Mental Health

Each year, about 2.6% of emergency department (ED) visits involve agitation.¹ ED clinicians are especially prone to workplace violence and assault, facing the challenge of caring for patients while maintaining safety. A 2013 prospective study found an average of 4.15 violent events per employee in 9 months; nurses and patient care assistants were most frequently affected.² A 2022 survey from the American College of Emergency Physicians found 55% of respondents reported being physically assaulted in the ED and 79% of respondents reported witnessing another assault. Most of these assaults (98%) were committed by the patients.³ Appropriate management of patients experiencing acute agitation is critical for the safety of all parties involved.

The initial approach to acute agitation management involves nonpharmacologic measures in an attempt to avoid coercive actions, such as physical restraints. Reducing environmental stimulation and verbal de-escalation are effective and help the patients with agitation regain control over their behavior.⁴

When these measures fail, however, pharmacologic therapy is often administered to ensure safety. The goal of pharmacologic therapy is to calm the patient without causing sedation.⁵ This allows the patient to continue participating in their care and allows the care team to accurately assess them, which is critical in determining the underlying etiology of agitation. Historically, haloperidol has commonly been used to manage acute agitation. It is frequently administered with lorazepam and diphenhydramine to reduce the incidence of haloperidol’s extrapyramidal adverse effects. However, there are several potential concerns with this method, including oversedation, QTc prolongation, potential drug interactions, and polypharmacy.^5,6

The American Association of Emergency Psychiatry Project BETA Psychopharmacology Workgroup published a Consensus Statement in 2012 regarding the psychopharmacology of agitation.⁵ When considering medication for agitation management, clinicians must first determine a provisional diagnosis outlining the most probable etiology of the patient’s behavior, such as delirium, intoxication, or a psychiatric disorder. Apart from alcohol intoxication, benzodiazepines (BZDs) or second-generation antipsychotics as monotherapy are generally preferred over haloperidol for acute agitation.⁵ Second-generation antipsychotics have demonstrated to be as effective as haloperidol but are thought to be safer options. Quetiapine is not recommended for use in the ED due to the risk of orthostatic hypotension, as patients are often volume depleted.⁵The Veterans Affairs Southern Nevada Healthcare System (VASNHS) serves veterans in the Las Vegas area. Among the nearly 220,000 veterans in Nevada, about 100,000 veterans are aged ≥ 65 years.⁷ The 2012 consensus statement on psychopharmacology for agitation offers no specific age-related guidance. However, there are safety concerns in older adults both with antipsychotics and BZDs, even with acute use. The US Food and Drug Administration (FDA) issued a boxed warning for all antipsychotics due to increased mortality in older adult patients with dementia-related psychosis.⁸ The 2023 American Geriatrics Society Beers Criteria provides guidance on pharmacological therapy for adults aged ≥ 65 years and recommends avoiding antipsychotics and BZDs.⁹ In addition to the FDA boxed warning, data suggest increased mortality with antipsychotic use independent of dementia. With BZDs, changes in pharmacodynamics make older adults more prone to adverse effects, including cognitive impairment, delirium, falls, and fractures. A retrospective chart review evaluated risperidone use in the ED and found that adults aged ≥ 65 years experienced higher rates of hypotension, even though this age group received about half the dose of risperidone compared with younger patients.¹⁰ For this patient population, the general approach in treating acute agitation has been to avoid the use of medications, but prescribe lower doses when necessary.¹¹

With limited research on acute agitation management in older adults, the purpose of this study was to compare current prescribing practices of anti-agitation medications between adults aged 18 to 64 years and adults aged ≥ 65 years in the VASNHS ED. This study was also conducted to better understand the anti-agitation prescribing practices at VASNHS, as no order sets or protocols existed at the time of the study to guide medication selection in agitation management. To our knowledge, this is the first observational study evaluating pharmacologic acute agitation management in the ED based on age.

Methods

This study was a retrospective chart review of patients aged ≥ 18 years who presented to the VASNHS ED and received medication for acute agitation. Patients were identified through active orders for a formulary agitation medication from August 1, 2019, to July 31, 2022. Formulary medication options included intravenous, oral, and intramuscular routes for haloperidol, droperidol, lorazepam, olanzapine, or ziprasidone. Veterans were excluded if they presented with alcohol intoxication, alcohol or BZD withdrawal, if the medication administration was unrelated to agitation, or whether the medication was not administered. While alcohol and/or BZDs can contribute to acute agitation, these patients were excluded due to a clear indication for BZD therapy and the challenge in a retrospective chart review to determine whether patients received medication for agitation vs other withdrawal-related symptoms.

Endpoints

The primary endpoint was the medication selection between 2 age groups: 18 to 64 years and ≥ 65 years. The secondary endpoints included ordered medication dose by regimen, additional anti-agitation medication use within 3 hours of initial medication administration, and disposition. Safety outcomes included incidence of newly occurring oxygen desaturation < 95%, supplemental oxygen requirement, intubation, QTc prolongation, and hypotension with systolic blood pressure < 90 mm Hg within 1 hour of medication administration. Data collected included patient demographics, substance use, conditions contributing to altered mental status, active psychotropic medication prescriptions, medication adherence, agitation medication prescriber, and doses. Adherence to psychotropic medication in the past 6 months was defined as ≥ 80% of days covered with medication and based on fill history. This was only calculated for applicable patients and did not include patients with only as-needed medications, such as hydroxyzine for anxiety.

Statistical Analysis

Statistical analyses were performed using IBM SPSS. Baseline characteristics were analyzed using descriptive statistics. χ² and Fisher exact tests were used to analyze categorical data. A student t test was used for continuous variables and a 2-sided P value of < .05 was considered statistically significant.

 

 

Results

During the study period, 2342 unique patient encounters with active anti-agitation medication orders in the ED were identified and 232 encounters met the inclusion criteria. Of those excluded, 605 encounters had alcohol involvement. The study included 152 patient encounters for 128 patients aged 18 to 64 years of whom 16 patients had > 1 encounter with a mean (SD) 2.5 (1.1) visits. The study included 80 patient encounters for 72 patients aged ≥ 65 years of whom 7 patients had > 1 encounter with a mean (SD) 2.1 (0.3) visits. The mean age was 45.5 years in the younger cohort and 72.2 years in the older cohort. For data analysis and characterization of the ED population, each patient encounter was treated as a unique patient.

Baseline characteristics significantly differed between the 2 groups (Table 1). When comparing patients aged 18 to 64 years and those aged ≥ 65 years, the younger cohort had higher rates of substance use disorder diagnosis (55.3% vs 27.5%, P < .001), positive urine drug screen (69.7% vs 22.5%, P < .001), and 72-hour legal hold (59.9% vs 32.5%, P < .001) and lower rates of cognitive impairment or dementia (0.7% vs 48.8%, P < .001), and altered mental status-related diagnosis (2.0% vs 18.8%, P < .001). Diagnoses in the younger cohort included 1 each for hyperglycemia, urinary tract infection, and hyponatremia. Diagnoses in the older cohort included 4 for urinary tract infections, 4 for sepsis, 2 for encephalopathy, 2, for hyperglycemia, 1 gastrointestinal bleed, 1 thyrotoxicosis, and 1 respiratory failure.

Endpoints

The primary outcome of anti-agitation medication selection significantly differed between the younger cohort and older cohort (P = .02). All medication combinations ordered are shown in the eAppendix based on patient age and the percentage of patients in the age cohort that received that medication combination. Lorazepam monotherapy was the most common anti-agitation medication regimen ordered: 43.4% in patients aged 18 to 64 years and 41.3% in patients aged ≥ 65 years. Second-generation antipsychotic use was low.

Only 10.5% of patients aged 18 to 64 years and 8.8% of patients aged ≥ 65 years received a medication combination including a second-generation antipsychotic. Intramuscular administration (41.4%) was most common followed by intravenous (37.5%), oral (19.8%), and oral disintegrating tablets (1.3%). The median (IQR) number of anti-agitation medications ordered by a prescriber was 6 (3-11) and 18 of 28 prescribers did not prescribe second-generation antipsychotics.

Medication doses ordered did not significantly differ except lorazepam monotherapy, as patients aged ≥ 65 received a lower dose (P = .007) (Table 2). Given the limited data within 1 hour, the first set of vital signs available after medication administration was used for analysis of safety outcomes. Vital signs were documented within 1 hour after medication administration for only 28.3% of patients aged 18 to 64 years and 42.5% of patients aged ≥ 65 years. The median (IQR) time to documentation for vital signs after medication administration was 96 minutes (56-177) for patients aged 18 to 64 years and 64 minutes (25-121) for patients aged ≥ 65 years. Electrocardiogram measurement after medication administration only occurred in 7.9% of patients aged 18 to 64 years and 5% of patients aged ≥ 65 years.

Fourteen patients (7.9%) aged 18 to 64 years and 17 patients (15.0%) aged ≥ 65 years experienced an adverse outcome (P = .09) (Table 3). Most patients who had an adverse safety outcome experienced new oxygen desaturation < 95%. Of those patients, only a small proportion required new supplemental oxygen or intubation. The 2 patients intubated had ongoing medical issues complicating their course in the ED. New QTc prolongation was only documented in haloperidol-containing regimens.

The proportion of patients requiring additional anti-agitation medication doses within 3 hours following initial administration was similar between the 2 groups. The mean (SD) amount of time to administration of subsequent dose was 55 minutes (30) in the younger cohort and 64 minutes (36) in the older cohort. Patient disposition from the ED, significantly differed based on age (P < .001) (Table 4). Patients aged 18 to 64 years were more frequently admitted to the psychiatry unit, while patients aged ≥ 65 years were primarily admitted to the hospital. One patient in the younger cohort died due to hyponatremia.

 

 

Discussion

The most likely causes of acute agitation significantly differed between patients aged 18 to 64 years and patients aged ≥ 65 years. Patients in the younger cohort were more likely to present with a history of substance use disorder or a positive urine drug screen for illicit substances. They were also more likely to have a 72-hour legal hold initiated, suggesting higher rates of suicidal and/or homicidal ideations. Patients in the older cohort were likely to present with a history of cognitive impairment or be diagnosed with a condition contributing to an altered mental status. To our knowledge, this is the first study that has assessed characteristics of patients experiencing acute agitation in the ED based on age and demonstrated significant differences in potential contributing factors to acute agitation. These findings may have important implications in helping guide the selection of empiric regimens, especially when the cause of agitation cannot immediately be elucidated.

Lorazepam monotherapy, haloperidol monotherapy, and a combination of haloperidol, lorazepam, and diphenhydramine were the 3 most frequently prescribed regimens for acute agitation. There was low second-generation antipsychotic use. Outside of the VASNHS formulary, there were no policies or restrictions that would have prevented clinicians from ordering a particular anti-agitation medication during the study period.

Since the end of the period assessed in this study, VASNHS clinicians have been educated on the guidelines for anti-agitation medication regimens to encourage higher use of second-generation antipsychotics when appropriate. Training has been developed to prevent unnecessary delays when using these products. Barriers to second-generation antipsychotic use at VASNHS have also been identified and addressed. Previously, second-generation antipsychotics and the sterile water required for medication reconstitution were not overridable in Pyxis machines, often resulting in delays in administering these medications to acutely agitated patients. As of February 2023, olanzapine, ziprasidone, and sterile water are overridable, making them more accessible in situations when medication is urgently needed. Clinicians also expressed concern regarding a lack of familiarity with reconstituting and administering intramuscular second-generation antipsychotics.

While the general guidance has been to use lower doses of anti-agitation medications in patients aged ≥ 65 years, no significant differences were seen in doses ordered other than for lorazepam. In our study, however, there were no significant differences in adverse safety outcomes, though a higher proportion of patients in the older cohort experienced new respiratory-related outcomes after medication administration. Given the retrospective nature of this study and limited documentation of vital signs after medication administration, we cannot conclude the adverse safety outcomes were directly related to the anti-agitation medications. Most patients in both groups did not require additional doses of anti-agitation medications. The results of this study have been used to guide the development of an order set for anti-agitation medications.

 

 

Limitations

As a retrospective chart review, this study is unable to prove any differences in prescribing patterns for anti-agitation medications based on age. As a single-center study, the prescribing patterns and baseline characteristics are unique to the facility and not generalizable to all patients with acute agitation in the ED. Future, higher-quality studies with adequate power in diverse patient populations are needed to further elucidate differences in acute agitation etiology and anti-agitation medications based on patient age.

The anti-agitation medication used may have been skewed for patients with multiple and/or previous ED encounters. If information was available on previous causes of agitation and/or previous efficacy of regimens, this may have influenced selection. Additionally, clinical pharmacy specialists began providing daytime coverage in the ED in April 2022. As a part of their role, these pharmacists provide recommendations for medication selection in the management of acute agitation and can order anti-agitation medications. While no pharmacist prescriptions were identified in the study, their recommendations may have influenced medication selection toward the end of the study period.

Given the retrospective nature of the study, it is unclear whether medication selection may have been guided by the patient’s presentation or comorbidities to avoid adverse effects. This may have influenced the safety outcomes observed. Another limitation to this data is vital signs documentation. Vital signs were rarely documented in the ED within 1 hour of medication administration, meaning the vital signs captured may not be related to the agitation medication. Among the patients with documented vital signs, 20 patients were documented within 10 minutes, likely prior to when the medication had taken full effect. This time variability further limits the ability to link safety outcomes to medications and demonstrates a need for additional research. Very few patients had electrocardiogram data after medication administration. If patients did have an electrocardiogram measured in the ED, this more commonly occurred prior to any medication administration, which may have also guided clinicians in initial medication selection.

This study may have also overlooked risperidone use. Though risperidone is on the VASNHS formulary, it was not expected to be commonly used in the ED setting due to it only being available by mouth. However, oral medication use was higher than expected, and there were instances where clinicians initially ordered 1 of the included anti-agitation medications but patients ultimately received risperidone. Based on these findings, the current study may have overlooked this as an anti-agitation medication regimen. In addition, by excluding alcohol intoxication, alcohol withdrawal, and BZD withdrawal, this study did not fully capture the agitated population in our ED.

Conclusions

Anti-agitation medication prescribing patterns may differ between adults aged 18 to 64 years and those aged ≥ 65 years. The findings of this study also suggest that the most common agitation etiologies may differ based on patient age. Future studies should further explore anti-agitation medication use and agitation etiologies among older adults to guide medication prescribing.

Acknowledgments

We acknowledge Ted Turner, PharmD, BCPP, and Phong Ly, PharmD, BCPS, for their support and assistance on this project.

Each year, about 2.6% of emergency department (ED) visits involve agitation.¹ ED clinicians are especially prone to workplace violence and assault, facing the challenge of caring for patients while maintaining safety. A 2013 prospective study found an average of 4.15 violent events per employee in 9 months; nurses and patient care assistants were most frequently affected.² A 2022 survey from the American College of Emergency Physicians found 55% of respondents reported being physically assaulted in the ED and 79% of respondents reported witnessing another assault. Most of these assaults (98%) were committed by the patients.³ Appropriate management of patients experiencing acute agitation is critical for the safety of all parties involved.

The initial approach to acute agitation management involves nonpharmacologic measures in an attempt to avoid coercive actions, such as physical restraints. Reducing environmental stimulation and verbal de-escalation are effective and help the patients with agitation regain control over their behavior.⁴

When these measures fail, however, pharmacologic therapy is often administered to ensure safety. The goal of pharmacologic therapy is to calm the patient without causing sedation.⁵ This allows the patient to continue participating in their care and allows the care team to accurately assess them, which is critical in determining the underlying etiology of agitation. Historically, haloperidol has commonly been used to manage acute agitation. It is frequently administered with lorazepam and diphenhydramine to reduce the incidence of haloperidol’s extrapyramidal adverse effects. However, there are several potential concerns with this method, including oversedation, QTc prolongation, potential drug interactions, and polypharmacy.^5,6

The American Association of Emergency Psychiatry Project BETA Psychopharmacology Workgroup published a Consensus Statement in 2012 regarding the psychopharmacology of agitation.⁵ When considering medication for agitation management, clinicians must first determine a provisional diagnosis outlining the most probable etiology of the patient’s behavior, such as delirium, intoxication, or a psychiatric disorder. Apart from alcohol intoxication, benzodiazepines (BZDs) or second-generation antipsychotics as monotherapy are generally preferred over haloperidol for acute agitation.⁵ Second-generation antipsychotics have demonstrated to be as effective as haloperidol but are thought to be safer options. Quetiapine is not recommended for use in the ED due to the risk of orthostatic hypotension, as patients are often volume depleted.⁵The Veterans Affairs Southern Nevada Healthcare System (VASNHS) serves veterans in the Las Vegas area. Among the nearly 220,000 veterans in Nevada, about 100,000 veterans are aged ≥ 65 years.⁷ The 2012 consensus statement on psychopharmacology for agitation offers no specific age-related guidance. However, there are safety concerns in older adults both with antipsychotics and BZDs, even with acute use. The US Food and Drug Administration (FDA) issued a boxed warning for all antipsychotics due to increased mortality in older adult patients with dementia-related psychosis.⁸ The 2023 American Geriatrics Society Beers Criteria provides guidance on pharmacological therapy for adults aged ≥ 65 years and recommends avoiding antipsychotics and BZDs.⁹ In addition to the FDA boxed warning, data suggest increased mortality with antipsychotic use independent of dementia. With BZDs, changes in pharmacodynamics make older adults more prone to adverse effects, including cognitive impairment, delirium, falls, and fractures. A retrospective chart review evaluated risperidone use in the ED and found that adults aged ≥ 65 years experienced higher rates of hypotension, even though this age group received about half the dose of risperidone compared with younger patients.¹⁰ For this patient population, the general approach in treating acute agitation has been to avoid the use of medications, but prescribe lower doses when necessary.¹¹

With limited research on acute agitation management in older adults, the purpose of this study was to compare current prescribing practices of anti-agitation medications between adults aged 18 to 64 years and adults aged ≥ 65 years in the VASNHS ED. This study was also conducted to better understand the anti-agitation prescribing practices at VASNHS, as no order sets or protocols existed at the time of the study to guide medication selection in agitation management. To our knowledge, this is the first observational study evaluating pharmacologic acute agitation management in the ED based on age.

Methods

This study was a retrospective chart review of patients aged ≥ 18 years who presented to the VASNHS ED and received medication for acute agitation. Patients were identified through active orders for a formulary agitation medication from August 1, 2019, to July 31, 2022. Formulary medication options included intravenous, oral, and intramuscular routes for haloperidol, droperidol, lorazepam, olanzapine, or ziprasidone. Veterans were excluded if they presented with alcohol intoxication, alcohol or BZD withdrawal, if the medication administration was unrelated to agitation, or whether the medication was not administered. While alcohol and/or BZDs can contribute to acute agitation, these patients were excluded due to a clear indication for BZD therapy and the challenge in a retrospective chart review to determine whether patients received medication for agitation vs other withdrawal-related symptoms.

Endpoints

The primary endpoint was the medication selection between 2 age groups: 18 to 64 years and ≥ 65 years. The secondary endpoints included ordered medication dose by regimen, additional anti-agitation medication use within 3 hours of initial medication administration, and disposition. Safety outcomes included incidence of newly occurring oxygen desaturation < 95%, supplemental oxygen requirement, intubation, QTc prolongation, and hypotension with systolic blood pressure < 90 mm Hg within 1 hour of medication administration. Data collected included patient demographics, substance use, conditions contributing to altered mental status, active psychotropic medication prescriptions, medication adherence, agitation medication prescriber, and doses. Adherence to psychotropic medication in the past 6 months was defined as ≥ 80% of days covered with medication and based on fill history. This was only calculated for applicable patients and did not include patients with only as-needed medications, such as hydroxyzine for anxiety.

Statistical Analysis

Statistical analyses were performed using IBM SPSS. Baseline characteristics were analyzed using descriptive statistics. χ² and Fisher exact tests were used to analyze categorical data. A student t test was used for continuous variables and a 2-sided P value of < .05 was considered statistically significant.

 

 

Results

During the study period, 2342 unique patient encounters with active anti-agitation medication orders in the ED were identified and 232 encounters met the inclusion criteria. Of those excluded, 605 encounters had alcohol involvement. The study included 152 patient encounters for 128 patients aged 18 to 64 years of whom 16 patients had > 1 encounter with a mean (SD) 2.5 (1.1) visits. The study included 80 patient encounters for 72 patients aged ≥ 65 years of whom 7 patients had > 1 encounter with a mean (SD) 2.1 (0.3) visits. The mean age was 45.5 years in the younger cohort and 72.2 years in the older cohort. For data analysis and characterization of the ED population, each patient encounter was treated as a unique patient.

Baseline characteristics significantly differed between the 2 groups (Table 1). When comparing patients aged 18 to 64 years and those aged ≥ 65 years, the younger cohort had higher rates of substance use disorder diagnosis (55.3% vs 27.5%, P < .001), positive urine drug screen (69.7% vs 22.5%, P < .001), and 72-hour legal hold (59.9% vs 32.5%, P < .001) and lower rates of cognitive impairment or dementia (0.7% vs 48.8%, P < .001), and altered mental status-related diagnosis (2.0% vs 18.8%, P < .001). Diagnoses in the younger cohort included 1 each for hyperglycemia, urinary tract infection, and hyponatremia. Diagnoses in the older cohort included 4 for urinary tract infections, 4 for sepsis, 2 for encephalopathy, 2, for hyperglycemia, 1 gastrointestinal bleed, 1 thyrotoxicosis, and 1 respiratory failure.

Endpoints

The primary outcome of anti-agitation medication selection significantly differed between the younger cohort and older cohort (P = .02). All medication combinations ordered are shown in the eAppendix based on patient age and the percentage of patients in the age cohort that received that medication combination. Lorazepam monotherapy was the most common anti-agitation medication regimen ordered: 43.4% in patients aged 18 to 64 years and 41.3% in patients aged ≥ 65 years. Second-generation antipsychotic use was low.

Only 10.5% of patients aged 18 to 64 years and 8.8% of patients aged ≥ 65 years received a medication combination including a second-generation antipsychotic. Intramuscular administration (41.4%) was most common followed by intravenous (37.5%), oral (19.8%), and oral disintegrating tablets (1.3%). The median (IQR) number of anti-agitation medications ordered by a prescriber was 6 (3-11) and 18 of 28 prescribers did not prescribe second-generation antipsychotics.

Medication doses ordered did not significantly differ except lorazepam monotherapy, as patients aged ≥ 65 received a lower dose (P = .007) (Table 2). Given the limited data within 1 hour, the first set of vital signs available after medication administration was used for analysis of safety outcomes. Vital signs were documented within 1 hour after medication administration for only 28.3% of patients aged 18 to 64 years and 42.5% of patients aged ≥ 65 years. The median (IQR) time to documentation for vital signs after medication administration was 96 minutes (56-177) for patients aged 18 to 64 years and 64 minutes (25-121) for patients aged ≥ 65 years. Electrocardiogram measurement after medication administration only occurred in 7.9% of patients aged 18 to 64 years and 5% of patients aged ≥ 65 years.

Fourteen patients (7.9%) aged 18 to 64 years and 17 patients (15.0%) aged ≥ 65 years experienced an adverse outcome (P = .09) (Table 3). Most patients who had an adverse safety outcome experienced new oxygen desaturation < 95%. Of those patients, only a small proportion required new supplemental oxygen or intubation. The 2 patients intubated had ongoing medical issues complicating their course in the ED. New QTc prolongation was only documented in haloperidol-containing regimens.

The proportion of patients requiring additional anti-agitation medication doses within 3 hours following initial administration was similar between the 2 groups. The mean (SD) amount of time to administration of subsequent dose was 55 minutes (30) in the younger cohort and 64 minutes (36) in the older cohort. Patient disposition from the ED, significantly differed based on age (P < .001) (Table 4). Patients aged 18 to 64 years were more frequently admitted to the psychiatry unit, while patients aged ≥ 65 years were primarily admitted to the hospital. One patient in the younger cohort died due to hyponatremia.

 

 

Discussion

The most likely causes of acute agitation significantly differed between patients aged 18 to 64 years and patients aged ≥ 65 years. Patients in the younger cohort were more likely to present with a history of substance use disorder or a positive urine drug screen for illicit substances. They were also more likely to have a 72-hour legal hold initiated, suggesting higher rates of suicidal and/or homicidal ideations. Patients in the older cohort were likely to present with a history of cognitive impairment or be diagnosed with a condition contributing to an altered mental status. To our knowledge, this is the first study that has assessed characteristics of patients experiencing acute agitation in the ED based on age and demonstrated significant differences in potential contributing factors to acute agitation. These findings may have important implications in helping guide the selection of empiric regimens, especially when the cause of agitation cannot immediately be elucidated.

Lorazepam monotherapy, haloperidol monotherapy, and a combination of haloperidol, lorazepam, and diphenhydramine were the 3 most frequently prescribed regimens for acute agitation. There was low second-generation antipsychotic use. Outside of the VASNHS formulary, there were no policies or restrictions that would have prevented clinicians from ordering a particular anti-agitation medication during the study period.

Since the end of the period assessed in this study, VASNHS clinicians have been educated on the guidelines for anti-agitation medication regimens to encourage higher use of second-generation antipsychotics when appropriate. Training has been developed to prevent unnecessary delays when using these products. Barriers to second-generation antipsychotic use at VASNHS have also been identified and addressed. Previously, second-generation antipsychotics and the sterile water required for medication reconstitution were not overridable in Pyxis machines, often resulting in delays in administering these medications to acutely agitated patients. As of February 2023, olanzapine, ziprasidone, and sterile water are overridable, making them more accessible in situations when medication is urgently needed. Clinicians also expressed concern regarding a lack of familiarity with reconstituting and administering intramuscular second-generation antipsychotics.

While the general guidance has been to use lower doses of anti-agitation medications in patients aged ≥ 65 years, no significant differences were seen in doses ordered other than for lorazepam. In our study, however, there were no significant differences in adverse safety outcomes, though a higher proportion of patients in the older cohort experienced new respiratory-related outcomes after medication administration. Given the retrospective nature of this study and limited documentation of vital signs after medication administration, we cannot conclude the adverse safety outcomes were directly related to the anti-agitation medications. Most patients in both groups did not require additional doses of anti-agitation medications. The results of this study have been used to guide the development of an order set for anti-agitation medications.

 

 

Limitations

As a retrospective chart review, this study is unable to prove any differences in prescribing patterns for anti-agitation medications based on age. As a single-center study, the prescribing patterns and baseline characteristics are unique to the facility and not generalizable to all patients with acute agitation in the ED. Future, higher-quality studies with adequate power in diverse patient populations are needed to further elucidate differences in acute agitation etiology and anti-agitation medications based on patient age.

The anti-agitation medication used may have been skewed for patients with multiple and/or previous ED encounters. If information was available on previous causes of agitation and/or previous efficacy of regimens, this may have influenced selection. Additionally, clinical pharmacy specialists began providing daytime coverage in the ED in April 2022. As a part of their role, these pharmacists provide recommendations for medication selection in the management of acute agitation and can order anti-agitation medications. While no pharmacist prescriptions were identified in the study, their recommendations may have influenced medication selection toward the end of the study period.

Given the retrospective nature of the study, it is unclear whether medication selection may have been guided by the patient’s presentation or comorbidities to avoid adverse effects. This may have influenced the safety outcomes observed. Another limitation to this data is vital signs documentation. Vital signs were rarely documented in the ED within 1 hour of medication administration, meaning the vital signs captured may not be related to the agitation medication. Among the patients with documented vital signs, 20 patients were documented within 10 minutes, likely prior to when the medication had taken full effect. This time variability further limits the ability to link safety outcomes to medications and demonstrates a need for additional research. Very few patients had electrocardiogram data after medication administration. If patients did have an electrocardiogram measured in the ED, this more commonly occurred prior to any medication administration, which may have also guided clinicians in initial medication selection.

This study may have also overlooked risperidone use. Though risperidone is on the VASNHS formulary, it was not expected to be commonly used in the ED setting due to it only being available by mouth. However, oral medication use was higher than expected, and there were instances where clinicians initially ordered 1 of the included anti-agitation medications but patients ultimately received risperidone. Based on these findings, the current study may have overlooked this as an anti-agitation medication regimen. In addition, by excluding alcohol intoxication, alcohol withdrawal, and BZD withdrawal, this study did not fully capture the agitated population in our ED.

Conclusions

Anti-agitation medication prescribing patterns may differ between adults aged 18 to 64 years and those aged ≥ 65 years. The findings of this study also suggest that the most common agitation etiologies may differ based on patient age. Future studies should further explore anti-agitation medication use and agitation etiologies among older adults to guide medication prescribing.

Acknowledgments

We acknowledge Ted Turner, PharmD, BCPP, and Phong Ly, PharmD, BCPS, for their support and assistance on this project.

Each year, about 2.6% of emergency department (ED) visits involve agitation.¹ ED clinicians are especially prone to workplace violence and assault, facing the challenge of caring for patients while maintaining safety. A 2013 prospective study found an average of 4.15 violent events per employee in 9 months; nurses and patient care assistants were most frequently affected.² A 2022 survey from the American College of Emergency Physicians found 55% of respondents reported being physically assaulted in the ED and 79% of respondents reported witnessing another assault. Most of these assaults (98%) were committed by the patients.³ Appropriate management of patients experiencing acute agitation is critical for the safety of all parties involved.

The initial approach to acute agitation management involves nonpharmacologic measures in an attempt to avoid coercive actions, such as physical restraints. Reducing environmental stimulation and verbal de-escalation are effective and help the patients with agitation regain control over their behavior.⁴

When these measures fail, however, pharmacologic therapy is often administered to ensure safety. The goal of pharmacologic therapy is to calm the patient without causing sedation.⁵ This allows the patient to continue participating in their care and allows the care team to accurately assess them, which is critical in determining the underlying etiology of agitation. Historically, haloperidol has commonly been used to manage acute agitation. It is frequently administered with lorazepam and diphenhydramine to reduce the incidence of haloperidol’s extrapyramidal adverse effects. However, there are several potential concerns with this method, including oversedation, QTc prolongation, potential drug interactions, and polypharmacy.^5,6

The American Association of Emergency Psychiatry Project BETA Psychopharmacology Workgroup published a Consensus Statement in 2012 regarding the psychopharmacology of agitation.⁵ When considering medication for agitation management, clinicians must first determine a provisional diagnosis outlining the most probable etiology of the patient’s behavior, such as delirium, intoxication, or a psychiatric disorder. Apart from alcohol intoxication, benzodiazepines (BZDs) or second-generation antipsychotics as monotherapy are generally preferred over haloperidol for acute agitation.⁵ Second-generation antipsychotics have demonstrated to be as effective as haloperidol but are thought to be safer options. Quetiapine is not recommended for use in the ED due to the risk of orthostatic hypotension, as patients are often volume depleted.⁵The Veterans Affairs Southern Nevada Healthcare System (VASNHS) serves veterans in the Las Vegas area. Among the nearly 220,000 veterans in Nevada, about 100,000 veterans are aged ≥ 65 years.⁷ The 2012 consensus statement on psychopharmacology for agitation offers no specific age-related guidance. However, there are safety concerns in older adults both with antipsychotics and BZDs, even with acute use. The US Food and Drug Administration (FDA) issued a boxed warning for all antipsychotics due to increased mortality in older adult patients with dementia-related psychosis.⁸ The 2023 American Geriatrics Society Beers Criteria provides guidance on pharmacological therapy for adults aged ≥ 65 years and recommends avoiding antipsychotics and BZDs.⁹ In addition to the FDA boxed warning, data suggest increased mortality with antipsychotic use independent of dementia. With BZDs, changes in pharmacodynamics make older adults more prone to adverse effects, including cognitive impairment, delirium, falls, and fractures. A retrospective chart review evaluated risperidone use in the ED and found that adults aged ≥ 65 years experienced higher rates of hypotension, even though this age group received about half the dose of risperidone compared with younger patients.¹⁰ For this patient population, the general approach in treating acute agitation has been to avoid the use of medications, but prescribe lower doses when necessary.¹¹

With limited research on acute agitation management in older adults, the purpose of this study was to compare current prescribing practices of anti-agitation medications between adults aged 18 to 64 years and adults aged ≥ 65 years in the VASNHS ED. This study was also conducted to better understand the anti-agitation prescribing practices at VASNHS, as no order sets or protocols existed at the time of the study to guide medication selection in agitation management. To our knowledge, this is the first observational study evaluating pharmacologic acute agitation management in the ED based on age.

Methods

This study was a retrospective chart review of patients aged ≥ 18 years who presented to the VASNHS ED and received medication for acute agitation. Patients were identified through active orders for a formulary agitation medication from August 1, 2019, to July 31, 2022. Formulary medication options included intravenous, oral, and intramuscular routes for haloperidol, droperidol, lorazepam, olanzapine, or ziprasidone. Veterans were excluded if they presented with alcohol intoxication, alcohol or BZD withdrawal, if the medication administration was unrelated to agitation, or whether the medication was not administered. While alcohol and/or BZDs can contribute to acute agitation, these patients were excluded due to a clear indication for BZD therapy and the challenge in a retrospective chart review to determine whether patients received medication for agitation vs other withdrawal-related symptoms.

Endpoints

The primary endpoint was the medication selection between 2 age groups: 18 to 64 years and ≥ 65 years. The secondary endpoints included ordered medication dose by regimen, additional anti-agitation medication use within 3 hours of initial medication administration, and disposition. Safety outcomes included incidence of newly occurring oxygen desaturation < 95%, supplemental oxygen requirement, intubation, QTc prolongation, and hypotension with systolic blood pressure < 90 mm Hg within 1 hour of medication administration. Data collected included patient demographics, substance use, conditions contributing to altered mental status, active psychotropic medication prescriptions, medication adherence, agitation medication prescriber, and doses. Adherence to psychotropic medication in the past 6 months was defined as ≥ 80% of days covered with medication and based on fill history. This was only calculated for applicable patients and did not include patients with only as-needed medications, such as hydroxyzine for anxiety.

Statistical Analysis

Statistical analyses were performed using IBM SPSS. Baseline characteristics were analyzed using descriptive statistics. χ² and Fisher exact tests were used to analyze categorical data. A student t test was used for continuous variables and a 2-sided P value of < .05 was considered statistically significant.

 

 

Results

During the study period, 2342 unique patient encounters with active anti-agitation medication orders in the ED were identified and 232 encounters met the inclusion criteria. Of those excluded, 605 encounters had alcohol involvement. The study included 152 patient encounters for 128 patients aged 18 to 64 years of whom 16 patients had > 1 encounter with a mean (SD) 2.5 (1.1) visits. The study included 80 patient encounters for 72 patients aged ≥ 65 years of whom 7 patients had > 1 encounter with a mean (SD) 2.1 (0.3) visits. The mean age was 45.5 years in the younger cohort and 72.2 years in the older cohort. For data analysis and characterization of the ED population, each patient encounter was treated as a unique patient.

Baseline characteristics significantly differed between the 2 groups (Table 1). When comparing patients aged 18 to 64 years and those aged ≥ 65 years, the younger cohort had higher rates of substance use disorder diagnosis (55.3% vs 27.5%, P < .001), positive urine drug screen (69.7% vs 22.5%, P < .001), and 72-hour legal hold (59.9% vs 32.5%, P < .001) and lower rates of cognitive impairment or dementia (0.7% vs 48.8%, P < .001), and altered mental status-related diagnosis (2.0% vs 18.8%, P < .001). Diagnoses in the younger cohort included 1 each for hyperglycemia, urinary tract infection, and hyponatremia. Diagnoses in the older cohort included 4 for urinary tract infections, 4 for sepsis, 2 for encephalopathy, 2, for hyperglycemia, 1 gastrointestinal bleed, 1 thyrotoxicosis, and 1 respiratory failure.

Endpoints

The primary outcome of anti-agitation medication selection significantly differed between the younger cohort and older cohort (P = .02). All medication combinations ordered are shown in the eAppendix based on patient age and the percentage of patients in the age cohort that received that medication combination. Lorazepam monotherapy was the most common anti-agitation medication regimen ordered: 43.4% in patients aged 18 to 64 years and 41.3% in patients aged ≥ 65 years. Second-generation antipsychotic use was low.

Only 10.5% of patients aged 18 to 64 years and 8.8% of patients aged ≥ 65 years received a medication combination including a second-generation antipsychotic. Intramuscular administration (41.4%) was most common followed by intravenous (37.5%), oral (19.8%), and oral disintegrating tablets (1.3%). The median (IQR) number of anti-agitation medications ordered by a prescriber was 6 (3-11) and 18 of 28 prescribers did not prescribe second-generation antipsychotics.

Medication doses ordered did not significantly differ except lorazepam monotherapy, as patients aged ≥ 65 received a lower dose (P = .007) (Table 2). Given the limited data within 1 hour, the first set of vital signs available after medication administration was used for analysis of safety outcomes. Vital signs were documented within 1 hour after medication administration for only 28.3% of patients aged 18 to 64 years and 42.5% of patients aged ≥ 65 years. The median (IQR) time to documentation for vital signs after medication administration was 96 minutes (56-177) for patients aged 18 to 64 years and 64 minutes (25-121) for patients aged ≥ 65 years. Electrocardiogram measurement after medication administration only occurred in 7.9% of patients aged 18 to 64 years and 5% of patients aged ≥ 65 years.

Fourteen patients (7.9%) aged 18 to 64 years and 17 patients (15.0%) aged ≥ 65 years experienced an adverse outcome (P = .09) (Table 3). Most patients who had an adverse safety outcome experienced new oxygen desaturation < 95%. Of those patients, only a small proportion required new supplemental oxygen or intubation. The 2 patients intubated had ongoing medical issues complicating their course in the ED. New QTc prolongation was only documented in haloperidol-containing regimens.

The proportion of patients requiring additional anti-agitation medication doses within 3 hours following initial administration was similar between the 2 groups. The mean (SD) amount of time to administration of subsequent dose was 55 minutes (30) in the younger cohort and 64 minutes (36) in the older cohort. Patient disposition from the ED, significantly differed based on age (P < .001) (Table 4). Patients aged 18 to 64 years were more frequently admitted to the psychiatry unit, while patients aged ≥ 65 years were primarily admitted to the hospital. One patient in the younger cohort died due to hyponatremia.

 

 

Discussion

The most likely causes of acute agitation significantly differed between patients aged 18 to 64 years and patients aged ≥ 65 years. Patients in the younger cohort were more likely to present with a history of substance use disorder or a positive urine drug screen for illicit substances. They were also more likely to have a 72-hour legal hold initiated, suggesting higher rates of suicidal and/or homicidal ideations. Patients in the older cohort were likely to present with a history of cognitive impairment or be diagnosed with a condition contributing to an altered mental status. To our knowledge, this is the first study that has assessed characteristics of patients experiencing acute agitation in the ED based on age and demonstrated significant differences in potential contributing factors to acute agitation. These findings may have important implications in helping guide the selection of empiric regimens, especially when the cause of agitation cannot immediately be elucidated.

Lorazepam monotherapy, haloperidol monotherapy, and a combination of haloperidol, lorazepam, and diphenhydramine were the 3 most frequently prescribed regimens for acute agitation. There was low second-generation antipsychotic use. Outside of the VASNHS formulary, there were no policies or restrictions that would have prevented clinicians from ordering a particular anti-agitation medication during the study period.

Since the end of the period assessed in this study, VASNHS clinicians have been educated on the guidelines for anti-agitation medication regimens to encourage higher use of second-generation antipsychotics when appropriate. Training has been developed to prevent unnecessary delays when using these products. Barriers to second-generation antipsychotic use at VASNHS have also been identified and addressed. Previously, second-generation antipsychotics and the sterile water required for medication reconstitution were not overridable in Pyxis machines, often resulting in delays in administering these medications to acutely agitated patients. As of February 2023, olanzapine, ziprasidone, and sterile water are overridable, making them more accessible in situations when medication is urgently needed. Clinicians also expressed concern regarding a lack of familiarity with reconstituting and administering intramuscular second-generation antipsychotics.

While the general guidance has been to use lower doses of anti-agitation medications in patients aged ≥ 65 years, no significant differences were seen in doses ordered other than for lorazepam. In our study, however, there were no significant differences in adverse safety outcomes, though a higher proportion of patients in the older cohort experienced new respiratory-related outcomes after medication administration. Given the retrospective nature of this study and limited documentation of vital signs after medication administration, we cannot conclude the adverse safety outcomes were directly related to the anti-agitation medications. Most patients in both groups did not require additional doses of anti-agitation medications. The results of this study have been used to guide the development of an order set for anti-agitation medications.

 

 

Limitations

As a retrospective chart review, this study is unable to prove any differences in prescribing patterns for anti-agitation medications based on age. As a single-center study, the prescribing patterns and baseline characteristics are unique to the facility and not generalizable to all patients with acute agitation in the ED. Future, higher-quality studies with adequate power in diverse patient populations are needed to further elucidate differences in acute agitation etiology and anti-agitation medications based on patient age.

The anti-agitation medication used may have been skewed for patients with multiple and/or previous ED encounters. If information was available on previous causes of agitation and/or previous efficacy of regimens, this may have influenced selection. Additionally, clinical pharmacy specialists began providing daytime coverage in the ED in April 2022. As a part of their role, these pharmacists provide recommendations for medication selection in the management of acute agitation and can order anti-agitation medications. While no pharmacist prescriptions were identified in the study, their recommendations may have influenced medication selection toward the end of the study period.

Given the retrospective nature of the study, it is unclear whether medication selection may have been guided by the patient’s presentation or comorbidities to avoid adverse effects. This may have influenced the safety outcomes observed. Another limitation to this data is vital signs documentation. Vital signs were rarely documented in the ED within 1 hour of medication administration, meaning the vital signs captured may not be related to the agitation medication. Among the patients with documented vital signs, 20 patients were documented within 10 minutes, likely prior to when the medication had taken full effect. This time variability further limits the ability to link safety outcomes to medications and demonstrates a need for additional research. Very few patients had electrocardiogram data after medication administration. If patients did have an electrocardiogram measured in the ED, this more commonly occurred prior to any medication administration, which may have also guided clinicians in initial medication selection.

This study may have also overlooked risperidone use. Though risperidone is on the VASNHS formulary, it was not expected to be commonly used in the ED setting due to it only being available by mouth. However, oral medication use was higher than expected, and there were instances where clinicians initially ordered 1 of the included anti-agitation medications but patients ultimately received risperidone. Based on these findings, the current study may have overlooked this as an anti-agitation medication regimen. In addition, by excluding alcohol intoxication, alcohol withdrawal, and BZD withdrawal, this study did not fully capture the agitated population in our ED.

Conclusions

Anti-agitation medication prescribing patterns may differ between adults aged 18 to 64 years and those aged ≥ 65 years. The findings of this study also suggest that the most common agitation etiologies may differ based on patient age. Future studies should further explore anti-agitation medication use and agitation etiologies among older adults to guide medication prescribing.

Acknowledgments

We acknowledge Ted Turner, PharmD, BCPP, and Phong Ly, PharmD, BCPS, for their support and assistance on this project.

The Veterans Health Administration (VHA) is understaffed for clinical psychologists who have specialty training in geriatrics (ie, geropsychologists) to meet the needs of aging veterans. Though only 16.8% of US adults are aged ≥ 65 years,¹ this age group comprises 45.9% of patients within the VHA.² The needs of older adults are complex and warrant specialized services from mental health clinicians trained to understand lifespan developmental processes, biological changes associated with aging, and changes in psychosocial functioning.

Older veterans (aged ≥ 65 years) present with higher rates of combined medical and mental health diagnoses compared to both younger veterans and older adults who are not veterans.³ Nearly 1 of 5 (18.1%) older veterans who use VHA services have confirmed mental health diagnoses, and an additional 25.5% have documented mental health concerns without a formal diagnosis in their health record.⁴ The clinical presentations of older veterans frequently differ from younger adults and include greater complexity. For example, older veterans face an increased risk of cognitive impairment compared to the general population, due in part to higher prevalence of posttraumatic stress, which doubles their risk of developing dementia.⁵ Additional examples of multicomplexity among older veterans may include co-occurring medical and psychiatric diagnoses, the presence of delirium, social isolation/loneliness, and concerns related to polypharmacy. These complex presentations result in significant challenges for mental health clinicians in areas like assessment (eg, accuracy of case conceptualization), intervention (eg, selection and prioritization), and consultation (eg, coordination among multiple medical and mental health specialists).

Older veterans also present with substantial resilience. Research has found that aging veterans exposed to trauma during their military service often review their memories and past experiences, which is known as later-adulthood trauma reengagement.⁶ Through this normative life review process, veterans engage with memories and experiences from their past that they previously avoided, which could lead to posttraumatic growth for some. Unfortunately, others may experience an increase in psychological distress. Mental health clinicians with specialty expertise and training in aging and lifespan development can facilitate positive outcomes to reduce distress.⁷

The United States in general, and the VHA specifically, face a growing shortage of geriatric mental health clinicians. In a 2015 American Psychological Association survey, 1528 of 4109 respondents (37.2%) reported they frequently or very frequently administered care to older adults, yet only 49 respondents (1.2%) reported geropsychology as their specialty.⁸ According to the National Provider Registry, 660 clinicians self-identified as geropsychologists (ie, those who self-reported “psychologist: adult development and aging” as an NPI Healthcare Provider taxonomy code) in the US, representing < 1% of all doctoral level psychologists.⁹ The number of psychologists who obtain board certification from the American Board of Geropsychology is even lower (only 112 clinicians as of February 2024).¹⁰ Many psychologists within the VHA treat older veterans in integrated health settings such as primary care, home-based primary care, community living centers, or behavioral health care, but many lack formal training in geropsychology.

The Geriatric Scholars Program (GSP) was developed in 2008 to address the training gap and provide education in geriatrics to VHA clinicians that treat older veterans, particularly in rural areas.^11,12 The GSP initially focused on primary care physicians, nurse practitioners, physician assistants, and pharmacists. It was later expanded to include other disciplines (ie, social work, rehabilitation therapists, and psychiatrists). In 2013, the GSP – Psychology Track (GSP-P) was developed with funding from the VHA Offices of Rural Health and Geriatrics and Extended Care specifically for psychologists.

This article describes the multicomponent longitudinal GSP-P, which has evolved to meet the target audience’s ongoing needs for knowledge, skills, and opportunities to refine practice behaviors. GSP-P received the 2020 Award for Excellence in Geropsychology Training from the Council of Professional Geropsychology Training Programs. GSP-P has grown within the context of the larger GSP and aligns with the other existing elective learning opportunities (Figure 1).

Program description

Introductory Course

Psychologist subject matter experts (SMEs) developed an intensive course in geropsychology in the absence of a similar course in the geriatric medicine board review curriculum. SMEs reviewed the guidelines for practice by professional organizations like the Pikes Peak Geropsychology Competencies, which outline knowledge and skills in various domains.¹³ SMEs integrated this review with findings from a needs assessment for postlicensed VHA psychology staff in 4 health care systems, drafted a syllabus, and circulated it to geropsychology experts for feedback. The resulting multiday course covered general mental health as well as topics particularly salient for mental health clinicians treating older veterans including suicide prevention and posttraumatic stress disorder (PTSD).¹⁴ This Geropsychology Competencies Review Course was piloted in 1 region initially before being offered nationally in 2014. The previously published evaluation findings demonstrated significant improvements from precourse to 3 months postcourse in confidence and knowledge in 4 key areas of geropsychology: General knowledge about adult development and aging, assessment, intervention, and consultation.¹⁵ These domains align with the Pikes Peak Geropsychology Competencies and are measured by a subset of items from the Geropsychology Knowledge and Skills Assessment Tool.^13,16 As of October 2023, 8 introductory courses have been held with 173 participants (Table).

Quality Improvement

Introductory course attendees also participate in an intensive day-long interactive workshop in quality improvement (QI). After completing these trainings, they apply what they have learned at their home facility by embarking on a QI project related to geriatrics. The QI projects reinforce learning and initiate practice changes not only for attendees but at times the larger health care system. Topics are selected by scholars in response to the needs they observe in their clinics. Recent GSP projects include efforts to increase screenings for depression and anxiety, improve adherence to VHA dementia policy, increase access to virtual care, and increase referrals to programs such as whole health or cognitive behavioral therapy for insomnia, a first-line treatment for insomnia in older adults.¹⁷ Another project targeted the improvement of referrals to the Compassionate Contact Corps in an effort to reduce social isolation and loneliness among older veterans.¹⁸ Evaluations demonstrate significant improvement in scholars’ confidence in related program development and management from precourse to 3 months postcourse.¹⁵

Webinars

The Addressing Geriatric Mental Health webinar series was created to introduce learners to topics that could not be covered in the introductory course. Topics were suggested by the expert reviewers of the curriculum or identified by the scholars themselves (eg, chronic pain, sexuality, or serious mental illness). A secondary function of the webinars was to reach a broader audience. Over time, scholars and webinar attendees requested opportunities to explore topics in greater depth (eg, PTSD later in life). These requests led the webinars to focus on annual themes.

The series is open to all disciplines of geriatric scholars, VHA staff, and non-VHA staff through the Veterans Affairs Talent Management System and the TRAIN Learning Network (train.org). Attendance for the 37 webinars was captured from logins to the virtual learning platform and may underestimate attendance if a group attended on a single screen. Average attendance increased from 157 attendees/webinar in 2015 to 418 attendees/webinar in 2023 (Figure 2). This may have been related to the increase in virtual learning during the COVID-19 pandemic, but represents a 166% increase in audience from the inaugural year of the series.

Advanced Learning Opportunities

To invest in the ongoing growth and development of introductory course graduates, GSP-P developed and offered an advanced workshop in 2019. This multiday workshop focused on further enhancement of geropsychology competencies, with an emphasis on treating older veterans with mental and physical comorbidities. Didactics and experiential learning exercises led by SMEs covered topics such as adjusting to chronic illness, capacity assessment, PTSD, insomnia and sleep changes, chronic pain, and psychological interventions in palliative care and hospice settings. Evaluation findings demonstrated significant improvements from precourse to 6 months postcourse in confidence and knowledge as defined by the Pikes Peak Geropsychology Competencies.¹⁹

To facilitate ongoing and individually tailored learning following the advanced workshop, scholars also developed and executed independent learning plans (ILPs) during a 6-month window with consultation from an experienced geropsychologist. Fifteen of 19 scholars (78.9%) completed ILPs with an average of 3 learning goals listed. After completing the ILPs, scholars endorsed their clinical and/or personal usefulness, citing increased confidence, enhanced skills for use with patients with complex needs, personal fulfillment, and career advancement. Most scholars noted ILPs were feasible and learning resources were accessible. Overall, the evaluation found ILPs to be a valuable way to enhance psychologists’ learning and effectiveness in treating older veterans with complex health needs.²⁰

 

 

Clinical Practica

All geriatric scholars who completed the program have additional opportunities for professional development through practicum experiences focused on specific clinical approaches to the care of older veterans, such as dementia care, pain management, geriatric assessment, and palliative care. These practica provide scholars with individualized learning experiences in an individualized or small group setting and may be conducted either in-person or virtually.

In response to an expressed need from those who completed the program, the GSP-P planning committee collaborated with an SME to develop a virtual practicum to assess patients’ decision making capacity. Evaluating capacities among older adults is a common request, yet clinicians report little to no formal training in how to conceptualize and approach these complex questions.^21,22 Utilizing an evidence-informed and structured approach promotes the balancing of an older adult’s autonomy and professional ethics. Learning capacity evaluation skills could better position psychologists to not only navigate complex ethical, legal, and clinical situations, but also serve as expert consultants to interdisciplinary teams. This virtual practicum was initiated in 2022 and to date has included 10 scholars. The practicum includes multiple modalities of learning: (1) self-directed review of core concepts; (2) attendance at 4 capacity didactics focused on introduction to evaluating capacities, medical consent and decision making, financial decision making and management, and independent living; and (3) participation in 5 group consultations on capacity evaluations conducted at their home sites. During these group consultations, additional case examples were shared to reinforce capacity concepts.

Discussion

The objective of GSP-P is to enhance geropsychology practice competencies among VHA psychologists given the outsized representation of older adults within the VHA system and their complex care needs. The curricula have significantly evolved to accomplish this, expanding the reach and investing in the continuing growth and development of scholars.

There are several elements that set GSP apart from other geriatric and geropsychology continuing medical education programs. The first is that the training is veteran focused, allowing us to discuss the unique impact military service has on aging. Similarly, because all scholars work within the integrated health care system, we can introduce and review key resources and programs that benefit all veterans and their families/care partners across the system. Through the GSP, the VA invests in ongoing professional development. Scholars can participate in additional experiential practica, webinars, and advanced workshops tailored to their individual learning needs. Lastly, the GSP works to create a community among its scholars where they can not only continue to consult with presenters/instructors, but also one another. A planned future direction for the GSP-P is to incorporate quarterly office hours and discussions for alumni to develop an increased sense of community. This may strengthen commitment to the overall VA mission, leading to increased retainment of talent who now have the knowledge, skills, and confidence to care for aging veterans.

Limitations

GSP is limited by its available funding. Additionally, the number of participants who can enroll each year in GSP-P (not including webinars) is capped by policy. Another limitation is the number of QI coaches available to mentor scholars on their projects.

 

 

Conclusions

Outcomes of GSP-P have been extremely favorable. Following participation in the program, we have found a significant increase in confidence in geropsychology practice among clinicians, as well as enhanced knowledge and skills across competency domains.^15,19 We have observed rising attendance in our annual webinar series and graduates of our introductory courses participate in subsequent trainings (eg, advanced workshop or virtual practicum). Several graduates of GSP-P have become board certified in geropsychology by the American Board of Geropsychology and many proceed to supervise geropsychology-focused clinical rotations for psychology practicum students, predoctoral interns, and postdoctoral fellows. This suggests that the reach of GSP-P programming may extend farther than reported in this article.

The needs of aging veterans have also changed based on cohort differences, as the population of World War II and Korean War era veterans has declined and the number of older Vietnam era veterans has grown. We expect different challenges with older Gulf War and post-9/11 era veterans. For instance, 17% of troops deployed to Iraq or Afghanistan following 9/11 experienced mild traumatic brain injury (TBI), and 59% of those experienced > 1 mild TBI.²³ Research indicates that younger post-9/11 veterans have a 3-fold risk of developing early onset dementia after experiencing a TBI.²⁴ Therefore, even though post-9/11 veterans are not older in terms of chronological age, some may experience symptoms and conditions more often occurring in older veterans. As a result, it would be beneficial for clinicians to learn about the presentation and treatment of geriatric conditions such as dementia.

Moving forward, the GSP-P should identify potential opportunities to collaborate with the non-VHA mental health community–which also faces a shortage of geriatric mental health clinicians–to extend educational opportunities to improve care for veterans in all settings (eg, cosponsor training opportunities open to both VHA and non-VHA clinicians).^8,25 Many aging veterans may receive portions of their health care outside the VHA, particularly those who reside in rural areas. Additionally, as veterans age, so do their support systems (eg, family members, friends, spouses, caregivers, and even clinicians), most of whom will receive care outside of the VHA. Community education collaborations will not only improve the care of older veterans, but also the care of older adults in the general population.

Promising directions include the adoption of the GSP model in other health care settings. Recently, Indian Health Service has adapted the model, beginning with primary care clinicians and pharmacists and is beginning to expand to other disciplines. Additional investments in VHA workforce training include the availability of geropsychology internship and fellowship training opportunities through the Office of Academic Affiliations, which provide earlier opportunities to specialize in geropsychology. Continued investment in both prelicensure and postpsychology licensure training efforts are needed within the VHA to meet the geriatric mental health needs of veterans.

Acknowledgments

The authors wish to acknowledge Terri Huh, PhD, for her contributions to the development and initiation of the GSP-P. The authors also appreciate the collaboration and quality initiative training led by Carol Callaway-Lane, DNP, ACNP-BC, and her team.

The Veterans Health Administration (VHA) is understaffed for clinical psychologists who have specialty training in geriatrics (ie, geropsychologists) to meet the needs of aging veterans. Though only 16.8% of US adults are aged ≥ 65 years,¹ this age group comprises 45.9% of patients within the VHA.² The needs of older adults are complex and warrant specialized services from mental health clinicians trained to understand lifespan developmental processes, biological changes associated with aging, and changes in psychosocial functioning.

Older veterans (aged ≥ 65 years) present with higher rates of combined medical and mental health diagnoses compared to both younger veterans and older adults who are not veterans.³ Nearly 1 of 5 (18.1%) older veterans who use VHA services have confirmed mental health diagnoses, and an additional 25.5% have documented mental health concerns without a formal diagnosis in their health record.⁴ The clinical presentations of older veterans frequently differ from younger adults and include greater complexity. For example, older veterans face an increased risk of cognitive impairment compared to the general population, due in part to higher prevalence of posttraumatic stress, which doubles their risk of developing dementia.⁵ Additional examples of multicomplexity among older veterans may include co-occurring medical and psychiatric diagnoses, the presence of delirium, social isolation/loneliness, and concerns related to polypharmacy. These complex presentations result in significant challenges for mental health clinicians in areas like assessment (eg, accuracy of case conceptualization), intervention (eg, selection and prioritization), and consultation (eg, coordination among multiple medical and mental health specialists).

Older veterans also present with substantial resilience. Research has found that aging veterans exposed to trauma during their military service often review their memories and past experiences, which is known as later-adulthood trauma reengagement.⁶ Through this normative life review process, veterans engage with memories and experiences from their past that they previously avoided, which could lead to posttraumatic growth for some. Unfortunately, others may experience an increase in psychological distress. Mental health clinicians with specialty expertise and training in aging and lifespan development can facilitate positive outcomes to reduce distress.⁷

The United States in general, and the VHA specifically, face a growing shortage of geriatric mental health clinicians. In a 2015 American Psychological Association survey, 1528 of 4109 respondents (37.2%) reported they frequently or very frequently administered care to older adults, yet only 49 respondents (1.2%) reported geropsychology as their specialty.⁸ According to the National Provider Registry, 660 clinicians self-identified as geropsychologists (ie, those who self-reported “psychologist: adult development and aging” as an NPI Healthcare Provider taxonomy code) in the US, representing < 1% of all doctoral level psychologists.⁹ The number of psychologists who obtain board certification from the American Board of Geropsychology is even lower (only 112 clinicians as of February 2024).¹⁰ Many psychologists within the VHA treat older veterans in integrated health settings such as primary care, home-based primary care, community living centers, or behavioral health care, but many lack formal training in geropsychology.

The Geriatric Scholars Program (GSP) was developed in 2008 to address the training gap and provide education in geriatrics to VHA clinicians that treat older veterans, particularly in rural areas.^11,12 The GSP initially focused on primary care physicians, nurse practitioners, physician assistants, and pharmacists. It was later expanded to include other disciplines (ie, social work, rehabilitation therapists, and psychiatrists). In 2013, the GSP – Psychology Track (GSP-P) was developed with funding from the VHA Offices of Rural Health and Geriatrics and Extended Care specifically for psychologists.

This article describes the multicomponent longitudinal GSP-P, which has evolved to meet the target audience’s ongoing needs for knowledge, skills, and opportunities to refine practice behaviors. GSP-P received the 2020 Award for Excellence in Geropsychology Training from the Council of Professional Geropsychology Training Programs. GSP-P has grown within the context of the larger GSP and aligns with the other existing elective learning opportunities (Figure 1).

Program description

Introductory Course

Psychologist subject matter experts (SMEs) developed an intensive course in geropsychology in the absence of a similar course in the geriatric medicine board review curriculum. SMEs reviewed the guidelines for practice by professional organizations like the Pikes Peak Geropsychology Competencies, which outline knowledge and skills in various domains.¹³ SMEs integrated this review with findings from a needs assessment for postlicensed VHA psychology staff in 4 health care systems, drafted a syllabus, and circulated it to geropsychology experts for feedback. The resulting multiday course covered general mental health as well as topics particularly salient for mental health clinicians treating older veterans including suicide prevention and posttraumatic stress disorder (PTSD).¹⁴ This Geropsychology Competencies Review Course was piloted in 1 region initially before being offered nationally in 2014. The previously published evaluation findings demonstrated significant improvements from precourse to 3 months postcourse in confidence and knowledge in 4 key areas of geropsychology: General knowledge about adult development and aging, assessment, intervention, and consultation.¹⁵ These domains align with the Pikes Peak Geropsychology Competencies and are measured by a subset of items from the Geropsychology Knowledge and Skills Assessment Tool.^13,16 As of October 2023, 8 introductory courses have been held with 173 participants (Table).

Quality Improvement

Introductory course attendees also participate in an intensive day-long interactive workshop in quality improvement (QI). After completing these trainings, they apply what they have learned at their home facility by embarking on a QI project related to geriatrics. The QI projects reinforce learning and initiate practice changes not only for attendees but at times the larger health care system. Topics are selected by scholars in response to the needs they observe in their clinics. Recent GSP projects include efforts to increase screenings for depression and anxiety, improve adherence to VHA dementia policy, increase access to virtual care, and increase referrals to programs such as whole health or cognitive behavioral therapy for insomnia, a first-line treatment for insomnia in older adults.¹⁷ Another project targeted the improvement of referrals to the Compassionate Contact Corps in an effort to reduce social isolation and loneliness among older veterans.¹⁸ Evaluations demonstrate significant improvement in scholars’ confidence in related program development and management from precourse to 3 months postcourse.¹⁵

Webinars

The Addressing Geriatric Mental Health webinar series was created to introduce learners to topics that could not be covered in the introductory course. Topics were suggested by the expert reviewers of the curriculum or identified by the scholars themselves (eg, chronic pain, sexuality, or serious mental illness). A secondary function of the webinars was to reach a broader audience. Over time, scholars and webinar attendees requested opportunities to explore topics in greater depth (eg, PTSD later in life). These requests led the webinars to focus on annual themes.

The series is open to all disciplines of geriatric scholars, VHA staff, and non-VHA staff through the Veterans Affairs Talent Management System and the TRAIN Learning Network (train.org). Attendance for the 37 webinars was captured from logins to the virtual learning platform and may underestimate attendance if a group attended on a single screen. Average attendance increased from 157 attendees/webinar in 2015 to 418 attendees/webinar in 2023 (Figure 2). This may have been related to the increase in virtual learning during the COVID-19 pandemic, but represents a 166% increase in audience from the inaugural year of the series.

Advanced Learning Opportunities

To invest in the ongoing growth and development of introductory course graduates, GSP-P developed and offered an advanced workshop in 2019. This multiday workshop focused on further enhancement of geropsychology competencies, with an emphasis on treating older veterans with mental and physical comorbidities. Didactics and experiential learning exercises led by SMEs covered topics such as adjusting to chronic illness, capacity assessment, PTSD, insomnia and sleep changes, chronic pain, and psychological interventions in palliative care and hospice settings. Evaluation findings demonstrated significant improvements from precourse to 6 months postcourse in confidence and knowledge as defined by the Pikes Peak Geropsychology Competencies.¹⁹

To facilitate ongoing and individually tailored learning following the advanced workshop, scholars also developed and executed independent learning plans (ILPs) during a 6-month window with consultation from an experienced geropsychologist. Fifteen of 19 scholars (78.9%) completed ILPs with an average of 3 learning goals listed. After completing the ILPs, scholars endorsed their clinical and/or personal usefulness, citing increased confidence, enhanced skills for use with patients with complex needs, personal fulfillment, and career advancement. Most scholars noted ILPs were feasible and learning resources were accessible. Overall, the evaluation found ILPs to be a valuable way to enhance psychologists’ learning and effectiveness in treating older veterans with complex health needs.²⁰

 

 

Clinical Practica

All geriatric scholars who completed the program have additional opportunities for professional development through practicum experiences focused on specific clinical approaches to the care of older veterans, such as dementia care, pain management, geriatric assessment, and palliative care. These practica provide scholars with individualized learning experiences in an individualized or small group setting and may be conducted either in-person or virtually.

In response to an expressed need from those who completed the program, the GSP-P planning committee collaborated with an SME to develop a virtual practicum to assess patients’ decision making capacity. Evaluating capacities among older adults is a common request, yet clinicians report little to no formal training in how to conceptualize and approach these complex questions.^21,22 Utilizing an evidence-informed and structured approach promotes the balancing of an older adult’s autonomy and professional ethics. Learning capacity evaluation skills could better position psychologists to not only navigate complex ethical, legal, and clinical situations, but also serve as expert consultants to interdisciplinary teams. This virtual practicum was initiated in 2022 and to date has included 10 scholars. The practicum includes multiple modalities of learning: (1) self-directed review of core concepts; (2) attendance at 4 capacity didactics focused on introduction to evaluating capacities, medical consent and decision making, financial decision making and management, and independent living; and (3) participation in 5 group consultations on capacity evaluations conducted at their home sites. During these group consultations, additional case examples were shared to reinforce capacity concepts.

Discussion

The objective of GSP-P is to enhance geropsychology practice competencies among VHA psychologists given the outsized representation of older adults within the VHA system and their complex care needs. The curricula have significantly evolved to accomplish this, expanding the reach and investing in the continuing growth and development of scholars.

There are several elements that set GSP apart from other geriatric and geropsychology continuing medical education programs. The first is that the training is veteran focused, allowing us to discuss the unique impact military service has on aging. Similarly, because all scholars work within the integrated health care system, we can introduce and review key resources and programs that benefit all veterans and their families/care partners across the system. Through the GSP, the VA invests in ongoing professional development. Scholars can participate in additional experiential practica, webinars, and advanced workshops tailored to their individual learning needs. Lastly, the GSP works to create a community among its scholars where they can not only continue to consult with presenters/instructors, but also one another. A planned future direction for the GSP-P is to incorporate quarterly office hours and discussions for alumni to develop an increased sense of community. This may strengthen commitment to the overall VA mission, leading to increased retainment of talent who now have the knowledge, skills, and confidence to care for aging veterans.

Limitations

GSP is limited by its available funding. Additionally, the number of participants who can enroll each year in GSP-P (not including webinars) is capped by policy. Another limitation is the number of QI coaches available to mentor scholars on their projects.

 

 

Conclusions

Outcomes of GSP-P have been extremely favorable. Following participation in the program, we have found a significant increase in confidence in geropsychology practice among clinicians, as well as enhanced knowledge and skills across competency domains.^15,19 We have observed rising attendance in our annual webinar series and graduates of our introductory courses participate in subsequent trainings (eg, advanced workshop or virtual practicum). Several graduates of GSP-P have become board certified in geropsychology by the American Board of Geropsychology and many proceed to supervise geropsychology-focused clinical rotations for psychology practicum students, predoctoral interns, and postdoctoral fellows. This suggests that the reach of GSP-P programming may extend farther than reported in this article.

The needs of aging veterans have also changed based on cohort differences, as the population of World War II and Korean War era veterans has declined and the number of older Vietnam era veterans has grown. We expect different challenges with older Gulf War and post-9/11 era veterans. For instance, 17% of troops deployed to Iraq or Afghanistan following 9/11 experienced mild traumatic brain injury (TBI), and 59% of those experienced > 1 mild TBI.²³ Research indicates that younger post-9/11 veterans have a 3-fold risk of developing early onset dementia after experiencing a TBI.²⁴ Therefore, even though post-9/11 veterans are not older in terms of chronological age, some may experience symptoms and conditions more often occurring in older veterans. As a result, it would be beneficial for clinicians to learn about the presentation and treatment of geriatric conditions such as dementia.

Moving forward, the GSP-P should identify potential opportunities to collaborate with the non-VHA mental health community–which also faces a shortage of geriatric mental health clinicians–to extend educational opportunities to improve care for veterans in all settings (eg, cosponsor training opportunities open to both VHA and non-VHA clinicians).^8,25 Many aging veterans may receive portions of their health care outside the VHA, particularly those who reside in rural areas. Additionally, as veterans age, so do their support systems (eg, family members, friends, spouses, caregivers, and even clinicians), most of whom will receive care outside of the VHA. Community education collaborations will not only improve the care of older veterans, but also the care of older adults in the general population.

Promising directions include the adoption of the GSP model in other health care settings. Recently, Indian Health Service has adapted the model, beginning with primary care clinicians and pharmacists and is beginning to expand to other disciplines. Additional investments in VHA workforce training include the availability of geropsychology internship and fellowship training opportunities through the Office of Academic Affiliations, which provide earlier opportunities to specialize in geropsychology. Continued investment in both prelicensure and postpsychology licensure training efforts are needed within the VHA to meet the geriatric mental health needs of veterans.

Acknowledgments

The authors wish to acknowledge Terri Huh, PhD, for her contributions to the development and initiation of the GSP-P. The authors also appreciate the collaboration and quality initiative training led by Carol Callaway-Lane, DNP, ACNP-BC, and her team.

The Veterans Health Administration (VHA) is understaffed for clinical psychologists who have specialty training in geriatrics (ie, geropsychologists) to meet the needs of aging veterans. Though only 16.8% of US adults are aged ≥ 65 years,¹ this age group comprises 45.9% of patients within the VHA.² The needs of older adults are complex and warrant specialized services from mental health clinicians trained to understand lifespan developmental processes, biological changes associated with aging, and changes in psychosocial functioning.

Older veterans (aged ≥ 65 years) present with higher rates of combined medical and mental health diagnoses compared to both younger veterans and older adults who are not veterans.³ Nearly 1 of 5 (18.1%) older veterans who use VHA services have confirmed mental health diagnoses, and an additional 25.5% have documented mental health concerns without a formal diagnosis in their health record.⁴ The clinical presentations of older veterans frequently differ from younger adults and include greater complexity. For example, older veterans face an increased risk of cognitive impairment compared to the general population, due in part to higher prevalence of posttraumatic stress, which doubles their risk of developing dementia.⁵ Additional examples of multicomplexity among older veterans may include co-occurring medical and psychiatric diagnoses, the presence of delirium, social isolation/loneliness, and concerns related to polypharmacy. These complex presentations result in significant challenges for mental health clinicians in areas like assessment (eg, accuracy of case conceptualization), intervention (eg, selection and prioritization), and consultation (eg, coordination among multiple medical and mental health specialists).

Older veterans also present with substantial resilience. Research has found that aging veterans exposed to trauma during their military service often review their memories and past experiences, which is known as later-adulthood trauma reengagement.⁶ Through this normative life review process, veterans engage with memories and experiences from their past that they previously avoided, which could lead to posttraumatic growth for some. Unfortunately, others may experience an increase in psychological distress. Mental health clinicians with specialty expertise and training in aging and lifespan development can facilitate positive outcomes to reduce distress.⁷

The United States in general, and the VHA specifically, face a growing shortage of geriatric mental health clinicians. In a 2015 American Psychological Association survey, 1528 of 4109 respondents (37.2%) reported they frequently or very frequently administered care to older adults, yet only 49 respondents (1.2%) reported geropsychology as their specialty.⁸ According to the National Provider Registry, 660 clinicians self-identified as geropsychologists (ie, those who self-reported “psychologist: adult development and aging” as an NPI Healthcare Provider taxonomy code) in the US, representing < 1% of all doctoral level psychologists.⁹ The number of psychologists who obtain board certification from the American Board of Geropsychology is even lower (only 112 clinicians as of February 2024).¹⁰ Many psychologists within the VHA treat older veterans in integrated health settings such as primary care, home-based primary care, community living centers, or behavioral health care, but many lack formal training in geropsychology.

The Geriatric Scholars Program (GSP) was developed in 2008 to address the training gap and provide education in geriatrics to VHA clinicians that treat older veterans, particularly in rural areas.^11,12 The GSP initially focused on primary care physicians, nurse practitioners, physician assistants, and pharmacists. It was later expanded to include other disciplines (ie, social work, rehabilitation therapists, and psychiatrists). In 2013, the GSP – Psychology Track (GSP-P) was developed with funding from the VHA Offices of Rural Health and Geriatrics and Extended Care specifically for psychologists.

This article describes the multicomponent longitudinal GSP-P, which has evolved to meet the target audience’s ongoing needs for knowledge, skills, and opportunities to refine practice behaviors. GSP-P received the 2020 Award for Excellence in Geropsychology Training from the Council of Professional Geropsychology Training Programs. GSP-P has grown within the context of the larger GSP and aligns with the other existing elective learning opportunities (Figure 1).

Program description

Introductory Course

Psychologist subject matter experts (SMEs) developed an intensive course in geropsychology in the absence of a similar course in the geriatric medicine board review curriculum. SMEs reviewed the guidelines for practice by professional organizations like the Pikes Peak Geropsychology Competencies, which outline knowledge and skills in various domains.¹³ SMEs integrated this review with findings from a needs assessment for postlicensed VHA psychology staff in 4 health care systems, drafted a syllabus, and circulated it to geropsychology experts for feedback. The resulting multiday course covered general mental health as well as topics particularly salient for mental health clinicians treating older veterans including suicide prevention and posttraumatic stress disorder (PTSD).¹⁴ This Geropsychology Competencies Review Course was piloted in 1 region initially before being offered nationally in 2014. The previously published evaluation findings demonstrated significant improvements from precourse to 3 months postcourse in confidence and knowledge in 4 key areas of geropsychology: General knowledge about adult development and aging, assessment, intervention, and consultation.¹⁵ These domains align with the Pikes Peak Geropsychology Competencies and are measured by a subset of items from the Geropsychology Knowledge and Skills Assessment Tool.^13,16 As of October 2023, 8 introductory courses have been held with 173 participants (Table).

Quality Improvement

Introductory course attendees also participate in an intensive day-long interactive workshop in quality improvement (QI). After completing these trainings, they apply what they have learned at their home facility by embarking on a QI project related to geriatrics. The QI projects reinforce learning and initiate practice changes not only for attendees but at times the larger health care system. Topics are selected by scholars in response to the needs they observe in their clinics. Recent GSP projects include efforts to increase screenings for depression and anxiety, improve adherence to VHA dementia policy, increase access to virtual care, and increase referrals to programs such as whole health or cognitive behavioral therapy for insomnia, a first-line treatment for insomnia in older adults.¹⁷ Another project targeted the improvement of referrals to the Compassionate Contact Corps in an effort to reduce social isolation and loneliness among older veterans.¹⁸ Evaluations demonstrate significant improvement in scholars’ confidence in related program development and management from precourse to 3 months postcourse.¹⁵

Webinars

The Addressing Geriatric Mental Health webinar series was created to introduce learners to topics that could not be covered in the introductory course. Topics were suggested by the expert reviewers of the curriculum or identified by the scholars themselves (eg, chronic pain, sexuality, or serious mental illness). A secondary function of the webinars was to reach a broader audience. Over time, scholars and webinar attendees requested opportunities to explore topics in greater depth (eg, PTSD later in life). These requests led the webinars to focus on annual themes.

The series is open to all disciplines of geriatric scholars, VHA staff, and non-VHA staff through the Veterans Affairs Talent Management System and the TRAIN Learning Network (train.org). Attendance for the 37 webinars was captured from logins to the virtual learning platform and may underestimate attendance if a group attended on a single screen. Average attendance increased from 157 attendees/webinar in 2015 to 418 attendees/webinar in 2023 (Figure 2). This may have been related to the increase in virtual learning during the COVID-19 pandemic, but represents a 166% increase in audience from the inaugural year of the series.

Advanced Learning Opportunities

To invest in the ongoing growth and development of introductory course graduates, GSP-P developed and offered an advanced workshop in 2019. This multiday workshop focused on further enhancement of geropsychology competencies, with an emphasis on treating older veterans with mental and physical comorbidities. Didactics and experiential learning exercises led by SMEs covered topics such as adjusting to chronic illness, capacity assessment, PTSD, insomnia and sleep changes, chronic pain, and psychological interventions in palliative care and hospice settings. Evaluation findings demonstrated significant improvements from precourse to 6 months postcourse in confidence and knowledge as defined by the Pikes Peak Geropsychology Competencies.¹⁹

To facilitate ongoing and individually tailored learning following the advanced workshop, scholars also developed and executed independent learning plans (ILPs) during a 6-month window with consultation from an experienced geropsychologist. Fifteen of 19 scholars (78.9%) completed ILPs with an average of 3 learning goals listed. After completing the ILPs, scholars endorsed their clinical and/or personal usefulness, citing increased confidence, enhanced skills for use with patients with complex needs, personal fulfillment, and career advancement. Most scholars noted ILPs were feasible and learning resources were accessible. Overall, the evaluation found ILPs to be a valuable way to enhance psychologists’ learning and effectiveness in treating older veterans with complex health needs.²⁰

 

 

Clinical Practica

All geriatric scholars who completed the program have additional opportunities for professional development through practicum experiences focused on specific clinical approaches to the care of older veterans, such as dementia care, pain management, geriatric assessment, and palliative care. These practica provide scholars with individualized learning experiences in an individualized or small group setting and may be conducted either in-person or virtually.

In response to an expressed need from those who completed the program, the GSP-P planning committee collaborated with an SME to develop a virtual practicum to assess patients’ decision making capacity. Evaluating capacities among older adults is a common request, yet clinicians report little to no formal training in how to conceptualize and approach these complex questions.^21,22 Utilizing an evidence-informed and structured approach promotes the balancing of an older adult’s autonomy and professional ethics. Learning capacity evaluation skills could better position psychologists to not only navigate complex ethical, legal, and clinical situations, but also serve as expert consultants to interdisciplinary teams. This virtual practicum was initiated in 2022 and to date has included 10 scholars. The practicum includes multiple modalities of learning: (1) self-directed review of core concepts; (2) attendance at 4 capacity didactics focused on introduction to evaluating capacities, medical consent and decision making, financial decision making and management, and independent living; and (3) participation in 5 group consultations on capacity evaluations conducted at their home sites. During these group consultations, additional case examples were shared to reinforce capacity concepts.

Discussion

The objective of GSP-P is to enhance geropsychology practice competencies among VHA psychologists given the outsized representation of older adults within the VHA system and their complex care needs. The curricula have significantly evolved to accomplish this, expanding the reach and investing in the continuing growth and development of scholars.

There are several elements that set GSP apart from other geriatric and geropsychology continuing medical education programs. The first is that the training is veteran focused, allowing us to discuss the unique impact military service has on aging. Similarly, because all scholars work within the integrated health care system, we can introduce and review key resources and programs that benefit all veterans and their families/care partners across the system. Through the GSP, the VA invests in ongoing professional development. Scholars can participate in additional experiential practica, webinars, and advanced workshops tailored to their individual learning needs. Lastly, the GSP works to create a community among its scholars where they can not only continue to consult with presenters/instructors, but also one another. A planned future direction for the GSP-P is to incorporate quarterly office hours and discussions for alumni to develop an increased sense of community. This may strengthen commitment to the overall VA mission, leading to increased retainment of talent who now have the knowledge, skills, and confidence to care for aging veterans.

Limitations

GSP is limited by its available funding. Additionally, the number of participants who can enroll each year in GSP-P (not including webinars) is capped by policy. Another limitation is the number of QI coaches available to mentor scholars on their projects.

 

 

Conclusions

Outcomes of GSP-P have been extremely favorable. Following participation in the program, we have found a significant increase in confidence in geropsychology practice among clinicians, as well as enhanced knowledge and skills across competency domains.^15,19 We have observed rising attendance in our annual webinar series and graduates of our introductory courses participate in subsequent trainings (eg, advanced workshop or virtual practicum). Several graduates of GSP-P have become board certified in geropsychology by the American Board of Geropsychology and many proceed to supervise geropsychology-focused clinical rotations for psychology practicum students, predoctoral interns, and postdoctoral fellows. This suggests that the reach of GSP-P programming may extend farther than reported in this article.

The needs of aging veterans have also changed based on cohort differences, as the population of World War II and Korean War era veterans has declined and the number of older Vietnam era veterans has grown. We expect different challenges with older Gulf War and post-9/11 era veterans. For instance, 17% of troops deployed to Iraq or Afghanistan following 9/11 experienced mild traumatic brain injury (TBI), and 59% of those experienced > 1 mild TBI.²³ Research indicates that younger post-9/11 veterans have a 3-fold risk of developing early onset dementia after experiencing a TBI.²⁴ Therefore, even though post-9/11 veterans are not older in terms of chronological age, some may experience symptoms and conditions more often occurring in older veterans. As a result, it would be beneficial for clinicians to learn about the presentation and treatment of geriatric conditions such as dementia.

Moving forward, the GSP-P should identify potential opportunities to collaborate with the non-VHA mental health community–which also faces a shortage of geriatric mental health clinicians–to extend educational opportunities to improve care for veterans in all settings (eg, cosponsor training opportunities open to both VHA and non-VHA clinicians).^8,25 Many aging veterans may receive portions of their health care outside the VHA, particularly those who reside in rural areas. Additionally, as veterans age, so do their support systems (eg, family members, friends, spouses, caregivers, and even clinicians), most of whom will receive care outside of the VHA. Community education collaborations will not only improve the care of older veterans, but also the care of older adults in the general population.

Promising directions include the adoption of the GSP model in other health care settings. Recently, Indian Health Service has adapted the model, beginning with primary care clinicians and pharmacists and is beginning to expand to other disciplines. Additional investments in VHA workforce training include the availability of geropsychology internship and fellowship training opportunities through the Office of Academic Affiliations, which provide earlier opportunities to specialize in geropsychology. Continued investment in both prelicensure and postpsychology licensure training efforts are needed within the VHA to meet the geriatric mental health needs of veterans.

Acknowledgments

The authors wish to acknowledge Terri Huh, PhD, for her contributions to the development and initiation of the GSP-P. The authors also appreciate the collaboration and quality initiative training led by Carol Callaway-Lane, DNP, ACNP-BC, and her team.

The Centers for Disease Control and Prevention (CDC) has identified factors that put patients at a higher risk of severe COVID-19 infection, which include advanced age, obesity, cardiovascular disease, diabetes, chronic kidney disease, lung disease, and immunocompromising conditions. The CDC also acknowledges that mood disorders, including depression and schizophrenia, contribute to the progression to severe COVID-19.¹ Antiviral therapies, such as nirmatrelvir and ritonavir combination, remdesivir, and molnupiravir, and monoclonal antibody (mAb) therapies, have been used to prevent hospitalization and mortality from COVID-19 infection for individuals with mild-to-moderate COVID-19 who are at high risk of progressing to severe infection.² Although antiviral and mAb therapies likely have mitigated many infections, poor prognoses are prevalent. It is important to identify all patients at risk of progressing to severe COVID-19 infection.

Although the CDC considers depression and schizophrenia to be risk factors for severe COVID-19 infection, the Captain James A. Lovell Federal Health Care Center (FHCC) in North Chicago, Illinois, does not, making these patients ineligible for antiviral or mAb therapies unless they have another risk factor. As a result, these patients could be at risk of severe COVID-19 infection, but might not be treated appropriately. Psychiatric diagnoses are common among veterans, with 19.7% experiencing a mental illness in 2020.³ It is imperative to determine whether depression or schizophrenia play a role in the progression of COVID-19 to expand access to individuals who are eligible for antiviral or mAb therapies.

Because COVID-19 is a novel virus, there are few studies of psychiatric disorders and COVID-19 prognosis. A 2020 case control study determined that those with a recent mental illness diagnosis were at higher risk of COVID-19 infection with worse outcomes compared with those without psychiatric diagnoses. This effect was most prevalent among individuals with depression and schizophrenia.⁴ However, these individuals also were found to have additional comorbidities that could have contributed to poorer outcomes. A meta-analysis determined that psychiatric disorders were associated with increased COVID-19-related mortality.⁵ A 2022 cohort study that included vaccinated US Department of Veterans Affairs (VA) patients determined that having a psychiatric diagnosis was associated with increased incidence of breakthrough infections.⁶ Individuals with psychiatric conditions are thought to be at higher risk of severe COVID-19 outcomes because of poor access to care and higher incidence of untreated underlying health conditions.⁷ Lifestyle factors also could play a role. Because there is minimal data on COVID-19 prognosis and mental illness, further research is warranted to determine whether psychiatric diagnoses could contribute to more severe COVID-19 infections.

Methods

This was a retrospective cohort chart review study at FHCC that compared COVID-19 outcomes in individuals with depression or schizophrenia with those without these diagnoses. FHCC patients with the International Classification of Diseases code for COVID-19 (U07.1) from fiscal years 2020 to 2022 were included. We then selected patients with a depression or schizophrenia diagnosis noted in the electronic health record (EHR). These 2 patient lists were consolidated to identify every individual with a COVID-19 diagnosis and a diagnosis of depression or schizophrenia.

Patients were included if they were aged ≥ 18 years with a positive COVID-19 infection confirmed via polymerase chain reaction or blood test. Patients also had to have mild-to-moderate COVID-19 with ≥ 1 symptom such as fever, cough, sore throat, malaise, headache, muscle pain, loss of taste and smell, or shortness of breath. Patients were excluded if they had an asymptomatic infection, presented with severe COVID-19 infection, or were an FHCC employee. Severe COVID-19 was defined as having oxygen saturation < 94%, a respiratory rate > 30 breaths per minute, or supplemental oxygen requirement.

Patient EHRs were reviewed and analyzed using the VA Computerized Patient Record System and Joint Legacy Viewer. Collected data included age, medical history, use of antiviral or mAb therapy, and admission or death within 30 days of a positive COVID-19 test. The primary outcome of this study was severe COVID-19 outcomes defined as hospitalization, admission to the intensive care unit, intubation or mechanical ventilation, or death within 30 days of infection. The primary outcome was analyzed with a student t test; P < .05 was considered statistically significant.

 

 

Results

More than 5000 individuals had a COVID-19 diagnosis during the study period. Among these patients, 4530 had no depression or schizophrenia diagnosis; 1021 individuals had COVID-19 and a preexisting diagnosis of depression or schizophrenia. Among these 1021 patients, 279 charts were reviewed due to time constraints; 128 patients met exclusion criteria and 151 patients were included in the study. Of the 151 patients with COVID-19, 78 had no depression or schizophrenia and 73 patients with COVID-19 had a preexisting depression or schizophrenia diagnosis (Figure).

The 2 groups were similar at baseline. The most common risk factors for severe COVID-19 included age > 60 years, obesity, and cardiovascular disease. However, more than half of the individuals analyzed had no risk factors (Table 1). Some patients with risk factors received antiviral or mAb therapy to prevent severe COVID-19 infection; combination nirmatrelvir and ritonavir was the most common agent (Table 2). Of the 73 individuals with a psychiatric diagnosis, 67 had depression (91.8%), and 6 had schizophrenia (8.2%).

Hospitalization or death within 30 days of COVID-19 infection between patients with depression or schizophrenia and patients without these psychiatric diagnoses was not statistically significant (P = .36). Sixteen individuals were hospitalized, 8 in each group. Three individuals died within 30 days; death only occurred in patients who had depression or schizophrenia (Table 3).

Discussion

This study found that hospitalization or death within 30 days of COVID-19 infection occurred more frequently among individuals with depression or schizophrenia compared with those without these psychiatric comorbidities. However, this difference was not statistically significant.

This study had several limitations. It was a retrospective, chart review study, which relied on accurate documentation. In addition, we reviewed COVID-19 cases from fiscal years 2020 to 2022 and as a result, several viral variants were analyzed. This made it difficult to draw conclusions, especially because the omicron variant is thought to be less deadly, which may have skewed the data. Vaccinations and COVID-19 treatments became available in late 2020, which likely affected the progression to severe disease. Our study did not assess vaccination status, therefore it is unclear whether COVID-19 vaccination played a role in mitigating infection. When the pandemic began, many individuals were afraid to come to the hospital and did not receive care until they progressed to severe COVID-19, which would have excluded them from the study. Many individuals had additional comorbidities that likely impacted their COVID-19 outcomes. It is not possible to conclude if the depression or schizophrenia diagnoses were responsible for hospitalization or death within 30 days of infection or if it was because of other known risk factors. Future research is needed to address these limitations.

Conclusions

More COVID-19 hospitalizations and deaths occurred within 30 days of infection among those with depression and schizophrenia compared with individuals without these comorbidities. However, this effect was not statistically significant. Many limitations could have contributed to this finding, which should be addressed in future studies. Because the sample size was small, further research with a larger patient population is warranted to explore the association between psychiatric comorbidities such as depression and schizophrenia and COVID-19 disease progression. Future studies also could include assessment of vaccination status and exclude individuals with other high-risk comorbidities for severe COVID-19 outcomes. These studies could determine if depression and schizophrenia are correlated with worse COVID-19 outcomes and ensure that all high-risk patients are identified and treated appropriately to prevent morbidity and mortality.

Acknowledgements

Thank you to the research committee at the Captain James A. Lovell Federal Health Care Center who assisted in the completion of this project, including Shaiza Khan, PharmD, BCPS; Yinka Alaka, PharmD; and Hong-Yen Vi, PharmD, BCPS, BCCCP.

The Centers for Disease Control and Prevention (CDC) has identified factors that put patients at a higher risk of severe COVID-19 infection, which include advanced age, obesity, cardiovascular disease, diabetes, chronic kidney disease, lung disease, and immunocompromising conditions. The CDC also acknowledges that mood disorders, including depression and schizophrenia, contribute to the progression to severe COVID-19.¹ Antiviral therapies, such as nirmatrelvir and ritonavir combination, remdesivir, and molnupiravir, and monoclonal antibody (mAb) therapies, have been used to prevent hospitalization and mortality from COVID-19 infection for individuals with mild-to-moderate COVID-19 who are at high risk of progressing to severe infection.² Although antiviral and mAb therapies likely have mitigated many infections, poor prognoses are prevalent. It is important to identify all patients at risk of progressing to severe COVID-19 infection.

Although the CDC considers depression and schizophrenia to be risk factors for severe COVID-19 infection, the Captain James A. Lovell Federal Health Care Center (FHCC) in North Chicago, Illinois, does not, making these patients ineligible for antiviral or mAb therapies unless they have another risk factor. As a result, these patients could be at risk of severe COVID-19 infection, but might not be treated appropriately. Psychiatric diagnoses are common among veterans, with 19.7% experiencing a mental illness in 2020.³ It is imperative to determine whether depression or schizophrenia play a role in the progression of COVID-19 to expand access to individuals who are eligible for antiviral or mAb therapies.

Because COVID-19 is a novel virus, there are few studies of psychiatric disorders and COVID-19 prognosis. A 2020 case control study determined that those with a recent mental illness diagnosis were at higher risk of COVID-19 infection with worse outcomes compared with those without psychiatric diagnoses. This effect was most prevalent among individuals with depression and schizophrenia.⁴ However, these individuals also were found to have additional comorbidities that could have contributed to poorer outcomes. A meta-analysis determined that psychiatric disorders were associated with increased COVID-19-related mortality.⁵ A 2022 cohort study that included vaccinated US Department of Veterans Affairs (VA) patients determined that having a psychiatric diagnosis was associated with increased incidence of breakthrough infections.⁶ Individuals with psychiatric conditions are thought to be at higher risk of severe COVID-19 outcomes because of poor access to care and higher incidence of untreated underlying health conditions.⁷ Lifestyle factors also could play a role. Because there is minimal data on COVID-19 prognosis and mental illness, further research is warranted to determine whether psychiatric diagnoses could contribute to more severe COVID-19 infections.

Methods

This was a retrospective cohort chart review study at FHCC that compared COVID-19 outcomes in individuals with depression or schizophrenia with those without these diagnoses. FHCC patients with the International Classification of Diseases code for COVID-19 (U07.1) from fiscal years 2020 to 2022 were included. We then selected patients with a depression or schizophrenia diagnosis noted in the electronic health record (EHR). These 2 patient lists were consolidated to identify every individual with a COVID-19 diagnosis and a diagnosis of depression or schizophrenia.

Patients were included if they were aged ≥ 18 years with a positive COVID-19 infection confirmed via polymerase chain reaction or blood test. Patients also had to have mild-to-moderate COVID-19 with ≥ 1 symptom such as fever, cough, sore throat, malaise, headache, muscle pain, loss of taste and smell, or shortness of breath. Patients were excluded if they had an asymptomatic infection, presented with severe COVID-19 infection, or were an FHCC employee. Severe COVID-19 was defined as having oxygen saturation < 94%, a respiratory rate > 30 breaths per minute, or supplemental oxygen requirement.

Patient EHRs were reviewed and analyzed using the VA Computerized Patient Record System and Joint Legacy Viewer. Collected data included age, medical history, use of antiviral or mAb therapy, and admission or death within 30 days of a positive COVID-19 test. The primary outcome of this study was severe COVID-19 outcomes defined as hospitalization, admission to the intensive care unit, intubation or mechanical ventilation, or death within 30 days of infection. The primary outcome was analyzed with a student t test; P < .05 was considered statistically significant.

 

 

Results

More than 5000 individuals had a COVID-19 diagnosis during the study period. Among these patients, 4530 had no depression or schizophrenia diagnosis; 1021 individuals had COVID-19 and a preexisting diagnosis of depression or schizophrenia. Among these 1021 patients, 279 charts were reviewed due to time constraints; 128 patients met exclusion criteria and 151 patients were included in the study. Of the 151 patients with COVID-19, 78 had no depression or schizophrenia and 73 patients with COVID-19 had a preexisting depression or schizophrenia diagnosis (Figure).

The 2 groups were similar at baseline. The most common risk factors for severe COVID-19 included age > 60 years, obesity, and cardiovascular disease. However, more than half of the individuals analyzed had no risk factors (Table 1). Some patients with risk factors received antiviral or mAb therapy to prevent severe COVID-19 infection; combination nirmatrelvir and ritonavir was the most common agent (Table 2). Of the 73 individuals with a psychiatric diagnosis, 67 had depression (91.8%), and 6 had schizophrenia (8.2%).

Hospitalization or death within 30 days of COVID-19 infection between patients with depression or schizophrenia and patients without these psychiatric diagnoses was not statistically significant (P = .36). Sixteen individuals were hospitalized, 8 in each group. Three individuals died within 30 days; death only occurred in patients who had depression or schizophrenia (Table 3).

Discussion

This study found that hospitalization or death within 30 days of COVID-19 infection occurred more frequently among individuals with depression or schizophrenia compared with those without these psychiatric comorbidities. However, this difference was not statistically significant.

This study had several limitations. It was a retrospective, chart review study, which relied on accurate documentation. In addition, we reviewed COVID-19 cases from fiscal years 2020 to 2022 and as a result, several viral variants were analyzed. This made it difficult to draw conclusions, especially because the omicron variant is thought to be less deadly, which may have skewed the data. Vaccinations and COVID-19 treatments became available in late 2020, which likely affected the progression to severe disease. Our study did not assess vaccination status, therefore it is unclear whether COVID-19 vaccination played a role in mitigating infection. When the pandemic began, many individuals were afraid to come to the hospital and did not receive care until they progressed to severe COVID-19, which would have excluded them from the study. Many individuals had additional comorbidities that likely impacted their COVID-19 outcomes. It is not possible to conclude if the depression or schizophrenia diagnoses were responsible for hospitalization or death within 30 days of infection or if it was because of other known risk factors. Future research is needed to address these limitations.

Conclusions

More COVID-19 hospitalizations and deaths occurred within 30 days of infection among those with depression and schizophrenia compared with individuals without these comorbidities. However, this effect was not statistically significant. Many limitations could have contributed to this finding, which should be addressed in future studies. Because the sample size was small, further research with a larger patient population is warranted to explore the association between psychiatric comorbidities such as depression and schizophrenia and COVID-19 disease progression. Future studies also could include assessment of vaccination status and exclude individuals with other high-risk comorbidities for severe COVID-19 outcomes. These studies could determine if depression and schizophrenia are correlated with worse COVID-19 outcomes and ensure that all high-risk patients are identified and treated appropriately to prevent morbidity and mortality.

Acknowledgements

Thank you to the research committee at the Captain James A. Lovell Federal Health Care Center who assisted in the completion of this project, including Shaiza Khan, PharmD, BCPS; Yinka Alaka, PharmD; and Hong-Yen Vi, PharmD, BCPS, BCCCP.

The Centers for Disease Control and Prevention (CDC) has identified factors that put patients at a higher risk of severe COVID-19 infection, which include advanced age, obesity, cardiovascular disease, diabetes, chronic kidney disease, lung disease, and immunocompromising conditions. The CDC also acknowledges that mood disorders, including depression and schizophrenia, contribute to the progression to severe COVID-19.¹ Antiviral therapies, such as nirmatrelvir and ritonavir combination, remdesivir, and molnupiravir, and monoclonal antibody (mAb) therapies, have been used to prevent hospitalization and mortality from COVID-19 infection for individuals with mild-to-moderate COVID-19 who are at high risk of progressing to severe infection.² Although antiviral and mAb therapies likely have mitigated many infections, poor prognoses are prevalent. It is important to identify all patients at risk of progressing to severe COVID-19 infection.

Although the CDC considers depression and schizophrenia to be risk factors for severe COVID-19 infection, the Captain James A. Lovell Federal Health Care Center (FHCC) in North Chicago, Illinois, does not, making these patients ineligible for antiviral or mAb therapies unless they have another risk factor. As a result, these patients could be at risk of severe COVID-19 infection, but might not be treated appropriately. Psychiatric diagnoses are common among veterans, with 19.7% experiencing a mental illness in 2020.³ It is imperative to determine whether depression or schizophrenia play a role in the progression of COVID-19 to expand access to individuals who are eligible for antiviral or mAb therapies.

Because COVID-19 is a novel virus, there are few studies of psychiatric disorders and COVID-19 prognosis. A 2020 case control study determined that those with a recent mental illness diagnosis were at higher risk of COVID-19 infection with worse outcomes compared with those without psychiatric diagnoses. This effect was most prevalent among individuals with depression and schizophrenia.⁴ However, these individuals also were found to have additional comorbidities that could have contributed to poorer outcomes. A meta-analysis determined that psychiatric disorders were associated with increased COVID-19-related mortality.⁵ A 2022 cohort study that included vaccinated US Department of Veterans Affairs (VA) patients determined that having a psychiatric diagnosis was associated with increased incidence of breakthrough infections.⁶ Individuals with psychiatric conditions are thought to be at higher risk of severe COVID-19 outcomes because of poor access to care and higher incidence of untreated underlying health conditions.⁷ Lifestyle factors also could play a role. Because there is minimal data on COVID-19 prognosis and mental illness, further research is warranted to determine whether psychiatric diagnoses could contribute to more severe COVID-19 infections.

Methods

This was a retrospective cohort chart review study at FHCC that compared COVID-19 outcomes in individuals with depression or schizophrenia with those without these diagnoses. FHCC patients with the International Classification of Diseases code for COVID-19 (U07.1) from fiscal years 2020 to 2022 were included. We then selected patients with a depression or schizophrenia diagnosis noted in the electronic health record (EHR). These 2 patient lists were consolidated to identify every individual with a COVID-19 diagnosis and a diagnosis of depression or schizophrenia.

Patients were included if they were aged ≥ 18 years with a positive COVID-19 infection confirmed via polymerase chain reaction or blood test. Patients also had to have mild-to-moderate COVID-19 with ≥ 1 symptom such as fever, cough, sore throat, malaise, headache, muscle pain, loss of taste and smell, or shortness of breath. Patients were excluded if they had an asymptomatic infection, presented with severe COVID-19 infection, or were an FHCC employee. Severe COVID-19 was defined as having oxygen saturation < 94%, a respiratory rate > 30 breaths per minute, or supplemental oxygen requirement.

Patient EHRs were reviewed and analyzed using the VA Computerized Patient Record System and Joint Legacy Viewer. Collected data included age, medical history, use of antiviral or mAb therapy, and admission or death within 30 days of a positive COVID-19 test. The primary outcome of this study was severe COVID-19 outcomes defined as hospitalization, admission to the intensive care unit, intubation or mechanical ventilation, or death within 30 days of infection. The primary outcome was analyzed with a student t test; P < .05 was considered statistically significant.

 

 

Results

More than 5000 individuals had a COVID-19 diagnosis during the study period. Among these patients, 4530 had no depression or schizophrenia diagnosis; 1021 individuals had COVID-19 and a preexisting diagnosis of depression or schizophrenia. Among these 1021 patients, 279 charts were reviewed due to time constraints; 128 patients met exclusion criteria and 151 patients were included in the study. Of the 151 patients with COVID-19, 78 had no depression or schizophrenia and 73 patients with COVID-19 had a preexisting depression or schizophrenia diagnosis (Figure).

The 2 groups were similar at baseline. The most common risk factors for severe COVID-19 included age > 60 years, obesity, and cardiovascular disease. However, more than half of the individuals analyzed had no risk factors (Table 1). Some patients with risk factors received antiviral or mAb therapy to prevent severe COVID-19 infection; combination nirmatrelvir and ritonavir was the most common agent (Table 2). Of the 73 individuals with a psychiatric diagnosis, 67 had depression (91.8%), and 6 had schizophrenia (8.2%).

Hospitalization or death within 30 days of COVID-19 infection between patients with depression or schizophrenia and patients without these psychiatric diagnoses was not statistically significant (P = .36). Sixteen individuals were hospitalized, 8 in each group. Three individuals died within 30 days; death only occurred in patients who had depression or schizophrenia (Table 3).

Discussion

This study found that hospitalization or death within 30 days of COVID-19 infection occurred more frequently among individuals with depression or schizophrenia compared with those without these psychiatric comorbidities. However, this difference was not statistically significant.

This study had several limitations. It was a retrospective, chart review study, which relied on accurate documentation. In addition, we reviewed COVID-19 cases from fiscal years 2020 to 2022 and as a result, several viral variants were analyzed. This made it difficult to draw conclusions, especially because the omicron variant is thought to be less deadly, which may have skewed the data. Vaccinations and COVID-19 treatments became available in late 2020, which likely affected the progression to severe disease. Our study did not assess vaccination status, therefore it is unclear whether COVID-19 vaccination played a role in mitigating infection. When the pandemic began, many individuals were afraid to come to the hospital and did not receive care until they progressed to severe COVID-19, which would have excluded them from the study. Many individuals had additional comorbidities that likely impacted their COVID-19 outcomes. It is not possible to conclude if the depression or schizophrenia diagnoses were responsible for hospitalization or death within 30 days of infection or if it was because of other known risk factors. Future research is needed to address these limitations.

Conclusions

More COVID-19 hospitalizations and deaths occurred within 30 days of infection among those with depression and schizophrenia compared with individuals without these comorbidities. However, this effect was not statistically significant. Many limitations could have contributed to this finding, which should be addressed in future studies. Because the sample size was small, further research with a larger patient population is warranted to explore the association between psychiatric comorbidities such as depression and schizophrenia and COVID-19 disease progression. Future studies also could include assessment of vaccination status and exclude individuals with other high-risk comorbidities for severe COVID-19 outcomes. These studies could determine if depression and schizophrenia are correlated with worse COVID-19 outcomes and ensure that all high-risk patients are identified and treated appropriately to prevent morbidity and mortality.

Acknowledgements

Thank you to the research committee at the Captain James A. Lovell Federal Health Care Center who assisted in the completion of this project, including Shaiza Khan, PharmD, BCPS; Yinka Alaka, PharmD; and Hong-Yen Vi, PharmD, BCPS, BCCCP.