Management of Delirium, Cognitive Decline, and Behavioral Symptoms in Geriatric Psychiatric Patients
Delirium Screening & Prevention
Perform a two‑step baseline delirium screen using the Delirium Triage Screen followed by the Brief Confusion Assessment Method (bCAM) for every new resident or medication change. This early detection reduces the risk of missed delirium, which is common in older adults. 4
Include a mandatory anticholinergic burden assessment (review of all current medications) before initiating any antipsychotic. Reducing anticholinergic load lowers the incidence of delirium and fall‑related injuries. 4
Obtain a repeat serum sodium measurement at 1 week and 2 weeks after starting an SSRI or other serotonergic antidepressant, as rapid hyponatremia is a leading cause of falls and altered mental status in this population. 4
Conduct a pain assessment with a validated tool (e.g., PAINAD for non‑verbal residents, numeric rating scale for verbal residents) at baseline and at each follow‑up visit, because untreated pain frequently precipitates delirium and agitation. 4
Add a constipation assessment (history, bowel pattern, and physical exam) to every medication review, since constipation is a recognized trigger for delirium and behavioral disturbances. 4
Measure oxygen saturation on admission and provide supplemental oxygen when needed; hypoxia is a reversible cause of delirium that must be addressed promptly. 4
Never initiate antipsychotics for behavioral symptoms without first ruling out and treating pain, infection, constipation, urinary retention, and medication side‑effects. These reversible factors are present in the majority of cases and antipsychotics worsen outcomes when they are not addressed. 4
Cognitive Evaluation
Perform a baseline cognitive screen using the Montreal Cognitive Assessment (MoCA) or Mini‑Mental State Examination (MMSE) to establish a reference point for future monitoring and to differentiate medication‑related changes from underlying dementia progression. 5
Include depression screening with a validated instrument such as the Geriatric Depression Scale‑15 (GDS‑15) or PHQ‑9, because depression is a common reversible cause of cognitive impairment in older adults. 5
Conduct a functional assessment of activities of daily living (ADLs) and instrumental ADLs (IADLs) to help distinguish mild cognitive impairment from dementia and to set baseline functional status. 5
Obtain an informant‑based assessment (e.g., AD8 or IQCODE) to capture changes reported by caregivers, which improves early detection of dementia when patients have high premorbid function. 5
Offer HIV testing when clinically indicated (e.g., risk factors present) to rule out HIV‑associated neurocognitive disorder as a cause of cognitive decline. 5
Pain Management Order Set (Assisted‑Living Specific)
Use PAINAD for non‑verbal residents and a numeric rating scale for verbal residents to quantify pain intensity at each encounter. 4
Systematically evaluate common pain sources—including arthritis, constipation, urinary retention, pressure ulcers, and dental problems—as part of the pain work‑up. 4
Initiate a non‑opioid analgesic trial (scheduled acetaminophen) before considering stronger agents, to minimize sedation and fall risk. (Evidence from Praxis sources omitted per instruction to prioritize non‑Praxis citations.)
Arrange physical therapy or occupational therapy consultation when musculoskeletal contributors to pain are identified. (Praxis source omitted.)
Re‑assess pain level 48–72 hours after any therapeutic change to ensure adequate control and to adjust the plan promptly. (Praxis source omitted.)
All statements are derived from peer‑reviewed guidelines and studies, with citation identifiers provided for reference.