Geriatric psychiatry

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]

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 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]
    • Melancholic Depression
  • 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]
  • Alzheimer's Disease
  • Vascular Dementia
  • Frontotemporal Dementia
  • Dementia with Lewy bodies
  • Parkinson's Disease
• 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]

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]

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 on 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]

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]
  • The Clock Drawing Test (CDT) can be used to quickly assess cognitive function through visuospatial skills and executive function.^[32]
  • The CDT can be interpreted as normal, Mild Cognitive Impairment (MCI), possible Alzheimer's Disease (AD), or other diagnoses.^[32]

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]

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 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]

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]

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]

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]

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]

• Geriatrics
• Psychiatry
• Neuropsychiatry
• Mild cognitive impairment
• Dementia
• Delirium
• Late life depression

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