Action 8.05

Be alert for signs of deterioration in a person’s mental state

Initial screening should identify people who are at risk of acute deterioration in their mental state, including patients at risk of developing delirium.

If screening identifies risk of deterioration in a person’s mental state, conduct a complete mental state examination. Mental health workers complete these routinely. Undertaking a mental state examination also forms part of the curriculum for all members of the clinical workforce.

Comprehensive assessment should differentiate among potential causes for the person’s deterioration in mental state.

Delirium can occur at any age and can be prevented. Patients aged 65 years or over, and patients with cognitive impairment (such as dementia), severe medical illness or a hip fracture are considered to be at greatest risk.¹

People who have not been identified as being at high risk can also experience deterioration in their mental state. Be alert for changes in mental state in all patients.

Use comprehensive care plans to manage patients at risk

If a person has been identified as being at high risk of acute deterioration in their mental state, conduct a comprehensive assessment as outlined in the Comprehensive Care Standard. The comprehensive care plan can incorporate information from a person’s advance care plan. When a person is experiencing deterioration in their mental state, they may be able to self-report this to members of the workforce. Similarly, carers or family members may recognise the specific signs that they know indicate the person’s mental state is deteriorating. Integrate this information into the comprehensive care plan, and engage the person – and, with permission, their carers and family – in decision-making.

Ensure that all members of the workforce involved in a person’s care are aware of the contents of the comprehensive care plan and are alert to changes that have been identified as individual markers indicating a deterioration in the person’s mental state.

For all patients at risk of delirium, this plan should include tailored delirium prevention interventions, regular monitoring and reassessment for delirium with any changes.¹

Monitor patients at risk

Develop systems to routinely monitor patients at risk of deterioration in mental state, including²:

• Prompts for assessment
• Identification of the clinician responsible for assessment, documentation and communication processes
• Actions to be taken, including level of nursing observation
• Regular review and feedback processes.

If delirium is identified as a cause of deterioration in the person’s mental state, use indicators from the Delirium Clinical Care Standard for local review and feedback mechanisms.^{1, 3}

Patients with dementia may experience deteriorating behaviour and mental state (such as agitation, aggression or psychosis) during a stay in a health service organisation. Although these may be viewed as behavioural and psychological symptoms of dementia, a comprehensive assessment is required to rule out possible delirium, pain and other physical problems.⁴

Assess observed or reported changes

With possible delirium, diseases can have atypical presentations in older people, so do not dismiss a family member’s non-specific concerns (for example, the person ‘is not usually like this’) and assess the person for delirium.⁵

Incorporate this information into shared decision making. A tool has been developed to capture and track a person’s self-reported mental state daily in inpatient settings.⁶ Good outcomes have been reported, and further research will assess the tool’s broader applicability.

Engagement with carers and families can help maintain safety for the person experiencing deterioration in their mental state and others, while arrangements for specialist intervention are under way.

Use tools and resources

No tool currently sets out objective criteria for tracking deterioration in a person’s mental state equivalent to observation charts for physiological deterioration. Nonetheless, there are parameters that can indicate deterioration in a person’s mental state, and these can be used to develop individualised monitoring plans in collaboration with the person, and their carers and families.

These parameters are based on the mental state examination, which is integrated into clinical assessment protocols in most states and territories. Training about mental state examination is available throughout the Mental Health Professional Online Development website.

In addition, a mental health triage tool was developed to augment the Australasian Triage Scale used in emergency departments. It provides a set of structured and defined terms that can be used to assess a person’s mental state. The tool also provides the workforce with language to describe and communicate their observations.⁷

The tool uses an ABC mnemonic to align with the airway, breathing, circulation parameters for identifying physiological health status. For mental health, these are described as:

• Appearance
• Behaviour
• Conversation.

Guidelines for using the mental health triage tool are available in the Emergency Triage Education Kit.

The Vanderbilt ICU Delirium and Cognitive Impairment Study Group website includes resources for monitoring and managing delirium in intensive care units as part of a bundle of measures for prevention and safety.

Although there is low prevalence of episodes of acute deterioration in a person’s mental state in day procedure services, members of the healthcare workforce need to be alert to signs indicating that a person may be experiencing acute deterioration in mental state, and know what to do when they recognise these signs.

The health service organisation needs to ensure that, if a person does experience acute deterioration in their mental state, members of the workforce have the skills to initiate an immediate response to ensure safety, and communicate their concerns to relevant parties.

Engagement with families and carers can help to maintain safety for the person experiencing deterioration in their mental state and others, while arrangements for specialist intervention are in train.

Use screening processes to identify patients with cognitive impairment or at risk of delirium to trigger strategies to keep the patient safe and minimise potential distress (see Action 5.29).

Examples of evidence

Select only examples currently in use:

• Policy documents about recognising, documenting and observing acute deterioration in mental state
• Screening and assessment policies and procedures for mental health in line with the Comprehensive Care Standard
• Training documents about recognising acute deterioration in mental state and how to deal with reports of deterioration from the patient, carer or family
• Documentation of patient involvement in developing individualised monitoring plans
• Audit results of compliance with the monitoring plan systems for mental state.

MPSs or small hospitals that are part of a local health network or private hospital group should adopt or adapt and use the established processes for detecting acute deterioration in mental health.

Small hospitals that are not part of a local health network or private hospital group should:

• Use comprehensive care plans to guide monitoring of people who are at risk of acute deterioration in mental state, incorporating knowledge from the person, and their carers and families about individual early warning signs
• Ensure that members of the workforce are alert to signs of deterioration in a person’s mental state, including for people who have not been previously identified as being at high risk
• Ensure that members of the workforce are alert to the signs of delirium
• Ensure that members of the workforce can implement an initial response and keep the person safe until arrangements are made for specialist review.

Be alert for signs of deterioration in a person’s mental state

Initial screening should identify people who are at risk of acute deterioration in their mental state, including patients at risk of developing delirium.

If screening identifies risk of deterioration in a person’s mental state, conduct a complete mental state examination.

In the absence of on-site mental health expertise, arrange specialist care through transfer to other services or consultation. The workforce should know how to gain access to these services, and management should set up partnerships with these organisations to enable patient referral or transfer.

Clinicians need to be able to recognise signs of deterioration early, and communicate these signs effectively to receiving clinicians when care is transferred.

Comprehensive assessment should differentiate among potential causes for the person’s deterioration in mental state.

Delirium can occur at any age and can be prevented. Patients aged 65 years or over, and patients with cognitive impairment (such as dementia), severe medical illness or a hip fracture are considered to be at greatest risk.¹

People who have not been identified as being at high risk can also experience deterioration in their mental state. Be alert for changes in mental state in all patients.

Use comprehensive care plans to manage patients at risk

If a person has been identified as being at high risk of acute deterioration in their mental state, conduct a comprehensive assessment as outlined in the Comprehensive Care Standard. The comprehensive care plan can incorporate information from a person’s advance care plan. When a person is experiencing deterioration in their mental state, they may be able to self-report this to members of the workforce. Similarly, carers or family members may recognise the specific signs that they know indicate the person’s mental state is deteriorating. Integrate this information into the comprehensive care plan, and engage the person – and, with permission, their carers and family – in decision-making.

Ensure that all members of the workforce involved in a person’s care are aware of the contents of the comprehensive care plan and are alert to changes that have been identified as individual markers indicating a deterioration in the person’s mental state.

For all patients at risk of delirium, this plan should include tailored delirium prevention interventions, regular monitoring and reassessment for delirium with any changes.¹

Monitor patients at risk

Develop systems to routinely monitor patients at risk of deterioration in mental state, including²:

• Prompts for assessment
• Identification of the clinician responsible for assessment, documentation and communication processes
• Actions to be taken, including level of nursing observation
• Regular review and feedback processes.

If delirium is identified as a cause of deterioration in the person’s mental state, use indicators from the Delirium Clinical Care Standard for local review and feedback mechanisms.^{1, 3}

Patients with dementia may experience deteriorating behaviour and mental state (such as agitation, aggression or psychosis) during a stay in a health service organisation. Although these may be viewed as behavioural and psychological symptoms of dementia, a comprehensive assessment is required to rule out possible delirium, pain and other physical problems.⁴

Assess observed or reported changes

With possible delirium, diseases can have atypical presentations in older people, so do not dismiss a family member’s non-specific concerns (for example, the person ‘is not usually like this’) and assess the person for delirium.⁵

Incorporate this information into shared decision making. A tool has been developed to capture and track a person’s self-reported mental state daily in inpatient settings.⁶ Good outcomes have been reported, and further research will determine the tool’s broader applicability.

Engagement with carers and families can help maintain safety for the person experiencing deterioration in their mental state and others, while arrangements for specialist care are under way.

Use tools and resources

No tool currently sets out objective criteria for tracking deterioration in a person’s mental state equivalent to observation charts for physiological deterioration. Nonetheless, there are parameters that can indicate deterioration in a person’s mental state, and these can be used to develop individualised monitoring plans in collaboration with the person, and their carers and families.

These parameters are based on the mental state examination, which is integrated into clinical assessment protocols in most states and territories. Training about mental state examination is available throughout the Mental Health Professional Online Development website.

In addition, a mental health triage tool was developed to augment the Australasian Triage Scale used in emergency departments. It provides a set of structured and defined terms that can be used to assess a person’s mental state. The tool also provides the workforce with language to describe and communicate their observations.⁷

The tool uses an ABC mnemonic to align with the airway, breathing, circulation parameters for identifying physiological health status. For mental health, these are described as:

• Appearance
• Behaviour
• Conversation.

Guidelines for using the mental health triage tool are available in the Emergency Triage Education Kit.

The Vanderbilt ICU Delirium and Cognitive Impairment Study Group website includes resources for monitoring and managing delirium in intensive care units as part of a bundle of measures for prevention and safety.