Managing Geriatric Psychiatry

Checkpoint A: Pre-Draft Intake (Mandatory)

1. What is the patient's age and living situation? (community-dwelling, assisted living, skilled nursing, memory care, long-term acute care) — default: identify setting
2. What is the referral question? (depression evaluation, BPSD management, medication review, delirium assessment, capacity evaluation, sleep disturbance) — default: specify
3. What is the patient's cognitive status? (normal cognition, MCI, mild/moderate/severe dementia) — default: assess with MoCA or MMSE
4. What is the current medication burden? (number of medications, number of prescribers) — default: complete medication reconciliation
5. Has a Beers Criteria review been completed? — default: conduct review
6. Are there current safety concerns? (falls, wandering, aggression, self-neglect, suicidal ideation, driving) — default: assess
7. Who is the primary caregiver and what is the caregiver's status? (burden, depression, support needs) — default: assess
8. Are there advance directives or a designated healthcare proxy? — default: review and document

Documents to Request

• Complete medication list from all prescribers (including OTC, supplements, herbals)
• Pharmacy records (medication fill dates for adherence assessment)
• Primary care and specialist records (complete problem list)
• Recent laboratory results: CBC, CMP, TSH, B12, folate, 25-OH vitamin D, urinalysis, albumin/prealbumin
• Cognitive testing results (MoCA, MMSE, neuropsychological testing)
• Brain imaging (MRI or CT)
• ECG (baseline QTc)
• Fall risk assessment and fall history
• Functional assessment (ADLs, IADLs)
• Nursing facility records including MDS (Minimum Data Set) assessments
• Advance directives, POLST/MOLST, healthcare proxy documentation
• Caregiver assessment (Zarit Burden Interview if applicable)

Step 1: Comprehensive Geriatric Psychiatric Assessment

Medical Complexity Assessment

Older adults present with psychiatric symptoms that are frequently caused or exacerbated by medical conditions:

• Delirium: The single most important diagnostic consideration in any acute behavioral change in an elderly patient. Screen with CAM or 4AT. Causes: UTI, pneumonia, medication toxicity (especially anticholinergics, benzodiazepines, opioids), dehydration, constipation, pain, metabolic derangement, post-surgical state.
• Thyroid dysfunction: Hypothyroidism mimics depression; hyperthyroidism mimics anxiety and mania. Check TSH.
• Vitamin deficiencies: B12 deficiency causes depression, cognitive impairment, peripheral neuropathy. Folate deficiency causes depression. Check levels.
• Chronic pain: Frequently drives depression, anxiety, insomnia, and substance misuse in older adults.
• Sleep disorders: Obstructive sleep apnea, REM sleep behavior disorder (associated with synucleinopathies), circadian rhythm changes.
• Sensory deficits: Hearing loss and visual impairment contribute to social isolation, paranoia, and depression.

Psychiatric Assessment

• Depression screening: Geriatric Depression Scale (GDS-15 or GDS-30) or PHQ-9. Note: Somatic symptoms of depression overlap with medical illness — use instruments validated for geriatric populations.
• Anxiety screening: GAD-7 or Geriatric Anxiety Inventory (GAI).
• Cognitive screening: MoCA (preferred for sensitivity to MCI) or MMSE. Interpret in context of education, language, and sensory function.
• BPSD assessment: Neuropsychiatric Inventory (NPI) — 12 behavioral domains rated for frequency and severity. Cohen-Mansfield Agitation Inventory (CMAI) for agitation-specific assessment.
• Suicide risk: Older adults have the highest suicide completion rate of any age group. White males over 85 are at the highest risk. Screen with C-SSRS. Risk factors: social isolation, chronic illness, pain, bereavement, access to firearms.
• Substance use: Screen for alcohol use (AUDIT-C) and benzodiazepine, opioid, and OTC medication misuse. Under-recognized in this population.

Step 2: Medication Reconciliation and Beers Criteria Review

Complete Medication Reconciliation

• Obtain medication lists from all prescribers, pharmacies, and the patient/caregiver
• Include OTC medications, supplements, and herbal products
• Identify duplicate therapies and drug-drug interactions
• Calculate Anticholinergic Cognitive Burden (ACB) Scale score — score ≥3 associated with cognitive impairment and delirium
• Identify medications with fall risk: benzodiazepines, opioids, antihypertensives, sedating antihistamines, skeletal muscle relaxants

AGS Beers Criteria — Key Psychotropic Medications to Avoid or Use with Caution

Strongly Avoid:

• First-generation antihistamines (diphenhydramine, hydroxyzine) — anticholinergic, sedating, delirium risk
• Benzodiazepines (all, short and long-acting) — falls, fractures, cognitive impairment, delirium, respiratory depression. If must use: lowest dose, shortest duration, lorazepam or oxazepam preferred (no active metabolites).
• Tricyclic antidepressants (amitriptyline, nortriptyline) — anticholinergic, cardiac conduction effects, orthostatic hypotension, falls
• Barbiturates — high risk of overdose, physical dependence
• Meprobamate — high risk of physical dependence, sedation

Use with Caution:

• SSRIs — hyponatremia risk (SIADH), especially with diuretics. Monitor sodium at baseline and 2 weeks.
• SNRIs — may increase blood pressure. Monitor BP.
• Mirtazapine — sedation (may be beneficial for insomnia/poor appetite; may worsen falls)
• Antipsychotics — FDA Black Box Warning: increased mortality in dementia (1.6-1.7x placebo). CMS F-Tag 758 requirements for documentation in nursing facilities. Use lowest dose for shortest duration with documented clinical justification.

Step 3: Managing Behavioral and Psychological Symptoms of Dementia (BPSD)

Non-pharmacological interventions (first-line per APA, AGS, and CMS guidelines):

• Identify and address triggers: pain (Pain Assessment in Advanced Dementia — PAINAD scale), infection, constipation, environmental overstimulation, unmet needs (hunger, toileting, boredom)
• Structured activities: music therapy, reminiscence therapy, art therapy, pet therapy
• Environmental modifications: consistent routines, adequate lighting, reduced noise, orientation cues
• Caregiver training: communication strategies, behavioral management, de-escalation techniques
• Exercise programs (walking, chair exercises)
• DICE approach (Describe, Investigate, Create, Evaluate) for systematic behavioral analysis

Pharmacological interventions (when non-pharmacological approaches insufficient):

• Agitation/aggression: Citalopram 10-30mg/day (CitAD trial showed efficacy, but QTc prolongation risk at higher doses — ECG monitoring required). Prazosin 1-6mg for trauma-related BPSD. Dextromethorphan/quinidine (Nuedexta) for pseudobulbar affect and agitation.
• Psychosis (delusions, hallucinations): Low-dose atypical antipsychotic (risperidone 0.25-1mg, quetiapine 12.5-100mg, aripiprazole 2-10mg) — document FDA Black Box Warning discussion, clinical justification, target symptoms, and plan for taper/discontinuation.
• Depression in dementia: Sertraline 25-100mg or citalopram 10-20mg. ECT if severe or treatment-resistant.
• Insomnia: Sleep hygiene first. Melatonin 0.5-3mg. Trazodone 25-50mg. Avoid benzodiazepines and Z-drugs (zolpidem).
• Avoid: Benzodiazepines (paradoxical disinhibition, falls, worsened cognition), anticholinergics (worsened cognition), typical antipsychotics (higher EPS risk in elderly).

Step 4: Late-Life Depression and Anxiety Treatment

Late-life depression treatment algorithm:

1. First-line: SSRI (sertraline or escitalopram — fewest drug interactions). Start at half adult dose (sertraline 25mg, escitalopram 5mg). Titrate slowly.
2. Monitor sodium level at 2 weeks (SIADH risk). Monitor for falls, GI bleeding (especially if on anticoagulants or NSAIDs).
3. Adequate trial: 8-12 weeks in elderly (longer than younger adults).
4. If inadequate response: optimize dose, then switch SSRI or try SNRI (venlafaxine or duloxetine — duloxetine also treats neuropathic pain).
5. Augmentation: Low-dose aripiprazole (2-5mg) or lithium (target level 0.4-0.6 mEq/L in elderly — renal monitoring essential).
6. For severe, treatment-resistant, or psychotic depression: ECT is highly effective in elderly and may be first-line for psychotic depression.
7. Psychotherapy: Problem-Solving Therapy (PST) and CBT adapted for older adults have strong evidence. Behavioral Activation is effective even in patients with cognitive impairment.

Late-life anxiety:

• First-line: SSRI or SNRI (same as depression)
• CBT adapted for older adults
• Buspirone 7.5-30mg/day (does not impair cognition, no fall risk, no dependence)
• Avoid benzodiazepines — fall risk, cognitive impairment, paradoxical reactions, physical dependence

Step 5: Care Coordination, Caregiver Support, and Safety Planning

Care coordination:

• Communicate medication changes to all prescribers (primary care, specialists, nursing facility)
• Coordinate with home health, adult day programs, and community services
• Ensure medication management support (pillbox, pharmacy sync, caregiver assistance)
• Assess need for higher level of care (assisted living, memory care, skilled nursing)

Caregiver assessment and support:

• Screen caregiver for depression and burden (Zarit Burden Interview)
• Provide psychoeducation about the disease course and behavioral management
• Connect with respite care services and support groups (Alzheimer's Association)
• Assess for elder abuse (financial exploitation, neglect, physical or emotional abuse)

Safety assessment:

• Fall prevention: Home safety evaluation, physical therapy referral, medication review
• Driving safety: Assess and document. Report to DMV if required by state law.
• Firearms access: Counsel on safe storage or removal
• Financial exploitation: Assess capacity for financial decision-making; referral to Adult Protective Services if exploitation suspected
• Wandering risk: GPS tracking, door alarms, MedicAlert + Safe Return enrollment

Checkpoint B: Post-Draft Alignment (Mandatory)

1. Has delirium been screened for and excluded in any acute behavioral change?
2. Has a complete medication reconciliation been performed with Beers Criteria review?
3. Are non-pharmacological interventions documented as first-line for BPSD?
4. Is the FDA Black Box Warning documented when antipsychotics are prescribed for dementia patients?
5. Are caregiver needs assessed and addressed in the treatment plan?

Quality Audit

• Delirium screen completed (CAM or 4AT) for any acute behavioral change
• Cognitive screening with validated tool (MoCA or MMSE) with score documented
• Complete medication reconciliation from all prescribers
• Beers Criteria review completed with Anticholinergic Cognitive Burden score
• Depression screened with geriatric-validated instrument (GDS or PHQ-9)
• Suicide risk assessed (older adults have highest completion rate)
• Non-pharmacological interventions documented as first-line for BPSD
• If antipsychotic prescribed: FDA Black Box Warning documented, target symptoms specified, taper plan included
• Medication dosing adjusted for age-related pharmacokinetic changes (start low, go slow)
• Falls risk assessment completed with intervention plan
• Caregiver burden assessed and support provided
• Safety assessment (driving, firearms, financial exploitation, wandering) documented
• Advance care planning status documented
• CMS F-Tag 758 compliance documented if patient is in nursing facility

Guidelines

1. In any acute behavioral change in an elderly patient, rule out delirium before attributing symptoms to psychiatric illness — delirium is a medical emergency with identifiable and treatable causes.
2. Apply "start low, go slow" for all psychotropic prescribing in the elderly — initial doses should be 25-50% of adult starting doses with slower titration intervals.
3. Complete Beers Criteria review before adding any psychotropic — polypharmacy is the rule, not the exception, in geriatric psychiatry, and drug interactions are the leading cause of adverse events.
4. Non-pharmacological interventions must be documented as first-line for BPSD — CMS and Joint Commission surveyors look specifically for this documentation before accepting antipsychotic use.
5. When prescribing antipsychotics for dementia, document the FDA Black Box Warning discussion, specific target symptoms, monitoring plan, and plan for dose reduction or discontinuation — indefinite antipsychotic use in dementia patients requires ongoing justification.
6. Monitor sodium levels when starting SSRIs in elderly patients, especially those on diuretics — SIADH-induced hyponatremia is the most common serious SSRI side effect in this population.
7. Assess caregiver health and burden at every visit — caregiver burnout is a primary driver of institutionalization and patient outcomes depend heavily on caregiver wellbeing.
8. Never attribute new psychiatric symptoms to "just getting old" — late-onset psychiatric illness always warrants a thorough medical and neurological workup.