I did not do a geriatric psychiatry rotation during residency, nor did I do a geriatric psychiatry fellowship but I style myself as a specialist in geriatric psychiatry and neuropsychiatry. Most of the geriatric fellowships are a waste of time anyway. You can certainly choose, if you go to a decent residency program, to focus on seeing geriatric patients.
I really enjoy working with the geriatric population. The population is ageing and there is great demand for psychiatric services for older populations. 80% of over 65s receiving treatment for "depression" in primary care do not actually have a major depressive disorder! Patients with dementia or other older patients with high risk of delirium are commonly prescribed benzodiazepines and other deliriogenic sedative hypnotics or psychotropics that increase their risk of depression. Few people are providing psychotherapy for older adults, many of whom would benefit from it. Our country is ill-equipped to deal with the ageing population of drug addicts and alcoholics who are now living into old age, and who are ending up in nursing homes. Dementia, while on the decline, continues to be a leading cause of the global burden of disease. Many patients are being misdiagnosed as having dementia, when they have treatable medical conditions. As the family structure breaks down and the traditional support systems fragment, older people are increasingly reliant on social or medical services. After pain, psychological symptoms are the major cause of suffering in end of life care - existential angst, anxiety, depression, loneliness, agitation, delirium, fatigue, and so on are. Because older patients have multiple medical comorbidities, it can be even trickier to treat their psychiatric issues pharmacologically thus requiring a strong grasp of psychopharmacology and medicine. Because of the multiple aspects of care, strong interdisciplinary working is the rule. Because of prevalence of neurodegenerative disorders in this population a good understanding of neurology and brain-behavior correlates comes in handy. Unlike most psychiatric patients, many geriatric patients have true brain diseases.
Some of the most fascinating conditions in psychiatry and disorders of later life - Charles Bonnet Syndrome, Posterior Cortical Atrophy, Lewy Body Dementia (where you see quite frank visual hallucinations), corticobasal syndrome (where you see alien limb phenomena), semantic dementia, late paraphrenia, bipolar dementia, punding and pathological gambling in parkinson's disease etc...
Also patients with vascular dementia in particular tend to develop delusional disorders including erotomania, Othello syndrome, delusional parasitosis etc
A good residency program should provide the flexibility to give you training emphasising work with older adults.
IMHO, a good fellowship (if one exists) should provide training in outpatient, inpatient, consulation, nursing home and day hospital settings. It should include rotations in movement disorders, sleep medicine, dementia (including young onset dementias), palliative medicine, and ECT. There should be training in sexual aspects of geriatric medicine and psychotherapy adapted to this population. The fellowship should also provide training in forensic issues including medical decision making capacity, testamentary capacity, financial capacity, undue influence, guardianship, elder abuse.
Contrary to the above, geriatric psychiatry is not "social work" (general psychiatry could similarly be denigrated in this way). While it is of course the case as it is for psychiatry and much of medicine in general that social aspects of care are far more important than the medical, that does not in anyway mean that there is not an important role for the physician in the care of these patients. This includes identifying too much care, reducing polypharmacy and other iatrogenic hazards, managing disruptive behavior, helping patients identify and meet goals, allow patients to stay in their homes for longer, providing support to families in complex cases, discussing genetic issues (related to inherited dementias), and relieving treatable suffering. While it is true that many conditions in the older population are incurable, degenerative, and even incurable, there are other conditions for which these patients respond marvellously. late paraphrenia and the involutional psychoses tend to respond better to treatment than the psychoses of childhood and early adulthood. The melancholia of old age (including delusional depression and catatonia) can respond very well to ECT. Older patients may be more ready to respond to psychotherapy and reflect over their past as it comes to haunt them in late life.
Before geriatric psychiatry, confused older people with neuropsychiatric disorders were consigned to the scrap heap. Geriatrics is one of the only areas in psychiatry where diagnosis actually matters. There was no effort to distinguish delirium, dementia, pseudodementia, or paraphrenia and thus treatable causes of "dementia" were going unchecked. This is still happening. I regularly see patients being misdiagnosed as demented when an underlying medical condition led to delirium, or a treatable depression has been missed. This has farreaching consequences and leaves older adults vulnerable to abuse and exploitation, financially and sexually. Whether you dx someone with bipolar, schizophrenia or schizoaffective disorder is inconsequential. But missing a diagnosis of pseudodementia or delirium in a patient presenting with "dementia" loss makes all the difference.