Domain 3 – Psychological needs


This domain is about mood and is linked to cognition and communication.  It is about how that mood impacts on the person overall, as it can have an effect on their general health both directly and indirectly.


There are 2 basic routes that relate to this domain.  One route is about “withdrawal” from engagement of care.  The easiest way to think of this route relates to all people, we all have bad moods when something goes wrong & don’t want to talk about it.  That mood of not wanting to talk can be stronger than just talking and we hide away from things or it can last for 10 minutes whilst we process the situation.  This is the scenario in the Decision Support Tool, so it is a question of how long the withdrawal lasts and what aspects of life (& the provision of care) does it impact upon.  Someone severely depressed is likely to not be in a motivated mood to want to take care of themselves, so they don’t eat well or engage in society etc.


In order to make a choice to neglect, an individual needs to have sufficient mental capacity to self neglect, so this route is only really available to people who retain the requisite mental capacity to “choose” to self neglect.  Mental health issues are serious and not a “choice” as such, someone with a clinical depression cannot just pull themselves together, but nevertheless they do have the cognitive mental capacity to begin the process of recovery via whatever therapy is going to work for them, but only when they are ready for it.  On occasions I have met assessors who will use this route for someone cognitively impaired and I would never try to sabotage the meeting by saying that I thought they were overscoring, even though the argument is usually rejected by the Panel, so when it happens, I just let the scoring stand, but this is normally considered overscoring or double scoring.  They would have scored well in the cognition domain in respect of their cognitive impairment, so could not score again in the psychological domain.


The other route of scoring is their anxiety and if a person is anxious, how this impacts on their health.  We can all be a little nervous about something from time to time, when we don’t eat well or sleep well.  This lack of sleep and either over or under eating or eating the wrong kinds of foods can have an overall impact on our health if it happens to us.  This is the scenario with this anxiety route, but eating and sleeping are not the exclusive ways that this can manifest.  So the question is therefore is someone anxious and if they are, what is the overall impact on their general health and wellbeing?


Although this is a generalisation, as people become cognitively impaired and understand that they are cognitively impaired, they get distressed at their loss of faculties, they can become for example tearful and/or agitated.  As their cognitively impairment progresses, they can become calmer, as they don’t know that they don’t know.  In my experience, most late stage dementia clients I have had, have been relatively calm.  Occasionally they can have issues about the invasion of their personal space, which has to happen multiple times a day with the provision of their care, including pad changing, position changing and feeding, but these resolve when the intervention ceases.  This is tough for them, as they have a series of incidents multiple times a day, every day, where they are having people interfere with them when they don’t want it, but from the carers perspective, they are providing essential care!


On very rare occasions and I have met late stage dementia clients who still demonstrate agitation.  I attended a meeting where the individual involved was described as “internally agitated” and it seemed a brilliant description of what was going on.  I’ve used it in every case that I’ve come across since then, as it seems to fit.  There are however, very few cases where this is relevant.


Psychological needs links to cognition, as if someone is severely depressed it can present as cognitively impaired.  When and if they are given some anti-depressants to stabilise the chemical imbalance in their brains, they can appear to cognitively improve.  It is linked also to communication, as if the person is too depressed to eat or sleep, they are probably also too depressed to talk.  Severe depression should warrant a full assessment by a psychiatrist and medication may be only part of the package of support that the individual might benefit from.