University of Pittsburgh
Hartford Center of Excellence in Geriatric Psychiatry

My mother was always very pleasant. After she fell and broke her leg she was taken to the emergency room and then to surgery. When she woke up after the surgery she was almost a completely different person. My mother has always been able to filter what she was thinking, which diminished a bit with the Alzheimer’s disease, but the filter was completely taken away with the delirium. She became incredibly agitated and angry.

When I called the hospital they told me she threw a water container across the floor and she was yelling at people. When my brothers and I went into the room she stared at us and said very nasty things, cursing and swearing. My mother never swore. It was upsetting and scary. First we thought it was caused by the anesthesia and it would wear off. Then we thought she had plummeted quickly into another stage of Alzheimer’s.

Dr. Solai, the psychiatrist who was treating her in the nursing home before the fall, adjusted her medications, and now we’re noticing that she’s more alert. She’s sweet and loving again. Even though she has Alzheimer’s disease, she’s still there. A lot of people misunderstand Alzheimer’s disease. It’s not like the disease is diagnosed and the person’s mind is completely gone. It’s sort of bittersweet, because they’re not the person they used to be, but you can enjoy who they are, and my mother is very special.

–Lisa, daughter of Patty

patty profile Patty still has forgetfulness from dementia, but she no longer has delirium.

Lisa (top, right) travels once a month to visit her mother Patty at the Masonic Village Nursing Home, where she receives expert care.
Patty, 77 years old, was brought to my attention by the nurses at Masonic Village because of increased confusion. It was clear she had dementia. I spoke to Patty, to her nurses, and to her daughter Lisa to get some background information. We did a routine workup, including blood tests, urine tests, and a medication review. Initially she was taking Benadryl for itching. Benadryl is not a good medication for an older adult because it tends to increase confusion. We took her off of that. Patty was also depressed about being in the nursing home, so I started her on an antidepressant. At about this time she had a fall and sustained a fracture, which is a risk factor for delirium. She was put on pain medication in the hospital, which further contributed to her confusion.

I knew that her mental state after the surgery was not her normal state. We had to manage her pain, but also be judicious about the dose of the pain medication, so she would not get confused. I also noticed she was placed on a medication for incontinence during the hospitalization, which can contribute to delirium. I had to stop that drug. We also identified and treated a urinary tract infection. There are multiple possible reasons for delirium and the management is an ongoing process.

Working with the nurses and the family we tried behavioral approaches to treating Patty’s delirium like redirecting her and engaging her in activities to keep her busy. Patty likes one-on-one attention and did her best during those times. She was still screaming and yelling profanity, so I added a small dose of an antipsychotic medication. As the pain  from the surgery subsided we switched her to non-sedating pain medicines. She’s still forgetful from the dementia, but she’s more alert, interactive, and not as anxious.

Lalith-Kumar Solai, MD
Assistant Professor of Psychiatry
Department of Psychiatry
University of Pittsburgh
Hartford Center of Excellence in Geriatric Psychiatry


Patty enjoys visits from her psychiatrist, Dr. Lalith-Kumar Solai.

University of Pittsburgh 
Hartford Center of Excellence in Geriatric Psychiatry


 “My mother has always been able to filter what she was thinking, which diminished a bit with the Alzheimer’s disease, but the filter was completely taken away with the delirium.”
Lisa, daughter of Patty
Designated as a John A. Hartford Foundation Center of Excellence in Geriatric Psychiatry in 2004, the University of Pittsburgh’s Department of Psychiatry houses one of the nation’s largest divisions of geriatric psychiatry, with an international reputation as a research leader for the study of mood and cognitive disorders in older adults. The University of Pittsburgh’s Department of Psychiatry trains 20 percent of the nation’s academic geriatric psychiatrists.

Through a grant to the American Federation for Aging Research, Inc. (AFAR), the Hartford Foundation provides funding for the Hartford Geriatric Psychiatry Fellowship Program, which offers academic geriatric psychiatrists the option to pursue one of two career paths: physician researcher or physician educator. Physician researchers generate new knowledge about mental health care for older adults and investigate new models of care. Physician educators teach generalist physicians and other health care providers appropriate models of geriatric care and disseminate new models of care that emerge from research.

research4Staff members work with Dr. Lalith-Kumar Solai in handling mental health issues.
Lalith-Kumar Solai, MD, Assistant Professor of Psychiatry, Department of Psychiatry, University of Pittsburgh, was a Hartford Geriatric Psychiatry Fellow (2005-2007), and chose the path of physician educator, with a focus on delirium in older adults. His interest in delirium began several years ago when he was providing psychiatry consultation services to several hospitals. He noticed that a large number of older adult patients were hospitalized with delirium that had not been diagnosed by their primary care providers or by emergency room staff.

To quantify his observations, Dr. Solai conducted a study of older adult patients who came to the emergency department at two community hospitals and were identified as having delirium. Previous studies have shown that about 10 to 15 percent of older adults who go to an emergency room have delirium. “We found that only one to two percent of the charts showed any documentation of delirium,” says Dr. Solai. Many cases were obviously being missed. With funding as a Hartford Fellow, Dr. Solai responded to his findings by creating a Web-based teaching module for emergency physicians and nurses on identifying and treating delirium (see Resources).

I’ve found that the amount of education needed by the nursing home staff on mental health issues is very high.”
Dr. Lalith-Kumar Solai
Assistant Professor of Psychiatry 
Department of Psychiatry University of Pittsburgh
Up to 50 percent of older surgical patients experience delirium.
“Through this work I have been identified as the local expert on delirium,” says Dr. Solai. At the University of Pittsburgh School of Medicine he gives lectures on delirium to medical students and to residents in psychiatry, surgery, anesthesiology, and other specialties. Dr. Solai also provides clinical services to nursing homes. “I’ve found that the amount of education needed by the nursing home staff on mental health issues is very high,” says Dr. Solai. To address this, he created a training module on late-life mental health issues, such as dementia, delirium, and depression, which is targeted to nursing home staff, including nurses, aides, social workers, physical therapists, and occupational therapists.

Prevention and Treatment of Depression in Older Adults

A major research focus of the University of Pittsburgh Center of Excellence in Geriatric Psychiatry is the prevention and treatment of depression in older adults.

“The connections between depression and physical disability and the connections between depression and mild cognitive impairment (MCI) or dementia are at the heart of what is unique about mental illnesses in older adults,” says Charles F. Reynolds III, MD, Director of the Hartford Center of Excellence in Geriatric Psychiatry, and University of Pittsburgh Medical Center Endowed Professor in Geriatric Psychiatry. Close to half of older adults with major depression have MCI. (A person with MCI has noticeable memory problems and may later develop Alzheimer’s disease or other types of dementia.) Dr. Reynolds notes that depression is now recognized as a risk factor for dementia, doubling the chances for dementia in later life. Older adults living alone with few social resources are at risk for depression.

Psychosocial issues, such as bereavement, can set the stage for depression or complicated (prolonged) grief (see page 50). Some specific medical problems have been shown to be highly associated with depression, such as stroke and disability secondary to a heart attack or chronic obstructive pulmonary disease.

“We are challenged by these complexities and want to sort them out in ways that are helpful to patients and their caregivers,” says Dr. Reynolds. Several new studies have been launched at the University of Pittsburgh to develop a menu of strategies that will help protect older adults from becoming depressed.

Depression doubles the risk for dementia and Alzheimer’s disease.
At the core of much of the experience of depression in older adults is a sense of helplessness, of no longer being able to cope. Therefore, one of the strategies involves teaching older adults and their caregivers better coping and problem-solving skills. Another intervention is a brief behavioral treatment for insomnia because insomnia is a risk factor for depression. “In older adults we often see particularly difficult and profound sleep disturbances,” says Dr. Reynolds. Another set of interventions relates to exercise. “All of these interventions help to enhance a sense of control over one’s life,” says Dr. Reynolds.

A Commitment to Education

In addition to research, the University of Pittsburgh Department of Psychiatry is also committed to providing quality education on important topics in geriatric mental health. With a grant from the National Institute of Mental Health, they created a series of documentaries on late-life mental health intended to inspire students across disciplines. The series is titled “Caring for Those Who Cared for Us” (see Resources). Topics include complicated grief, late-life suicide, minority elders and mental health, and successful aging. 

Accomplishments of Hartford Fellows

Attracting new researchers and educators in geriatric psychiatry is a critical priority as the number of adults over age 65 steadily grows. Both the University of California, San Diego, and the University of Pittsburgh have made great strides in recruiting and advancing the careers of promising geriatric psychiatrists, which ultimately will improve mental health care for older adults.

University of California, San Diego
Hartford Center of Excellence in Geriatric Psychiatry
Since 2004, 21 UCSD Hartford Scholars have been supported, including several who have both MD and PhD degrees. They have been extremely successful. Several of them are on the full-time faculty at UCSD or other major medical institutions. Almost all of them have published research papers and several of them have obtained funding as independent investigators. “This is a boon not just for us at UCSD but for the entire field of geriatric psychiatry,” says Dr. Jeste.

Some Hartford Scholars have been involved in modifying the curriculum for the UCSD Medical School to include more geriatrics and geriatric psychiatry. Dr. Alana Iglewicz is particularly interested in finding ways to inspire more medical students to specialize in geriatric medicine and geriatric psychiatry. She is working with the leaders of the UCSD Hartford Center of Excellence in Geriatric Pyschiatry to systematically study barriers to entering these specialties as well as programs for drawing more students to them. 

University of Pittsburgh 
Hartford Center of Excellence in Geriatric Psychiatry
All of the Hartford Geriatric Psychiatry Fellows funded at the University of Pittsburgh are now full-time academic geriatric psychiatrists. They are emerging as highly valued leaders in the department and are active in mentoring the next generation of students. The Fellows on the physician researcher track have all received National Institutes of Health grants. The Fellows on the physician educator track have also been very productive, creating programs to help clinician educators and recruiting medical students into geriatrics. The fellowship in geriatric psychiatry offered at the University of Pittsburgh trains three to five new geriatric psychiatrists annually. 

research 5 The “I AM HERE series” was developed by Dr. Lalith-Kumar Solai to teach nursing home staff about late-life mental health issues.