What are good order sets for geriatric patients requiring psychiatric services?

Geriatric Psychiatry Order Sets: Evidence-Based Framework

Comprehensive geriatric psychiatry order sets should prioritize systematic assessment protocols for delirium and dementia, standardized medication reconciliation to minimize polypharmacy, non-pharmacological interventions as first-line treatment, and structured monitoring for adverse effects when medications are necessary. 1

Core Assessment Components

Cognitive and Mental Status Screening

• Implement two-step delirium screening using the Delirium Triage Screen (highly sensitive) followed by the Brief Confusion Assessment Method (highly specific) for all geriatric psychiatric admissions 1
• Conduct dementia screening after ruling out delirium, as cognitive impairment is often undetected in geriatric ED patients and provides critical baseline documentation for future visits 1
• Re-evaluate delirium screening regularly, as mental status changes wax and wane throughout hospitalization 1
• Use validated quantitative measures such as the Cohen-Mansfield Agitation Inventory or Neuropsychiatric Inventory Questionnaire (NPI-Q) to establish objective baseline severity and monitor treatment response 2

Medical Workup for Behavioral Symptoms

Before any psychiatric intervention, systematically investigate reversible medical causes that commonly drive behavioral disturbances in geriatric patients who cannot verbally communicate discomfort 1, 2:

• Infections: Urinary tract infections and pneumonia are the most common triggers 1, 2
• Pain assessment: Use systematic pain scales, as untreated pain is a major contributor to agitation and aggression 1, 2
• Metabolic disturbances: Check for hypoxia, dehydration, electrolyte abnormalities, and hyperglycemia 1, 2
• Constipation and urinary retention: Both significantly contribute to restlessness and behavioral symptoms 1, 2
• Medication review: Identify anticholinergic medications (diphenhydramine, oxybutynin, cyclobenzaprine) that worsen confusion and agitation 2

Fall Risk Assessment

Order sets must include comprehensive fall evaluation for all geriatric psychiatric patients 1:

• Document fall history, time spent on floor, and circumstances of any falls 1
• Perform orthostatic blood pressure assessment 1
• Conduct neurologic assessment with attention to neuropathies and proximal motor strength 1
• Evaluate gait using the "get up and go test" before discharge—patients unable to rise from bed, turn, and steadily ambulate require reassessment 1
• Review medications, particularly vasodilators, diuretics, antipsychotics, and sedative/hypnotics 1

Medication Management Protocols

Comprehensive Medication Reconciliation

• Conduct medication reviews using the Medication Regimen Complexity Index (MRCI) to reduce polypharmacy risks that are particularly dangerous in elderly patients with multiple conditions 3
• Identify and minimize anticholinergic medications that worsen confusion and agitation 2
• Review all medications for drug toxicity or adverse effects that may worsen behavioral symptoms 2
• Document all current medications, including over-the-counter drugs and supplements 1

Pharmacological Treatment Algorithm for Behavioral Symptoms

Step 1: Non-pharmacological interventions must be attempted first and documented as failed before considering medications 1, 2:

• Environmental modifications: adequate lighting, reduced noise, structured routines 2
• Communication strategies: calm tones, simple one-step commands, gentle touch 2
• Activity-based interventions tailored to individual abilities 2
• Caregiver education about dementia-related behaviors 2

Step 2: Medication selection based on symptom profile 1, 2, 4:

For chronic agitation without psychotic features:

• First-line: SSRIs 1, 2
  • Citalopram 10 mg/day (maximum 40 mg/day) 2
  • Sertraline 25-50 mg/day (maximum 200 mg/day) 2
• Evaluate response within 4 weeks at adequate dosing 1, 2
• Taper and discontinue if no clinically significant response after 4 weeks 1, 2

For severe agitation with psychotic features (delusions, hallucinations causing distress):

• First-line: Atypical antipsychotics 1, 4
  • Risperidone 0.25-0.5 mg once daily at bedtime (target 0.5-1.25 mg daily, maximum 2 mg/day) 2, 4
  • Quetiapine 12.5 mg twice daily (maximum 200 mg twice daily) 2, 4
  • Olanzapine 2.5 mg at bedtime (maximum 10 mg/day)—less effective in patients over 75 years 2, 4

For acute severe agitation with imminent risk of harm:

• Haloperidol 0.5-1 mg orally or subcutaneously (maximum 5 mg daily in elderly patients) 1, 5, 2
• Use only when behavioral interventions have failed and patient is threatening substantial harm to self or others 5, 2

Critical Safety Requirements for Antipsychotic Use

Before initiating any antipsychotic, discuss with patient (if feasible) and surrogate decision maker 2:

• Increased mortality risk (1.6-1.7 times higher than placebo) in elderly dementia patients 2
• Cardiovascular effects including QT prolongation, sudden death, dysrhythmias, hypotension 2
• Cerebrovascular adverse reactions 2
• Falls risk 2
• Expected benefits and treatment goals 2

Monitoring requirements 2:

• Daily in-person examination to evaluate ongoing need 2
• ECG monitoring for QTc prolongation 2
• Assess for extrapyramidal symptoms, falls, metabolic changes 2
• Attempt taper within 3-6 months to determine lowest effective maintenance dose 1, 2

Medications to AVOID in Geriatric Psychiatry

• Benzodiazepines for routine agitation management (except alcohol/benzodiazepine withdrawal): increase delirium incidence and duration, cause paradoxical agitation in ~10% of elderly patients, risk respiratory depression 1, 5, 2
• Typical antipsychotics as first-line therapy: 50% risk of tardive dyskinesia after 2 years of continuous use in elderly patients 2
• Anticholinergic medications: diphenhydramine, oxybutynin, cyclobenzaprine worsen agitation and cognitive function 2
• Cholinesterase inhibitors for acute agitation: associated with increased mortality when newly prescribed for delirium 2

Specialized Order Sets by Clinical Scenario

Delirium Management Orders

• Limit chemical and physical restraints to only situations where absolutely necessary 1
• Maximize alternative safety measures and appropriate medication use 1
• Address underlying causes: infections, medications, metabolic disturbances 1
• For severe agitation: haloperidol 0.5-1 mg subcutaneously every 2 hours as required (maximum 5 mg daily) 5
• Consider midazolam 2.5-5 mg subcutaneously every 2-4 hours only if patient remains severely agitated despite haloperidol 5

Depression in Geriatric Patients

• First-line: SSRIs 3, 4
  • Sertraline 25-50 mg/day (minimal drug interactions, excellent tolerability) 3, 2
  • Escitalopram (favorable adverse effect profile) 3
• Start at 50% of standard adult doses due to age-related pharmacokinetic changes 3
• Allow 4-8 weeks for full therapeutic trial 2
• Continue treatment for 9 months after first episode, then reassess 2

Bipolar Disorder with Neurological Comorbidities

• Geriatric psychiatrists should coordinate care when managing bipolar disorder with conditions like Parkinson's disease, as they have expertise in managing medication interactions between mood stabilizers and dopaminergic treatments 3
• Apply the "Geriatric 5Ms" framework: Mind, Mobility, Medications, What Matters Most, Multicomplexity 3
• Monitor for orthostatic hypotension, falls risk, cognitive function changes, metabolic effects, QT prolongation 3

Workforce and Care Coordination Considerations

• Only 2,600 psychiatrists have received subspecialty certification in geriatric psychiatry since 1991, with 61% of fellowship positions remaining unfilled 1, 3
• Multidisciplinary team-based care models should coordinate with neurologists, pharmacists, and other specialists 3
• Hospital- and community-based mental healthcare organizations should include outreach to long-term care settings as an integrated service component 1

Documentation Requirements

• Document baseline cognitive function using validated screening instruments 1
• Record all non-pharmacological interventions attempted before medication initiation 1, 2
• Use ABC (antecedent-behavior-consequence) charting to identify triggers of behavioral symptoms 2
• Document informed consent discussions about antipsychotic risks with surrogate decision makers 2
• Record quantitative measures of symptom severity at baseline and follow-up 2

Common Pitfalls to Avoid

• Never add multiple psychotropics simultaneously without first treating reversible medical causes 2
• Avoid continuing antipsychotics indefinitely—review need at every visit and attempt taper if no longer indicated 1, 2
• Do not use antipsychotics for mild agitation or behaviors like unfriendliness, poor self-care, repetitive questioning, or wandering that are unlikely to respond 2
• Never skip pain assessment before attributing behavioral symptoms to psychiatric causes 1, 2
• Avoid polypharmacy—systematically deprescribe before adding new medications 2