Simply defined, geriatric psychiatrists specialize in geriatric (patients aged 65 and older) psychiatry (diagnosis, treatment and prevention of mental disorders and illnesses).
A geriatric psychiatrist offers comprehensive psychiatric care to senior and elderly patients in need, whether it be listening and responding to the concerns of the older adult, helping families and when necessary, working with older health care professionals to develop effective approaches to treatment (AAGP, 2017). They also consider the patient’s previous medical history, including illnesses and medications, family support or lack thereof, social issues and environmental aspects in order to provide wide-ranging care to the patient.
Geriatric psychiatrist may work in a hospital, outpatient medical center, private practice, or for the government. Regardless of their practice setting or type of practice, all geriatric psychiatrists have involvement with a multitude of long-term care settings, including nursing homes, skilled nursing facilities, assisted living facilities and continuing care communities (Agronin and Maletta, 2005). In addition to evaluating, diagnosing and treating patients, a geriatric psychiatrist may also provide crisis management, family counseling and education and staff education and training.
A geriatric psychiatrist must understand their patient’s strengths, capacities, hopes and desires in order to offer the best medical education and disease prevention care. Today’s older adults will be examined by how they differ from previous generations of older people (Agronin and Maletta, 2005). The capacity to change with age has previously been ignored or misunderstood. Given the findings from research on the positive effects on overall health and brain vitality that come from being challenged and engaged in productive endeavors along with social activities, the clinician needs to know how to help geriatric patients reassess and better plan their activities (Agronin and Maletta, 2005).
In this profession, the doctor will first perform a diagnostic evaluation in order to identify the patient’s issues, based on physical, genetic, developmental, emotional, cognitive, educational, family, peer and social components identified through the evaluation. After diagnosis, a treatment plan is developed and discussed with the patient and their family in most cases. A treatment plan is comprehensive and addresses all components of the patient’s disorder or condition. Referrals to other services or specialists may also be included in a comprehensive treatment plan.
Required Skill Set
The AAGP states that a geriatric psychiatrist must have specialized skills to be able to integrate biopsychosoical aspects of late-life mental disorders and understand the interplay of these factors across a variety of settings (Agronin and Maletta, 2005). The United States Accreditation Council for Graduate Medical Education (ACGME) requires a 12-month training period for specialization in geriatric psychiatry, including primary and consultative care, assessing and managing elderly patients with diverse socioeconomic, educational and cultural backgrounds. Patients evaluated should also have a wide variety of psychiatric issues, to include both chronic and acute illnesses.
Knowledge of biological, psychological and social factors is essential for a geriatric psychiatrist to offer the best comprehensive medical evaluation and treatment to their patients who may have difficulty coping with change, stress, death and bereavement, depression, memory problems, family history of dementia, anxiety, agitation, or poor sleep. Others may have emotional issues stemming from chronic pain, for example, when dealing with Parkinson’s disease, heart disease, diabetes, stroke or other medical disorders.
The Aging Population
Geriatric psychiatry as a profession is expected to be in extremely high demand in the very near future. Very few new geriatric psychiatrists enter the field compared with the number of aging patients who need geriatric psychiatric services and treatment.
The expected growth in the number of citizens aged 65 and over in addition to the projected increase in mental health issues among them creates quite a challenge for geriatric psychiatrists, who are already short-staffed. Since geriatric psychiatry is a sub-specialty of psychiatry, a physician must elect to complete additional education and training in order to become a geriatric psychiatrist.
Unfortunately, mental illness is not uncommon among aging adults, and studies show the incidence rates for mental illness are increasing as age increases, in addition to an increasing population of older adults. The proportion of the population over age 65 will increase from 12.4% of the U.S. population in 2000 to 20% by the year 2030 (U.S. Census Bureau, 2000). During the same time period, the number of older adults with mental illness is expected to nearly double in population.
According to the 2004 National Nursing Home Survey, mental and neurologic disorders such as Alzheimer’s disease and other dementias, Parkinson’s disease and multiple sclerosis comprised the second most prevalent group of diagnoses in residents that the time of admission, with diseases of the circulatory system taking the lead (Agronin and Maletta, 2005). Geriatric psychiatric conditions must also be considered with pain management, sleep disorders and behavioral issues, as they may all be associated to the psychiatric condition.
How to Become a Geriatric Psychiatrist
The required training and education to become a geriatric psychiatrist can be quite intensive, but the excellent career opportunities that exist in this field make it well worth the extra time spent in classes or training sessions. The length of education and training is similar to that of other medical specialty professions. An undergraduate degree, medical school, residency program and special fellowship training are all required in order to become a licensed geriatric psychiatrist. Most licensed geriatric psychiatrists spend at least a decade receiving their specialized education and training.
In order to become a licensed geriatric psychiatrist, a Doctor of Medicine (M.D.) or a Doctor of Osteopathy (D.O.) degree must be completed successfully. Geriatric psychiatrists receive specialized training in the diagnosis and treatment of mental disorders in older adult patients, for example, dementia, depression, anxiety, late life addiction disorders and schizophrenia (AAGP, 2017). Older adults need specialized care because they have a unique set of physical, emotional and social qualities and needs.
The initial undergraduate degree may be in any major, although most choose a pre-medical or science field such as biology, chemistry or physics to prepare for medical school. Prior to completing the undergraduate program, an aspiring geriatric psychiatrist will need to take and pass the Medical College Admissions Testing (MCAT) and be accepted into an accredited medical school program.
In the general psychiatry training years, the physician achieves competence in the fundamentals of the theory and practice of psychiatry. In the geriatric psychiatry training, the trainee acquires a thorough knowledge of specific body of scientific knowledge about aging and mental health including patient care, medical knowledge, interpersonal and communication skills, practice based learning and improvement, professionalism, and system-based practices (AAGP, 2017).
When the psychiatry residence has completed their geriatric psychiatry fellowship and successfully passed the certification examination in general psychiatry given by the American Board of Psychiatry and Neurology (ABPN), he/she is eligible to take the additional certification examination in the subspecialty of geriatric psychiatry. Although the ABPN examinations are not required for practice, they are an assurance of excellence and an indication to patients and employers of expertise in geriatric psychiatry (AAGP, 2017).
Fellowship coursework includes theories of aging, geriatric medicine, syndromes and treatments in aging, dementia, biologic treatment and memory disorders. Fellows must also be able to learn about ethnic, cultural, legal, ethical and socioeconomic factors that impact late-life psychiatric illness (Agronin and Maletta, 2005). The fellowship program should also include a focus on consultative skills and experiences in other medical fields such as neurology, physical therapy geriatric medicine and palliative care. This allows the student to receive comprehensive medical education and training.
Certification may only be obtained if the physician has a valid, unexpired and unrestricted license to practice medicine in at least one of the 50 United States. Additionally, physicians who are board certified by the ABPN (called ABPN Diplomates) must have successfully completed an approved training program and an evaluation process assessing their ability to provide quality patient care in a specialty and/or subspecialty (ABPN, 2017).
Geriatric physicians describe a higher level of job satisfaction when compared with other medical specialists. As mentioned elsewhere in this text, the profession in general is expected to see significant growth in the years to come.
History of Geriatric Psychiatry
Early History
The concept of geriatrics, or the process of aging, has been mentioned by many respected entities, including William Shakespeare and Benjamin Franklin. Historically, it was customary to group the mental failings of aging under a general title such as “senility” or “senile psychosis” (Agronin and Maletta, 2005). This grouping led to a lack of effort to research treatment options in the area of mental illness, particularly its association with the aging process.
It was only just over 100 years ago, at a scientific meeting in 1906, that Dr. Alois Alzheimer first described the condition that is now named after his discoveries (Agronin and Maletta, 2005). Almost 50 years later, in 1947, the Professor of Psychiatry at the University of London and Director of the Maudsley and Bethlem Royal Joint Hospitals, Aubrey Lewis, first proposed the formation of a dedicated geriatric psychiatry unit (Agronin and Maletta, 2005). Lewis’s consultant, Felix Post, was assigned the task of establishing the geriatric psychiatry unit, and Post is known today at one of the most influential founders of geriatric psychiatry. Felix Post published some of the first academic papers on geriatric psychiatric conditions, including mental illness.
Around the same time Felix Post was establishing the first geriatric psychiatry unit in England, the field was gaining momentum as an independent field of study in the United States. The American Geriatrics Society was founded in 1942 and the Gerontological Society of America was established in 1945 – both of which began publishing influential journals and academic research articles in subsequent years (Agronin and Maletta, 2005). Although the establishment of these organizations was important to the development of geriatric psychiatry as a medical specialty, clinical and scientific interest in the subject remained low.
The 1950s and 60s
During the 1950s, the expected life span of the average American was approaching 70 years of age, compared to 50 years of age in the early 1900s. The increase in average life expectancy led to an increase in geriatric patients who required medical services, including psychiatric services. Due to this increase in an aging population, there was an increased need for systemic and comprehensive study in the field of geriatric psychiatry in order to treat the patients in this growing, aging population.
Sir Martin Roth of the Graylingwell Hospital in England was one of the first to delve into the specifics of mental illness in elderly patients in the 1950s and 1960s. He was requested by the World Health Organization (WHO) to organize the first Expert Committee on Mental Health of the Aged – part of the overall effort that helped to refine late-life psychiatric disorders (Agronin and Maletta, 2005). Roth proposed the differentiation of mental illness in the elderly into major diagnostic categories that are now, with modifications, still in use (Agronin and Maletta, 2005).
Roth is credited with developing diagnostic categories including senile psychosis (dementia), arteriosclerotic dementia (vascular dementia), paraphrenia (delusional disorder), depression (now major depressive disorder), and confusional states (delirium) (Agronin and Maletta, 2005). As one of the most influential leaders in geriatric psychiatry at the time, another of Roth’s accomplishments was to identify patients who were institutionalized for permanent mental illnesses but were actually afflicted by reversible disorders, such as depression and/or anxiety.
In 1954, Ewald Busse founded the Center for the Study of Aging and Human Development at Duke University so he could study the physiological, psychological and social aspects of aging. Dr. Busse’s studies were unique in that he focused on healthy patients over the age of 60, as opposed to patients living in mental or other institutions as in previous studies.
The establishment of the Center for the Study of Aging at Duke University began a relationship with the NIH for performing longitudinal studies of physical and psychosocial data on a cohort of over 800 aging patients who allowed Busse and other medical specialists to perform extensive medical and psychological examinations over a 25-year period. This was known as the Duke Longitudinal Study and the outcome was a significant amount of data and research that would aid in the understanding of the physical, mental social and economic aspects of aging.
Dr. Busse went on to become the President of the American Psychiatric Association and the American Geriatrics Society and the Gerontological Society of America. Prior to his retirement in 1987, he received the highest honor given by the American College of Physicians, the William C. Menninger Award, for his contributions to mental health (Agronin and Maletta, 2005).
The White House Conferences on Aging was established in 1961, influencing many other organizations and programs to benefit older Americans. In 1965, the Older Americans Act was created, which established the Administration on Aging and local Area Agencies on Aging.
The 1970s and 80s
As recently as the 1970s, Alzheimer’s disease was considered by many to be a rare neurological condition and “senility” to be an inevitable, unpreventable and untreatable illness. In 1975, twelve grants related to all aspects of the effects of aging on the brain were provided to the National Institutes of Health (NIH) for further research. Alzheimer’s disease was elevated as a national priority in 1976 at the request and efforts of the American Association for Geriatric Psychiatry (AAGP) and the Department of Veteran’s Affairs (VA).
Florence Mahoney also played a significant role in the acknowledgement of the severity of Alzheimer’s disease. She collaborated with senators and congressional leaders and disease advocacy groups to raise awareness of Alzheimer’s and the need for further health research related to this disease.
In 1978, as interest in mental health and the process of aging grew, and older adults were increasing in number and as a percentage of the U.S. population, a small group of visionaries met to discuss late-life mental health needs and the field of geriatric psychiatry. From this meeting, the American Association for Geriatric Psychiatry (AAGP) was born. What began as the vision of 11 leaders in the field of psychiatry grew to a society of several hundred by the end of its first year. Today, the AAGP is an established membership association of nearly 2,000 geriatric psychiatrists and other health care professionals in the United States, Canada, and abroad, dedicated to the mental well-being of older adults (AAGP, 2017).
Funding for mental health services in late life paid by Medicare remained discriminatory for many years, for both patients and providers alike (Agronin and Maletta, 2005). In the late 1980s, legislation was passed to increase Medicare reimbursements for psychiatric services from $500 to $2000 annually, with elimination of a maximum reimbursement soon to follow. The Nursing Home Reform Amendment was passed to help regulate the use of both psychotropic medications and physical and chemical restraints in long-term care institutions (Agronin and Maletta, 2005), with the goal of improving management of older patients with psychiatric issues or disturbances. These amendments provided interpretive guidelines for facilities, pharmacists and clinicians to use to improve the management of psychiatric disturbances (Agronin and Maletta, 2005).
2000 and Beyond
The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 finally provided parity for mental health reimbursement by overturning the discriminatory co-payments by Medicare for mental health services provided to those aged 65 and older (Agronin and Maletta, 2005).
Given the high prevalence of interactive, co-occurring psychiatric and somatic illnesses late in life, it is vital to integrate more closely with physicians from other disciplines (e.g., geriatrics, rehabilitation, neurology) at the bedside in hospitals and long-term care facilities as well as in primary care clinics and other ambulatory settings (Agronin and Maletta, 2005). Collaboration with other specialists has already led to the development of multidisciplinary programs, in order to provide efficient and effective interventions when presented with warning signs of late-life mental illness. Perhaps the most encouraging and inspiring recent advance in the field of geriatric psychiatry is the growing awareness that many older persons make positive appraisals of their mental health in spite of negative life events and physical ailments (Agronin and Maletta, 2005).
Due to the increased population of adults aged 65 and older, there is a growing acceptance and acknowledgement of mental illness in a positive focus. The stigma of both aging and mental illness is in decline, and more aged individuals are seeking psychiatric care and seeing it as a part of their overall well-being (Agronin and Maletta, 2005). Although there are still challenges with mental health care and health coverage for such illnesses, the most pressing issue is the shortage of qualified geriatric psychiatrists.
Job Prospects
Since 1990, approximately 2,500 psychiatrists have received subspecialty certification in geriatric psychiatry (AAGP, 2017). This is an extremely low number of geriatric psychiatrist’s presents a shortage of physicians licensed in this field, which will be compounded as the aging population continues to grow. The current number of practicing geriatric psychiatrists is not adequate to provide comprehensive care for the growing number of the population age 65 and older.
According to estimates in the President’s Commission on Mental Health Subcommittee on Older Adults (2003), "at the current rate of graduating approximately 80 new geriatric psychiatrists each year and an estimated 3% attrition, there will be approximately 2,640 geriatric psychiatrists by the year 2030 or one per 5,682 older adults with a psychiatric disorder." It has been estimated that 4,000 − 5,000 geriatric psychiatrists who provide patient care are needed (National Institute on Aging, 1997) and an additional 1,220 physician faculty members and 919 non-physician faculty members who provide training in geriatric psychiatry to meet the future demand (AAGP, 2017).
The Veteran’s Affairs health care system consists of military veterans and 45% of them are aged 65 and older. Geriatrics in general and the associated long-term health care needed has created a shortage of physicians in the geriatrics field, including geriatric psychiatrists. The VA has multiple junior and senior level positions open at all times in order to attract additional employees in the geriatrics field. This is an excellent career opportunity for future or aspiring geriatric psychiatrists.
The Bureau of Labor Statistics (BLS) lists the average annual salary for a geriatric psychiatrist at almost $200,000 per year.
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