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Never has there been a more pressing time for the American Association for Geriatric Psychiatry (AAGP) to articulate a unified strategy to meet the challenges of our aging world. To this end, this report summarizes an AAGP leadership meeting that reviewed the results from a recent membership survey and launched a strategic planning process on behalf of AAGP members and stakeholders. This meeting was the first step in drafting a blueprint for the future that may serve as our guide in the context of finite resources to meet the infinitely complex and growing need for education, research, public advocacy, and clinical practice support. The following report serves to invite our valued colleagues to provide feedback and actively participate in defining our mission. Among the outcomes of the planning session, the following aspirations were identified by the participants 1) assert the AAGP as the "go to" organization for all things related to geriatric mental health, 2) prioritize activities that enhance the inclusivity/diversity of membership, and 3) collaborate across disciplines focused on geriatric mental health. From this initial framework, the group developed four general themes to guide AAGP's strategic future: 1) collaboration, 2) advocacy, 3) inclusivity, 4) high purpose. Inclusivity was further defined as encompassing growth, return on investment, and workforce development. Higher purpose was further defined as encompassing engagement, purpose, branding, communication, and expertise. The AAGP affirmed its commitment to serving the needs of its members and widening its scope of impact in view of staggering demands for better access to geriatric mental healthcare.

Objective The Accreditation Council of Graduate Medical Education (ACGME) Milestone Project is the next step in a series of changes revamping the system of graduate medical education. In 2013 the ACGME completed the general psychiatry milestones. The ACGME then pursued creation of milestones for accredited psychiatric subspecialty fellowships. This article documents the work of the geriatric psychiatry subspecialty milestones work group. It reports the history and rationale supporting the milestones, the milestone development process, and the implications for geriatric psychiatry fellowship training. Methods In consultation with the American Association for Geriatric Psychiatry, the American Board of Psychiatry and Neurology, and the ACGME Psychiatry Residency Review Committee, the ACGME appointed a working group to create the geriatric psychiatry milestones using the general psychiatry milestones as a guide. Conclusion The geriatric psychiatry milestones are the result of an iterative process resulting in the definition of the characteristics vital to a fellowship-trained geriatric psychiatrist. It is premature to assess their effect on psychiatric training. The true impact of the milestones will be determined as each training director uses the milestones to re-evaluate their program curriculum and the educational and clinical learning environment. The ACGME is currently collecting the information about the milestone performance of residents and fellows to further refine and determine how the milestones can best be used to assist programs in improving training.

Maintenance of Certification is a program required for continued board certification in geriatric psychiatry by the American Board of Psychiatry and Neurology. This symposium will provide AAGP meeting attendees with an update from a Psychiatry Director of the ABPN about its Maintenance of Certification (MOC) program (including recent changes in response to revised requirements issued by the American Board of Medical Specialties), information about how the AAGP can help support its members to maintain subspecialty certification, and an opportunity for participants to discuss issues related to maintaining ABPN subspecialty certification.

Delirium is a clinical syndrome that is disruptive to patients, their families, and clinicians and also the cause for great morbidity and mortality for hospital patients, a disproportionate number of whom are elderly. Delirium, also referred to as acute confusional state or encephalopathy, is a clinical presentation distinguished by a disturbance of consciousness and attention, cognitive impairment, disorientation, the development of perceptual disturbances, accompanied by psychomotor hyper- or hypoactivity and disrupted sleepewake cycle. The Latin roots for the term are derived fromde(“away from”) andlira(“furrow in the field”), literally meaning “to go away from aploughedtrack”or“togooffatrack.”Inhospitalized patients, delirium occurs at rates estimated to be between 14% and 80% (medical intensive care unit patients) and is accompanied by increased morbidity andmortalitythancanbeaccountedforbytheoriginal underlyingmedicalillnessalone. 2,3 Intheadultgeneral medicine population, the incidence of delirium ranges from 10% to 24%. 2,4 The incidence increases greatly to an estimated 60% in the frail geriatric patient. 5

According to U.S. Census Bureau projections, some 35 million Americans are 65 years of age and older today—about 12.6% of the population. This figure is expected to rise to about 70 million by 2030, by which time this age group will constitute 20% of the population. This tremendous growth in the geriatric population will most likely be accompanied by increases in the numbers of older patients presenting to general psychiatrists in the coming years. The most rapidly increasing segment of the older population is the “oldest old”—those 85 years of age and older. By 2010, it is estimated that 1.9 of every 100 persons will be 85 or older. This group has a high risk of psychiatric disorders, largely Agitation is one of the more prevalent as well as clinically distressing symptoms in the geriatric psychiatric patient. Agitation has myriad presentations and numerous possible causes. It can be the primary symptom for which a psychiatric consultation is sought, both for the cognitively intact and the cognitively impaired patient. In this article, the definition, diagnosis, etiology, and initial management strategy of agitation will be delineated. The aim of the article is to provide a practical overview and a clinical perspective on this topic.

Objective To document the development of geriatric psychiatry (GP) fellowship training in the United States through 2008. Methods A cross-sectional survey of the 56 U.S. GP fellowship programs was conducted in summer 2007. Longitudinal data from the American Medical Association and the Association of American Medical Colleges' National Graduate Medical Education Census and data from the Accreditation Council for Graduate Medical Education were also analyzed. Results Thirty-seven (66%) of 56 program directors responded. The number of fellowship programs has decreased over the past 7 years. During 2006/07, 72 fellows were in training, as compared with 94 fellows in 2001/02. Application rates declined significantly with a mean of 4.3 applications per program in 2006/07 as compared with the mean of 10 applications per program in 2001/02. The fill rate for first-year GP fellowship positions dropped from 61% in 2001/02 to 48% in 2006/07. During 2006/07, 67% of programs reported having two or fewer first-year fellows and 16% had no first-year fellows. Seventeen programs reported having no United States medical school graduates as first-year fellows. Conclusion The number of GP fellows in training has declined by 23% from 2001/02 to 2006/07. This decline has occurred at the same time when the number of older adults continues to expand rapidly. It is critical that an adequate number of geriatric psychiatrists be trained to support and educate general psychiatrists in the care of the elderly. Specific strategies need to be developed urgently to stimulate interest in careers in clinical and academic GP.

One of the more difficult psychopharmacologic aspects of current clinical psychiatry is finding a neuroleptic drug that adequately treats delusional states. Furthermore, many chronic schizophrenics remain resistant to standard antipsychotic medication, and clozapine is effective in only 30% to 50% of refractory cases. In addition, clozapine has several serious side effects and is expensive. We have determined that pimozide is clearly effective in Tourette's syndrome, maintenance schizophrenia, and some delusional disorders. We further demonstrate that the drug is likely to be effective in the treatment of the negative symptoms of schizophrenia and other delusional states. In addition, we suggest that a trial of pimozide may be indicated before giving clozapine to treatment-resistant schizophrenic patients. The side effect that probably most limits pimozide's current use is the possible production of ECG abnormalities. This side effect does not seem to be a realistic clinical concern, however, if the patients are properly screened and the pimozide dose is maintained at or below 20 mg/day.

Background We studied a visual artist with Lewy body dementia (LBD) to learn how this disease influenced his paintings during the course of the disease. Methods Study 1 evaluated two paintings of the same subject matter, one that the patient painted before his illness and the other after the onset of this disease. Study 2 evaluated a collection of his paintings from the time before he was ill (1994) until the time he stopped painting when he was suffering with LBD (2002). To learn how the onset and progression of LBD affected his paintings we had judges score the following qualities: aesthetic-beauty, closure completeness, evocative impact, novelty, technique and representational quality. Results In Study 1 we found that the representational ratings for the picture he painted when he had LBD was significantly lower than the picture he painted before he developed LBD. In Study 2, we found that all the artistic qualities measures temporally declined except novelty. We also found that the paintings that were judges as having the highest quality representations were significantly more novel than those that had poorer representations. In addition, we conducted a forward stepwise regression analysis using quality measures as predictor of year. This analysis revealed that only representational quality significantly predicted painting year. Conclusions Our results suggest that as LBD progresses, except for novelty there is a gradual degradation of the ability to visually express artistic subject matter. It possible that the preserved ability to paint novel picture is related to relative preservation of frontal lobe function, but the degradation of other artistic qualities might be related to deterioration of the parietal lobes which either impairs the brain's iconic representations or the knowledge needed to portray these representations.

Depression among older adults is a major public health concern in the U. S. Yet, time and again this condition goes undiagnosed, or attributed to other causes. Despite being treatable, few individuals older than age 65 are treated for this disorder. Using a community sample of 404 African-American and Caucasian older adults, the aim of this study was to identify the sources of racial group variance in self-reports of depressive symptoms. Descriptive and multivariate analyses reveal no racial/ethnic differences in the mean level of depressive symptoms, but differences in the correlates of self-reported depression, as well as differences in the distribution of individual indicators of depressive symptoms.

A case of Capgras syndrome in a 67-year-old man who failed to improve on haloperidol, but responded to pimozide, is described. The patient's paranoid delusions abated with 8 mg per day of pimozide. We believe pimozide's established benefit in the treatment of delusional disorders warrants its consideration in alleviating other delusions, including “the delusion of doubles.” ( J Geriatr Psychiatry Neurol 1992;5:217–219).

To the Editor. —We found Dr Eddy's essay, "A Conversation With My Mother," 1 both thought provoking and disturbing— thought provoking in that the essay presents, in a personal and dramatic manner, the numerous medical, emotional, ethical, legal, and philosophical issues surrounding euthanasia, patient autonomy, and physician-assisted suicide. These issues are far too complex for the scope of this letter; however, we wish to address the more disturbing point raised by the essay: suicidal intention in a chronically ill elderly patient with a known history of depression. Eddy reports that his mother, prior to the last 6 months of her life, was on Elavil (amitriptyline) for the successful treatment of depression. Following her cholecystectomy, complications occurred and "her antidepressants got out of balance." The antidepressants were stabilized and "working again" following her second surgery, "but she was very unhappy....She knew... it was very unlikely she would ever be able to

An issue in current animal welfare ethics is the use of animals in medical education. At stake is the conflict of pain and suffering of the animals vs. the benefit to the students. The educator's role is to balance these two concepts. If the animals do suffer, this has to be justified by clearly establishing the necessity of their use. Neither this justification nor the methods for making the decision are clear. Addressed in this discussion are the arguments for and against animal use, alternatives, and proposals for the resolution of the controversy.