Suggested Pre-Referral Evaluation and Management Guidelines
The Geriatric Psychiatry Clinic evaluates complex patients ages 65 years or older. Our expertise is in psychiatric presentations complicated by multiple medical co-morbidities, medications, unstable medical conditions, and dementia. We can address cognitive issues associated with mood disorders, and behavioral problems complicating cognitive impairment.
Age is NOT the only criteria for referral.
We will treat younger patients with early onset dementia.
Patients currently being treated through Community Mental Health/CSTS.
Patients with substance abuse problems may be best treated by referral to UMATS.
Older patients without medical complexity or cognitive issues should be referred to general psychiatry.
Suggested Additional Test/Management Prior to Specialty Visit
Initial management should include a basic workup of the presenting symptoms:
Depression Screen - see Geriatrics link to GDS
Cognitive Screen - perform MMSE
Medical exam - including focal neurological deficits
Labs: CBC, Comp, TSH, B12, Vit D Folate, Sed rate, RPR, UA, HIV if indicated
Imaging - CT or MRI if indicated
Consider providing a medication trial when initiating consult
Suggested guidelines for medication trials (does not replace clinical evaluation and judgment)
For Depression/Anxiety: START LOW, GO SLOW, DON’T STOP!!!
Start at 1/4 - 1/2 of adult starting dose, titrate up in 1-2 weeks to usual adult starting dose, increase again in 6-8 weeks if not responding First line agents SSRI(depression and/or anxiety)
• Escitalopram or Sertraline SNRI(good if concurrent pain)
• Venlafaxine XR or Duloxetine
• Bupropion SR (if low energy, little anxiety)
• Mirtazapine (if poor sleep and poor appetite)
For Behavioral Disturbances of Dementia
No medications are FDA indicated. Modify Environment and use behavioral strategies first.
(DICE approach- Kales HC, Gitlin LN, Lyketsos K for the Detroit Expert Panel on the Assessment and Management of Neuropsychiatric Symptoms of Dementia. Management of neuropsychiatric symptoms of dementia in clinical settings: Recommendations from a multidisciplinary expert panel. Journal of the American Geriatrics Society, In press.)
If medications must be used, use Low doses.
SSRI - may help decrease impulsivity
Divalproex Sodium - may help for impulsive-disinhibited behaviors.
Atypical Antipsychotics - (Quetiapine or Risperidone) for paranoia/hallucinations/delusions (black-box warning).
Referral to Turner Geriatric Social Work Services 734-764-2556
Group and individual Cognitive Behavioral Therapy for depression