Appendix:

Warning of the Presence of Cognitive Impairment

“Your Patient Has Cognitive Impairment (CI) as evidenced by a Short Portable Mental Status Questionnaire (SPMSQ: 0-10) score of ---- with / without Delirium. (if no delirium then just mention the SPMSQ score)

In comparison to Wishard patients without CI, those admitted with CI stay in Wishard 1.5 days longer, are re-hospitalized two months earlier, and have double the risk of dying within 30 days of their hospitalization. In WishardHospital, patients with CI are at high risk for developing hospital acquired complications such as adverse drugs reactions, falls, injuries, delirium, agitation, and pressure ulcers.”

“Please refer this vulnerable patient for a geriatrics consultation by the Acute Care for the Elders (ACE) team to accommodate his/her special needs.”

List of Medications to Avoid in Hospitalized Older Adults with CI

DRUG
Meperidine / Your patient has COGNITIVE IMPAIRMENT due to a deficit in her / his cholinergic system. Meperidine has central ANTICHOLINERGIC activities. Although this reminder does not serve as a substitute for clinical judgment, a local panel of geriatric pharmacology experts cautions that its use may place your patient at higher risk for delirium, hospital acquired complications and prolonged hospitalization. In its place, consider prescribing:
IV:
Morphine Sulfate 1-2 mg IV every 4 hours as needed for pain
Oral:
Morphine Sulfate IR 15 mg orally every 4 hours as needed for pain.
Oxycodone 5 mg with acetaminophen 325 mg (Percocet) one tablet every 6 hours as needed for pain.
Hydrocodone 5 mg with acetaminophen 500 mg orally every 6 hours as needed for pain
[Success: Not prescribing Meperidine to the patient]
Promethazine / Your patient has COGNITIVE IMPAIRMENT due to a deficit in her / his cholinergic system. Promethazine has central ANTICHOLINERGIC activities. Although this reminder does not serve as a substitute for clinical judgment, a local panel of geriatric pharmacology experts cautions that its use may place your patient at higher risk for delirium, hospital acquired complications and prolonged hospitalization. In its place, consider prescribing:
Dolasetron 50 mg orally every 12 hours as needed
Metoclopramide (Reglan) 5 mg orally every 6 hours as needed
[Success*: Not prescribing promethazine to the patient]
Diphenhydramine / Your patient has COGNITIVE IMPAIRMENT due to a deficit in her / his cholinergic system. Diphenhydramine has central ANTICHOLINERGIC activities. Although this reminder does not serve as a substitute for clinical judgment, a local panel of geriatric pharmacology experts cautions that its use may place your patient at higher risk for delirium, hospital acquired complications and prolonged hospitalization. In its place, consider prescribing:
Allergic reactions, itching, or urticaria:
Loratidine 10 mg orally once per day.
Assistance with sleeping:
Trazodone 25 mg orally once daily at bedtime as needed for insomnia
Blood transfusion:
Acetaminophen 650 mg orally 1.5 hours prior to infusion
Diphenhydramine 12.5 mg IV prior to blood transfusion if patient has history of previous severe reaction to blood transfusion.
Hydrocortisone 100 mg IV prior to blood transfusion
[Success: Not prescribing diphenhydramine to the patient]
Hydroxyzine / Your patient has COGNITIVE IMPAIRMENT due to a deficit in her / his cholinergic system. Hydroxyzine has central ANTICHOLINERGIC activities. Although this reminder does not serve as a substitute for clinical judgment, a local panel of geriatric pharmacology experts cautions that its use may place your patient at higher risk for delirium, hospital acquired complications and prolonged hospitalization. In its place, consider prescribing:
Allergic reactions, itching, or urticaria:
Loratidine 10 mg orally once per day.
Assistance with sleeping:
Trazodone 25 mg orally once daily at bedtime as needed for insomnia
[Success: Not prescribing hydroxyzine to the patient]
Chlorpheniramine / Your patient has COGNITIVE IMPAIRMENT due to a deficit in her / his cholinergic system. Chlorpheniramine has central ANTICHOLINERGIC activities. Although this reminder does not serve as a substitute for clinical judgment, a local panel of geriatric pharmacology experts cautions that its use may place your patient at higher risk for delirium, hospital acquired complications and prolonged hospitalization. In its place, consider prescribing:
Allergic reactions, itching, or urticaria:
Loratidine 10 mg orally once per day.
Assistance with sleeping:
Trazodone 25 mg orally once daily at bedtime as needed for insomnia
[Success: Not prescribing chlorpheniramine to the patient]
Meclizine / Your patient has COGNITIVE IMPAIRMENT due to a deficit in her / his cholinergic system. Meclizine has central ANTICHOLINERGIC activities. Although this reminder does not serve as a substitute for clinical judgment, a local panel of geriatric pharmacology experts cautions that its use may place your patient at higher risk for delirium, hospital acquired complications and prolonged hospitalization.
Please consider holding Meclizine until your patient is discharged from the hospital
D/C Meclizine.
Cyclobenzaprine / Your patient has COGNITIVE IMPAIRMENT due to a deficit in her / his cholinergic system. Cyclobenzaprine has central ANTICHOLINERGIC activities. Although this reminder does not serve as a substitute for clinical judgment, a local panel of geriatric pharmacology experts cautions that its use may place your patient at higher risk for delirium, hospital acquired complications and prolonged hospitalization. In its place, consider prescribing:
Acetaminophen 650 mg orally every 6 hours.
Oxycodone 5 mg with acetaminophen 325 mg (Percocet) one tablet orally every 6 hours as needed for pain.
[Success: Not prescribing cyclobenzaprine to the patient]
Methocarbamol / Your patient has COGNITIVE IMPAIRMENT due to a deficit in her / his cholinergic system. Methocarbamol has central ANTICHOLINERGIC activities. Although this reminder does not serve as a substitute for clinical judgment, a local panel of geriatric pharmacology experts cautions that its use may place your patient at higher risk for delirium, hospital acquired complications and prolonged hospitalization. In its place, consider prescribing:
Acetaminophen 650 mg orally every 6 hours.
Oxycodone 5 mg with acetaminophen 325 mg (Percocet) one tablet orally every 6 hours as needed for pain.
[Success: Not prescribing Methocarbamol to the patient]
Hyoscyamine / Your patient has COGNITIVE IMPAIRMENT due to a deficit in her / his cholinergic system. Hyoscyamine has central ANTICHOLINERGIC activities. Although this reminder does not serve as a substitute for clinical judgment, a local panel of geriatric pharmacology experts cautions that its use may place your patient at higher risk for delirium, hospital acquired complications and prolonged hospitalization.
Please consider holding Hyoscyamine until your patient is discharged from the hospital or consider substituting it
D/C Hyoscyamine.
Painful Cramps:
Morphine Sulfate IR15 mg orally every 4 hours as needed for pain
Reflux disorders:
Nexium 20 mg orally once per day
[Success: Not prescribing Hyoscyamine to the patient]
Oxybutinin / Your patient has COGNITIVE IMPAIRMENT due to a deficit in her / his cholinergic system. Oxybutinin has central ANTICHOLINERGIC activities. Although this reminder does not serve as a substitute for clinical judgment, a local panel of geriatric pharmacology experts cautions that its use may place your patient at higher risk for delirium, hospital acquired complications and prolonged hospitalization.
Please consider holding Oxybutinin until your patient is discharged from the hospital
D/C Oxybutinin.
[Success: Not prescribing Oxybutinin to the patient]
Tolterodine / Your patient has COGNITIVE IMPAIRMENT due to a deficit in her / his cholinergic system. Tolterodine has central ANTICHOLINERGIC activities. Although this reminder does not serve as a substitute for clinical judgment, a local panel of geriatric pharmacology experts cautions that its use may place your patient at higher risk for delirium, hospital acquired complications and prolonged hospitalization.
Please consider holding Tolterodine until your patient is discharged from the hospital
D/C Tolterodine.
[Success: Not prescribing Tolterodine to the patient]
Paroxetine / Your patient has COGNITIVE IMPAIRMENT due to a deficit in her / his cholinergic system. Paroxetine has central ANTICHOLINERGIC activities. Although this reminder does not serve as a substitute for clinical judgment, a local panel of geriatric pharmacology experts cautions that its use may place your patient at higher risk for delirium, hospital acquired complications and prolonged hospitalization. In its place, consider prescribing:
Sertraline 25 mg orally once per day for two weeks then increase to 50 mg orally once per day.
[Success: Not prescribing Paroxetine to the patient]
Amitriptyline / Your patient has COGNITIVE IMPAIRMENT due to a deficit in her / his cholinergic system. Amitriptyline has central ANTICHOLINERGIC activities. Although this reminder does not serve as a substitute for clinical judgment, a local panel of geriatric pharmacology experts cautions that its use may place your patient at higher risk for delirium, hospital acquired complications and prolonged hospitalization. In its place, consider prescribing:
Assistance with Sleeping:
Trazodone 25 mg orally once daily at bedtime as needed for insomnia.
Depression:
Consider referral for Geriatrics Consultation by the ACE teamfor alternative medications.
Neuropathic pain:
Gabapentin 100 mg orally once daily at bedtime.
[Success: Not prescribing amitriptyline to the patient]
Amoxapine / Your patient has COGNITIVE IMPAIRMENT due to a deficit in her / his cholinergic system. Amoxapin has central ANTICHOLINERGIC activities. Although this reminder does not serve as a substitute for clinical judgment, a local panel of geriatric pharmacology experts cautions that its use may place your patient at higher risk for delirium, hospital acquired complications and prolonged hospitalization.
Please consider:
Referral for Geriatrics Consultation by the ACE team for alternative medications.
[Success: Not prescribing Amoxapine to the patient]
Doxepin / Your patient has COGNITIVE IMPAIRMENT due to a deficit in her / his cholinergic system. Doxepin has central ANTICHOLINERGIC activities. Although this reminder does not serve as a substitute for clinical judgment, a local panel of geriatric pharmacology experts cautions that its use may place your patient at higher risk for delirium, hospital acquired complications and prolonged hospitalization. In its place, consider prescribing:
Assistance with Sleeping:
Trazodone 25 mg orally once daily at bedtime as needed for insomnia.
Depression:
Consider referral for Geriatrics Consultation by the ACE team for alternative medications.
Itching:
Loratidine 10 mg orally once daily.
[Success: Not prescribing Doxepin to the patient]
Imipramine / Your patient has COGNITIVE IMPAIRMENT due to a deficit in her / his cholinergic system. Imipramine has central ANTICHOLINERGIC activities. Although this reminder does not serve as a substitute for clinical judgment, a local panel of geriatric pharmacology experts cautions that its use may place your patient at higher risk for delirium, hospital acquired complications and prolonged hospitalization. In its place, consider prescribing:
Assistance with Sleeping:
Trazodone 25 mg orally once daily at bedtime as needed for insomnia.
Depression:
Consider referral for Geriatrics Consultation by the ACE team for alternative medications.
[Success: Not prescribing Imipramine to the patient]
Nortriptyline / Your patient has COGNITIVE IMPAIRMENT due to a deficit in her / his cholinergic system. Nortriptyline has central ANTICHOLINERGIC activities. Although this reminder does not serve as a substitute for clinical judgment, a local panel of geriatric pharmacology experts cautions that its use may place your patient at higher risk for delirium, hospital acquired complications and prolonged hospitalization. In its place, consider prescribing:
Assistance with Sleeping:
Trazodone 25 mg orally once daily at bedtime as needed for insomnia.
Depression:
Consider referral for Geriatrics Consultation by the ACE team for alternative medications.
Neuropathic pain:
Gabapentin 100 mg orally once daily at bedtime.
[Success: Not prescribing Nortriptyline to the patient]
Benztropine / Your patient has COGNITIVE IMPAIRMENT due to a deficit in her / his cholinergic system. Benztropine has central ANTICHOLINERGIC activities. Although this reminder does not serve as a substitute for clinical judgment, a local panel of geriatric pharmacology experts cautions that its use may place your patient at higher risk for delirium, hospital acquired complications and prolonged hospitalization.
Please consider holding Benztropine until your patient is discharged from the hospital or you observe extrapyramidal signs (EPS)
D/C Benztropine.
[Success: Not prescribing Benztropine to the patient]

Alternatives for the use of Physical Restraint and Foley Catheterization among Patients with Cognitive Impairment.

Physical Restraints / Your patient has COGNITIVE IMPAIRMENT. Although this reminder does not serve as a substitute for clinical judgment, a local panel of geriatricians, nurses, and pharmacists cautions that the use of PHYSICAL RESTRAINTS may place your patient at a higher risk for hospital acquired complications and prolonged hospitalization.
Please evaluate your patient for the presence of delirium.
If physical restraint is still indicated, please consider the following alternatives
D/C physical restraints.
A sitter as needed to help assure a safe environment for your patient.
Haloperidol 0.25 mg (orally, IV, IM) every 2-4 hours as needed for aggressive and unsafe agitated behaviors. Evaluate the continuous need for the medication within 24 hours.
Trazodone 25 mg orally at bedtime and if agitated behaviors persist then use Trazodone 25 mg orally every 6 hours as needed for aggressive and unsafe agitated behavior. Evaluate the continuous need for the medication in 24 hours.
[Success: Not prescribing physical restraints to the patient]
Foley Catheterization / Your patient has COGNITIVE IMPAIRMENT. Although this reminder does not serve as a substitute for clinical judgment, a local panel of geriatricians and nurses cautions that the use of FOLEY CATHETER may place your patient at a higher risk for hospital acquired complications and prolonged hospitalization.
Please consider the need for the Foley catheter in the presence of CI.
D/C Foley Catheter.