individual’s health and/or well-being. OR Due to their psychological or emotional state the individual has withdrawn from most attempts to engage them in care planning, support and/or daily activities.

Key Factors Evidence of frequent psychological and/or emotional symptoms (low mood, tearfulness, anxiety, worry, frustration). Psychotropic medication routinely prescribed. As-required medications may be used to manage acute distress. Routine involvement of Community Psychiatric Nurse/CMHT (monthly or less) Responds to attempts to assuage distress but may take a long time and/or repeated interventions. Needs prompts and support to engage in daily life with which they may not always comply.

CASE STUDY – MODERATE

Mrs. X suffers with severe cognitive impairment and is unable to communicate in any way. She requires full assistance from staff with aspects of daily living at frequent intervals throughout the day and is unable to understand what they are doing or why. Her inability to understand staff’s intentions leads her to become increasingly agitated and restless during any intervention and results in episodes of challenging behaviour which places her and others at risk of harm.

Mrs. X is frequently noted to be very agitated or unsettled within the daily records both during or following intervention and for no apparent reason. Due to her impaired cognition and communication abilities, she is not able to understand or respond to reassurance. She does not recognise her family and thus they are not able to reassure her either. According to the nursing home staff, there are no known or documented methods of reassuring or distracting her.

The degree of impact of her anxiety, agitation and distress is difficult to ascertain due to communication and cognitive impairment; however, when observable impacts are considered, her basic needs are met with assistance from staff and there is unlikely to be sufficient evidence to indicate a severe impact on her health and wellbeing. She eats well and maintains a healthy BMI.

Mrs. X is prescribed Haloperidol on a regular basis every morning which is an antipsychotic medication used in the treatment of agitation. She is not prescribed any other mood enhancing or sedative medications to help alleviate symptoms. Mrs. X may benefit from a referral to the Mental Health Team to see if anything can be done to reduce her distress.

Mrs. X presents with a ‘Moderate’ level of need as she presents with mood disturbance, hallucinations or anxiety symptoms, or periods of distress, which do not readily respond to prompts, distraction and/or reassurance and have an increasing impact on the individual’s health and/or well-being.

HIGH

Mood disturbance, hallucinations or anxiety symptoms, or periods of distress, that have a severe impact on the individual’s health and/or well-being. OR Due to their psychological or emotional state the individual has withdrawn from any attempts to engage them in care planning, support and/or daily activities.

Key Factors Evidence of prolonged psychological and/or emotional symptoms (low mood, tearfulness, anxiety, worry, frustration) on a frequent basis. Psychotropic medication prescribed and under titration. As-required medications frequently used to manage acute distress, with varying effectiveness. Ongoing involvement of Community Psychiatric Nurse/CMHT in symptom management. Psychiatrist overseeing titration of medications. Does not respond to attempts to assuage distress. Due to their psychological symptoms, does not engage in daily life, despite prompts and support. Physical health is impacted by psychological symptoms – weight loss, insomnia, lack of self-care, attempts to self-harm.

CASE STUDY – HIGH

Mr. X has a diagnosis of Parkinson’s Disease. Mr. X experiences paranoia and both auditory and visual hallucinations; he can become extremely distressed. The nursing home records indicate that when Mr. X experiences hallucinations he requires much support and reassurance from care staff, which is often ineffective.

Mr. X is prescribed medications to manage his Parkinsonian symptoms (Madopar, Stavelo); unfortunately, these medications do commonly cause hallucinations making it difficult to achieve an effective dose. Mr. X is also prescribed Quetiapine and Sertraline to manage symptoms of agitation and depression.

Mr. X is under the care of a Psychiatrist and a CPN, who visits him every month. He was reviewed by the Psychiatrist in October, when he was noted to be significantly distressed and experiencing weight loss and insomnia. As-required Lorazepam was prescribed and has been administered with increasing frequency over recent months. The nursing home records note increased frequency and duration of hallucinations from December, with increased use of Lorazepam; on occasions this has been used multiple times during a 24-hour period. The records are suggestive of increased need for carer intervention with Mr. X being less receptive to reassurance. Mr. X was reviewed by the Psychiatrist in January and PRN Madopar was discontinued, Donepezil was to be reduced and discontinued after two weeks and a referral was made to the Community Mental Health Team.

Mr. X used to engage in activities and had good relationships with his fellow residents. However, his psychological state is such that he no longer sits in the communal areas, spending increasing amounts of time alone in his room. He often refuses meals and will close his eyes when staff try to cajole him. He is apathetic about life and expressed to the Assessor that he “wished he was dead”.

Mrs. X presents with a ‘High’ level of need as he presents with mood disturbance, hallucinations or anxiety symptoms, or periods of distress, that have a severe impact on the individual’s health and/or well-being.

AND

Due to their psychological or emotional state the individual has withdrawn from any attempts to engage them in care planning, support and/or daily activities.

We hope this has helped you to understand the descriptors in the Psychological & Emotional Needs domain.  Don’t miss the next part of this series, Cognition, coming very soon!

If you need help assessing your relative’s level of need in any domain on the DST go to our “Contact Us” page, or contact one of our specialist Advice Lines to discuss your case today. If you need expert advocacy support with any stage of your assessment or appeal, visit our 1-2-1 support page.

If there is a particular topic you would like us to cover, we’d love to hear from you! Just send an email via our “Contact Us” page with the subject “blog request” and we’ll do our best to cover your suggested topic.