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
Medical Knowledge
Interpersonal and Communication
Skills
Practice-Based Learning and Improvement
Professionalism
Systems-Based Practice
References
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);
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- 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.
Back to top 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).
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top
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.
Back to top 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.
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References
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5-20-04
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