Substance Abuse Among Older Adults
Treatment Improvement Protocol (TIP) Series 26
Frederic C. Blow, Ph.D.
Consensus Panel Chair
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
Rockwall II, 5600 Fishers Lane
Rockville, MD 20857
This publication is part of the Substance Abuse Prevention and Treatment Block Grant technical assistance program. All material appearing in this volume except that taken directly from copyrighted sources is in the public domain and may be reproduced or copied without permission from the Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Substance Abuse Treatment (CSAT) or the authors. Citation of the source is appreciated.
This publication was written under contract number ADM 270-95-0013. Sandra Clunies, M.S., I.C.A.D.C., served as the CSAT Government project officer. Writers were Paddy Cook, Carolyn Davis, Deborah L. Howard, Phyllis Kimbrough, Anne Nelson, Michelle Paul, Deborah Shuman, Margaret K. Brooks, Esq., Mary Lou Dogoloff, Virginia Vitzthum, and Elizabeth Hayes. Special thanks go to Roland M. Atkinson, M.D.; David Oslin, M.D.; Edith Gomberg, Ph.D.; Kristen Lawton Barry, Ph.D.; Richard E. Finlayson, M.D.; Mary Smolenski, Ed.D., C.R.N.P.; MaryLou Leonard; Annie Thornton; Jack Rhode; Cecil Gross; Niyati Pandya; Mark A. Meschter; and Wendy Carter for their considerable contributions to this document.
The opinions expressed herein are the views of the Consensus Panel members and do not reflect the official position of CSAT, SAMHSA, or the U.S. Department of Health and Human Services (DHHS). No official support or endorsement of CSAT, SAMHSA, or DHHS for these opinions or for particular instruments or software that may be described in this document is intended or should be inferred. The guidelines in this document should not be considered substitutes for individualized patient care and treatment decisions.
DHHS Publication No. (SMA) 98-3179
Printed 1998
Treatment Improvement Protocols (TIPs) are best practice guidelines for the treatment of substance abuse, provided as a service of the Substance Abuse and Mental Health Service Administration's Center for Substance Abuse Treatment (CSAT). CSAT's Office of Evaluation, Scientific Analysis, and Synthesis draws on the experience and knowledge of clinical, research, and administrative experts to produce the TIPs, which are distributed to a growing number of facilities and individuals across the country. The audience for the TIPs is expanding beyond public and private substance abuse treatment facilities as alcohol and other drug disorders are increasingly recognized as a major problem.
The TIPs Editorial Advisory Board, a distinguished group of substance abuse experts and professionals in such related fields as primary care, mental health, and social services, works with the State Alcohol and Other Drug Abuse Directors to generate topics for the TIPs based on the field's current needs for information and guidance.
After selecting a topic, CSAT invites staff from pertinent Federal agencies and national organizations to a Resource Panel that recommends specific areas of focus as well as resources that should be considered in developing the content of the TIP. Then recommendations are communicated to a Consensus Panel composed of non-Federal experts on the topic who have been nominated by their peers. This Panel participates in a series of discussions; the information and recommendations on which they reach consensus form the foundation of the TIP. The members of each Consensus Panel represent substance abuse treatment programs, hospitals, community health centers, counseling programs, criminal justice and child welfare agencies, and private practitioners. A Panel Chair (or Co-Chairs) ensures that the guidelines mirror the results of the group's collaboration.
A large and diverse group of experts closely reviews the draft document. Once the changes recommended by these field reviewers have been incorporated, the TIP is prepared for publication, in print and online. The TIPs can be accessed via the Internet on the National Library of Medicine's home page at the URL: http://hstat2.nlm.nih.gov/download/651951783968.html#http://text.nlm.nih.gov. The move to electronic media also means that the TIPs can be updated more easily so they continue to provide the field with state-of-the-art information.
Although each TIP strives to include an evidence base for the practices it recommends, CSAT recognizes that the field of substance abuse treatment is evolving, and research frequently lags behind the innovations pioneered in the field. A major goal of each TIP is to convey "front-line" information quickly but responsibly. For this reason, recommendations proffered in the TIP are attributed to either Panelists' clinical experience or the literature. If there is research to support a particular approach, citations are provided.
This TIP, Substance Abuse Among Older Adults, presents treatment providers with much-needed information about a population that is underdiagnosed and underserved. Substance abuse, particularly of alcohol and prescription drugs, often goes undetected among adults over 60 in part due to societal reasons - older adults tend to be ashamed about drinking or drug problems and see them as a moral failing. Providers, for their part, may confuse symptoms of substance use disorders with age-related changes. Because so much of older adults' substance abuse is never even identified, this TIP is aimed at not only substance abuse treatment providers but also primary care clinicians, social workers, senior center staff, and anyone else who has regular contact with older adults.
The TIP discusses the relationship between aging and substance abuse and offers guidance on identifying, screening, and assessing not only substance abuse but also disorders such as dementia and delirium that can mask or mimic an alcohol or prescription drug problem. Practical accommodations to treatment for older adults and a discussion of how to assess outcomes and treat within a managed care context round out the document.
Other TIPs may be ordered by contacting the National Clearinghouse for Alcohol and Drug Information (NCADI), (800) 729-6686 or (301) 468-2600; TDD (for hearing impaired), (800) 487-4889.Editorial Advisory Board
Karen Allen, Ph.D., R.N., C.A.R.N.
President of the National Nurses Society on Addictions
Associate Professor
Department of Psychiatry, Community Health, and Adult Primary Care
University of Maryland
School of Nursing
Baltimore, Maryland
Richard L. Brown, M.D., M.P.H.
Associate Professor
Department of Family Medicine
University of Wisconsin School of Medicine
Madison, Wisconsin
Dorynne Czechowicz, M.D.
Associate Director
Medical/Professional Affairs
Treatment Research Branch
Division of Clinical and Services Research
National Institute on Drug Abuse
Rockville, Maryland
Linda S. Foley, M.A.
Former Director
Project for Addiction Counselor Training
National Association of State Alcohol and Drug Directors
Washington, D.C.
Wayde A. Glover, M.I.S., N.C.A.C. II
Director
Commonwealth Addictions Consultants and Trainers
Richmond, Virginia
Pedro J. Greer, M.D.
Assistant Dean for Homeless Education
University of Miami School of Medicine
Miami, Florida
Thomas W. Hester, M.D.
Former State Director
Substance Abuse Services
Division of Mental Health, Mental Retardation and Substance Abuse
Georgia Department of Human Resources
Atlanta, Georgia
Gil Hill
Director
Office of Substance Abuse
American Psychological Association
Washington, D.C.
Douglas B. Kamerow, M.D., M.P.H.
Director
Office of the Forum for Quality and Effectiveness in Health Care
Agency for Health Care Policy and Research
Rockville, Maryland
Stephen W. Long
Director
Office of Policy Analysis
National Institute on Alcohol Abuse and Alcoholism
Rockville, Maryland
Richard A. Rawson, Ph.D.
Executive Director
Matrix Center
Los Angeles, California
Ellen A. Renz, Ph.D.
Former Vice President of Clinical Systems
MEDCO Behavioral Care Corporation
Kamuela, Hawaii
Richard K. Ries, M.D.
Director and Associate Professor
Outpatient Mental Health Services and Dual Disorder Programs
Harborview Medical Center
Seattle, Washington
Sidney H. Schnoll, M.D., Ph.D.
Chairman
Division of Substance Abuse Medicine
Medical College of Virginia
Richmond, Virginia
Frederic C. Blow, Ph.D.
Assistant Professor and Assistant Research Scientist
Department of Psychiatry
Alcohol Research Center
University of Michigan
Ann Arbor, Michigan
Roland M. Atkinson, M.D.
Professor
Head of Division of Geriatric Psychiatry
Department of Psychiatry
School of Medicine
Oregon Health Sciences University
Portland, Oregon
James Campbell, M.D., M.S.
Associate Professor
Acting Chairman
Department of Family Medicine
Case Western Reserve University
Medical Director
Senior Health Recovery Resources
Metrohealth Medical Center
Cleveland, Ohio
Anne M. Gurnack, Ph.D.
Professor and Director of Assessment
Department of Political Science
University of Wisconsin at Parkside
Kenosha, Wisconsin
Jeanie L. Holt, R.N.C.
Clinical Staff Nurse
Heritage Home Health and Hospice
Meredith, New Hampshire
David Oslin, M.D.
Assistant Professor
Addiction and Geriatric Psychiatry
Department of Psychiatry
University of Pennsylvania
Philadelphia, Pennsylvania
Gerald D. Shulman, M.A., F.A.C.A.T.A.
Consultant
Winter Haven, Florida
Charles Bearcomesout
Traditional Coordinator
Traditional Component
Northern Cheyenne Recovery Center
Lame Deer, Montana
Larry W. Dupree, Ph.D.
Professor
Department of Aging and Mental Health
Florida Mental Health Institute
University of South Florida
Tampa, Florida
Richard E. Finlayson, M.D.
Consultant in Adult Psychiatry
Former Medical Director of Addiction Services
Department of Psychiatry and Psychology
Mayo Clinic
Associate Professor of Psychiatry
Mayo Medical School
Rochester, Minnesota
Lissy F. Jarvik, M.D., Ph.D.
Distinguished Physician (11L)
Psychiatry Department
West Los Angeles VA Medical Center
Professor Emerita
Department of Psychiatry and Biobehavioral Sciences
University of California-Los Angeles
Los Angeles, California
Hila Richardson, Dr.P.H.
Deputy Director
Medical Research and Practice Policy
National Center on Addiction and Substance Abuse
Columbia University
New York, New York
Marguerite T. Saunders, M.S.
Saunders Consulting Services
Albany, New York
Sharon L. Sheahan, Ph.D., C.F.N.P.
Associate Professor of Nursing
College of Nursing
University of Kentucky
Lexington, Kentucky
Erma Polly Williams, M.R.E.
Program Support Specialist
Robert Wood Johnson Medical School
University of Medicine and Dentistry of New Jersey
New Brunswick, New Jersey
The Treatment Improvement Protocol (TIP) series fulfills SAMHSA/CSAT's mission to improve treatment of substance use disorders by providing best practices guidance to clinicians, program administrators, and payers. TIPs are the result of careful consideration of all relevant clinical and health services research findings, demonstration experience, and implementation requirements. A panel of non-Federal clinical researchers, clinicians, program administrators, and patient advocates debates and discusses their particular area of expertise until they reach a consensus on best practices. This panel's work is then reviewed and critiqued by field reviewers.
The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly participatory process have bridged the gap between the promise of research and the needs of practicing clinicians and administrators. We are grateful to all who have joined with us to contribute to advances in the substance abuse treatment field.
Nelba Chavez, Ph.D.
Administrator
Substance Abuse and Mental Health Services Administration
David J. Mactas
Director
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration
Researchers are only beginning to realize the pervasiveness of substance abuse among people age 60 and older. Until relatively recently, alcohol and prescription drug misuse, which affects as many as 17 percent of older adults, was not discussed in either the substance abuse or the gerontological literature.
The reasons for this silence are varied: Health care providers tend to overlook substance abuse and misuse among older people, mistaking the symptoms for those of dementia, depression, or other problems common to older adults. In addition, older adults are more likely to hide their substance abuse and less likely to seek professional help. Many relatives of older individuals with substance use disorders, particularly their adult children, are ashamed of the problem and choose not to address it. The result is thousands of older adults who need treatment and do not receive it.
This TIP brings together the literature on substance abuse and gerontology to recommend best practices for identifying, screening, assessing, and treating alcohol and prescription drug abuse among people age 60 and older. The Consensus Panel, whose members include researchers, clinicians, treatment providers, and program directors, supplements this research base with its considerable experience treating and studying substance abuse among older adults. Because so much of older people's substance abuse is never identified, this TIP is aimed not only at substance abuse treatment providers but also at primary care clinicians, social workers, senior center staff, and anyone else who has regular contact with older adults.
The TIP aims to advance the understanding of the relationships between aging and substance abuse and to provide practical recommendations for incorporating that understanding into practice. The TIP's recommendations appear below in italic type. Those based on research evidence are marked (1), whereas those based on Panel members' clinical experience are marked (2). Citations for the former can be found in the body of the text.
Physiological changes, as well as changes in the kinds of responsibilities and activities pursued by older adults, make established criteria for classifying alcohol problems often inadequate for this population.
One widely used model for understanding alcohol problems is the medical diagnostic model as defined in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). The DSM-IV criteria for substance dependence (see Figure 2-2) include some that do not apply to many older adults and may lead to underidentification of drinking problems.
Diagnostic criteria for alcohol dependence are subsumed within the DSM-IV's general criteria for substance dependence. Dependence is defined as a "maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period" (American Psychiatric Association, 1994, p. 181).
The Panel recommends that clinicians consider that the DSM-IV criteria for substance abuse and dependence may not be adequate to diagnose older adults with alcohol problems. (2) See Figure 2-3 for an outline of special considerations.
Some experts use the model of at-risk, heavy, and problem drinking in place of the DSM-IV model of alcohol abuse and dependence because it allows for more flexibility in characterizing drinking patterns. In this classification scheme, an at-risk drinker is one whose patterns of alcohol use, although not yet causing problems, may bring about adverse consequences, either to the drinker or to others. As their names imply, the terms heavy and problem drinking signify more hazardous levels of consumption. Although the distinction between the terms heavy and problem is meaningful to alcohol treatment specialists interested in differentiating severity of problems among younger alcohol abusers, it is less relevant to older adults. To differentiate older drinkers, the Panel recommends using the terms at-risk and problem drinkers only. (2) In the two-stage conceptualization recommended by the Panel, the problem drinker category includes those who would otherwise fall into the heavy and problem classifications in the more traditional model as well as those who meet the DSM-IV criteria for abuse and dependence.
The Consensus Panel recommends that older men consume
The Panel recommends somewhat lower limits for women. (1)
People 65 and older consume more prescribed and over-the-counter medications than any other age group in the United States. Prescription drug misuse and abuse is prevalent among older adults not only because more drugs are prescribed to them but also because, as with alcohol, aging makes the body more vulnerable to drugs' effects.
Any use of drugs in combination with alcohol carries risk; abuse of these substances raises that risk, and multiple drug abuse raises it even further. For example, chronic alcoholics who use even therapeutic doses of acetaminophen may experience severe hepatoxicity. Alcohol can increase lithium toxicity and enhance central nervous system depression in persons taking tricyclic antidepressants. High doses of benzodiazepines used in conjunction with alcohol or barbiturates can be lethal. The many possible unfavorable reactions between prescription drugs and alcohol are summarized in Figure 3-6.
Benzodiazepine use for longer than 4 months is not recommended for geriatric patients. (2) Furthermore, among the different benzodiazepines, longer acting drugs such as flurazepam (Dalmane) have very long half-lives and are more likely to accumulate than the shorter acting ones. They are also more likely to produce residual sedation and such other adverse effects as decreased attention, memory, cognitive function, and motor coordination, and increased falls or motor vehicle crashes. By contrast, some shorter acting benzodiazepines such as oxazepam (Serax) and lorazepam (Ativan) have very simple metabolic pathways and are not as likely to produce toxic or dependence-inducing effects with chronic dosing. Because of these side effects, the Panel recommends caution in selecting the most appropriate benzodiazepines for elderly patients. (2)
Aging changes sleep architecture, decreasing the amount of time spent in the deeper levels of sleep (stages three and four) and increasing the number and duration of awakenings during the night. However, these new sleep patterns do not appear to bother most medically healthy older adults who recognize and accept that their sleep will not be as sound or as regular as when they were young. Although benzodiazepines and other sedative/hypnotics can be useful for short-term amelioration of temporary sleep problems, no studies demonstrate their long-term effectiveness beyond 30 continuous nights, and tolerance and dependence develop rapidly. The Panel recommends that symptomatic treatment of insomnia with medications be limited to 7 to 10 days with frequent monitoring and reevaluation if the prescribed drug will be used for more than 2 to 3 weeks. Intermittent dosing at the smallest possible dose is preferred, and no more than a 30-day supply of hypnotics should be prescribed. (1)
The Panel further recommends that clinicians teach older patients to practice good sleep hygiene rather than prescribe drugs in response to insomnia. (1) The former includes regularizing bedtime, restricting daytime naps, using the bedroom only for sleep and sexual activity, avoiding alcohol and caffeine, reducing evening fluid intake and heavy meals, taking some medications in the morning, limiting exercise immediately before retiring, and substituting behavioral relaxation techniques.
Older persons appear to be more susceptible to adverse anticholinergic effects from antihistamines and are at increased risk for orthostatic hypotension and central nervous system depression or confusion. In addition, antihistamines and alcohol potentiate one another, further exacerbating the above conditions as well as any problems with balance. Because tolerance also develops within days or weeks, the Panel recommends that older persons who live alone do not take antihistamines. (1)
The Consensus Panel recommends that every 60-year-old should be screened for alcohol and prescription drug abuse as part of his or her regular physical examination. (2) However, problems can develop after the screening has been conducted, and concurrent illnesses and other chronic conditions may mask abuse. Although no hard-and-fast rules govern the timing of screening, the Panel recommends screening or rescreening if certain physical symptoms (detailed in Chapter 4)are present or if the older person is undergoing major life changes or transitions. (2)
Although it is preferable to use standardized screening questionnaires, friendly visitors, Meals-On-Wheels volunteers, caretakers, and health care providers also can interject screening questions into their normal conversations with older, homebound adults. Although the line of questioning will depend on the person's relationship with the older person and the responses given, the Panel recommends that anyone who is concerned about an older adult's drinking practices try asking direct questions. (2) (Examples of these and of less direct questions appear in Chapter 4.)
The Panel recommends that health care providers preface questions about alcohol with a link to a medical condition when screening older people. (2) For example, "I'm wondering if alcohol may be the reason why your diabetes isn't responding as it should," or "Sometimes one prescription drug can affect how well another medication is working. Let's go over the drugs you're taking and see if we can figure this problem out." Do not use stigmatizing terms like alcoholic or drug abuser during these encounters. (2)
Although it is important to respect the older person's autonomy, in situations where a coherent response is unlikely, collateral participation from family members or friends may be necessary. In this case, the screener should first ask for the older adult's permission to question others on his or her behalf. (2)
The Panel recommends use of the CAGE Questionnaire and the Michigan Alcohol Screening Test-Geriatric Version (MAST-G) to screen for alcohol use among older adults. (1)
The Alcohol Use Disorders Identification Test (AUDIT) is recommended for identifying alcohol problems among older members of ethnic minority groups. (2)
The Panel recommends a sequential approach that looks at various dimensions of an older adult's suspected problem in stages, so that unnecessary tests are not conducted. (1)
The Panelists recommend the use of two structured assessments with older adults: the substance abuse sections of the Structured Clinical Interview for DSM-III-R (SCID) and the Diagnostic Interview Schedule (DIS) for DSM-IV. (2)
To identify functional impairments, the Panel recommends measuring the activities of daily living (ADLs) and the instrumental activities of daily living (IADLs) with the instruments in Appendix B. (1) Another useful instrument is the SF-36, a 36-item self-report questionnaire that measures health-related quality of life, including both ADLs and IADLs. (1)
Patients who have been medically detoxified should not be screened for cognitive dysfunction until several weeks after detoxification is completed, because a patient not fully recovered from detoxification may exhibit some reversible cognitive impairment. (2)
The Panel recommends use of the Orientation/Memory/Concentration Test (1), which is simple and can be completed in the office. The Folstein Mini-Mental Status Exam (MMSE) is an acceptable alternative (1), although it can be insensitive to subtle cognitive impairments among older problem drinkers who have recently attained sobriety (past 30-60 days). The MMSE is weak on visual-spatial testing, which is likely to show some abnormality in many recent heavy drinkers. The draw-a-clock task is a good additional task to complement the MMSE. (1) The Neurobehavioral Cognitive Status Examination, which includes screening tests of abstract thinking and visual memory (not measured on the MMSE), is also recommended for assessing mental status in this population. (1)
The Confusion Assessment Method (CAM) is widely used as a brief, sensitive, and reliable screening measure for detecting delirium. (1) The Panel recommends that a positive delirium screen be followed by careful clinical diagnostics based on DSM-IV criteria and that any associated cognitive impairment be followed clinically using the MMSE. (1)
The Panel recommends that initial medical assessment of older persons should routinely include screening for visual and auditory problems, and any problems discovered should be corrected as quickly as possible. (2) To assess the medication use of older adults, the Panel recommends the "brown bag approach." The practitioner can ask older adults to bring every medication they take in a brown paper bag, including over-the-counter and prescription medications, vitamins, and herbs. (1)
The Panel recommends that sleep history be recorded in a systematic way in order to both document the changes in sleep problems over time and to heighten the awareness of sleep hygiene. (2)
The Geriatric Depression Scale (GDS) and the Center for Epidemiological Studies Depression Scale (CES-D), reproduced in Appendix B, have been validated in older age groups although not specifically in older adults with addiction problems. The Panel recommends the CES-D for use in general outpatient settings as a screen for depression among older patients. (1)
The Consensus Panel recommends that the least intensive treatment options be explored first with older substance abusers. (1) These initial approaches, which can function either as pretreatment strategy or treatment itself, are brief intervention, intervention, and motivational counseling. They may be sufficient to address the problem; if not, they can help move a patient toward specialized treatment.
The Consensus Panel recommends that every reasonable effort be made to ensure that older substance abusers, including problem drinkers, enter treatment. Brief intervention is the recommended first step, supplemented or followed by intervention and motivational interviewing. (1) Because many older problem drinkers are ashamed about their drinking, intervention strategies need to be nonconfrontational and supportive.
A brief intervention is 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 such as self-help manuals. An older adult-specific brief intervention should include the following steps (2):
If the older problem drinker does not respond to the brief intervention, two other approaches - intervention and motivational interviewing - should be considered.
In an intervention, several significant people in a substance-abusing patient's life confront the patient with their firsthand experiences of his or her drinking or drug use. The formalized intervention process includes a progressive interaction by the counselor with the family or friends for at least 2 days before meeting with the patient.
The Panel recommends the following modifications to interventions for older patients. No more than one or two relatives or close associates should be involved along with the health care provider; having too many people present may be emotionally overwhelming or confusing for the older person. Inclusion of grandchildren is discouraged, because many older alcoholics resent their problems being aired in the presence of much younger relatives. (2)
Motivational counseling acknowledges differences in readiness and offers an approach for "meeting people where they are" that has proven effective with older adults. (1) An understanding and supportive counselor listens respectfully and accepts the older adult's perspective on the situation as a starting point, helps him or her to identify the negative consequences of drinking and prescription drug abuse, helps him or her shift perceptions about the impact of drinking or drug-taking habits, empowers him or her to generate insights about and solutions for his or her problem, and expresses belief in and support for his or her capacity for change. Motivational counseling is an intensive process that enlists patients in their own recovery by avoiding labels, avoiding confrontation (which usually results in greater defensiveness), accepting ambivalence about the need to change as normal, inviting clients to consider alternative ways of solving problems, and placing the responsibility for change on the client.
Some older patients should be withdrawn from alcohol or from prescription drugs in a hospital setting. Medical safety and removal from continuing access to alcohol or the abused drugs are primary considerations in this decision.
Indicators that inpatient hospital supervision is needed for withdrawal from a prescription drug include the following (2):
In general, the Panel recommends that the initial dose of a drug for suppression and management of withdrawal symptoms should be one-third to one-half the usual adult dose, sustained for 24 to 48 hours to observe reactions, and then gradually tapered with close attention to clinical responses. (1)
The Panel recommends that patients who are brittle, frail, acutely suicidal, or medically unstable or who need constant one-on-one monitoring receive 24-hour primary medical/psychiatric/nursing inpatient care in medically managed and monitored intensive treatment settings. (2)
As part of outpatient treatment, the Panel recommends drawing the physician into the treatment planning process and enrolling him or her as a player in the recovery network. (2)
The Panel also recommends serving older people who are dependent on psychoactive prescription drugs in flexible, community-oriented programs with case management services rather than in traditional, stand-alone substance abuse treatment facilities with standardized components. (2)
The Panel recommends incorporating the following six features into treatment of the older alcohol abuser (1):
Building from these six features, the Consensus Panel recommends that treatment programs adhere to the following principles (2):
To help ensure optimal benefits for older adults, the Consensus Panel recommends that treatment plans weave age-related factors into the contextual framework of the American Society of Addiction Medicine (ASAM) criteria. (2)
The Consensus Panel recommends the following general approaches for effective treatment of older adult substance abusers (2):
The Panel recommends that cognitive-behavioral treatment focus on teaching skills necessary for rebuilding the social support network; self-management approaches for overcoming depression, grief, or loneliness; and general problem solving. (1)
Within treatment groups, the Panel recommends that older clients should get more than one opportunity to integrate and act on new information. (2) For example, information on bereavement can be presented in an educational session, then reinforced in therapy. To help participants integrate and understand material, it may be helpful to expose them to all units of information twice. (2)
Older people in educational groups can receive, integrate, and recall information better if they are given a clear statement of the goal and purpose of the session and an outline of the content to be covered. The leader can post this outline and refer to it throughout the session. The outline may also be distributed for use in personal note-taking and as an aid in review and recall. Courses and individual sessions should be conceived as building blocks that are added to the base of the older person's life experience and needs. Each session should begin with a review of previously presented materials. (2)
Groups should accommodate clients' sensory decline and deficits by maximizing the use of as many of the clients' senses as possible. The Panel recommends use of simultaneous visual and audible presentation of material, enlarged print, voice enhancers, and blackboards or flip charts. (2) It is important to recognize clients' physical limitations. Group sessions should last no longer than about 55 minutes. The area should be well lighted without glare; and interruptions, noise, and superfluous material should be kept to a minimum. (2)
The Panel recommends that counselors providing individual psychotherapy treat older clients in a nonthreatening, supportive manner and assure the client that they will honor the confidentiality of the sessions. (2)
Medications used to modify drinking behavior in older adults must take into account age- and disease-related increases in vulnerability to toxic drug side effects, as well as possible adverse interactions with other prescribed medications. Disulfiram (Antabuse) is not generally recommended by the Panel for use in older patients because of the hazards of the alcohol-disulfiram interaction, as well as the toxicity of disulfiram itself. (1) Of the other pharmacotherapies for alcohol abuse, naltrexone (ReVia) is well tolerated by older adults and may reduce drinking relapses. (1)
Depression for several days or longer immediately after a prolonged drinking episode does not necessarily indicate a true comorbid disorder or the need for antidepressant treatment in most cases, but when depressive symptoms persist several weeks following cessation of drinking, specific antidepressant treatment is indicated. (1)
The advantages of quitting smoking are clear, even in older adults. The Panel recommends that efforts to reduce substance abuse among older adults also include help in tobacco smoking cessation.
The Consensus Panel recommends that the following principles guide staffing choices in substance abuse treatment programs (2):
Panel members believe that any program that treats even a few older adults should have at least one staff person who is trained in the specialization of gerontology within his or her discipline. This training should consist of at least a graduate certificate program (6- to 12- month) in the subfield of aging commonly called social gerontology. Staff with professional degrees should have a specialization in gerontology, geriatrics, or psychogeriatrics.
Outcome assessment is invaluable from both a management and a referral perspective. The providers of treatment, the clinicians and agencies referring patients, and patients themselves need to have information regarding the likely outcomes of treatment. Because treatment options range from brief interventions to structured outpatient and inpatient treatment programs, the Panel recommends evaluation of outcomes at varying points in the treatment process. (1) Baseline data should be obtained at the beginning of the intervention or treatment; first followup evaluations should be conducted 2 weeks to 1 month after the patient leaves the inpatient setting. The literature on patients receiving substance abuse treatment indicates that 60 to 80 percent of people who relapse do so within 3 to 4 months. Therefore, outpatient outcomes should be assessed no sooner than 3 months and possibly as long as 12 months after treatment. (1)
The Panel recommends that outcome measurement include not only abstinence or reduced consumption but also patterns of alcohol use, alcohol-related problems, physical and emotional health functioning, and quality of life and well-being. (1) One of the most widely used measures of physical and emotional health is the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36). (1) Another measure of psychological distress useful for alcohol outcomes assessment with older adults is the Symptom Checklist-90-Revised (SCL-90-R) and its abbreviated version, the Brief Symptom Inventory (BSI). (1) For measuring quality of life, an important measure for older adults with alcohol problems, the Panel recommends the Quality of Life Interview (QLI). (1)
The Panel believes that future research needs to be focused in some specific areas to advance the field and to address future problems that will arise in the coming years. Those areas are alcohol and other drug consumption, treatment, biomedical consequences, behavioral and psychological effects, and special issues. (1)
This TIP lays a foundation that research in the above areas must build upon if providers are to meet the treatment challenges on the horizon. In particular, providers must prepare for changes in demographics and in treatment delivery. As the country's over-60 population explodes and the health care system shifts to managed care, providers must adjust accordingly. The treatment protocols outlined in this book provide a roadmap for treating this unique and growing population into the next century.
Substance abuse, particularly of alcohol and prescription drugs, among adults 60 and older is one of the fastest growing health problems facing the country. Yet, even as the number of older adults suffering from these disorders climbs, the situation remains underestimated, underidentified, underdiagnosed, and undertreated. Until relatively recently, alcohol and prescription drug misuse, which affects up to 17 percent of older adults, was not discussed in either the substance abuse or the gerontological literature (D'Archangelo,1993; Bucholz et al., 1995; National Institute on Alcohol Abuse and Alcoholism, 1988; Minnis, 1988; Atkinson, 1987, 1990).
Because of insufficient knowledge, limited research data, and hurried office visits, health care providers often overlook substance abuse and misuse among older adults. Diagnosis may be difficult because symptoms of substance abuse in older individuals sometimes mimic symptoms of other medical and behavioral disorders common among this population, such as diabetes, dementia, and depression. Often drug trials of new medications do not include older subjects, so a clinician has no way of predicting or recognizing an adverse reaction or unexpected psychoactive effect.
Other factors responsible for the lack of attention to substance abuse include the current older cohort's disapproval of and shame about use and misuse of substances, along with a reluctance to seek professional help for what many in this age group consider a private matter. Many relatives of older individuals with substance use disorders, particularly their adult children, are also ashamed of the problem and choose not to address it. Ageism also contributes to the problem and to the silence: Younger adults often unconsciously assign different quality-of-life standards to older adults. Such attitudes are reflected in remarks like, "Grandmother's cocktails are the only thing that makes her happy," or "What difference does it make; he won't be around much longer anyway." There is an unspoken but pervasive assumption that it's not worth treating older adults for substance use disorders. Behavior considered a problem in younger adults does not inspire the same urgency for care among older adults. Along with the impression that alcohol or substance abuse problems cannot be successfully treated in older adults, there is the assumption that treatment for this population is a waste of health care resources.
These attitudes are not only callous, they rest on misperceptions. Most older adults can and do live independently: Only 4.6 percent of adults over 65 are nursing home or personal home care residents (Altpeter et al., 1994). Furthermore, Grandmother's cocktails aren't cheering her up: Older adults who "self-medicate" with alcohol or prescription drugs are more likely to characterize themselves as lonely and to report lower life satisfaction (Hendricks et al., 1991). Older women with alcohol problems are more likely to have had a problem-drinking spouse, to have lost their spouses to death, to have experienced depression, and to have been injured in falls (Wilsnack and Wilsnack, 1995).
The reality is that misuse and abuse of alcohol and other drugs take a greater toll on affected older adults than on younger adults. In addition to the psychosocial issues that are unique to older adults, aging also ushers in biomedical changes that influence the effects that alcohol and drugs have on the body. Alcohol abuse, for example, may accelerate the normal decline in physiological functioning that occurs with age (Gambert and Katsoyannis, 1995). In addition, alcohol may elevate older adults' already high risk for injury, illness, and socioeconomic decline (Tarter, 1995).
It will be increasingly difficult for older adults' substance abuse to remain a hidden problem as the demographic bulge known as the Baby Boom approaches old age early in the next century. Census estimates predict that 1994's older adult population of 33 million will more than double to 80 million by 2050 (Spencer, 1989; U. S. Bureau of the Census, 1996). Most of that growth will occur between 2010 and 2030, when the number of adults over 65 will grow by an average of 2.8 percent annually (U. S. Bureau of the Census, 1996). In 1990, 13 percent of Americans were over 65; by 2030, that bloc will represent 21 percent of the population (U. S. Bureaus of the Census, 1996). The demographic increases among older adults are summarized below and in Figure 1-1.
Life expectancy in the United States has increased. In 1950, it was 68 years, and by 1991, it had reached 79 years for women and 72 years for men (U. S. Bureau of the Census, 1996). Not only are adults in general living longer, substance abusers are also living longer than ever before (Gomberg, 1992b). Thus, more Americans face chronic, limiting illnesses or conditions such as arthritis, diabetes, osteoporosis, and senile dementia, becoming dependent on others for help in performing their activities of daily living (U. S. Bureau of the Census, 1996).
Alcohol use was less common in the 1930s, 1940s, and 1950s than it has been since the 1960s. Many of those who are now 60 and older, influenced by prevailing cultural beliefs and Prohibition, never drank at all, and a negligible number used illicit drugs. Younger birth cohorts in this century tend to have increasingly higher rates of alcohol consumption and alcoholism (Atkinson et al., 1992). Thus, "the prevalence of alcohol problems in old age may increase, especially among women, for birth cohorts entering their 60s in the 1990s and beyond"(Atkinson and Ganzini, 1994, p. 302). A recent study in Sweden found that the male-to-female ratio among older alcohol abusers admitted for addiction treatment decreased from 7.8:1 to 3.4:1 in the span of a decade (Osterling and Berglund, 1994).
Because there is a clear relationship between early alcohol problems and the development of alcohol problems in later life, drinking among older adults is likely to become an even greater problem in the near future (Rosin and Glatt, 1971; Gomberg, 1992; Zimberg, 1974; Helzer et al., 1991a; Beresford, 1995a). Liberto and colleagues concluded that the overall increase in alcohol problems throughout the population, coupled with the aging of the Baby Boomers, suggests that the number of older adults with alcohol-related problems will rise alarmingly (Liberto et al., 1992). Taken together, these factors raise the prospect of tomorrow's health services facing a "potentially preventable 'tide' of alcohol-induced morbidity" (Saunders, 1994, p. 801). Further research is needed on the physiological effects of marijuana on older adults, because many children of the 1960s can be expected to carry this habit into old age.
Health care and social service providers who currently care for Americans age 60 and older will mainly encounter abuse or misuse of alcohol or prescribed drugs. Abuse of heroin and other opioids is rare, although some older adults misuse over-the-counter drugs that have a high alcohol content, such as cough suppressants. Many of these over-the-counter drugs negatively interact with other medications and alcohol.
Problems stemming from alcohol consumption, including interactions of alcohol with prescribed and over-the-counter drugs, far outnumber any other substance abuse problem among older adults. Community prevalence rates range from 3 to 25 percent for "heavy alcohol use" and from 2.2 to 9.6 percent for "alcohol abuse" depending on the population sampled (Liberto et al., 1992). (Chapter 2 defines levels of use and adjusts them for older adults.) A recent study found that 15 percent of men and 12 percent of women age 60 and over treated in primary care clinics regularly drank in excess of limits recommended by the National Institute on Alcohol Abuse and Alcoholism (i.e., no more than one drink per day) (Saunders, 1994; Adams et al., 1996; National Institute on Alcohol Abuse and Alcoholism, 1995).
The differences in the prevalence rates above illustrate the difficulty in identifying how widespread the current problem is. One researcher suggests that alcohol abuse among older adults is easily hidden, partly because of its similarities to other diseases common as one ages and partly because elders remind clinicians of a parent or grandparent (Beresford, 1995b). Recent studies in Australia (McInnes and Powell, 1994) and a corroboration of similar data from the United States (Curtis et al., 1989) found that clinicians recognized alcoholism in only one-third of older hospitalized patients who had the disorder. Furthermore, many of the signs and symptoms of alcohol abuse among younger populations do not apply to older adults: Most older adults are no longer in the work force, have smaller social networks, and drive less (reducing the potential for being recognized as abusing alcohol).
Chapter 2 details drinking practices and problems among older adults. Identification, screening, and assessment of alcohol and drug use - specifically targeted to this population - are discussed in Chapter 4.
The abuse of narcotics is rare among older adults, except for those who abused opiates in their younger years (Jinks and Raschko, 1990). Prescribed opioids are an infrequent problem as well: Only 2 to 3 percent of noninstitutionalized older adults receive prescriptions for opioid analgesics (Ray et al., 1993), and the vast majority of those do not develop dependence. One study, for example, found that only 4 of nearly 12,000 patients who were prescribed morphine for self-administration became addicted (Hill and Chapman, 1989). The use of illicit drugs is limited to a tiny group of aging criminals and long-term heroin addicts (Myers et al., 1984). Although little published information exists, Panelists report that a far greater concern for drug misuse or abuse is the large number of older adults using prescription drugs, particularly benzodiazepines, sedatives, and hypnotics, without proper physician supervision (Gomberg, 1992). Older patients are prescribed benzodiazepines more than any other age group, and North American studies demonstrate that 17 to 23 percent of drugs prescribed to older adults are benzodiazepines (D'Archangelo, 1993). The dangers associated with these prescription drugs include problematic effects due to age-related changes in drug metabolism, interactions among prescriptions, and interactions with alcohol.
Unfortunately, these agents, especially those with longer half-lives, often result in unwanted side effects that influence functional capacity and cognition, which place the older person at greater risk for falling and for institutionalization (Roy and Griffin, 1990). Older users of these drugs experience more adverse effects than do younger adults, including excessive daytime sedation, ataxia, and cognitive impairment. Attention, memory, physiological arousal, and psychomotor abilities are often impaired as well (Pomara et al., 1985), and drug-related delirium or dementia may wrongly be labeled Alzheimer's disease. Misuse of psychoactive prescription drugs is discussed in Chapter 3.
For the purposes of this TIP, an older adult is defined as a person age 60 or older. Any age cutoff is somewhat arbitrary because age-related changes vary tremendously across individuals and even within one person from body system to body system. An 80-year-old can have better health functioning than a 50-year-old, and a 70-year-old can have "the spine of an 80-year-old, a heart typical of a 60-year-old, and a central nervous system equal in functioning to an average 60-year-old" (Altpeter et al., 1994, p. 30). Although some recommendations in this TIP may apply more to adults 70 and older, some of the age-related changes that affect the body's reactions to alcohol and other drugs begin as early as 50.
The age at which such changes occur varies from person to person, but invariably they do occur. Because many of the definitions, models, and classifications of alcohol consumption levels are static and do not account for age-related physiological and social changes, they simply do not apply to older adults. Drinking can be medically hazardous for this group even if the frequency and amount of consumption do not warrant a formal diagnosis of alcohol abuse or dependence. Weekly quantity of drinking levels can only serve as a rough parameter in this population; it is crucial for providers to view older drinkers and drug-takers as on a spectrum and to resist placing them into rigid categories for purposes of assessment and treatment. (Diagnosis, however, may require use of those classifications, as they often are the basis for reimbursement.)
Chapter 2 examines classifications such as at-risk, problem, and dependent alcohol consumption patterns, which have been the focus of major diagnostic systems, particularly the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association, 1994), and reconfigures them to suit older adults' unique responses to and experiences with alcohol and drug use.
Further complicating treatment of older substance abusers is the fact that they are more likely to have undiagnosed psychiatric and medical comorbidities. According to one study, 30 percent of older alcohol abusers have a primary mood disorder (Koenig and Blazer, 1996). A thorough evaluation of all problems is essential when caring for older adults: Failure to do so will undoubtedly increase the number of false diagnoses and diminish the quality of older patients' lives (Gomberg, 1992). Physical and mental comorbidities are discussed in detail in Chapter 4.
The sheer number and the interconnectedness of older adults' physical and mental health problems make diagnosis and treatment of their substance abuse more complex than for other populations. That complexity contributes - directly or indirectly - to the following barriers to effective treatment:
The term ageism was coined in the mid-1960s (Butler, 1969) to describe the tendency of society to assign negative stereotypes to older adults and to explain away their problems as a function of being old rather than looking for specific medical, social, or psychological causes. In American culture, ageism reflects a personal revulsion about growing old, comprising in part fear of powerlessness, uselessness, and death. Older adults often internalize such stereotypes and thus are less likely to seek out