Geriatric psychiatry
Medical speciality
From Wikipedia, the free encyclopedia
Geriatric psychiatry, also known as geropsychiatry, psychogeriatrics or psychiatry of old age, is a branch of medicine and a subspecialty of psychiatry dealing with the study, prevention, and treatment of neurodegenerative, cognitive impairment, and mental disorders in people of old age.[1][2] Geriatric psychiatry as a subspecialty has significant overlap with the specialties of geriatric medicine, behavioral neurology, neuropsychiatry, neurology, and general psychiatry.[3] Geriatric psychiatry has become an official subspecialty of psychiatry with a defined curriculum of study and core competencies.[4]
| System | Nervous system, mental health |
|---|---|
| Significant diseases | Alzheimer's disease, vascular dementia, dementia with Lewy bodies, Parkinson's disease, depression, bipolar disorder, schizophrenia, delirium, behavioral and psychological symptoms of dementia, substance use disorder |
| Significant tests | Mental status examination, cognitive testing, neuroimaging |
| Specialist | Geriatric psychiatrist |
Scope
| Occupation | |
|---|---|
| Names | Doctor, Psychiatry Specialist |
Occupation type | Specialty |
Activity sectors | Medicine, Psychiatry |
| Description | |
Education required |
|
Fields of employment | Hospitals, Clinics, Nursing Homes |
A geriatric psychiatrist is a physician who specializes in the field of medical sub-specialty called geriatric psychiatry.[5] A geriatric psychiatrist holds a board certification after specialized training after attaining a medical degree, residency, and an additional geriatric psychiatry fellowship training program.[5] The requirements may vary by countries.[6][7] Some geriatric psychiatrists also conduct research to determine the cause and better treatments for neurodegenerative disorders and late-life mental health disorders.[8]
Geriatric psychiatrists may perform neurological examinations, mental status examination, laboratory investigations, neuroimaging, cognitive assessments to investigate the causes of psychiatric or neurologic symptoms in old age.[9]
Diseases
Diseases and disorders diagnosed or managed by geriatric psychiatrists include, but are not limited to:[10]
- Late-life Presentations of Psychiatric Disorders[11]
- Late onset of depression is associated with higher rates of cardiovascular disease, higher risk of suicide, and higher possibility of treatment resistant depression.[12]
- Anxiety Disorders can be characterized by restlessness, irritability, and muscle tension, but in older adults can be misinterpreted as manifestation of aging.[13]
- Bipolar Disorder in older adults is associated with increased risk of premature death, increased risk of dementia and cognitive deficits.[14]
- Schizophrenia after the age of 65 is considered very-late onset and is associated with higher rates of psychosis, which are often secondary to other medical comorbidities.[15]
- Personality Disorders
- Dementia: often focusing on behavioral disturbances related to mild cognitive impairment and different types of dementia such as:[6]
- Medical-Psychiatric disorders such as catatonia and delirium.[16]
- Many risk factors for Substance use disorder are seen commonly in the elderly population such as: polypharmacy, multiple co-morbid health conditions, and social isolation.[17]
- Neuropsychiatric complications from stroke, Multiple Sclerosis.[18]
History
Origins
The origins of geriatric psychiatry began with Alois Alzheimer, a German psychiatrist and neuropathologist who first identified amyloid plaques and neurofibrillary tangles in a fifty-year-old woman he called Auguste D.[19] These plaques and tangles were later identified as being responsible for her behavioural symptoms, short-term memory loss, and psychiatric symptoms.[19] These brain anomalies would become identifiers of what later became known as Alzheimer's disease.[20]
Subspecialty
The subspecialty of geriatric psychiatry originated in the United Kingdom in the 1950s.[21] In 1958, the first mental health service was designed specifically for the elderly under the guidance of Dr. Ronald Robinson in Scotland.[22] At this time, much of the knowledge related to this field was based of notable psychiatrists in the United Kingdom including: Sir Martin Roth (psychiatrist), Dr. Felix Post, Dr. Aubrey Lewis, and Dr. David Henderson.[23]
In the United States, the American Association for Geriatric Psychiatry was founded in 1978 under the direction of its first president, Dr. Sanford Finkel.[24] It was not until 1991 when the American Board of Psychiatry and Neurology began to conduct examinations for this subspecialty.[25]
Diagnosis
There are many different screening tools used in the elderly.[26]
- The Patient Health Questionnare-9 (PHQ-9) is used to screen for depression.[27]
- The Generalized Anxiety Disorder 7 (GAD-7) is typically used to screen for anxiety, however it is typically used in younger adults (19-64).[28] In those 65+, the Geriatric Anxiety Inventory is used in its place.[28]
- The Alcohol Use Disorders Identification Test (AUDIT-C) is used to assess alcohol consumption to screen for alcohol use disorder.[29]
- Three tools used for detection of mild cognitive impairment and dementia include: Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), and the Clock Drawing Test.[30][31][32]
Treatments
When determining appropriate next steps in treatment for psychiatric conditions in the elderly, the discussion first focuses around pharmacologic intervention vs. non-pharmacologic intervention.[33]
Pharmacologic interventions
In the geriatric population, careful pharmacologic consideration is required due to possibility of drug-drug interactions, co-morbid conditions, and risk of adverse effects.[34] In 2023, The American Geriatric Society updated the Beers Criteria to outline potentially inappropriate medications in the elderly.[35] The Beers Criteria is meant to identify medications that may cause harm to geriatric patients, but it requires case by case interpretation for each patient.[36]
Common psychiatric medications used in the elderly include:[35]
- Antidepressants and anxiolytics such as SSRI's, SNRI's, TCA's, MAOi's.
- Antipsychotics such as Aripiprazole and Quetiapine.
- Mood stabilizers such as Lithium and Valproic Acid.
Adverse effects, particularly concerning in this age group include drowsiness, increased risk of falls, postural hypotension, and sleep disturbances.[34]
Non-pharmacologic interventions
Non-pharmacologic interventions such as exercise, phototherapy, and psychotherapy can be tried before, after, or in conjunction with pharmacologic treatment.[37] Two common psychotherapy styles used in the elderly are cognitive behavioral therapy and psychodynamic therapy.[37]
When pharmacologic intervention has failed, electroconvulsive therapy is an option for treatment resistant depression, agitation secondary to delirium, catatonia, psychosis, and other psychiatric conditions in the elderly.[38]
Training
International
The International Psychogeriatric Association is an international community of scientists and healthcare geriatric professionals working for mental health in aging.[39] International Psychogeriatrics is the official journal of the International Psychogeriatric Association.[40]
Canada
The Royal College of Physicians and Surgeons of Canada is responsible for training and certifying geriatric psychiatrists in Canada.[41] Geriatric psychiatry requires an additional year of subspecialty fellowship training in addition to general psychiatry training.[6]
United Kingdom
The Royal College of Psychiatrists is responsible for training and certifying psychiatrists in the United Kingdom.[42] Within the Royal College of Psychiatrists, the Faculty of Old Age Psychiatry is responsible for training in Old Age Psychiatry.[42] Doctors who have membership of the Royal College of Psychiatrists can undertake a three or four-year training program to become a specialist in Old Age Psychiatry.[43] There is currently a shortage of old age psychiatrists in the United Kingdom.[7]
United States
The American Association for Geriatric Psychiatry (AAGP) is the national organization representing health care providers specializing in late life mental disorders.[5] The American Journal of Geriatric Psychiatry[44] is the official journal of the AAGP.The American Board of Psychiatry and Neurology and the American Osteopathic Board of Neurology and Psychiatry both issue a board certification in geriatric psychiatry.[45][46]
After a 4-year residency in psychiatry, a psychiatrist can complete a one-year fellowship in geriatric psychiatry.[47]
