Addictions Among Older Adults
The "Invisible Epidemic" & elderly
- Alcohol abuse takes a greater toll on elderly - May accelerate aging associated with decrease in physiological functioning - May increase risk for injury, illness, socioeconomic decline
Brief Therapy Interventions
- 10-30% of problem drinkers reduce their drinking to moderate levels following BRIEF INTERVENTION - A brief intervention - one or more counseling sessions, which may include motivation for change strategies, patient education, assessment and direct feedback, contracting and goal setting, behavioral modification techniques, and the use of written materials - Cognitive Behavioral Therapy - The Frames Model: Feedback, Responsibility, Advice, Menu, Empathic, Self-Efficacy
Estimates of Alcohol Use Among Older Adults
- 2% to 15% of community-based elders exhibit symptoms consistent with alcoholism - 10-15% of older primary care patients met criteria for problem drinking - 8.6% patients (N = 140) in a geriatric mental health outpatient clinic met criteria for alcohol dependence - 21% of older adults hospitalized for medical conditions abuse alcohol - 1 in every 10 patients in a medical setting and 1/5 hospitalized older patients is most likely to suffer with an alcohol problem.
Culturally Appropriate Assessment Measures
- AUDIT-Cross-cultural studies (Babor, 1992) - Addiction Severity Index (ASI) (McLellan, 1980) a. Native Americans b. 1 hour face to face interview c. highlights seven potential problem areas: medical status, employment and support, drug use, alcohol use, legal status, family/social status, and psychiatric status. This broad overview helps to determine the client's level of stability. It has also proven useful for understanding life events that contribute to alcohol and drug dependency.
Who Should be Screened?
- All patients 60+ - If younger than 60, screen if: a. undergoing major life changes (Menopause, "Empty Nest Syndrome", Retirement, Death of spouse/partner, Assuming a "caretaker" role) b. exhibiting physical symptoms of possible alcohol use disorder (Incontinence, Neglected hygiene, Restlessness, Change in eating, Slurred speech, Tremor/motor problems, Falls/bruising, Difficulty sleeping, Cognitive problems, Seizures, Malnutrition, Liver problems, Irritability, depression, Unexplained somatic complaints)
Classifying Drinking Practices and Problems Among Older Adults
- At-Risk, Heavy, & Problem Drinking a. At-Risk 1. One whose patterns of alcohol use, although not yet causing problems, may bring about adverse consequences. b. Heavy/Problem Drinking 1. Signify more hazardous levels of consumption. - Special Considerations a. Threshold for "at risk" drinking decreases with advancing age b. Distinction between "heavy" and "problem drinking" narrows with age
The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?
- Committee on the Mental Health Workforce for Geriatric Populations concerning professionals entering into geriatric mental health/substance use - Essential ingredients for effective services a. Systematic outreach and diagnosis b. Pt and family education and self-management support c. Provider accountability for outcomes d. Close follow-up and monitoring to prevent relapse e. Patient centered f. Accessible (PCP, senior centers, or home-based) g. Coordination of care by trained personnel with access to specialty consultation
Asking Screening Questions
- Confidential setting - Non-threatening, non-judgmental manner a. Medical vs Psychiatric diagnosis b. Avoid stigmatizing terms (e.g., alcoholic) c. Prepare patient rather than blindside - Collateral report may be necessary a. Get permission b. Be ready for emergence of anger toward patient
Uniquely Vulnerable
- Drinking can be hazardous for elderly even when formal AUD diagnosis is not warranted a. Decreased body water, Increased sensitivity/decreased tolerance, & Decreased metabolism in GI tract - Combination of age-related changes and drinking can increase risk for: a. Hypertension, arrhythmia, infarction, Hemorrhagic stroke, Decreased immune system function, GI bleeding, Malnutrition, Depression, Decreased bone density (?) - Quantity of alcohol consumed and frequency of drinking can only serve as rough parameters in this population a. Age appropriate assessment techniques are not well known. For example, typical assessment involved QF, but this can only serve as a rough parameter in this population given individual differences, such as prescription medication regime.
Appropriate Treatment Strategies for family interventions
- Family Interventions a. One or two significant people in an older adult's life confront the older adult about their drinking problem under the guidance of a skilled counselor. b. Confrontation by younger relatives should be avoided because it increases shame in the older adult. c. Labels such as "alcoholic" should be avoided
Barriers to Treatment
- Few elders are screened for alcohol problems a. Less obvious signs of problem drinking - Transportation problems a. Driving after dark b. Evening aftercare/AA c. Rural communities lack public transportation d. Poor urban communities; dangerous - Lack of social support a. Shrinking circle of friends - Financial issues a. May not have adequate insurance coverage b. Fixed income - Homebound ("Shut-Ins") a. Extremely high risk for alcoholism b. Frequently have limited mobility (weak/frail) c. Always requires assistance of others 1. Socially isolated d. Leaving home requires considerable effort
Risk Factors of Alcohol Use among Older Adults
- Psychological Problems, particularly anxiety - Older adults who are withdrawn, isolated, impulsive, and hypersensitive - Stressful events - Stressful environmental setting - Culture considerations
Advising Appropriate Action:
- State your Concern - Be specific about patterns and health risks - Advise - a. Stop Drinking altogether 1. If there is substance use disorder, history of failed attempts to cut down, contraindicated medical condition, taking medication that interacts b. Cut down - If there is drinking above recommended levels but no evidence of substance use disorder - Make a Plan of Action - a. If no substance use disorder: 1. Recommend specific limits 2. Ask patient to set specific drinking goals 3. Provide education materials b. For suspected substance use disorder: 1. Refer for additional evaluation/treatment 2. Involve patient in referral decision 3. Discuss treatment options/services
Addictions at End of Life
- Substance abuse in patients at end of life who do not have a previous history is rare - Clinical problems: a. Poor compliance with treatment b. Poor prognosis c. Shorter life expectancy d. Poor social support networks e. Pain inadequately treated
High Risk for Drug/Alcohol Interactions
- Take more prescription and OTC meds than younger people - Aging body more susceptible to adverse reactions - Slowed metabolic and clearance mechanisms delay resolution of adverse reactions
Clinical Clues Suggesting Alcohol Use in an Older Patient
- Therapy is not working for a normally treatable medical illness (e.g. hypertension) - Insomnia or chronic fatigue related to poor sleep - Diarrhea, urinary incontinence, and weight loss or malnutrition - Complaints of anxiety (related to undiagnosed withdrawal), with frequent use of or request for anxiolytics, sedative, or hypnotics - Unexplained postoperative agitation, anxiety, confusion, or new-onset seizures (suggesting withdrawal)
Practice Guidelines for Treating Older Adults with Substance Abuse Problems
- Treatment Impairment Protocol Series (TIPS) #26: Substance Abuse Among Older Adults (SAMHSA) a. Emphasize age-specific, group treatment, supportive (not confrontive) b. Attend to negative emotions: depression, loneliness, overcoming losses c. Teach skills to rebuild social support network d. Employ staff who are experienced in working with elders e. Link with aging services, medical services, institutional settings f. Slow the pace and content of treatment g. Create a "culture of respect" for older clients h. Broad, holistic approach to treatment recognizing age-specific psychological, social and health aspects i. Adapt treatment as needed in response to client's gender
Clinical Characteristics
- late onset - early onset
Co-morbid Diagnoses
- psychological - physical
Moderate Drinking: Benefits?
-Possible association with lower rates of coronary heart disease in older people a. Diet/exercise likely to be as effective b. Vulnerability to alcohol-related problems - May be associated w/greater social contact a. However some people drink alone - Abstainers should not be advised to begin drinking in order to gain these "benefits
National Household Survey on Drug Use and Health
35% used alcohol in the past month 50% 60 and older 7% reported current binge drinking (5+ drinks on the same occasion on at least 1 day in the past month) 2% reported current heavy drinking (5+ drinks on the same occasion on each of 5+ days in the past 30 days)
Overview: Facts
Abuse of alcohol, illicit drugs, and prescription drugs among adults 60 and older is one of the fastest growing health problems facing this country. By the year 2020 the number of older adults in need of substance use treatment will double. Why? Adults age 65 and older consume more prescribed and over-the-counter medications than any other age group.
Psych co-morbidities
Anxiety disorders Depression Cognitive impairment Schizophrenia AntiSocialP Disorder
Drinking Patterns Among Older Adults Continuous & Intermittent
Continuous versus Intermittent Drinking Continuous: Drinking problem is ongoing Intermittent: Refers to regular heavy drinking followed by a period of abstinence/sobriety (3+ years) Problem drinkers who have been sober for many years are at risk for relapse as they age
Classification of Drinking Practices and Problems in Older Adults
DSM-V `. Substance Use Disorder (no longer a criteria between "abuse and dependence") Two or more criteria must be met (2-3 mild, 4-5 moderate and 6+ severe) 2. At-Risk, Heavy, and Problem Drinking
Special Considerations
DSM-V criteria may not apply to elderly making diagnosis more difficult Withdrawal: many elderly (late-onset) alcoholics do not develop physiological dependence Activities: may have fewer activities
Classifying Drinking Practices and Problems Among Older Adults: 11 Criteria
DSM-V: Substance Use (2+) 1. Taking the substance in larger amounts or for longer than the you meant to 2. Wanting to cut down or stop using the substance but not managing to 3. Spending a lot of time getting, using, or recovering from use of the substance 4. Cravings and urges to use the substance 5. Not managing to do what you should at work, home or school, because of substance use 6. Continuing to use, even when it causes problems in relationships 7. Giving up important social, occupational or recreational activities because of substance use 8. Using substances again and again, even when it puts the you in danger 9. Continuing to use, even when the you know you have a physical or psychological problem that could have been caused or made worse by the substance 10. Needing more of the substance to get the effect you want (tolerance) 11. Development of withdrawal symptoms, which can be relieved by taking more of the substance.
Drinking Patterns Among Older Adults
Early versus late-onset problem drinking - Early onset: longstanding alcohol-related problems, prior to age 40, high probability of psychiatric co-morbidity, continuance of established, abusive drinking patterns. - Late onset: problems began after age 40-50. Appear healthier than early onset. May be drinking in response to loss or life change.
Appropriate Treatment Strategies
For older adults with an identified substance use problem the consensus panel recommends the least intensive treatment options be explored first including - Brief Therapeutic Interventions - Family/ Friend Intervention - Motivational Counseling
Healthy Drinking Guidelines for 65+
Healthy (no problematic medications) No more than 1 drink per day (NIAAA) Maximum of 2 on any drinking occasion (CSAT consensus panel) Slightly lower for women (CSAT consensus panel) One standard drink is equivalent to: 12 oz beer 1.5 oz hard liquor 5 oz table wine 4 oz sherry or liqueur
Screening for Q & F
How many days/wk do you drink? On a typical day, how many? Maximum per occasion in past month? Define "drinks" Avoid questions like "do you drink?" Clarify terms like "socially" and "occasionally"
Cognitive Signs of Alcohol Use
Intellectual deficits consistently appear on tasks involving frontal lobe activity Perceptual-motor deficits Memory deficits particularly with short-term memory Verbal and arithmetic skills generally remain unimpaired
Drinking Patterns Among Older Adults
Late vs. Early Onset Continuous vs. Intermittent Binge and Heavy Drinking
Late onset
Likely female Higher SES Drinks in response to stressors Less commonly FHx+ Cognitive loss less severe, more reversible More tx compliant
early onset
Likely male Lower SES Drinks in response to stressors Commonly FHx+ Cognitive loss more severe, less reversible Less tx compliant
Physical co-morbidities
Liver disease COPD Peptic ulcer disease Psoriasis Malnutrition Risk factor for other problems (gastritis, injuries, pancreatitis, cerebrovascular disease, diarrhea)
Overview: Myths
Treating older adults for substance use disorders is not worthwhile. Alcohol or substance abuse problems cannot be successfully treated in older adults. Treatment for this population is a waste of health care resources.
Appropriate Treatment Strategies for motivational counseling
a. Acknowledges readiness to change b."Meets people where they are" c. Enlist patients in their own recovery by motivating them to shift their perceptions about their drinking habits d. Proven effective with older adults
Screening Instruments
Michigan Alcoholism Screening Test-Geriatric Version - MAST-G (Long 24/13/10 questions, focused on drinking over lifetime) (Blow et al., 1992) CAGE (Ewing, 1984) Drinking Problem Index (17 items specific to older adult population) (Finney, J.W., Moos, R.H. & Brennan, P.L. 1991) Alcohol Use Disorders Identification Test (AUDIT) - World Health Organization, 1982 (Saunders, 1993) ADLS, Cognitive Functioning, Depression
The "Invisible Epidemic"
Often overlooked because: - Difficult diagnosis: symptoms mimic other common disorders (dementia, depression) - Stereotyping: less likely to detect problems in women, the educated, and those with higher SES - Shame: Reluctance to seek help (private matter) - Ageism: different QOL standards applied to older people
Tx of Addictions at End of Life
Take a substance use history Involve a multidisciplinary team Set realistic goals for therapy Evaluate and treat comorbid psychiatry disorders Prevent or minimize withdrawal symptoms Consider impact of tolerance Apply appropriate pharmacologic principles to treat chronic pain Recognize specific drug abuse behaviors Utilize nondrug approaches as appropriate
