Mohammed T. Abou-Saleh

706 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYhealthcare services, especially for inpatient care 15,16 . In a climateof fiscal restrictions, such information lends needed support to thevalue of adequate mental health care.patients at remote locations, usually with the nurse in attendanceon the patient. Research to date suggests that this can be aneffective and economically viable medium 24 .CLINICIANS AS GERIATRIC SPECIALISTSThe tremendous need for expertise in caring for geriatric patientshas been part of the impetus for the evolution of geriatricpsychiatry into fully-fledged subspecialty status. The AmericanAssociation of Geriatric Psychiatry was founded in 1978.Recognition as a subspecialty came with the administration ofthe first examination for added qualifications in GeriatricPsychiatry in April 1991 by the American Board of Psychiatryand Neurology. By 1999, 2360 psychiatrists had passed theexamination and there were 39 ACGME-accredited geriatricpsychiatry fellowship programs nationwide.Becoming a geriatric specialist in psychiatry involves assuminga unique constellation of familiar roles, rather than somedistinctive singular role. Diversity is the hallmark of the teammembership roles geriatric psychiatrists are called upon toassume. Examples of that diversity include coordinating clinicalcare, taking part in community initiatives and participating atvarious levels in educational activities.CLINICAL ROLESClinical care has evolved to a model that is much morecomprehensive than before, with an emphasis on multidisciplinaryassessment. One successful model for a geriatric assessment clinicoriginating in Seattle 17 included a psychiatrist, an internist and asocial worker. The assessment took three to four clinic visits, onefor each of the following: (a) a psychiatric evaluation; (b) a medicalevaluation; (c) a home visit; and (d) a family conference at theconclusion of the evaluation, for discussion of results andrecommendations. When the patient suffered from cognitiveimpairment, the model often included neuropsychiatric assessment.The Seattle clinic demonstrates the emergence of a commontheme that has become the standard for comprehensive geriatricassessment: a focus on the patient’s psychosocial context. Familiesof geriatric patients have attracted much interest since theemergence of the subspecialty of geriatric psychiatry, because ofthe critical role they play in the care of demented elderly patients.While attention to families has always been characteristic of certainareas within psychiatry, notably child psychiatry, until the notionof comprehensive geriatric assessment was developed, families ofpsychiatrically ill geriatric patients were considered ancillary, ratherthan integral to patient care. A major catalyst behind thisbroadened perspective has been a large body of research, whichdemonstrates the vital role of psychosocial issues for the health andwell-being of older adults 18,19 . In recent years, research has focusedon the mental health of caregivers and caregiver factors influencingservice utilization and institutionalization 20,21 .Other innovative programs have been described, e.g. Bienenfeldreported on a liaison service to nursing homes 22 and Reifler et al.described an outreach program for mentally impaired older adultsin Seattle 23 . However, although it is by now well established thatthere is a high prevalence of psychiatric morbidity in nursinghomes, there remains a great need for psychiatric consultation inthis setting. Legislation limits the prescription of psychotropics inUS nursing homes in order to prevent the use of ‘‘chemicalrestraint’’, and pharmacists conduct periodic reviews to ensurecompliance with these rules. One innovation that may enhancepsychiatric involvement in the care of nursing home patients isvideo teleconsultation, which enables the psychiatrist to interviewCOMMUNITY ROLESSocial service agencies, nursing homes, local Alzheimer’s Associations,home healthcare organizations, hospice care and otherorganizations that coordinate services for the elderly are eager forpsychiatric expertise. Collaboration also allows geriatric psychiatriststo become well acquainted with available resources and tolearn when to refer to such organizations. An incentive for thedevelopment of innovative community-based programs is theincreasing cost of long-term care.One example of innovative community-based care that hasbegun to involve geriatric psychiatrists is the adult day center(ADC) movement. The idea of ADCs actually evolved from themental healthcare system, where day programs had been utilizedfor some of the more seriously ill psychiatric patients who neededgreater support than could be provided by periodic outpatientclinic visits. Adaptation of that notion to the needs of geriatricpatients began to appear in the mid-1970s and early 1980s, andthe movement mushroomed from only 15 documented ADCs in1975 to over 4000 by 1998 25 .The Robert Wood Johnson foundation initiated a nationaldemonstration project (the Dementia Care and Respite ServicesProgram) in the late 1980s to promote further growth ofdementia-specific ADCs. One of the primary goals of the projectwas to determine whether centers could become financially viablethrough charging for their services. Centers had struggled withunstable financial bases, which depended on their ability to obtaingrant support or contributions or to utilize transient state andfederal funds. The 4 year program began funding for 19 modelADCs in 1988 26 . The ‘‘Partners in Caregiving’’ initiative, whichincluded the initial 19 sites and a subsequent demonstrationprogram involving 50 sites across the USA, showed that adult daycare centers could care for individuals with all degrees ofdementia, from mild to severe, while remaining financially viableby meeting over 80% of their expenses through out-of-pocketpayments and Medicaid 25 .Other community-based models involving psychiatrists havedeveloped. Robinson 27 reviewed four of them, including: (a) theChanneling Demonstration, a federally-funded initiative awardedto 12 states, designed to serve severely impaired elderly people atrisk of being institutionalized and to test two types of casemanagement; (b) the Social/Health Maintenance Organization (S/HMO), a concept developed by Brandeis University, which is amanaged care system of health and long-term care; (c) the On LokSenior Services Program, a consolidated group of medical andsupport services based in San Francisco; and (d) Life CareCommunities, which include some 600 continuing care communitiesnationwide, as well as the case-management delivery systemcalled ‘‘Life Care at Home’’. The Channeling Demonstration,while it did not save money, did improve quality of life for clientsand caregivers. The S/HMO model achieved its goal of integratingthe funding and social services of long-term care, but did notsucceed in integrating medical and social services or utilizinggeriatric specialists 28 . An updated series of HMOs (‘‘S/HMO II’’)has begun, which have pledged to incorporate professionals withexpertise in geriatrics into the range of services provided. The OnLok model, now known as the Program of All-inclusive Care forthe Elderly (PACE), has been replicated in dozens of cities aroundthe USA, with almost 3000 enrollees nationwide. Participantsaverage 80 years of age, and have seven or eight medicalconditions. All of their health care is provided by a PACEinterdisciplinary team. Outcome studies are under way. So far, the