Predictors for Matriculation into Geriatric Psychiatry Fellowship: Data from a 2019-2020 National Survey of U.S. Program Directors.

OBJECTIVE: With the number of geriatric psychiatry fellows declining from a peak of 106 during 2002-2003 to 48 during 2020-2021, this study aims to investigate characteristics of the geriatric psychiatry training requirement across U.S. psychiatry residency programs and to identify specific factors which may influence residents to pursue geriatric psychiatry subspecialty training. METHODS: The authors queried the American Medical Association's Fellowship and Residency Electronic Interactive Database Access system to compile a list of program directors from the Accreditation Council for Graduate Medical Education sponsored general adult psychiatry residency programs. Program directors were emailed an anonymous multiple-choice survey to ascertain specific characteristics of their program's geriatric psychiatry training experiences. This study's primary outcome was the percentage of residents entering geriatric psychiatry fellowship after completion of general psychiatry training. Linear regression analysis determined which variables may be associated with this primary outcome. RESULTS: Of 248 surveyed, 60 programs (24%) responded to the survey. Only one of the independent variables revealed a statistically significant association with the percent of residents that became geriatric psychiatry fellows: the number of geriatric psychiatrists at the residents' home institution (p=0.002). CONCLUSIONS: Consistent with previous data, the presence of geriatric psychiatry faculty members is strongly associated with the decision to pursue subspecialty training in geriatric psychiatry.

The AAGP Scholars Program: Predictors of Pursuing Geriatric Psychiatry Fellowship Training.

OBJECTIVE: The American Association for Geriatric Psychiatry (AAGP) Scholars Program was developed to recruit trainees into geriatric psychiatry fellowships and is considered a pipeline for fellowship recruitment. Nonetheless, the number of trainees entering geriatric psychiatry fellowship is declining, making it important to identify modifiable factors that may influence trainees' decisions to pursue fellowship. We analyzed survey data from Scholars Program participants to identify demographic characteristics, attitudes toward program components, and behaviors after the program that were independently associated with the decision to pursue fellowship. METHODS: Web-based surveys were distributed to all 289 former Scholars participants (2010-2018), whether or not they had completed geriatric psychiatry fellowships. We conducted a hierarchical binary logistic regression analysis to examine demographics, program components, and behaviors after the program associated with deciding to pursue geriatric psychiatry fellowship. RESULTS: Sixty-one percent of Scholars decided to pursue geriatric psychiatry fellowship. Attending more than one AAGP annual meeting (relative variance explained [RVE] = 34.2%), maintaining membership in the AAGP (RVE = 28.2%), and rating the Scholars Program as important for meeting potential collaborators (RVE = 26.6%) explained the vast majority of variance in the decision to pursue geriatric psychiatry fellowship. CONCLUSION: Nearly two-thirds of Scholars Program participants decided to pursue geriatric psychiatry fellowship, suggesting the existing program is an effective fellowship recruitment pipeline. Moreover, greater involvement in the AAGP longitudinally may positively influence Scholars to pursue fellowship. Creative approaches that encourage Scholars to develop collaborations, maintain AAGP membership, and regularly attend AAGP annual meetings may help attract more trainees into geriatric psychiatry.

The American Association for Geriatric Psychiatry's Trainee Programs: Participant Characteristics and Perceived Benefits.

OBJECTIVE: The number of physicians trained in geriatric psychiatry is dwindling. The American Association for Geriatric Psychiatry (AAGP) developed novel educational programs designed to foster interest in the field. The objective of this study was to compare participant characteristics and perceived benefits of two AAGP educational programs for trainees: Stepping Stones (1997-2007) and the Scholars Program (2010-2016). METHODS: Web-based surveys were distributed to former participants of the Stepping Stones and Scholars Programs. Characteristics of participants in the two programs were compared using χ2, t tests, or Mann-Whitney U tests, as appropriate. The five-point Likert scale responses for each perceived benefit were compared using t tests, when normally distributed, or Mann-Whitney U tests as appropriate. RESULTS: Of the 476 Stepping Stones participants, 132 (27.8%) responded to the survey, while 64 (29.0%) of the 221 Scholars Program participants responded to the survey. Participant characteristics differed only in age. Compared to Stepping Stones participants, Scholars Program participants endorsed greater advancement of their scholarly work, more support and recognition from their home institution, and increased networking opportunities. CONCLUSION: Innovative approaches to addressing the geriatric psychiatry workforce shortage are critical. The member-funded AAGP Scholars Program offers several advantages over its predecessor Stepping Stones. Highlighted by the addition of medical student participants, a carefully matched mentoring program, and a required scholarly project, the Scholars Program is poised to enhance recruitment into geriatric psychiatry subspecialty training, although its impact on recruitment should be investigated directly in future research.

Patient-Centered Perioperative Care for a Victim of Military Sexual Trauma.

INTRODUCTION: The patient population seen in our nation's Veterans Affairs Healthcare system is increasingly female and an alarming percentage of our veterans, male and female alike, report a history of military sexual trauma (MST), which is associated with an increased burden of morbidities including post-traumatic stress disorder (PTSD) and substance abuse. The experience of surgery can produce symptoms of PTSD in a clinically significant percentage of patients. This article describes the challenges of achieving a patient-centered perioperative care plan in the case of a female veteran who suffers from PTSD as a result of MST. METHODS: We provide a brief background on the changing demographics of our nation's veterans, a review of MST and patient-centered care, and a description of the interdisciplinary care plan created and implemented for our patient. We note how this care model employs key elements of the Perioperative Surgical Home Model as developed by the American Society of Anesthesiologists. Finally, we propose an agenda for improving perioperative care for this group of veterans. No institutional review board was required for this case report-based discussion. RESULTS: The patient-centered care plan developed and implemented by an interdisciplinary team was well received by the patient and enabled her to comply with her postsurgical physical therapy. This recent interdisciplinary experience was in stark contrast to her experience of former surgical procedures, and produced much higher patient satisfaction. CONCLUSION: Improvements are needed in patient-centered perioperative care for victims of MST, both within the Veterans Affairs system and in the larger health care system. We suggest an agenda to improve care for these patients including: (1) increasing provider awareness and education about MST and about the potential psychological trauma of surgery per se, (2) employing elements of the Perioperative Surgical Home to encourage patient-centered care involving collaboration within an interdisciplinary team, (3) and measurement of patient centered outcomes. Perioperative care for the victim of MST is heretofore not addressed in the literature. We hope this case report and review will stimulate further research into optimizing care for these vulnerable patients.

Geriatrics and the Legal System.

Correctional systems, already struggling to meet the basic and functional requirements of older prisoners, will be further challenged by the increasing medical and psychiatric needs of this population. Mental health and general medical care for older adults requires specific on-site or consultation expertise in geriatric medicine and psychiatry, as well as potential changes in infrastructure, both of which may be prohibitively expensive. However, compassionate and effective treatment of older prisoners requires that prison and legal systems facilitate this expert care. To address this situation, strategic revisions of the criminal justice system are needed to alleviate prison overcrowding and consequent inadequate medical care for inmates, especially the elder ones. The unique, age-related demands of this older population predict an increased need for forensic psychiatrists with a thorough knowledge and expertise in geriatrics, as more forensic psychiatric evaluations will be needed before trial in both civil and criminal cases, during incarceration, and at the time of parole. In this article, we review the current state of elder inmates in correctional institutions and advocate for increased geriatric training for forensic psychiatrists in anticipation of this growing need.

Psychological resilience in U.S. military veterans: A 2-year, nationally representative prospective cohort study.

Although many cross-sectional studies have examined the correlates of psychological resilience in U.S. military veterans, few longitudinal studies have identified long-term predictors of resilience in this population. The current prospective cohort study utilized data from a nationally representative sample of 2157 U.S. military veterans who completed web-based surveys in two waves (2011 and 2013) as part of the National Health and Resilience in Veterans Study (NHRVS). Cluster analysis of cumulative lifetime exposure to potentially traumatic events and Wave 2 measures of current symptoms of posttraumatic stress, major depressive, and generalized anxiety disorders was performed to characterize different profiles of current trauma-related psychological symptoms. Different profiles were compared with respect to sociodemographic, clinical, and psychosocial characteristics. A three-group cluster analysis revealed a Control group with low lifetime trauma exposure and low current psychological distress (59.5%), a Resilient group with high lifetime trauma and low current distress (27.4%), and a Distressed group with both high trauma exposure and current distress symptoms (13.1%). These results suggest that the majority of trauma-exposed veterans (67.7%) are psychologically resilient. Compared with the Distressed group, the Resilient group was younger, more likely to be Caucasian, and scored lower on measures of physical health difficulties, past psychiatric history, and substance abuse. Higher levels of emotional stability, extraversion, dispositional gratitude, purpose in life, and altruism, and lower levels of openness to experiences predicted resilient status. Prevention and treatment efforts designed to enhance modifiable factors such as gratitude, sense of purpose, and altruism may help promote resilience in highly trauma-exposed veterans.

Purpose in Life is Associated with a Reduced Risk of Incident Physical Disability in Aging U.S. Military Veterans.

OBJECTIVES: The current study evaluated the incidence and determinants of physical disability in a contemporary, nationally representative sample of U.S. military veterans. DESIGN, SETTING, PARTICIPANTS: Data were analyzed from the National Health and Resilience in Veterans Study, a nationally representative, prospective cohort study of 1,686 veterans aged 55 years and older. Waves 1 and 2 were conducted in 2011 and 2013, respectively. MEASUREMENTS: Potential determinants of incident disability in activities of daily living (ADL; e.g., bathing, dressing) and instrumental activities of daily living (IADL; e.g., food preparation, medication adherence) were assessed at Wave 1, and included sociodemographic characteristics, and risk (e.g., medical conditions, psychiatric distress), and protective psychosocial (e.g., psychological resilience, purpose in life) factors. RESULTS: The two-year incidence of any physical disability (ADL or IADL) among veterans aged 55 years and older was 11.5%, and the incidence of ADL and IADL disability was 3.0% and 11.4%, respectively. Older age, being married/cohabiting, and number of medical conditions-specifically, diabetes, heart attack, and chronic pain-were associated with an increased risk of any incident physical disability and incident IADL disability (adjusted odds ratio [AOR] range: 1.10-3.10). Retirement was associated with an increased risk of incident ADL disability (AOR: 7.53, 95% CI: 1.37-41.51). Purpose in life was found to be protective for incident IADL disability (AOR: 0.93, 95% CI: 0.87-0.99). CONCLUSIONS: Although greater medical burden is associated with increased incidence of physical disability in U.S. veterans, results of this study suggest that initiatives designed to foster greater purpose in life may help protect against the development of physical disability in this rapidly growing segment of the population.

Late-life exacerbation of PTSD symptoms in US veterans: results from the National Health and Resilience in Veterans Study.

OBJECTIVE: More than 60% of US military veterans are 55 years or older. Although several case studies have suggested that older age is associated with a higher likelihood of reactivated or delayed-onset posttraumatic stress disorder (PTSD) symptoms in veterans, population-based data on the prevalence and determinants of this phenomenon are lacking. METHOD: Using data from the National Health and Resilience in Veterans Study (NHRVS: Wave 1 = October 2011-December 2011; Wave 2 = September 2013), a nationally representative, cohort study of US veterans, we evaluated the prevalence and determinants of exacerbated PTSD symptoms in 1,441 veterans 55 years or older using a DSM-IV-based measure in 2011 and a DSM-5-based measure in 2013. Veterans whose worst trauma occurred at least 5 years prior to Wave 2 of the NHRVS (mean = 28.6 years) and who reported a clinically significant increase (ie, ≥ 0.5 standard deviation [SD]; mean = 1.27, SD = 0.78) in PTSD symptoms from Wave 1 (lifetime) to Wave 2 (past-month) were identified as having exacerbated PTSD symptoms. RESULTS: Results revealed that 9.9% of older US veterans experienced exacerbated PTSD symptoms an average of nearly 3 decades after their worst trauma. A multivariable logistic regression model indicated that greater self-reported cognitive difficulties at Wave 1 independently predicted exacerbated PTSD symptoms at Wave 2. Post hoc analysis revealed that this association was driven by greater severity of executive dysfunction (adjusted odds ratio range, 1.27-3.22). CONCLUSIONS: Approximately 1 in 10 older US veterans experiences a clinically significant exacerbation of PTSD symptoms in late life. Executive dysfunction may contribute to risk for exacerbated PTSD symptoms. These results suggest that exacerbated PTSD symptoms are prevalent in US veterans and highlight potential targets for identifying veterans at risk for this phenomenon.

Comparing three methods of computerised cognitive training for older adults with subclinical cognitive decline.

Cognitive rehabilitation for mild cognitive impairment (MCI) and early Alzheimer's disease is readily available to the geriatric population. Initial evidence suggests that techniques incorporating motivational strategies to enhance treatment engagement may provide more benefit than computerised training alone. Seventy four adults with subclinical cognitive decline were randomly assigned to computerised cognitive training (CCT), Cognitive Vitality Training (CVT), or an Active Control Group (ACG), and underwent neuropsychological evaluations at baseline and four-month follow-up. Significant differences were found in changes in performance on the Modified Mini Mental State Examination (mMMSE) and measures of verbal learning and memory across treatment groups. Experimental groups showed greater preservation of functioning on the mMMSE than the ACG group, the CVT group performed better than the ACG group on one measure of verbal learning and both measures of verbal memory, and the CCT group performed better than the ACG group on one measure of verbal learning and one measure of verbal memory. There were no significant group differences between the CVT and CCT groups on measures of verbal learning or memory. It was concluded that computerised cognitive training may offer the most benefit when incorporated into a therapeutic milieu rather than administered alone, although both appear superior to more generic forms of cognitive stimulation.

Subsyndromal depression among older adults in the USA: prevalence, comorbidity, and risk for new-onset psychiatric disorders in late life.

BACKGROUND: Population-based data are lacking on the prevalence and comorbidity of subsyndromal depression (SSD) and its associated risk for incident psychiatric disorders in older adults. METHODS: Using nationally representative data from 10,409 US adults aged 55 years and older who participated in the National Epidemiologic Survey on Alcohol and Related Conditions, we evaluated associations between lifetime SSD at Wave 1, and lifetime and incident mood, anxiety, and substance use disorders over a 3-year period. RESULTS: Some 13.8% of older adults met criteria for SSD, and 13.7% met criteria for major depressive disorder (MDD). After adjustment for sociodemographic characteristics, older adults with SSD at Wave 1 had significantly increased odds of lifetime mood (adjusted odds ratios (AORs) = 3.65-10.55), anxiety (AORs = 1.61-2.50), and any personality (AOR = 1.62) disorders. After adjustment for sociodemographic characteristics and comorbid psychiatric disorders, older adults with SSD at Wave 1 had significantly increased odds of developing new-onset MDD (AOR = 1.44, 95% confidence interval (CI) = 1.01-2.05), as well as an anxiety disorder (AOR = 1.52, 95% CI = 1.04-2.20) at Wave 2. CONCLUSION: In addition to the 13.7% of US older adults with lifetime MDD, an additional 13.8% have lifetime SSD, which is not a formally recognized diagnosis. In addition to its high prevalence, SSD is associated with elevated rates of comorbid mood, anxiety, and personality disorders, as well as the development of a new-onset MDD and anxiety disorder. These results underscore the importance of dimensional approaches to assessing depressive symptoms in older persons, as diagnostic approaches that rely on rigorous categorical classifications may fail to identify a substantial proportion of at-risk individuals.

Increased risk among older veterans of prescribing psychotropic medication in the absence of psychiatric diagnoses.

OBJECTIVE: This study uses Veterans Health Administration (VHA) pharmacy and encounter claims to evaluate the use of psychotropic medications without a psychiatric diagnosis across age groups. METHODS: National VHA administrative data for fiscal year 2010 (FY2010) were used to identify all veterans who filled a prescription for at least one psychotropic medication from VHA (N = 1.85 million). Bivariate and multivariate analyses were used to compare the proportion of these veterans without any psychiatric diagnosis, across age groups, adjusting for possible medical indications. Analyses were repeated for six different classes of psychotropic medications and comparing mental health utilizers and non-mental health utilizers. Comparisons were made to prescribing of HIV and diabetes medications without an indicated diagnosis. RESULTS: Of all VHA patients prescribed a psychotropic medication in FY2010, 30% had no psychiatric diagnosis, with highest proportions among veterans ages 65-85. This practice was most frequent among nonmental health utilizers and far more prevalent for psychotropic medications than for HIV or diabetes medications. Logistic regression analysis found that age greater than 65 was the strongest predictor of being prescribed a psychotropic without a psychiatric diagnosis. Adjustment for possible medical use of psychotropics and overall medical comorbidity did not substantially alter these trends. CONCLUSION: Older veterans, especially those not using specialty mental healthcare, are more likely to be prescribed psychotropic medications in the absence of a psychiatric diagnosis, perhaps representing unnecessary use, under-diagnosis of mental illness, or incomplete documentation.

Successful aging among older veterans in the United States.

OBJECTIVE: To develop a unidimensional latent model of successful aging and to evaluate sociodemographic, medical, psychiatric, and psychosocial correlates of this construct in a nationally representative sample of older veterans in the United States. METHODS: Data were analyzed from a cross-sectional web survey of 2,025 U.S. veterans aged 60 to 96 years who participated in the National Health and Resilience in Veterans Study. Self-report measures of sociodemographics; subjective physical, mental, and cognitive functioning; and psychosocial characteristics were used. Confirmatory factor analysis was used to construct a unidimensional latent factor of successful aging. Correlates of scores on this factor were then evaluated. RESULTS: Most older veterans (82.1%) rated themselves as aging successfully. A unidimensional latent factor composed of seven measures of self-rated successful aging, quality of life, and physical, mental, cognitive, and social functioning provided a good fit to the data. Physical health difficulties (ß = -0.39) and current psychological distress (ß = -0.33) were most strongly negatively related to scores on this latent factor of successful aging, while protective psychosocial characteristics (ß = 0.22), most notably resilience, gratitude, and purpose in life, were most strongly positively related to these scores. Additional positive predictors of successful aging included White, non-Hispanic race, being married or living with partner, perceiving a positive effect of the military on one's life, active lifestyle, positive expectations regarding aging, and conscientiousness; additional negative predictors included substance abuse history. CONCLUSION: Results of this study provide a dimensional approach to characterizing components and correlates of successful aging in older veterans. Interventions and policy initiatives designed to mitigate physical health difficulties and psychological distress and to enhance protective psychosocial characteristics such as resilience, gratitude, and purpose in life may help promote successful aging in this population.

Programs for developing the pipeline of early-career geriatric mental health researchers: outcomes and implications for other fields.

This report summarizes the findings and recommendations of an expert consensus workgroup that addressed the endangered pipeline of geriatric mental health (GMH) researchers. The workgroup was convened at the Summit on Challenges in Recruitment, Retention, and Career Development in Geriatric Mental Health Research in late 2007. Major identified challenges included attracting and developing early-career investigators into the field of GMH research; a shortfall of geriatric clinical providers and researchers; a disproportionate lack of minority researchers; inadequate mentoring and career development resources; and the loss of promising researchers during the vulnerable period of transition from research training to independent research funding. The field of GMH research has been at the forefront of developing successful programs that address these issues while spanning the spectrum of research career development. These programs serve as a model for other fields and disciplines. Core elements of these multicomponent programs include summer internships to foster early interest in GMH research (Summer Training on Aging Research Topics-Mental Health Program), research sponsorships aimed at recruitment into the field of geriatric psychiatry (Stepping Stones), research training institutes for early career development (Summer Research Institute in Geriatric Psychiatry), mentored intensive programs on developing and obtaining a first research grant (Advanced Research Institute in Geriatric Psychiatry), targeted development of minority researchers (Institute for Research Minority Training on Mental Health and Aging), and a Web-based clearinghouse of mentoring seminars and resources (MedEdMentoring.org). This report discusses implications of and principles for disseminating these programs, including examples of replications in fields besides GMH research.

AAGP position statement: disaster preparedness for older Americans: critical issues for the preservation of mental health.

The Disaster Preparedness Task Force of the American Association for Geriatric Psychiatry was formed after Hurricane Katrina devastated New Orleans to identify and address needs of the elderly after the disaster that led to excess health disability and markedly increased rates of hopelessness, suicidality, serious mental illness (reported to exceed 60% from baseline levels), and cognitive impairment. Substance Abuse and Mental Health Services Administration (SAMHSA) outlines risk groups which fail to address later effects from chronic stress and loss and disruption of social support networks. Range of interventions recommended for Preparation, Early Response, and Late Response reviewed in the report were not applied to elderly for a variety of reasons. It was evident that addressing the needs of elderly will not be made without a stronger mandate to do so from major governmental agencies (Federal Emergency Management Agency [FEMA] and SAMHSA). The recommendation to designate frail elderly and dementia patients as a particularly high-risk group and a list of specific recommendations for research and service and clinical reference list are provided.

Increased cerebrospinal fluid corticotropin-releasing factor concentrations during tryptophan depletion in healthy adults.

BACKGROUND: Brain serotonin neurotransmission and hypothalamic-pituitary-adrenal axis function are implicated in the pathophysiology of depression, and these systems interact in a reciprocal modulatory fashion. This study examined the effect of tryptophan depletion, which acutely reduces brain serotonin concentrations, on serial cerebrospinal fluid concentrations of corticotropin-releasing factor in healthy humans. METHODS: Five subjects completed a standard tryptophan depletion protocol, and four subjects participated in a comparison condition. Subjects underwent continuous sampling of cerebrospinal fluid via lumbar peristaltic pump. Concentrations of cerebrospinal fluid corticotropin-releasing factor were measured by radioimmunoassay. RESULTS: No mood changes were observed in either group. Tryptophan-depleted subjects exhibited significantly greater increases in corticotropin-releasing factor concentrations over time than subjects in the comparison condition. CONCLUSIONS: These findings highlight the potential importance of corticotropin-releasing factor and serotonin interactions and suggest that activation of corticotropin-releasing-factor-containing neurons could play a role in the emergence of mood symptoms following tryptophan depletion in vulnerable individuals.