1 Substance Use Problems and Older AdultsNever Too Old: Substance Use Problems and Older Adults The University of Texas at Austin June 2009 The title slide indicates that we should never assume an individual is too old to develop a substance use problem, broadly defined; this is especially true for alcohol and problems related to medication use, both prescribed and over-the-counter.

2 Acknowledgements This slide acknowledges the John A. Hartford Foundation and the Council on Social Work Education Gero-Ed Center for their support of this project. Development of this presentation was made possible through a Gero Innovations Grant from the CSWE Gero-Ed Center’s Master’s Advanced Curriculum (MAC) Project and the John A. Hartford Foundation.

3 Never Too Old: Substance Use Problems and Older Adults*Incidence and Prevalence Risk Factors Prescription Drugs Screening Diagnosis Dementia, Delirium, and Psychiatric Comorbidity Culture Intervention References * Disclaimer: This presentation does not constitute legal, medical, or psychiatric advice. This slide presents a table of contents for the presentation to follow. Sections can be taught together or used separately and are divided by section headings in the presentation. Also note the disclaimer.

4 Incidence and Prevalence

5 How Many Older Adults Are Affected by Alcohol and Drug Problems?15% of men and 12% of women aged 60+ seen in primary care settings drank more than NIAAA recommended limits (Adams, Barry, & Fleming, 1996) As many as 17% misuse alcohol or prescription drugs (in addition to tobacco, these are the major problems) (Blow, 1998) This slide presents information on the extent of alcohol and prescription drug problems among older adults. It should be noted that these percentages are substantial.

6 Drug Use Among Adults Aged 50 and OlderBetween : 1.6 million adults reported some illicit drug use 719,ooo adults reported marijuana use 911,ooo adults reported using prescription psychotherapeutics for non-medical purposes It is projected that by 2020: 3.5 million adults will report illicit drug use (113% inc.) 3.3 million adults will report marijuana use (355% inc.) 2.7 million adults will report use of prescription psychotherapeutics for non-medical purposes (193% inc.) This slide shows how the number of older individuals using illicit drugs and licit drugs nontherapeutically is projected to increase in the next decades, especially given the aging of the baby boom generation, and indicates that social workers must be prepared to address these trends. (Colliver, Compton, Gfroerer, & Condon, 2006)

7 Ethnic Population ComparisonThis slide shows differences in use of various substances by race and ethnic group. The presenter may want to emphasize differences in levels of cigarette use and alcohol use by race and ethnicity. Ethnic and racial differences in binge and heavy alcohol use and in illicit drug use are less pronounced, though it should be remembered that even low levels of use may cause more problems for younger than older adults, generally speaking. (Office of Applied Studies, 2005)

8 Risk Factors

9 As the Life Cycle Turns: Substance Abuse Risks Across StagesYouth: genetic predisposition, temperament, nonconformist/antisocial behavior (delinquency/aggression), adults’ example, high-risk living environment, peer pressure, media, gender, ethnicity Young Adult: intimate relationships, sex, college, early family stressors Middle Age: achieving life goals, later family stressors Older Adult: empty nest, loneliness/lack of social support, changing roles, losses, health problems, metabolism, prescription drug use This slide puts substance use problems in a life cycle or intergenerational context and emphasizes that there are biopsychosocial risks for these problems at all life phases. The slide is consistent with the ecological perspective often used by social workers. (See, for example, National Institute on Alcohol Abuse and Alcoholism, 2000)

10 Important ConsiderationsDrinking and illicit drug use decline with age, but problems can occur at lower doses. Younger age cohorts more likely to drink and become dependent than older cohorts, but problems will increase as baby boomers age. Gender gap has decreased but men still have more alcohol problems; women, however, more likely to begin heavy drinking later in life. Older people are largest users of Rx drugs, and women prescribed more psychoactive Rx drugs than men. Most older adults do not intend to abuse Rx drugs (less nontherapeutic use than younger people). This slide provides information about alcohol and drug, including medication, problems with regard to age and gender. For example, though men are more likely to have alcohol problems than women, women are at greater risk for initiating heavy drinking in later life. In addition, women are prescribed more psychoactive drugs than men, and this is another cause for concern. Emphasize that when older adults use prescription drugs nontherapeutically (not as prescribed), it is often done unintentionally. (Blow, 1998; Center for Substance Abuse Prevention, 2002; National Institute on Alcohol Abuse and Alcoholism, 2000)

11 Alcohol Metabolism and AgingTolerance to alcohol decreases because: Lean body mass decreases (as body water decreases, alcohol concentration increases) Gastric alcohol dehydrogenase decreases (slows alcohol pharmacokinetics, increases alcohol that enters bloodstream) Increased alcohol sensitivity/decreased tolerance Many medications affect alcohol metabolism This slide provides information on alcohol metabolism and aging, including reasons why alcohol is metabolized more slowly in later life, another reason why older adults who wish to drink should do so judiciously. The presenter may also wish to note that older adults may become more sensitive to prescription medications. Gastric alcohol dehydrogenase is an enzyme. (Blow, 1998; Fingerhood, 2000)

12 Prescription Drugs

13 Misuse/abuse of prescription drugs has declined because:Safer drugs with fewer side effects Stricter federal and state regulations Health care providers given best practice guidelines Physicians better educated to treat older patients Consumers better educated This slide provides reasons why problems with prescription drug use have declined, but it should be emphasized that problems still occur and social workers should be aware of them, especially as the older adult population grows rapidly. Prescription drugs commonly misused/abused include anxiolytics/benzodiazepines, sedative/hypnotics, and opiates prescribed for anxiety, insomnia, and pain. (Blow, 1998)

14 But Prescription Drug Problems Still Occur Because…Older adults: Misunderstand directions for use or purpose of meds Forget to take meds Take too much by accident or to get greater effect Prescribing practices need improvement: Drugs’ effects among older adults not understood Multiple drugs prescribed by multiple physicians Insufficient diagnosis for prescribing Meds prescribed for too long Insufficient monitoring of effects and compliance This slide provides information about why problems with prescription drugs continue to occur. It emphasizes both challenges for older adults and for health care providers. (Blow, 1998)

15 Examples of Medication IssuesMany medications and street drugs interact with alcohol (e.g., additive effects with sedative/hypnotics/benzodiazepines) Some drugs may cause delirium: Sedative/hypnotics (e.g., benzodiazepines) Analgesics (narcotics) Drugs with anticholinergic effects* (e.g., disopyramide used for arrhythmia) (Alagiakrishnan & Wiens, 2004) *These drugs block the action of acetylcholine, a neurotransmitter that helps nerve cells communicate. This slide addresses problems that can occur with medication use, even at therapeutically prescribed doses, as well as with the street drugs. This slide describes some problems with medication use and street drugs that people may encounter and that may be more pronounced for older adults.

16 Screening

17 Recommended Limits for Alcohol Consumption Among Older AdultsNational Institute on Alcohol Abuse and Alcoholism People aged 65 and older: no more than one drink per day (NIAAA, 2000) TIP Consensus Panel Older men: No more than one drink per day; maximum of 2 drinks on any occasion Older women: Somewhat lower limits (Blow, 1998) Standard drink = 12 oz. beer; shot (1.5 oz.) hard liquor; 5 oz. wine; 4 oz. sherry, liqueur, or aperitif This slide indicates the drinking limits recommended by federal government agencies. This information should be emphasized as it might be lower than what many individuals assume it would be. It is also important to note that these recommendations are based on standard drinks. The typical definition of a standard drink is also provided.

18 Examples of Warning SignsPreoccupation with prescription drugs Malnutrition/dehydration Unnecessary requests for prescription refills Withdraws from normal social activities Uses more than prescribed Poor personal hygiene/grooming Minor traffic accidents Empty containers Hidden alcohol Unexplained bruises, burns, falls, fractures, accidents Expulsion from housing Avoids activities if alcohol not served Confusion/cognitive impairment This slide describes many possible signs of alcohol (or drug) problems among older adults. Some are also signs of other problems; when these signs are present, it is important to determine if they are signs of a substance use problem or other problem (e.g., dementia, depression) or a combination of problems. Later slides discuss dementia and psychiatric comorbidity. (Blow, 1998)

19 Barriers to Problem ResolutionHealth care providers poorly educated about substance use disorders Symptoms mistaken for depression, dementia, etc. Medical appointments rushed Attitude that treatment won’t be effective (waste of time, resources) Older adults more likely to hide problem (shame) Families also ashamed (stigma) Professionals and family members attitude of “why not– life is short” Older adults less likely to seek treatment Desire to solve problems on their own Alcohol and other drug problems among older adults often go unrecognized. This slide notes many reasons why this is so. (Blow, 1998)

20 Ask Yourself These Questions:If someone died of a cocaine overdose, what would be your first thought about their age? If someone died of accidental overdose due to combined effects of Rx painkillers, benzodiazepines or anti- anxiety agents, and sleep aids, what would be your first thought about their age? **Slide includes animation This slide and the following slide describe drug-related deaths that occurred in early They illustrate that we shouldn’t think in terms of stereotypes about problems or deaths related to medication use or illicit drug use. These slides can be omitted or replaced with more recent examples.

21 It’s never too early, and it’s never too late!Now consider this: Rock ‘n roll legend Ike Turner died of accidental cocaine toxicity (overdose) in January 2008 at age 76. Hypertensive cardiovascular disease and pulmonary emphysema were significant, contributing factors. Actor Heath Ledger died of an accidental overdose of prescription drugs (painkillers, anti-anxiety drugs, and sleeping pills) in February 2008 at age 28. It’s never too early, and it’s never too late! **Slide includes animation

22 Screening with the CAGEHave you ever felt you should Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye opener) (Ewing, 1984) For older adults, if one or more response is yes, assess further. (Blow, 1998) This slide presents the CAGE, a 4-item screening instrument for alcohol problems commonly used with adults. Health care and social service providers can easily commit the four items to memory. The items can be asked together or embedded with other questions or screening tools to make them less threatening to clients or patients.

23 Michigan Alcoholism Screening Test-Geriatric Version (MAST-G)Sample of items: Does alcohol make you sleepy so that you fall asleep in your chair? After a few drinks, have you sometimes not eaten or been able to skip a meal because you don’t feel hungry? Have you ever increased your drinking after experiencing a loss in your life? (Source: Blow et al., 1992) © The Regents of the University of Michigan, 1991.The complete instrument is reprinted with permission in Blow, 1998. This slide presents some items from the Michigan Alcohol Screening Test-Geriatric Version (MAST-G), an instrument specifically designed for use in screening older adults for alcohol problems. The instrument is copyrighted. It is reprinted in Blow, 1998.

24 Health Screening Survey (HSS), RevisedSample items: In the last three months, have you been drinking alcoholic drinks at all (e.g., beer, wine, sherry, vermouth, or hard liquor). In the last three months, have you felt guilty or bad about: Your weight How much you smoke How much you drink How unfit you are This slide presents items from the Health Screening Survey. It combines items about drinking and smoking with items about weight and keeping fit. An advantage of this approach is that it does not single out alcohol as an issue of concern but places it in the context of other health issues. CAGE items (Ewing, 1984) are included in the HSS. (Source: Fleming & Barry, 1991) The complete instrument is reprinted with permission in Blow, 1998.

25 Ideas for Improving ScreeningTeach health care providers, volunteers (Meals-on-Wheels), caretakers to screen. Ask alcohol/drug questions with health questions (“I’m wondering if alcohol may be the reason your diabetes isn’t responding as it should.”). Be non-confrontational, supportive, and show respect, but address denial and rationalization. Avoid stigmatizing terms like “alcoholic” or “drug abuser.” If older person cannot respond coherently, ask permission to speak with collaterals (e.g., family, friends). Use “brown bag approach” (bring all meds, Rx, OTC, herbs). Use preferred language and be aware of cultural issues. Take good social histories. This slide describes a number of ways to improve screening for alcohol and drug problems with older adults. It is especially important to be respectful of clients, no matter what their age. Treating an older adult like a child or talking to a person accompanying the older adult rather than the older adult, even when the older adult is capable of responding, happens far too often. Medical providers often use the “brown bag approach” in which a patient is asked to bring all their medications to a medical appointment so that everything the patient is taking can be evaluated by the physician to determine if certain medications should not be taken in combination and if medications may be causing the problems an older adult is experiencing. (Blow, 1998)

26 Consensus Panel Recommendation:“Every 60 year-old should be screened for alcohol and prescription drug abuse as part of his or her regular physical examination.” Screen again if physical symptoms indicated or older person undergoing major life changes. This slide indicates that older adults should be routinely screened for alcohol and drug (particularly prescription drug) problems. (Blow, 1998)

27 Diagnosis

28 Differential DiagnosisObtain a medical history Obtain a family and social history Obtain a behavioral health, psychiatric history Obtain an alcohol and drug history Determine current medication/alcohol/other drug use Consider effects of all drugs being used Consider effects of chronic diseases Screening is an initial step in determining whether an individual has an alcohol or drug problem. When a screening is positive, or if it is negative but concerns or questions remain, further diagnostic assessment/procedures are indicated. Differential diagnosis involves taking care to consider symptoms and related factors to determine what the patient’s correct or most plausible diagnosis is. This slide describes some strategies social workers can use to facilitate the process of differential diagnosis in order to determine the most appropriate diagnosis, including whether the client has co-occurring disorders. (Center for Substance Abuse Prevention, 2002; McNeece & DiNitto, 2005)

29 What are Substance Use Disorders?Pattern of use leading to clinically significant impairment or distress Abuse Obligations not met Recurrent hazardous use Recurrent legal problems Continued use despite recurring problems (One or more in 12-month period) Dependence Tolerance Withdrawal Larger amounts over longer time Can’t cut down More time using/recovering Important activities reduced/given up Recurrent physical or psychological problems (Three or more in 12-month period) This slide presents the criteria for substance use disorders (abuse and dependence) based on the DSM-IV-TR. The presenter may wish to elaborate on each DSM criterion for abuse and dependence. An important point to emphasize is that although abuse may be a precursor to dependence, a person may not progress to dependence. In addition, the DSM presents abuse and dependence as two distinct diagnoses. The presenter may wish to indicate that though health and mental health care providers usually use the DSM-IV-TR to make diagnoses and request reimbursement for treatment, there are other conceptualizations of substance use disorders; for example, substance use problems may also be presented on a continuum from no problems to severe problems. (American Psychiatric Association, 2000)

30 Substance Dependence Specify: Course Specifiers:With physiological dependence: tolerance and/or withdrawal present Without physiological dependence: neither tolerance nor withdrawal present Course Specifiers: Early full remission Early partial remission Sustained full remission Sustained partial remission On agonist therapy (medication) In a controlled environment This slide provides information about course specifiers for substance dependence. This slide can be omitted depending on the amount of time the presenter has and the level of detail desired. (American Psychiatric Association, 2000)

31 Applying DSM-IV Criteria to Older AdultsTolerance May not occur; small amounts can be a problem Withdrawal May not occur in late onset Larger amounts/ Cognitive impairment longer time impairs self monitoring Can’t cut down Same Low levels can be problem **Slide includes animation This slide shows why some DSM criteria may not apply well to older adults with substance use disorders. For example, tolerance may not occur and even low levels of use can cause problems for older adults, or activities the older adult has given up may be assumed to be due to advanced age rather than alcohol or drug problems. More time using/ Reduced activities may mask giving up activities detection Continued use May not understand problems are despite problems related to use even after medical advice (Barry, Blow & Oslin, 2002; Blow, 1998)

32 Alternative Classifications for Older AdultsAt Risk: Pattern of alcohol use not causing problems yet but may bring about adverse consequences Problem Drinkers: Includes heavy drinkers/hazardous consumers and those who fit abuse and dependence categories Given that DSM criteria may not sufficiently capture alcohol use problems among older adults, alternative criteria have been suggested, as this slide shows. (Blow, 1998)

33 What are Substance-Induced Disorders?Substance Intoxication Substance Withdrawal Substance Induced: Delirium Persisting Dementia Persisting Amnestic Disorder Psychotic Disorder Mood Disorder Anxiety Disorder Sexual Dysfunction Sleep Disorder This slide lists substance-induced disorders as described in the DSM-IV-TR. The level of detail the presenter offers on these disorders may depend on the audience and the time allowed. A general point that can be made is that there are several types of substance-induced disorders, and in some cases, these problems (e.g., mood, sexual dysfunction, sleep) may be presumed to be brought on by advancing age when they are actually caused by alcohol or other drug use. Also remember that an older person may have problems such as difficulty sleeping or changes in mood that may not rise to the level of a DSM diagnosis, but may still be related to alcohol or drug use. (American Psychiatric Association, 2000)

34 Eleven Drug Classes in DSM-IV-TRAlcohol Inhalants Amphetamines Nicotine Caffeine Opioids Cannabis Phencyclidine (PCP) Cocaine Hallucinogens Sedatives, hypnotics, and anxiolytics This slide presents the drug classifications used in the DSM-IV-TR. Again, the level of detail presenters will provide on each type, and in relation to their use by older adults, depends on the purpose of the presentation and the time allotted for the presentation. Nicotine, alcohol, and prescribed drugs are the main concerns among older adults, but as previously noted, more older adults will be using drugs like cannabis (marijuana) as the baby boom generation ages. (American Psychiatric Association, 2000)

35 Early vs. Late Onset Alcohol ProblemsEarly Onset (more intractable) 2/3 of older alcoholics Disorder begins before age 40, often in 20s or 30s Social supports less likely More likely to Drink to intoxication Have previous treatment Have legal, financial, other problems Have psychiatric comorbidity (mood & thought disorders) Late Onset (easier to treat) 1/3 of older alcoholics Disorder begins later (after age 40, 50, or 60) Former social drinkers or even teetotalers More likely to Enter treatment due to crisis/recent loss/health Be in better physical/ psychological health Be depressed or lonely Deny problem Have social support This slide provides information on early and late onset alcohol problems. Though most individuals who develop alcohol problems do so earlier in life, estimates are that approximately one-third do so in mid-life or later. This slide also reinforces the point that professionals should not assume that it is uncommon for people to develop alcohol-related problems later in life. (Studies on early and late onset are discussed in Blow, 1998; Fingerhood, 2000)

36 Late Onset: Three ScenariosLongtime “functional” alcoholics develop behavioral or cognitive impairment unrelated to alcohol use; can no longer function when drinking. Social drinkers become more vulnerable to alcohol even when drinking same quantity/frequency. Social drinkers increase quantity/frequency due to recent stressors (spouse’s death, retirement, disability). This slide describes three ways in which alcohol can become a problem in later life. (Fingerhood, 2000)

37 Dementia, Delirium, and Psychiatric Comorbidity

38 Dementia and Delirium Dementia: Marked loss in multiple areas of intellectual/cognitive functioning (e.g., memory, abstract thinking) that is chronic, progressive, and usually irreversible Delirium: Sudden or acute confusion that can be life threatening but generally reversible with medical treatment Older adults often present with symptoms of dementia and sometimes delirium. These diagnoses may be related to alcohol or drug use or abuse or they may have other etiologies. Delirium has an acute onset and is usually temporary, while dementia develops slowly and is usually irreversible. Sometime these problems are attributed to old age when they are actually related to alcohol and drug use. Misinformation or stereotypes may prevent accurate identification when alcohol or drugs are the cause. The next slide presents several symptoms of delirium and dementia. (Blow, 1998; also see American Psychiatric Association, 2000)

39 Dementia Impaired short- & long-term memory, abstract thinking, & judgment Language disorder Inability to carry out motor activities Constructional difficulties Personality change Mood disturbances Loss of self-care ability (Blow, 1998; Center for Substance Abuse Prevention, 2002)

40 Delirium Inability to appreciate/respond to environment normallyClouding of consciousness Reduced wakefulness Disoriented to time/space Increased motor activity (e.g., restless, plucking, picking) Impaired attention, concentration, memory Anxiety, suspicion, agitation Misinterpretations, illusions, hallucinations Disrupted thinking, delusions, speech abnormalities (Blow, 1998; Center for Substance Abuse Prevention, 2002)

41 Causes: Dementia Most common causes: Alzheimer’s, vascular dementia, alcohol-related Metabolic toxic causes (e.g., organ system failure, hypoglycemia) Infectious causes (e.g., AIDS/HIV, encephalitis) Other causes include Parkinson’s, Lewy body dementia This slide describes some causes of dementia and delirium. Depending on the nature of the presentation, the information presented may center on substance use or substance-induced disorders and information on other causes of delirium and dementia may be minimized. (Blow, 1998; Center for Substance Abuse Prevention, 2002)

42 Causes: Delirium Intracranial: infections (e.g., meningitis, encephalitis), seizures, stroke, subdural hematomas, tumors Extracranial: anesthesia, drug-drug or alcohol-drug interactions, alcohol or drug intoxication and withdrawal, hip fracture, infections, dehydration, malnutrition, diabetes, depression, etc. (Blow, 1998; Center for Substance Abuse Prevention, 2002)

43 Wernicke-Korsakoff SyndromeLoss of specific brain functions due to thiamine deficiency; often associated with chronic alcohol dependence Wernicke’s encephalopathy: Damage to nerves in CNS (brain, spinal cord) and peripheral nervous system (rest of body). Thiamine (vitamin B) deficiency common in alcoholics; heavy use prevents absorption. Korsakoff’s syndrome or psychosis: Develops as Wernicke’s symptoms remit. Symptoms: vision (double vision, eye movement abnormalities, dropping eyelids); ataxia (unsteady, uncoordinated walking); memory loss (may be profound), inability to form new memories; confabulation (makes up stories that may seem believable at first), and hallucinations This slide describes Wernicke-Korsakoff’s syndrome. It is usually associated with advanced stages of alcohol dependence. (Medline Plus, 2006)

44 Substance Use Disorders Often Comorbid with Psychiatric DisordersMood Disorders But memory impairment in major depressive episode may be mistaken for signs of dementia Alcohol and other sedatives (depressant drugs) may induce depression Anxiety Disorders Personality Disorders Potential for “self” medication Comorbidity, defined here as having one or more substance use disorders and one or more mental disorders, is common. Alcohol and drug problems often co-occur with mood, anxiety, personality, and other mental disorders. Depression is not uncommon among older adults. Mood disorders may occur independently of substance use problems, but they may also result from substance use or they may co-occur with substance use disorders. There are different theories as to why substance use disorders and mental disorders co-occur. The self-medication hypothesis, that people use alcohol or drugs to address the symptoms of mental disorders, is one of them. (See Blow, 1998; Center for Substance Abuse Prevention,2002)

45 Culture

46 Cultural ConsiderationsIn a given culture, what factors are believed to cause alcohol/drug problems--genetics, biology, psychology, culture, morality, choice, curses? How much stigma is attached to alcohol/drug problems? What are cultural considerations for screening, interventions, and treatment? Culture can be an important consideration in responding to alcohol and drug problems. This slide notes cultural considerations related to the (1) presumed causes of alcohol and drug problems, (2) stigma attached to these problems, and (3) treatment considerations, and the next two slides look at these topics with regard to Mexican American cultural considerations. Depending on the focus of the presentation this slide may be addressed in more general terms, or the next two slides may be replaced with slides emphasizing another culture or cultures. (See McNeece & DiNitto, 2005)

47 Example: Mexican AmericansPossible “causes”: Fatalism Moral weakness Culture-bound syndromes/illnesses (e.g., susto, nervios) Stigma: Greater for women Men entitled to drink but not irresponsibly More stigma attached to illicit drug use It may take considerable time to cover all the cultural considerations on this slide and the next. The presenter may need to give a few examples or focus on particular points. Fatalism may result in feeling that the problem is not under one’s control or is in God’s hands. The moral weakness explanation of substance use problems is common in many cultures. Culture-bound syndromes are defined in the DSM. Susto, for example, is a sudden fright that may cause a person to experience various symptoms of mental and physical distress. Nervios also refers to many distressful mental and somatic symptoms. It is possible that a person may self medicate in an attempt to alleviate these symptoms. Stigma is another consideration. Stigma is often attached to alcohol and drug problems regardless of culture. Stigma is generally greater for women who drink, especially if they drink excessively and stigma may be greater in some cultures than others. Drug problems may carry greater stigma. (See, for example, Alvarez & Ruiz, 2001; Kail & DeLaRosa, 1999; McNeece & DiNitto, 2005)

48 Example: Mexican Americans (cont.)Screening/Intervention Acculturation/acculturative stress Language Values (personalismo, respeto, familismo, confianza, dignidad, marianismo, fatalismo, machismo) Religion and clergy Health insurance (high rates of uninsured) Concrete services (meet basic needs) Fiestas and celebrations Folk medicine (curanderos/curanderas) Screening and intervention must be relevant to the individual being served. Among Mexican Americans, the level of acculturation varies. The acceptability of traditional U.S. treatment for alcohol and drug problems may also vary. The stress of acculturation or U.S. norms (e.g., women’s alcohol use being more acceptable) may result in greater use of alcohol or drugs. The values noted here may affect the way interventions are conducted. For example, it may be more acceptable or necessary to involve the family unit in the treatment process. Priests, nuns, or other clergy may be consulted for help instead of medical or mental health professionals. Some may seek the help of “alternative” helpers such as curanderos or curanderas, and traditional treatment providers. Access to treatment may be limited if the individual does not have insurance, and Mexican Americans have high rates of uninsured individuals. Drinking alcohol may be common at fiestas or other celebrations and could be a concern for relapse. (Alvarez & Ruiz, 2001; Kail & DeLaRosa, 1999; McNeece & DiNitto, 2005)

49 Intervention

50 Assess Stage of Change Precontemplation: lacks awareness of problem; no intent to change Contemplation: aware of problem; considers change Preparation: intends to change soon Action: successfully makes changes Maintenance: continues to change and prevent relapse The Transtheoretical Model or Stages of Change, developed by Prochaska, DiClemente, and Norcross, is a way to consider a person’s readiness for change. The model originated in smoking cessation but has been widely applied to alcohol and other drug problems. Determining an individual’s stage or readiness for change assists the practitioner in helping the client by determining what interventions are appropriate to his or her stage or readiness for change. For example, those in precontemplation will need help in identifying or deciding whether they have a problem. Those in contemplation may need assistance in weighing the pros and cons of changing their behavior. (Connors, Donovan, & DiClemente, 2001; Prochaska, DiClemente, & Norcross, 1992)

51 Elements of Brief InterventionCustomized feedback based on screening and assessment Discuss reasons to cut down or quit Discuss sensible drinking limits and strategies for cutting down or quitting Where patient fits in terms of drinking norms for his/her age group Drinking agreement in form of a prescription Discuss client’s reasons for drinking Discuss consequences of heavy drinking Discuss how to cope with risky situations Summarize session Brief interventions have gained attention as useful methods for helping adults, including older adults, change undesirable behaviors. The definition of brief intervention varies and can be a single brief session or a few meetings. This slide describes the elements or components generally found in brief interventions. (Barry et al., 2002; Blow, 1998)

52 FRAMES Approach to Brief InterventionGive feedback about personal risk from assessment results Emphasize personal responsibility (patient’s choice to reduce/stop drinking) Give clear advice about how to change drinking Provide a menu of change options Use an empathic counseling style (be warm, reflective, understanding) Encourage client self-efficacy and optimism Establish a drinking goal Follow up with client This slide presents the FRAMES approach, an approach for providing brief interventions to adults, developed by William R. Miller and Victoria C. Sanchez, and based on principles of Motivational Interviewing developed by William R. Miller and Stephen Rollnick. (Miller & Rollnick, 1991; Miller & Sanchez, 1994)

53 Brief Intervention with Older AdultsAppreciate the individual for meeting with you Identify health goals and other goals Summarize health habits Educate on standard drink and types of older drinkers Explore reasons older person drinks and reasons to cut down or quit Develop a drinking agreement Plan for situations that may trigger drinking This slide presents another approach for conducting brief interventions. This approach is featured in the video Brief Alcohol Interventions for Older Adults with Kristen Barry available at (Center for Substance Abuse Prevention, 2002; Fleming, Manwell, Barry, Adams, & Stauffacher, 1999)

54 Additional Treatment ApproachesDetoxification Inpatient, day treatment/partial hospitalization, extended outpatient treatment, case management as needed Alcoholics Anonymous and other mutual-help groups Community support programs or groups This slide lists treatment modalities for those who have alcohol and drug problems. When education or brief interventions are not appropriate or not successful, detoxification, inpatient or outpatient treatment of various types, mutual help groups, and community-based programs (e.g., senior activity or day programs) may be needed to help older adults address alcohol and other drug problems. (Blow, 1998; Vinton & Wambach, 2005)

55 Strategies for Improving Substance Use Disorder Treatment for Older AdultsInclude older person as full partner in recovery Age-specific treatment that is supportive, non- confrontational, builds self-esteem Focus on coping with depression, loneliness, loss Rebuild social support network Pace, content, environment appropriate for older persons Staff experienced and interested in serving older adults Links with medical, social, institutional and other services for older people This slide and the next offer many suggestions for improving practice with older adults. (Blow, 1998)

56 More Strategies Assure confidentiality to extent possibleInclude smoking cessation Provide transportation Hearing devices, large print materials Follow principles or work with older clients Address denial Motivate, inspire Provide hope and encouragement (Blow, 1998)

57 Remember It’s never too late to develop an alcohol or drug problem. It’s never too late (or too early) to intervene. AND It’s never too late to recover. This slide sums up major messages of this presentation—it’s never too late or too early to develop a substance use problem and never too late to intervene and recover.

58 References

59 References Adams, W. L., Barry, K. L., & Fleming, M. F. (1996). Screening for problem drinking in older primary care Patients. Journal of the American Medical Association, 276(24), Alagiakrishnan, K., & Wiens, C. A. (2004). An approach to drug induced delirium in the elderly. Postgraduate Medical Journal, 80, Alvarez, L. R., & Ruiz, P. (2001). Substance abuse in the Mexican American population. In S. L. A. Straussner, Ethnocultural factors in substance abuse treatment (pp ). New York: Guilford Press. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, 4th ed., text revision. Washington, DC: Author. Barry, K. L., Blow, F. C., & Oslin, D. W. (2002). Substance abuse in older adults: Review and recommendations for education and practice in medical settings. In M. R. Haack & H. Adger, Jr. (Eds.), Strategic plan for interdisciplinary faculty development: Arming the nation’s health professional for a new approach to substance use disorders. Substance Abuse, 23(3) supplement, Blow, F. C. (1998). Substance abuse among older adults, Treatment Improvement Protocol (TIP) Series 26. DHHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from Blow, F. C., Brower, K. J., Schulenberg, J. E., Demo-Dananberg, L. M., Young, J. P., & Beresford, T. P. (1992). The Michigan Alcoholism Screening Test-Geriatric Version (MAST-G): A new elderly-specific screening instrument. Alcoholism: Clinical and Experimental Research, 16, 372. This slide and the next present the references on which this presentation is based.

60 References (cont.) Center for Substance Abuse Prevention. (2002). At any age, it does matter: Substance abuse and older adults (for professionals). Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from Colliver, J. D., Compton, W. M., Gfroerer, J. C., & Condon, T. (2006). Projecting drug use among aging baby boomers in Annals of Epidemiology, 16(4), Connors, G. J., Donovan, D. M., & DiClemente, C. C. (2001). Substance abuse treatment and the stages of change: Selecting and planning interventions. New York: Guilford Press. Ewing, J. A. (1984). Detecting alcoholism: The CAGE questionnaire. Journal of the American Medical Association, 252, Fingerhood, M. (2000). Substance abuse in older people. Journal of the American Geriatrics Society, 48, Fleming, M. F., & Barry, K. L. (1991). A three-sample test of a masked alcohol screening questionnaire. Alcohol and Alcoholism, 26(1), Fleming, M. F., Manwell, L B., Barry, K. L., Adams, W; Stauffacher, E. A. (1999). Brief physician advice for alcohol problems in older adults: Randomized community-based trial. Journal of Family Practice, 48(5), Kail, B. L., & DeLaRosa, M. (1999). Challenges to treating the elderly Latino substance abuser: A not so hidden agenda. Journal of Gerontological Social Work, 30(1/2), McNeece, C. A., & DiNitto, D. M. (2005). Chemical dependency: A systems approach (3rd ed.). Boston Allyn & Bacon.

61 References (cont.) Medline Plus. (2006, September 10). Wernicke-Korsakoff syndrome. Retrieved from Miller, W. R., & Rollnick, S. (1991). Motivational interviewing. New York: Guilford Press. Miller, W. R., & Sanchez, V. C. (1994). Motivating young adults for treatment and lifestyle change. In G. S. Howard & P. E. Nathan (Eds.). Issues in alcohol use and misuse by young adults (pp ). Notre Dame, IN: University of Notre Dame Press. National Institute on Alcohol Abuse and Alcoholism. (2000). 10th special report to the U.S. Congress on alcohol and health. Washington, DC: U.S. Department of Health and Services. Office of Applied Studies. (2005). Substance use among older adults: 2002 and 2003 update. The NSDUH Report. Rockville, MD: Substance Abuse and Mental Health Services Administration. Prochaska, J. O., Di Clemente, C. C., & Norcross, J. C. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47, Vinton, L., & Wambach, K. G. (2005). Alcohol and drug use among elderly people. In C. A. McNeece & D.M. DiNitto, Chemical dependency: A systems approach (3rd ed., pp ). Boston: Allyn & Bacon. These slides present the references on which this presentation is based.