Assessment
It is important to carry out a comprehensive multidisciplinary assessment of the patient’s health, impairments, care and support needs.  This will enable staff to provide appropriate levels of support and intervention.  Areas of assessment should include:

Assessment should also include a comprehensive medical, psychological/psychiatric, occupational, educational and social history. This will involve gathering information from a variety of sources including interview with family/friend and a detailed review of all case records (medical and social work).  Assessment should continue after the period of PTA has ended and the person moves into the rehabilitation stage.

Safety
A fundamental principle in the management of PTA is to ensure safety within the environment.  Whilst in PTA, the patient is often unable to assess risks to themselves or others.  They may not understand the potential consequences of their actions.  Lack of awareness/insight and other cognitive difficulties including impulsivity, poor judgement, attentional and memory difficulties contribute to increased risks for the patient.  Safety may be compromised in the following circumstances:

  • Neurological impairments (e.g. physical impairments such as unsteady gait and hemiparesis, sensory deficits, perceptual impairments) result in increased risk of falls.
  • Dysphagia results in increased risk of choking and aspiration if the patient has access to inappropriate food/fluids.
  • Unrecognised dysphagia often in the context of significantly impaired cognition and communication and/or behavioural difficulties.
  • Attempting to eat non-food substances (pica) in the context of severe cognitive impairment.
  • Weight loss, malnutrition and dehydration.
  • Prescribed medication may be associated with side effects e.g. antipsychotic medication (haloperidol etc), benzodiazepines (Diazepam, Lorazepam).
  • Seizure risk.
  • Behavioural difficulties.
  • Self harm as a result of high levels of agitation.
  • Development of low mood, anxiety and feelings of social isolation contribute to distress and agitation. Depression and anxiety may go unrecognised and untreated.  The clinical presentation may be atypical.  The patient may be at increased risk of a suicide attempt.
  • Risk that the patient may abscond if not adequately supervised.
  • Risk to other patients and staff if the patient in PTA is fearful, paranoid and/or aggressive.

Compulsory Measures
During PTA the patient demonstrates significant cognitive and communicative impairments which are likely to impact on their ability to make informed decisions regarding their care, treatment and welfare.  Therefore it is appropriate to provide care and treatment under the Adults with Incapacity (Scotland) Act 2000.  However the use of compulsory measures to support care and treatment, i.e. the use of the Mental Health (Care and Treatment) (Scotland) Act 2003, may need to be considered under the following circumstances:

  • The patient is consistently expressing the desire to leave hospital.
  • The patient has made active attempts to leave the ward.
  • The patient is unable to comply with taking prescribed medication and the administration of medication covertly is being considered.
  • Physical aggression is a predominant clinical feature.
  • Management of behavioural difficulties has necessitated the need for use of control and restraint techniques and/or intramuscular sedative medication.
  • The patient is at significant risk of harm to self or others and failure to receive necessary care and treatment will be detrimental.

If the above issues arise then advice should be sought from a liaison psychiatrist with regard to the need for compulsory measures to be considered.