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 Wishard Hospital, 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
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:
Meperidine
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]
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.
Diphenhydramine
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]
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:
Hydroxyzine
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]
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:
Chlorpheniramine
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]
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
Hyoscyamine
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]
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:
Amitriptyline
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 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]
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:
Doxepin
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]
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:
Imipramine
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]
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:
Nortriptyline
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]
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.
Benztropine
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.
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
Physical Restraints
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.