The many consequences of the aging of baby boomers have made headlines in the media for well over a decade but have received considerably less dramatic attention in many medical school curricula. By the year 2030, when our recent graduates from medical school will still be practicing, 20% of the population will be age 65 and over (+1). The 85-and-over population, many with multiple comorbidities, the highest incidence of Alzheimer's disease (AD), and a preponderance of women, is the fastest growing in this sector. Thirty percent of every health care dollar and 33% of all hospital days are used by the elderly, and these percentages are on the rise (+2). Persons age 65 and over make more visits to physicians per person per year than any other age group (+2). Eighty percent of medical care for the geriatric population will be provided by primary care physicians with very little training in the fields of geriatrics or geriatric psychiatry, in spite of the inordinate scientific advances made in these fields in the past 30 years (+3).

Cognitive changes occur in later life and manifest clinically in many different ways. Inattention to and misdiagnosis of a patient's changes in cognition occur in many medical settings (+4). Dementia affects 5%—8% of persons 65 and over, 15%—20% age 75 and over, and 25%—50% age 85 and over (+5). From 50% to 75% of the reported cases of dementia are attributed to AD (+5). Accompanying the increase in the elderly population will be an increase of patients with dementia, specifically AD. It is imperative that medical students be prepared not only to diagnose, treat, or refer their elderly patients afflicted with this debilitating disease but also to address the many concomitant biopsychosocial issues and stay abreast of research advances in the field as they become applicable to practice. Much confusion and despair can be created on the part of the patient and his/her caregiver if the biopsychosocial issues surrounding a diagnosis of dementia are not addressed throughout the course of a dementing illness (+4).

Commitment to didactic and clinical educational efforts in the domains of geriatrics and geriatric psychiatry are needed to sensitize medical students to the biopsychosocial effects of aging processes, manifestations of conditions, and experiences frequently occurring in late life. Several medical schools have instituted mandatory geriatric clerkships for some of their students (+6—+8). Many medical school curricula have not treated the issues of aging as an integrated yet distinct part of the curriculum (+9, +10). As a consequence, many medical students may fail to realize that a high proportion of family and specialty practices will be composed of the elderly and their families.

The State University of New York at Buffalo School of Medicine and Biomedical Sciences has a "selective course" system for third-year clerks during four different weeks per year. With approval of several curricula committees and a vote by the Faculty Council, faculty can offer a 1-week selective and repeat it several times per year. A total of about 15 different selectives are offered. At the course coordinator's choice, the course can be offered one to four times. A minimum of 6, to a maximum of 15, students can choose to enroll during any 1 week in one of these courses. So, 140 third-year medical students have 15 courses and 60 sections to choose from. An average of 10 participants per course section is more than adequate interest to maintain the course, though this number constitutes only 14% of the entire class. The students are required to choose one of these courses during a time that they are not on a clerkship. The number of students available to choose a selective varies from 48 to 96 students at any one time. Enrollment depends on many variables, such as time of year a course is offered, how many students are available to select it, how many courses they can choose from, their interest in the subject, and its coverage or lack thereof in the overall curriculum. Geriatrics and geriatric psychiatry training in the curriculum requires consistent and knowledgeable administrative support to establish and sustain successful programs. This support is not consistently nor universally available in medical schools.

An annual, intensive 1-week course entitled "Dementia With Focus on Alzheimer Disease" was created for those students who recognized the need for comprehensive and experiential knowledge in this domain. We hypothesized that the attitudes and knowledge acquired during such an intensive 1-week medical training course would carry over into the practice of those physicians.

The course is coordinated by the Division of Geriatric Psychiatry, and the faculty is multidisciplinary and includes geriatric psychiatrists, neurologists, a neuropsychologist, a neuropathologist, a geriatrician, a family practitioner, a lawyer specializing in elder law, and administrative and professional staff from a local nursing home and the Western New York Alzheimer Association.

One modality of teaching used is clinical problem solving, including the original Alzheimer case of 1907. Issues applicable to diagnosis, treatment, and counseling of patients and families are emphasized. Current research in various domains of dementia, including medications that enhance cognition or delay decline, are discussed. The epidemiology, genetics, and differential diagnosis of AD are presented in lecture format. Special attention is paid to the differential diagnosis of dementia, depression, anxiety, delirium, and other neurologic diseases, as well as the laboratory testing required to determine the presence of a reversible dementia. A geriatric psychiatrist and a neuropsychologist cover the clinical and psychometric assessment of cognitive, affective, functional, behavioral, and communication problems that develop over the course of a slowly progressing, irreversible dementia.

Patients and their caregivers, spouse, or adult child are interviewed to provide clinical experiences with the wide variety of presentations associated with a dementing illness. The availability of escorts from the Alzheimer Association or the Alzheimer Assistance Center enables interviewing of patients and family members individually and together.

Environmental, psychotherapeutic, and pharmacologic treatment modalities are discussed. Emphasis is on early detection; continuity of care; issues of cognitive, behavioral, and physical decline; death; caregiver relief and bereavement following death; and research done at institutions that have brain banks. The role of the caregiver throughout the course of illness and issues of caregiver burden, stress, and reward are discussed, with clarification of the resources available for caregivers and the research done in this area. Interviews of caregivers reveal readily and repetitively that despite visits to several physicians, intensity of burden is considerably prolonged by lack of attention paid to the dementia and lack of referral to resources during the early stages of the patient's dementia. Gender and ethnic variations in caregiving attitudes and practices are explored. Students are brought to the Western New York Alzheimer Association to meet with professionals and trained volunteers who run support groups, help lines, and respite assistance for families of patients with dementia. Home health care, respite care, day care, elder abuse, neglect, and exploitation are topics for discussion. Students visit a nursing home, where they have the opportunity to administer a Mini-Mental State Exam (+11) under faculty supervision, after having practiced with each other.

A lawyer specializing in elder law is introduced to students as a source of information for families to deal with legal matters, including health care proxy, living wills, guardianship, and power of attorney, as well as financial issues of long-term care. Medical students are alerted to some of the current complexities of federal, state, and managed care mandates in the care of elderly patients with AD and their families.

To provide an opportunity for independent study and peer learning, students are given the opportunity to prepare a brief presentation on a dementia-related topic of their choice on the last day of the selective.

Nearly 100% attendance is recorded in both the morning and afternoon sessions, with only an occasional excused absence. Student course evaluations show that the majority of students appreciate and like the organization and content of the course and would recommend the course to their peers. Faculty evaluation by students makes frequent special mention of the relevance of choice of topic and excellence of presentation.

To assess self-perceived knowledge of the students participating in the dementia selective over the past 6 years (1990—1995), a survey was mailed to 50 of the 61 participants (subjects) whose addresses were available. The survey was also mailed to 50 randomly selected classmates who had not taken the dementia course (control subjects). A cover letter explained the nature of the survey. The control subjects received a cover letter in which the importance of their control status to the study was explained, so that they would return the filled-in questionnaire and not consider themselves as having received the questionnaire by mistake. The nonrespondents received a second mailing. The survey asked for the following identifying information: age, gender, ethnicity, marital and parental status, year of medical school graduation, nature of practice, and percent of patients age 60 and over seen currently. The respondents were asked how much the dementia course has helped them during residency; whether they have had additional training in geriatrics/geriatric psychiatry; how their knowledge of aging and dementia compares with that of their colleagues; how confident they feel in assessing and diagnosing dementia; differentiating among normal aging, depression, and dementia; and recognizing various stages and manifestations of dementia. The respondents were also asked to assess their awareness of community resources and whether they refer patients and families to these resources. The respondents were asked to indicate if they gave guidance in legal issues and were familiar with addressing issues of caregiver burden. The respondents answered on a 5-point Likert scale, in which a score of 1 signified least applicability and a score of 5 signified most.

The course participants and control subjects were compared with respect to background variables and indicators of course-based learning. Descriptive analysis specified frequencies of medical fields reported by the subjects and control subjects. Chi-square analyses assessed the relationship between course participation and categorical demographic variables (e.g., gender, marital status). We used t-tests to examine similar group differences on age and on practical indicators of dementia knowledge.

To assess the impact of continuity experiences with the geriatric population on dementia knowledge, we conducted two additional sets of t-tests. First, we repeated the t-tests of participant—control differences in knowledge after excluding the psychiatrists and neurologist, whom one might expect to have the most relevant continuity experiences and in which the groups differed most in frequency. Second, we compared the knowledge of a broader class of physicians with assumed continuity experiences (i.e., those in internal medicine, family medicine, psychiatry, or neurology) against that of other physicians.

There was a 52% return rate of the mailed questionnaires. The demographics and background characteristics of the respondents are shown in +Table 1 and +Table 2. The groups did not differ on gender, race, age, marital status, or parental status. The course participants more often practiced in fields expected to foster continuity experiences with geriatric patients (i.e., internal medicine, family medicine, psychiatry, or neurology). Notably, the physicians in the aforementioned fields reported significantly greater knowledge of all dementia-related issues than the other physicians did (+Table 3). The course participants, however, reported no more postgraduate training in geriatrics than the control subjects did (see +Table 4).

As shown in +Table 4, the participants in the dementia selective were more confident in assessing and diagnosing dementia than the control subjects were. The former were significantly more aware of community resources available for demented patients and their families and more familiar with the issues of caregiver burden. Nonsignificant statistical trends suggested that the participants considered their knowledge of aging and dementia to be slightly better than that of the control subjects and that the former more often gave guidance on legal resources. The participants and control subjects did not differ on the following: reliability of differentiation among aging, depression, and dementia; competence in recognizing the manifestations and stages of dementia; and actually referring demented patients and their families to resources.

After we excluded the psychiatrists and neurologist from this analysis, the course participants were no longer more aware of community resources than the control subjects. The pattern of between-group knowledge differences did not otherwise change.

This postcourse survey yields promising evidence that some of the course's content has been integrated into the knowledge base of the course participants. Differences in reported knowledge base of the participants and control subjects may be due to course experiences, unexplored background differences between the groups, and/or characteristics of the current health care training and practice environments.

Several methodological factors limit our study findings. First, course participants were self-selected and attracted a relatively high proportion of students with an interest in psychiatry, family practice, and internal medicine. Second, the design did not lend itself to pre- and posttesting. Third, the sample was relatively small. Fourth, not all participants' addresses were available. Fifth, the time between course participation and response to the survey varied by graduating class. Other confounds, such as having a close relative with dementia, could have contributed to the findings.

The participants in the course reported feeling significantly more confident in assessing and diagnosing dementia and more familiar with addressing caregiver burden with or without inclusion of psychiatrists/neurologists in the analysis. This finding can be interpreted to mean that those who might be presumed to have had more opportunity for subsequent dementia training and continuity of care experiences with geriatric patients were not the ones to influence this between-group difference. Considering the fact that only about one-third of psychiatric training programs have an accredited postgraduate yearV devoted to geriatrics underscores the fact that geriatric psychiatry experiences and didactics are minimal during residency and that the availability of geriatric supervisors /mentors is limited; therefore, our finding supports our hypothesis. The fact that there no longer was a between-group difference in awareness of community resources for demented patients and their families, when psychiatrists and the one neurologist were excluded from the analysis, can be attributed to unique integration of course experiences and subsequent exposure to a biopsychosocial model of medical care by the psychiatrists. Several realities of our current health care system contribute to mandating use of nonmedical community resources for mental health care. Reimbursements for medical mental health care for outpatients with a diagnosis of dementia and for family meetings are often denied. In New York state, patients with a diagnosis of dementia are excluded from admission to state hospitals, regardless of behavioral disturbances or psychiatric symptoms. This rule creates a situation in which patients with dementia get admitted to acute care units, and awareness of community resources is essential to implement discharge. So it stands to reason that the group of future psychiatrists in the course influenced this particular outcome of between-group differences.

Our comparison of physicians with and without assumed continuity of care experiences with geriatric patients (i.e., psychiatrists, neurologist, internists, and family practitioners) suggested a potential confounding effect of such experiences. Nonetheless, the removal of psychiatrists (and a single neurologist) did not markedly affect course-related outcomes in our re-analysis, despite their skewed between-group distribution. Notably, the internists and family practitioners were more evenly distributed between course participants and control subjects. The distribution of these primary care practitioners could not have explained away the presumed benefits of the course. Thus, continuity of care experiences of these primary care course participants, though perceived to be more extensive, probably does not account for existing between-group differences.

The significant differences found on all variables when responses from a group of physicians with presumed continuity of care experiences with elderly patients was compared with those presumed to lack such experiences confirms the fact that a lack of knowledge of dementia and related issues prevails among many physicians. We know from many studies of primary care practices that the knowledge reported here by primary care physicians is often not applied in practice because of inordinate time pressures, leading to a lack of attention to mental health issues of elderly patients and their caregivers.

We can make the following speculations about variables that lack differences between the participants and control subjects. Despite the larger number of psychiatrists and physicians more likely to have continuity experiences with an elderly patient population, the group taking the course and those who did not reported no significant difference in amount of training in geriatrics or geriatric psychiatry after medical school. This finding may well reflect the discrepancy between the ever-increasing number of elderly in the general population and patient population and the still prevailing relative lack of training in mental health issues of late life in many residency training programs. For example, until the essential requirements in psychiatric residency are changed, even psychiatric residents cannot be assigned to geriatric units to fulfill accreditation requirements—only elective time can be taken on such units. Family medicine residencies have as yet no requirement to experience a mental health rotation, let alone a geriatric rotation. It is of interest to note that the mean on the Likert scale used in this survey for this question (+Table 4) was below the middle mark of 2.5.

Both groups reported that their knowledge of aging and dementia was not different from that of their colleagues. There are reasons to assume that this knowledge may have been relatively limited in both groups. Generally, knowledge of aging and dementia is not discussed much among young physicians unless specialty mentors are available. Interest and desire for acquisition of knowledge of late-life issues is an "acquired taste" that is developed by active exposure, personally and professionally, as opposed to interest and knowledge acquisition about the earlier years in life. Physicians already exposed personally to the early years of life or who may be having or expecting experiences with their own children and in residency training experienced mandated rotations on units with children. Furthermore, physicians tend to interact predominantly with colleagues with similar training, as evidenced by the organizational structure of medicine and the frequently observed difficulties in articulating reasons for consultations from physicians in other specialties, especially in psychiatry. It is very likely that the respondents compared themselves with colleagues with similar training or lack of training in mental health issues of late life.

Both groups reported nonsignificant differences in levels of reliability in differentiating among normal aging, depression, and dementia. The control group, which constituted 12:27 physicians with noncontinuity practices, did not differ from the course participants with only 3:22 with noncontinuity experiences with the elderly. Many practitioners, including primary care physicians without specialty training in geriatrics and limited to brief patient visits, tend to overlook the need for differential diagnosis among normal aging, dementia, and depression. If the need for this differential is recognized by the physician, patient, or family, efforts are generally made to make a referral to a geriatric specialist, if available. A 1-week course in medical school does not suffice to teach, learn, retain, and integrate the skill of differentiating these conditions in future practice without considerable additional training. Competency in recognizing manifestations of various stages of progressive degenerative dementia also requires considerable additional training. This factor was another variable for which no significant difference was found between the participants and control subjects.

Our results indicate that confidence in assessment and diagnosis, awareness of resources, and familiarity with caregiver burden prevail in the subject group. However, self-reported practice patterns of referral to community resources do not reflect this knowledge. This lack of reflection of "awareness" of community resources to refer to may be attributed to the time pressures experienced under our managed health care system, with diversion away from actual best patient—caregiver care and toward mandated response for excessive requirements, including pre-authorization and justification of "medical necessity" for care, massive paperwork, and complex and varied billing requirements.

Enrollment, attendance, and evaluations of the course were consistently high. Enrollment ranged from 6—15 students during the 6 years. The response to the mailed survey was adequate for data analysis. The response rate was actually highest from the first academic year the course was offered and can be speculated to be possible evidence of knowledge retention over time and the relatively high number in that class who chose psychiatry as their specialty. There was also more time for intervening experiences. The variety of teaching modalities, with emphasis on issues beyond patient/disease-oriented medical model, though controversial among some of the participating faculty, may have contributed to a positive outcome in terms of self-reported knowledge. This possibility is indeed an interesting finding, since only those respondents in obstetrics-gynecology and pediatrics and one in psychiatry reported seeing less than 25% patients age 60 and over, whereas the majority reported seeing 50%—100% age 60 and over.

The attitudes of teachers, preceptors, and mentors greatly affect a student's view of the elderly (+12). Recruitment of devoted and enthusiastic geriatricians and geriatric psychiatrists, and other professionals specializing in the treatment of the elderly, can greatly improve medical students' attitudes toward the geriatric population (+13). Objectives of geriatric education need to be established that encompass biopsychosocial issues and help educators to cover all the topics necessary for a complete medical education (+14, +15). There are many obstacles to training in geriatrics and geriatric psychiatry. Among the most daunting are resistant faculty, overcrowded curricula, and the apparent "agism" that still exists today in many sectors of medicine (+16). Despite these obstacles, several mandatory clerkships in geriatrics have been successfully established, favorably received, and found to have excellent teaching effectiveness(+6—+8).

It would serve all patients and their families well if medical students had the opportunity to become knowledgeable and enthusiastic advocates for the geriatric patients they encounter in clinical clerkships, residency training, and practice beyond. If myths about the aged are dispelled early in medical education, residents of teaching hospitals will more likely be open to learning from their geriatric patients while providing them with the best care possible. The course and survey described here outline an example of the clinical and didactic experiences that all medical students could benefit from.

The authors thank Peter Kim, M.D., and Sandra Block, M.D., participants in the 1995—1996 dementia course, for gathering the names and addresses of the participants and control subjects that made this survey possible.

The authors also want to thank the dedicated and excellent faculty and staff participation of J. Edwards, M.D. (geriatrician); B. Truax, M.D. (neurologist); R. Benedict, Ph.D. (neuropsychologist); P. Ostrow, M.D. (pathologist); A. Szcygiel, J.D. (lawyer); and the staff of the Western New York Alzheimer Association and the Episcopalian Nursing Home, without whom this interdisciplinary selective could not have been coordinated. The authors want to especially thank the caregivers, spouses, children, and in-laws of persons with Alzheimer's disease for sharing their experiences. These individuals contributed considerably to helping medical students realize the role and importance of the physician in these persons' lives. The coordination of registration and evaluation by the State University of New York at Buffalo, Office of Medical Education, was exemplary.