Get Help Breaking Down the Decision Support Tool: Cognition, Part 2
This series takes a detailed look at the domains of the Decision Support Tool. This week we examine the second three descriptors in the Cognition domain, to help you assess your or your relative’s “level of need” in this important domain.
Don’t miss parts one to thirteen of this series!
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
Get Help Breaking Down the Decision Support Tool: Psychological & Emotional Needs
Get Help Breaking Down the Decision Support Tool: Cognition, Part 1
Last week we looked at the Cognition domain in Part 1, and the first two descriptors – ‘No Needs’ and ‘Low’ needs. Catch up with Cognition, Part 1 if you missed it!
In Part 2, we’ll examine the descriptors for ‘Moderate’, ‘High’ and ‘Severe’ needs in this important domain.
The following clinical factors are relevant to the assessment of needs in this domain:
- Does the person experience short-term memory issues?
- Do they experience long-term memory issues?
- Do they know where they are (orientated to place)?
- Do they know what day and time it is (orientated to time)?
- Do they suffer day-night reversal (sleeping in the day, awake at night)?
- Do they know who the people around them are (orientated to person)?
- Do they recognise their family members (orientated to person)?
- Are they aware of risks in their environment?
- Are they aware of their own limitations and need for assistance?
- Are they able to use the call bell or otherwise summon assistance?
- Are they able to express their needs and wishes?
- Are they able to follow instructions (e.g., personal care)?
- What is their score on the Mini Mental State Examination (MMSE)?
*REMEMBER – A great many people who require 24-hour care in a residential or nursing home are living with some type of dementia or cognitive impairment. The majority of individuals we assess for CHC funding meet the descriptor for ‘High’ or ‘Severe’ needs in the Cognition domain, requiring full assistance to meet their Activities of Daily Living and maintain a safe environment. Unless there are significant additional factors which increase the time and/or skill required to meet those needs – e.g., challenging behaviours, swallowing difficulties, pressure sores, pain – this does not amount to a primary need for healthcare. Eligibility for CHC funding is defined by the quality and quantity of care interventions required to meet the assessed needs, not by any one diagnosis or condition.
Now that we’ve outlined the type of things the Multi-Disciplinary Team (MDT) will be considering in this domain, let’s take a look at the descriptors for the ‘Moderate’, ‘High’ and ‘Severe’ 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.
MODERATE
| Cognitive impairment (which may include some memory issues) that requires some supervision, prompting and/or assistance with basic care needs and daily living activities. Some awareness of needs and basic risks is evident. The individual is usually able to make choices appropriate to needs with assistance. However, the individual has limited ability even with supervision, prompting or assistance to make decisions about some aspects of their lives, which consequently puts them at some risk of harm, neglect or health deterioration. |
| Key Factors
Short-term memory loss Usually orientated to time, place and person with some support Requires prompts, supervision and assistance to meet daily needs safely Retains some awareness of risks and limitations Able to indicate some needs and preferences Able to make simple daily choices – e.g., clothing, meals Requires assistance with complex decisions – e.g., finances May be prescribed a cognitive enhancer, e.g., Memantine |
CASE STUDY – MODERATE
Mrs. X has a diagnosis of dementia; her cognitive ability appears to be variable. There has been no formal capacity assessment since admission to the care home. The care home staff were unable to confirm if a DOLS application has been made. Her daughter is currently going through the application process for Lasting Power of Attorney.
The care home staff and family agree that Mrs. X is able to make basic decisions and at times some bigger decisions, but she would tend to discuss bigger decisions with her daughter. Her daughter reports that her decisions and conversations are rational. Mrs. X’s family have given examples that her short-term memory can be poor – she is unable to recall what she has eaten for lunch shortly after she has eaten – but is aware she has eaten.
Mrs. X can be repetitive in conversation and has got family mixed up, thinking her grandson was her son. She recognises her family but not individual care staff; we did discuss how the impact of staff wearing masks can affect this.
Mrs. X is not aware of the detail of where she is but is aware she is not at home and not in hospital; her daughter has explained to her that she is not unwell enough to be in hospital but not well enough to be at home and feels she understands this.
Mrs. X has some basic risk awareness; staff report she would test the temperature of a hot drink before consuming it but at times she will attempt to mobilise without her Zimmer frame placing her at high risk of recurring falls.
Mrs. X presents with a ‘MODERATE’ level of need as she has cognitive impairment (which may include some memory issues) that requires some supervision, prompting and/or assistance with basic care needs and daily living activities. Some awareness of needs and basic risks is evident. She is usually able to make choices appropriate to needs with assistance. However, she has limited ability even with supervision, prompting or assistance to make decisions about some aspects of her life, which consequently puts them at some risk of harm, neglect or health deterioration.
HIGH
| Cognitive impairment that could, for example, include frequent short-term memory issues and maybe disorientation to time and place. The individual has awareness of only a limited range of needs and basic risks. Although they may be able to make some choices appropriate to need on a limited range of issues they are unable to consistently do so on most issues, even with supervision, prompting or assistance. The individual finds it difficult even with supervision, prompting or assistance to make decisions about key aspects of their lives, which consequently puts them at high risk of harm, neglect or health deterioration. |
| Key Factors
Severe short-term memory loss Long-term memory generally intact May be disorientated to time, place and/or person but can be reorientated Usually able to recognise family members May experience day-night reversal (sleeping during the day, awake overnight) Limited awareness of risks and limitations, requiring close supervision May be able to indicate some basic needs and preferences Able to make some basic choices with support – e.g., clothing, meals Unable to make complex decisions – e.g., finances Cognitive ability may fluctuate May be prescribed a cognitive enhancer, e.g., Memantine |
CASE STUDY – HIGH
Mr. X has a diagnosis of Parkinson’s disease and is currently awaiting investigations regarding the possibility of Lewy Body dementia. He is noted to have impaired insight into his care needs and is disoriented to time and date, but retains orientation to place and person most of the time. He is usually able to recognise familiar carers, family and friends and can make some simple day-to-day decisions about care needs and preferences. However, he does experience episodes of confusion and disorientation. During these episodes, he lacks insight into needs and cannot communicate needs or preferences to staff – necessitating that they deliver care in his best interest to ensure his needs are met. It is difficult to ascertain any particular pattern to episodes of confusion with him previously being documented to be more confused in the evening, but in the daily records appearing to be more confused first thing in the morning.
Mr. X also exhibits impaired risk awareness resulting in him getting up and mobilising independently without assistance from staff despite being at high risk of falls. He lacks insight into his limitation in the context of his mobility and staff are documented to ensure that his walking frame is left out of his sight when he is unattended for any period of time in order to reduce the risk of him attempting to get up.
Mr. X does appear to retain some awareness of needs and is able to make some simple decisions about choices and preferences. Similarly, his impaired risk awareness appears to be episodic rather than a persistent state.
Mr. X presents with a ‘HIGH’ level of need as he experiences frequent short-term memory issues and maybe disorientation to time and place. He has awareness of only a limited range of needs and basic risks. Although he may be able to make some choices appropriate to need on a limited range of issues, he is unable to consistently do so on most issues, even with supervision, prompting or assistance. He finds it difficult even with supervision, prompting or assistance to make decisions about key aspects of his life, which consequently puts him at high risk of harm, neglect or health deterioration.
SEVERE
| Cognitive impairment that may, for example, include, marked short or long-term memory issues, or severe disorientation to time, place or person.
The individual is unable to assess basic risks even with supervision, prompting or assistance, and is dependent on others to anticipate their basic needs and to protect them from harm, neglect or health deterioration. |
| Key Factors
Severe short-term memory loss Long-term memory also impaired Severely disorientated to time, place and person; cannot be reorientated Usually does not recognise family members No awareness of risks and limitations No insight into needs or condition Unable to express needs or preferences; all needs anticipated Unable to make simple choices, even with full support Scores less than 10/30 on the MMSE Cognitive enhancers have been discontinued as no longer beneficial |
Mrs X has a diagnosis of vascular dementia and has significant cognitive impairment as a result. She is disorientated to time place and person and is completely unaware of her care needs. She scored 6/30 on a recent Mini Mental State Exam (MMSE). She appears to have no recognition of staff or family members.
Mrs. X’s short- and long-term memory is impaired and she has no insight into her needs and limitations. She is completely dependent on staff to anticipate all her needs for her and to deliver necessary care in her best interests.
Mrs. X has no awareness of even basic risks and is dependent on staff to identify and mitigate risks in her best interest, and to maintain a safe environment.
Mrs. X presents with a ‘SEVERE’ level of need as she has cognitive impairment that may, for example, include, marked short or long-term memory issues, or severe disorientation to time, place or person. She is unable to assess basic risks even with supervision, prompting or assistance, and is dependent on others to anticipate her basic needs and to protect her from harm, neglect or health deterioration.
For further reading around the subject look at this selection of blogs from our Care To Be Different website:
My Dad Has Dementia – So Will He Automatically Qualify For CHC Funding?
Essential: Have You Got A Power Of Attorney
Tackling consent: Keeping control if your relative lacks mental capacity.
Denied access because you don’t have the necessary legal authority to act for your relative?
We hope this has helped you to understand the descriptors in the Cognition domain. Don’t miss the next part of this series, Behaviour, coming very soon!
If you need help assessing your relative’s level of need in any domain on the DST, don’t hesitate to get in touch 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.
Don’t forget to take a look at our informative guide book How to Get the NHS to Pay for Care which is available as an email PDF or in paperback.
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.
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