Medicine/psychiatry and psychology at the undergraduate level

In a recent attempt to assess how geriatric medicine was being taught worldwide, the WHO Ageing and Life Course Program devised the Teaching Geriatrics in Medical Education Study which revealed that Portugal was among the countries considered to have an “old population but weak in geriatric education” (Keller et al, Reference Keller, Makipaa, Kale-nscher and Kalache2002). According to this study carried out in five of Portugal's seven medical schools, the curricula were conservative, except in the Faculty of Medical Sciences of Lisbon which offered an integrated curriculum in the clinical years. National objectives in medical education existed, but geriatric medicine was not included. There were no geriatric units or wards reported on an individualized level or on a sub-level. The main explanation of why geriatrics was not taught independently can be traced to the fact that it represents a small part of the national objectives. The lack of students' interest in this field is also presented as a complementary explanatory factor.

Increased teaching facilities for geriatric medicine and psychiatry for older people at universities (namely in the academic departments of old age psychiatry) within the European Union suggest an increased interest in specialist services for older people, and the European Commission has recognized geriatric medicine as an important specialty. However, there are large differences in structure, health care services and training opportunities. In Portugal, this medical specialty has not yet been recognized, although some faculties have proposed the integration of geriatrics into their medicine curriculum, broadening the scope of innovative study programs. Recently, the Graduate Outcomes of Portuguese Undergraduate Medical Education (GOPUME, 2005) has defined guidelines for curriculum development in Psychiatry and Mental Health, specifically in organic mental disorders with relevance for dementia and amnesic disorders. The inclusion of medical and psychiatric phenomena that occur in older people in the curriculum of residency training programs is rising, and the national educational plan on geriatric training is already recognized by the Psychiatry College of Medicine. However, in the current curriculum it continues to be regarded as optional, but with the prospect in the near future that it may be considered mandatory. The National Mental Health Plan stresses the importance of developing services for vulnerable groups, including older adults. It follows that, in the foreseeable future, there will be an increased need for more substantial training in geriatric psychiatry with the proposal of a sub-speciality/new competency pronouncement position.

Allowing for the particular situation of clinical psychologists in Portugal, their recognition as a professional group that can strongly contribute to the enhancement of older adults' quality of life and well-being is still emerging. It is important to acknowledge that the history of psychology in Portugal is quite recent, and the creation of the first university degree occurred only in 1968 in a private institute. Graduate courses in public universities emerged in 1976, after the April Revolution. During the past decade psychology has grown quite quickly as a degree course: in 2002, 23 degree courses in private and public higher education institutions were available and some 2,000 students have been admitted each year (Nogueira et al., Reference Nogueira, Saavedra and Neves2006). However, efforts have mainly been devoted to the national establishment of traditional psychological domains such as child and educational psychology. No commitment was made to geropsychology, and topics on aging scarcely featured in most psychology curricula.

Recent developments have highlighted the importance of considering an integrated life course perspective in psychology programs, and standard courses (e.g. psychological assessment, developmental psychology) now include specific late-life mental health issues and aging content. The American Psychological Association has suggested guidelines for psychological practice with older adults (American Psychological Association, 2000) which can easily be adapted to geropsychology in most European countries. In the case of Portugal, such suggestions have been particularly popular since they provide the most common frame of reference for teaching and training professionals in clinical work with older adults.

In spite of these achievements, most psychologists tend to disregard the potential of working with the senior population, not only because of limited training but also because ageism seems to affect the perceived attractiveness and status of aged care as a career (Gonçalves et al., Reference Gonçalves, Fonseca, Guedes, Azevedo and Martin2008). Moreover, particularly among young students, such reluctance may be expressed in low expectations on the potential for change in older adults, and in the difficulties associated with specific age-related contingencies such as the death of clients or work with those who have physical ailments or diminished capacity.

Postgraduate educational opportunities

Currently, psychiatrists and psychologists as well as other health care professionals can obtain training by working clinically with older adults through various pathways that provide a way to overcome the lack of undergraduate training. These include mainly master and doctoral fellowships, continuing education activities (e.g. workshops, training seminars) and other initiatives such as psychogeriatric seminars in psychiatric services and university hospitals all over the country.

The Portuguese Gerontopsychiatry Association and the Portuguese Psychogerontology Association constitute two important associations that have been prominent in encouraging the development of old age psychology and psychiatry in Portugal. The first, a psychiatry association, has played an important role in training technicians and in scientific dissemination, having promoted and/or sponsored several meetings, courses and symposiums for psychiatrists, family physicians and the public in general, as well as holding a congress on psychogeriatrics every two years. The complementary role of the Portuguese Psychogerontology Association, a wider professional association, has been instrumental in promoting several courses on aging topics (e.g. psychogerontology, cognitive and functional rehabilitation) and a biannual national congress, among other initiatives.

The Portuguese Gerontopsychiatry Association presently coordinates a national educational plan that includes the organization of the program of geriatric training (residents at a postgraduate level). The development of the first psychogeriatric course commenced in 2007 and has attracted great interest, with a good appreciation of the subjects covered and the quality and interest of the sessions (Fernandes and Firmino, Reference Fernandes and Firmino2008a; Reference Fernandes and Firmino2008b). This first initiative was also supported by the Portuguese Psychiatric Residents Association and its curriculum guidelines included diverse topics spanning neuropsychological assessment, late life psychopathology and most common cognitive disorders (Alzheimer's disease and other dementias), psychosomatics, delirium, and pharmacological and psychotherapeutic interventions.

Within the range of masters and postgraduate programs in psychogerontology that is currently available in several faculties and institutes, both in the public and private sector, the specialization in Clinical Psychogerontology at Coimbra University stands out in the national landscape. Since 2007 the Faculty of Psychology at Coimbra University has presented this area of specialization in the context of the Clinical and Health Psychology Masters degree course. The Clinical Psychogerontology course provides students with theoretical and practical knowledge (namely, biology and physiology of aging, psychosocial issues, neuropsychological assessment and rehabilitation, psychotherapeutic intervention with older adults and in chronic illnesses) as a basis for future clinical training. The students can then acquire experience and technical research skills in clinical internships and through writing a thesis respectively. The internship occurs in hospitals, clinics, and community day centers, and is supervised by psychologists, psychiatrists or neurologists; the thesis is based upon empirical research.

Mention should also be made of the postgraduate courses in Social Gerontology or Geriatrics and Gerontology (of one month to three years' duration), which are currently available in several universities and polytechnic institutions for several audiences, usually without required specialist backgrounds or prerequisites. These courses do not focus exclusively on clinical aspects of geriatric psychiatry and psychology, but tend to cover the most important issues of older adult mental health through geropsychology and/or late life psychopathology disciplines in their study plans.

With respect to Portuguese doctoral medical and psychology programs, there is a lack of an established body to sponsor clinical training directed at older adults. Like other academic levels, a modest investment in gerontological and geriatric topics has characterized this level of training. The lack of available options to gain deeper knowledge or engage in research opportunities has stymied the development of conceptual maturity in the field of aging within Portugal. With this concern in mind, the first doctoral program in gerontology and geriatrics has been launched (2009–2012) at the University of Oporto, in partnership with different faculties, and at the University of Aveiro. The PhD program is approved according to the Bologna process, consisting of one curricular year and two to three years of research leading to a dissertation, granting the degree of doctor in gerontology or geriatrics. Although this PhD is not specifically devoted to mental health training as it covers a broad spectrum of aging issues, it aims to establish geropsychology and psychogeriatrics as important areas of research and intervention.

Increase the offering of educational training programs for mental health specialists

Educational institutions appear to be the most practical starting place for breaking the cycle of a lack of knowledge, exposure and interest in working with older adults. In the national context, an important measure would be to conduct studies that accurately address the mental health training needs that may help to develop an empirically based model for comprehensive geriatric teaching to be implemented among Portuguese faculties. The WHO survey on geriatrics in the medical curriculum has clearly delineated – as a basic principle – the promotion of a holistic approach to training in old age care (Keller et al., Reference Keller, Makipaa, Kale-nscher and Kalache2002) and such a standard should be considered as an important guideline to curriculum development for mental health specialists.

Several researchers and clinicians have generated ideas for developing old age psychiatry training in European countries. In Portugal, Firmino and Fernandes (Reference Firmino and Fernandes2009) have promoted discussion concerning education and the development of the Portuguese Program for Old Age Psychiatry. In line with the recognized merit of the first program of Geriatric Training (postgraduate level) these authors propose that the program of specific training in geriatric psychiatry needs to be planned in collaboration with the College of the Specialty of Psychiatry of the Order of Physicians, with a committee that includes an expert from each of the departments of psychiatry and mental health network of hospitals, and with a representative from each of the national societies credited in this scientific field. According to these authors, training programs need to comprise two components: a biannual course (theoretical and practical basis) and practical training (taking place in recognized psychogeriatric units) with a final report subject to evaluation. It is also important to include within the Curriculum of the Psychiatric Residency practical mandatory training in old age psychiatry, ideally for 3–6 months (rather than on a voluntary basis as in the present curriculum). The most important geriatric mental health topics to be endorsed include communication with old people, neurobiological basis of aging, neuropsychology, neuroimaging, aging and memory, psychology of aging, dementia(s), behavioral and psychological symptoms of dementia, delirium, affective disorders, anxiety, psychosomatic disorders, suicide, psychosis, head trauma, sleep, sexuality, nutrition, elderly abuse, forensics, psychopharmacology, psychotherapy and caregiver interventions.

When introducing the Pikes Peak model of training in professional geropsychology, Knight et al. (Reference Knight, Karel, Hinrichsen, Qualls and Duffy2009) presented the conceptual bases of professional geropsychology as a focus of specialized training. According to these authors, these include four broad aspects (i) understanding normal aging before attempting to work with older adults with psychological disorders; (ii) knowing and having skills relevant to late-life psychopathologies, including those with higher prevalence in old age and those with different presentations, etiologies or treatment implications in older adults; (iii) understanding the interactions of physical and psychological symptoms, particularly the health psychology of late-life medical disorders and the impact of both psychological and physical conditions on functional disability; and (iv) having a working knowledge of age-specific environmental contexts in which older adults are embedded (e.g. nursing homes assisted living facilities) and where the psychologist can provide services.

These four aspects outline key conceptual foundations of training and could serve as a reference in the implementation of geropsychology educational programs in Portugal, particularly for those already working clinically with older adults and continuing to seek education in support of their practice skills. Available programs in gerontology and clinical neuropsychology at the Master's level can promote a more comprehensive understanding of the older person, but a broad spectrum of geropsychology-oriented programs is to be pursued with a specific and deeper focus on training issues concerned with clinical assessment and intervention. It seems unquestionable that the demand for psychologists with a sound understanding of the clinical issues pertaining to older adults will expand in future years as the older population grows and service demands increase (American Psychological Association, 2000). Specialization in old age care is thus an emerging imperative.

As an adjunct to this, the addition of geropsychology courses to Portuguese psychology curricula, principally for advanced undergraduate students, is to be broadened, and practical offerings to be increased. Supervised clinical experience contributes to the development of skills but also constitutes an opportunity to expose students to the older population, and this may draw some of them into a field that they might otherwise never have considered. Along with helping students acquire core knowledge and skills, the course content and practical opportunities should focus on raising interest in working with older adults. Marketing of old age mental care and the promotion of a positive attitude towards aging is crucial. Motivating young students, promoting the recognition and the countering of ageism – whether individual or collective, explicit or implicit – early in their academic careers, and targeting initiatives aimed at promoting the potentialities of working with older adults are all important aims to be achieved. Awards for best students and/or for superior empirical research could be options in this context. Those students who are looking for a career that allows interdisciplinary work on a broad range of issues may find a niche in geropsychology and are to be greatly encouraged.

Whereas geropsychology as a specialty may still be in its infancy in the national context, owing to the lack of significant numbers of professionals in the field and limited pathways to obtain training, a pronouncement is to be expected from the recently created Portuguese College of Psychologists. In the meantime, with general clinical psychologists having increasingly frequent contact with older adults, a major effort is to be made to expand the available mid-career training opportunities.

Improve other health care professionals' competencies for working with older adults

A second step in improving geriatric mental health care is to ensure some level of core training in geriatrics for all professionals who work directly with older adults in order to better address this population's specific needs. Specific knowledge and competences are required in gerontological contexts and several types of professionals who work directly with older adults make valuable contributions to improving their emotional, intellectual and social well-being. These professional must therefore receive specialized training.

Several efforts have already been made in undergraduate curricula to introduce topics on the psychology of aging and the specific skills and competencies for working with the older population, but these have not yet been standardized within different health professions. For example, most nursing training programs have embedded curricular topics related to old age assessment and intervention (Costa, Reference Costa, Paúl and Fonseca2005), but several other professionals, such as speech therapists, still lack any standardized training for working with the geriatric population.

Expanding health professionals' core curriculum on aging, late-life mental disorders and competencies for working with the older population can be achieved by diversifying the range of training opportunities available and by establishing short-term initiatives to meet specific demands. Specifically, it is important to organize the training within both undergraduate and postgraduate courses, and to establish centers of excellence to advance training and clinical care in late-life mental disorders with a multidisciplinary perspective.

With the new organization of mental health services in Portugal (CNRSSM, 2007) all education and research programs must be enhanced and professionals' skills and experience amplified. Health care providers in all settings will need to acquire improved knowledge of dementia and psychiatric disorders in older adults so that they can diagnose, manage and treat all of these problems. Focusing on an earlier and more complete diagnosis of the various psychopathologic circumstances related to this age group, and preparing and implementing intervention strategies requires the involvement of all professionals. Within specific geriatric contexts like hospitals and residential care settings, promoting continuous staff training on elementary mental health care provision (e.g. screening competencies) is also to be pursued. In this context, special reference must be made to general clinical practitioners. Presently, it is well established in the literature that when older adults seek a consultation for a mental health problem, they tend to use the general medical sector; however, general practitioners often miss many of their patients' psychiatric problems, particularly mood and anxiety disorders. Improving these professionals' competencies in screening for the presence of psychological symptoms, as well as signs of cognitive impairment, is a priority.

Improve mental health service delivery

With the growth of the geriatric population in Portugal it is also essential to implement actions to develop mental health service delivery. Most health institutions are finding it difficult to address the rapid rise in physical and psychological dependence expected in older cohorts, and face a shortfall of resources at institutional, social cooperation and health professional levels.

It is estimated that a third of older adults in Portugal present significant psychiatric symptoms, namely depression, anxiety, delirium, dementia, schizophrenia, bipolar disorder and substance abuse (in accordance with the Third Psychiatric Census undertaken in 2001). The National Health Plan, as well as the National Health Program for Elderly People (published in 2004), establishes strategic options and goals that should be considered when approaching this subject; both explicitly mention mental health in later life as one of the top priority sectors for the horizon to 2010 and beyond. In the context of the restructuring and development of mental health services, the recently published Mental Health National Plan (2007–2016) predicts the need for specialized interventions that take into account the “significant growth in the prevalence of psychiatric diseases, and in particular dementia conditions, due to the increased life span and consequent aging of the population” (CNRSSM, 2007). Among several initiatives presented in the document, the Support Programs for Elderly Patients include the development of primary care as the older person's first point of contact with the medical system, in addition to the development of units in general hospitals and specialized gerontopsychiatry units. The linkage between these institutions and primary care is a priority, with a clear emphasis on the development of new pilot projects in community psychiatry directed specifically to the geriatric population.

The need for the development and application of specialized medical knowledge, skills and attitudes in geriatric psychiatry results not only from demographic and epidemiological demands, but also derives from changes in Portuguese health policies. Here there is a shift in the orientation of mental health services from traditional psychiatric hospitals toward community and primary care services, especially psychiatry centers and new support systems, including the recently devised Integrated Continuing Care Network. The Portuguese National Plan for Mental Health emphasizes the decentralization and integration of patients, their families and community services. Preventing the onset of mental disorders or ameliorating them at an early stage can be achieved by conducting outreach to settings where older adults assemble (e.g. senior centers, primary care settings) and through mobile geriatric units that take part in prevention activities in rural areas. Since most of the care given to older patients with psychiatric pathology is provided by informal carers (family, neighbors or friends) who often receive little in the way of formal support (Sousa and Figueiredo, Reference Sousa and Figueiredo2007), new approaches to family and caregiver interventions are to be developed. Because of the progression of the disease, which overlaps with comorbidities and worsening functional dependency, many families are forced to put their older relatives in nursing homes. Taking into account the huge cost associated with institutionalization (both financial and emotional), it is essential to support these families (e.g. through psycho-educational programs) and to promote informal care.

Finally, adopting ethical guiding principles for clinical practice with older adults is essential. Several authors, such as Pachana et al. (Reference Pachana, Helmes and Koder2006), have presented specific recommendations regarding psychological clinical practice (challenges in assessment and therapeutic interventions) and similar guidelines are needed in the Portuguese context.

Connecting research with clinical practice

Regulation of old age psychiatry and geropsychology education is desirable, implying more and better care with a specialization in psychiatry services for older adults in general and university hospitals, psychiatric reference hospitals and all other levels of geriatric care (including primary and rehabilitation care). In these geriatric mental health centers, a continuum of innovation, sharing information, research and publishing that translates knowledge into clinical practice and vice versa is fundamental. With this in mind, a final and global effort is to be made to promote specific guidelines that link research and training issues relevant to working with older adults, and promote research projects that enhance the network that exists between different health care settings and different universities. Such guidelines will lead academics, such as PhD students, to seek careers in late-life mental health, increasing the base of academic faculty available to provide training, and will increase scientific findings that may lead to innovative interventions.

From an empirical point of view, national research oriented to clinical practice should include several major objectives such as (i) continuous validation of geriatric scales and other assessment instruments for the Portuguese population, (ii) development and integration of European epidemiology research, (ii) study of the most prevalent mental health disorders and their structural circumstances (e.g. social and health determinants); (iii) increasing our understanding of the main barriers to seeking mental health care; and (iv) the development of evidence-based psychological treatment for mental health problems. Overall, seeking to enable clinicians and academics to ground their theory and practice within an age-appropriate and culture-based set of assessments and interventions is crucial.

Finally, as well as focusing on the mental health aspects of an aging population, Portuguese aging research is to be linked to the priority directions and recommendations contained in the Second International Plan of Action on Aging that were approved in 2002 at the Madrid Second World Assembly (UN-IAG, 2003). An increased national and international publication level is also to be achieved.