Geriatric Psychiatry- An Emerging Specialty

Abstract

This paper reviews the emergence of geriatric psychiatry in the United States and Missouri. It discusses current and future needs for geriatric psychiatrists. Lastly, it focuses on recent developments in key psycho-geriatric syndromes with an emphasis on current and emerging treatments.

Introduction

Geriatric Psychiatry (GPsy) is the practice of psychiatry in older adults, who have traditionally been defined as patients older than 65 years of age (Medicare-eligible). Geriatric Psychiatrists (GPts) have at least an additional year of training beyond the four years of adult psychiatry residency training and have added qualifications from the American Board of Psychiatry and Neurology in Geriatric Psychiatry. Geriatric psychiatrists have special training in late-life psychiatric syndromes such as delirium, dementias, depression, and other mood disorders of later life, anxiety disorders, psychoses, alcohol and substance abuse, personality disorders, as well as bio-psycho-social problems in geriatric patients. Fellowship in GPsy also provides training in psychotherapy with older adults and their families as well as long term care psychiatry and consultation liaison. A key difference between general adult psychiatrists and the GPts is the comfort level and experience in dealing with older adults with multiple co-morbid medical problems who are on multiple medications. Consequently, additional training in geriatric medicine and neurology is a component of GPsy fellowships.

In this paper, I will review the emergence of Geriatric Psychiatry in the U.S. and Missouri. I will also discuss current and future needs for GPts. Lastly, I will focus on recent developments in key psycho-geriatric syndromes with an emphasis on current and emerging treatments.

Emergence of Geriatric Psychiatry

Geriatric Psychiatry is one of the newest specialties in American medicine. The American Association for Geriatric Psychiatry (AAGP) was founded in 1978 but it was not until 1991 that the first added qualifications in GPsy exams were administered with a mandatory recertification every 10 years. In the early 1990s, the Association of Directors of Geriatric Academic Programs (ADGAP) was founded. ADGAP has been instrumental in developing a database of GPsy resources and projected needs for the U.S. and each state. According to ADGAP statistics¹, as of 2009 there were 20 million Americans over the age of 75. It is estimated that a minimum of five GPsys per 10,000 population over the age 75 are needed; however, the current U.S. ratio is 0.9 per 10,000. There were 60 ACGME accredited programs in GPsy as of 2008 offering 136 spots. Of these, only 60 were filled. In 2007, Missouri reported 40 certified GPsys and Ilinois reported 57. As of March 2009, there were 1,773 physicians certified in GPsy in the U.S.

The first Division of Geriatric Psychiatry in Missouri was started in 1979 at Saint Louis University School of Medicine by the author. In 1993, GPsy fellowship training was started with a grant from the National Institutes for Mental Health. It was the sixth program funded in the U.S. The Division currently trains three fellows per year in GPsy. All fellows are required to complete an adult psychiatry residency prior to fellowship. Other “firsts” for the Division in Missouri include a specialized GPsy inpatient unit at Saint Louis University Hospital (1980); establishment of the Alzheimer’s Disease Community Brain Bank in 1985, made possible by a start-up grant from the St Louis Alzheimer’s Association; and the establishment of the Saint Louis University Center for Healthy Brain Aging² in 2009. A late-life mood and anxiety disorders program has also been recently developed.

Update on Psychogeriatric Syndromes

Delirium

Delirium, or acute confusion, is one of the most common conditions seen by GPsys. Studies estimate a prevalence of 10–60% among older adults in the acute care setting and about 0.5% among non-demented elders living independently in the community.³ Delirium is also common in long term care or the nursing home setting. Diagnosis of delirium has improved with the use of bedside screening tools such as the Confusion Assessment Method. (CAM)⁴ This useful observer rated tool is being increasingly utilized to look for acute, dateable onset, inattention, disorganized thinking, altered level of consciousness, disorientation, memory impairment, perceptual disturbances, and either psychomotor agitation or less commonly, psychomotor retardation, the so-called “quiet delirium.” The key feature of delirium is the area of attentiveness specifically difficulty focusing and maintaining attention. Consequently, even a simple task such as reciting the days of the week backwards from the current day or subtracting by threes from one hundred may prove difficult.

The major risk factors for delirium are advanced age and pre-existing cognitive impairment, such as dementia. Heading the list of causes are drugs (anti-cholinergics, benzodiazepines and narcotic analgesics) and infections (urinary tract and upper respiratory). In the evaluation of an older adult with acute confusion or delirium, look first at the medication list, especially for starting new drugs or increased dosage. Also rule out new medical conditions such as a urinary tract infection. If these are negative, a head-to-toe medical re-evaluation looking at what may have upset the delicate cognitive equilibrium of the patient is called for.

Delirium is always assumed to be reversible until proven otherwise. The key to treatment is to identify the cause or trigger and remove or address it. Until a cause is found the behavioral/psychiatric concomitants of delirium may be difficult to manage. These often include agitation and psychosis. Recent trends in the management of psychiatric symptoms of delirium are to minimize the use of psychotropics and to prioritize the use of environmental-behavioral interventions. These would include a quiet environment which is not over-stimulating, the use of soothing music, touch, aromas and presence of familiar, reassuring faces such as family members.⁵ In the acute, out of control patient, use of one of the newer antipsychotics or even use of an older non-anticholinergic drug, such as haloperidol, is warranted. The immediate goal is to prevent the patients from inadvertently harming themselves or others. Acute use of benzodiazepines is less optimal since these drugs may worsen confusion, cause balance problems and falls, and inter-dose withdrawal symptoms if given irregularly.

Dementia

Geriatric Psychiatrists are perhaps the only specialty in medicine that has something to offer dementia patients and their families/caregivers at every stage of the disease. GPts often diagnose and differentially diagnose complex dementias such as Lewy-Body dementia, fronto-temporal dementia, and Parkinson’s disease dementia as well as the more common disorders such as Alzheimer’s Disease (AD). Older adults who are experiencing “senior moments” and who fear AD, may also visit a GPsy who can determine whether one is dealing with normal aging, cognitive changes with depression, or other remediable conditions. Mild cognitive impairment (MCI) may be a prodrome for AD or early manifestations of a progressive dementia.

Alzheimer’s Disease is by far the most common cause of progressive dementia among older adults. The Alzheimer’s Association estimates that more than five million Americans are currently affected.⁶ Advanced age is the primary risk factor for AD. With our aging population, we will see a doubling of AD by 2030. We emphasize the benefits of early detection of AD for physicians and patients. See Tables 1 and 2.

Table 1.

Early Detection: Benefits to Physicians

Easier identification of treatable or reversible disorders that may cause further medical or psychosocial complications Reduction in possible errors or poor compliance when gauging self-care abilities of the patient Better ability to manage patient’s coexisting conditions Respect for a patient’s right of self-determination and ability to make health care decisions whenever possible More time to address safety issues before accidents or emergencies occur

Alzheimer’s Association. Available at: http//www.als.org/professionals_and_researchers_14897.asp. Accesses July 28, 2009.

Table 2.

Early Detection: Benefits to Patients

Better ability to understand the disease and make choices about treatment options Greater possible benefits from treatment Ability to participate in building a care team More opportunity to participate in clinical trials More time to make plans for employment and future financial security

Alzheimer’s Association. Available at: http//www.als.org/professionals_and_researchers_14897.asp. Accesses July 28, 2009.

An area of recent emphasis has been for improved diagnostic accuracy relative to diagnoses of AD or other specific dementias. A diagnosis of “dementia” has become a wastebasket diagnosis. GPsys have the ability to specifically diagnose dementias such as AD by doing a standard workup which includes a detailed history from a reliable informant, a physical/neurological examination, basic blood work including a CBC, CMP, TSH, B-12, folate and perhaps vitamin-D levels, a UA, chest X-ray if indicated, RPR/HIV testing if indicated and a brain CT or MRI. Data from the Saint Louis University Alzheimer’s Brain Bank shows that primary care physicians can diagnose AD with >90% accuracy if they follow this empiric approach. For complex patients who are difficult to diagnose, GPsy consultation and neuro-psychological testing may be useful.

The benefits of improved diagnostic accuracy include reduced family/caregiver burden and improved family/caregiver attitude,⁷ and improved quality of life for patient/family and delayed nursing home placement.⁸ After a comprehensive evaluation, the physician should not allow the patient and family to leave the office with a meaningless diagnosis of “dementia”. Often, family members use an Internet search engine for “dementia” to see what is wrong with their loved one. They will be even more confused since their search will turn up an extensive list of rare diseases (e.g. Jakub-Creutzfeld) and frightening conditions (AD).

A major recent emphasis in GPsy has been to focus on primary prevention and interventions, which may prevent or delay AD. See Table 3.

Table 3.

Primary Prevention

Social, mental and physical activity shown to be inversely associated with risks for dementia and AD Exercise speculated to enhance brain neurotrophic factors and modify apoptosis Longitudinal cohort studies show risk of AD increased among people who have received shorter periods of education Intellectually challenging activity has been associated with reduced risk of dementia in longitudinal studies Reasonable to encourage patients to maintain or increase physical activity, exercise, cognitive and leisure activities, and social interaction, though it is not know whether these interventions reduce dementia risk

Interventions that Might Prevent or Delay AD

Antihypertensive therapy Hormonal agents (estrogen) NSAIDs (naproxen and celecoxib) High-dose vitamin B, folic acid supplementation Statins PPAR-gamma agonists Fish oils, omega 3 fatty acids Weight control, healthy diet

Bassil N, Grossberg GT. Prim Psych 2009;16:33–38.

In the primary prevention and intervention area, the strongest evidence is for recommending mental and physical exercise and a Mediterranean diet. There is good evidence that “what is good for the heart is good for the brain.” Controlling stroke and heart attack-related risk factors such as hypertension, diabetes, smoking, obesity, hyperlipidemia, and lack of exercise may delay or decrease the risk for AD.⁹

Dementia Treatment

There are nearly 260 treatments for AD in clinical trials. (See Table 4.) There are more treatments in development for AD than any other disease except for cancer. There is growing evidence that current therapies such as the cholinesterase inhibitors and the NMDA-receptor antagonist memantine may improve or stabilize cognition, behavior and activities of daily living in some AD patients. A combination of these two classes of drugs may delay nursing home placement.¹⁰ Current therapies are classified as symptomatic but future treatments are disease-modifying. Most are amyloid modulating compounds including the immunotherapies. Both monoclonal antibody to A-Beta infusions and intravenous immunoglobulin are in advanced clinical trials for early AD. A possible AD vaccine is being investigated.

Table 4.

The Search for New AD Therapies

Drugs/nutraceuticals (based on epidemiologic observations) Neurotransmitter-based therapies Glial modulating drugs Neuroprotective drugs Tau modulating drugs Amyloid modulating drugs

GPsy is at the forefront of developing new treatments for AD as well as in better understanding and treating the behavioral and psychological symptoms of dementias (BPSD) such as AD. Symptoms such as agitation in AD may not respond as well as formerly thought to the use of neuroleptics.¹¹ There is a “black-box warning” relative to the use of all antipsychotics in patients with dementia and behavioral disturbances. The warning is related to an increased risk of mortality. Current recommendations for BPSD focus on behavioral and environmental interventions first and antipsychotics only in emergency, out-of-control patients, where the safety of patient and care givers is the primary issue. Use of antidepressants would be indicated if depression in the context of dementia is suspected. Use of anticonvulsants/mood-stabilizers such as divalproex and oxcarbazepine may also be useful.

Depression & Anxiety Disorders

Depression is a major problem in older adults, particularly among those in the hospital or outpatient setting and especially in the nursing home, where 20–25% of residents may suffer from depression.¹² Older adults have double the suicide rate of the general population and also have a higher rate of psychotic and catatonic depression.¹² In the latter condition severely depressed older adult stop eating and drinking and become cachectic. This may be a true psychiatric-medical emergency, often requiring electro-convulsive therapy (ECT).

Geriatric Psychiatrists are frequently called to treat severely depressed elders or those who are treatment resistant or actively suicidal. The newer antidepressants are useful for clinically significant depression in the elderly. Cognitive- Behavioral Therapy (CBT) may also be effective in non-severe cases and when the patient is cognitively intact and motivated. In instances where the patient is so severely depressed and/or suicidal that one does not have the luxury of time for the anti-depressants to work, or in treatment resistant cases, or where anti-depressants are not tolerated, ECT can be safe, rapidly effective and even life saving. Transcranial magnetic stimulation (TMS), vagal nerve stimulation (VNS), and even deep brain stimulation (DBS) may be warranted in truly treatment resistant depressives. All of these modalities, including pharmacotherapy, CBT, and neuromodulation are available at the Saint Louis University Late-life Mood and Anxiety Disorders program.

An emerging area of concern for GPsy is bipolar affective disorder (BAD) in the elderly. BAD usually begins in the second or third decade of life. Unfortunately, BAD gets worse with advanced age. Patients develop a tendency to rapid cycling from the heights of mania to the depths of depression in days to weeks, rather than the usual months or years.¹³ Older bipolar patients often do not tolerate drugs such as lithium, which is a mainstay among younger BAD patients. There is a trend toward more late-life bipolar admissions. This will continue since BAD does not ameliorate with advancing age.

While late-life onset anxiety disorders are quite rare, symptoms of anxiety, often accompanying medical illness, stress, or loss of loved ones become increasingly common in older adults.¹⁴ The most common anxiety disorder in later life is Generalized anxiety Disorder (GAD) with 5–10% affected.¹⁴ Acute treatment of anxiety is usually with short-acting benzodiazepines. These drugs need to be used cautiously in older patients and long-term treatment is usually with a serotonergic anti-depressant. Psychotherapy especially CBT are also useful in motivated, cognitively intact elders. Anxiety symptoms accompanying loss and stress may respond to supportive and interpersonal psychotherapy. An anxiety disorder, which is increasingly being recognized in older adults, is PTSD. We are seeing World War II veterans and the beginnings of Vietnam War veterans presenting with PTSD.

Other Syndromes

Geriatric Psychiatrists often evaluate older adults with sleep disturbances, pain syndromes, personality disorders, and alcohol-substance abuse issues. GPsys work with families who are dealing with end of life issues in an aged loved one and they educate about palliative care and the role of hospice and spirituality.

Long-term Care

Geriatric Psychiatrists play an important role in the fabric of long-term care facilities such as nursing homes and assisted-living environments. They provide staff education and training relative to late-life mental disorders and direct consultation to manage these disorders. They are often co-medical directors of extended care facilities.

Consultation-Liaison

Geriatric Psychiatrists consult on difficult psycho-geriatric patients on medical and surgical services of acute care hospitals.

Forensic Consultation

Geriatric Psychiatrists are often asked to consult on issues of competency and informed consent and the appropriateness of surrogate management arrangements such as guardianship. Elder abuse by family or care-givers may require a GPsy forensic consultation. An emerging area is the aging prison population and their special needs.

Conclusion

Although one of the newest fields in American Medicine, there is already a serious undersupply of Geriatric Psychiatrists in the United States due to our aging population. GPsts are at the forefront of education, research and clinical service delivery relative to patients and their families with a range of age-related neuro-psychiatric syndromes.

Biography

George T. Grossberg, MD, is the Samuel W. Fordyce Professor and Director, Division of Geriatric Psychiatry, in the Department of Neurology and Psychiatry at Saint Louis University School of Medicine.

Contact: grossbgt@slu.edu