Grandma is Acting Out

CASE:  Your patient brings in her grandmother (82 yrs old diagnosis with dementia) with complaints that she is up all night screaming incoherently, strikes out at caregivers, and angers easily.

What can you offer your patient to better manage her mother’s agitation?

Dementia patients commonly have behavioral and psychological symptoms that present in several clusters that include psychosis (delusions, hallucinations) and agitation/aggression, and disinhibition (agitated behaviors) Agitation and psychotic symptoms in demented patients is common, occurring in up to 30% of patients and may increase with disease progression. Dementia patients with agitation and other neuropsychiatric disorders cause significant stress on the caregivers, lead to excess hospitalizations and nursing home admissions, and carry higher mortality.  Environmental and non-pharmacologic interventions are the mainstay of treatment. These include reducing ambient noise and clutter, establishing schedules of activities, periodic orientation. It is important to stay alert to possible sources of pain that the patient may be experiencing but unable to express, and manage these as appropriate. Of note 36% of patients with agitated dementia have an underlying undetected illness.

In evaluating patients with dementia presenting with agitation or other behavioral problems, consider the three main factors that contribute:

Patient-related: acute medical illness, underlying psychiatric illness, sensory deficits

Care-giver related: poor communication, emotional instability

Environmental factors: clutter, overstimulation, understimulation

Pharmacologic therapies should be reserved for severe conditions that are not well managed just by non pharmacologic therapies alone. Note that the FDA has NOT approved any medication for the management of behavioral conditions related to dementia so all of the medications discussed below are used in an off label manner.

Anti-psychotics. The atypical anti-psychotics, risperidone and aripiprazole, have been shown in 15 randomized controlled trials to be modestly effective at managing behavioral symptoms. Oddly, presence of psychosis was associated with less clinical effectiveness for agitation than in patients without psychosis. The atypical anti-psychotics are not without their adverse effects. Based on re-analysis of 17 RCTs in 2005, the FDA issued a black box warning that indicated a 1.7 fold increase in mortality risk in patients treated with these drugs. Beyond excess mortality, this class of drugs was also associated with extrapyramidal effects, hyperprolactinemia, prolonged QT syndrome (thought to be the source of excess mortality) and greater anti-cholinergic side effects. Conventional antipsychotics such as haloperidol also carry a similar black box warning.

Benzodiazepines.  Curiously, there are no RCTs on clinical effectiveness of this class of drug in the management of agitated dementia, and are NOT recommended in the management of behavioral issues in dementia with the exception of acute crisis. Of particular concern with the use of benzodiazepines is the increased risk of dependency and worsening of dementia as well as excess falls.

Take home lessons are:

  1. evaluate the three categories of factors and address each
  2. Preference is for non pharmacologic strategies (environment, caregiver)
  3. use atypical anti-psychotics if behavior is severe and not managed well by non pharmacologic interventions
  4. Be cautious. Avoid benzodiazepines.

Advance Care Planning Series – #3 Advance Directives and POLST

Completion of the Advanced Directive: When a healthcare agent or surrogate is named and a living will is completed designating what the patient’s wishes might be, the Advanced Directive is signed by the patient. In order for the Advanced Directive to become a legal document, it must either be witnessed by two people or notarized by an authorized public notary. Note that both the witness signature and the notarization only testify that the signature belongs to the patient, and not to the validity or completeness of the Advanced Directive. As noted above, the patient can elect to activate the Advanced Directive immediately upon signature and witness/notarization or can elect to activate after signature and witness/ notarization only when the patient is incapacitated.

When to Consider a Physician Order for Life Sustaining Treatment (POLST): The Advanced Directive is appropriate when a serious illness or chronic disease is first diagnosed at minimum, and updated on a regular basis as the patient ages and their health status changes. A good case could be made for starting to do Advance Care Planning, having advance directive conversations, when the patient is young. One could consider for instance, a high school graduate to receive a diploma and an advance care planning document. What is key is the recognition that advance care planning is about repeated conversation over time with an individual about their wishes. The Advanced Directive is the document that captures these conversations.

When a patient becomes more seriously ill and is approaching the last phases of a terminal trajectory, you could discuss physician orders for life sustaining treatment and complete a POLST form ( This state approved form has four sections:

Section A: cardiopulmonary resuscitation (CPR or Do Not Attempt Resuscitation = allow natural death)

Section B: medical interventions (full, selective, comfort-focused)

Section C: artificial nutrition (long term, trial, no artificial means including feeding tubes)

Section D: Information and signatures.

This form can be signed by either a physician or a nurse practitioner/ physician’s assistant. Make copies for the patient’s medical record, provide copy to the patient and the patient caregiver/surrogate. This form should be with the patient at all times.

To learn more about POLST, the link below sponsored by the California Coaltion for Compassionate Care provides great resources.

Partnership HealthPlan Commitment:  Our commitment to the seriously ill members in our plan is strong and manifest through the Partnership HealthPlan’s Offering and Honoring Choices Initiative. This is a set of 14 activities that promote, support and facilitate a spectrum of palliative care activities, including completion of advance care directives and POLST completion. Of note, PHC has included advance care planning in the Quality Incentive Program (QIP) which includes $100 per member for attestation of an advance care plan conversation and an additional $100 for submission of a completed POLST.

Other Resources

Advance Care Planning Series – #2 The Health Care Surrogate

Counselling on Selection of a Health Care Agent (Surrogate): Anyone can be chosen by the individual to be their healthcare agent with three exceptions:

  • Patient’s supervising healthcare provider unless related to the patient
  • Any employee of the healthcare institution where the patient receives care unless related to the patient
  • Any operator or employee of the facility where the patient lives unless related to the patient

The optimal healthcare agent should be willing and able to serve (assess the capability of the surrogate as well as the patient), knows the patients values and preferences, is able to make difficult decisions, and is willing and capable of speaking for the patient. The scope of authority of a healthcare agent includes:

  • Choosing a healthcare provider
  • Approving or refusing medical treatment
  • Agreeing to testing
  • Reviewing medical records
  • Donating organs
  • Authorizing autopsy
  • Directing the disposition of remains

The legal standard for surrogate decision making is either in accordance with the expressed wishes of the patient (substituted judgement) or if wishes are unknown, based upon the values and preferences of the patient. This means decisions are made as if the surrogate were standing in the shoes of the patient, making the decisions the patient would have made.

To name a healthcare agent, assist the patient in writing in the name, address, phone number and other contact information (eg. email address) for the primary surrogate. Also assist the patient in considering and putting in writing a backup or secondary surrogate if the primary is not available.

If the patient has not designated a healthcare agent, should they become incapacitated, the default surrogate is activated. These default agents include the spouse or domestic partner, and adult sibling, an adult child, an adult grandchild, or an adult relative with the closest degree of kinship. In a skilled nursing facility, the default surrogate is the attending physician.

Leeway is the degree of autonomy granted to the surrogate in making decisions for the patient. A patient can decide not to grant leeway meaning the surrogate must follow strictly the wishes of the patient. In other circumstance, the patient may decide to grant partial or full autonomy or leeway to the surrogate to use their judgement.

A section of the Advanced Directive allows the patient to determine if the surrogacy is immediately active or is only activated when a physician determines there is loss of capacity of the patient. Note the term ‘competence’ is not used as it is a legal term and is determined by a court.

Counselling on Living Will: A living will is the component of the advanced directive that provides guidance to the surrogate on what values and wishes that patient has about their continuing care. It make include:

  • What makes life worth living
  • Where the patient wants to die
  • The role of religion or spirituality in the dying process
  • Desire or lack thereof for supportive treatments
    • Life support including CPR, feeding tubes, dialysis, blood transfusion, artificial ventilation
  • Donation of patient’s organs
  • Preference for autopsy

Advance Care Planning Series- #1 What is an Advance Care Plan?

The Case for Advance Care Planning. Advance care planning is a series of conversations that a patient and you, their care provider, have about end of life wishes. These can be captured into an advance care plan,  that may include both a selection of a health care agent or surrogate, and a living will with specific guidance on desires for interventions and level of care.  These two together can form an Advanced Directive. This is a legal document that has no expiration date. It is intended to provide guidance to the named or default healthcare agent on wishes of the individual for their care. Once legally completed, it is transportable across states

Why is counseling your patient on Advance Care Planning so important? Data are compelling that our population is aging, and the types and trajectories of death are changing. Whereas relatively acute episodes of untreatable disease or trauma used to be the norm which led to shortened and abrupt trajectory to death, chronic diseases, particularly cardiovascular and pulmonary disease, have become the predominant causes of death. Seven out of ten Americans die of a chronic disease. These common trajectory now is a prolonged, downhill course with occasional decompensations and recovery until a decompensation happens from which there isn’t recovery. Patients now live longer with serious illness and disability, making their life and dying decisions so important not only for the quality of their remaining lives, but also for more rationale use of healthcare resources.  Healthcare costs skyrocket in the last two years of life, accounting for almost 30% of healthcare expenditures. With the aging of the population, this is only going to increase. Although the Medicare hospice benefit provides for care in the last six months of life, the average duration in hospice in only a week. A California Health Care Foundation survey found that only 20% of Californians have talked about their end of life wishes with their doctors.

Advance care planning increases patient satisfaction and fulfillment of their healthcare wishes more often but also reduces hospitalizations, ED visits and costs in the last two years of life. Advance care planning is a win for patients, a win for providers, and a win for healthcare systems.

Next in Series:  Advanced Directives and Selection of a Surrogate

Written by: Scott Endsley MD, Associate Medical Director, Quality


What are the USPSTF recommendations on Depression Screening?

The USPSTF recommends screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. This screening is given a “B” grade rating meaning it is recommended and there is a moderate certainty that the net benefit is moderate to substantial.

Are there any Quality Measures required by DHCS for Depression Screening?

The Comprehensive Depression Follow Up (CDF) is a quality measure that DHCS is asking health plans to report on starting in 2017 that includes both screening and a plan for follow-up of abnormal results. Partnership has chosen to report CDF as an Administrative measure to DHCS for HEDIS 2017.

What Depression Screening tools are available?

The PHQ-9 is the most common screening tool to identify depression. It is available in Spanish as well as in a modified version for adolescents. It is available in multiple languages as this website. Most importantly, the PHQ-9 includes a question designed to screen for danger to self which the shorter PHQ-2 version does not include. Suicide prevention can arguably be regarded as the most important aspect of depression screening.

The Edinburgh Postnatal Depression Scale (EPDS) is highly recommended for screening postpartum women and can be completed in less than 5 minutes. Recommendations are that screening be done both pre-term and postpartum for at least several months or up to a year. The EPDS is available in multiple languages at this website.

NOTE: None of the above screening tools actually DIAGNOSE depression—that is done properly by the PCP or other appropriately licensed health care personnel.

How often should screening for depression take place?

The PHQ-9 recommends that patients newly diagnosed with depression or those in current treatment for depression be screened at baseline and at regular intervals (e.g. every 2 weeks) or at their next scheduled appointment. The PHQ-9 can be filled out at home by the patient and brought to their appointment.

The onset of major or other depression can occur at any time with onset at any level of acuity, unlike other medical conditions where mild indications are monitored so that treatment can be instituted when symptoms reach a critical level of severity. The best practice, adopted by many clinics, is to add depression screening to other routine screening measures, such as blood pressure, weight, or activity level at each appointment (unless completed within the prior 2 weeks). The logistics involve handing the patient a paper copy of the PHQ-9 in their primary language (or email or mail a copy to fill out at home prior to their appointment) and have it scored by office personnel (or use an online version with automated scoring,) and then having the results evaluated by the PCP for appropriate diagnosis, referral or treatment decisions.

What are the recommended effective treatment actions following Depression Screening with the PHQ-9?

  1. If a patient scores anything other than zero on the “suicide ideation” question (#9 on the PHQ-9), immediate referral to an in-house mental health professional or via a warm telephone transfer to a County mental health crisis center is recommended. The county MH systems are mandated by the State to provide services high risk situations.
  2. Total scores greater equal or greater than 10 on the PHQ-9 have an 88% specificity for major depression.
    1. For depression in the minimum to mild range of severity (total score of 0 to 9 on PHQ-9), psychotherapy is the primary recommendation.
    2. For scores in the moderate range (total score of 10-14 on PHQ-9), and even in the moderately severe range (total score of 15-19 on PHQ-9), EITHER psychotherapy or medication are recommended options. A PCP referral to Beacon Health Options (see referral procedures cited at end of this article) can be a good starting point, whether or not medication will be prescribed immediately or will be added later.
    3. For severe major depression (total score of 20-27 on PHQ-9), it is likely that BOTH medication and psychotherapy are needed, most often involving a referral to County Mental Health services because of the severity level.

Are there any caveats in screening for depression in primary care?

Throughout my 40 years as a therapist including 18 years with Kaiser, there were three scenarios that often led to less than positive outcomes when patients were screened for depression in primary care.

  1. Patients who were actually bipolar were diagnosed with major depression and treated with anti-depressant medications (such as SSRIs) that produced a manic “flip” (observed as an almost instantaneous response to the antidepressant with a sudden dramatic increase in the patient’s sense of well-being and energy). This often led to the necessity for psychiatric hospitalization with an increased risk of self-harm. This occurs because bipolar patients rarely present to primary care when in manic states. They present when depressed and thus the manic potential is missed. The Mood Disorder Questionnaire (MDQ) can be used as a further screening when illnesses in the bipolar spectrum are suspected or need to be ruled out.
  1. Patients were on medications, especially opioids, or were abusing or misusing alcohol or other drugs, which were actually contributing to if not producing the depressive symptoms. Screening for alcohol/drug/medication use, even if within prescribed limits, is important for proper referral. Substance abuse problems must be addressed before depression can be treated effectively. The reverse is NOT effective. At present all substance abuse treatment for Partnership members is provided by County Mental Health/Substance Abuse services (County MH telephone numbers).
  1. Patients with mild depression or dysthymia (total PHQ-9 score <10) were immediately placed on anti-depressant medication which was generally not effective for these mild conditions and because the patient was expecting the medication to “work”, they do not seek counseling, which actually could help. The worst case scenario is that dosages are increased or other psychoactive agents added to produce “better results” to the patient’s detriment.

What are some handy hints in diagnosing depression, with or without the use of screening tools?

  1. I would say that the majority of the literally thousands of patients to whom I gave a depression diagnosis did NOT cite depressed mood as a primary symptom. In my experience, the most significant symptoms for major depression, in order of prominence, were:
    1. Increased irritability (often more obvious to family members)
    2. Anhedonia (an inability to enjoy formerly enjoyable activities)
    3. Anergia (drop dead tiredness)
    4. Insomnia (especially mid or terminal insomnia).
    5. Crying easily and social isolation
  1. Remembering that most commonly prescribed anti-depressant medications take a few weeks to kick in, it is always appropriate to refer for psychotherapy at the outset. In fact, patients are more motivated for counseling because they have not yet experienced symptom relief. This is also recommended if the level of severity is in question. Beacon is experienced in making step-up referrals to the county MHPs.

How can a PCP refer to Beacon Health Options for patients diagnosed with depression or any other psychiatric disorder presenting in the mild to moderate range of severity?

The newly revised Beacon PCP Referral Form can be accessed in fillable form online at:

In completing the form, follow these suggested steps:

  1. Fill in identifying information and check Medi-Cal Eligibility
  2. [NEW] Check your preferred method of contact (email or FAX) to receive CONFIRMATION that your referral has been received and INFORMATION of the referral outcome. This will be referral information only, not clinical treatment information. But will let you know that your referral has been processed and the outcome of the Member contact concerning that referral.
  3. Check which service you are requesting for this Member:
    1. PCP Decision Support: A phone consult with a Beacon psychiatrist for diagnostic and prescribing support
    2. Out Patient Behavioral Health Services: Member referred to Beacon network provider for therapy and/or medication management (including coordination with county MH services).
    3. Referral for Local Care Management: Beacon case managers co-located with PHC will provide health care coordination services to engage and link Members who may have difficulty making their own appointments.
  4. Check all request reasons at bottom of form and submit (FAX to 866-422-3413 or email to

 NOTE: A follow-up blog will be coming soon, aimed at depression screening and maternal health including perinatal depression screening.

submitted by Karen Stephens, PhD, Mental Health Clinical Director, Partnership HealthPlan