Caring for Patients with Mental Health Conditions:

September 2018

Caring for Patients with

Mental Health

Conditions:

A Toolkit for Home Health Clinicians

Authors:

Kenneth L. Miller, PT, DPT

Board-Certified Clinical Specialist in Geriatric

Physical Therapy

Certified Exercise Expert for Aging Adults

Cathy Ciolek PT, DPT, FAPTA

Board-Certified Clinical Specialist in Geriatric

Physical Therapy

Sean Hagey, PTA

This content is for educational purposes only. It does not replace the advice

or counsel of a doctor or health care professional. Each clinical decision

must be made based on the unique condition of the patient and best

available evidence. APTA Home Health and the authors make every effort

to provide information that is accurate and timely but make no guarantee

in this regard. Due diligence is required with any use of this resource.

Page 1

About the Authors

Kenneth L Miller PT, DPT

is a board-certified geriatric specialist with over 20 years

of clinical practice in multiple practice settings with the older adult population. Dr.

Miller is a physical therapist clinical educator for a healthcare system focusing on

home care best practices and optimal transitions with the frail population. He

mentors an interdisciplinary staff in the home setting utilizing the clinical setting to

promote patient safety with patient engagement and interaction. As the Chair of the

Practice Committee of APTA Home Health, he led the development of the Providing

Physical Therapy in the Home handbook and other resources such as

home health

student roadmap and toolkit and APTA Home Health’s objective test toolbox.

Cathy Ciolek PT, DPT, FAPTA

has been a physical therapist for 28 years and board

certified as a Geriatric Clinical Specialist since 1996. She is a Certified Dementia

Practitioner (CDP) and Certified Alzheimer’s Disease and Dementia Care Trainer

(CADDCT) by the National Council of Certified Dementia Practitioners. She previously

served as Regional Director for the Pennsylvania Restraint Reduction Initiative (PARRI),

providing education and consultation for issues related to well-being (falls, engagement,

medication reduction) to nursing homes throughout the Commonwealth of Pennsylvania

via a CMS grant. Prior to that Dr. Ciolek served as assistant professor and director of

clinical education for the University of Delaware, Department of Physical Therapy. She has

practiced as a physical therapist in outpatient, SNF, home health and CCRC facilities over

the course of her career.

Sean Hagey, PTA

has been a PTA for 10 years and has experience working in

outpatient, SNF, and home health settings. He is the Public Relations Chair for APTA

Home Health.

He has previously presented at CSM and twice at the Kansas Chapter

conference.

Editing & Design:

Robin L. Childers

Additional Resources

Chronic Illness and Mental Health 2 pg:

https://www.nimh.nih.gov/health/publications/chronic-illness-mental-health/nih-

15- mh-8015 151898.pdf

Depression Basics (what, causes, s/s, etc) 6 pg:

https://www.nimh.nih.gov/health/publications/chronic-illness-mental-health/nih-

15-mh-8015 151898.pdf

Older Adult s and Depression 6 pg:

https://www.nimh.nih.gov/health/publications/older-adults-and-depression/gf-16-

7697 153371.pdf

Generalized Anxiety Disorder 8 Pg:

https://www.nimh.nih.gov/health/publications/generalized-anxiety-

Page 2

disorder-gad/generalized-anxiety-disorder 124169.pdf

Mental Health First Aid (website): https://www.mentalhealthfirstaid.org/

Forgetfulness: Knowing When To Ask For Help (cg resource):

https://www.wrpioneers.org/wp- content/uploads/2015/09/forgetfulness 0.pdf

Alzheimer's Association: Living With Alzheimer's - For Caregivers - Early Stage Tips

(pdf workbook) 17 pg:

https://www.alz.org/documents custom/early-stage-caregiver-tips.pdf

Staying Safe (patient safety tips for caregivers):

https://www.alz.org/national/documents/brochure stayingsafe.pdf

This content is for educational purposes only. It does not replace the advice or counsel of a doctor or

health care professional. Each clinical decision must be made based on the unique condition of the

patient and best available evidence. APTA Home Health and the authors make every effort to provide

information that is accurate and timely but make no guarantee in this regard. Due diligence is

required with any use of this resource.

reserved.

Page 3

Table of Contents

Introduction

Mental Health Safety Checklist

Suicide Protocol Flowchart

Mental Health Decision Tree

References

Appendices:

Case Scenario: Dementia

Dementia Decision Tree

Case Scenario: Depression

Depression Decision Tree

Case Scenario: Anxiety

Anxiety Decision Tree

Page 4

The purpose of this toolkit is to provide home care physical therapists with resources to

provide optimal care for patients with mental health conditions that may impact safety

and impede implementation and success of the plan of care. The mental health conditions

to be addressed are cognitive impairment (delirium, dementia, depression with dementia

and pain with dementia), depression, and anxiety.

Dementia is classified as a syndrome, a collection of symptoms with many causes.

According to the 2017 Alzheimer’s Facts and Figures: “The characteristic symptoms of

dementia are difficulties with memory, language, problem-solving and other cognitive

skills that affect a person’s ability to perform everyday activities.” It is believed that nearly

14% of the population over the age of 71 has a form of dementia. The most common type

of dementia is Alzheimer’s Dementia, representing nearly 5.3 million Americans over the

age of 65 and about 200,000 under the age of 65. Other forms of dementia include

Dementia with Lewy-Bodies, Vascular Dementia, Mixed-Dementia, Frontotemporal Lobar

Degeneration, and other neurological conditions that have associated cognitive impacts

such as Parkinson’s Disease and Normal Pressure Hydrocephalus. Dementia is the only

disease in the top ten of causal mortality that “cannot be prevented, slowed, or cured.”

Depression in older adults is believed to impact about 5% of the population, however

that number for those receiving home health care may be as high as 13.5% according to

the Centers for Disease Control & Prevention (CDC). Symptoms of depression in older

adults may include loss of energy, difficulty concentrating and remembering details,

insomnia or excessive sleeping, feelings of hopelessness or pessimism. Many health care

providers overlook depression in older adults assuming it may be normal for the current

situation (someone who is ill or experiencing loss) but any significant change in interest

or enthusiasm for everyday events should be screened to see if intervention is

appropriate.

Delirium is considered an acute decline in cognitive function often associated with major

surgery, infection, sepsis, under-treated pain and polypharmacy. It may occur in as many as

50% of hospitalized older adults, making it a significant concern for home health clinicians.

Unlike dementia that has a slow onset, delirium often has a rapid onset but may also

fluctuate across a 24-hour period. It is possible to have delirium on top of an existing

diagnosis of dementia.

The challenge for home health providers is that there is significant overlap in the

presentations of these three conditions. Accurate history taking, medical review and

assessment is required to help differentiate the possible cause of cognitive changes in the

older adults. This is of course complicated if the person receiving care cannot easily

communicate the information accurately and may not have another representative

available during your visit. It may be further complicated by an individual or family who is

unwilling to acknowledge that cognitive changes may be occurring due to fear for loss of

identity, the risk of institutionalization and the stigma associated with mental and

cognitive health issues.

Page 5

The clinical decision tree on Page 12 was designed to help aid the clinician in determining if

cognitive and mental health safety needs further assessment or intervention. The tools listed

here are appropriate to use for the home health patient but are not an exhaustive list of all

the possible screening tools. Further testing and referral for medical work up may need to

occur simultaneous with initiation of the physical therapy Plan of Care.

The mental health safety checklist also includes some additional questions for safety

concerns with possible interventions. Assessment should include root cause analysis of

behavioral and psychological symptoms of dementia (wandering, pacing, agitation) to

help determine how these may be mediated with non-pharmacological interventions.

Additional considerations such as sleep health are increasingly being better understood

for the impact they have on daily function along with general engagement and physical

activity. This list is not all-inclusive and there can be other factors that influence the plan

of care, however these areas are among the more common issues for families in helping

to provide care for a loved one with cognitive or mental health issues.

Page 6

Page 7

Screening Tools

Delirium:

• Confusion Assessment Method

Cognition/Dementia:

• Mini-Cog

Depression:

•

Pain:

•

Cornell Scale for Depression in Dementia

PHQ9

PHQ2

Painad

Anxiety:

• Hamilton Anxiety Rating Scale (HAM-A)

To properly address mental health conditions, it is important to understand the

difference between delirium and dementia. Many clinicians use the terms

interchangeably, which is unfortunate as delirium is an acute mental status change that is

often life-threatening and requires medical attention whereas, dementia is a slow and

chronic progression of cognitive loss.

The following key terms provide simple definitions of delirium, dementia and depression.

KEY TERMS

• Delirium: acute global brain failure with fluctuations in

attentiveness and disorientation. Sx are generally acute and may

fluctuate across the day.

• Dementia: a group of disorders of the brain that result in decline

in functioning, primarily associated with memory deficit.

Additional features include sensorimotor changes, verbal fluency

changes and difficulty in planning and other executive functions.

Sx are usually gradual and developing.

• Depression: mood disorder that affects how you think and handle

There are many screening tools for delirium, dementia, depression, anxiety, and

pain. The graphic below contains a sampling of commonly used tools and is not by

any means an exhaustive list.

Page 8

Clinicians work with older adults who may have chronic, progressive diseases, or

experience life changing events that result in suicidal ideations or actual suicide attempts.

Being able to triage suicide risk in the older population is important to ensuring patient

safety. The following suicide protocol is provided to triage patients into risk categories

and guide the clinician in how to handle these difficult situations. The national suicide

hotline is a resource that is recommended for all clinicians to have available and provide

routinely to patients, caregivers and patients’ representatives.

In the home health practice setting, the OASIS data set contains several items that

specifically address a patient’s neurological, emotional, and behavioral status. The answers

to these items should be supported by the screening tools listed above, as appropriate:

• M1700 Cognitive Functioning: Patient’s current (day of assessment) level of

alertness, orientation, comprehension, concentration, and immediate memory for

simple commands.

• M1710 When Confused (Reported or Observed within the Last 14 Days)

• M1720 When Anxious (Reported or Observed within the Last 14 Days)

• M1730 Depression Screen Has the patient been screened for depression, using a

standardized, validated depression screening tool? (PHQ-2)

• M1740 Cognitive, behavioral, and psychiatric symptoms that are demonstrated at

least once a week (Reported or Observed)

• M1745 Frequency of Disruptive Behavior Symptoms (Reported or Observed)

Page 9

Very high: Person has suicide

plan, means, and is acting or

ready to act.

High: Person has a suicide plan,

means, but no intention to act at

present time.

CALL 911

Lower: Person has no plan or no

obvious means and no immediate

intention to act on thoughts.

Suicide Prevention Protocol Flowchart

New observation of suicide clues

Express concern: “I am concerned about .”

Attempt to determine level of concern with clinical supervisor – do not promise to keep a secret.

Contact agency supervisor/manager for direction.

An option may be to have MSW make STAT visit or call 911.

In all cases, home care staff should remain with

client until an appropriate intervention is instituted.

Document what you observe

and what you did in the client’s record.

For client who chronically has suicide clues

Consult with primary MD re: plan and

request referral for psychiatric evaluation.

At each RN, Rehab, or MSW visit, ask,

“Are you still having thoughts about ?

If client appears unsettled or there is a change suggesting increased risk

Page 10

Adult Protective Services

• Must check HIPAA rules and Abuse reporting rules (state law)

• Mandated Reporting (state specific rules)

o Resource for all US states regulations

• Forms of elder abuse:

o Neglect (intentional and unintentional)

o Physical, sexual or emotional Abuse

o Financial abuse or exploitation

Beers Criteria

• List of potentially inappropriate medications to be avoided in older adults.

o Avoid in general

o Avoid based on diseases and syndromes

• List of select drugs that should be avoided

o Or have their dose adjusted based on the individual’s kidney function and

select drug-drug interactions documented to be associated with harms in

older adults.

• The 2015 AGS Beers Criteria are applicable to all older adults with the exclusion of

those in palliative and hospice care.

• Resources

Unfortunately, elder abuse and neglect are commonly encountered when working with

an older adult with cognitive impairment. The regulations on mandatory reporting are

state specific and due diligence is required to ensure compliance with these regulations.

Be sure to check with federal and state agencies and the agency policy and procedure

manual regarding the handling of suspected abuse or neglect. Reports go to Adult

Protective service (APS) agencies that are responsible for the safety of older adults,

similar to reports for child abuse to Child Protective Services (CPS). Resources on APS

are available in the table below.

The Beers Criteria developed by Dr Mark Beers and maintained by the American

Geriatrics Society (AGS) contain a list of medications that are potentially inappropriate

for the older adult due the increased risk for adverse effects. Many of the drugs on the

2015 Beers Criteria are known to cause delirium and are considered potentially

inappropriate medications. Several drug classes (with drug examples) are highlighted

here for the practicing physical therapist to incorporate medication review into the

review of systems and be aware of the effects the drugs, both intended and side effects to

report back to the prescriber.

Page 11

e home health practice setting, the OASIS data set contains several items that

cifically address a patient’s neurological, emotional, and behavioral status.

NSERT OASIS m1700

purpose of the clinical decision tree is to assist clinicians in determining when a

ent needs medical follow up or is appropriate to receive physical therapy services.

e case scenarios (delirium, delirium, depression and anxiety) are provided in the

ndices to demonstrate use of the decision tree.

n th

spe

The

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Thre

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Page 12

MENTAL HEALTH DECISION TREE

Signs/Symptoms of

Cognitive/Mental

Health issues and/or

behaviors* (CI)

YES

Is the current treatment

plan effectively

addressing these

issues?

YES

*Signs/Symptoms:

Confusion, Change in judgment,

Hallucinations/Delusions

Altered Memory, Loss of interest

Lethargy/Aggression

Complete Cognitive Screen

Assess other possible causes

Delirium, Normal Pressure

Hydrocephalus, Depression/Anxiety

**See Mental

Health Safety

Checklist

Signs/Symptoms

Untreated

Depression/Anxiety?

Proceed with

PT**

Continue to

monitor

Based on clinical findings:

• Contact MD to share findings for further

workup

• Advise urgent medical care visit

• Initiate 911 call for EMS to assess patient

Delirium due to

recent:

Hospitalization

UTI or dehydration

Infection

Med change or

initiation

Normal Pressure

Hydrocephalus:

Gait change + Incontinence?

Page 13

There are many interventions available to include in the care of people with dementia,

depression, and anxiety. Cognitive behavioral therapy is one approach that has been

shown to be effective in reducing inappropriate behaviors and encouraging appropriate

behaviors.

It's important to realize that there is no one-size-fits-all solution for depression, anxiety, or

other mood disorders. Talk therapy treatments like Cognitive Behavioral Therapy (CBT)

are effective and recommended as a first-line treatment for these conditions. The purpose

of CBT is to help the patient reduce or eliminate the behavior and thinking patterns that are

contributing to his or her suffering and to replace dysfunctional patterns of behavior and

thought with patterns that promote health and well-being. Cognitive Behavioral Therapy

helps the patient change his negative thought patterns, emotions, with resulting changes in

behavior. If your patient can change just one of these things, he will have a much greater

chance of changing the other two. Home care clinicians don't have to be trained or directly

involved in this type of treatment to understand that behavior change is an important part

of the process. Therapists can and should be involved in behavior change and can work

with their patients to develop a plan to meet those goals. One obvious example is to

improve gait, mobility, and safety so that they can resume community activities again and

improve their social life. Understanding how these things work together will help home

care clinicians design a plan of care that is more likely to succeed and achieve better

outcomes. The British Columbia Medical Journal has information on how to adapt the

principles of CBT to the older adult population. These resources are available here:

http://www.bcmj.org/articles/cognitive-behavioral-therapy-older-adults.

CBT is used in a variety of settings and by various professionals. A strength of CBT when

compared with other similar forms of psychotherapy is its use of manuals that facilitate

the effective provision of therapy by professionals whose primary training may not be in

psychiatry, psychology, or counseling. These manuals come in individual, group, and self-

help formats.

See the appendices for case scenarios.

Page 14

References

Weaver A, Himle JA. Cognitive–behavioral therapy for depression and anxiety

disorders in rural settings: A review of the literature. J Rural Ment Heal.

2017;41(3):189-221. doi:10.1037/rmh0000075

National Institute on Aging. (2014). Assessing Cognitive Impairment in Older Patients.

[online] Available at: https://www.nia.nih.gov/health/assessing-cognitive-

impairment-older-patients [Accessed 7 Dec. 2017].

Palmer, E. (2016). Dementia, Delirium, and Depression in Older Adults: Rehabilitation

Reference Center. [online] Web.b.ebscohost.com. Available at:

http://web.b.ebscohost.com/rrc/detail?vid=5&sid=a30229cd-35af- 4b5a-92b6-

63353dae8b49%40sessionmgr104&bdata=JnNpdGU9cnJjLWxpdmU%3d#AN=T908762

&db=rrc [Accessed 7 Dec. 2017].

Lombara, A. and Palmer, E. (2017). Hydrocephalus, Normal Pressure: Rehabilitation

Reference Center. [online] Web.b.ebscohost.com. Available at:

http://web.b.ebscohost.com/rrc/detail?vid=7&sid=a30229cd-35af- 4b5a-92b6-

63353dae8b49%40sessionmgr104&bdata=JnNpdGU9cnJjLWxpdmU%3d#AN=T709056

&db=rrc [Accessed 7 Dec. 2017].

Brodaty, H. and Arasaratnam, C. (2012) Meta-analysis of nonpharmacological

interventions for neuropsychiatric symptoms of dementia. Am J Psychiatry. 169:946-953.

Haigh, J. Mytton, C. (2015) Sensory interventions to support the wellbeing of people with

dementia: A critical review. British J of Occupational Therapy. 70(2):120-126.

Bakker, R. (2003) Sensory loss, dementia and environments. Generations. 27(1):46-51.

American Geriatrics Society 2015 Beers Criteria Update Expert Panel (2015) American

Geriatrics Society 2015 updated Beers Criteria for potentially inappropriate medication

use in older adults. 63(11):2227-2246

While, C. Jocelyn, A. (2009) Observational pain assessment scales for people with

dementia: a review. British J of Community Nursing. 14(10); 438-442.

Peng, HL. Chang YP. (2013) Sleep disturbance in family caregivers of individuals with

dementia: a review of the literature. Perspectives in Psychiatrics Care. 49:135-146.

Moore, K. Ozanne, E. Ames, D. and Dow, B. (2013) How do family carers respond

to behavioral and psychological symptoms of dementia? International

Psychogeriatrics. 25(5):742-753.

Varghese, R. and Ifran, M. (2017) Delirium versus dementia: a diagnostic

conundrum in clinical practice. Psychiatric Annals. 47(5):239-245.

Page 15 
 
Nimh.nih.gov. (2017). NIMH » Depression. [online] Available at: 
https://www.nimh.nih.gov/health/topics/depression/index.shtml [Accessed 7 Dec. 2017]. 
 
Patricia, A. (2003). Evidence-based protocol : Elderly suicide-secondary prevention 
 
Alzheimer’s Association. 2017 Alzheimer’s Fact and Figures 
https://www.alz.org/documents_custom/2017- facts-and-figures.pdf accessed 
2/4/18 
 
Center for Disease Control. Aging and Depression 
https://www.cdc.gov/aging/mentalhealth/depression.htm accessed 2/4/18 
 
Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet. 2014 March 
8; 383(9920): 911– 922.

Page 16

Reason for referral: Recent fall without loss of consciousness, unsteady gait

History of Present Illness: Patient has had three falls in the last past 6 months, however 2

in the past week.

Medications: Aricept 10 mg po qd (evening), pravastatin 40 mg po qd (morning),

metoprolol 25mg po bid, famotidine 20 mg bid, aspirin 81 mg qd (evening), trazodone

25mg prn, Tylenol 500 mg prn, MOM prn,

Health Condition (ICD-10): Dementia with behavioral disturbance, age-related

osteoporosis, h/o major depressive disorder, hypocholesteremia, hypertension, GERD

Body Structures/Body Functions (Impairments): Weakness in LE’s, back pain, and

impaired balance. Family reports that the patient is more confused over the past few

days.

Activities & Participations: ADL’s- dressing upper body independently, lower body with

supervision due to difficulty standing on 1 leg. Family notes more challenges with her

bathing, daughter now assists minimally for shower 3x/week, but they note she is more

resistant to getting in the shower and don’t know what to do. Grooming – independent

with setup. Bed mobility – Supervision with use of bed bar. Transfers – supervision

Ambulation – 50 feet x 1 without device and CG x 1 for safety. Gait is slow and steady with

decreased step length. Able to ascend/descend 6 steps with 1 rail and CG.

Environmental Factors: Split level home with no steps to enter, bed and half bath on

first level, full bath up 2 flights of 6 steps with rail. Home has hardwood floors, wide

doorways and clear access throughout the home. Kitchen, DR 6 steps with rail to access.

Personal Factors: 76-year-old female with a college education, former occupation –

retired nurse, financially able to meet needs. Divorced, lives with adult daughter and

family.

Physical Exam: BP – 126/78 supine; 118/68 standing. 30 second chair stand test – able

to complete 5 reps. Timed up and go – 24 seconds. Pain –

patient did not complain of pain when asked.

Mini Cog – 2 points; Confusion Assessment Method (CAM) = (+) acute mental status

changes (increased confusion, outbursts), greater distractibility; irrelevant conversation;

and appeared lethargic. Positive for features 1, 2, 3 and 4.

Falls review with daughter.

All 3 falls have been during the night. One occurred at 10:45 pm when she was getting

herself to bed about 4 months ago. One occurred at around 12:30 am 6 days ago, heard

Case Scenario: Dementia

Page 17

her calling for help in living room, she was on the floor near the couch. Third fall occurred

11:45 pm 4 days ago in the kitchen, she reported to her daughter that she was hungry

and fell while accessing the refrigerator. She is not sleeping well and seems to be getting

up to “putter around” more during the nighttime. She used to take long walks during the

day while family worked but she is walking less and less these days and with her

dementia progressing they are not encouraging her to “go outside” anymore during the

day. They are concerned she may need nursing home placement if she continues to fall

and/or injures herself.

Homebound status – Needs a person to leave the home, leaving is infrequent and

considered a taxing effort. Medical Necessity – Patient is at risk for falling and has had

recent falls. Utilize Mental Health Safety Checklist and the Decision tree to guide clinical

decision making…Follow the red arrows.

Are there Signs/Symptoms of Cognitive/Mental health Issues and/or behaviors? YES.

Patient has known cognitive impairment, but recent behavior changes. No gait changes,

no signs of depression or anxiety. Screening for delirium via CAM is (+) indicating

delirium superimposed on the cognitive impairment patient already has. Should 911 be

called? Should patient go to Urgent Care Center? Should patient’s physician be called? In

this case, vital signs are stable, so MD should be contacted for further workup.

Page 18

Signs/Symptoms of

Cognitive/Mental

Health issues and/or

behaviors* (CI)

YES

Is the current treatment

plan effectively

addressing these

issues?

YES

*Signs/Symptoms:

Confusion, Change in judgment,

Hallucinations/Delusions

Altered Memory, Loss of interest

Lethargy/Aggression

CAM = positive

Mini-Cog = 2 points

Delirium due to

recent:

Hospitalization

UTI or dehydration

Infection

Med change or

initiation

Complete Cognitive Screen

Assess other possible causes

Delirium, Normal Pressure

Hydrocephalus, Depression/Anxiety

No changes in gait

or incontinence.

Normal Pressure

Hydrocephalus:

Gait change + Incontinence?

No signs of

depression or

anxiety.

Signs/Symptoms

Untreated

Depression/Anxiety?

**See Mental

Health Safety

Checklist

Proceed with

PT**

Continue to

monitor

Based on clinical findings:

• Contact MD to share findings for further

workup

• Advise urgent medical care visit

• Initiate 911 call for EMS to assess patient

DEMENTIA DECISION TREE

Page 19

Reason for referral: Recent fall, difficulty with getting in and out of home.

History of Present Illness: Patient was found on the floor in her bedroom by adult

daughter. Patient was taken to MD for follow up. No fractures noted on x-ray. + contusion

on L buttock.

Medications: Metoprolol, Prozac, levothyroxine, atorvastatin

Health Condition (ICD-10): Hypertension, depression, hypothyroidism, high cholesterol

Body Structures/Body Functions (Impairments): Generalized weakness, nervous

system disorder.

Activities & Participations: ADL’s- dressing upper body independent with setup, lower

body with supervision once clothes were set up. Bathing – currently sponge baths at sink

with min assistance. Grooming – independent with setup. Bed mobility – Supervision

with use of bed bar. Transfers – sit to stand with contact guard x 1. Ambulation – 75 feet x

2 with supervision x 1 for safety. Gait is slow with shuffling steps noted.

Ascending/descending steps with contact guard due to weakness and increased risk of

falling. Patient reports limiting outdoor activities stating, “I don’t feel up to going out.”

Daughter reports, “My mom has been staying in bed more and more. She also doesn’t

have much of an appetite.”

Environmental Factors: Two floor mother/daughter home with 2 steps no hand rails to

enter, bed and bath on first level, daughter lives with spouse on second floor. Home has

hardwood floors throughout. Daughter is patient’s primary caregiver. Daughter works

full time approximately 20 minutes away from home and is available by phone during the

day. Daughter assists patient before going to work and during nights/weekends.

Currently homebound due to need for assistance to leave the home; leaving is infrequent

and requires considerable and taxing effort.

Personal Factors: 66-year-old female with a college education, former occupation –

receptionist, financially able to meet needs. Spouse recently passed away 2 months ago.

Physical Exam: BP – 104/66 supine; 100/64 standing, HR – 110 bpm at rest, 110 bpm

with activity, RR – 20 at rest, 24 with activity. Appears A and O x 4 at time of visit.

30 second chair stand test – unable to complete as patient needed assist to stand. Gait

Speed – 0.8 m/sec. 2 Minute Step Test (2MST) – 57 reps. Rate of Perceived Exertion

following 2MST – 5/10, Pain

– patient did not complain of pain when asked.

Case Scenario: Depression

Page 20

PHQ2 – 4 points.

Mini-Cog – 4 points.

Using the decision tree provided, Is this patient appropriate for physical therapy

services? Yes/No. If no, what is the appropriate course of action to take? Complete suicide

screen and contact MD for further workup. Vitals are stable. Physical Therapy is

appropriate depending on patient willingness to participate.

Signs/Symptoms of

Cognitive/Mental

Health issues and/or

behaviors* (CI)

YEYSES

Is the current treatment

plan effectively

addressing these

issues?

YES

*Signs/Symptoms:

Confusion, Change in judgment,

Hallucinations/Delusions

Altered Memory, Loss of interest

Lethargy/Aggression

Patient appears A and O

x 4 through observation

and interview. Min-cog =

4 points (negative for

cog impairment)

Hospitalization

UTI or dehydration

Infection

Med change or initiation

Complete Cognitive Screen

Assess other possible causes

Delirium, Normal Pressure

Hydrocephalus, Depression/Anxiety

No changes to

gait or

incontinence

noted

Normal Pressure

Hydrocephalus:

Gait change +Incontinence?

PHQ-2 = 4 points

suggestive of

depression

Signs/Symptoms

Depression/Anxiety

**See Mental

Health Safety

Checklist

Proceed with

PT**

Continue to

monitor

Complete

Suicide Screen

Page 21

Based on clinical findings:

• Contact MD to share findings for further

workup

• Advise urgent medical care visit

• Initiate 911 call for EMS to assess patient

DEPRESSION DECISION TREE

Page 22

Reason for referral: Difficulty performing ADLs due to shortness of breath and inability

to ascend/descend stairs. No reported falls within past year.

History of Present Illness: Patient hospitalized for shortness of breath was discharged

from hospital with referral for physical therapy to improve ADLs, gait and stair

negotiation. Unable to climb stairs due to anxiety related to SOB and fear of falling.

Medications: Boniva 150 mg PO monthly; Prednisolone 5 mg PO 1 tablet daily; Advair

(salmeterol/fluticasone) 50 mcg/250mcg PO 1 actuation every 12 hours; albuterol 2.5

mg (nebulizer) twice to three times per day as needed for bronchospasm. Metoprolol

25mg PO bid, Prozac 20mp PO daily, Xanax .025mg every 8-12 hours as needed for

anxiety no more than 3 tablets per day, Tylenol 500 mg 1-2 tablets every 6 hours as

needed for pain, no more than 8 tablets per day.

Health Condition (ICD-10): COPD, Anxiety, hypertension, osteoporosis

Body Structures/Body Functions (Impairments): Generalized weakness, shortness of

breath, excessive kyphosis, nervous system disorder.

Activities & Participations: ADL’s- dressing upper body moderate assistance due to SOB

with activity, lower body with moderate assistance with SOB with activity and anxiety

with reaching down towards feet. Bathing – not able – currently sponge baths at sink

with mod assistance. Grooming – independent with setup. Bed mobility – Supervision

with use of bed bar. Transfers – sit to stand with contact guard x 1 using FWW and erratic

breathing pattern, complaints of nervousness. Ambulation – 50 feet x 1 with FWW and

Min assist x 1 for safety and encouragement to perform needs VC for breathing pattern

and relaxation reminders as patient reports feeling nervous. Gait is slow and steady,

decreased step length and apprehension noted. Unable to ascend/descend steps at

present.

Homebound due to need for a person and device to leave home; leaving is infrequent and

requires considerable and taxing effort.

Environmental Factors: Split level home with 3 steps with one hand rail to enter, bed

and half bath on first level, full bath up 2 flights of 6 steps with rail. Home has hardwood

floors, and clear access throughout the home with FWW. Kitchen, DR 6 steps with rail to

access.

Personal Factors: 66-year-old female with a college education, former occupation –

receptionist, financially able to meet needs. Lives with spouse. Adult daughter and son

live nearby and are available as needed, nights and weekends.

Physical Exam: BP – 116/72 supine; 110/68 standing, HR – 110 bpm at rest, 124 bpm

Case Scenario: Anxiety

Page 23

with activity, RR – 20 at rest, 26 with activity. Excessive use of accessory respiratory

muscles noted.

30 second chair stand test – unable to complete as patient needed assist to stand. Gait

Speed – 0.9 m/sec. 2 Minute Step Test (2MST) – 7 reps, test was stopped at 32 seconds

due to patient request, due to anxiety. Rate of Perceived Exertion following 2MST – 8/10,

Pain – patient did not complain of pain when asked.

PHQ-2 = 0; Mini-COG = 5; HAM-A = 25 points

Using the decision tree provided, Is this patient appropriate for physical therapy

services? Yes/No. If no, what is the appropriate course of action to take. Decision is

patient is appropriate to continue with physical therapy as vital signs are stable, patient

is cognitively intact however, anxiety requires further workup. MD should be contacted.

Signs/Symptoms of

Cognitive/Mental

Health issues and/or

behaviors* (CI)

Y E S

Is the current treatment

plan effectively

addressing these

issues?

YES

*Signs/Symptoms:

Confusion, Change in judgment,

Hallucinations/Delusions

Altered Memory, Loss of interest

Lethargy/Aggression

Mini COG= 5 (not

indicative of cog

impairment)

Complete Cognitive Screen

Assess other possible causes

Delirium, Normal Pressure

Hydrocephalus, Depression/Anxiety

No changes in gait

or incontinence.

HAM-A – 25

points indicative

of Moderate

Anxiety

PHQ2 = 0

(not

indicative of

depression)

**See Mental

Health Safety

Checklist

Proceed with

PT**

Continue to

Normal Pressure

Hydrocephalus:

Gait change +Incontinence?

Signs/Symptoms

Untreated

depression/anxiety?

monitor

Page 24

Based on clinical findings:

• Contact MD to share findings for further

workup

• Advise urgent medical care visit

• Initiate 911 call for EMS to assess patient

Delirium due to

recent:

Hospitalization

UTI or dehydration

Infection

Med change or

initiation

ANXIETY DECISION TREE