Geriatric Psychiatric Order Set Review for Assisted Living Facilities
Overall Assessment
Your order sets are comprehensive and clinically sound, covering the essential monitoring parameters for geriatric psychiatric patients in assisted living facilities. 1, 2 I recommend several additions and modifications based on current guidelines to enhance safety monitoring and address common pitfalls in this vulnerable population.
Antipsychotic Initiation/Monitoring Order Set
Your Current Template is Strong
Your baseline workup captures the critical metabolic and cardiovascular monitoring parameters required before antipsychotic initiation. 1, 3
Critical Additions Needed
Add delirium screening at baseline using the two-step process: Delirium Triage Screen followed by Brief Confusion Assessment Method (bCAM). 4, 1 This is essential because delirium is present in 10-31% of admissions and antipsychotics worsen outcomes when delirium is the primary problem rather than a psychiatric indication. 2
Add anticholinergic burden assessment/medication review as a mandatory checkbox. 4, 1 Anticholinergic medications are major contributors to delirium and behavioral symptoms in elderly patients, and starting an antipsychotic on top of existing anticholinergic burden substantially increases fall risk and cognitive decline. 2
Add prolactin level to baseline labs. 5 This is particularly important in geriatric patients on risperidone or conventional antipsychotics, as hyperprolactinemia can cause additional morbidity.
Add documentation template for black box warning discussion. 3 You must document that you discussed the 1.6-1.7 times increased mortality risk in elderly patients with dementia-related psychosis, cardiovascular effects, cerebrovascular adverse reactions, falls, and metabolic changes, and why benefits are expected to outweigh risks. 3
Monitoring Frequency Specifications
Repeat orthostatic vitals and fall risk assessment at 1 week, 2 weeks, and 4 weeks after initiation or dose escalation. 1, 6 Falls occur most frequently in the first month after antipsychotic initiation due to orthostatic hypotension and sedation. 6
Reassess benefits versus harms at 2-4 weeks using quantitative measures like Cohen-Mansfield Agitation Inventory or NPI-Q. 3, 5 If causing more harm than benefit, begin deprescribing immediately. 6
Schedule AIMS exam at baseline, 3 months, 6 months, then every 6 months. 5 Your current template mentions AIMS but doesn't specify timing.
Mood Stabilizer Monitoring Order Set
Lithium-Specific Additions
Add baseline creatinine clearance calculation (not just serum creatinine in CMP). 7 Elderly patients often have reduced renal function despite normal serum creatinine due to decreased muscle mass, and lithium dosing must be adjusted accordingly. 7
Add baseline EKG. 7 Lithium can cause cardiac conduction abnormalities, particularly in elderly patients.
Specify lithium level timing: draw 8-12 hours after the previous dose when concentrations are relatively stable. 7 This is critical for accurate interpretation.
Specify monitoring frequency: lithium levels twice weekly during acute phase until stable, then every 2 months during maintenance. 7 Elderly patients often require lower doses (target 0.6-1.2 mEq/L) and exhibit toxicity at levels ordinarily tolerated by younger patients. 7
Valproate-Specific Additions
Add baseline ammonia level. 8 Hyperammonemia can occur even with therapeutic valproate levels and causes encephalopathy in elderly patients.
Add albumin level to baseline labs. 8 Lower baseline albumin concentration is associated with increased risk of somnolence, dehydration, and reduced nutritional intake in elderly patients on valproate. 8
Add platelet count monitoring at 2 weeks and 4 weeks after initiation. 8 Thrombocytopenia risk increases significantly at valproate concentrations ≥110 μg/mL (females) or ≥135 μg/mL (males), and 27% of patients receiving approximately 50 mg/kg/day develop platelets ≤75 x 10⁹/L. 8
Add specific monitoring for somnolence, nutritional intake, and weight at each visit. 8 In elderly patients with dementia, valproate causes significantly higher rates of somnolence and dehydration, with associated reduced nutritional intake and weight loss. 8
Antidepressant Initiation (Geriatric) Order Set
Critical Additions
Add baseline EKG for patients receiving citalopram, escitalopram, or tricyclic antidepressants. 5 QTc prolongation is a significant risk in elderly patients, particularly with citalopram doses >20 mg daily.
Add drug interaction screening specifically for CYP450 interactions. 5 Fluoxetine, fluvoxamine, paroxetine, nefazodone, and TCAs require extra caution when combined with other medications metabolized by CYP450 enzymes. 5
Add repeat sodium check at 1 week and 2 weeks after initiation. 4 Hyponatremia from SSRIs develops rapidly in elderly patients and is a leading cause of falls and altered mental status.
Add cognitive screening at baseline (MoCA or MMSE). 4 This establishes baseline cognitive function and helps distinguish medication-induced cognitive changes from underlying dementia progression.
Delirium/Acute Mental Status Change Workup
Your Template is Excellent
This order set captures the essential workup recommended by emergency medicine guidelines. 4, 1, 2
Suggested Additions
Add chest X-ray as standard (not just "consider if indicated"). 1, 2 Pneumonia is one of the two most common infectious causes of delirium in elderly patients, and clinical examination alone misses many cases. 2
Add blood cultures if fever or sepsis suspected. 1 Bacteremia causes neurological symptoms ranging from lethargy to coma in over 80% of cases. 2
Add pain assessment using validated tool (e.g., PAINAD for patients with dementia). 4, 3 Pain is a major contributor to behavioral disturbances and delirium but is often overlooked in nonverbal patients. 3
Add constipation assessment. 4, 3 Constipation worsens behavioral symptoms and can precipitate delirium. 3
Add hearing and vision assessment. 2, 3 Sensory impairments significantly contribute to delirium, and ensuring patients use glasses and hearing aids is a simple intervention. 2
Add dehydration assessment beyond just labs. 2 Dehydration is a common precipitating factor that may not be apparent on initial laboratory examination. 2
Add oxygen saturation and supplemental oxygen if needed. 4 Hypoxia is a reversible cause of delirium requiring immediate intervention. 4
Dementia Evaluation/Cognitive Decline Order Set
Additions to Consider
Add HIV testing in appropriate populations. 4 While RPR is optional in your template, HIV-associated dementia should be considered in the differential.
Add neuroimaging (CT or MRI brain) as standard for new cognitive complaints. 2 This identifies reversible causes including subdural hematoma, normal pressure hydrocephalus, and stroke. 2
Add depression screening using validated tool (GDS-15 or PHQ-9). 4 Depression is a common reversible cause of cognitive impairment in elderly patients and requires specific treatment. 4
Add functional assessment (ADLs/IADLs). 4 This helps distinguish MCI from dementia and establishes baseline for monitoring progression.
Add informant-based assessment (e.g., AD8 or IQCODE). 4 Cognitive testing alone can miss early dementia, particularly in patients with high premorbid function.
Additional Order Set to Consider
Pain Assessment and Management Order Set
Create a dedicated pain assessment order set for assisted living patients. 4, 3 Pain is a major contributor to behavioral disturbances, agitation, and delirium in elderly patients but is systematically undertreated, particularly in patients with dementia who cannot verbalize discomfort. 3
Include:
- Validated pain assessment tool (PAINAD for nonverbal patients, numeric rating scale for verbal patients) 3
- Assessment for common pain sources: arthritis, constipation, urinary retention, pressure ulcers, dental problems 4, 3
- Non-opioid analgesic trial (acetaminophen scheduled dosing) 2
- Physical therapy/occupational therapy consultation 2
- Reassessment within 48-72 hours 3
Common Pitfalls to Avoid
Never assume confusion is "just dementia" without screening for delirium. 1, 2 Delirium is a medical emergency with mortality rates twice as high if the diagnosis is missed, and it requires aggressive investigation for reversible causes. 2
Never start antipsychotics for behavioral symptoms without first ruling out and treating pain, infection, constipation, urinary retention, and medication side effects. 4, 1, 3 These reversible causes are present in the majority of cases and antipsychotics worsen outcomes when the underlying problem is not addressed. 1, 2
Never use benzodiazepines as first-line treatment for agitation or delirium (except alcohol or benzodiazepine withdrawal). 1, 2 Benzodiazepines are potent precipitants of delirium, increase fall risk, and cause paradoxical agitation in elderly patients. 2, 3
Never continue antipsychotics indefinitely without documented reassessment. 5, 6 For agitated dementia, taper within 3-6 months to determine the lowest effective maintenance dose or whether the medication can be discontinued entirely. 5
Never combine clozapine with carbamazepine. 5 More than 25% of experts consider this combination contraindicated due to additive bone marrow suppression risk. 5