Gary S. Moak, M.D.

Awareness that there is a sub-specialty called geriatric psychiatry is growing.Unfortunately, most people remain dubious about the value of an older person seeing a psychiatrist. Older people often are reticent to talk to a psychotherapist and are more comfortable seeing their primary care physician for psychiatric medications, should they see the need to take these.  Such views reflect the stigma of psychiatric treatment and a very simplified understanding of the practice of psychiatry (see the article in TOPICS IN GERIATRIC PSYCHIATRY Mental Health and Aging:  Facts and Myths).
As the ranks of senior citizens grows and demand for good mental health services increases, the shortage of geriatric psychiatrists will become more glaring (see the article Why You Can’t Find a Geriatric Psychiatrist…And Where to Look in TOPICS IN GERIATRIC PSYCHIATRY).  In the absence of a geriatric psychiatrist, some older patients will see general, adult psychiatrists.  This article will compare the knowledge, skills, and scope of practice of general, adult psychiatrists and sub-specialist, geriatric psychiatrists.

General Adult Psychiatrists

Foremost, psychiatrists are medical doctors. To become a psychiatrist, college graduates first attend four years of medical school, where they learn all the medical sciences and medical specialties that all other physicians do.  Psychiatrists-in-training then complete a medical internship, during which they learn to take care of sick patients with physical problems, and then they complete a four-year psychiatry residency.  During this time, they learn to diagnose mental health problems, prescribe psychiatric medication, perform psychotherapy with individuals, families, or groups, and provide consultation in hospitals and human service agencies.

Psychiatrists are the only professionals in the healthcare system whose training is comprehensive and overlaps that of other members of the team.  Psychiatrists are medical doctors who understand the input and actions of primary care physicians and other specialists as well as that of psychologists, social workers, and nurses.  Psychiatrists are thus uniquely positioned to integrate the contributions of others into a holistic picture of a patient and his or her needs.   What follows are the competencies of general psychiatrists:
Conducts comprehensive assessments of psychiatric problems

• Considers physical, pharmacological, neurological, psychiatric, psychological, and family and social factors and weighs their relative contributions to the problem.  Uses this approach to arrive at a specific diagnosis and treatment plan.
• Is familiar with the psychiatric toxicities of commonly used non-psychiatric medications (e.g., blood pressure medications)

Formulates multidimensional treatment plans

• Is qualified to weigh the relative utility and effectiveness of various treatments.
• Prioritizes treatments and coordinates care among other members of the healthcare team.
• Monitors mental health progress to ensure optimal outcome, safety, and cost-effective utilization of services.

Provides psychosocial treatments

• Is qualified to provide individual, marital, and family therapy, when indicated, or to oversee the delivery of such services when provided by other, non-physician mental health professionals.
  • Provides short and long term psychotherapy when appropriate
  • Psychiatrists are most effective providing crisis intervention to prevent mental health problems from interfering with needed general medical or surgical treatment.

Prescribes psychiatric medication or oversees the use of such medications.

• While primary care physicians can prescribe psychiatric medication, psychiatrists are more familiar with the safe and effective use of these medications.
  • Psychiatrists are more familiar with the proper uses of psychiatric medications their contraindications (i.e., when they should not be used).
  • Is aware of the Food and Drug Administration approved uses of medications as well as other, so-called “off-label” uses that may be recognized as appropriate in geriatric practice.
  • Psychiatrists have an appreciation of the effects of aging on the metabolism and clearance of medications used to treat psychiatric problems in the elderly.
  • Psychiatrists are more familiar with side effects that may be more troublesome for older people.
  • Psychiatrists are  more aware of drug interactions.

Educates patients and families about psychiatric problems, diagnosis, and treatments, especially involving the use of medication

• Helps patients and families appreciate the impact psychiatric disorders can have on physical health problems, and visa-versa.
• Helps patients and families understand the various options for treatment, including possible common side effects and more serious adverse effects.
• Helps patients and families develop realistic expectations of treatment.
• Psychiatrists commonly work as well with other caregivers or staff of geriatric agencies or long-term care facilities.

Psychiatrists have the expertise and qualifications to address medical-legal issues and assist in their resolution.

• Assessment of decision-making capacity and competence to consent to treatment or to refuse it.
• Assessment of competence to execute legal instruments such as healthcare proxies, powers of attorney, wills and living wills, etc.
• Assessment of capacity to handle business, legal, and financial affairs.
• May be involved in assessing whether an elderly person is in danger due to a mental disorders
  • Makes, or contributes to, decisions about the need for guardianship, or involuntary psychiatric treatment.

Geriatric Psychiatrists

Geriatric psychiatrists start with the same training, knowledge and skills of general psychiatrists.  After completing a four-year residency in psychiatry, geriatric psychiatrists train for an additional one to two years in a geriatric psychiatry fellowship that focuses entirely on the unique needs of older people.  At the end of this training, a geriatric psychiatrist has all of the skills described above plus the following additional knowledge and skill:
Additional training and experience in geriatric psychiatry makes geriatric psychiatrists uniquely qualified in the care of frail, elderly patients with late-life mental disorders with concurrent medical problems and functional impairments.
The most important distinction is that geriatric psychiatrists understand old age as a unique developmental stage of life (in this way, they are similar to pediatricians, who have a more specialized understanding of children than other doctors).

• Geriatric psychiatrists apply a lifespan developmental perspective to understanding elderly patients.  This means that they try to understand how the lifetime of experience that came before affects how people cope with problems in old age.
  • Geriatric psychiatrists understand common crises of old age, such as illness, disability, loss of loved ones, retirement, loss of independence, and social isolation.  Geriatric psychiatrists understand the impact changes of old age can have on individuals’ ability to adjust to such crises, and they are familiar with common patterns of maladaptive coping.
  • Geriatric psychiatrists understand how prior experience with childhood, family life, marriage, work and career, and parenting affects peoples’ ability to adjust emotionally to the problems of old age.

Geriatric psychiatrists are trained to recognize unique patterns of illness in old age that make geriatric conditions harder to diagnose correctly:

• Older patients sometimes conceal symptoms out of fear of the consequences or the belief that problems are normal for old age (see Mental Health and Aging:  Facts and Myths in TOPICS IN GERIATRIC PSYCHIATRY).
• Diseases present differently in old age.  The symptoms of an illness, such as heart attack, often are different in a ninety year old than a fifty year old.  Different illnesses often share common symptoms.  Diseases thus often masquerade as one another.  Geriatric psychiatrists are less easily mislead by this.
• Problems do not occur in isolation, but often as the additive effect of several conditions or as a chain reaction of other problems.  Geriatric recognize these patterns of symptom formation.
• Geriatric psychiatrists have special expertise sorting out and managing components of depression, dementia, and delirium when all three are present at the same time.
• Geriatric psychiatrists evaluate functional skills (memory and cognition, walking and mobility, continence, dressing, cooking, paying bills, etc.) as part of their comprehensive assessment of older patients.  They recognize the importance of mental state on functional abilities, and design treatment plans not only to improve mental and emotional symptoms but also to impact function in a positive way and to avoid inadvertently compromising function with side effects.
• Geriatric psychiatrists have expert knowledge of common geriatric problems including incontinence, falling, immobility, malnutrition, sensory impairment, and failure to thrive.
  • They understand the impact of psychiatric problems and psychiatric treatments on geriatric problems and can incorporate such considerations into a comprehensive treatment plan.

Geriatric psychiatrists have expertise in the diagnosis and management of psychiatric problems caused by other medical conditions and understand how to manage the interactions between multiple medical problems:

• Post-stroke depression and other post-stroke psychiatric problems (see Post Stroke Depression in the MENTAL HEALTH AND AGING RESOURCE LIBRARY).
• Psychiatric manifestations of Parkinson’s disease and similar movement disorders.
• Symptoms such as anxiety, depression, confusion, and paranoia can occur as the earliest symptoms of illnesses such as heart failure, diabetes, chronic lung disease, and chronic kidney disease, among others.

Geriatric psychiatrists understand the use of psychotherapy and other psychosocial treatments in geriatric treatment, and they can prescribe, supervise, or even perform such treatments.

• This includes the use of problem solving therapy, behavioral interventions for patients with dementia, and modifications of Interpersonal Psychotherapy and Cognitive-Behavioral Therapy for cognitively impaired patients.

Geriatric psychiatrists understand aspects of retirement communities, senior housing, assisted living facilities, nursing homes, adult day care, hospice, Medicare, Medicaid, Social Security, elder law, senior centers, home healthcare agencies, meals-on-wheels, etc., that affect the mental health and psychiatric treatment of geriatric patients, and know how to adjust treatment goals to accommodate the limitations of geriatric institutions, social programs, insurance coverage rules, and government regulations.

Moak Center for Healthy Aging ©
Updated December 2008