The goal of the UCLA Multicampus Geriatric Psychiatry Fellowship Training Program is to train psychiatrists to assume leadership roles in clinical and academic geriatric psychiatry.  Residents develop clinical expertise in assessing and treating the wide range of psychiatric disorders in the elderly.  Residents also develop the expert skills in scholarly activities and administration that are required of leaders in the clinical practice community and in academia. 

Core competencies for graduates of the Program, and objectives within each competency area are: 

1. Patient Care

Residents must be able to provide geriatric psychiatric patient care that is compassionate, appropriate and effective for the treatment of mental health problems and the promotion of mental health.

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 about their geriatric patients from the patients, their families, caregivers and other health professionals,
• make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence in the field and clinical judgment,
• develop and carry out geriatric psychiatric patient management,
• counsel and educate geriatric psychiatric patients and their families,
• use information technology to support patient care decisions and patient education,
• perform competently all medical and invasive procedures considered essential for the  practice of geriatric psychiatry,
• provide health care services aimed at preventing mental health problems or maintaining mental  health in the elderly; and
• work with health care professionals, including those from other disciplines, to provide patient-focused care.

Specific patient assessment skills include:

• interviewing skills of patients and other informants
• mental status examination including structured cognitive assessment
• functional assessment
• capacity assessments
• family and caregiver assessments
• recognition and assessment of direct or indirect elder abuse.
• community and environmental assessment
• medical assessment
• selection and use of ancillary investigations; corroborative history or information; laboratory tests; radiology/imaging, electrophysiologic, and neuropsychologic tests
• referrals to other healthcare specialists

Specific patient management skills include:

• primary and consultative care for geriatric psychiatric patients in both inpatient and outpatient settings
• formulation of biopsychosocial information into a comprehensive diagnosis and treatment plan
• organization and integration of input and recommendations from the mental health team, primary care physicians, consulting medical specialists and representatives of other allied disciplines
• formal and informal administrative leadership of the geriatric mental healthcare team which may include representatives from related clinical disciplines such as psychology, social work, psychiatric nursing, activity or occupational therapy, physical therapy, pharmacology and nutrition
• liaison with individuals representing disciplines within medicine, such as family practice and internal medicine (including their geriatric subspecialties), neurology, and physical medicine and rehabilitation
• skills in communicating treatment plans to the patient and the family and caregiver
• initiation and flexible guidance of treatment, with the need for ongoing monitoring of changes in mental and physical health status and medical regimens. Residents should be taught to recognize and manage psychiatric comorbid disorders, as well as the management of other disturbances often seen in the elderly, such as agitation, wandering, changes in sleep patterns and aggressiveness
• pharmacotherapy – the indications, side effects and therapeutic limitations of psychoactive drugs and the pharmacologic alterations associated with aging, including changes in pharmacokinetics, pharmacodynamics, drug interactions, overmedication and problems with compliance. Attention should be given to the psychiatric manifestations of iatrogenic influences such as the multiple medications frequently taken by the elderly
• ECT – appropriate use and application of electroconvulsive therapy in the elderly
• psychotherapy – awareness of appropriate modifications in techniques and goals in applying the various psychotherapies (with individual, group, and family focuses) and behavioral strategies. The 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 – the use of nonpharmacologic approaches, with particular reference to applications and limitations of behavioral therapeutic strategies, physical restraints
• social interventions – the appropriate use of community or home health services, crisis and outreach services, respite care and the need for institutional long-term care. Appropriate guidance of and protection of caregivers
• management of ethical and legal issues pertinent to geriatric psychiatry – including competence, guardianship, right to refuse treatment, wills, informed consent, patient abuse and the withholding of medical treatments.

 2. Medical Knowledge

Residents must demonstrate knowledge about 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.

Residents are expected to: 

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

Content areas for medical knowledge in geriatric psychiatry include:

A.     Biomedical      

    1)   Theories of Aging – biological, social and psychological

    2)   Age-related changes in organ systems, sensory systems, memory and cognition

    3)   Pharmacologic implications of biological changes

                           a)   pharmacokinetics and pharmacodynamics

                           b)   special considerations in the use of psychotropics in the elderly

                           c)   frequency and management of side effects

                           d)   polypharmacy and drug interactions in the elderly

    4)   Psychopathology in late life as compared to younger populations with regard to the following:

                           a)   epidemiology

                           b)   clinical presentation

                           c)   pathogenesis

                           d)   diagnosis

                           e)   differential diagnosis

                           f)    treatment

                     With particular attention to the following disorders:

                           a)   Mood Disorders

                           b)   Anxiety Disorders

                           c)   Adjustment Disorders/Bereavement

                           d)   Delirium

                           e)   Dementia

                           f)    Psychotic Disorders

                           g)   Substance Related Disorders

                           h)   Mental Disorders due to a General Medical Condition

                           i)    Sleep Disorders

                           j)    Sexual Disorders

    5)   Principles and practices of ECT

    6)      Sexuality

    7)      Common neurological disorders of the elderly (eg, stroke, Parkinson’s disease)

    8)      Common medical problems of the elderly (eg, falls, incontinence)

B.     Psychological

    1)   Developmental perspective of normal aging with understanding of adaptive and maladaptive responses to psychosocial changes (e.g. retirement, widowhood, role changes, $, relocation)

    2)   Psychotherapeutic principles and practice

    3)   Personality Disorders

    4)   Psychological and behavioral therapeutic techniques

    5)   Group and activity therapies

C.        Social 

    1)   Cultural and ethnic differences and special needs of disadvantaged minority groups

    2)   Caregiver issues

    3)   Elder abuse

    4)   Support and health care delivery systems

    5)   Legal and ethical issues

    6)      Economic aspects of health care and health care delivery – including but not limited to Title III of the Older Americans Act, Medicare, Medicaid and cost containment

    7)      Institutionalization and its impact

3. Interpersonal and Communication Skills

Residents must be able to demonstrate interpersonal and communication skills that result in effective and empathic information exchange between the geriatric psychiatrist, geriatric psychiatric patients, families, colleagues, staff and systems. Interpersonal skills require an underlying set of attitudes involving the resident’s personal beliefs and values, self-understanding, opinions about other people and understanding of the geriatric psychiatrist’s role as a consultant to patient’s and their contextual system. Development of interpersonal skills is enhanced by the acquisition of basic information about interpersonal communication as a consultant.

Residents are expected to:

• create and sustain a therapeutic and ethically sound relationship with geriatric psychiatric patients and their families from a full spectrum of ethnic, racial, gender, economic and educational backgrounds,
• use effective listening skills and elicit and provide information using effective nonverbal, explanatory, questioning and writing skills; and
• work effectively with others as a member or leader of a geriatric psychiatric mental health care team or other health care teams such as geriatric medicine, family practice and internal medicine (including their geriatric subspecialties), neurology, and physical medicine and rehabilitation.

4. Practice-Based Learning and Improvement

Residents must be able to demonstrate an ability to continually expands his/her knowledge and skills and assesses his/her practice to ensure highly competent evaluation and treatment of psychiatric disorders in older people and their families.  This process requires a willingness to develop new knowledge and skills, a recognition of knowledge and skill gaps, and an approach for continuously evaluating and improving one’s knowledge and skills and patient care practices through adherence to “best practices” and regular critical review of the scientific literature. The resident shall demonstrate appropriate skills for obtaining up-to-date information from the scientific and practice literature and other sources to assist in the quality care of patients.

Residents are expected to:

• locate, appraise, and assimilate evidence from scientific studies related to their geriatric patients’ mental health problems,
• apply knowledge of study designs and statistical methods to the appraisal of such 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; and
• obtain and use information about their own population of geriatric psychiatric patients and the larger population from which their patients are drawn.

5. Systems-Based Practice

Residents must be able to treat older people with psychiatric and/or neuropsychiatric problems within the context of multiple, complex intra-organization and extra-organization 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.

Residents are expected to:

• understand how their geriatric psychiatric care and other professional practices affect other health care professionals, the health care organization, and the larger society and 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,
• know how types of geriatric psychiatric practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources,
• 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,
• advocate for quality patient care and assist geriatric psychiatric patients in dealing with system complexities such as limitation of resources for health care, social or financial constraints or legal aspects of geropsychiatric diseases as they impact on patients and their families, know how to partner with health care managers and health care providers to assess, coordinate, and improve geriatric mental health care and know how these activities can affect system performance. The resident shall demonstrate knowledge of how to interact with Medicare managed care (“Medicare risk”) programs, including participating in utilization review communications and educating patients concerning such systems of care; and
• the resident shall 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 include ambulatory, consulting, acute care, partial hospital, adult day care, subacute care, rehabilitation settings, assisted living settings, subsidized senior housing, naturally occurring retirement communities, nursing homes, home care and hospice organizations.  The resident should demonstrate knowledge of the organization of care in each relevant delivery setting and the ability to integrate the care of patients within and across such settings.

6. 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, and business practices,
• demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and disabilities; and
• demonstrate responsibility for his/her geriatric psychiatric patient’s care  by responding to patient communications, using medical records for appropriate documentation of  the course of illness and treatment and provide coverage if unavailable.

Additional  information:

ACGME Program Requirements for geriatric psychiatry training programs are described at:

http://www.acgme.org/acWebsite/downloads/RRC_progReq/407pr703_u105.pdf

ABPN Board Requirements for certification in geriatric psychiatry are described at:

http://www.abpn.com/downloads/ifas/ifa_initial_psych_07_web.pdf