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Objectives of Training in the Subspecialty of Geriatric Psychiatry

2011

EDITORIAL REVISION 2016
VERSION 1.1

This document applies to those who begin training on or after July 1^st, 2010.

NOTE: Throughout this document, references to the patient’s family are intended to include all those who are personally significant to the patient and are concerned with his or her care, including, according to the patient’s circumstances, family members, partners, caregivers, legal guardians, and substitute decision-makers.

DEFINITION

Geriatric Psychiatry, a psychiatric subspecialty, focuses on the assessment, diagnosis, and treatment of complex mental disorders uniquely occurring later in life. Geriatric Psychiatry is focused on providing care for intensive-needs patients and their families at the end of the life cycle, a time when many complex physical and mental health issues coalesce. Geriatric Psychiatry organizes service delivery of psychiatric care to the elderly in multidisciplinary teams and in locations that best serve the needs of this elderly population. Geriatric Psychiatry is engaged in advocacy and development of health policy and planning related to late-life mental illness and mental health, caregiver and care provider support, and systems of care.

GOALS

Upon completion of training, a resident is expected to be a competent subspecialist in Geriatric Psychiatry, capable of assuming a consultant’s role in the subspecialty. The resident must acquire a working knowledge of the theoretical basis of the subspecialty, including its foundations in science and research, as it applies to medical practice.

Only candidates certified by the Royal College of Physicians and Surgeons of Canada in Psychiatry may be eligible for certification in Geriatric Psychiatry. Residents must demonstrate the requisite knowledge, skills, and behaviours for effective patient-centred care and service to a diverse elderly population. In all aspects of specialist practice, the graduate must be able to address ethical issues and issues of gender, religion, sexual orientation, age, culture, beliefs, and ethnicity in a professional manner.

GERIATRIC PSYCHIATRY COMPETENCIES

At the completion of training, the resident will have acquired the following competencies and will function effectively as a:

Medical Expert

Definition:

As Medical Experts, Geriatric Psychiatrists integrate all of the CanMEDS Roles, applying medical knowledge, clinical skills, and professional attitudes in their provision of patient and caregiver-centred care. Medical Expert is the central physician Role in the CanMEDS Framework.

All competencies are expected at the advanced level, unless otherwise specified.

Key and Enabling Competencies: Geriatric Psychiatrists are able to…

1. Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal, ethical, and patient-centred medical care
   1. Perform a consultation, including the presentation of well-documented assessments and recommendations in oral, written and/or electronic form in response to a request from another health care professional
   2. Demonstrate use of all CanMEDS competencies relevant to Geriatric Psychiatry
   3. Identify and appropriately respond to relevant clinical issues arising in care of elderly patients, including:
      1. Awareness of their own reactions when dealing with elderly patients
      2. Boundary issues
      3. Comorbidity
      4. Confidentiality
      5. Cultural issues relevant to elderly patients
      6. Emergency situations
      7. Factors influencing elderly patients’ reactions to the psychiatrist and other health professionals
      8. Family issues involving elderly patients
      9. Knowledge of the clinical, socio-behavioural, and fundamental biomedical sciences relevant to Geriatric Psychiatry
      10. Long-term illness and rehabilitation
      11. Medico-legal and forensic issues pertaining to the elderly
      12. Stigma associated with aging and with mental illness
      13. Suicide, self-harm, and/or harm directed towards others
      14. Therapeutic alliance
      15. Trauma
   4. Demonstrate the ability to prioritize professional duties when faced with multiple complex patients and problems
   5. Demonstrate compassionate and patient-centred care for elderly patients
   6. Recognize and respond to the ethical dimensions in medical decision-making
2. Establish and maintain clinical knowledge, skills, and behaviours at a proficient or advanced level, appropriate to Geriatric Psychiatry
   1. Demonstrate knowledge, at the advanced level, of the following:
      1. Normal and abnormal biological, psychological, and cognitive aspects of aging
      2. Systems of mental health care and delivery, community resources, institutions, services, and alternative living environments available for the elderly
      3. Psychotherapeutic constructs—individual, family, and group
      4. Psychopharmacology and somatic therapies appropriate and inappropriate as treatments in elderly patients
      5. Mental health legislation and regulations as they pertain to elderly patients, including provincial variation in these regulations across the country
      6. Principles of decisional capacity/competency determination in multiple domains, including the elderly person’s ability to manage property, grant a power of attorney, consent to placement in a supervised living setting, and consent to medical treatment
      7. Caregiver issues/burden
      8. Elder abuse
      9. End-of-life issues
      10. Use of restraints
   2. Demonstrate knowledge, at the advanced level, of the etiology, symptoms, course of illness, and treatment of the following:
      1. Anxiety disorders, obsessive-compulsive and related disorders, and trauma- and stressor-related disorders, in late life
      2. Behavioural disturbances in neurocognitive disorders, also known as behavioural and psychological symptoms of dementia (BPSD) or neuropsychiatric symptoms
      3. Major and mild neurocognitive disorders (dementias), including but not limited to those due to Alzheimer's disease, vascular disease, Lewy body disease, frontotemporal lobar degeneration, and multiple etiologies
      4. Delirium
      5. Bipolar disorders and depressive disorders (i.e., mood disorders) in late life
      6. Movement disorders, both resulting from degenerative brain conditions and secondary to pharmacotherapy side effects
      7. Psychiatric disorders secondary to medical conditions
      8. Psychiatric complications of medical illnesses, including neurodegenerative diseases such as Parkinson disease
      9. Schizophrenia, delusional disorder, and other psychotic disorders, both late onset and early onset, in patients who have aged
      10. Grieving process—normal or abnormal
   3. Demonstrate knowledge, at the proficient level, of the etiology, symptoms, course of illness, and treatment of the following:
      1. Adjustment disorders in late life
      2. Alcohol and other substance use disorders in late life
      3. Neurodevelopmental disorders, including intellectual disabilities in older patients
      4. Personality disorders, continuing into late life
      5. Sleep-wake disorders in late life
      6. Somatic symptom and related disorders in late life
3. Perform a complete and appropriate assessment of a patient
   1. Identify and effectively explore issues to be addressed in a patient encounter, including the elderly patient’s context and preferences
   2. Elicit a history that is relevant, concise, and accurate to context and preferences, for the purposes of diagnosis, management, health promotion, and disease prevention
      1. Elicit a history in an elderly patient who may have sensory deficits and/or functional/cognitive impairment
   3. Perform an appropriate and accurate mental status examination, including a cognitive assessment, for the purposes of diagnosis, management, health promotion, and disease prevention
   4. Perform a focused physical and neurological examination that is relevant and accurate, including an assessment for the presence of movement disorders in the elderly patient, for the purposes of diagnosis, management, health promotion, and disease prevention
   5. Perform an appropriate exploration of the family and caregiver issues and factors affecting the patient’s life
   6. Adapt the assessment, as required, to the setting in which it might take place, such as an inpatient unit, outpatient clinic, day treatment program, assisted living setting where assistance is provided, or the elderly patient’s independent residence
   7. Select medically appropriate investigative methods in a resource-effective and ethical manner, including:
      1. Medical investigation or consultation in elderly psychiatric patients with comorbid medical conditions
      2. Collateral information gathering from multiple sources, in situations where the elderly patients themselves may not be reliable sources of information
      3. Neuropsychological investigations
      4. Structured cognitive assessment tools, as required for complete assessment of the elderly patient
      5. Neuroimaging
   8. Demonstrate effective clinical problem solving and judgment to address patient problems, including interpreting available data and integrating information to generate differential diagnoses and management plans
   9. Demonstrate an appropriate and effective assessment of decisional capacity in the elderly patient in the possible specific domains of consent to medical treatment, manage property, designate a Power of Attorney, and/or consent to placement in a supervised living environment, when so requested
4. Use preventive and therapeutic interventions effectively
   1. Implement a management plan in collaboration with a patient and the patient’s family, including:
      1. Interpret results of appropriate laboratory investigations and radiological examinations as they relate to the elderly patient with psychiatric disorders and comorbid medical conditions
      2. Assess suitability for and prescribe appropriate psychopharmacological treatments in the acute and maintenance management of psychiatric disorders in elderly patients
      3. Assess suitability for, prescribe, and deliver somatic treatments such as electroconvulsive therapy (ECT) in elderly patients
      4. Assess suitability for appropriate psychological treatment in elderly patients, including:
         1. Supportive therapy
         2. Psychodynamic therapy
         3. Family therapy
         4. Cognitive behavioural therapy
         5. Crisis intervention
      5. Assess and manage treatment-emergent side effects of psychopharmacological, somatic, and psychological therapies in elderly patients
      6. Assess and manage treatment adherence
      7. Ensure elderly patients receive appropriate end-of-life care
   2. Demonstrate appropriate and timely application of preventive interventions relevant to Geriatric Psychiatry
   3. Demonstrate appropriate and timely application of therapeutic interventions relevant to Geriatric Psychiatry
   4. Obtain appropriate informed consent for therapies, from the capable elderly patient or substitute decision-maker
   5. Document and disseminate information related to interventions performed and their outcomes
   6. Ensure adequate followup is arranged, and that elderly patients and their families are informed of the plan
5. Seek appropriate consultation from other health professionals, recognizing the limits of their own expertise
   1. Demonstrate insight into their own limits of expertise
   2. Demonstrate effective, appropriate, and timely consultation of other health professionals as needed for optimal care of elderly patients with mental illness
   3. Discriminate clinical cases along the simple—complicated—complex continuum of Geriatric Psychiatry care, and appropriately identify those complex situations for which subspecialized care is most appropriate
   4. Arrange appropriate followup care services for elderly patients and their families

Communicator

Definition:

As Communicators, Geriatric Psychiatrists effectively facilitate the doctor-patient relationship and the dynamic exchanges that occur before, during, and after the medical encounter.

Key and Enabling Competencies: At a proficient level, Geriatric Psychiatrists are able to…

1. Develop rapport, trust, and ethical therapeutic relationships with elderly patients and their families
   1. Recognize that being a good communicator is a core clinical skill for physicians, and that effective physician–patient communication can foster patient and family satisfaction, physician satisfaction, adherence, and improved clinical outcomes for elderly patients
   2. Establish positive therapeutic relationships with patients and their families that are characterized by understanding, trust, respect, honesty, and empathy
   3. Respect patients’ privacy, confidentiality, and autonomy
   4. Listen effectively to patients and, when appropriate, to the substitute decision-maker
   5. Be aware of and responsive to nonverbal cues in patients
   6. Recognize transference and countertransference towards the aged and the aging process
   7. Facilitate a structured clinical encounter effectively in various settings where elderly patients are usually assessed, including community settings and long-term care homes
      1. Use telepsychiatry, as appropriate
2. Accurately elicit and synthesize relevant information and perspectives of elderly patients and their families, colleagues, and other professionals
   1. Gather information about a disease and about a patient’s beliefs, concerns, expectations, and illness experience
   2. Seek out and synthesize relevant information from other sources, such as a patient’s family, caregivers, and other professionals, while demonstrating an understanding of the potential limitations of accuracy of that information and respecting individual privacy and confidentiality
3. Convey relevant information and explanations accurately to elderly patients and their families, colleagues, and other professionals
   1. Deliver information to a patient and the patient’s family, colleagues, and other professionals in a humane manner and in such a way that it is understandable and encourages discussion and participation in decision-making
   2. Respect patient privacy, demonstrating knowledge of provincial legislation governing confidentiality of patient information, and judge the appropriate extent of information sharing when multiple agencies are involved
   3. Adapt communication, as required, for both direct and indirect care, across the varied settings where Geriatric Psychiatry care is provided
4. Develop a common understanding on issues, problems, and plans with patients, families, and other professionals to develop a shared plan of care
   1. Identify and effectively explore problems to be addressed from a patient encounter, including the patient’s context, responses, concerns, and preferences
   2. Respect diversity and differences, including but not limited to the impact of gender, religion, sexual orientation, and cultural beliefs on decision-making
   3. Encourage discussion, questions, and interaction with both the patient and the patient’s family during the encounter
   4. Engage patients, their families, and relevant health professionals in shared decision-making to develop a plan of care
   5. Address challenging communication issues effectively, including but not limited to obtaining informed consent, delivering bad news, and addressing anger, confusion, misunderstanding, sensory impairment, educational limitations, cognitive impairment, and frailty
5. Convey oral, written, and/or electronic information effectively about a medical encounter
   1. Maintain clear, concise, accurate, and appropriate records of clinical encounters and plans
   2. Produce a clear, concise, and timely consultation report
   3. Present oral reports of clinical encounters and plans
   4. Convey medical information appropriately to ensure safe transfer of care

Collaborator

Definition:

As Collaborators, Geriatric Psychiatrists work effectively within a health care team to achieve optimal patient care.

Key and Enabling Competencies: At a proficient level, Geriatric Psychiatrists are able to…

1. Participate effectively and appropriately in an interprofessional circle of care
   1. Describe the Geriatric Psychiatrist’s roles and responsibilities to other professionals
   2. Describe the roles and responsibilities of other professionals within the geriatric mental health care team, across various typical geriatric psychiatry settings
   3. Recognize the roles of family members and caregivers of elderly patients as important members of the health care team
   4. Work with others to assess, plan, provide, and integrate care for individual elderly patients or groups of patients
   5. Work collaboratively in other activities and tasks; examples are research, educational work, program review, system delivery issues, and/or administrative responsibilities
   6. Enter into interdependent relationships with other professions for the provision of quality care, which may include working with primary care providers in a shared care model, with community agency professionals, other community resource personnel, and/or other medical specialties as part of the extended health care team
      1. Act as an expert resource on issues such as ethics, privacy/confidentiality, safety, mental health legislation, resource allocation, system delivery, and professionalism
   7. Demonstrate an appreciation of the contributions of local community resources, such as day and other respite programs, Meals on Wheels, seniors’ centres, home care agencies, driving assessment facilities, and others, as integral components of the spectrum of services available to elderly persons and their families
   8. Demonstrate leadership in a geriatric mental health care team, as appropriate
2. Work with other health professionals effectively to prevent, negotiate, and resolve interprofessional conflict
   1. Demonstrate a respectful attitude towards other colleagues and members of an interprofessional team
   2. Participate in interprofessional team interactions, demonstrating awareness of the principles of team dynamics
   3. Work collaboratively with other professionals to prevent and resolve conflicts and address misunderstandings
   4. Respect differences and the scopes of practice of other professions
   5. Reflect on their own differences, misunderstandings, and limitations that may contribute to interprofessional tension

Manager

Definition:

As Managers, Geriatric Psychiatrists are integral participants in health care organizations, organizing sustainable practices, making decisions about allocating resources, and contributing to the effectiveness of the health care system.

Key and Enabling Competencies: At a proficient level, Geriatric Psychiatrists are able to…

1. Participate in activities that contribute to the effectiveness of their health care organizations and systems
   1. Describe the structure and function of the health care system as it relates to the comprehensive care of elderly patients, including the roles of physicians
   2. Work collaboratively with others in their own organizations and in other organizations involved in the care of elderly patients
   3. Participate in systemic quality process evaluation and improvement, such as patient safety initiatives, as relevant to health care service delivery for the elderly
2. Manage their practice and career effectively
   1. Demonstrate the ability to prioritize professional duties when faced with multiple complex patients and problems
   2. Implement processes to ensure personal practice improvement
3. Allocate finite health care resources appropriately
   1. Demonstrate an understanding of the importance of just allocation of health care resources, balancing effectiveness, efficiency, and access with optimal patient care
   2. Apply evidence and management processes for cost-appropriate care
   3. Apply knowledge of patient frailty, stage of illness, patient and caregiver preferences, and potential impact on quality of life when making decisions regarding allocation of resources
4. Demonstrate an understanding of administration and leadership issues
   1. Identify relevant administrative and leadership issues in health care service delivery
   2. Serve, as appropriate, in a process to lead or implement change in health care service delivery

Health Advocate

Definition:

As Health Advocates, Geriatric Psychiatrists use their expertise and influence responsibly to advance the health and well-being of individual patients, communities, and populations. Geriatric patients are a vulnerable group offering numerous and unique opportunities for advocacy at the individual level on a daily basis.

Key and Enabling Competencies: At a proficient level, Geriatric Psychiatrists are able to…

1. Respond to individual patient health needs and issues as part of patient care
   1. Identify and prioritize the health needs of individual elderly patients and their families
   2. Identify opportunities for advocacy, health promotion, and disease prevention with elderly patients to whom they provide care
   3. Identify an elderly patient’s status with respect to the determinants of health, adapt the assessment and management as required, and assess the patient’s ability to access required medical and support services
2. Respond to the health needs of the communities of elderly patients that they serve
   1. Identify opportunities for advocacy, health promotion, and disease prevention in the community that they serve, and respond appropriately
   2. Demonstrate an appreciation of the possibility of competing interests between the elderly and other populations
3. Identify the determinants of health for elderly populations that they serve
   1. Identify the determinants of health of the population, including barriers to access to care and resources, taking into account cultural variations
   2. Identify vulnerable or marginalized populations within those served and respond appropriately
4. Promote the health of individual elderly patients, their families, communities, and populations
   1. Describe an approach to implementing a change in a determinant of health of the populations they serve
   2. Identify current public policies, on local, provincial, and national levels, that affect the health of patients, either positively or negatively
   3. Describe how public policy impacts on the health of the elderly population and their families
   4. Identify points of influence in the health care system and its structure, including a variety of relevant advocacy groups at local, provincial, and national levels
   5. Demonstrate an appreciation of the possibility of conflict inherent in their role as a health advocate for a patient or community with that of manager or gatekeeper

Scholar

Definition:

As Scholars, Geriatric Psychiatrists demonstrate a lifelong commitment to reflective learning, and the creation, dissemination, application, and translation of medical knowledge.

Key and Enabling Competencies: At a proficient level, Geriatric Psychiatrists are able to…

1. Maintain and enhance professional activities through ongoing learning in Geriatric Psychiatry
   1. Ensure breadth of knowledge through awareness of pertinent literature beyond Geriatric Psychiatry in relevant related disciplines
2. Critically evaluate medical information and its sources, and apply this appropriately to practice decisions in Geriatric Psychiatry
   1. Critically appraise retrieved evidence to address a clinical question
   2. Integrate critical appraisal conclusions into clinical care
   3. Demonstrate an understanding that limitations exist in the available literature specific to the elderly, and demonstrate the ability to evaluate the applicability of research based on younger adults to the elderly population
3. Facilitate the learning of patients, families, students, residents, other health professionals, the public, and others in topics of Geriatric Psychiatry
   1. Identify collaboratively the learning needs and desired learning outcomes of others, and target education appropriately to audience
   2. Deliver effective lectures, presentations, or workshops to a variety of audiences
   3. Provide effective feedback to team members and other learners
4. Contribute to the development, dissemination, and translation of new knowledge and practices in Geriatric Psychiatry
   1. Identify gaps in the existing literature pertinent to Geriatric Psychiatry
   2. Pose a scholarly question in Geriatric Psychiatry
   3. Select and apply appropriate methods to address the question in the geriatric population
   4. Disseminate the findings of a study pertaining to Geriatric Psychiatry

Professional

Definition:

As Professionals, Geriatric Psychiatrists are committed to the health and well-being of individuals and society through ethical practice, profession-led regulation, and high personal standards of behaviour.

Key and Enabling Competencies: At a proficient level, Geriatric Psychiatrists are able to…

1. Demonstrate a commitment to their patients, profession, and society through ethical practice
   1. Recognize and appropriately respond to ethical issues encountered in Geriatric Psychiatry
   2. Maintain appropriate boundaries with elderly patients and their families
   3. Demonstrate an awareness of and appropriately manage their own reactions when caring for elderly patients
   4. Demonstrate a commitment to delivering the highest quality care and maintenance of competence in Geriatric Psychiatry
2. Demonstrate a commitment to their patients, profession, and society through participation in profession-led regulation
   1. Demonstrate knowledge and understanding of professional, legal, and ethical codes of practice in Geriatric Psychiatry
   2. Demonstrate accountability to professional regulatory bodies
   3. Recognize and respond appropriately to others’ unprofessional behaviours in practice
   4. Participate in peer review
3. Demonstrate a commitment to physician health and sustainable practice
   1. Balance personal and professional priorities to ensure personal health and a sustainable practice in Geriatric Psychiatry
   2. Strive to heighten personal and professional awareness and insight
   3. Recognize other professionals in need and respond appropriately

• REVISED – Specialty Committee – April 2016
• EDITORIAL REVISION APPROVED – Office of Specialty Education – June 2016

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