American Association for Geriatric Psychiatry (AAGP)

SAN ANTONIO – Preventing or treating depression after a stroke can help patients with varying degrees of disability and adaptive skills recover functional ability.

Treatment for depression can help patients develop the plasticity they need to recover physical function, or in the case of more serious poststroke disabilities, help them more readily adapt to their limitations, Dr. Ellen M. Whyte said at the annual meeting of the American Association for Geriatric Psychiatry.

Both the brain’s plasticity and adaptation rely on the ability of patients to practice and learn new skills to help themselves recover or adapt after a major medical illness such as a stroke. But evidence from several studies shows that "depression after a stroke is associated with poor functional recovery and decreased efficiency of recovery," said Dr. Whyte, a geriatric psychiatrist at the University of Pittsburgh.

Decreased Participation. Depression may impede recovery from a stroke by decreasing a patient’s participation in rehabilitation activities, she said. Depression is also associated with cognitive problems, such as executive impairment, that can interfere with recovery or adaptation, and with motor impairment, such as decreased gait speed, which may also hinder rehabilitation.

A 2004 study from the University of Pittsburgh of 242 patients admitted for rehabilitation showed that patients who were "frequent poor participators" in rehabilitation activities had less physical recovery and longer length of stay, and were more likely to be institutionalized than either occasionally poor participators or good participators (Arch. Phys. Med. Rehabil. 2004;85:1599-601).

A separate study by Dr. Whyte and her colleagues looked at the effects of mood, apathy, memory, attention, executive function, and level of disability on participation in rehabilitation. The patients all had evidence of cognitive impairment, but they were without major depression.

The investigators found that among the 44 stroke survivors aged 60 years and older who were admitted for inpatient rehabilitation, baseline disability and impairment of executive function were independent predictors of participation. They also found that "while level of depressive symptoms was not an independent predictor of rehabilitation participation in this sample, it was strongly correlated with executive functions. Depressive symptoms and impairment in executive functions frequently overlap in late lifeand after stroke, and potentially represent ischemic injury to frontal-subcortical pathways" (Arch. Phys. Med. Rehabil. 2010;91:203-7).

Falls and Depression Linked. Other studies found that depression, as measured by the Symptom Checklist-90, was associated with a doubling of falls in community-dwelling adults aged 70 years or older (J. Clin. Epidemiol. 2002;55:1088-94), and that poor self-rated health, poor cognitive status, impaired activities of daily living, two or more clinic visits in the past month, and slow walking speed predicted both an elderly patient’s risk of falling and depressive symptoms (J. Epidemiol. Community Health 2002;56:631-6), she said.

Additionally, investigators looking at the effect of depression remission after a stroke found that patients with remission of a depressive disorder at follow-up had significantly greater recovery in activities of daily living (ADL) functions than did patients without remission. The authors also found that patients with remission of either major or minor depression showed greater improvement in ADL than did patients without remission, some of whom had received the antidepressant nortriptyline, and some of whom had received placebo. The finding suggests that nondrug mechanisms of recovery from depression may have accounted for the improvements in ADL among patients with remission (J. Nerv. Ment. Dis. 2001;189:421-5).

The evidence points to a stroke-recovery model in which preventing or treating depression would lead to increased motivation and participation in rehabilitation programs, reduced depression-related cognitive impairments, and decreases in depression-related motor impairments, Dr. Whyte said.

Dr. Whyte receives research support from the National Center for Medical Rehabilitation Research. She has previously received research support from Eli Lilly, Forest Pharmaceuticals, Ortho-McNeil, Pfizer Pharmaceuticals, and the National Institute of Mental Health.

SAN ANTONIO – Preventing or treating depression after a stroke can help patients with varying degrees of disability and adaptive skills recover functional ability.

Treatment for depression can help patients develop the plasticity they need to recover physical function, or in the case of more serious poststroke disabilities, help them more readily adapt to their limitations, Dr. Ellen M. Whyte said at the annual meeting of the American Association for Geriatric Psychiatry.

Both the brain’s plasticity and adaptation rely on the ability of patients to practice and learn new skills to help themselves recover or adapt after a major medical illness such as a stroke. But evidence from several studies shows that "depression after a stroke is associated with poor functional recovery and decreased efficiency of recovery," said Dr. Whyte, a geriatric psychiatrist at the University of Pittsburgh.

Decreased Participation. Depression may impede recovery from a stroke by decreasing a patient’s participation in rehabilitation activities, she said. Depression is also associated with cognitive problems, such as executive impairment, that can interfere with recovery or adaptation, and with motor impairment, such as decreased gait speed, which may also hinder rehabilitation.

A 2004 study from the University of Pittsburgh of 242 patients admitted for rehabilitation showed that patients who were "frequent poor participators" in rehabilitation activities had less physical recovery and longer length of stay, and were more likely to be institutionalized than either occasionally poor participators or good participators (Arch. Phys. Med. Rehabil. 2004;85:1599-601).

A separate study by Dr. Whyte and her colleagues looked at the effects of mood, apathy, memory, attention, executive function, and level of disability on participation in rehabilitation. The patients all had evidence of cognitive impairment, but they were without major depression.

The investigators found that among the 44 stroke survivors aged 60 years and older who were admitted for inpatient rehabilitation, baseline disability and impairment of executive function were independent predictors of participation. They also found that "while level of depressive symptoms was not an independent predictor of rehabilitation participation in this sample, it was strongly correlated with executive functions. Depressive symptoms and impairment in executive functions frequently overlap in late lifeand after stroke, and potentially represent ischemic injury to frontal-subcortical pathways" (Arch. Phys. Med. Rehabil. 2010;91:203-7).

Falls and Depression Linked. Other studies found that depression, as measured by the Symptom Checklist-90, was associated with a doubling of falls in community-dwelling adults aged 70 years or older (J. Clin. Epidemiol. 2002;55:1088-94), and that poor self-rated health, poor cognitive status, impaired activities of daily living, two or more clinic visits in the past month, and slow walking speed predicted both an elderly patient’s risk of falling and depressive symptoms (J. Epidemiol. Community Health 2002;56:631-6), she said.

Additionally, investigators looking at the effect of depression remission after a stroke found that patients with remission of a depressive disorder at follow-up had significantly greater recovery in activities of daily living (ADL) functions than did patients without remission. The authors also found that patients with remission of either major or minor depression showed greater improvement in ADL than did patients without remission, some of whom had received the antidepressant nortriptyline, and some of whom had received placebo. The finding suggests that nondrug mechanisms of recovery from depression may have accounted for the improvements in ADL among patients with remission (J. Nerv. Ment. Dis. 2001;189:421-5).

The evidence points to a stroke-recovery model in which preventing or treating depression would lead to increased motivation and participation in rehabilitation programs, reduced depression-related cognitive impairments, and decreases in depression-related motor impairments, Dr. Whyte said.

Dr. Whyte receives research support from the National Center for Medical Rehabilitation Research. She has previously received research support from Eli Lilly, Forest Pharmaceuticals, Ortho-McNeil, Pfizer Pharmaceuticals, and the National Institute of Mental Health.

SAN ANTONIO – Preventing or treating depression after a stroke can help patients with varying degrees of disability and adaptive skills recover functional ability.

Treatment for depression can help patients develop the plasticity they need to recover physical function, or in the case of more serious poststroke disabilities, help them more readily adapt to their limitations, Dr. Ellen M. Whyte said at the annual meeting of the American Association for Geriatric Psychiatry.

Both the brain’s plasticity and adaptation rely on the ability of patients to practice and learn new skills to help themselves recover or adapt after a major medical illness such as a stroke. But evidence from several studies shows that "depression after a stroke is associated with poor functional recovery and decreased efficiency of recovery," said Dr. Whyte, a geriatric psychiatrist at the University of Pittsburgh.

Decreased Participation. Depression may impede recovery from a stroke by decreasing a patient’s participation in rehabilitation activities, she said. Depression is also associated with cognitive problems, such as executive impairment, that can interfere with recovery or adaptation, and with motor impairment, such as decreased gait speed, which may also hinder rehabilitation.

A 2004 study from the University of Pittsburgh of 242 patients admitted for rehabilitation showed that patients who were "frequent poor participators" in rehabilitation activities had less physical recovery and longer length of stay, and were more likely to be institutionalized than either occasionally poor participators or good participators (Arch. Phys. Med. Rehabil. 2004;85:1599-601).

A separate study by Dr. Whyte and her colleagues looked at the effects of mood, apathy, memory, attention, executive function, and level of disability on participation in rehabilitation. The patients all had evidence of cognitive impairment, but they were without major depression.

The investigators found that among the 44 stroke survivors aged 60 years and older who were admitted for inpatient rehabilitation, baseline disability and impairment of executive function were independent predictors of participation. They also found that "while level of depressive symptoms was not an independent predictor of rehabilitation participation in this sample, it was strongly correlated with executive functions. Depressive symptoms and impairment in executive functions frequently overlap in late lifeand after stroke, and potentially represent ischemic injury to frontal-subcortical pathways" (Arch. Phys. Med. Rehabil. 2010;91:203-7).

Falls and Depression Linked. Other studies found that depression, as measured by the Symptom Checklist-90, was associated with a doubling of falls in community-dwelling adults aged 70 years or older (J. Clin. Epidemiol. 2002;55:1088-94), and that poor self-rated health, poor cognitive status, impaired activities of daily living, two or more clinic visits in the past month, and slow walking speed predicted both an elderly patient’s risk of falling and depressive symptoms (J. Epidemiol. Community Health 2002;56:631-6), she said.

Additionally, investigators looking at the effect of depression remission after a stroke found that patients with remission of a depressive disorder at follow-up had significantly greater recovery in activities of daily living (ADL) functions than did patients without remission. The authors also found that patients with remission of either major or minor depression showed greater improvement in ADL than did patients without remission, some of whom had received the antidepressant nortriptyline, and some of whom had received placebo. The finding suggests that nondrug mechanisms of recovery from depression may have accounted for the improvements in ADL among patients with remission (J. Nerv. Ment. Dis. 2001;189:421-5).

The evidence points to a stroke-recovery model in which preventing or treating depression would lead to increased motivation and participation in rehabilitation programs, reduced depression-related cognitive impairments, and decreases in depression-related motor impairments, Dr. Whyte said.

Dr. Whyte receives research support from the National Center for Medical Rehabilitation Research. She has previously received research support from Eli Lilly, Forest Pharmaceuticals, Ortho-McNeil, Pfizer Pharmaceuticals, and the National Institute of Mental Health.

SAN ANTONIO – Older adults with bipolar disorder who receive antipsychotic agents are at increased risk for death, compared with those who received the mood stabilizer valproate, investigators reported at the annual meeting of the American Association for Geriatric Psychiatry.

A review of Veterans Affairs data on 4,854 patients aged 65 and older with bipolar disorder showed that the risk of death within 180 days of receiving an antipsychotic prescription was highest for haloperidol, followed by risperidone, olanzapine, and quetiapine; valproate was associated with the lowest excess risk, according to Dr. Sachin J. Bhalerao, a second-year psychiatry resident at the University of Michigan, Ann Arbor, and his colleagues.

"Although antipsychotics are FDA approved for use in bipolar disorder (unlike with the neuropsychiatric symptoms of dementia), our data indicate that they should be used judiciously when traditional mood stabilizers and psychosocial interventions and psychotherapies do not fully address the patient’s needs," they wrote in a poster presentation.

The investigators looked at VA data on 4,854 adults 65 and older with a new medication start of haloperidol, risperidone, olanzapine, quetiapine, or valproate, no history of antipsychotic or anticonvulsant use in the previous year, monotherapy during 180-day follow-up, and for valproate users, no concurrent seizure disorders.

About one-third of the sample (35.1%) took valproate, followed by quetiapine (23%), risperidone (21.2%), olanzapine (17.9%), and haloperidol (2.8%). Although the demographics of the various drug groups were generally similar, the haloperidol group had a higher proportion of African Americans and unmarried people than the other groups. Patients on haloperidol also had more medical comorbidities than others, as well as higher rates of comorbid dementia, delirium, and substance abuse.

During 6-month follow-up, there were 21 deaths among 137 patients on haloperidol (15.3%), 68 among 1,027 on risperidone (6.6%), 43 among 868 on olanzapine (5%), 29 among 1,119 on quetiapine (2.6%), and 38 among 1,703 on valproate (2.2%).

In covariate-adjusted exposure and intent-to-treat models, the relationship between drug type and mortality remained essentially the same, with haloperidol users at highest risk (relative risk, 1.31), followed by risperidone (reference), olanzapine (RR, 0.75), valproate (RR, 0.42), and quetiapine (RR, 0.28).

Although the mechanism by which antipsychotic agents might increase the risk of death in the elderly is unknown, "a growing body of evidence suggests that antipsychotics increase mortality risk in both elderly dementia and nondementia populations," the investigators wrote. "This may be interpreted to indicate that the link to mortality in these conditions has less to do with the particular psychiatric condition or underlying brain pathology (for example, in dementia) and more to do with age and associated medical comorbidity."

The study was supported by a National Institute of Mental Health grant to principal investigator, Dr. Helen C. Kales. The authors had no conflict of interest disclosures.

SAN ANTONIO – Older adults with bipolar disorder who receive antipsychotic agents are at increased risk for death, compared with those who received the mood stabilizer valproate, investigators reported at the annual meeting of the American Association for Geriatric Psychiatry.

A review of Veterans Affairs data on 4,854 patients aged 65 and older with bipolar disorder showed that the risk of death within 180 days of receiving an antipsychotic prescription was highest for haloperidol, followed by risperidone, olanzapine, and quetiapine; valproate was associated with the lowest excess risk, according to Dr. Sachin J. Bhalerao, a second-year psychiatry resident at the University of Michigan, Ann Arbor, and his colleagues.

"Although antipsychotics are FDA approved for use in bipolar disorder (unlike with the neuropsychiatric symptoms of dementia), our data indicate that they should be used judiciously when traditional mood stabilizers and psychosocial interventions and psychotherapies do not fully address the patient’s needs," they wrote in a poster presentation.

The investigators looked at VA data on 4,854 adults 65 and older with a new medication start of haloperidol, risperidone, olanzapine, quetiapine, or valproate, no history of antipsychotic or anticonvulsant use in the previous year, monotherapy during 180-day follow-up, and for valproate users, no concurrent seizure disorders.

About one-third of the sample (35.1%) took valproate, followed by quetiapine (23%), risperidone (21.2%), olanzapine (17.9%), and haloperidol (2.8%). Although the demographics of the various drug groups were generally similar, the haloperidol group had a higher proportion of African Americans and unmarried people than the other groups. Patients on haloperidol also had more medical comorbidities than others, as well as higher rates of comorbid dementia, delirium, and substance abuse.

During 6-month follow-up, there were 21 deaths among 137 patients on haloperidol (15.3%), 68 among 1,027 on risperidone (6.6%), 43 among 868 on olanzapine (5%), 29 among 1,119 on quetiapine (2.6%), and 38 among 1,703 on valproate (2.2%).

In covariate-adjusted exposure and intent-to-treat models, the relationship between drug type and mortality remained essentially the same, with haloperidol users at highest risk (relative risk, 1.31), followed by risperidone (reference), olanzapine (RR, 0.75), valproate (RR, 0.42), and quetiapine (RR, 0.28).

Although the mechanism by which antipsychotic agents might increase the risk of death in the elderly is unknown, "a growing body of evidence suggests that antipsychotics increase mortality risk in both elderly dementia and nondementia populations," the investigators wrote. "This may be interpreted to indicate that the link to mortality in these conditions has less to do with the particular psychiatric condition or underlying brain pathology (for example, in dementia) and more to do with age and associated medical comorbidity."

The study was supported by a National Institute of Mental Health grant to principal investigator, Dr. Helen C. Kales. The authors had no conflict of interest disclosures.

SAN ANTONIO – Older adults with bipolar disorder who receive antipsychotic agents are at increased risk for death, compared with those who received the mood stabilizer valproate, investigators reported at the annual meeting of the American Association for Geriatric Psychiatry.

A review of Veterans Affairs data on 4,854 patients aged 65 and older with bipolar disorder showed that the risk of death within 180 days of receiving an antipsychotic prescription was highest for haloperidol, followed by risperidone, olanzapine, and quetiapine; valproate was associated with the lowest excess risk, according to Dr. Sachin J. Bhalerao, a second-year psychiatry resident at the University of Michigan, Ann Arbor, and his colleagues.

"Although antipsychotics are FDA approved for use in bipolar disorder (unlike with the neuropsychiatric symptoms of dementia), our data indicate that they should be used judiciously when traditional mood stabilizers and psychosocial interventions and psychotherapies do not fully address the patient’s needs," they wrote in a poster presentation.

The investigators looked at VA data on 4,854 adults 65 and older with a new medication start of haloperidol, risperidone, olanzapine, quetiapine, or valproate, no history of antipsychotic or anticonvulsant use in the previous year, monotherapy during 180-day follow-up, and for valproate users, no concurrent seizure disorders.

About one-third of the sample (35.1%) took valproate, followed by quetiapine (23%), risperidone (21.2%), olanzapine (17.9%), and haloperidol (2.8%). Although the demographics of the various drug groups were generally similar, the haloperidol group had a higher proportion of African Americans and unmarried people than the other groups. Patients on haloperidol also had more medical comorbidities than others, as well as higher rates of comorbid dementia, delirium, and substance abuse.

During 6-month follow-up, there were 21 deaths among 137 patients on haloperidol (15.3%), 68 among 1,027 on risperidone (6.6%), 43 among 868 on olanzapine (5%), 29 among 1,119 on quetiapine (2.6%), and 38 among 1,703 on valproate (2.2%).

In covariate-adjusted exposure and intent-to-treat models, the relationship between drug type and mortality remained essentially the same, with haloperidol users at highest risk (relative risk, 1.31), followed by risperidone (reference), olanzapine (RR, 0.75), valproate (RR, 0.42), and quetiapine (RR, 0.28).

Although the mechanism by which antipsychotic agents might increase the risk of death in the elderly is unknown, "a growing body of evidence suggests that antipsychotics increase mortality risk in both elderly dementia and nondementia populations," the investigators wrote. "This may be interpreted to indicate that the link to mortality in these conditions has less to do with the particular psychiatric condition or underlying brain pathology (for example, in dementia) and more to do with age and associated medical comorbidity."

The study was supported by a National Institute of Mental Health grant to principal investigator, Dr. Helen C. Kales. The authors had no conflict of interest disclosures.

SAN ANTONIO – Older adults with bipolar disorder who receive antipsychotic agents are at increased risk for death, compared with those who received the mood stabilizer valproate, investigators reported at the annual meeting of the American Association for Geriatric Psychiatry.

A review of Veterans Affairs data on 4,854 patients aged 65 and older with bipolar disorder showed that the risk of death within 180 days of receiving an antipsychotic prescription was highest for haloperidol, followed by risperidone, olanzapine, and quetiapine; valproate was associated with the lowest excess risk, according to Dr. Sachin J. Bhalerao, a second-year psychiatry resident at the University of Michigan, Ann Arbor, and his colleagues.

"Although antipsychotics are FDA approved for use in bipolar disorder (unlike with the neuropsychiatric symptoms of dementia), our data indicate that they should be used judiciously when traditional mood stabilizers and psychosocial interventions and psychotherapies do not fully address the patient’s needs," they wrote in a poster presentation.

The investigators looked at VA data on 4,854 adults 65 and older with a new medication start of haloperidol, risperidone, olanzapine, quetiapine, or valproate, no history of antipsychotic or anticonvulsant use in the previous year, monotherapy during 180-day follow-up, and for valproate users, no concurrent seizure disorders.

About one-third of the sample (35.1%) took valproate, followed by quetiapine (23%), risperidone (21.2%), olanzapine (17.9%), and haloperidol (2.8%). Although the demographics of the various drug groups were generally similar, the haloperidol group had a higher proportion of African Americans and unmarried people than the other groups. Patients on haloperidol also had more medical comorbidities than others, as well as higher rates of comorbid dementia, delirium, and substance abuse.

During 6-month follow-up, there were 21 deaths among 137 patients on haloperidol (15.3%), 68 among 1,027 on risperidone (6.6%), 43 among 868 on olanzapine (5%), 29 among 1,119 on quetiapine (2.6%), and 38 among 1,703 on valproate (2.2%).

In covariate-adjusted exposure and intent-to-treat models, the relationship between drug type and mortality remained essentially the same, with haloperidol users at highest risk (relative risk, 1.31), followed by risperidone (reference), olanzapine (RR, 0.75), valproate (RR, 0.42), and quetiapine (RR, 0.28).

Although the mechanism by which antipsychotic agents might increase the risk of death in the elderly is unknown, "a growing body of evidence suggests that antipsychotics increase mortality risk in both elderly dementia and nondementia populations," the investigators wrote. "This may be interpreted to indicate that the link to mortality in these conditions has less to do with the particular psychiatric condition or underlying brain pathology (for example, in dementia) and more to do with age and associated medical comorbidity."

The study was supported by a National Institute of Mental Health grant to principal investigator, Dr. Helen C. Kales. The authors had no conflict of interest disclosures.

SAN ANTONIO – Older adults with bipolar disorder who receive antipsychotic agents are at increased risk for death, compared with those who received the mood stabilizer valproate, investigators reported at the annual meeting of the American Association for Geriatric Psychiatry.

A review of Veterans Affairs data on 4,854 patients aged 65 and older with bipolar disorder showed that the risk of death within 180 days of receiving an antipsychotic prescription was highest for haloperidol, followed by risperidone, olanzapine, and quetiapine; valproate was associated with the lowest excess risk, according to Dr. Sachin J. Bhalerao, a second-year psychiatry resident at the University of Michigan, Ann Arbor, and his colleagues.

"Although antipsychotics are FDA approved for use in bipolar disorder (unlike with the neuropsychiatric symptoms of dementia), our data indicate that they should be used judiciously when traditional mood stabilizers and psychosocial interventions and psychotherapies do not fully address the patient’s needs," they wrote in a poster presentation.

The investigators looked at VA data on 4,854 adults 65 and older with a new medication start of haloperidol, risperidone, olanzapine, quetiapine, or valproate, no history of antipsychotic or anticonvulsant use in the previous year, monotherapy during 180-day follow-up, and for valproate users, no concurrent seizure disorders.

About one-third of the sample (35.1%) took valproate, followed by quetiapine (23%), risperidone (21.2%), olanzapine (17.9%), and haloperidol (2.8%). Although the demographics of the various drug groups were generally similar, the haloperidol group had a higher proportion of African Americans and unmarried people than the other groups. Patients on haloperidol also had more medical comorbidities than others, as well as higher rates of comorbid dementia, delirium, and substance abuse.

During 6-month follow-up, there were 21 deaths among 137 patients on haloperidol (15.3%), 68 among 1,027 on risperidone (6.6%), 43 among 868 on olanzapine (5%), 29 among 1,119 on quetiapine (2.6%), and 38 among 1,703 on valproate (2.2%).

In covariate-adjusted exposure and intent-to-treat models, the relationship between drug type and mortality remained essentially the same, with haloperidol users at highest risk (relative risk, 1.31), followed by risperidone (reference), olanzapine (RR, 0.75), valproate (RR, 0.42), and quetiapine (RR, 0.28).

Although the mechanism by which antipsychotic agents might increase the risk of death in the elderly is unknown, "a growing body of evidence suggests that antipsychotics increase mortality risk in both elderly dementia and nondementia populations," the investigators wrote. "This may be interpreted to indicate that the link to mortality in these conditions has less to do with the particular psychiatric condition or underlying brain pathology (for example, in dementia) and more to do with age and associated medical comorbidity."

The study was supported by a National Institute of Mental Health grant to principal investigator, Dr. Helen C. Kales. The authors had no conflict of interest disclosures.

SAN ANTONIO – Older adults with bipolar disorder who receive antipsychotic agents are at increased risk for death, compared with those who received the mood stabilizer valproate, investigators reported at the annual meeting of the American Association for Geriatric Psychiatry.

A review of Veterans Affairs data on 4,854 patients aged 65 and older with bipolar disorder showed that the risk of death within 180 days of receiving an antipsychotic prescription was highest for haloperidol, followed by risperidone, olanzapine, and quetiapine; valproate was associated with the lowest excess risk, according to Dr. Sachin J. Bhalerao, a second-year psychiatry resident at the University of Michigan, Ann Arbor, and his colleagues.

"Although antipsychotics are FDA approved for use in bipolar disorder (unlike with the neuropsychiatric symptoms of dementia), our data indicate that they should be used judiciously when traditional mood stabilizers and psychosocial interventions and psychotherapies do not fully address the patient’s needs," they wrote in a poster presentation.

The investigators looked at VA data on 4,854 adults 65 and older with a new medication start of haloperidol, risperidone, olanzapine, quetiapine, or valproate, no history of antipsychotic or anticonvulsant use in the previous year, monotherapy during 180-day follow-up, and for valproate users, no concurrent seizure disorders.

About one-third of the sample (35.1%) took valproate, followed by quetiapine (23%), risperidone (21.2%), olanzapine (17.9%), and haloperidol (2.8%). Although the demographics of the various drug groups were generally similar, the haloperidol group had a higher proportion of African Americans and unmarried people than the other groups. Patients on haloperidol also had more medical comorbidities than others, as well as higher rates of comorbid dementia, delirium, and substance abuse.

During 6-month follow-up, there were 21 deaths among 137 patients on haloperidol (15.3%), 68 among 1,027 on risperidone (6.6%), 43 among 868 on olanzapine (5%), 29 among 1,119 on quetiapine (2.6%), and 38 among 1,703 on valproate (2.2%).

In covariate-adjusted exposure and intent-to-treat models, the relationship between drug type and mortality remained essentially the same, with haloperidol users at highest risk (relative risk, 1.31), followed by risperidone (reference), olanzapine (RR, 0.75), valproate (RR, 0.42), and quetiapine (RR, 0.28).

Although the mechanism by which antipsychotic agents might increase the risk of death in the elderly is unknown, "a growing body of evidence suggests that antipsychotics increase mortality risk in both elderly dementia and nondementia populations," the investigators wrote. "This may be interpreted to indicate that the link to mortality in these conditions has less to do with the particular psychiatric condition or underlying brain pathology (for example, in dementia) and more to do with age and associated medical comorbidity."

The study was supported by a National Institute of Mental Health grant to principal investigator, Dr. Helen C. Kales. The authors had no conflict of interest disclosures.

SAN ANTONIO – Older adults with bipolar disorder who receive antipsychotic agents are at increased risk for death, compared with those who received the mood stabilizer valproate, investigators reported at the annual meeting of the American Association for Geriatric Psychiatry.

A review of Veterans Affairs data on 4,854 patients aged 65 and older with bipolar disorder showed that the risk of death within 180 days of receiving an antipsychotic prescription was highest for haloperidol, followed by risperidone, olanzapine, and quetiapine; valproate was associated with the lowest excess risk, according to Dr. Sachin J. Bhalerao, a second-year psychiatry resident at the University of Michigan, Ann Arbor, and his colleagues.

"Although antipsychotics are FDA approved for use in bipolar disorder (unlike with the neuropsychiatric symptoms of dementia), our data indicate that they should be used judiciously when traditional mood stabilizers and psychosocial interventions and psychotherapies do not fully address the patient’s needs," they wrote in a poster presentation.

The investigators looked at VA data on 4,854 adults 65 and older with a new medication start of haloperidol, risperidone, olanzapine, quetiapine, or valproate, no history of antipsychotic or anticonvulsant use in the previous year, monotherapy during 180-day follow-up, and for valproate users, no concurrent seizure disorders.

About one-third of the sample (35.1%) took valproate, followed by quetiapine (23%), risperidone (21.2%), olanzapine (17.9%), and haloperidol (2.8%). Although the demographics of the various drug groups were generally similar, the haloperidol group had a higher proportion of African Americans and unmarried people than the other groups. Patients on haloperidol also had more medical comorbidities than others, as well as higher rates of comorbid dementia, delirium, and substance abuse.

During 6-month follow-up, there were 21 deaths among 137 patients on haloperidol (15.3%), 68 among 1,027 on risperidone (6.6%), 43 among 868 on olanzapine (5%), 29 among 1,119 on quetiapine (2.6%), and 38 among 1,703 on valproate (2.2%).

In covariate-adjusted exposure and intent-to-treat models, the relationship between drug type and mortality remained essentially the same, with haloperidol users at highest risk (relative risk, 1.31), followed by risperidone (reference), olanzapine (RR, 0.75), valproate (RR, 0.42), and quetiapine (RR, 0.28).

Although the mechanism by which antipsychotic agents might increase the risk of death in the elderly is unknown, "a growing body of evidence suggests that antipsychotics increase mortality risk in both elderly dementia and nondementia populations," the investigators wrote. "This may be interpreted to indicate that the link to mortality in these conditions has less to do with the particular psychiatric condition or underlying brain pathology (for example, in dementia) and more to do with age and associated medical comorbidity."

The study was supported by a National Institute of Mental Health grant to principal investigator, Dr. Helen C. Kales. The authors had no conflict of interest disclosures.

SAN ANTONIO – Older adults with bipolar disorder who receive antipsychotic agents are at increased risk for death, compared with those who received the mood stabilizer valproate, investigators reported at the annual meeting of the American Association for Geriatric Psychiatry.

A review of Veterans Affairs data on 4,854 patients aged 65 and older with bipolar disorder showed that the risk of death within 180 days of receiving an antipsychotic prescription was highest for haloperidol, followed by risperidone, olanzapine, and quetiapine; valproate was associated with the lowest excess risk, according to Dr. Sachin J. Bhalerao, a second-year psychiatry resident at the University of Michigan, Ann Arbor, and his colleagues.

"Although antipsychotics are FDA approved for use in bipolar disorder (unlike with the neuropsychiatric symptoms of dementia), our data indicate that they should be used judiciously when traditional mood stabilizers and psychosocial interventions and psychotherapies do not fully address the patient’s needs," they wrote in a poster presentation.

The investigators looked at VA data on 4,854 adults 65 and older with a new medication start of haloperidol, risperidone, olanzapine, quetiapine, or valproate, no history of antipsychotic or anticonvulsant use in the previous year, monotherapy during 180-day follow-up, and for valproate users, no concurrent seizure disorders.

About one-third of the sample (35.1%) took valproate, followed by quetiapine (23%), risperidone (21.2%), olanzapine (17.9%), and haloperidol (2.8%). Although the demographics of the various drug groups were generally similar, the haloperidol group had a higher proportion of African Americans and unmarried people than the other groups. Patients on haloperidol also had more medical comorbidities than others, as well as higher rates of comorbid dementia, delirium, and substance abuse.

During 6-month follow-up, there were 21 deaths among 137 patients on haloperidol (15.3%), 68 among 1,027 on risperidone (6.6%), 43 among 868 on olanzapine (5%), 29 among 1,119 on quetiapine (2.6%), and 38 among 1,703 on valproate (2.2%).

In covariate-adjusted exposure and intent-to-treat models, the relationship between drug type and mortality remained essentially the same, with haloperidol users at highest risk (relative risk, 1.31), followed by risperidone (reference), olanzapine (RR, 0.75), valproate (RR, 0.42), and quetiapine (RR, 0.28).

Although the mechanism by which antipsychotic agents might increase the risk of death in the elderly is unknown, "a growing body of evidence suggests that antipsychotics increase mortality risk in both elderly dementia and nondementia populations," the investigators wrote. "This may be interpreted to indicate that the link to mortality in these conditions has less to do with the particular psychiatric condition or underlying brain pathology (for example, in dementia) and more to do with age and associated medical comorbidity."

The study was supported by a National Institute of Mental Health grant to principal investigator, Dr. Helen C. Kales. The authors had no conflict of interest disclosures.

SAN ANTONIO – Older adults with bipolar disorder who receive antipsychotic agents are at increased risk for death, compared with those who received the mood stabilizer valproate, investigators reported at the annual meeting of the American Association for Geriatric Psychiatry.

A review of Veterans Affairs data on 4,854 patients aged 65 and older with bipolar disorder showed that the risk of death within 180 days of receiving an antipsychotic prescription was highest for haloperidol, followed by risperidone, olanzapine, and quetiapine; valproate was associated with the lowest excess risk, according to Dr. Sachin J. Bhalerao, a second-year psychiatry resident at the University of Michigan, Ann Arbor, and his colleagues.

"Although antipsychotics are FDA approved for use in bipolar disorder (unlike with the neuropsychiatric symptoms of dementia), our data indicate that they should be used judiciously when traditional mood stabilizers and psychosocial interventions and psychotherapies do not fully address the patient’s needs," they wrote in a poster presentation.

The investigators looked at VA data on 4,854 adults 65 and older with a new medication start of haloperidol, risperidone, olanzapine, quetiapine, or valproate, no history of antipsychotic or anticonvulsant use in the previous year, monotherapy during 180-day follow-up, and for valproate users, no concurrent seizure disorders.

About one-third of the sample (35.1%) took valproate, followed by quetiapine (23%), risperidone (21.2%), olanzapine (17.9%), and haloperidol (2.8%). Although the demographics of the various drug groups were generally similar, the haloperidol group had a higher proportion of African Americans and unmarried people than the other groups. Patients on haloperidol also had more medical comorbidities than others, as well as higher rates of comorbid dementia, delirium, and substance abuse.

During 6-month follow-up, there were 21 deaths among 137 patients on haloperidol (15.3%), 68 among 1,027 on risperidone (6.6%), 43 among 868 on olanzapine (5%), 29 among 1,119 on quetiapine (2.6%), and 38 among 1,703 on valproate (2.2%).

In covariate-adjusted exposure and intent-to-treat models, the relationship between drug type and mortality remained essentially the same, with haloperidol users at highest risk (relative risk, 1.31), followed by risperidone (reference), olanzapine (RR, 0.75), valproate (RR, 0.42), and quetiapine (RR, 0.28).

Although the mechanism by which antipsychotic agents might increase the risk of death in the elderly is unknown, "a growing body of evidence suggests that antipsychotics increase mortality risk in both elderly dementia and nondementia populations," the investigators wrote. "This may be interpreted to indicate that the link to mortality in these conditions has less to do with the particular psychiatric condition or underlying brain pathology (for example, in dementia) and more to do with age and associated medical comorbidity."

The study was supported by a National Institute of Mental Health grant to principal investigator, Dr. Helen C. Kales. The authors had no conflict of interest disclosures.

SAN ANTONIO – Simple steps such as treating infections, avoiding physical restraints, and letting patients sleep at night can go a long way toward reducing delirium episodes among elderly patients in acute and postacute settings, delirium experts said at the annual meeting of the American Association for Geriatric Psychiatry.

"Starting anywhere is better than the status quo," said Dr. David J. Loreck, director of Baltimore VA Medical Center Mental Health Consultation Services, and assistant professor of psychiatry at the University of Maryland in Baltimore.

Delirium is an insidious, underrecognized problem associated with significant morbidity and mortality. It frequently falls through the cracks between different disciplines and services within the hospital, he said.

"Delirium is common among older people and is associated with significant morbidity and mortality, but we still underrecognize it," said Dr. Yesne Alici, a geriatric psychiatrist at Central Regional Hospital in Butner, N.C.

She pointed to a meta-analysis of studies of delirium in elderly patients, which showed that patients with delirium had a nearly twofold risk for death, compared with controls, and that "delirium in elderly patients is associated with poor outcome independent of important confounders, such as age, sex, comorbid illness or illness severity, and baseline dementia" (JAMA 2010;304:443-51).

But every difficult case of delirium also provides educational, clinical, and/or performance-improvement opportunities for hospital administration, medical and surgical services, nursing, geriatrics, pharmacy, and other disciplines, Dr. Loreck noted.

Early recognition and intervention are critical, because the longer the episode of delirium, the less likely the patient is to fully recover to baseline status, both noted.

Unit-Based Solution

The unique leadership, administrative structure, and work environment of each hospital unit will suggest the best approach to preventing delirium among patients in that unit, Dr. Loreck said.

One option is to identify a "dementia champion" within each unit – whether the champion is a physician, nurse manager, or clinical nurse specialist – and work with that individual to be a dementia leader who can develop a team within the unit to help identify those patients most at risk for delirium.

A more practical and realistic option, however, is for the hospital to have a specific consultation service composed of geriatricians, psychiatrists, or neurologists who act as institution-wide dementia specialists to help identify delirium triggers and institute measures appropriate to each unit for reducing delirium.

"Even though you’re not training a whole team, you’re still going to need a point person on the unit to trigger the consult team into action," Dr. Loreck said.

Clocks, Calendars, Caregiver IDs

Nursing staff, who spend the most time with patients, are the clinicians most likely to detect changes in patient mental status. But generally, nurses are not that good at recognizing delirium, both Dr. Loreck and Dr. Alici said.

Nonetheless, nurses are often well positioned to implement delirium prevention strategies; identify delirium risk factors, signs, and symptoms; and intervene early to ameliorate the negative effects of delirium when it occurs. Nursing staff can be trained to differentiate delirium from dementia, and to distinguish between hypoactive delirium and the effects of illness, medications, fatigue, or environmental influences on sleep.

All unit staff also should be aware of delirium triggers, such as infections (especially urinary tract infections), constipation, hypoxia, hypotension, pain, and medications.

Simple time and place cues such as easily visible clocks, calendars, and caregiver IDs, can help orient patients to their whereabouts. The unit also should allow for appropriate sensory stimulation of patients, with a quiet room, adequate light, and engagement in only one task at a time.

Delirium Toolbox

He briefly described a delirium-care model outlined by Dr. James L. Rudolph, a geriatrician at Brigham and Women’s Hospital, Boston, and the VA Boston Healthcare System.

The model focuses on universal prevention measures, tools for identifying and modifying delirium risk, and a standardized treatment protocol.

Universal prevention measures include providing a better sleep environment – "Hospitals stink for sleep, and all patients would benefit from better sleep," Dr. Loreck said – with lights out at 10 p.m., headsets for "night owls" and earplugs for their sleeping roommates, as well as reduction of ambient noises, and reduction of overnight vital-signs taking.

At admission or during a unit stay, patients can be assessed for delirium by being asked to recite the months of the year backward while being timed, or the Clock-in-the-Box test for cognitive function. Clinicians also should identify visual and hearing deficits that might put the patient at risk for delirium, ensure that they have adequate nutrition and hydration, assess their acuity of illness, and identify any high-risk medications they might be taking, such as alcohol, opiates, benzodiazepines, anticholinergics (for example, diphenhydramine or tricyclic antidepressants), corticosteroids, central-acting antihypertensives, and levodopa.

High-risk patients can be given a delirium toolbox designed to encourage appropriate stimulations, including pocket talkers (audio amplification devices), reading glasses, earplugs, nightlights, flashlights, cards, puzzles, and Play-Doh–brand modeling compound.

For daytime, patients can be furnished with radios, preloaded MP3 players with speakers, DVD players, white-noise generators, and games and puzzles for stimulation.

One of the most cost-effective measures is sitter-training, with bedside aides instructed about how to recognize delirium and engage the patient through reading, conversation, playing music, and providing stimulation, rather than sitting mutely and passively by.

Although no one-size-fits-all solution exists to prevent delirium, taking action to prevent it, and, when necessary, to treat it, is critically important, Dr. Loreck emphasized.

"You don’t have to do everything, but do something," he said.

Neither Dr. Loreck nor Dr. Alici had conflicts of interest to disclose.

SAN ANTONIO – Simple steps such as treating infections, avoiding physical restraints, and letting patients sleep at night can go a long way toward reducing delirium episodes among elderly patients in acute and postacute settings, delirium experts said at the annual meeting of the American Association for Geriatric Psychiatry.

"Starting anywhere is better than the status quo," said Dr. David J. Loreck, director of Baltimore VA Medical Center Mental Health Consultation Services, and assistant professor of psychiatry at the University of Maryland in Baltimore.

Delirium is an insidious, underrecognized problem associated with significant morbidity and mortality. It frequently falls through the cracks between different disciplines and services within the hospital, he said.

"Delirium is common among older people and is associated with significant morbidity and mortality, but we still underrecognize it," said Dr. Yesne Alici, a geriatric psychiatrist at Central Regional Hospital in Butner, N.C.

She pointed to a meta-analysis of studies of delirium in elderly patients, which showed that patients with delirium had a nearly twofold risk for death, compared with controls, and that "delirium in elderly patients is associated with poor outcome independent of important confounders, such as age, sex, comorbid illness or illness severity, and baseline dementia" (JAMA 2010;304:443-51).

But every difficult case of delirium also provides educational, clinical, and/or performance-improvement opportunities for hospital administration, medical and surgical services, nursing, geriatrics, pharmacy, and other disciplines, Dr. Loreck noted.

Early recognition and intervention are critical, because the longer the episode of delirium, the less likely the patient is to fully recover to baseline status, both noted.

Unit-Based Solution

The unique leadership, administrative structure, and work environment of each hospital unit will suggest the best approach to preventing delirium among patients in that unit, Dr. Loreck said.

One option is to identify a "dementia champion" within each unit – whether the champion is a physician, nurse manager, or clinical nurse specialist – and work with that individual to be a dementia leader who can develop a team within the unit to help identify those patients most at risk for delirium.

A more practical and realistic option, however, is for the hospital to have a specific consultation service composed of geriatricians, psychiatrists, or neurologists who act as institution-wide dementia specialists to help identify delirium triggers and institute measures appropriate to each unit for reducing delirium.

"Even though you’re not training a whole team, you’re still going to need a point person on the unit to trigger the consult team into action," Dr. Loreck said.

Clocks, Calendars, Caregiver IDs

Nursing staff, who spend the most time with patients, are the clinicians most likely to detect changes in patient mental status. But generally, nurses are not that good at recognizing delirium, both Dr. Loreck and Dr. Alici said.

Nonetheless, nurses are often well positioned to implement delirium prevention strategies; identify delirium risk factors, signs, and symptoms; and intervene early to ameliorate the negative effects of delirium when it occurs. Nursing staff can be trained to differentiate delirium from dementia, and to distinguish between hypoactive delirium and the effects of illness, medications, fatigue, or environmental influences on sleep.

All unit staff also should be aware of delirium triggers, such as infections (especially urinary tract infections), constipation, hypoxia, hypotension, pain, and medications.

Simple time and place cues such as easily visible clocks, calendars, and caregiver IDs, can help orient patients to their whereabouts. The unit also should allow for appropriate sensory stimulation of patients, with a quiet room, adequate light, and engagement in only one task at a time.

Delirium Toolbox

He briefly described a delirium-care model outlined by Dr. James L. Rudolph, a geriatrician at Brigham and Women’s Hospital, Boston, and the VA Boston Healthcare System.

The model focuses on universal prevention measures, tools for identifying and modifying delirium risk, and a standardized treatment protocol.

Universal prevention measures include providing a better sleep environment – "Hospitals stink for sleep, and all patients would benefit from better sleep," Dr. Loreck said – with lights out at 10 p.m., headsets for "night owls" and earplugs for their sleeping roommates, as well as reduction of ambient noises, and reduction of overnight vital-signs taking.

At admission or during a unit stay, patients can be assessed for delirium by being asked to recite the months of the year backward while being timed, or the Clock-in-the-Box test for cognitive function. Clinicians also should identify visual and hearing deficits that might put the patient at risk for delirium, ensure that they have adequate nutrition and hydration, assess their acuity of illness, and identify any high-risk medications they might be taking, such as alcohol, opiates, benzodiazepines, anticholinergics (for example, diphenhydramine or tricyclic antidepressants), corticosteroids, central-acting antihypertensives, and levodopa.

High-risk patients can be given a delirium toolbox designed to encourage appropriate stimulations, including pocket talkers (audio amplification devices), reading glasses, earplugs, nightlights, flashlights, cards, puzzles, and Play-Doh–brand modeling compound.

For daytime, patients can be furnished with radios, preloaded MP3 players with speakers, DVD players, white-noise generators, and games and puzzles for stimulation.

One of the most cost-effective measures is sitter-training, with bedside aides instructed about how to recognize delirium and engage the patient through reading, conversation, playing music, and providing stimulation, rather than sitting mutely and passively by.

Although no one-size-fits-all solution exists to prevent delirium, taking action to prevent it, and, when necessary, to treat it, is critically important, Dr. Loreck emphasized.

"You don’t have to do everything, but do something," he said.

Neither Dr. Loreck nor Dr. Alici had conflicts of interest to disclose.

SAN ANTONIO – Simple steps such as treating infections, avoiding physical restraints, and letting patients sleep at night can go a long way toward reducing delirium episodes among elderly patients in acute and postacute settings, delirium experts said at the annual meeting of the American Association for Geriatric Psychiatry.

"Starting anywhere is better than the status quo," said Dr. David J. Loreck, director of Baltimore VA Medical Center Mental Health Consultation Services, and assistant professor of psychiatry at the University of Maryland in Baltimore.

Delirium is an insidious, underrecognized problem associated with significant morbidity and mortality. It frequently falls through the cracks between different disciplines and services within the hospital, he said.

"Delirium is common among older people and is associated with significant morbidity and mortality, but we still underrecognize it," said Dr. Yesne Alici, a geriatric psychiatrist at Central Regional Hospital in Butner, N.C.

She pointed to a meta-analysis of studies of delirium in elderly patients, which showed that patients with delirium had a nearly twofold risk for death, compared with controls, and that "delirium in elderly patients is associated with poor outcome independent of important confounders, such as age, sex, comorbid illness or illness severity, and baseline dementia" (JAMA 2010;304:443-51).

But every difficult case of delirium also provides educational, clinical, and/or performance-improvement opportunities for hospital administration, medical and surgical services, nursing, geriatrics, pharmacy, and other disciplines, Dr. Loreck noted.

Early recognition and intervention are critical, because the longer the episode of delirium, the less likely the patient is to fully recover to baseline status, both noted.

Unit-Based Solution

The unique leadership, administrative structure, and work environment of each hospital unit will suggest the best approach to preventing delirium among patients in that unit, Dr. Loreck said.

One option is to identify a "dementia champion" within each unit – whether the champion is a physician, nurse manager, or clinical nurse specialist – and work with that individual to be a dementia leader who can develop a team within the unit to help identify those patients most at risk for delirium.

A more practical and realistic option, however, is for the hospital to have a specific consultation service composed of geriatricians, psychiatrists, or neurologists who act as institution-wide dementia specialists to help identify delirium triggers and institute measures appropriate to each unit for reducing delirium.

"Even though you’re not training a whole team, you’re still going to need a point person on the unit to trigger the consult team into action," Dr. Loreck said.

Clocks, Calendars, Caregiver IDs

Nursing staff, who spend the most time with patients, are the clinicians most likely to detect changes in patient mental status. But generally, nurses are not that good at recognizing delirium, both Dr. Loreck and Dr. Alici said.

Nonetheless, nurses are often well positioned to implement delirium prevention strategies; identify delirium risk factors, signs, and symptoms; and intervene early to ameliorate the negative effects of delirium when it occurs. Nursing staff can be trained to differentiate delirium from dementia, and to distinguish between hypoactive delirium and the effects of illness, medications, fatigue, or environmental influences on sleep.

All unit staff also should be aware of delirium triggers, such as infections (especially urinary tract infections), constipation, hypoxia, hypotension, pain, and medications.

Simple time and place cues such as easily visible clocks, calendars, and caregiver IDs, can help orient patients to their whereabouts. The unit also should allow for appropriate sensory stimulation of patients, with a quiet room, adequate light, and engagement in only one task at a time.

Delirium Toolbox

He briefly described a delirium-care model outlined by Dr. James L. Rudolph, a geriatrician at Brigham and Women’s Hospital, Boston, and the VA Boston Healthcare System.

The model focuses on universal prevention measures, tools for identifying and modifying delirium risk, and a standardized treatment protocol.

Universal prevention measures include providing a better sleep environment – "Hospitals stink for sleep, and all patients would benefit from better sleep," Dr. Loreck said – with lights out at 10 p.m., headsets for "night owls" and earplugs for their sleeping roommates, as well as reduction of ambient noises, and reduction of overnight vital-signs taking.

At admission or during a unit stay, patients can be assessed for delirium by being asked to recite the months of the year backward while being timed, or the Clock-in-the-Box test for cognitive function. Clinicians also should identify visual and hearing deficits that might put the patient at risk for delirium, ensure that they have adequate nutrition and hydration, assess their acuity of illness, and identify any high-risk medications they might be taking, such as alcohol, opiates, benzodiazepines, anticholinergics (for example, diphenhydramine or tricyclic antidepressants), corticosteroids, central-acting antihypertensives, and levodopa.

High-risk patients can be given a delirium toolbox designed to encourage appropriate stimulations, including pocket talkers (audio amplification devices), reading glasses, earplugs, nightlights, flashlights, cards, puzzles, and Play-Doh–brand modeling compound.

For daytime, patients can be furnished with radios, preloaded MP3 players with speakers, DVD players, white-noise generators, and games and puzzles for stimulation.

One of the most cost-effective measures is sitter-training, with bedside aides instructed about how to recognize delirium and engage the patient through reading, conversation, playing music, and providing stimulation, rather than sitting mutely and passively by.

Although no one-size-fits-all solution exists to prevent delirium, taking action to prevent it, and, when necessary, to treat it, is critically important, Dr. Loreck emphasized.

"You don’t have to do everything, but do something," he said.

Neither Dr. Loreck nor Dr. Alici had conflicts of interest to disclose.

SAN ANTONIO – Simple steps such as treating infections, avoiding physical restraints, and letting patients sleep at night can go a long way toward reducing delirium episodes among elderly patients in acute and postacute settings, delirium experts said at the annual meeting of the American Association for Geriatric Psychiatry.

"Starting anywhere is better than the status quo," said Dr. David J. Loreck, director of Baltimore VA Medical Center Mental Health Consultation Services, and assistant professor of psychiatry at the University of Maryland in Baltimore.

Delirium is an insidious, underrecognized problem associated with significant morbidity and mortality. It frequently falls through the cracks between different disciplines and services within the hospital, he said.

"Delirium is common among older people and is associated with significant morbidity and mortality, but we still underrecognize it," said Dr. Yesne Alici, a geriatric psychiatrist at Central Regional Hospital in Butner, N.C.

She pointed to a meta-analysis of studies of delirium in elderly patients, which showed that patients with delirium had a nearly twofold risk for death, compared with controls, and that "delirium in elderly patients is associated with poor outcome independent of important confounders, such as age, sex, comorbid illness or illness severity, and baseline dementia" (JAMA 2010;304:443-51).

But every difficult case of delirium also provides educational, clinical, and/or performance-improvement opportunities for hospital administration, medical and surgical services, nursing, geriatrics, pharmacy, and other disciplines, Dr. Loreck noted.

Early recognition and intervention are critical, because the longer the episode of delirium, the less likely the patient is to fully recover to baseline status, both noted.

Unit-Based Solution

The unique leadership, administrative structure, and work environment of each hospital unit will suggest the best approach to preventing delirium among patients in that unit, Dr. Loreck said.

One option is to identify a "dementia champion" within each unit – whether the champion is a physician, nurse manager, or clinical nurse specialist – and work with that individual to be a dementia leader who can develop a team within the unit to help identify those patients most at risk for delirium.

A more practical and realistic option, however, is for the hospital to have a specific consultation service composed of geriatricians, psychiatrists, or neurologists who act as institution-wide dementia specialists to help identify delirium triggers and institute measures appropriate to each unit for reducing delirium.

"Even though you’re not training a whole team, you’re still going to need a point person on the unit to trigger the consult team into action," Dr. Loreck said.

Clocks, Calendars, Caregiver IDs

Nursing staff, who spend the most time with patients, are the clinicians most likely to detect changes in patient mental status. But generally, nurses are not that good at recognizing delirium, both Dr. Loreck and Dr. Alici said.

Nonetheless, nurses are often well positioned to implement delirium prevention strategies; identify delirium risk factors, signs, and symptoms; and intervene early to ameliorate the negative effects of delirium when it occurs. Nursing staff can be trained to differentiate delirium from dementia, and to distinguish between hypoactive delirium and the effects of illness, medications, fatigue, or environmental influences on sleep.

All unit staff also should be aware of delirium triggers, such as infections (especially urinary tract infections), constipation, hypoxia, hypotension, pain, and medications.

Simple time and place cues such as easily visible clocks, calendars, and caregiver IDs, can help orient patients to their whereabouts. The unit also should allow for appropriate sensory stimulation of patients, with a quiet room, adequate light, and engagement in only one task at a time.

Delirium Toolbox

He briefly described a delirium-care model outlined by Dr. James L. Rudolph, a geriatrician at Brigham and Women’s Hospital, Boston, and the VA Boston Healthcare System.

The model focuses on universal prevention measures, tools for identifying and modifying delirium risk, and a standardized treatment protocol.

Universal prevention measures include providing a better sleep environment – "Hospitals stink for sleep, and all patients would benefit from better sleep," Dr. Loreck said – with lights out at 10 p.m., headsets for "night owls" and earplugs for their sleeping roommates, as well as reduction of ambient noises, and reduction of overnight vital-signs taking.

At admission or during a unit stay, patients can be assessed for delirium by being asked to recite the months of the year backward while being timed, or the Clock-in-the-Box test for cognitive function. Clinicians also should identify visual and hearing deficits that might put the patient at risk for delirium, ensure that they have adequate nutrition and hydration, assess their acuity of illness, and identify any high-risk medications they might be taking, such as alcohol, opiates, benzodiazepines, anticholinergics (for example, diphenhydramine or tricyclic antidepressants), corticosteroids, central-acting antihypertensives, and levodopa.

High-risk patients can be given a delirium toolbox designed to encourage appropriate stimulations, including pocket talkers (audio amplification devices), reading glasses, earplugs, nightlights, flashlights, cards, puzzles, and Play-Doh–brand modeling compound.

For daytime, patients can be furnished with radios, preloaded MP3 players with speakers, DVD players, white-noise generators, and games and puzzles for stimulation.

One of the most cost-effective measures is sitter-training, with bedside aides instructed about how to recognize delirium and engage the patient through reading, conversation, playing music, and providing stimulation, rather than sitting mutely and passively by.

Although no one-size-fits-all solution exists to prevent delirium, taking action to prevent it, and, when necessary, to treat it, is critically important, Dr. Loreck emphasized.

"You don’t have to do everything, but do something," he said.

Neither Dr. Loreck nor Dr. Alici had conflicts of interest to disclose.

SAN ANTONIO – Simple steps such as treating infections, avoiding physical restraints, and letting patients sleep at night can go a long way toward reducing delirium episodes among elderly patients in acute and postacute settings, delirium experts said at the annual meeting of the American Association for Geriatric Psychiatry.

"Starting anywhere is better than the status quo," said Dr. David J. Loreck, director of Baltimore VA Medical Center Mental Health Consultation Services, and assistant professor of psychiatry at the University of Maryland in Baltimore.

Delirium is an insidious, underrecognized problem associated with significant morbidity and mortality. It frequently falls through the cracks between different disciplines and services within the hospital, he said.

"Delirium is common among older people and is associated with significant morbidity and mortality, but we still underrecognize it," said Dr. Yesne Alici, a geriatric psychiatrist at Central Regional Hospital in Butner, N.C.

She pointed to a meta-analysis of studies of delirium in elderly patients, which showed that patients with delirium had a nearly twofold risk for death, compared with controls, and that "delirium in elderly patients is associated with poor outcome independent of important confounders, such as age, sex, comorbid illness or illness severity, and baseline dementia" (JAMA 2010;304:443-51).

But every difficult case of delirium also provides educational, clinical, and/or performance-improvement opportunities for hospital administration, medical and surgical services, nursing, geriatrics, pharmacy, and other disciplines, Dr. Loreck noted.

Early recognition and intervention are critical, because the longer the episode of delirium, the less likely the patient is to fully recover to baseline status, both noted.

Unit-Based Solution

The unique leadership, administrative structure, and work environment of each hospital unit will suggest the best approach to preventing delirium among patients in that unit, Dr. Loreck said.

One option is to identify a "dementia champion" within each unit – whether the champion is a physician, nurse manager, or clinical nurse specialist – and work with that individual to be a dementia leader who can develop a team within the unit to help identify those patients most at risk for delirium.

A more practical and realistic option, however, is for the hospital to have a specific consultation service composed of geriatricians, psychiatrists, or neurologists who act as institution-wide dementia specialists to help identify delirium triggers and institute measures appropriate to each unit for reducing delirium.

"Even though you’re not training a whole team, you’re still going to need a point person on the unit to trigger the consult team into action," Dr. Loreck said.

Clocks, Calendars, Caregiver IDs

Nursing staff, who spend the most time with patients, are the clinicians most likely to detect changes in patient mental status. But generally, nurses are not that good at recognizing delirium, both Dr. Loreck and Dr. Alici said.

Nonetheless, nurses are often well positioned to implement delirium prevention strategies; identify delirium risk factors, signs, and symptoms; and intervene early to ameliorate the negative effects of delirium when it occurs. Nursing staff can be trained to differentiate delirium from dementia, and to distinguish between hypoactive delirium and the effects of illness, medications, fatigue, or environmental influences on sleep.

All unit staff also should be aware of delirium triggers, such as infections (especially urinary tract infections), constipation, hypoxia, hypotension, pain, and medications.

Simple time and place cues such as easily visible clocks, calendars, and caregiver IDs, can help orient patients to their whereabouts. The unit also should allow for appropriate sensory stimulation of patients, with a quiet room, adequate light, and engagement in only one task at a time.

Delirium Toolbox

He briefly described a delirium-care model outlined by Dr. James L. Rudolph, a geriatrician at Brigham and Women’s Hospital, Boston, and the VA Boston Healthcare System.

The model focuses on universal prevention measures, tools for identifying and modifying delirium risk, and a standardized treatment protocol.

Universal prevention measures include providing a better sleep environment – "Hospitals stink for sleep, and all patients would benefit from better sleep," Dr. Loreck said – with lights out at 10 p.m., headsets for "night owls" and earplugs for their sleeping roommates, as well as reduction of ambient noises, and reduction of overnight vital-signs taking.

At admission or during a unit stay, patients can be assessed for delirium by being asked to recite the months of the year backward while being timed, or the Clock-in-the-Box test for cognitive function. Clinicians also should identify visual and hearing deficits that might put the patient at risk for delirium, ensure that they have adequate nutrition and hydration, assess their acuity of illness, and identify any high-risk medications they might be taking, such as alcohol, opiates, benzodiazepines, anticholinergics (for example, diphenhydramine or tricyclic antidepressants), corticosteroids, central-acting antihypertensives, and levodopa.

High-risk patients can be given a delirium toolbox designed to encourage appropriate stimulations, including pocket talkers (audio amplification devices), reading glasses, earplugs, nightlights, flashlights, cards, puzzles, and Play-Doh–brand modeling compound.

For daytime, patients can be furnished with radios, preloaded MP3 players with speakers, DVD players, white-noise generators, and games and puzzles for stimulation.

One of the most cost-effective measures is sitter-training, with bedside aides instructed about how to recognize delirium and engage the patient through reading, conversation, playing music, and providing stimulation, rather than sitting mutely and passively by.

Although no one-size-fits-all solution exists to prevent delirium, taking action to prevent it, and, when necessary, to treat it, is critically important, Dr. Loreck emphasized.

"You don’t have to do everything, but do something," he said.

Neither Dr. Loreck nor Dr. Alici had conflicts of interest to disclose.

SAN ANTONIO – Simple steps such as treating infections, avoiding physical restraints, and letting patients sleep at night can go a long way toward reducing delirium episodes among elderly patients in acute and postacute settings, delirium experts said at the annual meeting of the American Association for Geriatric Psychiatry.

"Starting anywhere is better than the status quo," said Dr. David J. Loreck, director of Baltimore VA Medical Center Mental Health Consultation Services, and assistant professor of psychiatry at the University of Maryland in Baltimore.

Delirium is an insidious, underrecognized problem associated with significant morbidity and mortality. It frequently falls through the cracks between different disciplines and services within the hospital, he said.

"Delirium is common among older people and is associated with significant morbidity and mortality, but we still underrecognize it," said Dr. Yesne Alici, a geriatric psychiatrist at Central Regional Hospital in Butner, N.C.

She pointed to a meta-analysis of studies of delirium in elderly patients, which showed that patients with delirium had a nearly twofold risk for death, compared with controls, and that "delirium in elderly patients is associated with poor outcome independent of important confounders, such as age, sex, comorbid illness or illness severity, and baseline dementia" (JAMA 2010;304:443-51).

But every difficult case of delirium also provides educational, clinical, and/or performance-improvement opportunities for hospital administration, medical and surgical services, nursing, geriatrics, pharmacy, and other disciplines, Dr. Loreck noted.

Early recognition and intervention are critical, because the longer the episode of delirium, the less likely the patient is to fully recover to baseline status, both noted.

Unit-Based Solution

The unique leadership, administrative structure, and work environment of each hospital unit will suggest the best approach to preventing delirium among patients in that unit, Dr. Loreck said.

One option is to identify a "dementia champion" within each unit – whether the champion is a physician, nurse manager, or clinical nurse specialist – and work with that individual to be a dementia leader who can develop a team within the unit to help identify those patients most at risk for delirium.

A more practical and realistic option, however, is for the hospital to have a specific consultation service composed of geriatricians, psychiatrists, or neurologists who act as institution-wide dementia specialists to help identify delirium triggers and institute measures appropriate to each unit for reducing delirium.

"Even though you’re not training a whole team, you’re still going to need a point person on the unit to trigger the consult team into action," Dr. Loreck said.

Clocks, Calendars, Caregiver IDs

Nursing staff, who spend the most time with patients, are the clinicians most likely to detect changes in patient mental status. But generally, nurses are not that good at recognizing delirium, both Dr. Loreck and Dr. Alici said.

Nonetheless, nurses are often well positioned to implement delirium prevention strategies; identify delirium risk factors, signs, and symptoms; and intervene early to ameliorate the negative effects of delirium when it occurs. Nursing staff can be trained to differentiate delirium from dementia, and to distinguish between hypoactive delirium and the effects of illness, medications, fatigue, or environmental influences on sleep.

All unit staff also should be aware of delirium triggers, such as infections (especially urinary tract infections), constipation, hypoxia, hypotension, pain, and medications.

Simple time and place cues such as easily visible clocks, calendars, and caregiver IDs, can help orient patients to their whereabouts. The unit also should allow for appropriate sensory stimulation of patients, with a quiet room, adequate light, and engagement in only one task at a time.

Delirium Toolbox

He briefly described a delirium-care model outlined by Dr. James L. Rudolph, a geriatrician at Brigham and Women’s Hospital, Boston, and the VA Boston Healthcare System.

The model focuses on universal prevention measures, tools for identifying and modifying delirium risk, and a standardized treatment protocol.

Universal prevention measures include providing a better sleep environment – "Hospitals stink for sleep, and all patients would benefit from better sleep," Dr. Loreck said – with lights out at 10 p.m., headsets for "night owls" and earplugs for their sleeping roommates, as well as reduction of ambient noises, and reduction of overnight vital-signs taking.

At admission or during a unit stay, patients can be assessed for delirium by being asked to recite the months of the year backward while being timed, or the Clock-in-the-Box test for cognitive function. Clinicians also should identify visual and hearing deficits that might put the patient at risk for delirium, ensure that they have adequate nutrition and hydration, assess their acuity of illness, and identify any high-risk medications they might be taking, such as alcohol, opiates, benzodiazepines, anticholinergics (for example, diphenhydramine or tricyclic antidepressants), corticosteroids, central-acting antihypertensives, and levodopa.

High-risk patients can be given a delirium toolbox designed to encourage appropriate stimulations, including pocket talkers (audio amplification devices), reading glasses, earplugs, nightlights, flashlights, cards, puzzles, and Play-Doh–brand modeling compound.

For daytime, patients can be furnished with radios, preloaded MP3 players with speakers, DVD players, white-noise generators, and games and puzzles for stimulation.

One of the most cost-effective measures is sitter-training, with bedside aides instructed about how to recognize delirium and engage the patient through reading, conversation, playing music, and providing stimulation, rather than sitting mutely and passively by.

Although no one-size-fits-all solution exists to prevent delirium, taking action to prevent it, and, when necessary, to treat it, is critically important, Dr. Loreck emphasized.

"You don’t have to do everything, but do something," he said.

Neither Dr. Loreck nor Dr. Alici had conflicts of interest to disclose.

SAN ANTONIO – Simple steps such as treating infections, avoiding physical restraints, and letting patients sleep at night can go a long way toward reducing delirium episodes among elderly patients in acute and postacute settings, delirium experts said at the annual meeting of the American Association for Geriatric Psychiatry.

"Starting anywhere is better than the status quo," said Dr. David J. Loreck, director of Baltimore VA Medical Center Mental Health Consultation Services, and assistant professor of psychiatry at the University of Maryland in Baltimore.

Delirium is an insidious, underrecognized problem associated with significant morbidity and mortality. It frequently falls through the cracks between different disciplines and services within the hospital, he said.

"Delirium is common among older people and is associated with significant morbidity and mortality, but we still underrecognize it," said Dr. Yesne Alici, a geriatric psychiatrist at Central Regional Hospital in Butner, N.C.

She pointed to a meta-analysis of studies of delirium in elderly patients, which showed that patients with delirium had a nearly twofold risk for death, compared with controls, and that "delirium in elderly patients is associated with poor outcome independent of important confounders, such as age, sex, comorbid illness or illness severity, and baseline dementia" (JAMA 2010;304:443-51).

But every difficult case of delirium also provides educational, clinical, and/or performance-improvement opportunities for hospital administration, medical and surgical services, nursing, geriatrics, pharmacy, and other disciplines, Dr. Loreck noted.

Early recognition and intervention are critical, because the longer the episode of delirium, the less likely the patient is to fully recover to baseline status, both noted.

Unit-Based Solution

The unique leadership, administrative structure, and work environment of each hospital unit will suggest the best approach to preventing delirium among patients in that unit, Dr. Loreck said.

One option is to identify a "dementia champion" within each unit – whether the champion is a physician, nurse manager, or clinical nurse specialist – and work with that individual to be a dementia leader who can develop a team within the unit to help identify those patients most at risk for delirium.

A more practical and realistic option, however, is for the hospital to have a specific consultation service composed of geriatricians, psychiatrists, or neurologists who act as institution-wide dementia specialists to help identify delirium triggers and institute measures appropriate to each unit for reducing delirium.

"Even though you’re not training a whole team, you’re still going to need a point person on the unit to trigger the consult team into action," Dr. Loreck said.

Clocks, Calendars, Caregiver IDs

Nursing staff, who spend the most time with patients, are the clinicians most likely to detect changes in patient mental status. But generally, nurses are not that good at recognizing delirium, both Dr. Loreck and Dr. Alici said.

Nonetheless, nurses are often well positioned to implement delirium prevention strategies; identify delirium risk factors, signs, and symptoms; and intervene early to ameliorate the negative effects of delirium when it occurs. Nursing staff can be trained to differentiate delirium from dementia, and to distinguish between hypoactive delirium and the effects of illness, medications, fatigue, or environmental influences on sleep.

All unit staff also should be aware of delirium triggers, such as infections (especially urinary tract infections), constipation, hypoxia, hypotension, pain, and medications.

Simple time and place cues such as easily visible clocks, calendars, and caregiver IDs, can help orient patients to their whereabouts. The unit also should allow for appropriate sensory stimulation of patients, with a quiet room, adequate light, and engagement in only one task at a time.

Delirium Toolbox

He briefly described a delirium-care model outlined by Dr. James L. Rudolph, a geriatrician at Brigham and Women’s Hospital, Boston, and the VA Boston Healthcare System.

The model focuses on universal prevention measures, tools for identifying and modifying delirium risk, and a standardized treatment protocol.

Universal prevention measures include providing a better sleep environment – "Hospitals stink for sleep, and all patients would benefit from better sleep," Dr. Loreck said – with lights out at 10 p.m., headsets for "night owls" and earplugs for their sleeping roommates, as well as reduction of ambient noises, and reduction of overnight vital-signs taking.

At admission or during a unit stay, patients can be assessed for delirium by being asked to recite the months of the year backward while being timed, or the Clock-in-the-Box test for cognitive function. Clinicians also should identify visual and hearing deficits that might put the patient at risk for delirium, ensure that they have adequate nutrition and hydration, assess their acuity of illness, and identify any high-risk medications they might be taking, such as alcohol, opiates, benzodiazepines, anticholinergics (for example, diphenhydramine or tricyclic antidepressants), corticosteroids, central-acting antihypertensives, and levodopa.

High-risk patients can be given a delirium toolbox designed to encourage appropriate stimulations, including pocket talkers (audio amplification devices), reading glasses, earplugs, nightlights, flashlights, cards, puzzles, and Play-Doh–brand modeling compound.

For daytime, patients can be furnished with radios, preloaded MP3 players with speakers, DVD players, white-noise generators, and games and puzzles for stimulation.

One of the most cost-effective measures is sitter-training, with bedside aides instructed about how to recognize delirium and engage the patient through reading, conversation, playing music, and providing stimulation, rather than sitting mutely and passively by.

Although no one-size-fits-all solution exists to prevent delirium, taking action to prevent it, and, when necessary, to treat it, is critically important, Dr. Loreck emphasized.

"You don’t have to do everything, but do something," he said.

Neither Dr. Loreck nor Dr. Alici had conflicts of interest to disclose.

SAN ANTONIO – Simple steps such as treating infections, avoiding physical restraints, and letting patients sleep at night can go a long way toward reducing delirium episodes among elderly patients in acute and postacute settings, delirium experts said at the annual meeting of the American Association for Geriatric Psychiatry.

"Starting anywhere is better than the status quo," said Dr. David J. Loreck, director of Baltimore VA Medical Center Mental Health Consultation Services, and assistant professor of psychiatry at the University of Maryland in Baltimore.

Delirium is an insidious, underrecognized problem associated with significant morbidity and mortality. It frequently falls through the cracks between different disciplines and services within the hospital, he said.

"Delirium is common among older people and is associated with significant morbidity and mortality, but we still underrecognize it," said Dr. Yesne Alici, a geriatric psychiatrist at Central Regional Hospital in Butner, N.C.

She pointed to a meta-analysis of studies of delirium in elderly patients, which showed that patients with delirium had a nearly twofold risk for death, compared with controls, and that "delirium in elderly patients is associated with poor outcome independent of important confounders, such as age, sex, comorbid illness or illness severity, and baseline dementia" (JAMA 2010;304:443-51).

But every difficult case of delirium also provides educational, clinical, and/or performance-improvement opportunities for hospital administration, medical and surgical services, nursing, geriatrics, pharmacy, and other disciplines, Dr. Loreck noted.

Early recognition and intervention are critical, because the longer the episode of delirium, the less likely the patient is to fully recover to baseline status, both noted.

Unit-Based Solution

The unique leadership, administrative structure, and work environment of each hospital unit will suggest the best approach to preventing delirium among patients in that unit, Dr. Loreck said.

One option is to identify a "dementia champion" within each unit – whether the champion is a physician, nurse manager, or clinical nurse specialist – and work with that individual to be a dementia leader who can develop a team within the unit to help identify those patients most at risk for delirium.

A more practical and realistic option, however, is for the hospital to have a specific consultation service composed of geriatricians, psychiatrists, or neurologists who act as institution-wide dementia specialists to help identify delirium triggers and institute measures appropriate to each unit for reducing delirium.

"Even though you’re not training a whole team, you’re still going to need a point person on the unit to trigger the consult team into action," Dr. Loreck said.

Clocks, Calendars, Caregiver IDs

Nursing staff, who spend the most time with patients, are the clinicians most likely to detect changes in patient mental status. But generally, nurses are not that good at recognizing delirium, both Dr. Loreck and Dr. Alici said.

Nonetheless, nurses are often well positioned to implement delirium prevention strategies; identify delirium risk factors, signs, and symptoms; and intervene early to ameliorate the negative effects of delirium when it occurs. Nursing staff can be trained to differentiate delirium from dementia, and to distinguish between hypoactive delirium and the effects of illness, medications, fatigue, or environmental influences on sleep.

All unit staff also should be aware of delirium triggers, such as infections (especially urinary tract infections), constipation, hypoxia, hypotension, pain, and medications.

Simple time and place cues such as easily visible clocks, calendars, and caregiver IDs, can help orient patients to their whereabouts. The unit also should allow for appropriate sensory stimulation of patients, with a quiet room, adequate light, and engagement in only one task at a time.

Delirium Toolbox

He briefly described a delirium-care model outlined by Dr. James L. Rudolph, a geriatrician at Brigham and Women’s Hospital, Boston, and the VA Boston Healthcare System.

The model focuses on universal prevention measures, tools for identifying and modifying delirium risk, and a standardized treatment protocol.

Universal prevention measures include providing a better sleep environment – "Hospitals stink for sleep, and all patients would benefit from better sleep," Dr. Loreck said – with lights out at 10 p.m., headsets for "night owls" and earplugs for their sleeping roommates, as well as reduction of ambient noises, and reduction of overnight vital-signs taking.

At admission or during a unit stay, patients can be assessed for delirium by being asked to recite the months of the year backward while being timed, or the Clock-in-the-Box test for cognitive function. Clinicians also should identify visual and hearing deficits that might put the patient at risk for delirium, ensure that they have adequate nutrition and hydration, assess their acuity of illness, and identify any high-risk medications they might be taking, such as alcohol, opiates, benzodiazepines, anticholinergics (for example, diphenhydramine or tricyclic antidepressants), corticosteroids, central-acting antihypertensives, and levodopa.

High-risk patients can be given a delirium toolbox designed to encourage appropriate stimulations, including pocket talkers (audio amplification devices), reading glasses, earplugs, nightlights, flashlights, cards, puzzles, and Play-Doh–brand modeling compound.

For daytime, patients can be furnished with radios, preloaded MP3 players with speakers, DVD players, white-noise generators, and games and puzzles for stimulation.

One of the most cost-effective measures is sitter-training, with bedside aides instructed about how to recognize delirium and engage the patient through reading, conversation, playing music, and providing stimulation, rather than sitting mutely and passively by.

Although no one-size-fits-all solution exists to prevent delirium, taking action to prevent it, and, when necessary, to treat it, is critically important, Dr. Loreck emphasized.

"You don’t have to do everything, but do something," he said.

Neither Dr. Loreck nor Dr. Alici had conflicts of interest to disclose.

SAN ANTONIO – Simple steps such as treating infections, avoiding physical restraints, and letting patients sleep at night can go a long way toward reducing delirium episodes among elderly patients in acute and postacute settings, delirium experts said at the annual meeting of the American Association for Geriatric Psychiatry.

"Starting anywhere is better than the status quo," said Dr. David J. Loreck, director of Baltimore VA Medical Center Mental Health Consultation Services, and assistant professor of psychiatry at the University of Maryland in Baltimore.

Delirium is an insidious, underrecognized problem associated with significant morbidity and mortality. It frequently falls through the cracks between different disciplines and services within the hospital, he said.

"Delirium is common among older people and is associated with significant morbidity and mortality, but we still underrecognize it," said Dr. Yesne Alici, a geriatric psychiatrist at Central Regional Hospital in Butner, N.C.

She pointed to a meta-analysis of studies of delirium in elderly patients, which showed that patients with delirium had a nearly twofold risk for death, compared with controls, and that "delirium in elderly patients is associated with poor outcome independent of important confounders, such as age, sex, comorbid illness or illness severity, and baseline dementia" (JAMA 2010;304:443-51).

But every difficult case of delirium also provides educational, clinical, and/or performance-improvement opportunities for hospital administration, medical and surgical services, nursing, geriatrics, pharmacy, and other disciplines, Dr. Loreck noted.

Early recognition and intervention are critical, because the longer the episode of delirium, the less likely the patient is to fully recover to baseline status, both noted.

Unit-Based Solution

The unique leadership, administrative structure, and work environment of each hospital unit will suggest the best approach to preventing delirium among patients in that unit, Dr. Loreck said.

One option is to identify a "dementia champion" within each unit – whether the champion is a physician, nurse manager, or clinical nurse specialist – and work with that individual to be a dementia leader who can develop a team within the unit to help identify those patients most at risk for delirium.

A more practical and realistic option, however, is for the hospital to have a specific consultation service composed of geriatricians, psychiatrists, or neurologists who act as institution-wide dementia specialists to help identify delirium triggers and institute measures appropriate to each unit for reducing delirium.

"Even though you’re not training a whole team, you’re still going to need a point person on the unit to trigger the consult team into action," Dr. Loreck said.

Clocks, Calendars, Caregiver IDs

Nursing staff, who spend the most time with patients, are the clinicians most likely to detect changes in patient mental status. But generally, nurses are not that good at recognizing delirium, both Dr. Loreck and Dr. Alici said.

Nonetheless, nurses are often well positioned to implement delirium prevention strategies; identify delirium risk factors, signs, and symptoms; and intervene early to ameliorate the negative effects of delirium when it occurs. Nursing staff can be trained to differentiate delirium from dementia, and to distinguish between hypoactive delirium and the effects of illness, medications, fatigue, or environmental influences on sleep.

All unit staff also should be aware of delirium triggers, such as infections (especially urinary tract infections), constipation, hypoxia, hypotension, pain, and medications.

Simple time and place cues such as easily visible clocks, calendars, and caregiver IDs, can help orient patients to their whereabouts. The unit also should allow for appropriate sensory stimulation of patients, with a quiet room, adequate light, and engagement in only one task at a time.

Delirium Toolbox

He briefly described a delirium-care model outlined by Dr. James L. Rudolph, a geriatrician at Brigham and Women’s Hospital, Boston, and the VA Boston Healthcare System.

The model focuses on universal prevention measures, tools for identifying and modifying delirium risk, and a standardized treatment protocol.

Universal prevention measures include providing a better sleep environment – "Hospitals stink for sleep, and all patients would benefit from better sleep," Dr. Loreck said – with lights out at 10 p.m., headsets for "night owls" and earplugs for their sleeping roommates, as well as reduction of ambient noises, and reduction of overnight vital-signs taking.

At admission or during a unit stay, patients can be assessed for delirium by being asked to recite the months of the year backward while being timed, or the Clock-in-the-Box test for cognitive function. Clinicians also should identify visual and hearing deficits that might put the patient at risk for delirium, ensure that they have adequate nutrition and hydration, assess their acuity of illness, and identify any high-risk medications they might be taking, such as alcohol, opiates, benzodiazepines, anticholinergics (for example, diphenhydramine or tricyclic antidepressants), corticosteroids, central-acting antihypertensives, and levodopa.

High-risk patients can be given a delirium toolbox designed to encourage appropriate stimulations, including pocket talkers (audio amplification devices), reading glasses, earplugs, nightlights, flashlights, cards, puzzles, and Play-Doh–brand modeling compound.

For daytime, patients can be furnished with radios, preloaded MP3 players with speakers, DVD players, white-noise generators, and games and puzzles for stimulation.

One of the most cost-effective measures is sitter-training, with bedside aides instructed about how to recognize delirium and engage the patient through reading, conversation, playing music, and providing stimulation, rather than sitting mutely and passively by.

Although no one-size-fits-all solution exists to prevent delirium, taking action to prevent it, and, when necessary, to treat it, is critically important, Dr. Loreck emphasized.

"You don’t have to do everything, but do something," he said.

Neither Dr. Loreck nor Dr. Alici had conflicts of interest to disclose.

SAN ANTONIO – When an earthquake or other natural disaster strikes, adult day health centers can play a critical role in feeding, housing, and relocating elderly members of the community with more serious health needs, reported administrators of a center who developed an impromptu disaster-management plan in the immediate aftermath of a 2010 earthquake.

After a 7.2 Richter magnitude quake in Baja California, Mexico, on Easter Sunday 2010, the staff of the Alegria Adult Day Healthcare Center (ADHC) in nearby Calexico, Calif., took on the task of helping displaced residents from an adjacent assisted living facility that had been irreparably damaged by the tremors, according to Dr. Bernardo Ng of the department of psychiatry at the University of California, San Diego, and medical director of the Alegria ADHC.

The staffers contacted primary care physicians to discuss medical needs, arranged access to clothing, meals, transportation, and nursing services for suddenly homeless seniors, and helped prevent exacerbations or new onset of mental illness, they reported in a poster presentation at the annual meeting of the American Association for Geriatric Psychiatry.

"An ADHC that has the expertise of dealing with older adults on a daily basis should play a principal role in this kind of disaster plan. A key factor to be successful in whatever you want to carry out is that you partner with agencies or entities involved with whatever resources are available in the community," Dr. Ng said in an interview.

He acknowledged that, as a day facility, his center did not have a specific plan in place to act as a surrogate for the assisted living facility. As a result, he and his colleagues had to make it up as they went along.

The condemned building, a former hotel that had served as an assisted living facility since 1999, housed 98 seniors who had to be evacuated overnight, when building inspectors condemned it as unsound after the quake. The residents were relocated to local hotels but had no access to their clothes, medications, or personal belongings.

On the 3rd through 5th days after the seismic rift, the day center staff provided the residents with meals and transportation, and contacted their primary care physicians to discuss immediate needs. Many of the primary care offices and local pharmacies were damaged in the quake and remained closed for several days after the event.

In addition to providing the seniors with their own clothing and helping them with hygiene such as showering and shaving, the staff performed blood pressure and glycemia checks, provided physical therapy and regular activities, conducted tuberculosis screening and cognitive screening, and contacted family members.

Thirty days after the event, patients were reported to be more anxious, but none required hospitalization. No changes were required in psychotherapy or in medications, and no new onset mental illnesses were reported. The percentage of assisted living residents who attended the day center rose from 15% before the quake to 25% afterward. Some of the other displaced seniors went to stay with families out of town or friends, and those who were able to live more independently relocated to senior apartments, primarily outside the city.

"Disaster management after an earthquake is especially challenging, since there is little warning, an inability to predict potential scale of impairment of mental health services, and a loss of broad infrastructure," the authors wrote.

They noted that their sample was relatively small, but with appropriate support and monitoring, such plans could help to minimize the negative mental health consequences of disasters in larger communities.

SAN ANTONIO – When an earthquake or other natural disaster strikes, adult day health centers can play a critical role in feeding, housing, and relocating elderly members of the community with more serious health needs, reported administrators of a center who developed an impromptu disaster-management plan in the immediate aftermath of a 2010 earthquake.

After a 7.2 Richter magnitude quake in Baja California, Mexico, on Easter Sunday 2010, the staff of the Alegria Adult Day Healthcare Center (ADHC) in nearby Calexico, Calif., took on the task of helping displaced residents from an adjacent assisted living facility that had been irreparably damaged by the tremors, according to Dr. Bernardo Ng of the department of psychiatry at the University of California, San Diego, and medical director of the Alegria ADHC.

The staffers contacted primary care physicians to discuss medical needs, arranged access to clothing, meals, transportation, and nursing services for suddenly homeless seniors, and helped prevent exacerbations or new onset of mental illness, they reported in a poster presentation at the annual meeting of the American Association for Geriatric Psychiatry.

"An ADHC that has the expertise of dealing with older adults on a daily basis should play a principal role in this kind of disaster plan. A key factor to be successful in whatever you want to carry out is that you partner with agencies or entities involved with whatever resources are available in the community," Dr. Ng said in an interview.

He acknowledged that, as a day facility, his center did not have a specific plan in place to act as a surrogate for the assisted living facility. As a result, he and his colleagues had to make it up as they went along.

The condemned building, a former hotel that had served as an assisted living facility since 1999, housed 98 seniors who had to be evacuated overnight, when building inspectors condemned it as unsound after the quake. The residents were relocated to local hotels but had no access to their clothes, medications, or personal belongings.

On the 3rd through 5th days after the seismic rift, the day center staff provided the residents with meals and transportation, and contacted their primary care physicians to discuss immediate needs. Many of the primary care offices and local pharmacies were damaged in the quake and remained closed for several days after the event.

In addition to providing the seniors with their own clothing and helping them with hygiene such as showering and shaving, the staff performed blood pressure and glycemia checks, provided physical therapy and regular activities, conducted tuberculosis screening and cognitive screening, and contacted family members.

Thirty days after the event, patients were reported to be more anxious, but none required hospitalization. No changes were required in psychotherapy or in medications, and no new onset mental illnesses were reported. The percentage of assisted living residents who attended the day center rose from 15% before the quake to 25% afterward. Some of the other displaced seniors went to stay with families out of town or friends, and those who were able to live more independently relocated to senior apartments, primarily outside the city.

"Disaster management after an earthquake is especially challenging, since there is little warning, an inability to predict potential scale of impairment of mental health services, and a loss of broad infrastructure," the authors wrote.

They noted that their sample was relatively small, but with appropriate support and monitoring, such plans could help to minimize the negative mental health consequences of disasters in larger communities.

SAN ANTONIO – When an earthquake or other natural disaster strikes, adult day health centers can play a critical role in feeding, housing, and relocating elderly members of the community with more serious health needs, reported administrators of a center who developed an impromptu disaster-management plan in the immediate aftermath of a 2010 earthquake.

After a 7.2 Richter magnitude quake in Baja California, Mexico, on Easter Sunday 2010, the staff of the Alegria Adult Day Healthcare Center (ADHC) in nearby Calexico, Calif., took on the task of helping displaced residents from an adjacent assisted living facility that had been irreparably damaged by the tremors, according to Dr. Bernardo Ng of the department of psychiatry at the University of California, San Diego, and medical director of the Alegria ADHC.

The staffers contacted primary care physicians to discuss medical needs, arranged access to clothing, meals, transportation, and nursing services for suddenly homeless seniors, and helped prevent exacerbations or new onset of mental illness, they reported in a poster presentation at the annual meeting of the American Association for Geriatric Psychiatry.

"An ADHC that has the expertise of dealing with older adults on a daily basis should play a principal role in this kind of disaster plan. A key factor to be successful in whatever you want to carry out is that you partner with agencies or entities involved with whatever resources are available in the community," Dr. Ng said in an interview.

He acknowledged that, as a day facility, his center did not have a specific plan in place to act as a surrogate for the assisted living facility. As a result, he and his colleagues had to make it up as they went along.

The condemned building, a former hotel that had served as an assisted living facility since 1999, housed 98 seniors who had to be evacuated overnight, when building inspectors condemned it as unsound after the quake. The residents were relocated to local hotels but had no access to their clothes, medications, or personal belongings.

On the 3rd through 5th days after the seismic rift, the day center staff provided the residents with meals and transportation, and contacted their primary care physicians to discuss immediate needs. Many of the primary care offices and local pharmacies were damaged in the quake and remained closed for several days after the event.

In addition to providing the seniors with their own clothing and helping them with hygiene such as showering and shaving, the staff performed blood pressure and glycemia checks, provided physical therapy and regular activities, conducted tuberculosis screening and cognitive screening, and contacted family members.

Thirty days after the event, patients were reported to be more anxious, but none required hospitalization. No changes were required in psychotherapy or in medications, and no new onset mental illnesses were reported. The percentage of assisted living residents who attended the day center rose from 15% before the quake to 25% afterward. Some of the other displaced seniors went to stay with families out of town or friends, and those who were able to live more independently relocated to senior apartments, primarily outside the city.

"Disaster management after an earthquake is especially challenging, since there is little warning, an inability to predict potential scale of impairment of mental health services, and a loss of broad infrastructure," the authors wrote.

They noted that their sample was relatively small, but with appropriate support and monitoring, such plans could help to minimize the negative mental health consequences of disasters in larger communities.

SAN ANTONIO – When an earthquake or other natural disaster strikes, adult day health centers can play a critical role in feeding, housing, and relocating elderly members of the community with more serious health needs, reported administrators of a center who developed an impromptu disaster-management plan in the immediate aftermath of a 2010 earthquake.

After a 7.2 Richter magnitude quake in Baja California, Mexico, on Easter Sunday 2010, the staff of the Alegria Adult Day Healthcare Center (ADHC) in nearby Calexico, Calif., took on the task of helping displaced residents from an adjacent assisted living facility that had been irreparably damaged by the tremors, according to Dr. Bernardo Ng of the department of psychiatry at the University of California, San Diego, and medical director of the Alegria ADHC.

The staffers contacted primary care physicians to discuss medical needs, arranged access to clothing, meals, transportation, and nursing services for suddenly homeless seniors, and helped prevent exacerbations or new onset of mental illness, they reported in a poster presentation at the annual meeting of the American Association for Geriatric Psychiatry.

"An ADHC that has the expertise of dealing with older adults on a daily basis should play a principal role in this kind of disaster plan. A key factor to be successful in whatever you want to carry out is that you partner with agencies or entities involved with whatever resources are available in the community," Dr. Ng said in an interview.

He acknowledged that, as a day facility, his center did not have a specific plan in place to act as a surrogate for the assisted living facility. As a result, he and his colleagues had to make it up as they went along.

The condemned building, a former hotel that had served as an assisted living facility since 1999, housed 98 seniors who had to be evacuated overnight, when building inspectors condemned it as unsound after the quake. The residents were relocated to local hotels but had no access to their clothes, medications, or personal belongings.

On the 3rd through 5th days after the seismic rift, the day center staff provided the residents with meals and transportation, and contacted their primary care physicians to discuss immediate needs. Many of the primary care offices and local pharmacies were damaged in the quake and remained closed for several days after the event.

In addition to providing the seniors with their own clothing and helping them with hygiene such as showering and shaving, the staff performed blood pressure and glycemia checks, provided physical therapy and regular activities, conducted tuberculosis screening and cognitive screening, and contacted family members.

Thirty days after the event, patients were reported to be more anxious, but none required hospitalization. No changes were required in psychotherapy or in medications, and no new onset mental illnesses were reported. The percentage of assisted living residents who attended the day center rose from 15% before the quake to 25% afterward. Some of the other displaced seniors went to stay with families out of town or friends, and those who were able to live more independently relocated to senior apartments, primarily outside the city.

"Disaster management after an earthquake is especially challenging, since there is little warning, an inability to predict potential scale of impairment of mental health services, and a loss of broad infrastructure," the authors wrote.

They noted that their sample was relatively small, but with appropriate support and monitoring, such plans could help to minimize the negative mental health consequences of disasters in larger communities.

SAN ANTONIO – When an earthquake or other natural disaster strikes, adult day health centers can play a critical role in feeding, housing, and relocating elderly members of the community with more serious health needs, reported administrators of a center who developed an impromptu disaster-management plan in the immediate aftermath of a 2010 earthquake.

After a 7.2 Richter magnitude quake in Baja California, Mexico, on Easter Sunday 2010, the staff of the Alegria Adult Day Healthcare Center (ADHC) in nearby Calexico, Calif., took on the task of helping displaced residents from an adjacent assisted living facility that had been irreparably damaged by the tremors, according to Dr. Bernardo Ng of the department of psychiatry at the University of California, San Diego, and medical director of the Alegria ADHC.

The staffers contacted primary care physicians to discuss medical needs, arranged access to clothing, meals, transportation, and nursing services for suddenly homeless seniors, and helped prevent exacerbations or new onset of mental illness, they reported in a poster presentation at the annual meeting of the American Association for Geriatric Psychiatry.

"An ADHC that has the expertise of dealing with older adults on a daily basis should play a principal role in this kind of disaster plan. A key factor to be successful in whatever you want to carry out is that you partner with agencies or entities involved with whatever resources are available in the community," Dr. Ng said in an interview.

He acknowledged that, as a day facility, his center did not have a specific plan in place to act as a surrogate for the assisted living facility. As a result, he and his colleagues had to make it up as they went along.

The condemned building, a former hotel that had served as an assisted living facility since 1999, housed 98 seniors who had to be evacuated overnight, when building inspectors condemned it as unsound after the quake. The residents were relocated to local hotels but had no access to their clothes, medications, or personal belongings.

On the 3rd through 5th days after the seismic rift, the day center staff provided the residents with meals and transportation, and contacted their primary care physicians to discuss immediate needs. Many of the primary care offices and local pharmacies were damaged in the quake and remained closed for several days after the event.

In addition to providing the seniors with their own clothing and helping them with hygiene such as showering and shaving, the staff performed blood pressure and glycemia checks, provided physical therapy and regular activities, conducted tuberculosis screening and cognitive screening, and contacted family members.

Thirty days after the event, patients were reported to be more anxious, but none required hospitalization. No changes were required in psychotherapy or in medications, and no new onset mental illnesses were reported. The percentage of assisted living residents who attended the day center rose from 15% before the quake to 25% afterward. Some of the other displaced seniors went to stay with families out of town or friends, and those who were able to live more independently relocated to senior apartments, primarily outside the city.

"Disaster management after an earthquake is especially challenging, since there is little warning, an inability to predict potential scale of impairment of mental health services, and a loss of broad infrastructure," the authors wrote.

They noted that their sample was relatively small, but with appropriate support and monitoring, such plans could help to minimize the negative mental health consequences of disasters in larger communities.

SAN ANTONIO – When an earthquake or other natural disaster strikes, adult day health centers can play a critical role in feeding, housing, and relocating elderly members of the community with more serious health needs, reported administrators of a center who developed an impromptu disaster-management plan in the immediate aftermath of a 2010 earthquake.

After a 7.2 Richter magnitude quake in Baja California, Mexico, on Easter Sunday 2010, the staff of the Alegria Adult Day Healthcare Center (ADHC) in nearby Calexico, Calif., took on the task of helping displaced residents from an adjacent assisted living facility that had been irreparably damaged by the tremors, according to Dr. Bernardo Ng of the department of psychiatry at the University of California, San Diego, and medical director of the Alegria ADHC.

The staffers contacted primary care physicians to discuss medical needs, arranged access to clothing, meals, transportation, and nursing services for suddenly homeless seniors, and helped prevent exacerbations or new onset of mental illness, they reported in a poster presentation at the annual meeting of the American Association for Geriatric Psychiatry.

"An ADHC that has the expertise of dealing with older adults on a daily basis should play a principal role in this kind of disaster plan. A key factor to be successful in whatever you want to carry out is that you partner with agencies or entities involved with whatever resources are available in the community," Dr. Ng said in an interview.

He acknowledged that, as a day facility, his center did not have a specific plan in place to act as a surrogate for the assisted living facility. As a result, he and his colleagues had to make it up as they went along.

The condemned building, a former hotel that had served as an assisted living facility since 1999, housed 98 seniors who had to be evacuated overnight, when building inspectors condemned it as unsound after the quake. The residents were relocated to local hotels but had no access to their clothes, medications, or personal belongings.

On the 3rd through 5th days after the seismic rift, the day center staff provided the residents with meals and transportation, and contacted their primary care physicians to discuss immediate needs. Many of the primary care offices and local pharmacies were damaged in the quake and remained closed for several days after the event.

In addition to providing the seniors with their own clothing and helping them with hygiene such as showering and shaving, the staff performed blood pressure and glycemia checks, provided physical therapy and regular activities, conducted tuberculosis screening and cognitive screening, and contacted family members.

Thirty days after the event, patients were reported to be more anxious, but none required hospitalization. No changes were required in psychotherapy or in medications, and no new onset mental illnesses were reported. The percentage of assisted living residents who attended the day center rose from 15% before the quake to 25% afterward. Some of the other displaced seniors went to stay with families out of town or friends, and those who were able to live more independently relocated to senior apartments, primarily outside the city.

"Disaster management after an earthquake is especially challenging, since there is little warning, an inability to predict potential scale of impairment of mental health services, and a loss of broad infrastructure," the authors wrote.

They noted that their sample was relatively small, but with appropriate support and monitoring, such plans could help to minimize the negative mental health consequences of disasters in larger communities.

SAN ANTONIO – When an earthquake or other natural disaster strikes, adult day health centers can play a critical role in feeding, housing, and relocating elderly members of the community with more serious health needs, reported administrators of a center who developed an impromptu disaster-management plan in the immediate aftermath of a 2010 earthquake.

After a 7.2 Richter magnitude quake in Baja California, Mexico, on Easter Sunday 2010, the staff of the Alegria Adult Day Healthcare Center (ADHC) in nearby Calexico, Calif., took on the task of helping displaced residents from an adjacent assisted living facility that had been irreparably damaged by the tremors, according to Dr. Bernardo Ng of the department of psychiatry at the University of California, San Diego, and medical director of the Alegria ADHC.

The staffers contacted primary care physicians to discuss medical needs, arranged access to clothing, meals, transportation, and nursing services for suddenly homeless seniors, and helped prevent exacerbations or new onset of mental illness, they reported in a poster presentation at the annual meeting of the American Association for Geriatric Psychiatry.

"An ADHC that has the expertise of dealing with older adults on a daily basis should play a principal role in this kind of disaster plan. A key factor to be successful in whatever you want to carry out is that you partner with agencies or entities involved with whatever resources are available in the community," Dr. Ng said in an interview.

He acknowledged that, as a day facility, his center did not have a specific plan in place to act as a surrogate for the assisted living facility. As a result, he and his colleagues had to make it up as they went along.

The condemned building, a former hotel that had served as an assisted living facility since 1999, housed 98 seniors who had to be evacuated overnight, when building inspectors condemned it as unsound after the quake. The residents were relocated to local hotels but had no access to their clothes, medications, or personal belongings.

On the 3rd through 5th days after the seismic rift, the day center staff provided the residents with meals and transportation, and contacted their primary care physicians to discuss immediate needs. Many of the primary care offices and local pharmacies were damaged in the quake and remained closed for several days after the event.

In addition to providing the seniors with their own clothing and helping them with hygiene such as showering and shaving, the staff performed blood pressure and glycemia checks, provided physical therapy and regular activities, conducted tuberculosis screening and cognitive screening, and contacted family members.

Thirty days after the event, patients were reported to be more anxious, but none required hospitalization. No changes were required in psychotherapy or in medications, and no new-onset mental illnesses were reported. The percentage of assisted living residents who attended the day center rose from 15% before the quake to 25% afterward. Some of the other displaced seniors went to stay with families out of town or friends, and those who were able to live more independently relocated to senior apartments, primarily outside the city.

"Disaster management after an earthquake is especially challenging, since there is little warning, an inability to predict potential scale of impairment of mental health services, and a loss of broad infrastructure," the authors wrote.

They noted that their sample was relatively small, but with appropriate support and monitoring, such plans could help to minimize the negative mental health consequences of disasters in larger communities.

SAN ANTONIO – When an earthquake or other natural disaster strikes, adult day health centers can play a critical role in feeding, housing, and relocating elderly members of the community with more serious health needs, reported administrators of a center who developed an impromptu disaster-management plan in the immediate aftermath of a 2010 earthquake.

After a 7.2 Richter magnitude quake in Baja California, Mexico, on Easter Sunday 2010, the staff of the Alegria Adult Day Healthcare Center (ADHC) in nearby Calexico, Calif., took on the task of helping displaced residents from an adjacent assisted living facility that had been irreparably damaged by the tremors, according to Dr. Bernardo Ng of the department of psychiatry at the University of California, San Diego, and medical director of the Alegria ADHC.

The staffers contacted primary care physicians to discuss medical needs, arranged access to clothing, meals, transportation, and nursing services for suddenly homeless seniors, and helped prevent exacerbations or new onset of mental illness, they reported in a poster presentation at the annual meeting of the American Association for Geriatric Psychiatry.

"An ADHC that has the expertise of dealing with older adults on a daily basis should play a principal role in this kind of disaster plan. A key factor to be successful in whatever you want to carry out is that you partner with agencies or entities involved with whatever resources are available in the community," Dr. Ng said in an interview.

He acknowledged that, as a day facility, his center did not have a specific plan in place to act as a surrogate for the assisted living facility. As a result, he and his colleagues had to make it up as they went along.

The condemned building, a former hotel that had served as an assisted living facility since 1999, housed 98 seniors who had to be evacuated overnight, when building inspectors condemned it as unsound after the quake. The residents were relocated to local hotels but had no access to their clothes, medications, or personal belongings.

On the 3rd through 5th days after the seismic rift, the day center staff provided the residents with meals and transportation, and contacted their primary care physicians to discuss immediate needs. Many of the primary care offices and local pharmacies were damaged in the quake and remained closed for several days after the event.

In addition to providing the seniors with their own clothing and helping them with hygiene such as showering and shaving, the staff performed blood pressure and glycemia checks, provided physical therapy and regular activities, conducted tuberculosis screening and cognitive screening, and contacted family members.

Thirty days after the event, patients were reported to be more anxious, but none required hospitalization. No changes were required in psychotherapy or in medications, and no new-onset mental illnesses were reported. The percentage of assisted living residents who attended the day center rose from 15% before the quake to 25% afterward. Some of the other displaced seniors went to stay with families out of town or friends, and those who were able to live more independently relocated to senior apartments, primarily outside the city.

"Disaster management after an earthquake is especially challenging, since there is little warning, an inability to predict potential scale of impairment of mental health services, and a loss of broad infrastructure," the authors wrote.

They noted that their sample was relatively small, but with appropriate support and monitoring, such plans could help to minimize the negative mental health consequences of disasters in larger communities.

SAN ANTONIO – When an earthquake or other natural disaster strikes, adult day health centers can play a critical role in feeding, housing, and relocating elderly members of the community with more serious health needs, reported administrators of a center who developed an impromptu disaster-management plan in the immediate aftermath of a 2010 earthquake.

After a 7.2 Richter magnitude quake in Baja California, Mexico, on Easter Sunday 2010, the staff of the Alegria Adult Day Healthcare Center (ADHC) in nearby Calexico, Calif., took on the task of helping displaced residents from an adjacent assisted living facility that had been irreparably damaged by the tremors, according to Dr. Bernardo Ng of the department of psychiatry at the University of California, San Diego, and medical director of the Alegria ADHC.

The staffers contacted primary care physicians to discuss medical needs, arranged access to clothing, meals, transportation, and nursing services for suddenly homeless seniors, and helped prevent exacerbations or new onset of mental illness, they reported in a poster presentation at the annual meeting of the American Association for Geriatric Psychiatry.

"An ADHC that has the expertise of dealing with older adults on a daily basis should play a principal role in this kind of disaster plan. A key factor to be successful in whatever you want to carry out is that you partner with agencies or entities involved with whatever resources are available in the community," Dr. Ng said in an interview.

He acknowledged that, as a day facility, his center did not have a specific plan in place to act as a surrogate for the assisted living facility. As a result, he and his colleagues had to make it up as they went along.

The condemned building, a former hotel that had served as an assisted living facility since 1999, housed 98 seniors who had to be evacuated overnight, when building inspectors condemned it as unsound after the quake. The residents were relocated to local hotels but had no access to their clothes, medications, or personal belongings.

On the 3rd through 5th days after the seismic rift, the day center staff provided the residents with meals and transportation, and contacted their primary care physicians to discuss immediate needs. Many of the primary care offices and local pharmacies were damaged in the quake and remained closed for several days after the event.

In addition to providing the seniors with their own clothing and helping them with hygiene such as showering and shaving, the staff performed blood pressure and glycemia checks, provided physical therapy and regular activities, conducted tuberculosis screening and cognitive screening, and contacted family members.

Thirty days after the event, patients were reported to be more anxious, but none required hospitalization. No changes were required in psychotherapy or in medications, and no new-onset mental illnesses were reported. The percentage of assisted living residents who attended the day center rose from 15% before the quake to 25% afterward. Some of the other displaced seniors went to stay with families out of town or friends, and those who were able to live more independently relocated to senior apartments, primarily outside the city.

"Disaster management after an earthquake is especially challenging, since there is little warning, an inability to predict potential scale of impairment of mental health services, and a loss of broad infrastructure," the authors wrote.

They noted that their sample was relatively small, but with appropriate support and monitoring, such plans could help to minimize the negative mental health consequences of disasters in larger communities.