Geriatric Mental Health Research Articles

‘Mental health is a mystery’: patient perspectives on treatment engagement in the referral process to specialty geriatric mental health services

Objectives Raue and Sirey proposed a theoretical treatment engagement model for older adults outlining steps from identifying mental health problems, referral to specialty care, and involvement in treatment. Using this model as a guide, the current study aimed to explore patient perspectives of their experience in the process of referral and first meeting with geriatric mental health services. Furthermore, the current study aimed to identify opportunities to enhance patient engagement in these beginning steps of the treatment engagement process. Method Thirteen geriatric outpatients (7 psychology, 6 psychiatry) presenting with concerns of anxiety, depression, and/or stress were interviewed. Interviews were analyzed using the framework method. Results Themes emerged as suggested by Raue and Sirey’s model, including attitudes toward treatment (e.g. stigma), treatment expectations, and treatment preferences. In addition, new themes emerged related to modifiable individual factors (the patient as a passive recipient of care, mental health literacy, and ageism) as well as social influences on treatment engagement. Participants primarily noted opportunities for psychoeducation as a potential treatment engagement intervention to implement within the current referral system. Conclusions This is the first study to examine the applicability of Raue and Sirey’s theoretical engagement model in a clinical sample. Findings both support and expand the model and offer several recommendations for improving treatment engagement for older patients.

The influence of resilience and social support on mental health of older adults living in community: a cross-sectional study

BackgroundMental health is an important fundamental element of health that influences different dimensions of an older individual’s life. There are various factors that affect the mental health of older adults, such as resilience and social support. However, the relationship between various factors and mental health is unclear. Purposes of the study were to investigates whether resilience and social support affect the mental health of older adults and to analyze the structural equation model of mental health among the older adults with resilience as a mediating variable.MethodsA cross-sectional study was conducted among 964 older adults by multi-stage random sampling. The data were collected using the following questionnaires: Thai Elderly Resilience Scale, Social Support Scale, and Thai Geriatric Mental Health Assessment. Data analysis used descriptive statistics, Pearson’s correlation, and Path analysis.ResultsThe older adults had a high level of resilience, social support, and mental health (MH). The best model we obtained demonstrated that social support and resilience had directly statistically significant influences the MH. Social support also had statistically significant indirect effect via resilience to the MH.ConclusionUnderstanding the factors that influence mental health of older adults can be beneficial for health professionals to provide appropriate social support and resilience, including helping the older adult can join with others, be confident in life, have necessities, live with spiritual security, and be able to de-stress and management problems were recommended.

Layperson-Delivered Telephone-Based Behavioral Activation Among Low-Income Older Adults During the COVID-19 Pandemic

Older adults are particularly vulnerable to loneliness and its physical and psychosocial sequelae, but scalable interventions are lacking, especially during disasters such as pandemics. To compare the effects of layperson-delivered, telephone-based behavioral activation and mindfulness interventions vs telephone-based befriending on loneliness among at-risk older adults. This assessor-blinded, 3-arm randomized clinical trial screened Chinese older adults through household visits and community referrals from April 1, 2021, to April 30, 2023, in Hong Kong. Eligible participants (≥65 years of age) who were lonely, digitally excluded, living alone, and living below the poverty line and provided consent to participate were randomized into behavioral activation, mindfulness, and befriending groups. Assessments were conducted at baseline, 1 month, and 3 months. As part of the Helping Alleviate Loneliness in Hong Kong Older Adults (HEAL-HOA) dual randomized clinical trial, 148 older laypersons were trained to deliver a twice-weekly 30-minute intervention via telephone for 4 weeks. The primary outcome was loneliness measured by the UCLA Loneliness Scale (range, 20-80) and the De Jong Gierveld Loneliness Scale (range, 0-6), with higher scores on both scales indicating greater loneliness. Secondary outcomes were depression, perceived stress, life satisfaction, psychological well-being, sleep quality, perceived social support, and social network. A total of 1151 participants (mean [SD] age, 76.6 [7.8] years; 843 [73.2%] female) were randomized to the behavioral activation (n = 335), mindfulness (n = 460) or befriending (n = 356) group. Most were widowed or divorced (932 [81.0%]), had primary education or below (782 [67.9%]), and had 3 or more chronic diseases (505 [43.9%]). Following intention-to-treat principles, linear mixed-effects regression model analyses showed that loneliness measured by the UCLA Loneliness Scale was significantly reduced in the behavioral activation group (mean difference [MD], -1.96 [95% CI, -3.16 to -0.77] points; P < .001]) and in the mindfulness group (MD, -1.49 [95% CI, -2.60 to -0.37] points; P = .004) at 3 months compared with befriending. Loneliness measured by the De Jong Gierveld Loneliness Scale was not significantly reduced at 3 months in the behavioral activation group (MD, -0.06 [95% CI, -0.26 to 0.13] points; P > .99]) but was in the mindfulness group (MD, 0.22 [95% CI, 0.03 to 0.40] points; P = .01) at 3 months compared with befriending. In the behavioral activation and mindfulness groups, sleep quality improved compared with befriending, but perceived stress increased. Psychological well-being and perceived social support improved in the behavioral activation group. No statistically significant between-group differences were observed in depression, life satisfaction, or social network. In this randomized clinical trial, scalable psychosocial interventions delivered remotely by older laypersons appeared promising in reducing later life loneliness and addressing the pressing mental health challenges faced by aging populations and professional geriatric mental health workforce shortages. Further research should explore ways to maximize the clinical relevance and cost-effectiveness of these interventions. Chinese Clinical Trial Registry Identifier: ChiCTR2300072909.

Digital Phenotyping of Geriatric Depression Using a Community-Based Digital Mental Health Monitoring Platform for Socially Vulnerable Older Adults and Their Community Caregivers: 6-Week Living Lab Single-Arm Pilot Study.

Despite the increasing need for digital services to support geriatric mental health, the development and implementation of digital mental health care systems for older adults have been hindered by a lack of studies involving socially vulnerable older adult users and their caregivers in natural living environments. This study aims to determine whether digital sensing data on heart rate variability, sleep quality, and physical activity can predict same-day or next-day depressive symptoms among socially vulnerable older adults in their everyday living environments. In addition, this study tested the feasibility of a digital mental health monitoring platform designed to inform older adult users and their community caregivers about day-to-day changes in the health status of older adults. A single-arm, nonrandomized living lab pilot study was conducted with socially vulnerable older adults (n=25), their community caregivers (n=16), and a managerial social worker over a 6-week period during and after the COVID-19 pandemic. Depressive symptoms were assessed daily using the 9-item Patient Health Questionnaire via scripted verbal conversations with a mobile chatbot. Digital biomarkers for depression, including heart rate variability, sleep, and physical activity, were measured using a wearable sensor (Fitbit Sense) that was worn continuously, except during charging times. Daily individualized feedback, using traffic signal signs, on the health status of older adult users regarding stress, sleep, physical activity, and health emergency status was displayed on a mobile app for the users and on a web application for their community caregivers. Multilevel modeling was used to examine whether the digital biomarkers predicted same-day or next-day depressive symptoms. Study staff conducted pre- and postsurveys in person at the homes of older adult users to monitor changes in depressive symptoms, sleep quality, and system usability. Among the 31 older adult participants, 25 provided data for the living lab and 24 provided data for the pre-post test analysis. The multilevel modeling results showed that increases in daily sleep fragmentation (P=.003) and sleep efficiency (P=.001) compared with one's average were associated with an increased risk of daily depressive symptoms in older adults. The pre-post test results indicated improvements in depressive symptoms (P=.048) and sleep quality (P=.02), but not in the system usability (P=.18). The findings suggest that wearable sensors assessing sleep quality may be utilized to predict daily fluctuations in depressive symptoms among socially vulnerable older adults. The results also imply that receiving individualized health feedback and sharing it with community caregivers may help improve the mental health of older adults. However, additional in-person training may be necessary to enhance usability. ClinicalTrials.gov NCT06270121; https://clinicaltrials.gov/study/NCT06270121.

Group A streptococcal outbreak in a geriatric mental health unit

We report a group A streptococcal outbreak in a geriatric mental health inpatient unit. Communication with cognitively impaired patients, limitations in adherence to hygiene practices, and communal dining may have facilitated transmission. Settle plates aided in identifying a colonized patient. Rapid access to whole-genome sequencing facilitated assessment and management.

Evaluating the impact of a national geriatric mental health ECHO educational program on healthcare providers’ practice

ABSTRACT Project Extension for Community Healthcare Outcomes (ECHO) enables healthcare providers to share knowledge and best practices via telementoring. The ECHO model builds provider capacity and improves care for patients with a variety of health conditions. This study describes a Canada-wide National ECHO pilot project in the area of geriatric mental health and reports on the program’s impact on providers’ care practices. A mixed-methods approach was used to analyze surveys completed by participating healthcare providers. Program evaluation measured satisfaction, achievement of learning objectives, awareness of issues related to geriatric mental health, and comfort and self-efficacy working with older adults. The program led to a statistically significant increase in participants’ awareness of issues related to support for older adults with mental illness and comfort and self-efficacy in managing these patients in their own practice. The National ECHO pilot project was successful in building healthcare providers’ capacity to care for older adults with mental health issues and positively impacting their practice. These findings support using the ECHO model to provide ongoing geriatric mental health education for clinicians from across Canada and beyond.

Something Old, Something New: Educational Innovations in Geriatric Mental Health

In this general session, we will be discussing educational innovations in geriatric mental health implemented at the University of Connecticut Health Center, including relevant case studies. Sub sessions will include:1. Medical student cognitive disorders elective, which takes a multidisciplinary approach to training 4th year UConn medical students in the assessment and management of cognitive disorders. Students work with geriatric psychiatrists, neuropsychologists and geriatricians in multiple settings including outpatient and facility settings- systemic differences between approach to treatment between various settings are discussed. Presenting medical student will review their experience with the elective.2. Geriatric Fellowship Psychotherapy Track, which is a longitudinal track with various components including the curriculum, supervision, and clinical requirements. We will discuss how the curriculum was adapted to the individual needs of the fellow and how supervision influenced these adaptations. We will review a related case example and reflect on how the fellow applied the curriculum and supervision to patient interactions. Future directions, including possible research opportunities and a proposed curriculum outline, will also be discussed.3. Medical student telepsychiatry elective, which provides a 4-week education opportunity for 4th year medical students to learn the basics of telepsychiatry visits for older adults, including remote cognitive assessments, treatment planning, psychotherapy, and medication management. Issues specific to older adults and virtual visits will be discussed, focusing on common challenges and possible solutions. Presenting student will discuss their experience with the elective including specific case study.

Implementing Culturally-Informed Solutions for Addressing Geriatric Mental Health in Nepal

Implementing Culturally-Informed Solutions for Addressing Geriatric Mental Health in Nepal

(R)evolutions in Artificial Intelligence in Dementia and Geriatric Mental Health Care

As the population ages, demands for dementia and geriatric mental health care are rapidly growing. At the same time, resources are scarce, which means there is a strong need for innovative approaches to serve older adults.The use of Artificial Intelligence (AI) can help in prevention, diagnosis and treatment in geriatric mental health. By identifying patterns in data, AI can help in gaining insights that are clinically relevant but would otherwise not be possible. Earlier diagnosis or more objective assessments become possible. AI can be incorporated in new treatment modalities for managing symptoms such as in closed-loop stimulation systems or the use of augmented reality. AI can be vital in dealing with the worldwide lack of resources, for example by assisting caregivers or facilitating remote delivery of care.In this General Session we want to go deeper into the new possibilities AI provides for geriatric mental health care. An international panel of experts, who are all active in both clinical care and clinical research, will provide an overview of the state of the art, combined with results of own research studies into this rapidly evolving domain. Practical implications for current and future clinical geriatric mental health care will be made clear.AI can potentially increase access to geriatric mental healthcare, but it also may pose a risk for widening inequity. Moreover, the use of AI comes with specific ethical concerns. These issues will also be addressed in this session.Prof. Maarten Van Den Bossche (KU Leuven, Leuven, Belgium) will discuss the possibilities and limitations of AI for better management of neuropsychiatric symptoms in dementia, illustrated by own research studies. Prof. Lynn Haslam-Larmer (University Health Network, Toronto, Canada) will present how real-time location systems can provide insights in social interactions and other behaviors of people with dementia. Ir. Hannah Davidoff (KU Leuven and imec, Heverlee, Belgium) will zoom in on detection and analysis of agitation in dementia by multimodal sensing. Prof. Ipsit Vahia (McLean Hospital, Belmont, United States) will provide an overview of the possibilities of extended reality (including virtual reality and augmented reality) for geriatric psychiatry as well as original data from early studies of virtual reality applied to late life mental health.

Fall Risk and Prevention: A Guide for the Geriatric Mental Health Workforce

In adults aged 65 and older, falls are the leading cause of injury and injury related death, with over a quarter of older adults experiencing a fall each year. As the population of older adults increases, the morbidity and mortality associated with falls is also anticipated to increase. According to the Centers for Disease Control, over 1 in 4 older adults fall each year. Annually, 36,000 older adults die from fall related injuries, and falls lead to 3 million emergency department visits. Fear of falling can limit activities and quality of life for vulnerable older adults. Studies show that interventions by health care providers can reduce the risk of falling by approximately 25%. As frontline healthcare workers, geriatric psychiatrists can play a pivotal role in recognizing and helping to prevent falls in older adults. In this session, we provide information and tools to help identify, evaluate, and intervene with older adults to prevent falls and fall related injury.In this session, we will provide an update on validated screening tools that can be used by geriatric psychiatrists to evaluate older adults at risk of falling, even before the first fall happens. Screening tools include self-report measures such as the STEADI questionnaire, as well as in office evaluations such as the Timed Up and Go. We will also review screenings for fear of falling, which is a known risk factor for falls.Next, we will review methodology for the evaluation of an older adult, including assessment of mobility, medication, sensory impairment, home environment, and other factors that contribute to fall risk. This portion of the symposium will be presented by a Geriatric Medicine faculty member and Combined Medicine/Psychiatry Resident, who will translate best practices into methods that can be easily adapted by the geriatric mental health workforce in the course of clinical practice. We will then describe evidence-based interventions to decrease falls risk in a way that is tailored to patients' individual risk, and we will and share resources that can be readily accessed for additional training and intervention. To elucidate these points, we will discuss a representative clinical case of an older adult at risk for falls.In this presentation, we will draw on new literature through initiatives such as the CDC's Stopping Elderly Deaths, Injury, and Accidents (STEADI) program that highlights innovation in this area. We will also draw attention to how this problem impacts diverse communities, and how interventions may be tailored to a diverse patient population.

Preparing Veterans Health Administration Psychologists to Meet the Complex Needs of Aging Veterans.

There are significant workforce shortages for geriatric mental health care. The imbalance is particularly pronounced in the Veterans Health Administration (VHA) due to the large number of aging veterans receiving care. Workforce-based educational programs are needed to train existing clinicians to meet the mental health needs of aging veterans. This article describes an expansion of the Geriatric Scholars Program to train VHA psychologists to care for aging veterans. The multicomponent program includes an introductory course and opportunities to apply geriatric knowledge and skills through quality improvement initiatives. The Geriatric Scholars Program-Psychology Track evolved to incorporate ongoing specialized elective learning opportunities for scholars. A webinar series extends the educational programs to reach the entire VHA workforce. The Geriatric Scholars Program-Psychology Track represents a longitudinal educational approach to training VHA psychologists in clinical geropsychology. Other community-based organizations can use this model to construct and implement similar programs.

Clinical and psychometric characteristics of depression in the elderly

IntroductionDepression in the elderly represents a multifaceted and critical area of study within the realm of geriatric mental health. As the global population continues to age, the prevalence and impact of depression among older adults have garnered increased attention from researchers and clinicians.ObjectivesThis abstract delves into the comprehensive exploration of the clinical and psychometric characteristics of depression in the elderly population. This study aims to contribute to a deeper understanding of depression’s manifestation in the third age, providing invaluable insights that can inform tailored interventions, improve diagnostic accuracy, and enhance the overall quality of life for older adults.MethodsA cross-sectional study was conducted that gathered 80 patients. Their common characteristics were the signing of the consent, their admission to the Psychiatry Clinic in Timișoara and their main diagnosis with one of the ICD-10 codes F32.x, F33.x or F06.8.This selection resulted in three groups: patients younger than 65 years old, patients older than 65 years in whom depression began before this age, and patients older than 65 years in whom depression began after 65 years of age. Anamnestic data, paraclinical, socio-demographic data, psychometric scales that measured the level of depression as well as personality scales were collected. The data that was obtained was compared and examined to find significant correlations between the 3 batches.ResultsThe results show that there are no significant differences between patients with depression from rural or urban areas, showing the universality of the occurrence of this disorder among the population, regardless their environment. Depression in the third age is most often found in the elderly who have only finished secondary school, education levels playing a role in depression prevalence suggest the significance of socio-economic factors, warranting targeted outreach and education efforts in vulnerable populations. Correlations were also found between the level of depression and certain blood parameters. The integration of these findings for an understanding of the etiology of depression can pave the way for new therapeutic approaches. Certain personality traits were correlated more with certain items on the scales that evaluated depression, thus in those with a neurotic personality it is very strongly correlated with the appearance of guilt as a symptom, agreeableness with psychomotor slowness, paranoid with insomnia, and anankastic and dependent personalities were correlated much more with social isolation.ConclusionsBy recognizing the distinct clinical features and implications of depression in older adults, we can pave the way for improved mental health care and better quality of life for this growing population. This study reinforces the importance of continuous research and collaboration in the field of geriatric mental health.Disclosure of InterestNone Declared

Growing Trends in Conceptualizing Geriatric Mental Health within a Neural Context.

Growing Trends in Conceptualizing Geriatric Mental Health within a Neural Context.

Coming Up…

The American Association for Geriatric Psychiatry will hold its 2024 Annual Meeting, “Reimagining Geriatric Mental Health: Innovations to promote the well‐being of caregivers and patients,” March 15–18 in Atlanta. For more information, visit https://www.aagponline.org/education‐events/annual‐meeting.

Coming Up…

The American Association for Geriatric Psychiatry will hold its 2024 Annual Meeting, “Reimagining Geriatric Mental Health: Innovations to promote the well‐being of caregivers and patients,” March 15–18 in Atlanta. For more information, visit https://www.aagponline.org/education‐events/annual‐meeting.

Effectiveness of Pet Therapy on Depression among Elderly Residing In Selected Old Age Homes at Bangalore

Introduction: Depression is prevalent among elderly individuals, significantly affecting their quality of life. Pet therapy, or animal-assisted therapy, is gaining attention as a potential intervention to alleviate these symptoms. This study aims to assess pet therapy's impact on depression among elderly residents in selected Bangalore old age homes. The findings suggest implications for geriatric care and mental health interventions, underscoring pet therapy's potential as a complementary approach to enhancing emotional well-being in institutional settings. Background of the study: Depression in seniors can result from factors like bereavement, retirement, social isolation, health issues, or traumatic events such as strokes or falls. Prompt identification and treatment are crucial to alleviate symptoms and prevent severe outcomes like physical illness, strained relationships, neglect, self-harm, or suicide. Late-onset depression in old age is a significant aspect of geriatric major depression, differing from early-onset depression experienced earlier in life. Objectives of the Study: 1. To evaluate the level of depression in elderly individuals before undergoing pet therapy. 2. To assess the effectiveness of pet therapy in reducing depression among elderly individuals post-intervention. 3. To examine the association between depression levels and selected demographic variables among elderly residents in selected old age homes in Bangalore. Methods: This quasi-experimental study utilized a non-equivalent control group design with 60 depressed patients (30 in each group) selected via convenient sampling. Data collection involved a structured questionnaire for socio-demographic details and Beck’s Depression Inventory to measure depression levels. Pet therapy was administered exclusively to the experimental group for 14 days after the pre-test, followed by a post-test using the same scale for both groups. Analysis included descriptive and inferential statistics. Results: Pre-test results showed the experimental group had 40% severe and 6.7% extreme depression, while the control group had 40% moderate and 10% extreme depression. Post-test results indicated no extreme depression in the experimental group, with 40% showing moderate depression. In contrast, the control group had 36.7% moderate and 10% extreme depression. The experimental group showed a significant reduction in depression levels from pre-test to post-test (t=16.53*, p &lt; 0.05). Additionally, post-test scores differed significantly between the experimental and control groups (t=2.04*, p &lt; 0.05), confirming hypothesis H1. Conclusion: Pet therapy integration into nursing practice for elderly patients with depression emphasizes its efficacy in reducing depression levels, highlighting its importance in clinical settings.

Coming Up…

The American Association for Geriatric Psychiatry will hold its 2024 Annual Meeting, “Reimagining Geriatric Mental Health: Innovations to promote the well‐being of caregivers and patients,” March 15–18, 2024 in Atlanta. For more information, visit https://www.aagponline.org/education‐events/annualmeeting.

OVERVIEW OF THE NEBRASKA GERIATRIC BEHAVIORAL HEALTH WORKFORCE SURVEY

Abstract According to the US Census, more than 16% of Nebraska’s population is 65 and older. Many older Nebraskans reside in rural communities. Although clinicians in existing state-wide workforce surveys endorse working with older adults, it is unclear how frequently they are involved in geriatric mental health. To identify the needs of those who are providing mental health services to older Nebraskans, the Behavioral Health Education Center of Nebraska (BHECN) conducted an online survey of eligible licensed practitioners from August to December 2022. This presentation highlights the background characteristics of 193 respondents, nearly 40% of whom came from rural areas. Two-thirds identified either as licensed mental health therapists (38%), licensed clinical social workers (26%), or licensed psychologists (14%). More than a quarter did not provide direct clinical services to older adults. On average, respondents estimated devoting 18% of their time working with older adults. Respondents listed insurance restrictions, lower reimbursement rates, and limited specialized geriatric mental health training opportunities as major reasons that had kept them from serving older clients more frequently. These findings support BHECN’s ongoing efforts to further develop training and support, and advocate for potential policy changes to enhance the state’s geriatric behavioral and mental health workforce.

CONNECTING AGING RURAL VETERANS WITH TELE-GERIATRIC MENTAL HEALTH: REFERRING PROVIDERS’ SURVEYED PERSPECTIVE

Abstract Providing comprehensive, individualized care to older Veterans with complex needs is particularly challenging in rural areas. Geriatric mental health specialists are scarce but needed for care including psychiatric medication and behavior management, consultation on complex comorbidities, cognition, and caregiver support and education. Tele-geriatric mental health services were initially developed in one VA regional telehealth hub and then expanded to three more regional telehealth hubs. Referring providers (N = 37) to tele-geriatric mental health services during a 1-year period were surveyed via REDCap. Providers came from varied settings in the 4 VA regions with 76% serving rural Veterans. Referring providers included prescribers (N = 26; pharmacists, physicians, physician assistants, nurse practitioners and advanced practice nurses) and non-prescribers (N = 11; psychologists, social workers). Most worked in Patient Aligned Care Teams, mental health clinics, or Community Living Centers and reported geriatric training and comfort with geriatric patients. When asked about their perception of the impact of the services, most providers believed that patients (91.9%) and care teams (94.6%) benefitted from the telehealth services and would recommend the services (94.6%). Most followed through on recommendations (83.7%) and believed the service increased access to geriatric mental health (89.2%). Open-ended feedback included gratefulness for providing care to aging rural Veterans lacking resources. These services are appreciated by providers and may facilitate access to specialized mental health care particularly in rural areas. Having access to specialists to assist with the care of patients with complex needs may ease the care coordination needed by referring providers.

ENHANCING CARE FOR OLDER VETERANS WITH COMPLEX PHYSICAL, COGNITIVE, AND PSYCHOLOGICAL COMORBIDITIES

Abstract Older veterans present in healthcare settings with more diagnoses than younger veterans and non-veteran older adults. Older veterans are also more likely to present with co-occurring physical, cognitive, and psychological conditions that are difficult to assess and treat. This is further complicated by the fact that many older veterans reside in rural areas without easy access to specialty care and, even in non-rural settings, there is a dire shortage of providers with geriatric expertise both within and outside of the Veterans Health Administration (VHA) system. The current symposium highlights promising findings from a variety of VHA programs aimed at enhancing the quality and reach of care provided to older veterans with complex needs. First, Dr. Bamonti will present mixed-methods results from her work in the development of Step-Cognitive Behavioral Therapy, a novel virtual intervention for older veterans with COPD. Second, Ms. Carlson will describe program evaluation outcomes from a project aimed at expanding geriatric mental health services via telehealth to older veterans with complex needs residing in rural areas. Third, Dr. Peeples will discuss factors affecting the implementation of the VA Behavioral Recovery Outreach Team model, which is aimed at facilitating successful discharge from inpatient settings and preventing rehospitalization for older veterans. Finally, Dr. Gregg will describe qualitative findings examining a component of the Geriatric Scholars Program for Psychologists, a national post-licensure training program for psychologists treating older rural veterans with complex needs. Dr. Karel, National Director of VHA Geriatric Mental Health, will close with discussion and highlight future directions.