I got a call from my dad’s home health aide saying that my dad had fallen and he was in the hospital. When I got to the hospital, my dad said that he went to a party at a hotel with some Indians, and they were all his relatives. I said, ‘Dad that must have been a dream.’ He said, ‘Maybe it was,’ and then he just kept talking about these Indians. I was confused because he kept thinking it was so real. The doctors at the hospital didn’t know why he passed out and fell. They kept him in the hospital for a couple of weeks for testing. He kept talking about the Indians, and he talked about how his mother left him fifty million dollars. I kept saying, ‘Dad, stop playing,’ because my dad is a joker. I said, ‘Your mom didn’t leave you fifty million dollars.’ Then he said, ‘Your mom is dead and my mom is alive.’ I said, ‘Dad, your wife is still alive. My mom is your wife. She’s still alive. Your mother is no longer here.’ He said, ‘No, no, no.’ That’s when I realized he’s really confused. But I really didn’t understand the extent of his confusion. I kept trying to put it off, thinking it was because of the fall or he doesn’t remember because he’s a little old. I guess I was in denial about my dad’s mental state.

–Mignonne, daughter of Roberto 

roberto Roberto suffered from delirium after a fall.
Roberto is an 82-year-old man who is a member of Living Independently For Elders (LIFE) ( LIFE is a community-based Program for All-inclusive Care for the Elderly (PACE) that provides care for nursing home-eligible older adults and is operated by the University of Pennsylvania School of Nursing. Roberto was living alone in an apartment with help from a home health aide when he fell and wasn’t found for 24 hours. He developed rhabdomyolysis, which is a breakdown of muscles, and kidney failure. Roberto was hospitalized for several weeks and then went to a nursing home for rehabilitation. I’m a nurse practitioner focusing on the geropsychiatric needs of the LIFE members. While Roberto was at the nursing home, the staff called and asked me to evaluate him for depression. I brought along Ashley King, a psychiatric nurse practitioner student doing her clinical practicum at LIFE. When we evaluated Roberto, he talked a lot about Indians.

It became clear there was something more serious than depression going on. He clearly had delirium and we needed to address it. I was glad to have a student with me that day because this was a good teaching case. Ashley had the opportunity to evaluate the patient, review his chart, and communicate with his primary care providers to tease out what might be causing the delirium. She also followed him over time as he improved. It’s wonderful to see how well he’s doing now.

Pamela Z.Cacchione, PhD, RN,  BC
Advanced Practice Nurse, Living Independently For Elders (LIFE) 
Associate Director, Hartford Center of Geriatric Nursing Excellence
University of Pennsylvania School of Nursing, Philadelphia, PA

cacchioneRoberto recovered from delirium because Pamela Z. Cacchione and her student, Ashley King, recognized the condition.

I came to the University of Pennsylvania School of Nursing to get my master’s degree in psychiatric nursing, but I did not have an interest in geropsychiatry at the time. In fact, I was disappointed to be placed at LIFE (Living Independently For Elders) for the clinical practicum. I was afraid it might be boring because I thought, ’There isn’t much a nurse can do with this population.’ I was very, very wrong.

Treating Roberto was an excellent learning experience. We went to assess him for depression and we determined that he was actually delirious. He had an acute onset of change in mental status. It was fluctuating and he was disoriented. It was a marked change from his normal behavior. I was able to identify these features of delirium because of a required course I took at the University of Pennsylvania called Mental Health and Aging. Once the delirium was treated, Roberto left the nursing home and moved to an independent, supportive living environment.

This was an eye-opening experience and helped me to realize how nurses can treat acute and chronic mental health conditions and really improve quality of life. I can now definitely see myself focusing on an older adult population.

Ashley King, MSN, RN 
Advanced Practice Nurse, Center for Family Guidance
Marlton, New Jersey

All Nurses Need Skills to Care for Older Adults with Mental Health Issues

education1 Interdisciplinary team meetings, like those held at LIFE with the participation of nurses and nursing students, provide a holistic approach to physical and mental health care needs of older adults.

“My dad got so much support from the nurses and social workers at LIFE, if it hadn’t been for them I wouldn’t have known what to do with him. He probably would have ended up staying in the nursing home permanently.” 
Mignonne, daughter of Roberto
At some point in their careers, every nurse will encounter and/or care for older adults with mental health issues. Therefore, all nurses must have the skills to recognize and treat mental health conditions or refer the patient to an appropriate mental health professional. For the patient, this may mean the difference between functioning independently and being permanently incapacitated.

Roberto’s case was particularly complex, and having a nurse recognize his delirium and make sure he received effective treatment meant that he could eventually leave the nursing home and live in a supportive housing environment. After falling at home and not being found for 24 hours, Roberto was hospitalized. He had a breakdown of his muscles (rhabdomyolysis) and kidney failure. His daughter immediately noticed a change in his mental status, but she did not understand what it meant.

What is Delirium?

Delirium is a sudden, fluctuating and usually reversible state of mental confusion that affects up to 50 percent of hospitalized older adults. People with delirium may be disoriented and have memory problems. They have difficulty thinking clearly, focusing, and paying attention. They also may be agitated, have sleep disturbances, and in some cases have hallucinations (for example, hearing or seeing something that is not there) and delusions (false beliefs).1 Older adults with delirium are more likely to have longer hospital stays, more functional impairment, delayed rehabilitation, more frequent hospitalization, and higher mortality.2 Causes of delirium include an underlying medical condition (such as a urinary tract infection), medications, or withdrawal from medications.

Delirium may be mistaken for dementia, depression, or psychosis because of similar signs and symptoms. Dementia is irreversible and results in a slow, progressive decline in memory and other cognitive functions. With delirium, a person can go from being cognitively intact to cognitively impaired very quickly, and it tends to fluctuate throughout the day. The diagnosis may be complicated because delirium can occur along with dementia. In fact, having dementia is a risk factor for delirium.

Recognizing delirium is important because it indicates that there is a medical condition that must be identified and treated. The underlying condition is not always readily identifiable, and there may be more than one cause. In up to one-half of older adults with delirium two or more conditions are responsible for the delirium. Delirium is treated by correcting the underlying problem and managing the behavioral and psychiatric symptoms. 

Roberto was treated in the hospital for his physical problems, but no one addressed his delusions, mistakenly attributing them to the irreversible condition of dementia. He was discharged to a nursing home for rehabilitation where he drastically lost weight. The staff at the nursing home thought his weight loss was due to depression. Because of his affiliation with LIFE, they called Pamela Z. Cacchione, PhD, RN, BC, a geriatric nurse practitioner focusing on geropsychiatric care at LIFE, to evaluate him.

Dr. Cacchione brought nursing student Ashley King, and the two of them determined that Roberto had signs of delirium, such as inattention, fluctuating levels of consciousness, and acute onset of delusions. They also discovered he had a hospital-acquired bowel infection. The infection was causing diarrhea and was the actual cause of the weight loss.

Working with a team of health care professionals, they determined that the delirium had multiple causes. It most likely began in the hospital with an electrolyte imbalance related to the rhabdomyolysis and kidney failure. The bowel infection that became apparent when he was in the nursing home caused dehydration and a further electrolyte imbalance. These exacerbated the delirium.

Roberto was treated with intravenous fluids, antibiotics, and other appropriate interventions focused on keeping him safe and functioning. This resulted in gradual improvement of both his physical and mental status.

“My dad got so much support from the nurses and social workers at LIFE,” says Roberto’s daughter, Mignonne. “If it hadn’t been for them I wouldn’t have known what to do with him. He probably would have ended up staying in the nursing home permanently.”

“When I told my dad he was moving to supportive housing and brought him his key he was ecstatic. He told everyone, ‘I’ve got my own place’.” Roberto continues to go to the LIFE day center three days a week where he can socialize with other members and receive primary and mental health care and rehabilitation services. He still has some memory problems, but he no longer has delirium.

“The fact that Roberto was able to leave the nursing home was a huge accomplishment,” says Dr. Cacchione. This probably would not have happened if it hadn’t been for a nurse with the knowledge and skills to identify the problem and make sure he received the appropriate care.

Improving Mental Health of Older Adults

education2Nursing student Ashley King learned important lessons as part of family meetings and the interdisciplinary team of health care providers focused on Roberto’s recovery.
A 2004 survey of all nursing graduate programs in the United States found that less than 20 percent of geriatric nurse practitioner programs and only 38 percent of psychiatric mental health advanced practice programs included any geropsychiatric content in their curricula.3

To address this inadequacy, the John A. Hartford Foundation awarded the American Academy of Nursing a grant to create the Geropsychiatric Nursing Collaborative (GPNC). The aim of this initiative was to improve the education of nurses at every level in 
the care of older adults suffering depression, dementia, and other mental health disorders.

The leaders of the GPNC hail from three of the Hartford Centers of Geriatric Nursing Excellence—Cornelia Beck, PhD, RN, Louise Hearn Chair in Dementia and Long-term Care and Professor, College of Medicine and College of Nursing, University of Arkansas for Medical Sciences; Kathleen C. Buckwalter, PhD, RN, Professor Emerita, University of Iowa; and Lois K. Evans, PhD, RN, van Ameringen Professor in Nursing Excellence, University of Pennsylvania School of Nursing.

“Rather than develop a new subspecialty area—advanced practice nurse in geriatric mental health—we decided we could get a bigger bang by making sure all nurses have basic competence in recognizing and assessing mental health issues and providing basic care,” says Dr. Evans. Accomplishing this required building awareness in schools of nursing and compiling curriculum materials that faculty can easily access.

The GPNC had two main goals: 1) establish a core set of geropsychiatric nursing competencies for all levels of nursing education, and 2) develop and disseminate geropsychiatric nursing curricular materials. “Nursing competencies” is a term used in nursing education that describes the skills, knowledge, or other characteristics required for a particular type of nursing practice.

In this case, the GPNC articulated the essential knowledge and skills required to assure that high quality mental health care is provided to older adults.

education4 With assistance from a home health aide Roberto is able to live independently. He travels several times a week by van to the LIFE day center to socialize and receive health care services.
One reason nursing faculty may not teach mental health is they don’t feel comfortable with the material. “Unless we provide some tools for them, it is unlikely that this content will be integrated into undergraduate and graduate programs,” says Dr. Evans. Therefore, the GPNC compiled a comprehensive set of curricular materials on geriatric mental health. These are posted on a Web site called Portal of Geriatric Online Education (POGOe) ( POGOe is a free public repository of geriatric educational materials in various e-learning formats, including lectures, exercises, virtual patients, case-based discussions, and simulations. The GPNC materials can be accessed by typing “geropsych” into the search box.

The materials posted on the POGOe Web site are among the most frequently accessed on the entire site. For example, in November 2011 these materials received the highest number of hits for the site, which houses over 700 gero-focused curricular products.

This project is being accomplished with the help of doctoral and master’s level students at the Universities of Arkansas, Iowa, and Pennsylvania. One of these students is Lauren Massimo, MSN, CRNP, a doctoral student and a Hartford Foundation Building Academic Geriatric Nursing Capacity Scholar. Ms. Massimo became passionate about a career addressing mental health in older adults when she was a master’s degree student and wrote about depression in the older adult. “I realized that depression is frequently missed in the elderly, and there are higher rates of mortality and suicide as a consequence,” she says.

After receiving her master’s degree, Ms. Massimo co-taught a course on caring for the older adult to undergraduate nursing students at the University of Pennsylvania School of Nursing. “The care of older adults with mental health issues is very complex, and we did a good job of integrating it into our course curriculum,” she says, “but I think it could have been even better if we had had more resources.”


“The fact that Roberto was able to leave the nursing home was a huge accomplishment.” 
Dr. Pamela Z. Cacchione
Associate Professor of Geropsychiatric Nursing
University of Pennsylvania School of Nursing
Philadelphia, PA
Ms. Massimo is now on the team of nurse professionals compiling and disseminating those resources, which she believes will be especially useful for nursing schools that lack a strong geriatric and mental health focus. Materials are organized into manuals within four domains: assessment, management, approach to the older adult, and role. Each online manual has abstracts describing the topics and provides access to materials that can be used or adapted, such as Web sites, podcasts, and slide presentations. The manuals are user-friendly and save time, making it more likely that faculty will be able to weave these mental health topics into their curriculum.

“If I had these resources just a few years ago when I was teaching the course on caring for the older adult, I would have taught these very sensitive topics even more effectively,” says Ms. Massimo. By including these topics in the curriculum, nursing students like Ashley King will be better equipped to appropriately care for older adults with mental health issues like Roberto.

1. Gleason, O. C. (2003). Delirium. American Family Physician, 67(5),1027-1034.

2. Fick, D. M., Kolanowski, A. M., Waller, J. L., Inouye, S. K. (2005). Delirium superimposed on dementia in a community-dwelling managed care population: A 3-year retrospective study of occurrence, costs, and utilization. Journal of Gerontology. Series A, Biological Sciences and Medical Sciences, 60, 748-753.

3. Kurlowicz, L. H., Puentes, W. J., Evans, L. K., Spool, M. M., Ratcliffe, S. J. (2007). Graduate education in geropsychiatric nursing: findings from a national survey. Nursing Outlook, 55, 303-310.