Appendix A - Legal and Ethical Issues

by Margaret K. Brooks, Esq.^1a

Screening any population for substance abuse raises key legal and ethical concerns: how one can inquire about an individual's alcohol and drug use while continuing to respect that person's autonomy and privacy. Screening of older adults for substance abuse brings these concerns into particularly sharp focus - whether the person screening is a clinician, a staff member at a senior center, a member of the clergy, an adult protective service worker, a Meals-On-Wheels volunteer, a pharmacist, a community health worker, an adult day care worker, or staff member at a long-term care facility.

This appendix examines how the issues of autonomy and privacy (or confidentiality) affect the way providers working with older adults may screen for substance use problems. The first section discusses the relationship between patient or client autonomy and the provider's obligation to inform and counsel the older individual about the health risks of alcohol or other drug use. The second section concerns privacy of information about substance use problems: How can a provider keep accurate records and communicate with others concerned about the older individual's welfare without disclosing information that may subject the individual to scorn or create problems with family or third-party payers?

Autonomy and the Provider's Mission: A Dilemma

Americans attach extraordinary importance to being left alone. We pride ourselves on having perfected a social and political system that limits how far the government - and others - can control what we do. The principle of autonomy is enshrined in our Constitution, and our courts have repeatedly confirmed our right to make our own decisions for ourselves.

Most of us cherish our autonomy and fear its loss, particularly as we age. Although providers who screen or assess for substance abuse do so because they are genuinely concerned about an individual's health or functioning, screening means seeking very personal information - an unavoidable intrusion on a person's autonomy and privacy. Alert to suggestions that their judgment or abilities are impaired, older adults may not always see a provider's effort to "help" as benign.

Performed insensitively, screening or assessment may intensify denial. A person of any age who is "in denial" may not realize, or want to realize, that he has to cut back on or give up his intake of alcohol or prescription medications; an older person may view the provider's questions and suggestions as intrusive, threatening, and offensive. Suggestions that an older individual's complaint has an emotional basis may tap an underlying reluctance to acknowledge an emotional component to any problem and reinforce the individual's resistance. Because the substance abuse label carries a powerful stigma, an older individual may become alarmed if a provider intimates that alcohol or drug abuse may be involved. It will be tempting for the older individual to point to the "normal" infirmities of old age as the source of his difficulty rather than acknowledge a problem with alcohol or other drugs.

How can the provider raise the question of alcohol and drug use constructively, without eliciting a defensive response? Should she raise the issue and then drop it at the slightest hint of resistance on the part of the older individual? Or should she intervene more forcefully - with argument or by involving the family?

To fulfill her ethical responsibility, the provider should do more than simply raise the issue. As the Consensus Panel suggests, most older adults are unaware that their metabolism of alcohol and prescription drugs changes as they age and that lower amounts of alcohol and medicines may incapacitate them. Respect for a person's autonomy means informing him of all relevant medical facts and engaging him in a discussion about his alternatives. If there is a substance abuse problem, the provider can supply the information and encouragement, but only the person with the problem has the power to change what he is doing. Respecting the patient's autonomy - his right to make choices - is central to encouraging that change.

Privacy and Confidentiality

Aside from perceived threats to autonomy, an older person may also be concerned about the practical consequences of admitting a substance use problem. Such patients may find it difficult or impossible to obtain coverage for hospitalization costs if an insurer or health maintenance organization (HMO) learns that their traumatic injuries were related to alcoholism. Relationships with a spouse, children, grandchildren, or friends may suffer. Adverse consequences such as these may discourage patients with substance use problems from seeking treatment.

Concern about privacy and confidentiality is fueled by the widespread perception that people with substance use disorders are weak and/or morally impaired. For an older person, this concern may well be compounded by an apprehension that others may view acknowledgment of a substance use disorder as a sign of inability to continue living independently. If the individual is having family problems - with a spouse or with children - information about substance use could have an adverse impact on resolution of those problems. Or the individual may experience difficulties with health insurance.

Federal Law

The concern about the adverse effects that social stigma and discrimination have on patients in recovery (and how those adverse effects might deter people from entering treatment) led the Congress to pass legislation and the U.S. Department of Health and Human Services to issue a set of regulations to protect information about individuals' substance abuse. The law is codified at 42 U.S.C.§ 290dd-2. The implementing Federal regulations, "Confidentiality of Alcohol and Drug Abuse Patient Records," are contained in 42 CFR Part 2 (Vol. 42 of the Code of Federal Regulations, Part 2).

The Federal law and regulations severely restrict communications about identifiable individuals by "programs" providing substance use diagnosis, treatment, or referral for treatment (42 CFR§ 2.11). The purpose of the law and regulations is to decrease the risk that information about individuals in recovery will be disseminated and that they will be subjected to discrimination and to encourage people to seek treatment for substance use disorders.

In most settings where older adults receive care or services, Federal confidentiality laws and regulations do not apply.^1b Providers should be aware, however, that if a health care practice or social service organization includes someone whose primary function is to provide substance abuse assessment or treatment and if the practice or organization benefits from "Federal assistance,"² that practice or organization must comply with the Federal law and regulations and implement special rules for handling information about patients who may have substance abuse problems.³

Moreover, the fact that most providers for older adults are not subject to the Federal rules does not mean that they can handle information about their clients' substance use problems in a cavalier manner. Because of the potential for damage, providers should always handle such information with great care.

State Law

Although Federal rules do not restrict how most providers gather and handle information about an older individual's substance abuse, there are other rules that may limit how such information may be handled. State laws offer some protection to medical and mental health information about patients and clients. Most doctors, social service workers, and clients think of these laws as the "doctor-patient privilege" or "social worker-client privilege" or "psychotherapist-patient privilege."

Strictly speaking, these privileges are rules of evidence that govern whether a professional provider can be asked or compelled to testify in a court case about a patient or client. In many States, however, laws offer wider protection. Some States have special confidentiality laws that explicitly prohibit physicians, social workers, psychologists, and others from divulging information about patients or clients without consent. States often include such prohibitions in professional licensing laws; such laws generally prohibit licensed professionals from divulging information about patients or clients, and they make unauthorized disclosures grounds for disciplinary action, including license revocation.

Each State has its own set of rules, which means that the scope of protection offered by State law varies widely. Whether a communication is "privileged" or "protected" may depend on a number of factors:

1. The type of professional provider holding the information and whether he or she is licensed or certified by the State
2. The context in which the information was communicated
3. The context in which the information will be or was disclosed
4. Exceptions to any general rule protecting information, and
5. How the protection is enforced.

Professionals covered by the "doctor-patient" or "therapist-client" privilege

Which professions and which practitioners within each profession are covered depends on the State where the professional practices. California, which grants its citizens "an inalienable right to privacy" in its Constitution, has what may be the most extensive protections for medical (including mental health) information. California law protects communications with a wide variety of professionals, including licensed physicians, nurses, and psychotherapists (which includes clinical social workers, psychologists, marriage and family counselors), as well as many communications with trainees practicing under the supervision of a number of these professionals. A California court has held that information given to an unlicensed professional by an uneducated patient may be privileged if the patient reasonably believes the professional is authorized to practice medicine.⁴

Other States' laws cover fewer kinds of professionals. In Missouri, for example, protection is limited to communications with State-licensed psychologists, clinical social workers, professional counselors, and physicians.

Depending on their professional training (and licensing), primary care physicians, physician assistants, nurse-practitioners, nurses, psychologists, social workers, and others may be covered by State prohibitions on divulging information about patients or clients. Note that even within a single State, the kind of protection afforded information may vary from profession to profession. Professional providers should learn whether any confidentiality law in the State where they practice applies to their profession.

The context in which the information was communicated

State laws vary tremendously in this area, too. Some States protect only the information that a patient or client communicates to a professional in private, in the course of the medical or mental health consultation. Information disclosed to a clinician in the presence of a third party (like a spouse) is not protected. Other States, such as California, protect all information the patient or client tells the professional or the professional gains during examination.⁵ California also protects other information acquired by the professional about the patient's mental or physical condition, as well as the advice the professional gives the patient.⁶ When California courts are called upon to decide whether a particular communication of information is privileged, State law requires them to presume that it is.

California affords great protection to communications between patients and psychotherapists, a term that covers a wide range of professions. Not only are communications by and to the patient protected, information communicated by a patient's intimate family members to therapists and psychiatric personnel⁷ is also protected. California also protects information the patient discloses in the presence of a third party or in a group setting.

Understanding what medical information is protected requires professional providers to know whether State law recognizes the confidentiality of information in the many contexts in which the professional acquires it.

Circumstances in which "confidential" information is protected from disclosure

Some States protect medical or mental health information only when that information is sought in a court proceeding. If a professional divulges information about a patient or client in any other setting, the law in those States will not recognize that there has been a violation of the individual's right to privacy. Other States protect information in many different contexts and may discipline professionals who violate their patients' privacy, allow patients to sue them for damages, or criminalize behavior that violates patients' privacy. The diversity of State rules in this area compounds the difficulty professionals face in becoming knowledgeable about what rules apply to them.

Exceptions to State laws protecting medical and mental health information

Consent

All States permit health, mental health, and social service professionals to disclose information if the patient or client consents. However, each State has different requirements regarding consent. In some States, consent can be oral; in others, it must be written. States that require written consent sometimes require that certain elements be included in the consent form or that everyone use a State-mandated form. Some States have different consent forms with different requirements for particular diseases.

Other exceptions

Consent is not the only exception. All States also require the reporting of certain infectious diseases to public health authorities and some require the reporting of elder abuse to protective service agencies, although definitions of "infectious disease" and "elder abuse" vary. And most States require health care professionals and mental health counselors to report to the authorities threats patients make to inflict harm on others. There are States that permit or require health care professionals to share information about patients with other health care professionals without the patients' consent, but some limit the range of disclosure for certain diseases, like HIV. Most States make some provision for communicating information to health insurance or managed care companies.

Many of the situations that physicians and social service workers face daily - processing health claims or public benefit applications, for example - are covered by one of these exceptions. To fully understand the "rules" regarding privacy of medical and mental health information, professionals must also know about the exceptions to those rules. Those exceptions are generally in the statute books - in either the sections on evidence or the professional licensing sections, or both. The state licensing authority as well as professional associations can usually help answer questions about State rules and the exceptions to those rules.

Enforcing confidentiality protections

The role of the courts

To determine the "law" - that is, the rule one must follow - in any particular area, an attorney will search for statutes, regulations, administrative rulings, and court decisions. There is no question that in this country, the courts play a large role in "making" law - particularly in an area like privacy, which involves human behavior, shades of meaning, and intent. No legislator drafting a statute (or bureaucrat drafting a regulation) can foresee all the circumstances under which it may be applied. When one party sues another, a court is forced to decide whether a provider's disclosure of medical information was appropriate or whether such information should be disclosed during the lawsuit itself.

For example, after a car crash, the drivers may sue each other and ask the court to order the disclosure of medical records. Or the victim of an assault by an adolescent may sue the parents and seek disclosure of medical records to prove they knew their child was dangerous. How a court decides whether to order disclosure in such cases will depend on a variety of factors, including State law and regulation, court rules, and the relevance of the information sought to the dispute at hand. Similarly, when a patient or client sues a professional for releasing information to someone without her consent, the court will be called upon to weigh a variety of factors to decide whether the disclosure violated what the State recognizes as the patient's privacy.

Over time, court decisions like these add flesh to the bare statutory and regulatory rules and suggest how those rules will be applied the next time. When a difficult case arises that does not fit neatly within the rule of law as understood, it may be helpful to consult with an attorney familiar with the rules and how the State's courts are likely to interpret them.

Penalties for violations

States differ in the ways they discipline professionals for violations of patients' or clients' privacy. In some States, violation of confidentiality is a misdemeanor, punishable by a fine or short jail term. In many States, the professional licensing agency has the power to bring disciplinary charges against a professional who violates a client's privacy. Such charges may result in censure or license suspension or revocation. Finally, the State may permit the aggrieved patient or client to sue the professional for damages caused by the violation of his right to confidentiality.

The reality is, these enforcement mechanisms are rarely used. States rarely prosecute privacy violation offenses and professional disciplinary committees in most States are more concerned with other kinds of professional infractions. That is not to say that violation of a patient's privacy is cost-free. A patient or client who thinks he has been hurt by a professional's indiscretion is free to sue; while such cases are difficult for clients to win, they can cause the professional and the organization employing her a good deal of grief - financial, emotional, and professional. Even short of litigation, no professional wants to acquire the reputation of being thoughtless or indiscreet.

Strategies for Dealing With Common Situations

Charting substance use information

One way for a professional to safeguard clients' privacy and avoid breaking the rules is to develop a charting, or record-keeping, system that is accurate but still protects clients' rights to privacy and confidentiality. It is important to remember how many people could see a client's medical, mental health, or social service record. A medical chart, for example, will be seen by the medical office staff, the insurance company (or HMO or managed care organization [MCO]), and in the event of a referral, another set of clinicians, nurses, clerical workers, and insurers. If the patient is involved in litigation and his medical or mental health is in issue, the court will most likely order disclosure of his chart or file in response to a subpoena.

When a provider documents the results of substance abuse screening or assessment or flags an issue to be raised the next time he sees the client, he should use neutral notations or reminders that do not identify the problem as being substance-use-related. Following are three record-keeping systems that comply with the stringent Federal confidentiality regulations, protect clients' autonomy and privacy, and can be used in a wide variety of settings (TIP 16, Alcohol- and Other-Drug Screening of Hospitalized Trauma Patients, CSAT, 1995):

• The "minimalist" approach, which relies on the provider to enter only that information in the chart that is required for accuracy and to use neutral terms wherever possible.
• The "rubber band" approach, which segregates substance abuse information in a separate "confidential" section in the chart. Information in this section would be shared with other providers only on a need-to-know basis, without being open to the view of every staff person who picked up the chart.
• The "separate location" approach, which keeps sensitive information separate from the rest of the client's chart. The other place might be a locked cabinet or other similarly secure area. A "gatekeeper" familiar with the provider's record-keeping system and the reasons for the extra security would be responsible for deciding when others - within or outside the office - will have access to this information. This approach provides, in effect, a stronger "rubber band" than that described in the second approach.⁸

The push toward computerization of medical records will complicate the problem of keeping sensitive information in medical records private. Currently, there is protection afforded by the cumbersome and inefficient way many, if not most, medical, mental health, and social service records make their way from one provider to another. When records are stored in computers, retrieval can be far more efficient. Computerized records may allow anyone with a disc and access to the computer in which the information is stored to instantly copy and carry away vast amounts of information without anyone's knowledge. Modems that allow communication about patients among different components of a managed care network extend the possibility of unauthorized access to anyone with a modem, the password(s), and the necessary software. The ease with which computerized information can be accessed can lead to "casual gossip" about a client, particularly one of importance in a community, making privacy difficult to preserve.

Communicating with others

One of the trickiest issues is whether and how providers of older adults health care should communicate with others about their clients' substance use problems. Communications with others concerned about the client may confirm the provider's judgment that the client has a substance use problem or may be useful in persuading a reluctant client that treatment is necessary.

Before a provider attempts to gather information from other sources or enlist help for a patient or client struggling with recovery, he should ask the older client's permission to do so. Speaking with relatives (including children), doctors, or other health and mental health professionals not only intrudes on the client's autonomy, it also poses a risk to her right to privacy. Gathering information (or responding to questions about a client's problems) from a spouse, child, or other provider can involve an explicit or implicit disclosure that the provider believes the client or patient has a substance use problem. And the provider making such a disclosure may be inadvertently stepping on a land mine.

Making inquiries or answering questions behind the client's back may seriously jeopardize the trust that has developed between the provider and the client and undermine his attempt to offer help. The professional who talks to the client's son and then confronts her with their joint conclusions runs the risk that he will damage his relationship with the client. Feeling she can no longer trust the provider and angry that he has shown little respect for her autonomy or privacy, the client may refuse to participate in any further discussions about her problems.

Dealing with questions of incapacity

Most older clients or patients are fully capable of comprehending the information and weighing the alternatives offered by a provider and making and articulating decisions. A small percentage of older patients or clients are clearly incapable of participating in a decision-making process. In such cases, the older person may have signed a health care proxy or may have a court-appointed guardian to make decisions in his stead.

The real difficulty arises when a provider is screening or assessing an older person whose mental capacity lies between those two extremes. The client or patient may have fluctuating capacity, with "good days" and "bad days" or periods of greater or lesser alertness depending upon the time of day. His condition may be transient or deteriorating. His diminished capacity may affect some parts of his ability to comprehend information but not others.

How can the provider determine whether the patient or client understands the information she is presenting, appreciates the implication of each alternative, and is able to make a "rational" decision, based on his own best interests? There is no easy answer to this question. One can, however, suggest several approaches.

Maximizing autonomy. The provider can help the patient or client who appears to have diminished capacity through a gradual information-gathering and decisionmaking process. Information the client needs should be presented in a way that allows the patient or client to absorb it gradually. The provider should clarify and restate information as necessary and may find it helpful to summarize the issues already covered at regular intervals. Each alternative and its possible consequences should be laid out and examined separately. Finally, the provider can help the client identify his values and link those values to the alternatives presented. By helping the patient or client narrow his focus and proceed step-by-step, the provider may be able to assure herself that the client, despite his diminished capacity, has understood the decision to be made and acted in his own best interest.

Enlisting the help of a health or mental health professional. If working with the patient or client in a process of gradual information-gathering and decision-making is not making headway, the provider can suggest that together they consult a health or mental health professional. Perhaps there is someone who has known the patient or client for a number of years who has a grasp of the client's history and better understanding of the obstacles to decision-making. Or, the provider may suggest a specialist who can help determine why the patient is having difficulty and whether he has the capacity to make this kind of decision.

Enlisting the help of family or close friends. Another approach is for the provider to suggest to the patient or client that they call in a family member or close friend who can help them organize the information and sort through the alternatives. Asking the client who he thinks would be helpful may win his endorsement of this approach.

When the client cannot grasp the information or come to a decision. If the provider's efforts to inform the patient or client and help him reach a decision are unsuccessful, she might seek his permission to consult a family member or close friend to discuss the problem. If the client consents, the provider should lay out her concerns for the family member or friend. It may be that the client has already planned for the possibility of his incapacity and has signed a durable power of attorney or a health care proxy.

Guardianship. A guardian⁹ is a person appointed by a court to manage some or all aspects of another person's life. Anyone seeking appointment of a guardian must show the court (1) that an individual is disabled in some way by disease, illness, or senility, and (2) that the disability prevents him from performing the tasks necessary to manage an area or areas of his life.

Each state handles guardianship proceedings differently, but some principles apply across the board: Guardianship is not an all-or-nothing state. Courts generally require that the person seeking appointment of a guardian prove the individual's incapacity in a variety of tasks or areas. Courts may apply different standards to different life tasks - managing money, managing a household, making health care decisions, entering contracts. A person may be found incompetent to make contracts and manage money but not to make his own health care decisions (or vice versa), and the guardianship will be limited accordingly.

Guardianship diminishes the older adult's autonomy and is an expensive process. It should, therefore, be considered only as a last resort.

Making referrals to substance abuse treatment programs

The provider has persuaded the patient or client to try outpatient treatment and knows the director of an excellent program in the immediate area. Rather than simply picking up the phone and letting the director know she has referred the patient, she should consult the patient about the specific treatment facility. Though it may seem that consent to treatment is the same as consent to referral to a particular facility, it takes very little time to get the patient's consent, demonstrates respect for the client or patient, and protects the provider if, say, the treatment program's director is a relative or has some other connection to the client.

Communications with insurers, HMOs, and other third-party payers

The structure of health, mental health, and ancillary social service care for older adults is changing rapidly. Of course, older adults are covered by Medicare, but many have supplementary insurance or have joined HMOs or are entitled to government-sponsored social services because of particular medical, physical, or mental disabilities. How should the professional provider communicate with these different types of entities?

Traditional health insurance programs offering reimbursement to patients for health care expenditures typically require patients to sign claim forms containing language consenting to the release of information about their care. The patient's signature authorizes the practitioner to release such information. Although HMOs do not require patients to submit claim forms, both practitioners and patients understand that the HMO or MCO can review clinical records at any time and may well review records if it has questions about the patient's or client's care.

Should the provider rely on the patient's signed consent on the health insurance form or the HMO contract and release what she has in her chart (or a neutral version of that information)? Or should she consult the patient?

The better practice is for the provider to frankly discuss with the patient what information she intends to disclose, the alternatives open to the client (disclosure and refusal to disclose), and the likely consequences of those alternatives. Will the information the provider sends explicitly or implicitly reveal the nature of the patient's problem? Does the client's chart contain a substance abuse diagnosis? Once again, the provider confronts the question of how such information should be recorded. Has she balanced the need for accuracy with discretion and a respect for patients' privacy? Finally, even if the chart or file contains explicit information about the client's substance use problem, can the provider characterize the information and her diagnosis in more neutral terms when releasing information to the third-party payer?

Once the client understands what kind and amount of information the provider intends to send a third-party payer, he can decide whether to agree to the disclosure. The provider should explain that if she refuses to comply with the third-party payer's request for information, it is likely that at least some related services will not be covered. If the client expresses concern, she should not mislead him, but confirm that once a third-party payer learns he has had a substance use problem, he could and may lose either some of his insurance coverage or parts of other entitlements and be unable to obtain other coverage.¹⁰

The final decision should be the client's. He may well decide to pay out of pocket. Or he may agree to the limited disclosure and ask the provider to inform him if more information is requested.

As managed care becomes more prevalent throughout the country, medical and mental health providers are finding that third-party payers demand more and more information about patients and about the treatment provided to those patients in order to monitor care and contain costs. Providers need to be sensitive about the amount and kind of information they disclose because there is a risk that this information may be used to deny future benefits to the client. Chart notes may also contain detailed and very personal information about family life that may be unnecessary for a third-party payer to review in order to determine whether and what kind of treatment should be covered.

As in so many other areas involving patients' privacy, it is best to follow two simple rules: First, keep notations and documentation as neutral as possible while maintaining professionally acceptable standards of accuracy. Second, consult the client and let the client decide whether to agree to the disclosure.

Communicating with the legal system

If a doctor, psychologist, social worker, or other provider gets a call from a lawyer asking about a patient or client, or a visit from a law enforcement officer asking to see records, or a subpoena to testify or produce medical records, what should he or she do? As in other matters of privacy and confidentiality, (1) consult the patient, (2) use common sense, and (3) as a last resort, consult State law (or a lawyer familiar with State law).

Responding to lawyers' inquiries. Say a lawyer calls and asks about Emma Bailey's medical, mental health, or social service history or treatment. As a first approach to the question, the provider could tell the lawyer, "I don't know that I have a client with that name. I'd have to check my records"¹¹ or tell the caller that he must consult with his client before having a conversation about her: "I'm sure you understand that I am professionally obligated to speak with Emma Bailey before I speak with you." It will be hard for any lawyer to disagree with this statement.

The provider should then ask the client if she knows what information the caller is seeking and whether the client wants him to disclose that or any other information. He should leave the conversation with a clear understanding of the client's instructions - whether he should disclose the information, and if so, how much and what kind. It may be that the lawyer is representing the client in a case and the client wants the provider to share all the information he has. On the other hand, the lawyer may represent someone with whom the client has a dispute. There is nothing wrong with refusing to answer a lawyer's questions.¹²

If the lawyer represents the client and the client asks the provider to share all information, the provider can speak freely with the lawyer. However, if the provider is answering the questions of a lawyer who does not represent the client (but the client has consented to the disclosure of some information), the provider should listen carefully to each question, choose his words with care, limit each answer to the question asked, and take care not to volunteer information not called for.

Visits by law enforcement. A police officer, detective, or probation officer who asks a provider to disclose medical, mental health, or social service information about a client or a client's case records can usually be handled in a similar manner:¹³ The provider can safely tell the officer, as he might a lawyer, "I'm sure you understand that I am professionally obligated to speak with my patient before I speak to you."¹⁴

The provider should then speak with the client to find out whether she knows the subject of the officer's inquiry, whether she wants the provider to disclose information and if so, how much and what kind. The caretaker might end the conversation by asking whether there are any particular areas the client would prefer he not discuss with the officer.

When a law enforcement officer comes armed with a search warrant, the answer is different. In this case, the provider has no choice but to hand over the records listed in the warrant.

Responding to subpoenas. Subpoenas come in two varieties. One is an order requiring a person to testify, either at a deposition out of court or at a trial. The other - known as a subpoena duces tecum - requires a person to appear with the records listed in the subpoena. Depending on the State, a subpoena can be signed by a lawyer or a judge. Unfortunately, it cannot be ignored.

In this instance, the provider's first step should be to call Emma Bailey - the client about whom he is asked to testify or whose records are sought - and ask what the subpoena is about. It may be that the subpoena has been issued by or on behalf of Emma's lawyer, with Emma's consent. However, it is equally possible that the subpoena has been issued by or on behalf of the lawyer for an adverse party. If that is the case, the provider's best option is to consult with Emma's lawyer to find out whether the lawyer will object - ask the court to "quash" the subpoena - or whether the provider should simply get the client's consent to testify or turn over her records.¹⁵ An objection can be based on a number of grounds and can be raised by any party as well as by the person whose medical information is sought. If the provider is covered by a State statutory privilege, he may be able to assert the client's privilege for her.

Conclusion

It is essential for those who work with older adults to respect their clients' autonomy and rights to privacy and confidentiality if they are to be effective in screening and assessing clients for substance use disorders and persuading them to cut down their use or enter treatment. In most situations, providers can follow these simple rules: (1) consult the client, (2) let the client decide, and (3) be sensitive to how information is recorded or disclosed. It is only as a last resort that the provider will have to consult State law or a lawyer.

Endnotes

^1a Margaret K. Brooks is an independent consultant in Montclair, New Jersey.

^1b For many years, there was confusion about whether general medical care settings such as primary care clinics or hospital emergency rooms were subject to the Federal law and regulations because they provided substance abuse diagnosis, referral, and treatment as part of their services. In 1995, DHHS revised the definition of the kinds of "programs" subject to the regulations that made it clear that the regulations do not generally apply to a general medical care facility unless that facility (or person) holds itself out as providing, and provides, alcohol or drug abuse diagnosis, treatment, or referral for treatment . . . (42 CFR§ 2.11).

The full text of § 2.11 now reads:

Program means:

(a) An individual or entity (other than a general medical care facility) who holds itself out as providing, and provides, alcohol or drug abuse diagnosis, treatment, or referral for treatment; or

(b) An identified unit within a general medical facility which holds itself out as providing and provides, alcohol or drug abuse diagnosis, treatment, or referral for treatment; or

(c) Medical personnel or other staff in a general medical care facility whose primary function is the provision of alcohol or drug abuse diagnosis, treatment, or referral for treatment and who are identified as such providers. (See § 2.12(e)(1) for examples.)

60 Federal Register 22,297 (May 5, 1995).

² The regulations provide that "federally assisted" programs include:

• Programs run directly by or under contract for the Federal government;
• Programs carried out under a Federal license, certification, registration, or other authorization, including certification under the Medicare Program, authorization to conduct a methadone maintenance treatment program, or registration to dispense a drug that is regulated by the Controlled Substances Act to treat alcohol or drug abuse;
• Programs supported by any federal department or agency of the United States, even when the federal support does not directly pay for the alcohol or drug abuse diagnosis, treatment, or referral activities;
• Programs conducted by State or local government units that are supported by Federal funding that could be (but is not necessarily) spent for the substance abuse treatment program;
• Tax-exempt programs.

42 C.F.R.§ 2.12(b).

³ For a full explanation of the Federal law and regulations, see TIP 8, Intensive Outpatient Treatment for Alcohol and Other Drug Abuse (CSAT, 1994) and TAP 13, Confidentiality of Patient Records for Alcohol and Other Drug Treatment (CSAT, 1994).

⁴ Luhndorff v. The Superior Court of Tulare County, 166 CA 3d 485, 212 Cal. Rptr. 516 (5th District, 1985). Interestingly, Luhndorff was a criminal case in which the prosecution sought the records of an unlicensed social worker who interviewed the defendant, diagnosed his problem, determined the appropriate treatment, and treated him for 3 months. The social worker was working under a licensed individual's supervision. The defendant thought the social worker was a psychiatrist.

⁵ Section 451 of the California Evidence Code codifies the doctor-patient privilege. See Grosslight v. Superior Court of Los Angeles, 42 CA 3d 502, 140 Cal. Rptr. 278 (1977), in which the court held that information communicated by the parents of a minor psychiatric patient to her doctor and his secretary was privileged, even though the parents were being sued by someone the child injured on the theory that the parents knew their child was a danger to others.

⁶ Note that the breadth of the protection may vary according to the clinician's profession.

⁷ Grosslight v. Superior Court of Los Angeles, 72 Cal. App. 3d 502, 140 Cal. Rptr. 278 (1977), interpreting Section 451 of the California Evidence Code (see footnote 5).

⁸ The Consensus Panel for TIP 16 noted: "Physical separation of clinical information is not unusual. Patient charts from past years are generally kept in a separate location. Physicians routinely request charts to be sent to them from this location so that they can review historical clinical information about the patient. In addition, nurses are quite accustomed to keeping some medications locked up and accessible only to designated personnel." (TIP 16, CSAT, 1995, p. 76)

⁹ In some States, a guardian is referred to as a fiduciary, conservator, or committee. The person who has a guardian is generally called a "ward" or an "incapacitated person."

¹⁰ Some States prohibit insurance companies from discriminating against individuals who have received substance abuse treatment; however, these kinds of discriminatory practices continue. Insurance companies routinely share information about applicants for life and disability insurance through the Medical Information Bureau - a data bank maintained by a private organization and supported by the industry.

¹¹ In fact, in some States, depending on the provider's profession, the identity of patients or clients as well as their records are protected. Therefore, professionals should find out whether disclosing a patient's name or acknowledging that the individual about whom the lawyer is inquiring is a client would be considered a violation of the client's right to confidentiality.

¹² A firm, but polite, tone is best. If confronted by what could be characterized as "stonewalling," a lawyer may be tempted to subpoena the information he is asking for, and more. The clinician will not want to provoke the lawyer into taking action that will harm the patient.

¹³ The only exception to this advice would be if the provider knew the patient was a fugitive being sought by law enforcement. In that case, in some States, a refusal to assist or give officers information might be a criminal offense.

¹⁴ As noted above, in those States where the identity of clients or patients as well as their medical or mental health records are protected, the professional should give a noncommittal response, such as "I'll have to check my records to see whether I have such a patient."

¹⁵ In most instances, the provider is not legally required to notify the client or get his consent to release records that have been subpoenaed. However, notifying the client shows respect for his autonomy and privacy and gives him an opportunity to object to the subpoena.

Appendix B - Tools

Appendix B contains the following items:

• The Alcohol Use Disorders Identification Test (AUDIT)
• Index of Activities of Daily Living (Index of ADLs)
• Instrumental Activities of Daily Living (IADL) Scale
• Geriatric Depression Scale (GDS) Short Form
• Center for Epidemiologic Studies - Depression Scale (CES-D)
• Health Screening Survey (HSS), Revised.

The Alcohol Use Disorders Identification Test (AUDIT)

The following guidelines, questions, and scoring instructions are excerpted from Babor, T.F.; de la Fuente, J.R.; Saunders, J.; and Grant, M. AUDIT: The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Health Care. Geneva, Switzerland: World Health Organization, 1992.

How To Use AUDIT

Screening with AUDIT can be conducted in a variety of primary care settings by persons who have different kinds of training and professional backgrounds. The core AUDIT is designed to be used as a brief structured interview or self-report survey that can easily be incorporated into a general health interview, lifestyle questionnaire, or medical history. When presented in this context by a concerned and interested interviewer, few patients will be offended by the questions. The experience of the WHO collaborating investigators (Saunders and Aasland, 1987) indicated that AUDIT questions were answered accurately regardless of cultural background, age, or gender. In fact, many patients who drank heavily were pleased to find that a health worker was interested in their use of alcohol and the problems associated with it.

In some patients, the AUDIT questions may not be answered accurately because they refer specifically to alcohol use and problems. Some patients may be reluctant to confront their alcohol use or to admit that it is causing them harm. Individuals who feel threatened by revealing this information to a health worker, who are intoxicated at the time of the interview, or who have certain kinds of mental impairment may give inaccurate responses. Patients tend to answer most accurately when

• The interviewer is friendly and nonthreatening
• The purpose of the questions is clearly related to a diagnosis of their health status
• The patient is alcohol- and drug-free at the time of the screening
• The information is considered confidential
• The questions are easy to understand.

Health workers should try to establish these conditions before AUDIT is given. When these conditions are not present, the Clinical Screening Instrument following the AUDIT questionnaire may be more useful. Alternatively, health workers may also use AUDIT to guide an interview with a concerned friend, spouse, or family member. In some settings (such as waiting rooms), AUDIT may be administered as a self-report questionnaire, with instructions for the patient to discuss the meaning of the results with the primary care worker. In addition to these general considerations, the following interviewing techniques should be used:

• Try to interview patients under the best possible circumstances. For patients requiring emergency treatment or who are severely impaired, it is best to wait until their condition has stabilized and they have become accustomed to the health setting where the interview is to take place.
• Look for signs of alcohol or drug intoxication. Patients who have alcohol on their breath or who appear intoxicated may be unreliable respondents. Consider conducting the interview at a later time. If this is not possible, make note of these findings on the patient's record.
• If AUDIT is embedded, as recommended, in a longer health interview, then a transitional statement will be needed when the AUDIT questions are asked. The best way to introduce the AUDIT questions is to give the patient a general idea of the content of the questions, the purpose for asking them, and the need for accurate answers. The following is an illustrative introduction: "Now I am going to ask you some questions about your use of alcoholic beverages during the past year. Because alcohol use can affect many areas of health (and may interfere with certain medications), it is important for us to know how much you usually drink and whether you have experienced any problems with your drinking. Please try to be as honest and as accurate as you can be." This statement should be followed by a description of the types of alcoholic beverages typically consumed in the population to which the patient belongs (e.g., "By alcoholic beverages we mean your use of wine, beer, vodka, sherry, and so on."). If necessary, include a description of beverages that may not be considered alcoholic (e.g., cider, low alcohol beer).
• It is important to read the questions as written and in the order indicated. By following the exact wording, better comparability will be obtained between your results and those obtained by other interviewers.
• Most of the questions in AUDIT are phrased in terms of "how often" symptoms occur. It is useful to offer the patient several examples of the response categories (for example, "Never," "Several times a month," "Daily") to suggest how he might answer. When he has responded, it is useful to probe during the initial questions to be sure that the patient has selected the most accurate response (for example, "You say you drink several times a week. Is this just on weekends or do you drink more or less every day?"). If responses are ambiguous or evasive, continue asking for clarification by repeating the question and the response options, asking the patient to choose the best one. At times, answers are difficult to record because the patient may not drink on a regular basis. For example, if the patient was drinking intensively for the month prior to an accident, but not before or since, then it will be difficult to characterize the "typical" drinking sought by the question. In these cases it is best to record the amount of drinking and related symptoms for the heaviest drinking period of the past year, making note of the fact that this may be atypical or transitory for that individual.

Record answers carefully, using the comments section of the interview brochure to explain any special circumstances, additional information, or clinical inferences. Often patients will provide the interviewer with useful comments about their drinking that can be valuable in the interpretation of the total AUDIT score.

The AUDIT Questionnaire

The AUDIT Questionnaire
Circle the number that comes closest to the patient's answer. 1. How often do you have a drink containing alcohol?
(0) Never	(1) Monthly or less	(2) Two to four times a month	(3)Two to three times a week	(4)Four or more times a week
2. How many drinks containing alcohol do you have on a typical day when you are drinking? [Code number of standard drinks.^1
(0) 1 or 2	(1) 3 or 4	(2 5 or 6	(3) 7 to 9	(4)10 or more
3. How often do you have six or more drinks on one occasion?
(0) Never	(1) Less than monthly	(2) Monthly	(3)Weekly	(4) Daily or almost daily
4. How often during the last year have you found that you were not able to stop drinking once you had started?
(0) Never	(1) Less than monthly	(2) Monthly	(3)Weekly	(4)Daily or almost daily
5. How often during the last year have you failed to do what was normally expected from you because of drinking?
(0) Never	(1) Less than monthly	(2) Monthly	(3)Weekly	(4)Daily or almost daily
6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
(0) Never	(1) Less than monthly	(2) Monthly	(3)Weekly	(4)Daily or almost daily
7. How often during the last year have you had a feeling of guilt or remorse after drinking?
(0) Never	(1) Less than monthly	(2) Monthly	(3)Weekly	(4)Daily or almost daily
8. How often during the last year have you been unable to remember what happened the night before because you had been drinking?
(0) Never	(1) Less than monthly	(2) Monthly	(3)Weekly	(4)Daily or almost daily
9. Have you or someone else been injured as a result of your drinking?
(0) No	(2) Yes, but not in the last year	(4)Yes, during the last year
10. Has a relative or friend or a doctor or other health worker been concerned about your drinking or suggested you cut down?
(0) No	(2) Yes, but not in the last year	(4)Yes, during the last year

¹ In determining the response categories it has been assumed that one drink contains 10 g alcohol. In countries where the alcohol content of a standard drink differs by more than 25 percent from 10 g, the response category should be modified accordingly.

Record sum of individual item scores here. ____________________________

Procedure for scoring AUDIT

Procedure for scoring AUDIT
Questions 1-8 are scored 0, 1, 2, 3, or 4. Questions 9 and 10 are scored 0, 2, or 4 only. The response is as follows:
	0	1	2	3	4
Question 1	Never	Monthly or less	Two to four times per month	Two to three times per week	Four or more times per week
Question 2	1 or 2	3 or 4	5 or 6	7 to 9	10 or more
Question 3-8	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
Question 9-10	No		Yes, but not in the last year		Yes, during the last year

The minimum score (for nondrinkers) is 0 and the maximum possible score is 40. A score of 8 or more indicates a strong likelihood of hazardous or harmful alcohol consumption.

AUDIT "Clinical" Questions and Procedure

AUDIT "Clinical" Questions and Procedure
Trauma history
1. Have you injured your head since your 18th birthday?
(3) Yes		(0) No
2. Have you broken any bones since your 18th birthday?
(3) Yes		(0) No
Clinical examination
1. Conjunctival injections
(0) NOT PRESENT	(1) MILD	(2) MODERATE	(3) SEVERE
2. Abnormal skin vascularization
(0) NOT PRESENT	(1) MILD	(2) MODERATE	(3) SEVERE
3. Hand tremor
(0) NOT PRESENT	(1) MILD	(2) MODERATE	(3) SEVERE
4. Tongue tremor
(0) NOT PRESENT	(1) MILD	(2) MODERATE	(3) SEVERE
5. Hepatomegaly
(0) NOT PRESENT	(1) MILD	(2) MODERATE	(3) SEVERE
GGT Values*	Lower normal	(0-30 IU/1)=(0)
	Upper normal	(30-50 IU/1)=(1)
	Abnormal	(50 IU/1)=(3)

*These values may change with laboratory methods, and standards may vary with sex and age of the drinker.

Record sum of individual item scores here. ____________________________

Scoring and Interpretation of AUDIT

As indicated by the AUDIT questions, each item is scored by checking the response category that comes closest to the patient's answer.

On the basis of evidence from the validation study (Saunders et al., in press), two cutoff points are suggested, depending on the purpose of the screening program or the nature of the research project. A score of 8 or more produces the highest sensitivity, while a score of 10 or more results in higher specificity. In general, high scores on the first three items in the absence of elevated scores on the remaining items suggest hazardous alcohol use. Elevated scores on items 4 through 6 imply the presence or emergence of alcohol dependence. High scores on the remaining items suggest harmful alcohol use. As discussed in the following section on diagnosis, each of these areas of alcohol-related problems implies different types of management.

The Clinical Screening Instrument is considered to be elevated when the total score is 5 or greater. Here, too, the examiner should give careful consideration to the different meanings attributed to alcohol-related trauma, physical signs, and the elevated liver enzyme. It should be noted that false positives can occur when the individual is accident prone, uses drugs (such as barbiturates) that induce GGT, or has hand tremor because of nervousness, neurological disorder, or nicotine dependence.

References

Saunders, J.B., and Aasland, O.G.

WHO Collaborative Project on the Identification and Treatment of Persons with Harmful Alcohol Consumption. Report on Phase I: Development of a Screening Instrument. Geneva, Switzerland: World Health Organization, 1987.

Saunders, J.B.; Aasland, O.G.; Babor, T.F.; de la Fuente, J.R.; and Grant, M.

WHO collaborative project on early detection of persons with harmful alcohol consumption. II. Development of the screening instrument "AUDIT." British Journal of Addictions, in press.

Index of Activities of Daily Living (ADLs)

Index of Independence in Activities of Daily Living

The Index of Independence in Activities of Daily Living is based on an evaluation of the functional independence or dependence of patients in bathing, dressing, going to the toilet, transferring, continence, and feeding. Specific definitions of functional independence and dependence appear below the index. (These definitions can be used to convert the data recorded in the evaluation form in the next section into an Index of ADL grade.)

A--Independent in feeding, continence, transferring, going to the toilet, dressing, and bathing.

B--Independent in all but one of these functions.

C--Independent in all but bathing and one additional function.

D--Independent in all but bathing, dressing, and one additional function.

E--Independent in all but bathing, dressing, going to the toilet, and one additional function.

F--Independent in all but bathing, dressing, going to toilet, transferring, and one additional function.

G--Dependent in all six functions.

Other--Dependent in at least two functions, but not classifiable as C, D, E, or F.

Independence means without supervision, direction, or active personal assistance, except as specifically noted below. This is based on actual status and not on ability. A patient who refuses to perform a function is considered as not performing the function, even though he is deemed able.

Bathing (Sponge, Shower, or Tub)

Independent: assistance only in bathing a single part (as back or disabled extremity) or bathes self completely

Dependent: assistance in bathing more than one part of body; assistance in getting in or out of tub or does not bathe self

Dressing

Independent: gets clothes from closets and drawers; puts on clothes, outer garments, braces; manages fasteners; act of tying shoes is excluded

Dependent: does not dress self or remains partly undressed

Going to Toilet

Independent: gets to toilet; gets on and off toilet; arranges clothes; cleans organs of excretion; (may manage own bedpan used at night only and may or may not be using mechanical supports)

Dependent: uses bedpan or commode or receives assistance in getting to and using toilet

Transfer

Independent: moves in and out of bed independently and moves in and out of chair independently (may or may not be using mechanical supports)

Dependent: assistance in moving in or out of bed and/or chair; does not perform one or more transfers

Continence

Independent: urination and defecation entirely self-controlled

Dependent: partial or total incontinence in urination or defecation, partial or total control by enemas, catheters, or regulated use of urinals and/or bedpans

Feeding

Independent: gets food from plate or its equivalent into mouth; (precutting of meat and preparation of food, as buttering bread, are excluded from evaluation)

Dependent: assistance in act of feeding (see above); does not eat at all or parental feeding

Evaluation Form

Name_________________________ Day of Evaluation________________________

For each area of functioning listed below, check description that applies. (The word "assistance" means supervision, direction, or personal assistance.)

Bathing--either sponge bath, tub bath, or shower.

• Receives no assistance (gets in and out of tub by self if tub is usual means of bathing)
• Receives assistance in bathing only one part of the body (such as back or a leg)
• Receives assistance in bathing more than one part of the body (or not bathed)

Dressing--gets clothes from closets and drawers--including underclothes, outer garments, and using fasteners (including braces if worn)

• Gets clothes and gets completely dressed without assistance
• Gets clothes and gets dressed without assistance except for assistance in tying shoes
• Receives assistance in getting clothes or in getting dressed, or stays partially or completely undressed

Toileting--going to the "toilet room" for bowel and urine elimination, cleaning self after elimination, and arranging clothes

• Goes to "toilet room," cleans self, and arranges clothes without assistance (may use object for support such as cane, walker, or wheelchair and may manage night bedpan or commode emptying same in morning)
• Receives assistance in going to "toilet room" or in cleansing self or in arranging clothes after elimination or in use of night bedpan or commode
• Doesn't go to room termed "toilet" for the elimination process

Transfer--

• Moves in and out of bed as well as in and out of chair without assistance (may be using object for support such as cane or walker)
• Moves in and out of bed or chair with assistance
• Doesn't get out of bed

Continence--

• Controls urination and bowel movement completely by self
• Has occasional "accidents"
• Supervision helps keep urine or bowel control; catheter is used, or is incontinent

Feeding--

• Feeds self without assistance
• Feeds self except for getting assistance in cutting meat or buttering bread
• Receives assistance in feeding or is fed partly or completely by using tubes or intravenous fluids

After filling out the form, convert the data collected into an ADL grade by using the definitions provided in the introductory section.

Source: Katz, S.; Ford, A.B.; Moskowitz, R.W.; Jackson, B.A.; and Jaffe, M.W. Studies of Illness in the Aged. The Index of ADL: A standardized measure of biological and psychosocial function. Journal of the American Medical Association 185:914-919, 1963.

References

Katz, S.; Downs, T.D.; Cash, H.R.; and Grotz, R.C.

Progress in development of the Index of ADL. Gerontologist 10(1):20-30, 1970.

Katz, S., and Akpom, C.A.

Index of ADL. Medical Care 14(suppl. 5):116-118. 1976.

Instrumental Activities of Daily Living (IADL) Scale

Self-Rated Version Extracted From the Multilevel Assessment Instrument (MAI)
1.	Can you use the telephone:
	Without help,	3
	With some help, or	2
	Are you completely unable to use the telephone?	1
2.	Can you get to places out of walking distance:
	Without help,	3
	With some help, or	2
	Are you completely unable to travel unless special arrangements are made?	1
3.	Can you go shopping for groceries:
	Without help,	3
	With some help, or	2
	Are you completely unable to do any shopping?	1
4.	Can you prepare your own meals:
	Without help,	3
	With some help, or	2
	Are you completely unable to prepare any meals?	1
5.	Can you do your own housework:
	Without help,	3
	With some help, or	2
	Are you completely unable to do any housework?	1
6.	Can you do your own handyman work:
	Without help,	3
	With some help, or	2
	Are you completely unable to do any handyman work?	1
7.	Can you do your own laundry:
	Without help,	3
	With some help, or	2
	Are you completely unable to do any laundry at all?	1
8a.	Do you take any medications or use any medications?
	(ASK Q. 8b) Yes	1
	(ASK Q. 8c) No	2
8b.	(ASK IF SUBJECT TAKES MEDICINE NOW)
	Do you take your own medicine: (CHECK BELOW)
8c.	(ASK IF SUBJECT DOES NOT TAKE MEDICINE NOW)
	If you had to take medicine, can you do it: (CHECK BELOW)
	Without help (in the right doses at the right time),	3
	With some help (take medicine if someone prepares it for you and/or reminds you to take it), or	2
	(Are you/would you be) completely unable to take your own medicines?	1
9.	Can you manage your own money:
	Without help,	3
	With some help, or	2
	Are you completely unable to handle money?	1

Note on Scoring:

If fewer than 5 items are valid, then scoring cannot be done reliably.

Source: Lawton, M.P.; Moss, M.; Fulcomer, M.; and Kleban, M.H. A research and service-oriented Multilevel Assessment Instrument. Journal of Gerontology 37:91-99, 1982.

References

Lawton, M.P.

Scales to measure competence in everyday activities. Psychopharmacology Bulletin 24(4):609-614, 1988.

Lawton, M.P., and Brody, E.M.

Assessment of older people: Self-maintaining and instrumental activities of daily living. Gerontologist 9:179-186, 1969.

Reproduced with permission from M. Powell Lawton, Ph.D.

Geriatric Depression Scale (GDS) Short Form

Choose the best answer for how you have felt over the past week:

1. Are you basically satisfied with your life? YES/NO
2. Have you dropped many of your activities and interests? YES/NO
3. Do you feel that your life is empty? YES/NO
4. Do you often get bored? YES/NO
5. Are you in good spirits most of the time? YES/NO
6. Are you afraid that something bad is going to happen to you? YES/NO
7. Do you feel happy most of the time? YES/NO
8. Do you often feel helpless? YES/NO
9. Do you prefer to stay at home, rather than going out and doing new things? YES/NO
10. Do you feel you have more problems with memory than most? YES/NO
11. Do you think it is wonderful to be alive now? YES/NO
12. Do you feel pretty worthless the way you are now? YES/NO
13. Do you feel full of energy? YES/NO
14. Do you feel that your situation is hopeless? YES/NO
15. Do you think that most people are better off than you are? YES/NO

Answers in bold indicate depression, and each answer counts as one point. For clinical purposes, a score greater than 5 suggests depression and warrants a followup interview. Scores greater than 10 are almost always depression.

Source: Sheikh, J.I., and Yesavage, J.A. Geriatric Depression Scale (GDS): Recent evidence and development of a shorter version. Clinical Gerontologist 5(1&2):165-173, 1986.

References

Brink, T.L.; Yesavage, J.A.; Lum, O.; Heersema, P.; Adey, M.B.; and Rose, T.L.

Screening tests for geriatric depression. Clinical Gerontologist 1:37-44, 1982.

Yesavage, J.A.; Brink, T.L.; Rose, T.L.; Lum, O.; Huang, V.; Adey, M.B.; and Leirer, V.O.

Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research 17:37-49, 1983.

The Center for Epidemiologic Studies Depression Scale (CES-D)

For the 20 items below, circle the number next to each item that best reflects how frequently the indicated event was experienced in the past 7 days.

The Center for Epidemiologic Studies Depression Scale (CES-D)

		Rarely or none of the time (Less than 1 Day)	Some or a little of the time (1--2 days)	Occasionally or a moderate amount of time (3--4 Days)	Most or all of the time (5--7 Days)
DURING THE PAST WEEK:
1.	I was bothered by things that usually don't bother me.	0	1	2	3
2.	I did not feel like eating: my appetite was poor.	0	1	2	3
3.	I felt that I could not shake off the blues even with help from my family or friends.	0	1	2	3
4.	I felt that I was just as good as other people.	0	1	2	3
5.	I had trouble keeping my mind on what I was doing.	0	1	2	3
6.	I felt depressed.	0	1	2	3
7.	I felt that everything I did was an effort.	0	1	2	3
8.	I felt hopeful about the future.	0	1	2	3
9.	I thought my life had been a failure.	0	1	2	3
10.	I felt fearful.	0	1	2	3
11.	My sleep was restless.	0	1	2	3
12.	I was happy.	0	1	2	3
13.	I talked less than usual.	0	1	2	3
14.	I felt lonely.	0	1	2	3
15.	People were unfriendly.	0	1	2	3
16.	I enjoyed life.	0	1	2	3
17.	I had crying spells.	0	1	2	3
18.	I felt sad.	0	1	2	3
19.	I felt that people disliked me.	0	1	2	3
20.	I could not get "going."	0	1	2	3

---

Scoring: Since items 4, 8, 12, and 16 reflect positive experiences rather than negative ones, the scale should be reversed on these items so that 0 = 3, 1 = 2, 2 = 1, and 3 = 0. To determine the "depression score," add together the number for each answer. The score will be somewhere in the range of 0 to 60. A score of 16 or greater indicates that some depression may have been experienced in the past week.
Source: Radloff, L.S. The CES-D Scale: A self-report depression scale for research in the general population. Applied Psychological Measurement 1(3):385-401, 1977.

Health Screening Survey (HSS), Revised

Check the appropriate answer
1. In the last three months, have you been dieting to lose weight?
	___YES	___NO
IF YES: How many pounds have you managed to lose?
	___0	___1 - 3	___4 - 7	___8 or more
2. In the last three months, have you performed physical activity or exercise in your leisure time at least 20 minutes without stopping, enough to make you breathe hard and/or sweat?
	___YES	___NO
IF YES: On average, how many days per week have you been exercising
	___1 - 2	___3 - 4	___5 - 6	___Every day
3. In the last three months, have you been smoking cigarettes at all?
	___YES	___NO
IF YES: On average, how many cigarettes have you been smoking each day?
	___1 - 9	___10 - 19	___20 - 29	___30 or more
4. In the last three months, have you been drinking alcoholic drinks at all (e.g., beer, wine, sherry, vermouth, or hard liquor)?
	___YES	___NO
IF NO, go to question 5.
IF YES, ANSWER 4a through 4c.
4a. On average, how many days per week have you been drinking beer or wine coolers?
___None	___1 - 2	___3 - 4	___5 - 6	___Every day
On a day when you have had wine, sherry, or vermouth to drink, how many glasses, bottles, or cans have you been drinking?
___1 - 2	___3 - 4	___5 - 8	___9 - 14	___15 or more
AND
4b. On average how many days per week have you been drinking wine, sherry, or vermouth?
___None	___1 - 2	___3 - 4	___5 - 6	___Every day
On a day when you have had wine, sherry, or vermouth to drink, how many glasses have you been drinking?
___1 - 2	___3 - 4	___5 - 8	___9 - 14	___15 or more
AND
4c. On average how many days per week have you been drinking liquor (gin, vodka, rum, brandy, whiskey, etc.)?
___None	___1 - 2	___3 - 4	___5 - 6	___Every day
On a day when you have had liquor to drink, how many single shots have you been drinking?
___1 - 2	___3 - 4	___5 - 8	___9 - 14	___15 or more
5. In the last three months have you felt you should:
a. lose some weight		___No	___Sometimes	___Quite Often	___Very Often
b. cut down or stop smoking		___No	___Sometimes	___Quite Often	___Very Often
c. cut down or stop drinking		___No	___Sometimes	___Quite Often	___Very Often
d. do more to keep fit		___No	___Sometimes	___Quite Often	___Very Often
6. In the last three months has anyone annoyed you or got on your nerves by telling you to:
a. change your weight		___No	___Sometimes	___Quite Often	___Very Often
b. cut down or stop smoking		___No	___Sometimes	___Quite Often	___Very Often
c. cut down or stop drinking		___No	___Sometimes	___Quite Often	___Very Often
d. do more to keep fit		___No	___Sometimes	___Quite Often	___Very Often
7. In the last three months, have you felt guilty or bad about:
a. your weight		___No	___Sometimes	___Quite Often	___Very Often
b. how much you smoke		___No	___Sometimes	___Quite Often	___Very Often
c. how much you drink		___No	___Sometimes	___Quite Often	___Very Often
d. how unfit you are		___No	___Sometimes	___Quite Often	___Very Often
8. In the last three months, have you been waking up wanting to:
a. exercise to keep fit		___No	___Sometimes	___Quite Often	___Very Often
b. smoke a cigarette		___No	___Sometimes	___Quite Often	___Very Often
c. have an alcoholic drink		___No	___Sometimes	___Quite Often	___Very Often
d. have something to eat		___No	___Sometimes	___Quite Often	___Very Often
9. Now that you have completed this form, do you think you currently have:
a. a weight problem		___Definitely	___Probably	___No	___Don't Know
b. a smoking problem		___Definitely	___Probably	___No	___Don't Know
c. a drinking problem		___Definitely	___Probably	___No	___Don't Know
d. a fitness problem		___Definitely	___Probably	___No	___Don't Know
10. Thinking back, would you say at any time in the past you had:
a. a weight problem		___Definitely	___Probably	___No	___Don't Know
b. a smoking problem		___Definitely	___Probably	___No	___Don't Know
c. a drinking problem		___Definitely	___Probably	___No	___Don't Know
d. a fitness problem		___Definitely	___Probably	___No	___Don't Know

Scoring: The HSS contains four subscales: one measuring amount of alcohol consumption (question 4 a, b, c; Kristenson and Trell, 1982), the CAGE questionnaire (questions 5-8; Mayfield et al., 1974), one for self-perception of current problem with alcohol (question 9), and one for self-perception of past problem with alcohol (question 10). Consumption of 20 or more drinks per week, two or more positive responses to the four CAGE questions, self-perception of a current problem with alcohol use, or self-perception of a past problem with alcohol use indicates problem drinking.
Source: Fleming, M.F., and Barry, K.L. A three-sample test of a masked alcohol screening questionnaire. Alcohol and Alcoholism 26(1):81-91, 1991.

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Appendix D - Resource Panel

Kathleen Austin, CDC III, NCAC II

Alcohol Therapist II

Adult Medicine/Ambulatory Care

Harborview Medical Center

Seattle, Washington

James D. Baxendale, Ph.D.

Deputy Director

Quality Assurance and Case Management

National Association of State Alcohol and Drug Abuse Directors

Washington, D.C.

Gwendolyn G. Bennett

Special Assistant to the Director

Division of State and Community Systems Development

Center for Mental Health Services

Rockville, Maryland

Gayle Boyd, Ph.D.

Health Scientist Administrator

Prevention Research Branch

National Institute on Alcohol Abuse and Alcoholism

Rockville, Maryland

Mildred Brooks-McDow, M.S.W., L.I.C.S.W.

Public Health Advisor

Division of State and Community Systems Development

Center for Mental Health Services

Rockville, Maryland

Carol Cober

Acting Manager

Social Outreach and Support Division

American Association of Retired Persons

Washington, D.C.

Peter J. Cohen, M.D., J.D.

Special Expert

Medications Development Division

National Institute on Drug Abuse

Rockville, Maryland

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

Betty Davis

Senior Project Specialist

Social Outreach and Support Division

American Association of Retired Persons

Washington, D.C.

Loretta Finnegan, M.D.

Director

Women's Health Initiative

National Institutes of Health

Bethesda, Maryland

Linda S. Foley, M.A.

Member

TIPS Editorial Advisory Board

Director

Treatment Improvement Exchange

Health Systems Research, Inc.

Washington, D.C.

Rizalina C. Galicinao

Program Analyst

Office of Minority Health

Public Health Service

Rockville, Maryland

Deborah Horan

Manager

Special Issues

American College of Obstetrics and Gynecology

Washington, D.C.

Alixe McNeill

Senior Program Manager

National Council on the Aging

Washington, D.C.

Reba L. Novich, M.S.W.

Resource Manager

National Resource Center

Osteoporosis and Related Bone Diseases

Washington, D.C.

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

Anita Rosen, Ph.D.

Senior Staff Associate for Aging

National Association of Social Workers

Washington, D.C.

Eleanor Sargent

Director

Clinical Issues

National Association of Alcoholism and Drug Abuse Counselors

Arlington, Virginia

Joanne G. Schwartzberg, M.D.

Director

Department of Geriatric Health

American Medical Association

Chicago, Illinois

Doralie L. Segal, M.S.

Senior Advisor

PHS Office of Women's Health

Medical Development Division

National Institute on Drug Abuse

Rockville, Maryland

Nancy J. Wartow

Policy Specialist

Administration on Aging

Washington, D.C.

Paul Wohlford, Ph.D.

Acting Branch Chief

Division of State and Community Systems Development

Center for Mental Health Services

Rockville, Maryland

Appendix E - Field Reviewers

Ruth Airey-Vidal

Coordinator

Wellness Initiative for Senior Educators

Sussex Council on Alcohol and Drug Abuse

Newton, New Jersey

Sharon Amatteti

Public Health Analyst

Office of Policy Coordination and Planning

Center for Substance Abuse Treatment

Rockville, Maryland

Mary Candace Burger, Ph.D.

Assistant Professor

Division of Geriatric Psychiatry

Department of Psychiatry

Vanderbilt Medical School

Nashville, Tennesee

James Donagher

Director

Senior Services

Special Populations of Office of Behavioral Health

Department of Mental Health and Addiction Services

Hartford, Connecticut

Charles M. Donahue, M.Div.

Community Liaison

Behavioral Health Network

Alexian Brothers Hospital

Saint Louis, Missouri

Nancy L. Erckenbrack

Regional Director

Operations and Housing

Long-Term Care Division

Providence Health Systems

Portland, Oregon

Hugh Everman

Staff Assistant

Department of Sociology

Morehead State University

Morehead, Kentucky

Robert S. Geissinger

Counselor

Division of Alcoholism and Substance Abuse

Washington State Department of Social and

Health Services

Lacey, Washington

Charles V. Giannasio, M.D.

Senior Consultant for Addictive Disorders

Northwest Institute of Psychiatry

Jenkintown, Pennsylvania

Robert K. Heaton, Ph.D.

Professor of Psychiatry

Neuropsychology Laboratory

University of California at San Diego

San Diego, California

Robert Holden, M.A.

Program Director

Partners in Drug Abuse Rehabilitation Counseling

Washington, D.C.

Ronald J. Hunsicker

Executive Director

National Association of Addiction Treatment Providers

Lititz, Pennsylvania

Carol L. Joseph, M.D.

Associate Chief

Staff for Geriatric and Extended Care

Honolulu VAMROC

Honolulu, Hawaii

Joseph Liberto, M.D.

Director

UAMC

Baltimore, Maryland

Jane E. Myers, Ph.D.

Professor

Department of Counseling and

Educational Development

University of North Carolina at Greensboro

Greensboro, North Carolina

Reba L. Novich, M.S.W.

Resource Manager

National Resource Center

Osteoporosis and Related Bone Diseases

Washington, D.C.

Robert Rawlings

Director

OBRA and LTC

Community Programs

Oklahoma Department of Mental Health

and Substance Abuse Services

Oklahoma City, Oklahoma

Patricia Reihl

Coordinator

Spring House

Paramus, New Jersey

Anita Rosen, Ph.D.

Senior Staff Associate for Aging

National Association of Social Workers

Washington, D.C.

Margaret M. Salinger, M.S.N., R.N., C.A.R.N.

National Nurses Society on Addiction

c/o Department of Veterans Affairs Medical Center

Coatesville, Pennsylvania

Eleanor Sargent

Director

Clinical Issues

National Association of Alcoholism and Drug Abuse Counselors

Arlington, Virginia

Timothy M. Scanlan

President

Addiction Specialists of Kansas

Wichita, Kansas

Larry I. Schonfeld, Ph.D.

Professor

Department of Aging and Mental Health

Florida Mental Health Institute

University of South Florida

Tampa, Florida

Anthony Sims

Acting Director

Office of Communications and External Liaison

Center for Substance Abuse Treatment

Rockville, Maryland

Richard T. Suchinsky, M.D.

Associate Chief

Addictive Disorders

Mental Health and Behavioral Sciences Services

Department of Veterans Affairs

Washington, D.C.

David O. Turner

Program Manager

Health Aging Program

Salt Lake County Aging Services

Salt Lake City, Utah

John W. Welte, Ph.D.

Research Scientist

Research Institute on Addiction

Buffalo, New York

Larry W. Whorley

Program Coordinator

Substance Abuse Treatment Program

Lexington, Kentucky

[Figures]

Figure 2-1: DSM-IV Diagnostic Criteria for Substance Abuse

Figure 2-1
DSM-IV Diagnostic Criteria for Substance Abuse

The DSM-IV defines the diagnostic criteria for substance abuse as a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one or more of the following, occurring within a 12-month period:

1. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household).
2. Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use).
3. Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct).
4. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights).

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Copyright 1994, American Psychiatric Association.

Figure 2-2: DSM-IV Diagnostic Criteria for Substance Dependence

Figure 2-2
DSM-IV Diagnostic Criteria for Substance Dependence

The DSM-IV defines the diagnostic criteria for substance dependence 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:

1. Tolerance, as defined by either of the following:
• The need for markedly increased amounts of the substance to achieve intoxication or desired effect.
• Markedly diminished effect with continued use of the same amount of the substance.
2. Withdrawal, as manifested by either of the following:
• The characteristic withdrawal syndrome for the substance.
• The same (or closely related) substance is taken to relieve or avoid withdrawal symptoms.
3. Taking the substance often in larger amounts or over a longer period than was intended.
4. A persistent desire or unsuccessful efforts to cut down or control substance use.
5. Spending a great deal of time in activities necessary to obtain or use the substance or to recover from its effects.
6. Giving up social, occupational, or recreational activities because of substance use.
7. Continuing the substance use with the knowledge that it is causing or exacerbating a persistent or recurrent physical or psychological problem.

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Copyright 1994, American Psychiatric Association.

Figure 2-3: Applying DSM-IV Diagnostic Criteria to Older Adults With Alcohol Problems

Figure 2-3 Applying DSM-IV Diagnostic Criteria to Older Adults With Alcohol 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). There are special considerations when applying DSM-IV criteria to older adults with alcohol problems.
Criteria	Special Considerations for Older Adults
Tolerance	May have problems with even low intake due to increased sensitivity to alcohol and higher blood alcohol levels
Withdrawal	Many late onset alcoholics do not develop physiological dependence
Taking larger amounts or over a longer period than was intended	Increased cognitive impairment can interfere with self-monitoring; drinking can exacerbate cognitive impairment and monitoring
Unsuccessful efforts to cut down or control use	Same issues across life span
Spending much time to obtain and use alcohol and to recover from effects	Negative effects can occur with relatively low use
Giving up activities due to use	May have fewer activities, making detection of problems more difficult
Continuing use despite physical or psychological problem caused by use	May not know or understand that problems are related to use, even after medical advice

Figure 2-4: Clinical Characteristics of Early and Late Onset Problem Drinkers

Figure 2-4 Clinical Characteristics of Early and Late Onset Problem Drinkers
Variable	Early Onset	Late Onset
Age at onset	Various, e.g., < 25, 40, 45	Various, e.g., > 55, 60, 65
Gender	Higher proportion of men than women	Higher proportion of women than men
Socioeconomic status	Tends to be lower	Tends to be higher
Drinking in response to stressors	Common	Common
Family history of alcoholism	More prevalent	Less prevalent
Extent and severity of alcohol problems	More psychosocial, legal problems, greater severity	Fewer psychosocial, legal problems, lesser severity
Alcohol-related chronic illness (e.g., cirrhosis, pancreatitis, cancers)	More common	Less common
Psychiatric comorbidities	Cognitive loss more severe, less reversible	Cognitive loss less severe, more reversible
Age-associated medical problems aggravated by alcohol (e.g., hypertension, diabetes mellitus, drug-alcohol interactions)	Common	Common
Treatment compliance and outcome	Possibly less compliant; Relapse rates do not vary by age of onset (Atkinson et al., 1990; Blow et al., 1997; Schonfeld and Dupree, 1991)	Possibly more compliant; Relapse rates do not vary by age of onset (Atkinson et al., 1990; Blow et al., 1997; Schonfeld and Dupree, 1991)

Figure 3-2: Effect of Aging on Response to Drug Effect

Figure 3-2 Effect of Aging on Response to Drug Effect
Drug	Action	Effects of Aging
Analgesics
Aspirin	Acute gastroduodenal mucosal damage	No change
Morphine	Acute analgesic effect	Increased
Pentazocine	Analgesic effect	Increased
Anticoagulants
Heparin	Activated partial thromboplastin time	No change
Warfarin	Prothrombin time	Increased
Bronchodilators
Albuterol	Bronchodilation	No change
Ipratropium	Bronchodilation	No change
Cardiovascular Drugs
Adenosine	Minute ventilation and heart rate	No change
Diltiazem	Acute antihypertensive effect	Increased
Enalepril	Acute antihypertensive effect	Increased
Isoproterenol	Chronotropic effect	Decreased
Phenylephrine	Acute vasoconstriction	No change
	Acute antihypertensive effect	No change
Prazocin	Chronotropic effect	Decreased
Timolol	Chronotropic effect	No change
Verapamil	Acute antihypertensive effect	Increased
Diuretics
Furosemide	Latency and size of peak diuretic response	Decreased
Psychotropics
Diazepam	Acute sedation	Increased
Diphenhydramine	Psychomotor function	No change
Haloperidol	Acute sedation	Decreased
Midazolam	Electroencephalographic activity	Increased
Temazepam	Postural sway, psychomotor effect, and sedation	Increased
Triazolam	Psychomotor activity	Increased
Others
Levodopa	Dose elimination due to side effects	Increased
Tolbutamide	Acute hypoglycemic effect	Decreased
Source: Adapted from Cusack and Vestal, 1986.

Figure 3-3: Commonly Prescribed Anxiolytics

Figure 3-3 Commonly Prescribed Anxiolytics^a
Class	Drug	Brand Name	Elimination Half-Life for Older Adults
Benzodiazepines	Alprazolam	Xanax	9-20 hours
	Chlordiazepoxide	Librium	5-30 hours, with short- and long-acting active metabolites
	Diazepam	Valium	20-50 hours, with short- and long-acting active metabolites effective up to 200 hours
	Lorazepam	Ativan	18-24 hours; clearance may be reduced in older adults
	Oxazepam	Serax	3-25 hours
Serotonin agonist	Buspirone	BuSpar	1-11 hours
^aRefer to product information insert for each drug as to its suitability for use in older adults.

Figure 3-4: Commonly Prescribed Sedative/Hypnotics

Figure 3-4 Commonly Prescribed Sedative/Hypnotics^a
Class	Drug	Brand Name	Elimination Half-Life for Older Adults
Benzodiazepines	Flurazepam	Dalmane	72 hours, with short- and long-acting active metabolites
	Prazepam	Centrax	Less than 3 hours, with long-acting active metabolites
	Quazepam	Doral	25-41 hours, with long-acting active metabolites
	Temazepam	Restoril	10-20 hours
	Triazolam	Halcion	2-6 hours, with reports of clinical effects up to 16 hours following a single dose
Imidazopyridine	Zolpidem	Ambien	1.5-4.5 hours (longer in older adults)
Chloral derivatives	Chloral hydrate	Noctec	4-8 hours (loses effect in 2 weeks)
Antihistamines	Hydroxyzine	Atarax	1-3 hours
	Diphen-hydramine	Benadryl (over-the-counter)	8-10 hours
	Doxylamine	Unisom (over-the-counter)	8-10 hours
^aRefer to product information insert for each drug as to its suitability for use in older adults.

Figure 3-5: Commonly Prescribed Opiate/Opioid Analgesics

Figure 3-5 Commonly Prescribed Opiate/Opioid Analgesics^a
Class	Drug	Brand Name	Comments
Opiates	Methylmorphine Morphine		Common ingredient of analgesics.
	Codeine	e.g., Tylenol III, Robitussin A-C	Common ingredient of analgesics and antitussives. Can cause sedation and mild, dose-related impairment of psychomotor coordination.
Opioids (synthetic)	Hydrocodone	Lortab	Can produce dose-related respiratory depression and irregular breathing if taken in large amounts.
	Meperidine	Demerol	Contraindicated if patient is taking MAO inhibitors. Can produce psychomimetic effects and impair vision, attention, and motor coordination.
	Oxycodone	Percodan/ Percocet	Can produce substantial impairment of vision, attention, and motor coordination.
	Propoxyphene	Darvon	Can produce sedation and mild, dose-related impairment of psychomotor coordination.
	Pentazocine	Talwin	Age does not appear to increase sedative effects.
^aRefer to product information insert for each drug as to its suitability for use in older adults.

Figure 3-6: Drug-Alcohol Interactions and Adverse Effects

Figure 3-6 Drug-Alcohol Interactions and Adverse Effects
Drug	Adverse Effect With Alcohol
Acetaminophen	Severe hepatoxicity with therapeutic doses of acetaminophen in chronic alcoholics
Anticoagulants, oral	Decreased anticoagulant effect with chronic alcohol abuse
Antidepressants, tricyclic	Combined central nervous system depression decreases psychomotor performance, especially in the first week of treatment
Aspirin and other nonsteroidal anti-inflammatory drugs	Increased the possibility of gastritis and gastrointestinal hemorrhage
Barbiturates	Increased central nervous system depression (additive effects)
Benzodiazepines	Increased central nervous system depression (additive effects)
Beta-adrenergic blockers	Masked signs of delirium tremens
Bromocriptine	Combined use increases gastrointestinal side effects
Caffeine	Possible further decreased reaction time
Cephalosporins and Chloramphenicol	Disulfiram-like reaction with some cephalosporins and chloramphenicol
Chloral hydrate	Prolonged hypnotic effect and adverse cardiovascular effects
Cimetidine	Increased central nervous system depressant effect of alcohol
Cycloserine	Increased alcohol effect or convulsions
Digoxin	Decreased digitalis effect
Disulfiram	Abdominal cramps, flushing, vomiting, hypotension, confusion, blurred vision, and psychosis
Guanadrel	Increased sedative effect and orthostatic hypotension
Glutethimide	Additive central nervous system depressant effect
Heparin	Increased bleeding
Hypoglycemics, sulfonylurea	Acutely ingested, alcohol can increase the hypoglycemic effect of sulfonylurea drugs; chronically ingested, it can decrease hypoglycemic effect of these drugs
Tolbutamide, chlorpropamide	Disulfiram-like reaction
Isoniazid	Increased liver toxicity
Ketoconazole, griseofulvin	Disulfiram-like reaction
Lithium	Increased lithium toxicity
Meprobamate	Synergistic central nervous system depression
Methotrexate	Increased hepatic damage in chronic alcoholics
Metronidazole	Disulfiram-like reaction
Nitroglycerin	Possible hypotension
Phenformin	Lactic acidosis (synergism)
Phenothiazines	Additive central nervous system depressant activity
Phenytoin	Acutely ingested, alcohol can increase the toxicity of phenytoin; chronically ingested, it can decrease the anticonvulsant effect of phenytoin
Quinacrine	Disulfiram-like reaction
Tetracyclines	Decreased effect of doxycycline
Source: Korrapati and Vestal, 1995.

Figure 4-1: Spokane's Gatekeeper Program

Figure 4-1
Spokane's Gatekeeper Program

The Elderly Services at the Community Mental Health Center in Spokane, Washington, created the Gatekeeper Program to recruit, organize, and train nontraditional referral sources who may be in contact with at-risk older adults during their daily activities. The Gatekeepers - apartment managers, meter readers, bank personnel, postal carriers, utility repair personnel, and others - are the Elderly Services' eyes within the community. They are trained to identify at-risk older adults and provide referrals back to the program, which in turn will send a case manager and a nurse team leader to the individual's home for an evaluation. The program integrates case management for older adults with mental health and substance abuse treatment services, with the Gatekeepers serving as the case-finding component. Overall, the Gatekeepers now account for 4 out of every 10 admissions to this multidisciplinary in-home evaluation, treatment, and case management program. Nearly half of the older adults treated specifically for substance abuse were referred by the Gatekeepers (Raschko, 1990).

Figure 4-2: Physical Symptom Screening Triggers

Figure 4-2
Physical Symptom Screening Triggers

• Sleep complaints; observable changes in sleeping patterns; unusual fatigue, malaise, or daytime drowsiness; apparent sedation (e.g., a formerly punctual older adult begins oversleeping and is not ready when the senior center van arrives for pickup)
• Cognitive impairment, memory or concentration disturbances, disorientation or confusion (e.g., family members have difficulty following an older adult's conversation, the older adult is no longer able to participate in the weekly bridge game or track the plot on daily soap operas)
• Seizures, malnutrition, muscle wasting
• Liver function abnormalities
• Persistent irritability (without obvious cause) and altered mood, depression, or anxiety
• Unexplained complaints about chronic pain or other somatic complaints
• Incontinence, urinary retention, difficulty urinating
• Poor hygiene and self-neglect
• Unusual restlessness and agitation
• Complaints of blurred vision or dry mouth
• Unexplained nausea and vomiting or gastrointestinal distress
• Changes in eating habits
• Slurred speech
• Tremor, motor uncoordination, shuffling gait
• Frequent falls and unexplained bruising

Figure 4-3: The CAGE Questionnaire

Figure 4-3
The CAGE Questionnaire

1. Have you ever felt you should cut down on your drinking?
2. Have people annoyed you by criticizing your drinking?
3. Have you ever felt bad or guilty about your drinking?
4. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye opener)?

Scoring: Item responses on the CAGE are scored 0 for "no" and 1 for "yes" answers, with a higher score an indication of alcohol problems. A total score of 2 or greater is considered clinically significant.
Source: Ewing, 1984.

Figure 4-4: Michigan Alcoholism Screening Test - Geriatric Version (MAST-G)

Figure 4-4 Michigan Alcoholism Screening Test - Geriatric Version (MAST-G)
After drinking have you ever noticed an increase in your heart rate or beating in your chest?	YES	NO
When talking with others, do you ever underestimate how much you actually drink?	YES	NO
Does alcohol make you sleepy so that you often fall asleep in your chair?	YES	NO
After a few drinks, have you sometimes not eaten or been able to skip a meal because you didn't feel hungry?	YES	NO
Does having a few drinks help decrease your shakiness or tremors?	YES	NO
Does alcohol sometimes make it hard for you to remember parts of the day or night?	YES	NO
Do you have rules for yourself that you won't drink before a certain time of the day?	YES	NO
Have you lost interest in hobbies or activities you used to enjoy?	YES	NO
When you wake up in the morning, do you ever have trouble remembering part of the night before?	YES	NO
Does having a drink help you sleep?	YES	NO
Do you hide your alcohol bottles from family members?	YES	NO
After a social gathering, have you ever felt embarrassed because you drank too much?	YES	NO
Have you ever been concerned that drinking might be harmful to your health?	YES	NO
Do you like to end an evening with a nightcap?	YES	NO
Did you find your drinking increased after someone close to you died?	YES	NO
In general, would you prefer to have a few drinks at home rather than go out to social events?	YES	NO
Are you drinking more now than in the past?	YES	NO
Do you usually take a drink to relax or calm your nerves?	YES	NO
Do you drink to take your mind off your problems?	YES	NO
Have you ever increased your drinking after experiencing a loss in your life?	YES	NO
Do you sometimes drive when you have had too much to drink?	YES	NO
Has a doctor or nurse ever said they were worried or concerned about your drinking?	YES	NO
Have you ever made rules to manage your drinking?	YES	NO
When you feel lonely, does having a drink help?	YES	NO
Scoring: Five or more "yes" responses are indicative of an alcohol problem. For further information, contact Frederic C. Blow, Ph.D., at University of Michigan Alcohol Research Center, 400 E. Eisenhower Parkway, Suite A, Ann Arbor, MI 48108; (734) 998-7952. Source: Blow, F.C.; Brower, K.J.; Schulenberg, J.E.; Demo-Dananberg, L.M.; Young, J.P.; and Beresford, T.P. The Michigan Alcoholism Screening Test - Geriatric Version (MAST-G): A new elderly-specific screening instrument. Alcoholism: Clinical and Experimental Research 16:372, 1992. © The Regents of the University of Michigan, 1991.

Figure 4-5: Comparison of Dementia and Delirium: Characteristics and Causes

Figure 4-5 Comparison of Dementia and Delirium: Characteristics and Causes
	Dementia	Delirium
Characteristics	Impairments in short- and long-term memory, abstract thinking, and judgment Aphasia (language disorder) Apraxia (inability to carry out motor activities despite intact comprehension and motor function) Agnosia (inability to recognize or identify items despite intact sensory function) Constructional difficulty (inability to copy three-dimensional figures, assemble blocks, or arrange sticks in specific designs) Personality change or alteration and accentuation of premorbid traits Mood disturbances Loss of self-care abilities	Inability to appreciate and respond normally to the environment, often with altered awareness, disorientation, inability to process visual and auditory stimuli, and other signs of cognitive dysfunction Potentially life-threatening Acute onset Clouding of consciousness Reduced wakefulness Disorientation to time and space Increased motor activity (e.g., restlessness, plucking, picking) Impaired attention and concentration Impaired memory Anxiety, suspicion, and agitation Variability of symptoms over time Misinterpretation, illusions, or hallucinations Disrupted thinking, delusions, speech abnormalities
Causes	Most Common Causes Alzheimer's disease Vascular dementia Alcohol-related dementia Common Metabolic/Toxic Causes Chronic drug-alcohol-nutritional abuse (e.g., Wernicke-Korsakoff syndrome) Organ system failure Anoxia Folic acid deficiency Hypothyroidism Bromide intoxication Hypoglycemia Common Infectious Causes Neurosyphilis paresis (a syphilitic infection manifested as dementia, seizures, and problems walking and standing) AIDS/HIV-related disorders Meningitis Encephalitis Other Common Causes Huntington's Chorea Parkinson's disease Jakob-Creutzfeldt disease Lewy body's dementia	Common Intracranial Causes Infections (e.g., meningitis, encephalitis) Seizures Stroke Subdural hematomas Tumors Common Extracranial Causes Anesthesia Drug-drug or alcohol-drug interactions Intoxication and/or withdrawal from alcohol or drugs (particularly psychoactive drugs) Toxic effects of prescribed or over-the-counter drugs Giant cell arteritis (a chronic inflammatory process involving the extracranial arteries) Hip fracture Hydrocephalus (increased fluid in the brain) Hypercapnia (reduced ventilation often associated with chronic obstructive pulmonary disease) Infections Dehydration Malnutrition Metabolic disturbances (e.g., liver or kidney failure, electrolyte disturbances, hyper- or hypoglycemia, diabetes, thyroid disorders) Myocardial infarction (heart attack) Sudden environmental changes Depression

Figure 5-1: ASAM-PPC-2 Assessment Dimensions

Figure 5-1
ASAM-PPC-2 Assessment Dimensions

Dimension 1 - Acute Intoxication and/or Withdrawal Potential

What risk is associated with the patient's current level of acute intoxication? Is there significant risk of severe withdrawal symptoms or seizures, based on the patient's previous withdrawal history, amount, frequency, and recency of discontinuation or significant reduction of alcohol or other drug use? Are there current signs of withdrawal? Does the patient have supports to assist in ambulatory detoxification, if medically safe?

Dimension 2 - Biomedical Conditions and Complications

Are there current physical illnesses, other than withdrawal, that need to be addressed or that may complicate treatment? Are there chronic conditions that affect treatment?

Dimension 3 - Emotional/Behavioral Conditions and Complications

Are there current psychiatric illnesses or psychological, behavioral, or emotional problems that need to be addressed or which complicate treatment? Are there chronic conditions that affect treatment? Do any emotional/behavioral problems appear to be an expected part of addiction illness, or do they appear to be autonomous? Even if connected to the addiction, are they severe enough to warrant specific mental health treatment?

Dimension 4 - Treatment Acceptance/Resistance

Is the patient actively objecting to treatment? Does the patient feel coerced into treatment? How ready is the patient to change? If willing to accept treatment, how strongly does the patient disagree with others' perceptions that he or she has an addiction problem? Does the patient appear to be compliant only to avoid a negative consequence, or does he or she appear to be internally distressed in a self-motivated way about his or her alcohol/other drug use problems?

Dimension 5 - Relapse/Continued Use Potential

Is the patient in immediate danger of continued severe distress and drinking/drug-taking behavior? Does the patient have any recognition of, understanding of, or skills with which to cope with his or her addiction problems in order to prevent relapse or continued use? What severity of problems and further distress will potentially continue or reappear if the patient is not successfully engaged in treatment at this time? How aware is the patient of relapse triggers, ways to cope with cravings to use, and skills to control impulses to use?

Dimension 6 - Recovery Environment

Are there any dangerous family members, significant others, living situations, or school/working situations that pose a threat to treatment engagement and success? Does the patient have supportive friendships, financial resources, or education/vocational resources that can increase the likelihood of successful treatment? Are there legal, vocational, social service agency, or criminal justice mandates that may enhance the patient's motivation for engagement in treatment?

Source: American Society of Addiction Medicine, 1996.

Figure 5-2: Life Changes Associated With Substance Abuse in Older Adults

Figure 5-2 Life Changes Associated With Substance Abuse in Older Adults
Emotional and Social Problems
Bereavement and sadness Loss of Friends Famiy members Social status Occupation and sense of professional identity Hopes for the future Ability to function	Consequent sense of being a "nonperson" Social isolation and loneliness Reduced self-regard or self-esteem Family conflict and estrangement Problems in managing leisure time/boredom Loss of physical attractiveness (especially important for women)
Medical Problems
Physical distress Chronic pain Physical disabilities and handicapping conditions Insomnia	Sensory deficits Hearing Sight Reduced mobility Cognitive impairment and change
Practical Problems
Impaired self-care Reduced coping skills Decreased economic security or new poverty status due to Loss of income Increased health care costs	Dislocation Move to new housing, or family moves away Homelessness Inadequate housing

Figure 5-3: Treatment Objectives and Approaches

Figure 5-3 Treatment Objectives and Approaches
General Objectives/ Examples	General Approaches/Examples
Eliminate or reduce substance abuse	Cognitive-behavioral (group or individual) Alcohol (drug) effects Relapse prevention Stress management Group approaches Alcohol (drug) effects education Medical Naltrexone, acamprosate (alcohol)
Safely manage intoxication episodes during treatment	Medical Remove patient from activities and observe Link and refer to detoxification program
Enhance relationships	Cognitive-behavioral (group or individual) Social skills and network building Group approaches Social support Socialization skill education Gender-specific issues Marital and family approaches Spouse counseling Marital therapy Family therapy Case management Linkage to community social programs Home visitation Individual counseling Focus on psychodynamic issues in relationships
Promote health Improve sleep habits Improve nutrition Increase exercise Reduce tobacco use Reduce stress	Medical Provide primary medical care Cognitive-behavioral (group or individual) Self-management skills training Group approaches Health education Education on nutrition, diet, cooking, shopping Sleep hygiene
Stabilize and resolve comorbidities Medical Psychiatric (e.g., depression, anxiety) Sensory deficits	Medical Consultation and special assessments, including medication assessment Primary and specialized medical care Psychiatric care for chronic mental disorders (by geriatric psychiatrist, if possible) Pain management for chronic pain disorders Antidepressants, antianxiety medication Cognitive-behavioral (group or individual) Relaxation training Depression

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