Finding Common Ground: An Integrative Model of Geriatric Medicine and Geriatric Psychiatry Fellowship Education

Currently, the fastest-growing segment of the U.S. population is the group aged 85 and older; referred to as the oldest old, this group is expected to reach 10 million by 2030. They are more likely to live in metropolitan areas with many aging in place ( A Profile of Older Americans, 2006). Our institution, Saint Vincent's Hospital, Manhattan, serves the needs of the surrounding urban community in lower Manhattan, including older adults from culturally and socioeconomically diverse backgrounds. Often having grown to advanced age with little family or social support, many have to cope with functional decline, chronic medical illness, and complicating issues, such as cognitive impairment, bereavement, isolation, depression, and chronic mental illness. Meeting the needs of this population requires an interdisciplinary approach that includes a strong psychosocial component, as medical and psychiatric syndromes commonly coexist, are often overlapping in nature, and occur with a high frequency. Chronic medical illness is expected in older adults; 80% have at least one chronic condition, and 50% have two or more ( Healthy Aging, 2007). Mental disorders are less frequent than medical ones but still common in older persons, as evidenced by the Epidemiologic Catchment Area Survey (Regier et al., 1984). Using a structured psychiatric interview from which diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders (3rd ed.) were constructed, the prevalence in this sample of community-dwelling adults was 12.3%. Behavioral and cognitive issues that arise frequently complicate the care of older patients. For example, 1 of 10 older adults over age 65 will develop dementia, as will 40% to 50% of those over age 85 ( ADEAR, 2006). Moreover, there is a high frequency of behavioral symptoms in patients with dementia, including psychotic symptoms in up to 20% of Alzheimer's patients, depression in 40%, and aggression or agitation at some point in 80% ( BPSD, 2007). A study looking at behavioral disturbances in dementia (Alzheimer's and non-Alzheimer's) revealed that 61% had behavioral disturbances in the prior month, including apathy (27%), agitation (24%), and depression (24%) (Lyketsos et al., 2000). These figures are even higher in the nursing home population (Task Force on Nursing Homes and the Mentally Ill Elderly, 1989). In addition, depression is prevalent in the geriatric population and very often associated with negative life events, death of friends and family, and change of residence (Hybels & Blazer, 2003). Effective treatment of these conditions is challenging and complex; older adults are at higher risk for adverse drug reactions (Hanlon et al., 1997) and interactions that often present atypically as a geriatric syndrome (e.g., falls, mental status changes, loss of function, or failure to thrive). The geriatrician is expected to be able to address competently the medical, behavioral, and psychiatric aspects of a patient's condition. The future demographic trends, the stigmatization of mental illness, and general resistance to seeking treatment from mental health professionals among many elderly emphasize this (Klap, Unroe, & Unutzer, 2003). To care effectively for older adults, the geriatrician needs a strong foundation in geriatric psychiatry. Conversely, the geriatric psychiatrist needs to be aware of common medical comorbidities and drug interactions. Effective practice of either geriatric medicine or geriatric psychiatry requires clinicians to have a fund of geriatrics knowledge that encompasses aspects of both medicine and psychiatry in order to provide appropriate care to complex, frail adults. Therefore, it is important that geriatricians possess the skills necessary to recognize and manage common psychiatric and behavioral conditions occurring in older adults, especially since it is predicted that there will be a continued shortage of geriatric psychiatrists in the near future (Lieff et al. …