Proposed Geriatric Psychiatry Core Competencies

Task Force Workgroup: Susan Lieff, MD, MEd; Paul Kirwin, MD; Christopher Colenda, MD, MPH

Adapted for geriatric psychiatry from the Accreditation Council for Graduate Medical Education (ACGME) General Competencies Vers. 1.3 (1) and the Program Requirements for Residency Education in Geriatric Psychiatry sections V c and V d (2).

PATIENT CARE

Residents must be able to provide comprehensive psychiatric medical care that is compassionate, appropriate, and effective for the treatment of mental health problems and the promotion of mental health for older adults suffering from psychiatric and neuropsychiatric disorders.

Residents are expected to:

  • communicate effectively and demonstrate caring and respectful behaviors when interacting with geriatric psychiatric patients and their families;
  • gather essential and accurate information through interviews with their geriatric psychiatric patients, family members, caregivers and other health professionals with attention to:
    • relevant history;
    • mental status examination including structured cognitive assessment;
    • functional assessment (e.g., IADL, ADL);
    • assessment of decisional capacity (e.g., decisions regarding treatment, personal care, etc);
    • medical assessment including relevant neurological examination;
    • recognition and assessment of direct or indirect elder abuse;
    • family and caregiver emotional state and ability to function;
    • community and environmental assessment (e.g., community connections, home services, supports, housing, safety, etc);
  • develop a multiaxial diagnosis and formulation of biopsychosocial information (3);
  • develop an evaluation plan which may include selection and use of ancillary investigations, corroborative history or information, laboratory tests, radiology/imaging, electrophysiologic, polysomnographic, and neuropsychologic tests (3); 
  • make informed decisions about therapeutic interventions based on patient information and preferences, up-to-date scientific evidence in the field, and clinical judgment;
  • develop and carry out a comprehensive geriatric psychiatric treatment plan addressing biological, psychological, and sociocultural domains including(3):
    • consultative and primary care (short-term as well as longitudinal management) for geriatric psychiatric patients in multiple settings such as inpatient, outpatient, day programs, nursing home, assisted living, foster care and home care settings;
    • organization and integration of input and recommendations from the multidisciplinary mental health team, as well as integrating recommendations and input from primary care physicians, consulting medical specialists, and representatives of other allied disciplines;
    • use of information technology to support patient care decisions and patient education;
    • communication of treatment plans to and educating geriatric psychiatric patients, their families, and caregivers;
    • initiation and flexible guidance of treatment, with the need for ongoing monitoring of changes in mental and physical health status and medical regimens;
    • recognition and management of medical and psychiatric co-morbid disorders, especially their altered presentation in the elderly, as well as the management of other disturbances often seen in the elderly, such as agitation, aggressiveness, wandering, changes in sleep patterns,and aggressiveness;
    • pharmacotherapy
      • recognition of drug interactions, treatment non-adherence, psychiatric manifestations of iatrogenic influences, such as polypharmacy as well as strategies to correct these issues;
      • the indications for and the adverse effects and therapeutic limitations of psychotropic drugs, including the pharmacologic alterations associated with aging, such as changes in pharmacokinetics and pharmacodynamics;
    • appropriate indications and application of electroconvulsive therapy (ECT) in the elderly;
    • psychotherapy(4)
      • identification of patients and presenting problems likely to be appropriate for the various psychotherapies (e.g., interpersonal therapy (IPT), cognitive behavioral therapy (CBT), problem-solving therapy (PST), dynamic therapy, and reminiscence therapy);
      • development of a working formulation of the relevant issues for the specific recommended therapy;
      • awareness of appropriate modifications in techniques and goals in applying these psychotherapies and behavioral strategies to the elderly (with individual, group, and family focuses);
      • appropriate use of psychodynamic understanding of developmental problems, conflict, and adjustment difficulties in the elderly that may complicate the clinical presentation and influence the doctor-patient relationship or treatment planning;
    • behavioral treatments using non-pharmacologic approaches, especially in dementia patients with particular reference to applications and limitations of behavioral therapeutic strategies, including physical restraints;
    • social interventions--the appropriate use of community programs, home health services, crisis and outreach services, respite care, and institutional long-term care, including the appropriate guidance and protection of caregivers;
    • management of ethical and legal issues pertinent to geriatric psychiatry, including assessment of decisional capacity, guardianship, advance directives, right to refuse treatment, wills, informed consent, elder abuse, the withholding of medical treatments, end-of-life issues, palliative care and federal legislative guidelines governing psychotropic prescribing in nursing home;
  • work with health care professionals, including those from other disciplines, to provide patient-focused care including:
    • formal and informal administrative leadership of the geriatric mental health care team, which may include representatives from related clinical disciplines, such as psychology, psychiatric social work, psychiatric nursing, activity or occupational therapy, physical therapy, psychopharmacology, and nutrition (5);
    • liaison with individuals and teams, where available, representing disciplines within medicine, such as family practice and internal medicine (including their geriatric subspecialties), neurology, and physical medicine and rehabilitation;
  • provide health care services aimed at preventing mental health problems or maintaining mental health in the elderly. 

MEDICAL KNOWLEDGE

Residents must demonstrate knowledge of established and evolving biomedical, clinical and cognate (e.g., epidemiological and social-behavioral) sciences and the application of this knowledge to the care of geriatric psychiatric patients and their families (6), (7), (8).

Residents are expected to:

  • demonstrate an investigatory and analytic thinking approach to clinical situations; and
  • know and apply the basic and clinically supportive sciences, appropriate to their discipline.

Specific knowledge for residency education in geriatric psychiatry includes:

Biomedical

  • Theories of aging--biological, social, and psychological;
  • Age-related changes in organ systems, sensory systems, memory, and cognition;
  • Pharmacologic implications of biological changes:
    • pharmacokinetics and pharmacodynamics;
    • special considerations in the use of psychotropics in the elderly;
    • frequency and management of side effects;
    • polypharmacy and drug interactions in the elderly;
  • Psychopathology beginning in or continuing into late life as compared to younger populations with regard to the following:
    • epidemiology;
    • clinical presentation;
    • pathogenesis;
    • diagnosis;
    • differential diagnosis;
    • treatment;
  • Attributes of disorders, as specified above, with particular attention to the following:
    • mood disorders;
    • anxiety disorders;
    • adjustment disorders/bereavement;
    • delirium;
    • dementia;
    • psychotic disorders;
    • substance related disorders;
    • mental disorders due to a general medical condition including acute and chronic physical illnesses, as well as iatrogenesis;
    • sleep disorders;
    • sexual disorders;
  • Principles and practices of ECT;
  • Sexuality in late life;
  • Psychiatric aspects of general medical conditions including:
    • complications of medical treatments for systemic disease;
    • psychological factors affecting physical illness;
  • Common neurological disorders of the elderly (e.g., Parkinson’s, stroke);
  • Common medical problems of the elderly (e.g., falls, incontinence, pain). 

Psychological

  • Developmental perspective of normal aging with understanding of adaptive and maladaptive responses to psychosocial changes (e.g., retirement, widowhood, role changes, financial issues, environmental relocation, interpersonal and health status, and increased dependency);
  • Psychotherapeutic principles and practice:
    • Interpersonal;
    • Cognitive-behavioral;
    • Problem-solving;
    • Supportive;
    • Reminiscence;
    • Dynamic;
  • Personality disorders
  • Psychological and behavioral therapeutic techniques;
  • Group and activity therapies.

Sociocultural

  • Cultural and ethnic differences among various groups of people;
  • Special problems of disadvantaged minority groups;
  • Caregiver and family issues;
  • Institutionalization and its impact on individuals and families;
  • Practice related and policy and legal issues:
    • Role of geriatric psychiatrist in healthcare systems;
    • Elder abuse;
    • Forensic issues;
    • Current economic aspects of health care supporting services and health care delivery, including, but not limited to, Title III of the Older Americans Act, Medicare, Medicaid, and cost containment;
    • Treatment setting regulations and the impact on treatment and patient outcomes, such as OBRA regulations in nursing homes.
  • Ethical issues;
  • Practice of psychiatry in nursing homes and other long term care facilities. 

INTERPERSONAL AND COMMUNICATION SKILLS

Residents must be able to demonstrate interpersonal and communication skills that result in effective and empathic information exchange and teaming with geriatric psychiatric patients, families, colleagues, staff, and systems. Interpersonal skills require an understanding of the geriatric psychiatrist’s role as a consultant to patients and their contextual systems. Development of interpersonal skills is enhanced by the acquisition of basic information about interpersonal communication (6).

Residents are expected to:

  • create and sustain a therapeutic and ethically sound relationship with geriatric psychiatric patients and their families from a spectrum of available ethnic, racial, cultural, gender, socioeconomic, and educational backgrounds;
  • understand the impact of transference and countertransference on treatment of geriatric psychiatry patients (9);
  • use effective listening skills and elicit information using effective nonverbal, questioning and written skills as appropriate with geriatric psychiatry patients and their families;
  • provide information using effective nonverbal, explanatory, questioning, and written skills as appropriate with geriatric psychiatry patients and their families;
  • communicate effectively and work collaboratively with others as a member or leader of a geriatric psychiatric mental health care team which may include representatives from related clinical disciplines, such as psychology, psychiatric social work, psychiatric nursing, activity or occupational therapy, physical therapy, psychopharmacology, and nutrition (10);
  • communicate effectively and work collaboratively with other health care teams, if available, such as family medicine and internal medicine (including their geriatric subspecialties), neurology, and physical medicine and rehabilitation (10);
  • facilitate the learning of students and other health care professionals, such as other residents, medical students, nurses, and allied health professionals.

PRACTICE-BASED LEARNING AND IMPROVEMENT

Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents must be able to recognize limitations in their own knowledge base and clinical skills and understand and address the need for lifelong learning (11). Residents must be able to demonstrate an ability to continually expand their knowledge and skills and assess their practices to ensure highly competent evaluation and treatment of psychiatric disorders in older people and support for their families (6). Residents shall demonstrate appropriate skills for obtaining up-to-date information from scientific and practice literature and other sources to assist in the quality care of patients.

Residents are expected to:

  • locate, critically appraise, and assimilate evidence from scientific studies and literature reviews related to their geriatric patients’ mental health problems to determine how quality of care can be improved in relation to practice (11);
  • apply knowledge of research study designs and statistical methods related to geriatric psychiatry to appraise clinical studies and other information on diagnostic and therapeutic effectiveness;
  • use medical libraries and information technology, including internet-based searches and literature and drug databases (e.g., Medline) to manage information, access on-line medical information and support their own education;
  • facilitate the learning of students and other health care professionals, such as other residents, medical students, nurses, and allied health professionals;
  • analyze practice experience and perform practice-based improvement activities using a systematic methodology which may include case-based learning, use of best practices, critical literature review, obtaining appropriate supervision and/or consultation, record review and/or patient evaluations (11);
  • obtain and use information about their own population of geriatric psychiatric patients and the larger population from which their patients are drawn.

PROFESSIONALISM

Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse geriatric psychiatric patient population.

Residents are expected to:

  • demonstrate respect, compassion, and integrity; a responsiveness to the needs of geriatric psychiatric patients and society that supercedes self-interest; accountability to such patients, society, and the profession; and a commitment to excellence and on-going professional development;
  • demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, competence, guardianship, advance directives, wills, elder abuse, and business practices;
  • demonstrate sensitivity and responsiveness to patients’ culture, age, gender, disabilities, ethnicity, socioeconomic background, religious beliefs, political leanings, and sexual orientation (12);
  • demonstrate responsibility for the care of geriatric psychiatric patients by responding to patient communications and other health professionals in a timely manner, using medical records for appropriate documentation of the course of illness and treatment, coordinating care with other members of the team, and providing coverage if unavailable (12);
  • demonstrate understanding of and sensitivity to end-of-life care and issues regarding provision of care (10);*
  • review their professional conduct and remediate when appropriate (10);*
  • participate in the review of the professional conduct of their colleagues (10);*
  • be aware of safety issues, including acknowledging and remediating medical errors, should they occur (10).*

* Indicates that the statement is not an ACGME requirement

SYSTEMS-BASED PRACTICE

Residents must be able to treat older people with psychiatric and/or neuropsychiatric problems within the context of multiple, complex intra-organizational and extra-organizational systems. The resident should have a working knowledge of the larger context and the diverse systems involved in treating older patients and their family members and understand how to use and integrate multiple systems of care as part of a comprehensive system of care, in general and as part of a comprehensive, individualized treatment plan (6).

Residents are expected to:

  • be aware of how types of geriatric psychiatric practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources;
  • demonstrate knowledge of community systems of care and assist patients to access appropriate care and other support services. This requires knowledge of treatment settings in the community, which might include ambulatory, consulting, acute care, partial hospital, adult day care, subacute care, rehabilitation, nursing homes, assisted living, subsidized senior housing, naturally occurring retirement communities (NORCs), home care, and hospice care settings. The resident should demonstrate knowledge of the organization of care in each relevant delivery setting and the ability to utilize and work with such settings;
  • understand how to partner with health care managers and health care providers to assess, coordinate, and improve geriatric mental health care and understand how these activities can affect system performance. The resident shall demonstrate knowledge of how multiple systems of care coordinate as comprehensive systems of care and educate patients concerning such systems of care;
  • understand how geriatric psychiatric care and other professional practices affect other health care professionals, the health care organization and the larger society, including how these elements of the system affect their own practice. Particular attention should be paid to development of skills for the practice of ambulatory medicine, including time management, clinic scheduling, and efficient communication with referring physicians as well as utilization of appropriate consultation and referral (9), (10);
  • practice cost-effective geriatric psychiatric care and resource allocation that does not compromise quality of care with attention to practice guidelines and community, national and allied health professional resources available both publicly and privately which may enhance the quality of life of such patients (9), (10);
  • advocate for quality patient care and assist geriatric psychiatric patients in dealing with system complexities, such as limitation of resources for health care, social and/or financial constraints, and legal aspects of geropsychiatric diseases as they impact patients and their families. 

References

  1. http://www.acgme.org/outcome/comp/ – Last accessed 5-20-04
  2. http://www.acgme.org/downloads/RRC progReq/407pr703.pdf – Program Requirements for Residency Education in Geriatric Psychiatry. Last accessed 5-20-04
  3. Davis GC: General and psychiatry – Specific patient care core competencies, in Core Competencies for Psychiatric Practice. What Clinicians Need to Know. A Report of the ABPN, Inc. Edited by Scheiber SC, Kramer TAM, Adamowski SE. Arlington, VA, APPI, 2003
  4. http://www.aadprt.org/public/educators.html – Basic psychotherapy competencies from Thomas Jefferson University. Last accessed 5-20-04
  5. Colenda CC. Essential curriculum in geriatric psychiatry for general internal medicine residency and geriatric medicine fellowship programs. Am J Med 1994; 97(suppl 4A):15S 18S
  6. Sexson S, Sargent J, Zima B, et al: Sample core competencies in child and adolescent psychiatry training. Academic Psychiatry 2001; 25(4):201 213
  7. Thorpe L, LeClair K, Donnelly M, et al: Geriatric psychiatry: Training guidelines and their application. Can J Psych 1993; 38:90 95
  8. Marin RS, Foster JR, Ford CV, et al: A curriculum for education in geriatric psychiatry. Am J Psych 1988;145:836 843
  9. Scheiber SC, Kramer TAM, Adamowski SE. The 5 W’s of core competency assessment (Who, What, Where, When, Why). Proceedings from AADPRT Annual Meeting Workshop, March 7, 2002. Long Beach, CA
  10. http://www.abpn.com – General Information: Psychiatry and Neurology Core Competencies Version 4.0. Last accessed 5-20-04
  11. Faulkner LR: Practice-based learning and improvement core competencies, in Core Competencies for Psychiatric Practice. What Clinicians Need to Know. A Report of the ABPN, Inc. Edited by Scheiber SC, Kramer TAM, Adamowski SE. Arlington, VA, APPI, 2003
  12. Weller EB: Professionalism core competencies, in Core Competencies for Psychiatric Practice. What Clinicians Need to Know. A Report of the ABPN, Inc. Edited by Scheiber SC, Kramer TAM, Adamowski SE. Arlington, VA, APPI, 2003