E0100: Potential Indicators of Psychosis
E0100: Potential Indicators of Psychosis
Item Rationale
Health-related Quality of Life
• Psychotic symptoms may be associated with
— delirium,
— dementia,
— adverse drug effects,
— psychiatric disorders, and
— hearing or vision impairment.
• Hallucinations and delusions may
— be distressing to residents and families,
— cause disability,
— interfere with delivery of medical, nursing, rehabilitative and personal care, and
— lead to dangerous behavior or possible harm.
Planning for Care
• Reversible and treatable causes should be identified and addressed promptly. When the cause is not reversible, the focus of management strategies should be to minimize the amount of disability and distress.
Steps for Assessment
1. Review the resident’s medical record for the 7-day look-back period.
2. Interview staff members and others who have had the opportunity to observe the resident in a variety of situations during the 7-day look-back period.
3. Observe the resident during conversations and the structured interviews in other assessment sections and listen for statements indicating an experience of hallucinations, or the expression of false beliefs (delusions).
4. Clarify potentially false beliefs:
• When a resident expresses a belief that is plausible but alleged by others to be false (e.g., history indicates that the resident’s spouse died 20 years ago, but the resident states their spouse has been visiting them every day), try to verify the facts to determine whether there is reason to believe that it could have happened or whether it is likely that the belief is false.
• When a resident expresses a clearly false belief, determine if it can be readily corrected by a simple explanation of verifiable (real) facts (which may only require a simple reminder or reorientation) or demonstration of evidence to the contrary. Do not, however, challenge the resident.
• The resident’s response to the offering of a potential alternative explanation is often helpful in determining whether the false belief is held strongly enough to be considered fixed.
Coding Instructions
Code based on behaviors observed and/or thoughts expressed in the last 7 days rather than the presence of a medical diagnosis. Check all that apply.
• Check E0100A, hallucinations: if hallucinations were present in the last 7 days. A hallucination is the perception of the presence of something that is not actually there. It may be auditory or visual or involve smells, tastes or touch.
• Check E0100B, delusions: if delusions were present in the last 7 days. A delusion is a fixed, false belief not shared by others that the resident holds true even in the face of evidence to the contrary.
• Check E0100Z, none of the above: if no hallucinations or delusions were present in the last 7 days.
Coding Tips and Special Populations
• If a belief cannot be objectively shown to be false, or it is not possible to determine whether it is false, do not code it as a delusion.
• If a resident expresses a false belief but easily accepts a reasonable alternative explanation, do not code it as a delusion. If the resident continues to insist that the belief is correct despite an explanation or direct evidence to the contrary, code as a delusion.
Examples
1. A resident carries a doll, which they believe is their baby, and the resident appears upset. When asked about this, they report they are distressed from hearing their baby crying and think that the baby is hungry and they want to get the baby a bottle.
Coding: E0100A would be checked and E0100B would be checked.
Rationale: The resident believes the doll is a baby, which is a delusion, and they hear the doll crying, which is an auditory hallucination.
2. A resident reports that they heard a gunshot. In fact, there was a loud knock on the door. When this is explained to them, they accept the alternative interpretation of the loud noise.
Coding: E0100Z would be checked.
Rationale: They misinterpreted a real sound in the external environment. Because they are able to accept the alternative explanation for the cause of the sound, their report of a gunshot is not a fixed false belief and is therefore not a delusion.
3. A resident is found speaking aloud in their room. When asked about this, they state that they are answering a question posed to them by an individual in front of them. Staff note that no one is present and that no other voices can be heard in the environment.
Coding: E0100A would be checked.
Rationale: The resident reports auditory and visual sensations that occur in the absence of any external stimulus. Therefore, this is a hallucination.
4. A resident announces that they must leave to go to work, because they are needed in theiroffice right away. In fact, they have been retired for 15 years. When reminded of this, theycontinue to insist that they must get to their office.
Coding: E0100B would be checked.
Rationale: The resident adheres to the belief that they still work, even after being reminded about their retirement status. Because the belief is held firmly despite an explanation of the real situation, it is a delusion.
5. A resident believes they must leave the facility immediately because their parents arewaiting for them to return home. Staff know that, in reality, their parents are deceased and gently remind them that their parents are no longer living. In response to this reminder, the resident acknowledges, “Oh yes, I remember now. My parents passed away years ago.”
Coding: E0100Z would be checked.
Rationale: The resident’s initial false belief is readily altered with a simple reminder, suggesting that their mistaken belief is due to forgetfulness (i.e., memory loss) rather than psychosis. Because it is not a firmly held false belief, it does not fit the definition of a delusion.
DEFINITIONS
HALLUCINATION
The perception of the presence of something that is not actually there. It may be auditory or visual or involve smells, tastes or touch.
DELUSION
A fixed, false belief not shared by others that the resident holds even in the face of evidence to the contrary.
