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The population of older adults with mental health and substance use disorders in the United States is increasing at a significant rate. This growth creates a critical need for trained geriatric psychiatrists. Unfortunately, the number of psychiatrists choosing to receive subspecialty training in geriatric psychiatry has not kept pace with the growing needs of society. Many different methods for enhancing the recruitment of physicians interested in subspecialty training are being discussed nationally. One way to improve recruitment is to provide prospective residents a clear understanding of the process by which one may apply to and select a fellowship program. In this article, we discuss the process by which physicians interested in pursuing fellowship training in geriatric psychiatry can make an informed decision to apply to and choose programs that best fit their needs.

In this chapter, we review pertinent indications and contraindications for commonly used structural and functional imaging techniques in geriatric psychiatry.

In this chapter, we review the topic of psychiatric interviewing with a focus on pertinent adaptations for the older adult.

In this chapter, we review pertinent aspects of the mental status examination as part of the psychiatric interview of older adults.

Highlights • What is the primary question addressed by this study? This study analyzes survey data from Scholars Program participants (2010-2018) to identify demographic characteristics, attitudes toward components of the Scholars Program, and behaviors after the program that were independently associated with the decision to pursue fellowship training in geriatric psychiatry. • What is the main finding of the study? Rating the AAGP Scholars Program as important for meeting potential collaborators, maintaining AAGP membership and attending a subsequent AAGP annual meeting were all associated with the decision to pursue fellowship in our final model. • What is the meaning of the finding? The AAGP Scholars Program plays a role in recruiting trainees into the field of geriatric psychiatry., 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.

Behavioral and psychological symptoms of dementia (BPSD) are common among patients with dementia. BPSD have significant implications on outcomes for patients and caregivers. Available literature for pharmacological approaches to BPSD is sparse and at times inconsistent. There are no FDA-approved medications for the management of BPSD, and the use of available medications is associated with significant adverse effects among aged populations with dementia. This review outlines the assessment of BPSD, discusses general principles of management, and examines current evidence for non-pharmacologic and pharmacologic treatment strategies as well as associated risks.

Brain-derived neurotrophic factor (BDNF) is a neurotrophin that promotes neuronal survival, growth, and differentiation. The role of BDNF in learning and memory suggests that it may also modulate the clinical course of Alzheimer's disease (AD). This study aimed to determine whether BDNF genetic variants are related to premorbid educational attainment, progression of cognitive and functional decline, and associated neuropsychiatric symptoms in AD patients. A sample of AD subjects (N = 341) was genotyped for the BDNF polymorphisms: Val66Met, C270T, and G-712A. Subjects received tests of cognition and daily function at baseline and at multiple subsequent time points. They were also characterized for the frequency and severity of neuropsychiatric symptoms. There was a significant effect of Val66Met genotype on educational attainment (F = 7.49, df = 2,329, P = 0.00066), with Met/Met homozygotes having significantly lower education than both the Val/Met and Val/Val groups. No association was observed between any BDNF polymorphism and measures of cognitive or functional decline. The T-allele of the C270T polymorphism was associated with a higher prevalence of neuropsychiatric symptoms and specifically with the presence of hallucinations. The effect of the Val66Met polymorphism on premorbid educational attainment is intriguing and should be verified in a larger sample.

Recent data points to glutamatergic dysfunction in mood disorders, anxiety disorders, obsessive-compulsive disorder, and schizophrenia. Memantine, a drug approved by the FDA for the treatment of moderate to severe Alzheimer's disease that acts at the N-methyl-d-aspartate receptor, has been used off-label for various psychiatric disorders. Although promising, the available data for the use of memantine in these disorders is limited. Given this data, the routine use of memantine for depression, schizophrenia, obsessive-compulsive disorder, substance abuse, pervasive developmental disorders, bipolar disorder, and binge eating disorder cannot be recommended at this time.

Sleep disturbances are a common presenting symptom of older-age adults to their physicians. This article explores normal changes in sleep pattern with aging and primary sleep disorders in the elderly. Behavioral factors and primary psychiatric disorders affecting sleep in this population are reviewed. Further discussion examines sleep changes associated with 2 common forms of neurocognitive disorder: Alzheimer disease and Lewy Body Dementia. Common medical illnesses in the elderly are discussed in relation to sleep symptoms. Nonpharmacological and pharmacologic treatment strategies are summarized, with emphasis placed on risk of side effects in older adults. Future targets are considered.

The apolipoprotein E (ApoE) epsilon4 allele is a well-documented genetic risk factor for sporadic Alzheimer's disease (AD). Its association with psychopathology among AD patients has been the subject of discrepant reports. We aimed to determine whether ApoE epsilon4+ and epsilon4- AD patients exhibit a different risk profile for psychotic symptoms and other behavioral disturbances. The Neuropsychiatric Inventory (NPI) was administered to determine the frequency and severity of psychotic and other behavioral symptoms in a sample of n=266 AD patients who had been genotyped for ApoE. Multiple logistic regression models were used to calculate the association between the ApoE epsilon4 allele and the presence of psychotic symptoms (delusions or hallucinations). Exploratory analyses were also conducted to determine the impact of disease severity on epsilon4 effects and to examine the association between epsilon4 and other behavioral symptoms. ApoE epsilon4 was significantly associated with psychotic symptoms (odds ratio (OR)=1.87, 95% CI=1.07-3.29, P=0.029), adjusting for age, sex, education, and MMSE score. More stringent definitions of clinically significant psychosis yielded similar results. Exploratory analyses suggested that this effect accrued specifically from patients with severe-stage AD and primarily from an association between epsilon4 and delusions. The epsilon4 allele did not appear to influence the development of most other behavioral symptoms in our sample. In conclusion, AD patients who carry the ApoE epsilon4 allele are at greater risk than noncarriers for developing psychotic symptoms, particularly as the severity of their dementia progresses.

Objective: The apolipoprotein E (ApoE) Ε4 allele is a well-documented genetic risk factor for Alzheimer’s disease (AD). Its role, if any, in the progression of cognitive and functional impairment in AD has been the subject of discrepant reports in the literature. This study aimed to determine whether ApoE Ε4 dose is related to the progression of cognitive and functional decline in AD patients by combined retrospective and prospective analyses. Methods: A sample of 366 AD patients was genotyped for ApoE. Subjects received tests of cognition (Mini-Mental State Examination, MMSE; Alzheimer’s Disease Assessment Scale-Cognitive subscale, ADAS-Cog) and daily function (Instrumental Activities of Daily Living, IADL; Alzheimer’s Disease Cooperative Study-Activities of Daily Living, ADCS-ADL) at baseline and at multiple subsequent time points during their participation in a variety of research protocols. In retrospective analyses, scores on baseline cognitive and functional measures were compared cross-sectionally among genotype groups, controlling for duration of symptoms. In prospective analyses, longitudinal rates of change for each measure were computed by linear regression and compared across genotype groups. Results: No association was observed between ApoE Ε4 dose and any of the retrospective or prospective measures of cognitive or functional decline in this AD patient sample. Conclusions: Although ApoE Ε4 increases the risk for AD and decreases the age of disease onset in population studies, it did not significantly influence the rate of disease progression in cognitive or functional domains in our sample.

Dire shortages of psychiatrists with special expertise in geriatrics, substance abuse, forensics, and psychosomatics create barriers to care for populations with complex mental disorders and pose a significant public health concern. To address these disparities in access to care, we propose streamlining graduate medical education to increase efficiency and enhance cost-effectiveness while simultaneously increasing the number of psychiatric subspecialists in these key areas. We propose that trainees interested in subspecialties complete their general training in 3 years, while meeting ACGME required milestones, and then utilize their 4th year to complete subspecialty fellowship training. Eligible trainees would then qualify for psychiatry subspecialty certification and general psychiatry ABPN certification at the end of 4 years.