Helen H. Kyomen, MD, MS

FROM THE GROUP FOR ADVANCEMENT OF PSYCHIATRY

As the United States population ages, safe and effective geriatric care is needed as never before. By 2030, 20% of the population will be aged 65 years or older according to current 

s, a dramatic increase from the rate of 13% reported in the 2010 census.

 It is estimated that 14% to 20% of older adults require treatment for mental health conditions and/or substance use disorders.

 The anticipated increase in the number of older adults will place unprecedented and unrealistic burdens on our health care system, which now 

 fewer than 1400 board-certified geriatric psychiatrists.

 The current population of specialists is insufficient to meet even our present needs, and too few physicians are presently enrolled in geriatric psychiatry and geriatric medicine fellowship training to meet anticipated future needs. Because of the widening gap between the number of experts and the magnitude of patient needs, clinicians who have not had specialty training in geriatrics or geriatric psychiatry will provide the majority of mental health care for older adults.

The necessity for more geriatric mental health specialists and the urgent need to establish competencies in geriatric care for all clinicians who care for older adults were identified as national priorities in reports issued by the Institute of Medicine in 2008 and 2012.

 These goals have yet to be achieved. The Liaison Committee on Medical Education, which 

 accreditation for American medical schools, requires the undergraduate medical curriculum to “address each phase of the human life cycle,” but there is no stipulation for specific content or competencies in aging, geriatric care or geriatric mental health.

 Similarly, there are no national geriatric competency standards for nursing students, physician assistant students, or other allied health care trainees. In the absence of national competency requirements, curricula and training in aging and in geriatric care vary widely across institutions and training programs.

Inadequate recognition and management of common geriatric mental health conditions has serious consequences. Delirium, too often undetected on medical and surgical inpatient units, disproportionately affects older adults, and contributes to avoidable suffering and death.

 Aggression and other behavioral disturbances of dementias (major neurocognitive disorders) contribute to caregiver burnout and premature institutionalization.

 Late-life depression, the most frequent antecedent of suicide in older adults, is associated with potentially treatable suffering, excess disability, increased health care costs, and higher mortality.

 in older adults, is associated with falls, confusion, and preventable hospitalizations.

 Notwithstanding educational campaigns such as “

” (an initiative by the American Board of Internal Medicine Foundation

), benzodiazepines continue to be overprescribed to older adults, despite the complications associated with their excessive and chronic use.

There are 2 important reports that can help advance medical student geriatric education:

• In 2007, the American Association of Medical Colleges and John A. Hartford Foundation Consensus Conference developed the Minimum Geriatric Competencies for Medical Students. These include 26 behaviorally focused competencies nested in 8 domains: medication management; cognitive and behavioral disorders; self-care capacity; falls, balance, gait disorders; health care planning and promotion; atypical presentation of disease; palliative care, and hospital care for elders (

 Within each of these domains are listed between 2 to 5 specific skills that medical students should master before graduating medical school to ensure safe care of elders. While a number of medical schools have incorporated these competencies as objectives in creating clinical rotations for their students, wider adoption and implementation remain critical.

 a broader set of Geriatric Mental Health Learning Objectives for medical students that expands the domain of cognitive and behavioral disorders and addresses the need for specific knowledge and reasoning skills that medical students should attain in 6 key areas of normal aging, mental health assessment, psychopharmacology, depression, dementia, and delirium.

The intent of both of these reports was to establish proficiencies that delineate core material that all students should learn by the time of graduation from medical school in order to provide competent and safe care to older patients encountered during and after residency training.

 requires establishing an infrastructure of geriatric experts within key health care training organizations to dynamically and continuously build a workforce of appropriately trained clinicians, schooled and skilled in the health needs and vulnerabilities of older adults. These 2 reports support the development of that workforce by providing a framework for the creation of national curricula in geriatrics for medical students and allied health professions. They represent the consensuses of experts, derived from an evidence-based understanding of the essential and specific health care needs of older patients.

While achievement of these minimal competencies will not eliminate the need for specialty training and geriatric specialists, adoption of basic standards will improve the recognition and clinical management of key health conditions in older adults that impact quality of life and health care costs. Needed are national education mandates from accreditation organizations and congressional support to require enhanced education of all clinicians who care for older adults.

Such attention to improving education and training standards couldn’t be more pressing or timelier. We have just witnessed a United States presidential election in which both candidates were septuagenarians and we will soon inaugurate the oldest individual ever to assume the presidency. We urge the new president and members of Congress to make national standards for education in geriatric care a priority of health care reform. On local and national levels, psychiatrists have a leadership role to play in implementing effective and actionable strategies for increased geriatric mental health education in medical school and allied healthcare curricula.

Building upon existing competency guidelines to create national curricula will prepare the eldercare workforce to handle the growing health care needs of our aging population. Given the urgency of rapidly changing demographics, training the requisite workforce to care for the mental health needs of older patients must become a national priority.

is clinical director, Division of Geriatric Psychiatry and Neuropsychiatry, and associate professor of Psychiatry and Behavioral Sciences, Johns Hopkins Medicine, Baltimore, MD.

holds the Swank Foundation Endowed Chair in Memory Care and Geriatrics, Christiana Care Health System, Wilmington, DE, and is professor of Psychiatry and Human Behavior, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA.

is Dr Sakauye is Emeritus Professor of Psychiatry at the University of Tennessee Health Science Center in Memphis, TN.

is clinical assistant professor at Boston University School of Medicine, adjunct clinical assistant professor at Tufts University School of Medicine and lecturer, part-time, at Harvard Medical School, Boston, MA. 

is professor of Psychiatry and Health Policy and Director, Center for Biomedical Ethics and Society at Vanderbilt University, Nashville, TN. 

 is vice chair in the Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD, and chair of the American Psychiatric Association Council on Geriatric Psychiatry.

1. Ortman JM, Velkoff VA, Hogan H. An Aging Nation: The Older Population in the United States. May 2014. U.S. Census Bureau. Accessed December 3, 2020. 

https://www.census.gov/prod/2014pubs/p25-1140.pdf

2. Eden J, Maslow, K, Le M, Blazer D. The mental health and substance use workforce for older adults: In whose hands? 

Committee on the Mental Health Workforce for Geriatric Populations, Board on Health Care Services; Institute of Medicine.

 Washington, DC. National Academies Press. 2012.

3. American Board of Psychiatry and Neurology, Inc. 2019 Annual Report. Accessed December 3, 2020. 

https://www.abpn.com/wp-content/uploads/2020/05/ABPN_2019_Annual_Report.pdf

4. Institute of Medicine Committee on the Future Health Care Workforce for Older Americans. Retooling for an Aging America: Building the Health Care Workforce. Washington, DC: National Academies Press; 2008.

5. Liaison Committee on Medical Education. Functions and structure of a medical school, 2019. Accessed December 3, 2020. 

http://www.lcme.org/publications/#standards

6. Witlox J, Eurelings LS, de Jonghe JF, et al. Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis. 

7. Hiyoshi-Taniguchi K, Becker CB, Kinoshita A.

 What Behavioral and Psychological Symptoms of Dementia Affect Caregiver Burnout?

8.Kales HC, Gitlin LN, Lyketsos CG, Detroit Expert Panel on Assessment and Management of Neuropsychiatric Symptoms of Dementia.

 Management of neuropsychiatric symptoms of dementia in clinical settings: recommendations from a multidisciplinary expert panel

9. Wei J, Hou R, Zhang X, et al. The association of late-life depression with all-cause and cardiovascular mortality among community-dwelling older adults: systematic review and meta-analysis. 

10. Bock JO, Hajek A, Weyerer S, et al. The impact of depressive symptoms on healthcare costs in late life: Longitudinal findings from the AgeMoodDe Study. 

Polypharmacy including falls risk-increasing medications and subsequent falls in community-dwelling middle-aged and older adults

12. Choosing Wisely. Promoting conversations between patients and clinicians. Accessed December 3, 2020. 

13. Maust DT, Kales HC, Wiechers IR, et al. No end in sight: Benzodiazepine use in older adults in the United States. 

14. Leipzig RM, Granville L, Simpson D, et al. Keeping Granny safe on July 1: A consensus on minimum geriatric competencies for graduating medical students. 

15. Lehmann SW, Brooks WB, Popeo D, et al. 

Development of geriatric mental health learning objectives for medical students: A response to the Institute of Medicine 2012 report

Articles

The authors make the case for national education mandates from accreditation organizations and congressional support to require enhanced education of all clinicians who care for older adults.

Raising the Bar on Geriatric Mental Health Competency Training

Agitation in older adults is frequently associated with multiple psychiatric and medical conditions and comorbidities. It commonly occurs in patients with anxiety, affective illness, psychosis, dementia, stroke, brain injury, delirium, or pain, and in those who misuse psychoactive medications or other substances. Optimal treatment strategies to reduce or prevent agitation in older adults encompass a multidisciplinary model that used nonpharmacological and pharmacological/somatic approaches. In this article, we discuss clinical approaches for evaluating and managing agitation in older adults.



Defining and determining the causes of agitation



To focus treatments appropriately, it is important to specifically define the target signs or symptoms that are being labeled as “agitation.” Agitation is a nonspecific concept that broadly encompasses various activity disturbances such as those delineated in Table 1.

Specifying the actual behavior is especially important so that all treatment team members can be consistent in their understanding and subsequent approach to and treatment of the patient. For example, it is difficult to devise an effective treatment plan for agitation if some staff members refer to a patient’s combativeness as agitation, and other staff members use the term agitation to describe the same patient’s hypersexual behaviors. If each type of agitation is defined, a focused plan to manage, monitor, and evaluate the progress of each unique behavior can be developed.

Once the behavioral target signs and symptoms are identified, the next step is to determine their causes in order to formulate appropriate multidisciplinary interventions. A clinically relevant way to categorize causes is to first identify the circumstances antecedent to the behavioral target signs and symptoms that trigger the agitation and then to identify the illnesses or pathological conditions that exacerbate the agitation.

Nonpharmacological interventions are often effective for managing agitated behaviors that stem from such antecedent triggers. The solution is to develop an appropriately stimulating environment, remove or limit exposure to noxious stimuli, and provide the patient with basic nutritional and personal needs. Table 2 describes the circumstances that may trigger agitation.

Various nonpharmacological therapies have been developed to provide patients with appropriately stimulating environments and to help redirect the patient and manage the setting to minimize events that can trigger agitation. These include music therapy, animal-assisted activities and therapy, touch/massage therapy, simulated presence therapy, light therapy, multisensory stimulation, validation group therapy, and skills training and behavioral-milieu management.

Psychiatric disorders (such as anxiety, mania, depression, psychosis, and dementia) and somatic conditions (such as stroke, brain injury, delirium, pain, discomfort, and adverse effects of medications) have all been implicated in exacerbating agitation. Common disorders, separately or in combination, that may co-occur with psychiatric conditions and cause acute pain and discomfort, and may contribute to delirium, are listed in Table 3. These conditions are more likely to contribute to agitated behaviors in patients with underlying dementia, partly because such persons have an impaired ability to obtain help for pain or discomfort through coherent conversation.

Common disorders (eg, arthritis, hearing loss) are often overlooked because of their chronic nature or because of difficulties in the patient evaluation (eg, difficulty of obtaining a clean-catch urine specimen for cultures and sensitivities from a resistant patient). Iatrogenic causes, such as diuretics given at bedtime rather than early in the day, a rebound effect from a sedative or hypnotic dose reduction or discontinuation, and paradoxical disinhibiting reactions from benzodiazepine use can also exacerbate agitation.

Thorough evaluation of the patient’s physical condition is essential so that agitation exacerbated by such disorders is not mistakenly attributed entirely to psychiatric illness and treated primarily with psychotropic medication. Table 4 presents some psychiatric conditions that may contribute to agitation.

When it is judged that the patient’s agitation is primarily caused by psychiatric illness, it is important to determine which psychiatric conditions, signs, or symptoms are dominant and to treat accordingly with psychotropic medications. These include typical and atypical antipsychotics, mood stabilizers, sedatives/hypnotics, and nootropic agents.





Most of the nonpharmacological treatment interventions were developed for older adults with agitation and cognitive impairment or dementia. A great deal of research is still needed to evaluate these therapies more fully in combination with other therapies and in comparison with placebo or other active treatments.

Music therapy is the “clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program.”

 Although music therapy reduces overall agitation to a greater degree than no intervention, individualized or preferred music seems to offer greater benefit than general calming or “relaxation” music in patients with dementia.

 The long-term benefits of this intervention remain unclear; one study found short-term improvements in agitation but no significant differences in outcomes between music therapy and standard nursing home care groups over the course of a year.



Animal-assisted activities and therapy use animals to encourage patient well-being, socialization, and mental and sensorimotor stimulation.

 Animal-assisted therapy with dogs was found to decrease agitated behaviors and enhance socialization in patients with dementia.

 A preliminary study showed that interacting with a therapeutic robotic cat decreased agitation and increased pleasure and interest in nursing home residents with dementia.

 Although the effects of animal-assisted activities and therapy on agitated behaviors in the elderly are promising, the duration of beneficial effect, the relative benefits of dogs residing on a special care unit for patients with Alzheimer disease versus visiting the patients, and the confounding effects of animals on caregivers are unclear.



Preliminary studies suggest that tender touch, hand, and slow-stroke massage may help reduce agitation and improve well-being in older adults with dementia.

 Although limited, the available information is in favor of touch and massage therapy for behavioral disturbances in patients with dementia; however, definitive evidence about their benefits and adverse effects is lacking.



Simulated presence therapy is an individualized therapy that uses voice recordings to suggest the presence of meaningful persons and evoke associated positive emotional experiences in patients with memory loss. Simulated presence therapy seems to decrease overall agitation and withdrawn behavior in patients with dementia, but the number and quality of studies evaluating this therapy are limited.

 One recent small study compared simulated family presence therapy with preferred music therapy and found that both were effective in reducing the frequency of physical agitation, that simulated presence but not preferred music decreased the frequency of verbal agitation, and that although behavioral incidents fell by one-half or more in many patients, others became more agitated.



Light therapy uses time-limited, daytime-specific exposure to daylight, certain wavelengths of light, or full-spectrum light to treat various conditions including depression, seasonal affective disorder, and sleep disturbances. Agitated behaviors and sleep disturbances in older adults with dementia have been linked to abnormal circadian rhythms caused, in part, by a lack of exposure to light. Light therapy has been used to treat disruptive behaviors in dementia patients with variable short-term success, and it may be more effective in those with milder dementia.

 is an approach that “actively stimulates the senses of hearing, touch, vision, and smell in a resident-oriented, nonthreatening environment. It is intended to provide individualized, gentle sensory stimulation without the need for higher cognitive processes, such as memory or learning, in order to achieve or maintain a state of well-being.”

When integrated as part of 24-hour care in nursing home residents with dementia, it was found to be effective in reducing agitated behaviors over an 18-month period.

 program did not show any effects on behavior disturbances during or just after the sessions or at a 1-month postintervention evaluation.



Validation therapy was developed for the elderly with cognitive impairments and is based on the concept of validation, the acceptance of the patient’s reality and personal experience. Preliminary studies suggest that validation therapy helps decrease behavioral disturbances and depression in older adults with dementia.

 A recent case-control study suggests that validation therapy reduces the severity and frequency of behavioral and psychological symptoms of dementia.

 However, there is inadequate evidence from randomized trials to allow definitive conclusions about the efficacy of validation therapy.



Behavioral and milieu management skills for caregivers emphasize respectful redirection, positive expressions of concern, and an appropriate approach to the patient. Such programs have been shown to effectively reduce patient agitation.

 When compared to information and support-oriented interventions for caregivers, skill-building interventions reduced caregiver emotional distress more over 18 months.

 The available data suggest that caregiver-skills training may be an effective way to prevent and reduce agitated behaviors in elderly patients and improve the caregivers’ sense of mastery while decreasing stress.





When nonpharmacological strategies fail to effectively manage agitation, pharmacological treatment may be indicated. If there are clear psychiatric conditions and target symptoms that accompany the agitation patients are likely to be responsive to psychotropic medication. Benefit-to-risk ratio should be evaluated in choosing pharmacological interventions, and informed consent from the patient and/or legal surrogate should be obtained and documented.

Agitated behaviors have been commonly treated with typical and atypical antipsychotics, mood stabilizers, sedative/hypnotics, and/or nootropic agents; other pharmacological interventions include serotonergic agents, b-adrenergic blockers, and hormonal therapies.

Antipsychotics are the best studied and have been shown to modestly impact agitation. However, recent studies have questioned their effectiveness and demonstrated an increased risk of death with the use of both typical and atypical antipsychotics.

Current FDA black box warnings that caution against the use of atypical antipsychotics in older patients, especially those with dementia, may have diminished the enthusiasm for their use, even in patients who exhibit clear psychotic signs and symptoms in addition to agitation.

 The use of nootropic agents, promoted as a first-line treatment for agitation in dementia, also came under greater scrutiny as recent evidence showed limited efficacy of donepezil for the treatment of agitation in patients with Alzheimer disease.



There is little evidence for the efficacy of anticonvulsants, lithium, or b-blockers for treating agitation in dementia. Because these medications have significant adverse effects, they are not recommended except for patients in whom other treatments have failed.

 Trazodone and serotonergic agents have not been well studied, except for treatment of depression. However, they may be appropriate for nonpsychotic, mildly agitated patients.

 Benzodiazepines may be helpful, as needed, for agitation. Those with short half-lives and no active metabolites, such as lorazepam or oxazepam, are preferred.



In the light of limited evidence-based literature to support the use of psychotropic medications in the treatment of agitation, the decision about which medication to use should be determined largely by the patient’s unique needs and characteristics, the adverse-effect profile of the medication, and the benefit-to-risk ratio of treating versus not treating with a given medication.



Agitation in older adults is a complex syndrome associated with multiple psychiatric and medical conditions and comorbidities. Despite its impact on elderly patients, caregivers, and health care costs, there is much that is unclear about the causes, prevention, and treatment of agitation. Yet, clinical interventions that use individualized, multidisciplinary best-practice approaches are routine. Further investigation to develop new interventions and more rigorously test existing ones is needed.

Dr Kyomen is associate psychiatrist in the department of psychiatry at Mclean Hospital in Belmont, Mass, and clinical instructor in the department of psychiatry at Massachusetts General Hospital, Boston. Dr Whitfield is a biostatician in the department of psychiatry at Massachusetts General Hospital.

Dr Kyomen reports that she is a consultant for AstraZeneca Pharmaceuticals LP, Bayer Corporation, Bristol-Meyers Squibb, Merck, Eli Lilly, Roche, GlaxoSmithKline, Novartis, UCB Pharma, Wyeth-Ayerst Laboratories, and Pfizer Inc. She has received grant/research support from Bayer Corporation, Bristol-Myers Squibb, Eli Lilly, Roche, UCB Pharma, Wyeth-Ayerst, Pfizer, Inc, NIH, the John A. Hartford Foundation, the National Institute on Aging, and the Veterans Administration.

Dr Whitfield reports that he has no conflicts of interest concerning the subject matter of this article.

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Agitation in older adults is frequently associated with multiple psychiatric and medical conditions and comorbidities. It commonly occurs in patients with anxiety, affective illness, psychosis, dementia, stroke, brain injury, delirium, or pain.

Helen H. Kyomen, MD, MS

Articles

Raising the Bar on Geriatric Mental Health Competency Training

Agitation in Older Adults