Raising the Bar on Geriatric Mental Health Competency Training

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 projections, a dramatic increase from the rate of 13% reported in the 2010 census.¹ It is estimated that 14% to 20% of older adults require treatment for mental health conditions and/or substance use disorders.² The anticipated increase in the number of older adults will place unprecedented and unrealistic burdens on our health care system, which now includes fewer than 1400 board-certified geriatric psychiatrists.³ 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.^2,4 These goals have yet to be achieved. The Liaison Committee on Medical Education, which provides 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.⁵ 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.⁶ Aggression and other behavioral disturbances of dementias (major neurocognitive disorders) contribute to caregiver burnout and premature institutionalization.^7,8 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.^9,10 Polypharmacy, all too common in older adults, is associated with falls, confusion, and preventable hospitalizations.¹¹ Notwithstanding educational campaigns such as “Choosing Wisely” (an initiative by the American Board of Internal Medicine Foundation¹²), benzodiazepines continue to be overprescribed to older adults, despite the complications associated with their excessive and chronic use.¹³

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 (Table).¹⁴ 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 recent report proposes 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.¹⁵

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.

Optimal geriatric mental health care 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.

Dr Lehmannis clinical director, Division of Geriatric Psychiatry and Neuropsychiatry, and associate professor of Psychiatry and Behavioral Sciences, Johns Hopkins Medicine, Baltimore, MD. Dr Ellison 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. Dr Sakauye is Dr Sakauye is Emeritus Professor of Psychiatry at the University of Tennessee Health Science Center in Memphis, TN. Dr Kyomen 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. Dr Meador is professor of Psychiatry and Health Policy and Director, Center for Biomedical Ethics and Society at Vanderbilt University, Nashville, TN. Dr Roca 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.

References

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. JAMA. 2010;28;304(4):443-451.

7. Hiyoshi-Taniguchi K, Becker CB, Kinoshita A. What Behavioral and Psychological Symptoms of Dementia Affect Caregiver Burnout? Clin Gerontol. 2018;41(3):249-254.

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 .J Am Geriatr Soc. 2014; 62:762-769.

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. Br J Psychiatry. 2019;10:1-7.

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. Am J Geriatr Psychiatry. 2017;25(2):131-141.

11. Richardson K, Bennett K, Kenny RA. Polypharmacy including falls risk-increasing medications and subsequent falls in community-dwelling middle-aged and older adults. Age Ageing. 2015;44(1):90-96.

12. Choosing Wisely. Promoting conversations between patients and clinicians. Accessed December 3, 2020. https://www.choosingwisely.org

13. Maust DT, Kales HC, Wiechers IR, et al. No end in sight: Benzodiazepine use in older adults in the United States. J Am Geriatr Soc. 2016;64(12):2546-2553.

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. Acad Med. 2009;84:604-610.

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. Am J Geriatr Psychiatry. 2017;25:1041-1047.