Substance Abuse Among Older Adults. Treatment Improvement Protocol (TIP) Series 26

DOCUMENT RESUME

ED 443 054 CG 030 131

AUTHOR Cook, Paddy; Davis, Carolyn; Howard, Deborah L.; Kimbrough, Phyllis; Nelson, Anne; Paul, Michelle; Shuman, Deborah; Brooks, Margaret K.; Dogoloff, Mary Lou; Vitzthum, Virginia; Hayws, Elizabeth TITLE Substance Abuse among Older Adults. Treatment Improvement Protocol (TIP) Series 26. INSTITUTION Substance Abuse and Mental Health Services Administration (DHHS/PHS), Rockville, MD. Center for Substance Abuse Treatment. REPORT NO SMA-98-3179 PUB DATE 1998-00-00 NOTE 191p.; For other documents in the TIP Series, see CG 030 099-103 and CG 030 130-134. CONTRACT 270-95-0013 AVAILABLE FROM National Clearinghouse for Alcohol and Drug Information, P.O. Box 2345, Rockville, MD 20847-2345. Tel: 800-729-6686 (Toll Free). PUB TYPE Guides Non-Classroom (055) Information Analyses (070) Tests/Questionnaires (160) EDRS PRICE MF01/PC08 Plus Postage. DESCRIPTORS *Alcohol Abuse; Behavior Modification; Counseling; *Counselor Training; *Drug Rehabilitation; *Gerontology; Intervention; Mental Health; Motivation; *Older Adults; *Substance Abuse IDENTIFIERS Nonprescription Drugs; Prescription Drugs; Solution Focused Brief Therapy

ABSTRACT As alcohol and other drug disorders become acknowledged as major problems, the need increases for current information on the scope of the problem and appropriate treatment. This TIP serves to educate treatment providers with information about older adults who, in general, are more likely to hide their substance abuse, less likely to seek professional help, and mistake symptoms of substance abuse for another ailment. It brings together literature on substance abuse and gerontology to recommend best practices for identifying, screening, assessing, and treating alcohol, prescription drugs, and other medication abuse among people age 60 and older. Brief intervention is recommended as the first step of treatment, followed by motivational interviewing, and intervention. Brief interventions may include motivation for change strategies, patient education, assessment and direct feedback, contracting and goal setting, and behavioral modification techniques. Treatment programs take a holistic approach since a number of interrelated emotional, social, medical, and spiritual problems characterize older adults' experiences with substance abuse. It also includes information on cognitive-behavioral, group, individual, and family therapy approaches to treatment. Appendixes include: "Legal and Ethical Issues," "Tools," "Bibliography," "Resource Panel," and "Field Reviewers." (Contains 19 figures and approximately 400 resources.) (JDM)

Reproductions supplied by EDRS are the best that can be made from the original document. U.S. DEPARTMENT' OF HEALTH AND Substance Abuse and Mental Health Services Administration H ,_,MAN SERVICES Public Health Service Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration Substance Abuse Among Older Adults

Treatment Improvement Protocol (TIP) Series 26

U.S. DEPARTMENT OF EDUCATION Mee of Educational Research and Improvement EDUCATIONAL RESOURCES INFORMATION CENTER (ERIC) -WWWW1a =NM ailiMENIMM=1Mi amM=SMRs.. O This document has been reproduced as dri;.salmIr received from the person or organization =INN ETMZMINEZINZEN EZIMINIDESN isimmstiMSWINIIEW eammi 111111111111 originating it. a232=i=i 1-"=Mi O Minor changes have been made to improve reproduction quality. lsay Points of view or opinions stated in this document do not necessarily represent CZ official OERI position or policy.

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.;1- COPY AVAILABLE RESOURCES FOR PROVIDERS American Association of Retired Persons 601 E St., NW Washington, DC 20049 202-434-2277 202-434-2562 (fax) www.aarp.org National Center on Addiction and Substance Abuse at Columbia University 152 West 57th St. New York, NY 10019 212-841-5200 212-956-8020 (fax) www.casacolumbia.org Join Together 441 Stuart St. Boston, MA 02116 617-437-1500 617-437-9394 (fax) www.jointogether.org National Aging Information Center U.S. Administration on Aging 330 Independence Ave., SW, Rm. 4656 Washington, DC 20201 202-619-7501 202-401-7620 (fax) 202-401-7575 (TTY) www.ageinfo.org

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0 3) Please mail this registration form to receive notice of future publications Substance Abuse Among Older Adults Tll'26 OrganiLation:Name:Please indicate your field: Administrator UClinician Title: Counselor 0 Researcher Other Address: eo 80 '.<=1.., la .-' la' o a ' L'1,t, ," y'84, ts.) .t( ra ,--).).s.0 .t:L).ad. 7.800 ,-, '6'1- .t-L6)..-. p,o 6 Ld u., .::-'1 a. Phone: ( ) Fax: ( ) E-mail 0,1 ..i.: N N cp ta. F.0- ,j,8 8 .---.sl) E .9': 0%.°: 7 '24,-. .-, '(4 4., %. ta Q.3Cl Pao .4. 5'''- El (i) F1.1. :)4 1,-CO 8s. & ..; 113 IT X'5 tj ''! :-.. 0 c.". 1.O1 .1. psto How did you obtain this TIP? 0 Was sent a copy 0 Ordered from NCADI ra0 ,...., I' t.) 13 ;_ii ts) 0 T .-9 R - oo ui2Si 9 ---:-V IV 0 z CJ ..... c r) Ca .S: 11, co Q., 6.5 dr, o-, ;1.,,. ui LN ::-.. !2 0.rT, O Obtained from professional meeting ui al u, 8 ? (/10 - ..:::. --1:-: ir IQ !..ri 0 Other Is,:,0.1-,El. ..,_, 03cp (L) IV 0 (o r ' ) a. :,. x NOG 0 4 co 1 --x C _, r-16-as 0 ....) r.D., g ';''3 ,r Rate this TIP on the following characteristics: te 1`) . F.) .. 0 Cl ' o .1:1 The TIP is informative. No I 2 3 4 5 Yes ro N,,,n--lz to' 0 1.-.) cs. 0,9 . 4. Is.) E Si's- The TIP is understandable.comprehensive. No I I 22 3 4 5 Yes s... 1 ..tsa 0r° Ott > cra > c.n z -1 r'T.o i..< Thethis TIP TIP is well will .groundedbe useful inin researchmy work. and scholarship. No I '2 2 3 3 4 5 Yes g ..z...- 0n>> 0o to071iril WhatHow willtopics you would use this you Tip? suggest (cheek for futureall that TIPS? apply) 0 ForniaVin- service training 0 PersonalCommunity reference education 0 Audit0 Other of practice standards Substance Abuse Among Older Adults

Treatment Improvement Protocol (TIP) Series 26

Frederic C. Blow, Ph.D. Consensus Panel Chair

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment Rockwall II, 5600 Fishers Lane Rockville, MD 20857

5 This publication is part of the Substance Abuse Gomberg, Ph.D.; Kristen Lawton Barry, Ph.D.; Prevention and Treatment Block Grant technical Richard E. Finlayson, M.D.; Mary Smolenski, assistance program. All material appearing in Ed.D., C.R.N.P.; Mary Lou Leonard; Annie this volume except that taken directly from Thornton; Jack Rhode; Cecil Gross; Niyati copyrighted sources is in the public domain and Pandya; Mark A. Meschter; and Wendy Carter may be reproduced or copied without for their considerable contributions to this permission from the Substance Abuse and document. Mental Health Services Administration's The opinions expressed herein are the views of (SAMHSA) Center for Substance Abuse the Consensus Panel members and do not reflect Treatment (CSAT) or the authors. Citation of the official position of CSAT, SAMHSA, or the the source is appreciated. U.S. Department of Health and Human Services This publication was written under contract (DHHS). No official support or endorsement of number ADM270-95-0013.Sandra Clunies, CSAT, SAMHSA, or DHHS for these opinions or M.S., I.C.A.D.C., served as the CSAT for particular instruments or software that may Government project officer. Writers were Paddy be described in this document is intended or Cook, Carolyn Davis, Deborah L. Howard, should be inferred. The guidelines in this Phyllis Kimbrough, Anne Nelson, Michelle Paul, document should not be considered substitutes Deborah Shuman, Margaret K. Brooks, Esq., for individualized patient care and treatment Mary Lou Dogoloff, Virginia Vitzthum, and decisions. Elizabeth Hayes. Special thanks go to Roland DHHS Publication No. (SMA)98-3179 M. Atkinson, M.D.; David Os lin, M.D.; Edith Printed1998

6 Contents

What Is a TIP? vii

Editorial Advisory Board ix

Consensus Panel xi

Foreword xiii

Executive Summaryand Recommendations xv Alcohol Abuse xv Abuse of Prescription Drugs xvi Identification, Screening, and Assessment xvii Treatment xix Outcomes and Cost Issues in Alcohol Treatment xxii Future Research xxiii

Chapter 1Substance Abuse Among Older Adults: An Invisible Epidemic 1 The Problem Projected 2 The Problem Now 3 Older Adults' Unique Vulnerabilities 5 Barriers To Identifying and Treating Older Adults With Substance Abuse Problems 5 Summary 10

Chapter 2Alcohol 13

Alcohol and Aging 13 Classifying Drinking Practices and Problems Among Older Adults 15 Drinking Patterns Among Older Adults 19 Risk Factors for Alcohol Abuse 22 Concomitant Substance Use 25

Chapter 3Use and Abuse of Psychoactive Prescription Drugs and Over-the-Counter Medications29 Evolution of Psychoactive Prescribing 29 Patterns of Use 31 Risk Factors for Misuse and Abuse of Psychoactive Drugs 31 Adverse Effects 35 iii 7 Contents

Interactions With Other Drugs and With Alcohol 43

Chapter 4Identification, Screening, and Assessment 47

Screening for Alcohol and Prescription Drug Abuse 48 Screening Instruments 53 Communicating Positive Screening Results 53 Communicating Negative Screening Results 56 Assessment 56 Special Assessments 57 Moving the Older Adult Into Treatment 63

Chapter 5Referral and Treatment Approaches 65

Least Intensive Options 65 Specialized Treatment of Older Problem Drinkers and Substance Abusers 68 Levels of Treatment Services 69 Program Philosophy and Basic Principles 73 Treatment Approaches 77 Specialized Treatment Issues for Prescription Drug Abuse 88 Staffing Considerations 91

Chapter 6Outcomes and Cost Issues in Alcohol Treatment for Older Adults 95

Spectrum of Alcohol Treatment Outcomes 95 Measurement of Multidimensional Outcomes for Older Adults 99 Costs of Alcohol Treatment 102 Reimbursement Issues in the Treatment of Older Adults 103 Areas Requiring Future Research 104

Appendix ALegal and Ethical Issues 107

Autonomy and the Provider's Mission: A Dilemma 107 Privacy and Confidentiality 108 Conclusion 117 Endnotes 118

Appendix BTools 121

The Alcohol Use Disorders Identification Test (AUDIT) 122 Index of Activities of Daily Living (Index of ADLs) 129 Instrumental Activities of Daily Living (IADL) Scale 132 Geriatric Depression Scale (GDS) Short Form 134 The Center for Epidemiologic Studies Depression Scale (CES-D) 135 Health Screening Survey (HSS), Revised 137

Appendix CBibliography 141

Appendix DResource Panel 169

Appendix EField Reviewers 171 iv Contents

Figures 1-1: Percentage Distribution of the U.S. Population by Age: 1995, 2010, 2025 3 2-1: DSM-IV Diagnostic Criteria for Substance Abuse 16 2-2: DSM-IV Diagnostic Criteria for Substance Dependence 17 2-3: Applying DSM-IV Diagnostic Criteria to Older Adults With Alcohol Problems 18 2-4: Clinical Characteristics of Early and Late Onset Problem Drinkers 21 3-1: Continuum of Psychoactive Prescription Drug Use 32 3-2: Effect of Aging on Response to Drug Effect 34 3-3: Commonly Prescribed Anxiolytics 36 3-4: Commonly Prescribed Sedative/Hypnotics 39 3-5: Commonly Prescribed Opiate/Opioid Analgesics 43 3-6: DrugAlcohol Interactions and Adverse Effects 44 4-1: Spokane's Gatekeeper Program 48 4-2: Physical Symptom Screening Triggers 49 4-3: The CAGE Questionnaire 53 4-4: Michigan Alcoholism Screening TestGeriatric Version (MAST-G) 55 4-5: Comparison of Dementia and Delirium: Characteristics and Causes 60 5-1: ASAM-PPC-2 Assessment Dimensions 70 5-2: Life Changes Associated With Substance Abuse in Older Adults 76 5-3: Treatment Objectives and Approaches 78

9 What IsaTIP?

Treatment Improvement Protocols (TIPs) of discussions; the information and are best practice guidelines for the recommendations on which they reach treatment of substance abuse, provided consensus form the foundation of the TIP. The as a service of the Substance Abuse and Mental members of each Consensus Panel represent Health Service Administration's Center for substance abuse treatment programs, hospitals, Substance Abuse Treatment (CSAT). CSAT's community health centers, counseling Office of Evaluation, Scientific Analysis, and programs, criminal justice and child welfare Synthesis draws on the experience and agencies, and private practitioners. A Panel knowledge of clinical, research, and Chair (or Co-Chairs) ensures that the guidelines administrative experts to produce the TIPs, mirror the results of the group's collaboration. which are distributed to a growing number of A large and diverse group of experts closely facilities and individuals across the country. reviews the draft document. Once the changes The audience for the TIPs is expanding beyond recommended by these field reviewers have public and private substance abuse treatment been incorporated, the TIP is prepared for facilities as alcohol and other drug disorders are publication, in print and online. The TIPs can be increasingly recognized as a major problem. accessed via the Internet on the National Library The TIPs Editorial Advisory Board, a of Medicine's home page at the URL: distinguished group of substance abuse experts http: / /text.nlm.nih.gov. The move to electronic and professionals in such related fields as media also means that the TIPs can be updated primary care, mental health, and social services, more easily so they continue to provide the field works with the State Alcohol and Other Drug with state-of-the-art information. Abuse Directors to generate topics for the TIPs Although each TIP strives to include an based on the field's current needs for evidence base for the practices it recommends, information and guidance. CSAT recognizes that the field of substance After selecting a topic, CSAT invites staff abuse treatment is evolving, and research from pertinent Federal agencies and national frequently lags behind the innovations organizations to a Resource Panel that pioneered in the field. A major goal of each TIP recommends specific areas of focus as well as is to convey "front-line" information quickly but resources that should be considered in responsibly. For this reason, recommendations developing the content of the TIP. Then proffered in the TIP are attributed to either recommendations are communicated to a Panelists' clinical experience or the literature. If Consensus Panel composed of non-Federal there is research to support a particular experts on the topic who have been nominated approach, citations are provided. by their peers. This Panel participates in a series vii 10 What Is a TIP?

This TIP, Substance Abuse Among Older anyone else who has regular contact with older Adults, presents treatment providers with much- adults. needed information about a population that is The TIP discusses the relationship between underdiagnosed and underserved. Substance aging and substance abuse and offers guidance abuse, particularly of alcohol and prescription on identifying, screening, and assessing not only drugs, often goes undetected among adults over substance abuse but also disorders such as 60 in part due to societal reasonsolder adults dementia and delirium that can mask or mimic tend to be ashamed about drinking or drug an alcohol or prescription drug problem. problems and see them as a moral failing. Practical accommodations to treatment for older Providers, for their part, may confuse symptoms adults and a discussion of how to assess of substance use disorders with age-related outcomes and treat within a managed care changes. Because so much of older adults' context round out the document. substance abuse is never even identified, this TIP is aimed at not only substance abuse Other TIPs may be ordered by contacting the treatment providers but also primary care National Clearinghouse for Alcohol and Drug clinicians, social workers, senior center staff, and Information (NCADI), (800) 729-6686 or (301) 468- 2600; TDD (for hearing impaired), (800) 487-4889.

viii 11 E itorial Advisory Board

Karen Allen, Ph.D., R.N., C.A.R.N. Pedro J. Greer, M.D. President of the National Nurses Society on Assistant Dean for Homeless Education Addictions University of Miami School of Medicine Associate Professor Miami, Florida Department of Psychiatry, Community Thomas W. Hester, M.D. Health, and Adult Primary Care Former State Director University of Maryland Substance Abuse Services School of Nursing Division of Mental Health, Mental Baltimore, Maryland Retardation and Substance Abuse Richard L. Brown, M.D., M.P.H. Georgia Department of Human Resources Associate Professor Atlanta, Georgia Department of Family Medicine Gil Hill University of Wisconsin School of Medicine Director Madison, Wisconsin Office of Substance Abuse Dorynne Czechowicz, M.D. American Psychological Association Associate Director Washington, D.C. Medical/Professional Affairs Douglas B. Kamerow, M.D., M.P.H. Treatment Research Branch Director Division of Clinical and Services Research Office of the Forum for Quality and National Institute on Drug Abuse Effectiveness in Health Care Rockville, Maryland Agency for Health Care Policy and Research Linda S. Foley, M.A. Rockville, Maryland Former Director Stephen W. Long Project for Addiction Counselor Training Director National Association of State Alcohol and Office of Policy Analysis Drug Directors National Institute on Alcohol Abuse and Washington, D.C. Alcoholism Wayde A. Glover, M.I.S., N.C.A.C. II Rockville, Maryland Director Richard A. Rawson, Ph.D. Commonwealth Addictions Consultants and Executive Director Trainers Matrix Center Richmond, Virginia Los Angeles, California ix 12 Editorial Advisory Board

Ellen A. Renz, Ph.D. Sidney H. Schnoll, M.D., Ph.D. Former Vice President of Clinical Systems Chairman MEDCO Behavioral Care Corporation Division of Substance Abuse Medicine Kamuela, Hawaii Medical College of Virginia Richard K. Ries, M.D. Richmond, Virginia Director and Associate Professor Outpatient Mental Health Services and Dual Disorder Programs Harborview Medical Center Seattle, Washington

11 3

x Consensus Panel

Chair Jeanie L. Holt, R.N.C. Clinical Staff Nurse Frederic C. Blow, Ph.D. Heritage Home Health and Hospice Assistant Professor and Assistant Research Meredith, New Hampshire Scientist David Os lin, M.D. Department of Psychiatry Assistant Professor Alcohol Research Center Addiction and Geriatric Psychiatry University of Michigan Department of Psychiatry Ann Arbor, Michigan University of Pennsylvania Workgroup Leaders Philadelphia, Pennsylvania Roland M. Atkinson, M.D. Gerald D. Shulman, M.A., F.A.C.A.T.A. Professor Consultant Head of Division of Geriatric Psychiatry Winter Haven, Florida Department of Psychiatry Panelists School of Medicine Oregon Health Sciences University Charles Bearcomesout Portland, Oregon Traditional Coordinator Traditional Component James Campbell, M.D., M.S. Northern Cheyenne Recovery Center Associate Professor Lame Deer, Montana Acting Chairman Department of Family Medicine Larry W. Dupree, Ph.D. Case Western Reserve University Professor Medical Director Department of Aging and Mental Health Senior Health Recovery Resources Florida Mental Health Institute Metrohealth Medical Center University of South Florida Cleveland, Ohio Tampa, Florida Anne M. Gurnack, Ph.D. Professor and Director of Assessment Department of Political Science University of Wisconsin at Parkside Kenosha, Wisconsin

xi Consensus Panel

Richard E. Finlayson, M.D. Hi la Richardson, Dr.P.H. Consultant in Adult Psychiatry Deputy Director Former Medical Director of Addiction Medical Research and Practice Policy Services National Center on Addiction and Substance Department of Psychiatry and Psychology Abuse Mayo Clinic Columbia University Associate Professor of Psychiatry New York, New York Mayo Medical School Marguerite T. Saunders, M.S. Rochester, Minnesota Saunders Consulting Services Lissy F. Jarvik, M.D., Ph.D. Albany, New York Distinguished Physician (11L) Sharon L. Sheahan, Ph.D., C.F.N.P. Psychiatry Department Associate Professor of Nursing West Los Angeles VA Medical Center College of Nursing Professor Emerita University of Kentucky Department of Psychiatry and Biobehavioral Lexington, Kentucky Sciences University of California-Los Angeles Erma Polly Williams, M.R.E. Los Angeles, California Program Support Specialist Robert Wood Johnson Medical School University of Medicine and Dentistry of New Jersey New Brunswick, New Jersey

15 xii Foreword

The Treatment Improvement Protocol participatory process have bridged the gap (TIP) series fulfills SAMHSA/CSAT's between the promise of research and the needs mission to improve treatment of of practicing clinicians and administrators. We substance use disorders by providing best are grateful to all who have joined with us to practices guidance to clinicians, program contribute to advances in the substance abuse administrators, and payers. TIPs are the result treatment field. of careful consideration of all relevant clinical and health services research findings, Nelba Chavez, Ph.D. demonstration experience, and implementation Administrator requirements. A panel of non-Federal clinical Substance Abuse and Mental Health researchers, clinicians, program administrators, Services Administration and patient advocates debates and discusses David J. Mactas their particular area of expertise until they reach Director a consensus on best practices. This panel's work Center for Substance Abuse Treatment is then reviewed and critiqued by field Substance Abuse and Mental Health reviewers. Services Administration The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly Executive Summary and Recommendations

Researchers are only beginning to realize adults. Because so much of older people's the pervasiveness of substance abuse substance abuse is never identified, this TIP is among people age 60 and older. Until aimed not only at substance abuse treatment relatively recently, alcohol and prescription providers but also at primary care clinicians, drug misuse, which affects as many as 17 social workers, senior center staff, and anyone percent of older adults, was not discussed in else who has regular contact with older adults. either the substance abuse or the gerontological The TIP aims to advance the understanding literature. of the relationships between aging and The reasons for this silence are varied: substance abuse and to provide practical Health care providers tend to overlook recommendations for incorporating that substance abuse and misuse among older understanding into practice. The TIP's people, mistaking the symptoms for those of recommendations appear below in italic type. dementia, depression, or other problems Those based on research evidence are marked common to older adults. In addition, older (1), whereas those based on Panel members' adults are more likely to hide their substance clinical experience are marked (2). Citations abuse and less likely to seek professional help. for the former can be found in the body of the Many relatives of older individuals with text. substance use disorders, particularly their adult children, are ashamed of the problem and Alcohol Abuse choose not to address it. The result is thousands Physiological changes, as well as changes in the of older adults who need treatment and do not kinds of responsibilities and activities pursued receive it. by older adults, make established criteria for This TIP brings together the literature on classifying alcohol problems often inadequate substance abuse and gerontology to recommend for this population. best practices for identifying, screening, One widely used model for understanding assessing, and treating alcohol and prescription alcohol problems is the medical diagnostic drug abuse among people age 60 and older. The model as defined in the American Psychiatric Consensus Panel, whose members include Association's Diagnostic and Statistical Manual of researchers, clinicians, treatment providers, and Mental Disorders, Fourth Edition (DSM-IV). The program directors, supplements this research DSM-IV criteria for substance dependence (see base with its considerable experience treating Figure 2-2, p. 17) include some that do not apply and studying substance abuse among older

1 7 Executive Summary and Recommendations

to many older adults and may lead to A maximum of two drinks on any drinking underidentification of drinking problems. occasion (e.g., New Year's Eve, weddings). (1) Diagnostic criteria for alcohol dependence are subsumed within the DSM-IV's general The Panel recommends somewhat lower limits for women. (1) criteria for substance dependence. Dependence is defined as a "maladaptive pattern of substance use, leading to clinically significant Abuse of Prescription impairment or distress, as manifested by three Drugs (or more) of the following, occurring atany time People 65 and older consume more prescribed in the same 12-month period" (American and over-the-counter medications thanany Psychiatric Association, 1994, p. 181). other age group in the United States. The Panel recommends that clinicians consider Prescription drug misuse and abuse is prevalent that the DSM-IV criteria for substance abuse and among older adults not only because more dependence may not be adequate to diagnose older drugs are prescribed to them but also because, adults with alcohol problems. (2) See Figure 2-3 (p. as with alcohol, aging makes the body more 18) for an outline of special considerations. vulnerable to drugs' effects. Some experts use the model of at-risk, heavy, Any use of drugs in combination with and problem drinking in place of the DSM-IV alcohol carries risk; abuse of these substances model of alcohol abuse and dependence because raises that risk, and multiple drug abuse raises it it allows for more flexibility in characterizing even further. For example, chronic alcoholics drinking patterns. In this classification scheme, who use even therapeutic doses of an at-risk drinker is one whose patterns of alcohol acetaminophen may experience severe use, although not yet causing problems, may hepatoxicity. Alcohol can increase lithium bring about adverse consequences, either to the toxicity and enhance central nervous system drinker or to others. As their names imply, the depression in persons taking tricyclic terms heavy and problem drinking signify more antidepressants. High doses of benzodiazepines hazardous levels of consumption. Although the used in conjunction with alcohol or barbiturates distinction between the terms heavy and problem can be lethal. The many possible unfavorable is meaningful to alcohol treatment specialists reactions between prescription drugs and interested in differentiating severity of problems alcohol are summarized in Figure 3-6 (p. 44). among younger alcohol abusers, it is less relevant to older adults. To differentiate older Benzodiazepines drinkers, the Panel recommends using the terms at- Benzodiazepine use for longer than 4 months is not risk and problem drinkers only. (2) In the two- recommended for geriatric patients. (2) stage conceptualization recommended by the Furthermore, among the different Panel, the problem drinker category includes benzodiazepines, longer acting drugs such as those who would otherwise fall into the heavy flurazepam (Dalmane) have very long half-lives and problem classifications in the more and are more likely to accumulate than the traditional model as well as those who meet the shorter acting ones. They are also more likely to DSM-IV criteria for abuse and dependence. produce residual sedation and such other The Consensus Panel recommends that older men adverse effects as decreased attention, memory, consume cognitive function, and motor coordination, and NNo more than one drink per day (1) increased falls or motor vehicle crashes. By contrast, some shorter acting benzodiazepines xvi 18 Executive Summary and Recommendations such as oxazepam (Serax) and lorazepam Antihistamines (Ativan) have very simple metabolic pathways Older persons appear to be more susceptible to and are not as likely to produce toxic or adverse anticholinergic effects from dependence-inducing effects with chronic antihistamines and are at increased risk for dosing. Because of these side effects, the Panel orthostatic hypotension and central nervous recommends caution in selecting the most system depression or confusion. In addition, appropriate benzodiazepines for elderly patients. (2) antihistamines and alcohol potentiate one another, further exacerbating the above Sedative/Hypnotics conditions as well as any problems with balance. Aging changes sleep architecture, decreasing the Because tolerance also develops within days or amount of time spent in the deeper levels of weeks, the Panel recommends that older persons sleep (stages three and four) and increasing the who live alone do not take antihistamines. (1) number and duration of awakenings during the night. However, these new sleep patterns do Identification, Screening, not appear to bother most medically healthy older adults who recognize and accept that their and Assessment sleep will not be as sound or as regular as when The Consensus Panel recommends that every 60- they were young. Although benzodiazepines year -old should be screened for alcohol and and other sedative/hypnotics can be useful for prescription drug abuse as part of his or her regular short-term amelioration of temporary sleep physical examination. (2) However, problems can problems, no studies demonstrate their long- develop after the screening has been conducted, term effectiveness beyond 30 continuous nights, and concurrent illnesses and other chronic and tolerance and dependence develop rapidly. conditions may mask abuse. Although no hard- The Panel recommends that symptomatic treatment and-fast rules govern the timing of screening, the of insomnia with medications be limited to 7 to 10 Panel recommends screening or rescreening if certain days with frequent monitoring and reevaluation if physical symptoms (detailed in Chapter 4) are the prescribed drug will be used for more than 2 to 3 present or if the older person is undergoing major weeks. Intermittent dosing at the smallest possible life changes or transitions. (2) dose is preferred, and no more than a 30-day supply Although it is preferable to use standardized of hypnotics should be prescribed. (1) screening questionnaires, friendly visitors, The Panel further recommends that clinicians Meals-On-Wheels volunteers, caretakers, and teach older patients to practice good sleep hygiene health care providers also can interject screening rather than prescribe drugs in response to insomnia. questions into their normal conversations with (1) The former includes regularizing bedtime, older, homebound adults. Although the line of restricting daytime naps, using the bedroom questioning will depend on the person's only for sleep and sexual activity, avoiding relationship with the older person and the alcohol and caffeine, reducing evening fluid responses given, the Panelrecommends that anyone intake and heavy meals, taking some who is concerned about an older adult's drinking medications in the morning, limiting exercise practices try asking direct questions. (2) (Examples immediately before retiring, and substituting of these and of less direct questions appear in behavioral relaxation technique's. Chapter 4.)

xvii 19 Executive Summary and Recommendations

The Panel recommends that health care providers (ADLs) and the instrumental activities of daily preface questions about alcohol witha link to a living (IADLs) with the instruments in Appendix medical condition when screening older people. (2) B. (1) Another useful instrument is the SF-36,a 36- For example, "I'm wondering if alcoholmay be item self-report questionnaire thatmeasures the reason why your diabetes isn't responding health-related quality of life, including both as it should," or "Sometimes one prescription ADLs and IADLs. (1) drug can affect how well another medication is working. Let's go over the drugs you're taking Cognitive dysfunction and see if we can figure this problem out." Do Patients who have been medically detoxified should not use stigmatizing terms like alcoholicor drug not be screened for cognitive dysfunction until abuser during these encounters. (2) several weeks after detoxification is completed, Although it is important to respect the older because a patient not fully recovered from person's autonomy, in situations wherea detoxification may exhibit some reversible coherent response is unlikely, collateral cognitive impairment. (2) participation from family membersor friends The Panel recommends use of the may be necessary. In this case, the screener should Orientation/Memory/Concentration Test (1), which first ask for the older adult's permission to question is simple and can be completed in the office. The others on his or her behalf. (2) Folstein Mini-Mental Status Exam (MMSE) isan acceptable alternative (1), although itcan be Instruments insensitive to subtle cognitive impairments The Panel recommends use of the CAGE among older problem drinkers who have Questionnaire and the Michigan Alcohol Screening recently attained sobriety (past 30-60 days). The TestGeriatric Version (MAST-G) toscreen for MMSE is weak on visualspatial testing, which alcohol use among older adults. (1) is likely to show some abnormality inmany The Alcohol Use Disorders Identification Test recent heavy drinkers. The draw-a-clock task isa (AUDIT) is recommended for identifying alcohol good additional task to complement the MMSE. (1) problems among older members of ethnic minority The Neurobehavioral Cognitive Status Examination, groups. (2) which includes screening tests of abstract thinking and visual memory (not measuredon the MMSE), is Assessment also recommended for assessing mental status in this Substance abuse population. (1) The Confusion Assessment Method (CAM) is The Panel recommends a sequential approach that widely used as a brief, sensitive, and reliable looks at various dimensions of an older adult's screening measure for detecting delirium. (I) The suspected problem in stages, so thatunnecessary Panel recommends that a positive delirium tests are not conducted. (1) screen be followed by careful clinical diagnostics basedon The Panelists recommend the use of two DSM-IV criteria and that any associated cognitive structured assessments with older adults: the impairment be followed clinically using the MMSE. substance abuse sections of the Structured Clinical (1) Interview for DSM-III-R (SCID) and the Diagnostic Interview Schedule (DIS) for DSM-IV. (2) Medical status Functioning The Panel recommends that initial medical assessment of older persons should routinely include To identify functional impairments, the Panel screening for visual and auditory problems, andany recommends measuring the activities of daily living problems discovered should be correctedas quickly as xviii 20 Executive Summary and Recommendations possible. (2) To assess the medication use of Conducting Brief Interventions older adults, the Panel recommends the "brown bag A brief intervention is one or more counseling approach." The practitioner can ask older adults to sessions, which may include motivation for bring every medication they take in a brown paper change strategies, patient education, assessment bag, including over-the-counter and prescription and direct feedback, contracting and goal medications, vitamins, and herbs. (1) setting, behavioral modification techniques, and Sleep disorders the use of written materials such as self-help manuals. An older adult-specific brief intervention The Panel recommends that sleep history be recorded should include the following steps (2): in a systematic way in order to both document the changes in sleep problems over time and to heighten 1. Customized feedback on screening questions the awareness of sleep hygiene. (2) relating to drinking patterns and other health habits such as smoking and nutrition. Depression 2. Discussion of types of drinkers in the United The Geriatric Depression Scale (GDS) and the States and where the patient's drinking Center for Epidemiological Studies Depression patterns fit into the population norms for his Scale (CES-D), reproduced in Appendix B, have or her age group. been validated in older age groups although not 3. Reasons for drinking. This is particularly specifically in older adults with addiction important because the practitioner needs to problems. The Panel recommends the CES-D for understand the role of alcohol in the context use in general outpatient settings as a screen for of the older patient's life, including coping depression among older patients. (1) with loss and loneliness. 4. Consequences of heavier drinking. Some Treatment older patients may experience problems in The Consensus Panel recommends that the least physical, psychological, or social functioning intensive treatment options be explored first with even though they are drinking below cutoff older substance abusers. (1) These initial levels. approaches, which can function either as 5. Reasons to cut down or quit drinking. pretreatment strategy or treatment itself, are Maintaining independence, physical health, brief intervention, intervention, and financial security, and mental capacity can be motivational counseling. They may be sufficient key motivators in this age group. to address the problem; if not, they can help 6.Sensible drinking limits and strategies for move a patient toward specialized treatment. cutting down or quitting. Strategies that are The Consensus Panel recommends that every useful in this age group include developing reasonable effort be made to ensure that older social opportunities that do not involve substance abusers, including problem drinkers, alcohol, getting reacquainted with hobbies enter treatment. Brief intervention is the and interests from earlier in life, and recommended first step, supplemented or followed by pursuing volunteer activities, if possible. intervention and motivational interviewing. (1) 7.Drinking agreement in the form of a Because many older problem drinkers are prescription. Agreed-upon drinking limits ashamed about their drinking, intervention that are signed by the patient and the strategies need to be nonconfrontational and practitioner are particularly effective in supportive. changing drinking patterns.

xix Executive Summary and Recommendations

8. Coping with risky situations. Social expresses belief in and support for his or her isolation, boredom, and negative family capacity for change. Motivational counseling is interactions can present special problems in an intensive process that enlists patients in their this age group. own recovery by avoiding labels, avoiding 9. Summary of the session. confrontation (which usually results in greater If the older problem drinker does not defensiveness), accepting ambivalence about the respond to the brief intervention, two other need to change as normal, inviting clients to approachesintervention and motivational consider alternative ways of solving problems, interviewingshould be considered. and placing the responsibility for changeon the client. Intervention Detoxification In an intervention, several significant people ina substance-abusing patient's life confront the Some older patients should be withdrawn from patient with their firsthand experiences of hisor alcohol or from prescription drugs ina hospital her drinking or drug use. The formalized setting. Medical safety and removal from intervention process includes a progressive continuing access to alcohol or the abused drugs interaction by the counselor with the familyor are primary considerations in this decision. friends for at least 2 days before meeting with Indicators that inpatient hospital supervision is the patient. needed for withdrawal from a prescription drug The Panel recommends the following include the following (2): modifications to interventions for older patients. No A high potential for developing dangerous more than one or two relatives or close associates abstinence symptoms such as a seizureor should be involved along with the health care delirium because the dosage of a provider; having too many people presentmay benzodiazepine or barbiturate has been be emotionally overwhelming or confusing for particularly high or prolonged and has been the older person. Inclusion of grandchildren is discontinued abruptly or because the patient discouraged, because many older alcoholics has experienced these serious symptoms at resent their problems being aired in the presence any time previously of much younger relatives. (2) Suicidal ideation or threats Motivational Counseling The presence of other major psychopathology Motivational counseling acknowledges Unstable or uncontrolled comorbid medical differences in readiness and offers an approach conditions requiring 24-hour care or for "meeting people where they are" that has parenterally administered medications (e.g., proven effective with older adults. (1) An renal disease, diabetes) understanding and supportive counselor listens Mixed addictions, including alcohol respectfully and accepts the older adult's A lack of social supports in the living perspective on the situation as a starting point, situation or living alone with continued helps him or her to identify the negative access to the abused drug(s). consequences of drinking and prescription drug abuse, helps him or her shift perceptions about In general, the Panel recommends that the initial the impact of drinking or drug-taking habits, dose of a drug for suppression and management of empowers him or her to generate insights about withdrawal symptoms should be one-third to one-half and solutions for his or her problem, and the usual adult dose, sustained for 24 to 48 hours to xx 22 Executive Summary and Recommendations observe reactions, and then gradually tapered with Treat older people in age-specific settings close attention to clinical responses. (1) where feasible Create a culture of respect for older clients Treatment Settings Take a broad, holistic approach to treatment The Panel recommends that patients who are brittle, that emphasizes age-specific psychological, frail, acutely suicidal, or medically unstable or who social, and health problems need constant one-on-one monitoring receive 24-hour Keep the treatment program flexible primary medical/psychiatric/nursing inpatient care Adapt treatment as needed in response to in medically managed and monitored intensive clients' gender. treatment settings. (2) To help ensure optimal benefits for older As part of outpatient treatment, the Panel adults, the Consensus Panel recommends that recommends drawing the physician into the treatment plans weave age-related factors into the treatment planning process and enrolling him or her contextual framework of the American Society of as a player in the recovery network. (2) Addiction Medicine (ASAM) criteria. (2) The Panel also recommends serving older people The Consensus Panel recommends the following who are dependent on psychoactive prescription general approaches for effective treatment of older drugs in flexible, community-oriented programs with adult substance abusers (2): case management services rather than in traditional, stand-alone substance abuse treatment facilities with Cognitivebehavioral approaches standardized components. (2) Group-based approaches Individual counseling Treatment Approaches Medical/psychiatric approaches The Panel recommends incorporating the following Marital and family involvement/family six features into treatment of the older alcohol abuser therapy (1): Case management/community-linked Age-specific group treatment that is services and outreach. supportive and nonconfrontational and aims The Panel recommends that cognitivebehavioral to build or rebuild the patient's self-esteem treatment focus on teaching skills necessary for A focus on coping with depression, rebuilding the social support network; self- loneliness, and loss (e.g., death of a spouse, management approaches for overcoming depression, retirement) grief, or loneliness; and general problem solving. (1) A focus on rebuilding the client's social Within treatment groups, the Panel support network recommends that older clients should get more than A pace and content of treatment appropriate one opportunity to integrate and act on new for the older person information. (2) For example, information on Staff members who are interested and bereavement can be presented in an educational experienced in working with older adults session, then reinforced in therapy. To help Linkages with medical services, services for participants integrate and understand material, the aging, and institutional settings for it may be helpful to expose them to all units of referral into and out of treatment, as well as information twice. (2) case management. Older people in educational groups can receive, integrate, and recall information better Building from these six features, the if they are given a clear statement of the goal Consensus Panel recommends that treatment and purpose of the session and an outline of the programs adhere to the following principles (2): xxi Executive Summary and Recommendations

content to be covered. The leader can post this symptoms persist several weeks following cessation of outline and refer to it throughout the session. drinking, specific antidepressant treatment is The outline may also be distributed for use in indicated. (1) personal note-taking and as an aid in review The advantages of quitting smoking are and recall. Courses and individual sessions should clear, even in older adults. The Panel recommends be conceived as building blocks that are added to the that efforts to reduce substance abuse among older base of the older person's life experience and needs. adults also include help in tobacco smoking cessation. Each session should begin with a review of previously presented materials. (2) Staffing Considerations Groups should accommodate clients' sensory The Consensus Panel recommends that the following decline and deficits by maximizing the use of as principles guide staffing choices in substance abuse many of the clients' senses as possible. The Panel treatment programs (2): recommends use of simultaneous visual and audible Whenever possible, employ staff who have presentation of material, enlarged print, voice completed training in gerontology enhancers, and blackboards or flip charts. (2) It is Employ staff who like working with older important to recognize clients' physical adults limitations. Group sessions should last no longer Provide training in empirically demonstrated than about 55 minutes. The area should be well principles effective with older adults to all lighted without glare; and interruptions, noise, and staff who will interact with these clients. superfluous material should be kept to a minimum. (2) Panel members believe that any program The Panel recommends that counselors providing that treats even a few older adults should have individual psychotherapy treat older clients in a at least one staff person who is trained in the nonthreatening, supportive manner and assure the specialization of gerontology within his or her client that they will honor the confidentiality of the discipline. This training should consist of at sessions. (2) least a graduate certificate program (6- to 12- Medications used to modify drinking month) in the subfield of aging commonly called behavior in older adults must take into account social gerontology. Staff with professional age- and disease-related increases in degrees should have a specialization in vulnerability to toxic drug side effects, as well as gerontology, geriatrics, or psychogeriatrics. possible adverse interactions with other prescribed medications. Disulfiram (Antabuse) is Outcomes and Cost Issues not generally recommended by the Panel for use in In Alcohol Treatment older patients because of the hazards of the alcohol disulfiram interaction, as well as the toxicity of Outcome assessment is invaluable from both a disulfiram itself (1) Of the other management and a referral perspective. The pharmacotherapies for alcohol abuse, naltrexone providers of treatment, the clinicians and (ReVia) is well tolerated by older adults and agencies referring patients, and patients may reduce drinking relapses. (1) themselves need to have information regarding Depression for several days or longer the likely outcomes of treatment. Because immediately after a prolonged drinking episode treatment options range from brief interventions does not necessarily indicate a true comorbid to structured outpatient and inpatient treatment disorder or the need for antidepressant programs, the Panel recommends evaluation of treatment in most cases, but when depressive outcomes at varying points in the treatment process. 24 Executive Summary and Recommendations

(1) Baseline data should be obtained at the an important measure for older adults with alcohol beginning of the intervention or treatment; first problems, the Panel recommends the Quality of Life followup evaluations should be conducted 2 Interview (QLI). (1) weeks to 1 month after the patient leaves the inpatient setting. The literature on patients Future Research receiving substance abuse treatment indicates that 60 to 80 percent of people who relapse do so The Panel believes that future research needs to within 3 to 4 months. Therefore, outpatient be focused in some specific areas to advance the outcomes should be assessed no sooner than 3 months field and to address future problems that will and possibly as long as 12 months after treatment. arise in the coming years. Those areas are alcohol and other drug consumption, treatment, biomedical (1) The Panel recommends that outcome consequences, behavioral and psychological effects, measurement include not only abstinence or reduced and special issues. (1) consumption but also patterns of alcohol use, alcohol- This TIP lays a foundation that research in related problems, physical and emotional health the above areas must build upon if providers are to meet the treatment challenges on the horizon. functioning, and quality of life and well-being. (1) One of the most widely used measures of In particular, providers must prepare for physical and emotional health is the Medical changes in demographics and in treatment Outcomes Study 36-Item Short Form Health delivery. As the country's over-60 population Survey (SF-36). (1) Another measure of explodes and the health care system shifts to psychological distress useful for alcohol managed care, providers must adjust outcomes assessment with older adults is the accordingly. The treatment protocols outlined Symptom Checklist-90-Revised (SCL-90-R) and in this book provide a roadmap for treating this its abbreviated version, the Brief Symptom unique and growing population into the next Inventory (BSI). (1) For measuring quality of life, century.

23 1 Substance Abuse Among Older Adults: An Invisible Epidemic

Substance abuse, particularly of alcohol use and misuse of substances, along with a and prescription drugs, among adults 60 reluctance to seek professional help for what and older is one of the fastest growing many in this age group consider a private health problems facing the country. Yet, even as matter. Many relatives of older individuals with the number of older adults suffering from these substance use disorders, particularly their adult disorders climbs, the situation remains children, are also ashamed of the problem and underestimated, underidentified, choose not to address it. Ageism also contributes underdiagnosed, and undertreated. Until to the problem and to the silence: Younger relatively recently, alcohol and prescription adults often unconsciously assign different drug misuse, which affects up to 17 percent of quality-of-life standards to older adults. Such older adults, was not discussed in either the attitudes are reflected in remarks like, substance abuse or the gerontological literature "Grandmother's cocktails are the only thing that (D'Archangelo, 1993; Bucholz et al., 1995; makes her happy," or "What difference does it National Institute on Alcohol Abuse and make; he won't be around much longer Alcoholism, 1988; Minnis, 1988; Atkinson, 1987, anyway." There is an unspoken but pervasive 1990). assumption that it's not worth treating older Because of insufficient knowledge, limited adults for substance use disorders. Behavior research data, and hurried office visits, health considered a problem in younger adults does care providers often overlook substance abuse not inspire the same urgency for care among and misuse among older adults. Diagnosis may older adults. Along with the impression that be difficult because symptoms of substance alcohol or substance abuse problems cannot be abuse in older individuals sometimes mimic successfully treated in older adults, there is the symptoms of other medical and behavioral assumption that treatment for this population is disorders common among this population, such a waste of health care resources. as diabetes, dementia, and depression. Often These attitudes are not only callous, they rest drug trials of new medications do not include on misperceptions. Most older adults can and older subjects, so a clinician has no way of do live independently: Only 4.6 percent of predicting or recognizing an adverse reaction or adults over 65 are nursing home or personal unexpected psychoactive effect. home care residents (Altpeter et al., 1994). Other factors responsible for the lack of Furthermore, Grandmother's cocktails aren't attention to substance abuse include the current cheering her up: Older adults who "self- older cohort's disapproval of and shame about medicate" with alcohol or prescription drugs are

1 2 Chapter 1

more likely to characterize themselves as lonely for men (U.S. Bureau of the Census, 1996). Not and to report lower life satisfaction (Hendricks only are adults in general living longer, et al., 1991). Older women with alcohol substance abusers are also living longer than problems are more likely to have had a problem- ever before (Gomberg, 1992b). Thus, more drinking spouse, to have lost their spouses to Americans face chronic, limiting illnesses or death, to have experienced depression, and to conditions such as arthritis, diabetes, have been injured in falls (Wilsnack and osteoporosis, and senile dementia, becoming Wilsnack, 1995). dependent on others for help in performing The reality is that misuse and abuse of their activities of daily living (U.S. Bureau of the alcohol and other drugs take a greater toll on Census, 1996). affected older adults than on younger adults. In Alcohol use was less common in the 1930s, addition to the psychosocial issues that are 1940s, and 1950s than it has been since the 1960s. unique to older adults, aging also ushers in Many of those who are now 60 and older, biomedical changes that influence the effects influenced by prevailing cultural beliefs and that alcohol and drugs have on the body. Prohibition, never drank at all, and a negligible Alcohol abuse, for example, may accelerate the number used illicit drugs. Younger birth normal decline in physiological functioning that cohorts in this century tend to have increasingly occurs with age (Gambert and Katsoyannis, higher rates of alcohol consumption and 1995). In addition, alcohol may elevate older alcoholism (Atkinson et al., 1992). Thus, "the adults' already high risk for injury, illness, and prevalence of alcohol problems in old age may socioeconomic decline (Tarter, 1995). increase, especially among women, for birth cohorts entering their 60s in the 1990s and The Problem Projected beyond"(Atkinson and Ganzini, 1994, p. 302). A recent study in Sweden found that the male-to- It will be increasingly difficult for older adults' female ratio among older alcohol abusers substance abuse to remain a hidden problem as admitted for addiction treatment decreased the demographic bulge known as the Baby from 7.8:1 to 3.4:1 in the span of a decade Boom approaches old age early in the next (Osterling and Berglund, 1994). century. Census estimates predict that 1994's Because there is a clear relationship between older adult population of 33 million will more early alcohol problems and the development of than double to 80 million by 2050 (Spencer, 1989; alcohol problems in later life, drinking among U.S. Bureau of the Census, 1996). Most of that older adults is likely to become an even greater growth will occur between 2010 and 2030, when problem in the near future (Rosin and Glatt, the number of adults over 65 will grow by an 1971; Gomberg, 1992; Zimberg, 1974; Helzer et average of 2.8 percent annually (U.S. Bureau of al., 1991a; Beresford, 1995a). Liberto and the Census, 1996). In 1990, 13 percent of colleagues concluded that the overall increase in Americans were over 65; by 2030, that bloc will alcOhol problems throughout the population, represent 21 percent of the population (U.S. coupled with the aging of the Baby Boomers, Bureaus of the Census, 1996). The demographic suggests that the number of older adults with increases among older adults are summarized alcohol-related problems will rise alarmingly below and in Figure 1-1. (Liberto et al., 1992). Taken together, these Life expectancy in the United States has factors raise the prospect of tomorrow's health increased. In 1950, it was 68 years, and by 1991, services facing a "potentially preventable 'tide' it had reached 79 years for women and 72 years of alcohol-induced morbidity" (Saunders, 1994, 2 27 Substance Abuse Among Older Adults p. 801). Further research is needed on the will mainly encounter abuse or misuse of physiological effects of marijuana on older alcohol or prescribed drugs. Abuse of heroin adults, because many children of the 1960s can and other opioids is rare, although some older be expected to carry this habit into old age. adults misuse over-the-counter drugs that have a high alcohol content, such as cough The Problem Now suppressants. Many of these over-the-counter drugs negatively interact with other medications Health care and social service providers who and alcohol. currently care for Americans age 60 and older

Figure 1-1 Percentage Distribution of U.S. Population by Age:1995, 2010, and 2025

Year 01995 02010 60 IN2025

b.0

P-1 20

Under 20 Years 20-64 Years 65 Years and Over

Source: U.S. Censits Bureau, 1996

3 Chapter 1

usespecifically targeted to this population Alcohol Disorders: Older Adults' are discussed in Chapter 4. Major Substance Abuse Problem Problems stemming from alcohol consumption, Prescription Drugs including interactions of alcohol with prescribed The abuse of narcotics is rare among older and over-the-counter drugs, far outnumber any adults, except for those who abused opiates in other substance abuse problem among older their younger years (Jinks and Raschko, 1990). adults. Community prevalence rates range from Prescribed opioids are an infrequent problem as 3 to 25 percent for "heavy alcohol use" and from well: Only 2 to 3 percent of noninstitutionalized 2.2 to 9.6 percent for "alcohol abuse" depending older adults receive prescriptions for opioid on the population sampled (Liberto et al., 1992). analgesics (Ray et al., 1993), and the vast (Chapter 2 defines levels of use and adjusts majority of those do not develop dependence. them for older adults.) A recent study found One study, for example, found that only 4 of that 15 percent of men and 12 percent of women nearly 12,000 patients who were prescribed age 60 and over treated in primary care clinics morphine for self-administration became regularly drank in excess of limits addicted (Hill and Chapman, 1989). The use of recommended by the National Institute on illicit drugs is limited to a tiny group of aging Alcohol Abuse and Alcoholism (i.e., no more criminals and long-term heroin addicts (Myers than one drink per day) (Saunders, 1994; Adams et al., 1984). Although little published et al., 1996; National Institute on Alcohol Abuse information exists, Panelists report that a far and Alcoholism, 1995). greater concern for drug misuse or abuse is the The differences in the prevalence rates above large number of older adults using prescription illustrate the difficulty in identifying how drugs, particularly benzodiazepines, sedatives, widespread the current problem is. One and hypnotics, without proper physician researcher suggests that alcohol abuse among supervision (Gomberg, 1992). Older patients are older adults is easily hidden, partly because of prescribed benzodiazepines more than any other its similarities to other diseases common as one age group, and North American studies ages and partly because elders remind clinicians demonstrate that 17 to 23 percent of drugs of a parent or grandparent (Beresford, 1995b). prescribed to older adults are benzodiazepines Recent studies in Australia (McInnes and (D'Archangelo, 1993). The dangers associated Powell, 1994) and a corroboration of similar data with these prescription drugs include from the United States (Curtis et al., 1989) found problematic effects due to age-related changes in that clinicians recognized alcoholism in only drug metabolism, interactions among one-third of older hospitalized patients who had prescriptions, and interactions with alcohol. the disorder. Furthermore, many of the signs Unfortunately, these agents, especially those and symptoms of alcohol abuse among younger with longer half-lives, often result in unwanted populations do not apply to older adults: Most side effects that influence functional capacity older adults are no longer in the work force, and cognition, which place the older person at have smaller social networks, and drive less greater risk for falling and for (reducing the potential for being recognized as institutionalization (Roy and Griffin, 1990). abusing alcohol). Older users of these drugs experience more Chapter 2 details drinking practices and adverse effects than do younger adults, problems among older adults. Identification, including excessive daytime sedation, ataxia, screening, and assessment of alcohol and drug and cognitive impairment. Attention, memory,

4 29 Substance Abuse Among Older Adults physiological arousal, and psychomotor abilities classifications, as they often are the basis for are often impaired as well (Pomara et al., 1985), reimbursement.) and drug-related delirium or dementia may Chapter 2 examines classifications such as at- wrongly be labeled Alzheimer's disease. Misuse risk, problem, and dependent alcohol consumption of psychoactive prescription drugs is discussed patterns, which have been the focus of major in Chapter 3. diagnostic systems, particularly the Diagnostic and Statistical Manual of Mental Disorders, Fourth Older Adults' Unique Edition (DSM-IV) (American Psychiatric Vulnerabilities Association, 1994), and reconfigures them to suit older adults' unique responses to and For the purposes of this TIP, an older adult is experiences with alcohol and drug use. defined as a person age 60 or older. Any age Further complicating treatment of older cutoff is somewhat arbitrary because age-related substance abusers is the fact that they are more changes vary tremendously across individuals likely to have undiagnosed psychiatric and and even within one person from body system medical comorbidities. According to one study, to body system. An 80-year-old can have better 30 percent of older alcohol abusers have a health functioning than a 50-year-old, and a 70- primary mood disorder (Koenig and Blazer, year -old can have "the spine of an 80-year-old, a 1996). A thorough evaluation of all problems is heart typical of a 60-year-old, and a central essential when caring for older adults: Failure nervous system equal in functioning to an to do so will undoubtedly increase the number average 60-year-old" (Altpeter et al., 1994, p. 30). of false diagnoses and diminish the quality of Although some recommendations in this TIP older patients' lives (Gomberg, 1992). Physical may apply more to adults 70 and older, some of and mental comorbidities are discussed in detail the age-related changes that affect the body's in Chapter 4. reactions to alcohol and other drugs begin as early as 50. Barriers To Identifying The age at which such changes occur varies And Treating Older from person to person, but invariably they do occur. Because many of the definitions, models, Adults With Substance and classifications of alcohol consumption levels Abuse Problems are static and do not account for age-related physiological and social changes, they simply do The sheer number and the interconnectedness of not apply to older adults. Drinking can be older adults' physical and mental health medically hazardous for this group even if the problems make diagnosis and treatment of their frequency and amount of consumption do not substance abuse more complex than for other warrant a formal diagnosis of alcohol abuse or populations. That complexity contributes dependence. Weekly quantity of drinking levels directly or indirectlyto the following barriers can only serve as a rough parameter in this to effective treatment: population; it is crucial for providers to view Ageism older drinkers and drug-takers as on a spectrum Lack of awareness and to resist placing them into rigid categories Clinician behavior for purposes of assessment and treatment. Comorbidity. (Diagnosis, however, may require use of those

30 5 Chapter 1

Ageism even if they are successfully treated for their The term ageism was coined in the mid-1960s substance abuse. Such lowered expectations (Butler, 1969) to describe the tendency of society may also be compounded by "therapeutic to assign negative stereotypes to older adults nihilism": Older substance abusers may be and to explain away their problems as a function deemed not worthy of the effort involved in of being old rather than looking for specific treating or changing behavior because "they are medical, social, or psychological causes. In likely to die soon anyway." American culture, ageism reflects a personal Lack of Awareness revulsion about growing old, comprising in part fear of powerlessness, uselessness, and death. A second barrier to treatment is a lack of Older adults often internalize such stereotypes awareness of the problem that is often shared by and thus are less likely to seek out mental health the older substance abuser, his or her loved and substance abuse care (Patterson and ones, the community, and society as a whole. A Dupree, 1994). Ageism may result in an older lack of awareness or denial of the signs of adult being classified as "senile," when in reality alcohol abuse (more common among older he or she may be afflicted with specific and adults), combined with the personal or sometimes treatable comorbid conditions such community-specific stigma of the disease, may as Alzheimer's disease, depression, multi-infarct effectively raise one or more barriers to dementia, and alcoholism. treatment. Not only is a younger adult with comorbid Stigma, shame, or denial associated with conditions more likely to receive a correct substance abuse may be related to generation, diagnosis for substance abuse, but a younger religion, gender, culture, or a combination of patient diagnosed with, say, hypertension, will these and other factors. Many older adults more likely be examined for underlying formed their attitudes about alcohol before the etiologies, including substance abuse. With 1950s, when advertising and wider accessibility older adults, providers often do not look beyond helped change the use of alcohol from a moral the presenting problem for which the patient is failing to an accoutrement of postwar seeking care (Curtis et al., 1989). Despite prosperity. If adults attribute their alcohol caregivers' good intentions, instances of ageism problems to a breakdown in morals, they are not also occur in congregate meal settings and in the likely to seek substance abuse treatment. provision of homemaker services to the Many older adults are also very sensitive to homebound. Changes in eating habits, for the stigma associated with psychiatric disorders. example, may not be explored because "older They are much more willing to accept a medical people get fussy about their food." Confusion in diagnosis than a mental or psychiatric one, and older adults may go unchallenged because home they may translate this bias into a reluctance to health aides attribute it to "a bad night" or age- describe mood disturbances or to acknowledge related "spaciness." Older patients are symptoms that might be interpreted as significantly less likely to have substance abuse manifestations of weakness, irresponsibility, or problems identified during routine medical care. "craziness." They may genuinely think many If a diagnosis of substance abuse is made, an problems are simply related to old age or be older patient is less likely to have treatment reluctant to complain too much (Weiss, 1994). In recommended (Curtis 'et al., 1989). addition, many older adults do not accept that Ageism is reflected in some providers' belief alcohol- or other drug-related disorders are that older adults' quality of life will remain poor health care problems or diseases.

6 31 Substance Abuse Among Older Adults

It may be difficult for other adults to the amount of time physicians spend with a conceive of an older person, especially a woman, patient decreases as the age of the patient as having problems with alcohol or other increases (Keeler et al., 1982). (Obviously, this is substances. This particular limitation can be not due to older patients' having fewer medical true of an alcohol abuser's daughter or of an complaints.) It is unlikely that abbreviated office entire community, which may have decided that visits are sufficient to identify an older adult's alcoholism is a youth problem. Drinking among underlying problem with alcoholism. older adults is often perceived as a pleasure they Not only do the physician encounters have earned and, lacking work and family become shorter, but problems related to alcohol responsibilities, should be allowed to enjoy: and drugs increasingly compete for discussion Because social drinking is an acceptable time against other health problems. During a behavior, it can serve to mask a more serious short office visit, there are many topics to cover drinking problem. in patient-provider discourse, ranging from renewal of multiple prescriptions to the impact Clinicians' and Service of the death of a spouse. Substance abuse often Professionals' Behavior ends up at the bottom of the list or is not Health care and older adult service providers considered at all when a patient presents with may be as slow to spot a substance abuse many medical or personal problems. Providers, problem as everyone else is: Despite its older patients, and family members typically frequency, there is often a low index of place higher priority on physical conditions suspicion for this problem. Even when there is such as heart problems and renal failure than on the suspicion of a substance abuse disorder, the alcohol abuse. practitioner may have difficulty applying the Providers may also believe that older diagnostic criteria to a wide variety of substance abusers do not benefit from treatment nonspecific symptoms. With a younger patient, as much as younger patients, despite studies serious physical problems (e.g., heart disease, that have dispelled this persistent myth. diabetes) can be more easily ruled out, leading Research indicates that, compared with younger quickly to a diagnosis of substance abuse in the patients, older adults are more likely to presence of certain symptoms. With an older complete treatment (Linn, 1978; Cartensen et al., patient, health care providers are often in a 1985) and have outcomes that are as good as or quandarysymptoms such as fatigue, better than those of younger adults (Kashner et irritability, insomnia, chronic pain, or impotence al., 1992; Atkinson, 1995; in press). Yet health may be produced or influenced by substance care providers still need more education about abuse, common medical and mental disorders, substance abuse treatment options and success or a combination of these conditions. Another rates (see Chapter 6). clinician barrier to diagnosing alcohol problems Clinicians may not know that certain drugs in older adults is stereotyping. Clinicians are are habit-forming or about specific drug less likely to detect alcohol problems in women, interactions and side effects. One diagnostic the educated, and those with higher barrier is that many physicians believe socioeconomic status (Moore et al., 1989). alcoholics must be heavy drinkers and often Other barriers related to clinician behavior miss the opportunity to intervene because their are noted in the literature. Keeler and definition of problem drinking rests on amounts colleagues studied the effect of patient age and and frequencies that do not apply to older length of physician encounter. They found that adults (see Chapter 2). Those treating older 32 7 Chapter 1

substance abusers should receive training on male subjects. In 1994, among adults 65 to 69, drug-to-drug interaction, drug-to-disease there were 82 men for every 100 women. interaction, drug-to-alcohol interaction, and Among those 85 to 89, there were 44 men for alcohol-to-disease interaction (discussed in every 100 women, and the disparity is even Chapters 2 and 3). greater for those 90 and older (U.S. Bureau of the Census, 1996). Despite women's greater Comorbidity numbers, they constitute the minority of older Medical and psychiatric comorbidities present substance abusers. There are, however, more yet another challenge to the effective treatment older women living alone, and their substance of the older substance abuser. Comorbid abuse can be difficult to identify (Moore et al., conditions such as medical complications, 1989). Older women as a group conceal their cognitive impairment, mental disorders such as drinking or drug use vigilantly because their major depression, sensory deficits, and lack of stigma is greater than that for men. Other mobility not only can complicate a diagnosis but treatment obstacles particular to women include can sway the provider from encouraging older the following: patients to pursue treatment for their substance Compared with men, women have less abuse problems. For example, older patients insurance coverage and supplemental who cannot walk up stairs or drive after dark income (such as a pension). Women are less may not be encouraged to attend evening likely to have worked, more likely to lose Alcoholics Anonymous (AA) meetings. Older insurance coverage with the death of a patients may also be screened out of treatment spouse, and more likely to live in poverty. programs because of poor cognitive tests or Women drink less often in public places and simply because health professionals do not think are therefore less likely to drive while they will benefit. In addition, treatment intoxicated or engage in other behaviors that programs may be reluctant to accept them or might reveal an alcohol problem. may not have the facilities to accommodate their Many older women never learned to drive, special needs. Comorbid depression and and they are more likely to live at home anxiety pose other barriers. Although inpatient alone. Overall, women are healthier and psychiatric hospitals generally have staff trained more independent but are also more isolated. to treat dually diagnosed patients, outpatient They often drink alone. programs may not. These programs may not Older women are prescribed more and accept medicated older adults with mental consume more psychoactive drugs, disorders. particularly benzodiazepines, than are men Special Populations and are more likely to be long-term users of Women, minorities, and those who are these substances (Gomberg, 1995). homebound, including adults with physical disabilities, confront more specific barriers to Racial and ethnic minorities treatment. Although little research has been done on older minority populations, the Panelists agreed that Women older minority individuals also face barriers to Although women constitute the majority of treatment. Recent data suggest that older older adults, their treatment challenges are members of minority groups, particularly considered here in part because most of the African-Americans, may be more vulnerable to research in the substance abuse field has studied 8 33 Substance Abuse Among Older Adults late-life drinking than previously thought lung diseases, and other conditions diminish (Gomberg, 1995). older adults' ability to perform the basic For many older minority adults in urban activities of daily living, making it less likely areas, health care is delivered in busy hospital they will seek treatment for their substance outpatient departments or in emergency rooms. problems. Adults bound to their homes by These settings further diminish the likelihood physical disabilities are at particularly high risk that alcohol and other drug issues will be for alcoholism. addressed. The weakness and frail physical condition of Language is another major issue in many homebound older adults also limit identifying and treating substance abuse among mobility and transportation options beyond the minority elders because many of them were problems faced by older adults in general. By first-generation immigrants who never learned definition, homebound older adults cannot get English. In order to access services, these out of their homes without "considerable and patients need an interpreter or a family member taxing effort" and almost always require the who can serve as an interpreter. This raises an assistance of another person (Health Care additional issue: Interpreters can bias Financing Administration, 1997). In practical communications, adding yet another barrier to terms, this means these older adults cannot effective treatment. drive or take public transportation, taxicabs, or Non-English-speaking minorities have also rides from friends who are also frail. They must been at a disadvantage in treatment and therapy depend on able-bodied others, who they may in many areas of the country. Cultural not want to bother in nonemergency situations. competence is crucial when the treatment Such dependency can be embarrassing and provider has a different ethnic or cultural depressing, which may trigger alcohol or drug background than the client. The clinician needs use. some knowledge of the belief systems of the Finally, homebound older adults are often client to effectively interview and interpret very isolated socially. Limited contacts with responses from, for example, Native Americans. others may allow serious abuse to go Although some progress has been made in undetected. Lack of a social support network providing culturally appropriate prevention and makes these older adults even more susceptible treatment programs for the Hispanic to depression and despair. population, much less is available for other cultural or linguistic minorities, such as Eastern Other Barriers to Identification and Europeans and Asians. Treatment Other barriers to treatment in the older Homebound older adults population are The barriers that prevent identification and treatment of substance abuse among all older Transportation (may be available to go to a adults are even greater for the homebound, hospital but not to AA or aftercare or particularly comorbidities, transportation and evening programs): This is especially handicapped accessibility, isolation, and gender problematic in rural communities that lack (over 70 percent of home care patients are public transportation or in poor urban women [Dey, 1996]). communities where accessing transportation Older adults are often restricted to their can be dangerous (Fortney et al., 1995). homes by an array of health problems that limit their mobility. Heart disease, diabetes, chronic 34 9 Chapter 1

m Shrinking social support network: Fewer the research literature in 1964 (Droller, 1964). friends to support them, participate in the Researchers in the 1960s and 1970s were treatment process, or take them places. convinced that substance abuse was rare among m Time: Despite the assumption that older older adults (Atkinson and Ganzini, 1994). adults have an excess of free time, they may Thus, researchers and clinicians alike widely well have to provide 24-hour supervision to believed that substance use disorders among a spouse, other relative, or friend, or have to this age group did not merit the attention given care for grandchildren while the parent to drinking and drug abuse among younger works. adults (Bucholz et al., 1995). inLack of expertise: Few programs have Most professional service providers thought specialists in geriatrics, treat many older that lifelong alcohol- and other drug-addicted adults, or are designed to accommodate individuals either died early or recovered functional disabilities such as hearing lossor spontaneously, "maturing out" of their ambulation problems. problems (Saunders, 1994; Vaillant et al., 1983). g Financial: The structure of insurance policies Older drinkers tended to be viewed "merely as can be a barrier to treatment. The carving survivors of a long, dissolute history of heavy out of mental health services from physical alcohol use followed by predictably poor health health services under managed care in and early demise" (Beresford, 1995b, p. 3), and particular can prevent older adults from alcoholism was considered predominantly a receiving inpatient substance abuse male problem, affecting four males for every treatment. female (Bucholz et al., 1995). Therefore, the Because of the increased potential for typical older adult with a drinking problem was enhanced reactions to alcohol and to alcohol in considered most often to be a man with a long combination with other drugs, it is important history of drinking. Even as recently as 1987, that clinicians, family members, and social the Diagnostic and Statistical Manual of Mental service providers be on the lookout for signs of Disorders, Third Edition, Revised (DSM-III-R), the problems. Communities can implement standard diagnostic manual the American "gatekeeper" systems, wherein meter readers, Psychiatric Association used at that time, stated, credit office workers, repair personnel, postal "In males, symptoms of alcohol dependence or carriers, police, apartment managers, and others abuse rarely occur for the first time after age 45" watch for and report signs of depression and (American Psychiatric Association, 1987, p. 174). other psychiatric disorders (often exacerbated by The last decade has seen as much research as substance abuse) (see Chapter 4). Suggestions the 35 years preceding, and many for who can help move older adults into misperceptions have been corrected. Yet the treatment and various treatment approaches are problem remains elusive even as it grows. discussed in Chapter 5. Many Americans who are now young or middle-aged will carry their use and abuse of Summary alcohol and other drugs with them into old ageand they will also live longer. Life Given the scope of the problem, the literatureon expectancy jumped almost 30 years between substance abuse problems among older adults is 1900 and 1989, and it continues to climb. By the surprisingly sketchy. Substance abuse among year 2050, one out of four Americans over age 65 older adults as a distinct subgroup with will be 85 and older (U.S. Bureau of the Census, definable characteristics was first described in 1996). Substance use disorders, if not diagnosed

10 37 Substance Abuse Among Older Adults and treated, may ruin the last stage of life for and treating older substance abusers. The Panel countless Americans. aims to advance the understanding of the This TIP illuminates this invisible epidemic relationships between aging and substance and advises how to treat it, combining the best abuse and to provide practical of the existing literature with the years of the recommendations for incorporating that Consensus Panelists' experience in researching understanding into practice.

11 3(3 2 Alcoho:

Alcohol abuse and misuse is the major Alcoh 11 and Aing substance abuse problem among older adults. "In the United States, it is Despite a certain heterogeneity in drinking estimated that 2.5 million older adults have practices, there are substantial differences problems related to alcohol, and 21 percent of between an older and a younger adult's

hospitalized adults over age 40... have a response to alcohol, the majority of which stem diagnosis of alcoholism with related hospital from the physiological changes wrought by the costs as high as $60 billion per year" (Schonfeld aging process. and Dupree, 1995, p. 1819). In 1990, those over Adults over the age of 65 are more likely to the age of 65 comprised 13 percent of the U.S. be affected by at least one chronic illness, many population; by the year 2030, older adults will of which can make them more vulnerable to the account for 21 percent of the population (U.S. negative effects of alcohol consumption Bureau of the Census, 1996). This projected (Bucholz et al., 1995). population explosion has serious implications In addition, three age-related changes for both the number of alcohol-related problems significantly affect the way an older person likely to occur among older adults and the responds to alcohol: subsequent costs involved in responding to E Decrease in body water them. Currently, rates for alcohol-related El Increased sensitivity and decreased tolerance hospitalizations among older patients are to alcohol similar to those for heart attacks (Adams et al., E Decrease in the metabolism of alcohol in the 1993). Those rates vary greatly by geographic gastrointestinal tract. location, from 19 per 10,000 admissions in Arkansas to 77 per 10,000 in Alaska. As lean body mass decreases with age, total As disturbing as these figures are, they body water also decreases while fat increases. probably represent a gross underestimation of Because alcohol is water-soluble and not fat- the true problem. Studies consistently find that soluble, this change in body water means that, older adults are less likely to receive a primary for a given dose of alcohol, the concentration of diagnosis of alcoholism than are younger adults alcohol in the blood system is greater in an older (Booth et al., 1992; Stinson et al., 1989; Beresford person than in a younger person. For this et al., 1988). A study of 417 patients found that reason, the same amount of alcohol that house officers accurately diagnosed the disease previously had little effect can now cause in only 37 percent of older alcoholic patients intoxication (Smith, 1995; Vestal et al., 1977). compared with 60 percent of the younger This often results in increased sensitivity and alcoholic patients (Geller et al., 1989). decreased tolerance to alcohol as people age

13 3 7 Chapter 2

(Rosin and Glatt, 1971). Researchers speculate history of alcoholism. Alcohol use may have that the change in relative alcohol content direct neurotoxic effects leading to a combined with the slower reaction times characteristic syndrome called alcohol-related frequently observed in older adults may be dementia (ARD) or may be associated with the responsible for some of the accidents and development of other dementing illnesses such injuries that plague this age group (Bucholz et as Alzheimer's disease or Wemicke-Korsakoff al., 1995; Salthouse, 1985; Ray, 1992). syndrome, an illness characterized by The decrease in gastric alcohol anterograde memory deficits, gait ataxia, and dehydrogenase enzyme that occurs with age is nystagmus. Indeed several researchers have another factor that exacerbates problems with cast doubt on the existence of ARD as a alcohol. This enzyme plays a key role in the neuropathological disease and suggest that the metabolism of alcohol that occurs in the gastric majority of cases of ARD are in fact Wernicke- mucosa. With decreased alcohol Korsakoff syndrome (Victor et al., 1989). dehydrogenase, alcohol is metabolized more Sleep patterns typically change as people age slowly, so the blood alcohol level remains raised (Haponik, 1992). Increased episodes of sleep for a longer time. With the stomach less actively with rapid eye movement (REM), decreased involved in metabolism, an increased strain is REM length, decreased stage III and IV sleep, also placed on the liver (Smith, 1995). and increased awakenings are common patterns, all of which can be worsened by alcohol use. Comorbidities Moeller and colleagues demonstrated in Although alcohol can negatively affect a person younger subjects that alcohol and depression of any age, the interaction of age-related had additive effects on sleep disturbances when physiological changes and the consumption of occurring together (Moeller et al., 1993). One alcohol can trigger or exacerbate additional study concluded that sleep disturbances, serious problems among older adults, including especially insomnia, may be a potential etiologic E Increased risk of hypertension, cardiac factor in the development of late-life alcohol arrhythmia, myocardial infarction, and problems or in precipitating relapse (Oslin and cardiomyopathy Liberto, 1995). This hypothesis is supported by a study demonstrating that abstinent alcoholics El Increased risk of hemorrhagic stroke experienced insomnia, frequent awakenings, iaImpaired immune system and capability to combat infection and cancer and REM fragmentation (Wagman et al., 1977). o Cirrhosis and other liver diseases However, when these subjects ingested alcohol, sleep periodicity normalized and REM sleep gl Decreased bone density o Gastrointestinal bleeding was temporarily suppressed, suggesting that E Depression, anxiety, and other mental health alcohol can be used to self-medicate sleep problems disturbances. El Malnutrition. Positive Effects of Alcohol Other biomedical changes of aging are Consumption cognitive impairments, which are both confused Small amounts of alcohol have been shown to with and exacerbated by alcohol use. Chronic provide some health benefits, although alcoholism can cause serious, irreversible abstinence is still recommended for anyone who changes in brain function, although this is more has a history of alcoholism or drug abuse, who likely to be seen in older adults who have a long is taking certain medications (see Chapter 3), or

14 38 Alcohol

who is diagnosed with certain chronic diseases Although moderate alcohol consumption has such as diabetes and congestive heart failure. been shown to improve HDL levels in women Some studies, largely conducted on male (Fuchs et a1.,1995), it also has been linked to samples, show that low levels of alcohol breast cancer in postmenopausal women consumption (one standard drink per day or (Bucholz et al., 1995). More studies on the risks less) reduce the risks of coronary heart disease and benefits of alcohol consumption for older (Shaper et al., 1988). However, this women are needed to clarify this issue. cardiovascular benefit may not apply to adults Low levels of alcohol consumption also already diagnosed with heart disease. Older appear to promote and facilitate socialization adults in this category should not drink unless among older adults, suggesting that alcohol their physician says otherwise. plays an important role in community life for "An intriguing epidemiologic finding is the older adults (Gomberg, 1990). However, the association of regular, but moderate, alcohol use health of some older adults (e.g., those with (up to two drinks per day) with lower morbidity chronic conditions, those using certain and mortality from coronary artery disease," medications) may be compromised by any especially in men, when compared with heavy alcohol consumption. Again, recommendations alcohol users and abstainers (Atkinson and for use of alcohol should always be Ganzini, 1994, p. 302). "This 'U' or 'J' shaped individualized. relationship appears to be quite robust," occurring in diverse cultural and national Classifying Drinking cohorts (Atkinson and Ganzini, 1994, p. 302). That heavy drinkers have more coronary disease Practices and Pr >blems is to be expected, but why should abstainers Among Older Adults have higher morbidity and mortality than Physiological changes, as well as changes in the moderate drinkers? One explanation may be kinds of responsibilities and activities pursued that the abstainer group was heterogeneous in by older adults, make established criteria for composition and may have included former classifying alcohol problems largely irrelevant alcoholics as well as others predisposed to for this population. cardiac disease (Atkinson et al., 1992). A Two classic models for understanding number of other studies, including the only one alcohol problemsthe medical diagnostic reported to date that consisted of exclusively model and the at-risk, heavy, and problem older adult subjects, likewise failed to account drinking classificationinclude criteria that for this possibility in their study designs (Scherr may not adequately apply to many older adults et al., 1992). and may lead to underidentification of drinking Other analyses of abstainer groups report problems (Atkinson, 1990). conflicting findings (Shaper et al., 1988; Klatsky et al., 1990). Further study is needed to ISM -IV determine the contributions of alcohol-induced Most clinicians rely on the conventional medical rise in high-density lipoproteins (HDLs) model defined in the American Psychiatric (Srivastava et al., 1994; Davidson, 1989) and Association's Diagnostic and Statistical Manual of antioxidant effects of beverage alcohol (Artaud- Mental Disorders, Fourth Edition (DSM-IV) Wild et al., 1993) to the association between (American Psychiatric Association, 1994) for abstinence and coronary artery disease. classifying the signs and symptoms of alcohol- related problems. The DSM-IV uses specific

15 399 Chapter 2

criteria to distinguish between those drinkers attribute these problems, in whole or in part, to who abuse alcohol and those who are the aging process or age-related comorbidities. dependent on alcohol. Figures 2-1 and 2-2 Although tolerance is one of the DSM-IV present the DSM-IV criteria, which subsume criteria for a diagnosis of substance alcohol abuse indicators within the general dependenceand one weighted heavily by categories of substance abuse and dependence. clinicians performing an assessment for Although widely used, the DSM-IV criteria substance dependencethe thresholds of may not apply to many older adults who consumption often considered by clinicians as experience neither the legal, social, nor indicative of tolerance may be set too high for psychological consequences specified. For older adults because of their altered sensitivity example, "a failure to fulfill major role to and body distribution of alcohol (Atkinson, obligations at work, school, or home" is less 1990). The lack of tolerance to alcohol does not applicable to a retired person with minimal necessarily mean that an older adult does not familial responsibilities. Nor does the criterion have a drinking problem or is not experiencing "continued use of the substance(s) despite serious negative effects as a result of his or her persistent or recurrent problems" always apply. drinking. Furthermore, many late onset Many older alcoholics do not realize that their alcoholics have not developed physiological persistent or recurrent problems are in fact dependence, and they do not exhibit signs of related to their drinking, a view likely to be withdrawal. Figure 2-3 presents the DSM-IV reinforced by health care clinicians who may criteria for substance dependence as they apply to older adults with alcohol problems.

Figure 2-1 DSIVI-1V Diagnostic Criteria for Substance Ab 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.

40 16 Alcohol

Figure 2-2 .

DSM-IV Diagnostic Criteria for SubstanceDependence . The DSM-IV defines the diagnostic criteria for substancedependence as a maladaptive pattern of substance use, leading to clinically significant impairmentor distress, as manifested by three or more of the following, occurring at any time in thesame 12-month period: 1. Tolerance, as defined by either of the following: The need for markedly increased amounts of the substanceto achieve intoxication or desired effect. Markedly diminished effect with continueduse 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 relieveor avoid withdrawal symptoms. 3. Taking the substance often in larger amountsor over a longer period than was intended. 4. A persistent desire or unsuccessful efforts to cut downor control substance use. 5. Spending a great deal of time in activitiesnecessary to obtain or use the substance or to recover from its effects. 6. Giving up social, occupational, or recreational activities becauseof substance use. 7. Continuing the substance use with the knowledge that it iscausing or exacerbating a persistent or recurrent physical or psychological problem. Source: Reprinted with permission from the Diagnostic andStatistical Manual of Mental Disorders, Fourth Edition. Co. ri:ht 1994, American Ps chiatric Association.

The drinking practices of many older adults preclude an older patient from making who do not meet the diagnostic criteria for significant improvements in his or her life. abuse or dependence place them at risk of complicating an existing medical or psychiatric At-Risk, Heavy, and Problem disorder. Consuming one or two drinksper Drinking day, for example, may lead to increased Some experts use the model of at-risk, heavy, cognitive impairment in patients who already and problem-drinking in place of the DSM-IV have Alzheimer's disease, may lead to model of alcohol abuse and dependence because worsening of sleep problems in patients with it allows for more flexibility in characterizing sleep apnea, or may interact with medications drinking patterns. In this classification scheme, rendering them less effective or causing adverse an at-risk drinker is one whose patterns of alcohol side effects. A barrier to good clinical use, although not yet causing problems, may management in these cases may be the lack of bring about adverse consequences, either to the understanding of the risks of so-called drinker or to others. Occasional moderate "moderate drinking." Limiting access to drinking at social gatherings and then driving treatment because symptoms do not meet the home is an example of at-risk drinking. rigorous diagnostic criteria of the DSM-IVmay Although an accident may not have occurred, all the elements for disaster are present.

17 41 Chapter 2

Figure 2-3 Applying DSM-IV Diagnostic Criteriato Older Adults With Alcohol Problems Diagnostic criteria for alcohol dependenceare subsumed within the DSM-IV's general criteria for substance dependence. Dependence is definedas a "maladaptive pattern of substance use, leadingto clinically significant impairmentor 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-IVcriteria to older adults with alcohol problems. Criteria Special Considerations for Older Adults 1. Tolerance May have problems witheven low intake due to increased sensitivity to alcohol and higher blood alcohol levels 2. Withdrawal Many late onset alcoholics do not developphysiological dependence 3. Taking larger amounts orover a Increased cognitive impairmentcan interfere with self- longer period than was intended monitoring; drinking can exacerbate cognitiveimpairment and monitoring 4. Unsuccessful efforts to cut downor Same issues across life span control use 5. Spending much time to obtain and Negative effects can occur with relatively lowuse use alcohol and to recover from effects 6. Giving up activities due touse May have fewer activities, making detection ofproblems more difficult 7. Continuing use despite physicalor May not know or understand that problemsare related to psychological problem caused by use, even after medical advice use

As their names imply, the terms heavy and individual's health and functional status problem drinking signify more hazardous levels determine the degree of impact, the of consumption than at-risk drinking.Although pharmacokinetic and pharmacodynamic effects the distinction between the terms heavy and of alcohol on aging organ systems result in problem is meaningful to alcoholtreatment higher peak blood alcohol levels (BALs) and specialists interested in differentiating severity increased responsiveness to doses that caused of problems among younger alcohol abusers,it little impairment at a youngerage. For example, may have less relevance for older adults body sway increases and the capacity to think (Atkinson and Ganzini, 1994), whomay clearly decreases with age aftera standard experience pervasive consequences with less alcohol load, even when controlling for BALs consumption due to their heightened sensitivity (Beresford and Lucey, 1995; Vogel-Sprott and to alcohol or the presence of such coexisting Barret, 1984; Vestal et al., 1977). diseases as diabetes mellitus, hypertension, Certain medical conditions, for example, cirrhosis, or dementia. hypertension and diabetes mellitus,can be made In general, the threshold for at-risk alcohol worse by regular drinking of relatively small use decreases with advancing age. Althoughan amounts of alcohol. In addition, the tendency 18 4 r' Alcohol

"to take the edge off" with alcohol during times o Maximum of two drinks on any drinking of stress, and its subsequent impact on cognition occasion (New Year's Eve, weddings) and problem-solving skills, may provoke o Somewhat lower limits for women. inadequate or destructive responses, even in A standard drink is one can (12 oz.) of beer those older adults whose overall consumption or ale; a single shot (1.5 oz.) of hard liquor; a over 6 months is lower than that for some glass (5 oz.) of wine; or a small glass (4 oz.) of younger, problem-free, social drinkers. sherry, liqueur, or aperitif. The Panel's purpose Furthermore, older drinkers who do not meet in promoting these limits is to establish a "safety the substance abuse criteria for "recurrent use" zone" for healthy older adults who drink. Older behavior or consequences may, nonetheless, men and women who do not have serious or pose potential risk to themselves or others. unstable medical problems and are not taking For many adults, the phenomenon of aging, psychoactive medications are unlikely to incur with its accompanying physical vulnerabilities problems with alcohol if they adhere to these and distinctive psychosocial demands, may be guidelines. The goal is to foster sensible the key risk factor for alcohol problems. To drinking that avoids health risks, while allowing differentiate older drinkers, the Consensus Panel older adults to obtain the beneficial effects that recommends using the terms at-risk and problem may accrue from alcohol. Older adults' alcohol drinkers only. As discussed above, not only do use should be considered as spanning a the concepts of quantity/frequency implicit in spectrum from abstinence to dependence rather the term heavy drinking have less application to than falling into rigid categories. older populations, but the "distinction between heavy and problem drinking narrows with age" Drinking Patterns Among (Atkinson and Ganzini, 1994, p. 300). In the two-stage conceptualization recommended by Older Adults the Panel, the problem drinker category includes Although more research on substance abuse those who would otherwise fall into the heavy among older adults is needed, studies to date and problem classifications in the more suggest three ways of categorizing older adults' traditional model as well as those who meet the problem-drinkingearly versus late onset DSM-IV criteria for abuse and dependence. drinking, continuous versus intermittent Age-Appropriate Levels of drinking, and binge drinking. Consumption Early Onset Versus Late Onset In its Physician's Guide to Helping Patients With Problem Drinking Alcohol Problems, the National Institute on One of the most striking and potentially useful Alcohol Abuse and Alcoholism (NIAAA) offers findings in contemporary geriatric research is recommendations for low-risk drinking. For the new understanding about the age at which individuals over the age of 65, NIAAA individuals begin experiencing alcohol-related recommends "no more than one drink per day" problems. Although it appears that alcohol use (National Institute on Alcohol Abuse and declines with increasing age for most adults Alcoholism, 1995). The Consensus Panel (Temple and Leino, 1989; Fillmore, 1987), some endorses that recommendation and the begin to experience alcohol-related problems at accompanying refinements presented below or after age 55 or 60. (Dufour et al., 1992): Early onset drinkers tend to have No more than one drink per day longstanding alcohol-related problems that 19 43 Chapter 2

generally begin before age 40, most often in the appear too healthy, too "normal," to raise 20s and 30s. In contrast, late onset drinkers suspicions about problem drinking. generally experience their first alcohol-related The literature suggests that about one-third problems after age 40 or 50 (Atkinson, 1984, of older adults with drinking problems are late 1994; Liberto and Os lin, 1995; Atkinson et al., onset abusers ( Liberto and Oslin, 1995). Late 1990). onset alcoholism is often milder and more Early onset drinkers amenable to treatment than early onset drinking Early onset drinkers comprise the majority of problems (Atkinson and Ganzini, 1994), and it sometimes resolves spontaneously. When older patients receiving treatment for alcohol abuse, and they tend to resemble younger appraising their situation, late onset drinkers often view themselves as affected by alcohol abusers in their reasons for use. developmental stages and circumstances related Throughout their lives, early onset alcohol to growing older. Early onset drinkers are more abusers have turned to alcohol to cope with a likely to have exacerbated their adverse range of psychosocial or medical problems. Psychiatric comorbidity is common among this circumstances through their history of problem alcohol use (Atkinson, 1994). group, particularly major affective disorders Data from the Epidemiologic Catchment (e.g., major depression, bipolar disorder) and Area Project (ECA), a large-scale, community- thought disorders. For the most part, they based survey of psychiatric disorders including continue their established abusive drinking patterns as they age (Schonfeld and Dupree, alcohol abuse and dependence, provide relevant information on the occurrence of late onset 1991; Atkinson, 1984; Atkinson et al., 1985, 1990; alcoholism, which has been defined by various Stall, 1986). researchers as occurring after ages 40, 45, 50, or Late onset drinkers 60 (Bucholtz et al., 1995). From the ECA study, 3 In comparison, late onset drinkers appear percent of male alcoholics between 50 and 59 psychologically and physically healthier. Some reported first having a symptom of alcoholism studies have found that late onset drinkersare after 49, compared with 15 percent of those more likely to have begun or to have increased between 60 and 69 and 14 percent of those drinking in response to recent losses such as between 70 and 79. For women, 16 percent death of a spouse or divorce, to a change in between 50 and 59 reported a first symptom of health status, or to such life changes as alcoholism after the age of 50, with 24 percent of retirement (Hurt et al., 1988; Finlayson et al., women between 60 and 69 and 28 percent of 1988; Rosin and Glatt, 1971). Because late onset women between 70 and 79. These percentages problem drinkers have a shorter history of suggest that late onset alcoholism is a significant problem drinking and therefore fewer health problem, especially among women. (Gender problems than early onset drinkers do, health differences are discussed further below.) care providers tend to overlook their drinking. Both early and late onset problem drinkers Panelists report that, in addition, this group's appear to use alcohol almost daily, outside psychological and social pathology, family social settings, and at home alone. Both are relationships, past work history, and lack of more likely to use alcohol as a palliative, self- involvement with the criminal justice system medicating measure in response to hurts, losses, contradict the familiar clinical picture of and affective changes rather than as a socializing alcoholism. Late onset drinkers frequently agent.

20 44 Alcohol

Although there is controversy over the issue 1991). Figure 2-4 outlines the essential of whether early and late onset distinctions similarities and differences between early and influence treatment outcomes (Atkinson, 1994), late onset drinkers. The most consistent the Panel believes that problem onset affects the findings concern medical and psychiatric choice of intervention. Panelists believe, for comorbidity; demographic and psychosocial example, that late onset problem drinkers may factors are less consistent. Little is known about respond better than early onset drinkers to brief the impact of early versus late onset on the intervention because late onset problems tend to complications and treatment outcomes of be milder and are more sensitive to informal concomitant medication and alcohol use. social pressure (Atkinson, 1994; Moos et al.,

Figure 2-4 Clinical Characteristicsof Early and Late Onset ProblemDrinkers Variable Earl Onset Late Onset A:e at onset Various, e.:., < 25, 40, 45 Various, e.:., > 55, 60, 65 Gender Higher proportion of men than Higher proportion of women women than men Socioeconomic status Tends to be lower Tends to be hi her Drinkin: in res onse to stressors Common Common Famil historof alcoholism More prevalent Less prevalent Extent and severity of alcohol More psychosocial, legal Fewer psychosocial, legal roblems roblems,reater severit roblems, lesser severit Alcohol-related chronic illness More common Less common (e.g., cirrhosis, pancreatitis, cancers) Psychiatric comorbidities Cognitive loss more severe, less Cognitive loss less severe, reversible more reversible Age-associated medical problems Common Common aggravated by alcohol (e.g., hypertension, diabetes mellitus, dru:--alcohol interactions) Treatment compliance and Possibly less compliant; Possibly more compliant; outcome Relapse rates do not vary by ageRelapse rates do not vary by of onset (Atkinson et al., 1990; age of onset (Atkinson et al., Blow et al., 1997; Schonfeld and 1990; Blow et al., 1997; Dupree, 1991) Schonfeld and Dupree, 1991)

45 21 Chapter 2

Continuous Versus Intermittent drive. Although research is needed on the Drinking natural history of binge drinkers as they age, anecdotal observations indicate that younger Another way of understanding the patterns of binge drinkers who survive to their later years drinking over a life span is to look at the time often become continuous or near-daily drinkers. frames in which people drink and the frequency of their drinking. In contrast to ongoing, Risk Factors for Alcohol continuous drinking, intermittent drinking refers to regular, perhaps daily, heavy drinking that Abuse has resumed after a stable period of abstinence of 3 to 5 years or more (National Institute on Gender Alcohol Abuse and Alcoholism, 1995). Studies indicate that older men are much more Intermittent drinking problems are easy to likely than older women to have alcohol-related overlook, but crucial to identify. Even those problems (Myers et al., 1984; Atkinson, 1990; problem drinkers who have been sober for Bucholz et al., 1995). Since the issue was first many years are at risk for relapse as they age. studied, most adults with alcohol problems in For this reason, during routine health old age have been found to have a long history screenings, it is important for clinicians to take a of problem drinking, and most of them have history that includes both current and lifetime been men (D'Archangelo, 1993; Helzer et al., use of alcohol in order to identify prior episodes 1991b). About 10 percent of men report a of alcoholism. When armed with this history of heavy drinking at some point in their information, caregivers can help their older lives. Being a member of this group predicts patients anticipate situations that tend to that one will have widespread physical, provoke relapse and plan strategies for psychological, and social dysfunction in later life addressing them when they occur. (Colsher and Wallace, 1990) and confers a Binge Drinking greater than fivefold risk of late-life psychiatric illness despite cessation of heavy drinking Binge drinking is generally defined as short (Saunders et al., 1991). Forty-three percent of periods of loss of control over drinking veterans (who can be assumed to be mostly alternating with periods of abstinence or much male and mostly alcoholas opposed to drug lighter alcohol use. A binge itself is usually abusers) receiving long-term care were found to defined as any drinking occasion in which an have a history of substance abuse problems individual consumes five or more standard (Joseph et al., 1995; D'Archangelo, 1993). Men drinks. For older adults, the Consensus Panel who drink have been found to be two to six defines a binge as four or more drinks per times more likely to have medical problems than occasion. People who are alcohol-free women who drink (Adams et al., 1993), even throughout the work week and celebrate with though women are more vulnerable to the Friday night or holiday "benders" would be development of cirrhosis. considered binge drinkers. Older women are less likely to drink and less Identifying older binge drinkers can be likely to drink heavily than are older men difficult because many of the usual clues, (Bucholz et al., 1995). The ratio of male-to- including disciplinary job actions or arrests for female alcohol abusers, however, is an open driving while intoxicated, are infrequently seen question. Bucholz and colleagues noted a among aging adults who no longer work or "substantial excess of men over women," larger 22 46' Alcohol than the gap observed in younger age groups facilities. Among older women who may be (Bucholz et al., 1995, p. 30). Another study, socially isolated or homebound, outreach is however, found "a higher than expected particularly important. Families, physicians, number of females," (Beresford, 1995b, p. 11), senior centers and senior housing staff, and the whereas a study of older patients in treatment police play important roles in helping to identify facilities found a ratio of 2:1 (83 men to 42 women who abuse alcohol (see Chapter 5 for women) (Gomberg, 1995). more on community outreach). To be effective, Both epidemiological research, including the however, all of these potential outreach agents findings of the ECA studies of the National must be sensitive to women's feelings of stigma, Institute of Mental Health (Holzer et al., 1984), shame, and social censure. and clinical research consistently report later onset of problem drinking among women Loss of Spouse (Gomberg, 1995; Hurt et al., 1988; Moos et al., Alcohol abuse is more prevalent among older 1991). In one study by Gomberg, for example, adults who have been separated or divorced and women reported a mean age at onset of 46.2 among men who have been widowed (Bucholz years, whereas men reported 27.0 years. et al., 1995). Some researchers have Furthermore, 38 percent of older female patients hypothesized that a significant triad of disorders but only 4 percent of older male patients may be triggered in older men when their wives reported onset within the last 10 years diedepression, development of alcohol (Gomberg, 1995). problems, and suicide. The highest rate of A number of other differences between older completed suicide among all population groups male and female alcohol abusers have been is in older white men who become excessively reported: In contrast to men, women are more depressed and drink heavily following the death likely to be widowed or divorced, to have had a of their spouses (National Institute on Alcohol problem drinking spouse, and to have Abuse and Alcoholism, 1988; Brennan and experienced depression (Gomberg, 1993). Moos, 1996). Women also report more negative effects of Other Losses alcohol than men (Gomberg, 1994), greater use of prescribed psychoactive medication (Brennan As individuals age, they not only lose their et al., 1993; Gomberg, 1994; Graham et al., 1995), spouse but also other family members and and more drinking with their spouses. friends to death and separation. Retirement Although research has not identified any may mean loss of income as well as job-related social support systems and the structure and definite risk factors for drinking among older women, Wilsnack and colleagues suggest that self-esteem that work provides. Other losses increased amounts of free time and lessening of include diminished mobility (e.g., greater role responsibilities may serve as an etiological difficulty using public transportation where available, inability to drive or driving limited to factor (Wilsnack et al., 1995). It should also be noted that women generally are more the daylight hours, problems walking); impaired vulnerable than men to social pressure, so their sensory capabilities, which may be isolating even when the elder is in physical proximity to move into retirement communities where drinking is common probably has an impact. others; and declining health due to chronic Differences between men and women have illnesses. implications for treatment. Women of all ages are less likely than men to appear at treatment

23 47 Chapter 2

Health Care Settings alcoholism in older adults, there is evidence that High rates of alcoholism are consistently they may be either precipitating or maintenance reported in medical settings, indicating the need factors in late onset drinking. Depression, for for screening and assessment of patients seen for example, appears to precipitate drinking, problems other than substance abuse (Douglass, particularly among women. Some problem 1984; Liberto et al., 1992; Adams et al., 1996). drinkers of both sexes who do not meet the Among community-dwelling older adults, clinical criteria for depression often report investigators have found a prevalence of feeling depressed prior to the first drink ona alcoholism between 2 and 15 percent (Gomberg, drinking day (Dupree et al., 1984; Schonfeld and 1992b; Adams et al., 1996) and between 18 and Dupree, 1991). 44 percent among general medical and Patients with severe cognitive impairment psychiatric inpatients (Colsher and Wallace, generally drink less than nonimpaired alcohol 1990; Saunders et a1.,1991). users. Panelists report that, among individuals who are only mildly impaired, however, alcohol Substance Abuse Earlier in Life use may increase as a reaction to lower self- A strong relationship exists between developing esteem and perceived loss of memory. Axis II a substance use disorder earlier in life and disorders are more likely to be associated with experiencing a recurrence in later life. Some early onset interpersonal and alcohol-related recovering alcoholics with long periods of problems and less likely to affect the individual sobriety undergo a recurrence of alcoholic for the first time at age 60 or older. Late onset drinking as a result of major losses or an excess alcohol abuse is less associated with of discretionary time (Atkinson and Ganzini, psychological or psychiatric problems and more 1994). Among the 10 percent of older men who likely linked to age-associated losses. The reported a history of heavy drinking at some exception might be the intermittent drinker who point in their lives, widespread physical and has been in control and whose alcohol or social problems occurred in later life (Colsher psychiatric problems surface again later in life. and Wallace, 1990). Drinking problems early in See Chapter 4 for more on psychiatric life confer a greater than fivefold risk of late-life comorbidity. psychiatric illness despite cessation of heavy drinking. Indeed, some research suggests that a Family History of Alcohol Problems previous drinking problem is the strongest There is substantial cumulative evidence that indicator of a problem in later life (Welte and genetic factors are important in alcohol-related Mirand, 1992) and that "studying older behaviors (Cotton, 1979). Some studies have alcoholics today may help to anticipate the suggested that there may be a greater genetic demands that these younger alcoholics will etiology of problem drinking in early onset than eventually place on our resources and society" in late onset male alcohol abusers (Atkinson et (Bucholz et al., 1995, p. 19). al., 1990). Researchers studying the genetic tendency of a group of male alcohol abusers Comorbid Psychiatric Disorders assert that these men often have an early history Estimates of primary mood disorder occurring of drinking that worsens over time (Goodwin in older alcohol abusers vary from 12 to 30 and Warnock, 1991; Schuckit, 1989). percent or more (Finlayson et al., 1988; Koenig Although most human genetic studies of and Blazer, 1996). Although research does not alcohol use have been conducted on relatively support the notion that mood disorders precede young subjects, several studies using a twin

24 48 Alcohol registry of U.S. veterans have focused on younger relative or partner who uses or sells significantly older individuals (Carmel li et al., drugs. 1993; Swan et al., 1990). The results of these Tobacco studies provide strong evidence that drinking behaviors are greatly influenced by genetics Smoking is the major preventable cause of throughout the lifespan (Heller and McClearn, premature death in the United States, 1995; Atkinson, 1984). accounting for an estimated five million years of potential life lost (U.S. Preventive Services Task Concomitant Force, 1996). Every year, tobacco smoking is responsible for one out of every five American Substance Use deaths (U.S. Preventive Services Task Force, The substances most commonly abused by older 1996). Despite these compelling statistics, adults besides alcohol are nicotine and however, 25.5 percent or 48 million adults are psychoactive prescription medications. (See current smokers (National Center for Health Chapter 3 for further discussion of psychoactive Statistics, 1996). drug abuse and of drug interactions.) Both Surveys show that cigarette smoking, nicotine and prescription drug abuse are far although fairly widespread among older adults, more prevalent among older adults who also declines sharply after age 65. In 1994, abuse alcohol than among the general approximately 28 percent of men ages 45 to 64 population of this age group (Gronbaek et al., reported current use of cigarettes; among those 1994; Goldberg et al., 1994; Colsher et al., 1990; age 65 and older, however, this figure was only Finlayson et al., 1988). The Panel recognizes that about 13 percent. In the younger age group the concomitant use of prescribed (ages 45 to 64), women have lower smoking benzodiazepines and alcohol is also common rates than men, but after age 65, the levels are among older adults, especially older women. similar. Approximately 23 percent of women This includes nonabusive use of both ages 45 to 64 reported smoking cigarettes in substances, which may be harmful even at 1994, whereas about 11 percent of those age 65 modest dosesfor example, consuming one or and older currently smoked (National Center for two drinks plus a small dose of a sedative at Health Statistics, 1996). Although the trend in night. A similar concern is raised with the use declines with age, the problem remains concomitant use of alcohol and opiates significant with over 4 million older adults prescribed for pain relief. Although there is smoking regularly (Salive et al., 1992). little empirical evidence in this area, clinical Smoking is a "major risk factor for at least 6 practice suggests that dual addiction decreases of the 14 leading causes of death among the effectiveness of specific interventions and individuals 60 years and older (i.e., heart increases the individual's severity of symptoms. disease, cerebrovascular disease, chronic Although there is little research on the abuse obstructive pulmonary disease, of other illicit substances (e.g., heroin, cocaine, pneumonia/influenza, lung cancer, colorectal marijuana) by older adults, therapists and health cancer) and a complicating factor of at least care personnel are seeing more older adults who three others" (Cox, 1993, p. 424). Current present with symptoms of illicit drug abuse. cigarette smoking is also "associated with an Panel members believe that many of these older increased risk of losing mobility in both men illicit drug abusers receive drugs from a and women" (LaCroix et al., 1993). Not surprisingly, older adult smokers have a "70

25 4J Chapter 2

percent overall risk of dying prematurely" cessation strategies to older adults so that their (Carethers, 1992, p. 2257), and fewer smokers unique concerns and barriers to quitting are "make it to the ranks of older adults as addressed improves success rates. Brief compared with non-smokers and quitters" (Cox, intervention, for example (see Chapter 5),can 1993, p. 423). In addition to increasing the risk more than double 1-year quit rates for older of disease, smoking may also affect the adults (Rimer and Orleans, 1994). In one study performance of prescription drugs. For of older smokers using transdermal nicotine example, smokers tend to require higher doses patches, 29 percent of the subjects quit smoking of benzodiazepines to achieve efficacy than do for 6 months (Orleans et al., 1994). Because nonsmokers (Ciraulo et al., 1995). there is little evidence that adults in recovery Smoking in older problem drinkers is far from alcohol problems relapse when they stop more prevalent than in the general older adult smoking, the Panel recommends that efforts to population, making tobacco use the most reduce substance abuse among older adults also common substance use disorder among older include tobacco smoking (Hurt et al., 1993). adults. Some researchers estimate that 60 to 70 percent of older male alcohol users smoke a Psychoactive Drugs pack a day (Finlayson et al., 1988), an Older adults' use of psychoactive drugs assessment consistent with studies indicating combined with alcohol is a growing concern (see that the prevalence of smokingamong alcoholics Chapter 3). In a study of inpatients age 65 and generally is above 80 percent (Jarvik and older in a chemical dependency program, 12 Schneider, 1992). percent had combined dependence on alcohol Although there have been few studies on and one or more prescription drugs ( Finlayson interventions that are especially useful to older et al., 1988). In addition, an early report by adults regarding smoking cessation, the Schuckit and Morrissey found that two-thirds of advantages of quitting at any age are clear (Fiore women in an alcohol treatment center had et al., 1990; Orleans et al., 1994a; Rimer and received prescriptions for abusable drugs, Orleans, 1994; Orleans et al., 1994b). Twoyears usually hypnotic and antianxiety drugs, and after stopping, for example, the risk of stroke one-third reported abusing them (Schuckit and begins to decrease. Mortality rates for chronic Morrissey, 1979). The drug-abusing women in obstructive pulmonary disease decline; this study reported more suicide attempts and bronchitis, pneumonia, and other infections early antisocial problems and had receivedmore decrease; and respiratory symptoms suchas psychiatric care than the alcoholic women who cough, wheezing, and sputum production lessen did not abuse their prescriptions. These (U.S. Preventive Services Task Force, 1996). As findings are of particular concern because another example, a 60-year-old male smoker anxiolytics, hypnotics, and stimulants may be who quits can expect to reduce his risk of used to treat alcohol and other drug abusers. smoking-related illness by about 10 percent over An additional concern is that psychoactive the next 15 years (Cox, 1993). drugs may combine with alcohol to create As with alcohol and drug abuse, studies adverse drug reactions. A recent study found suggest that many clinicians fail to counsel that the combination of alcohol and over-the- patients about the health effects of smoking, counter pain medications was the most common despite the fact that "older smokers aremore source of adverse drug reactions among older likely to quit than younger smokers" (Salive et patients (Forster et al., 1993). Such drug al., 1992, p. 1268). However, tailoring smoking interactions result from a lack of understanding

26 Alcohol among physicians, pharmacists, and older consuming alcohol when taking certain adults themselves about the potential dangers of medications.

27 5 I 3 UseanAbuse of Psychoactive Prescription Drugs and Over- the-Counter Medications

Adults age 65 and older consume more psychoactive drug within the last year, and 20 prescribed and over-the-counter percent used a tranquilizer daily. Indeed, 27 medications than any other age group percent of all tranquilizer prescriptions and 38 in the United States. Although older adults percent of hypnotic prescriptions in 1991 were constituted less than 13 percent of the written for older adults. Moreover, older adults population in 1991, they received 25 to 30 are apparently more likely to continue use of percent of all prescriptions (Woods and Winger, psychoactive drugs for longer periods than their 1995; Ray et al., 1993; Sheahan et al., 1989) and younger counterparts (Sheahan et al., 1995; experienced more than half of all reported Woods and Winger, 1995). adverse drug reactions leading to This chapter focuses on the most commonly hospitalization (Chastain, 1992). Some 80 to 86 prescribed abusable psychoactive medications percent of older adults over age 65 reportedly for older adultsbenzodiazepines, suffer from one or more chronic diseases or antidepressants, and opiate/ opioid analgesics. conditions (Administration on Aging and Staff Also covered are risk factors that make older of the U.S. Senate Special Committee on Aging, adults more vulnerable to misuse and abuse of 1991; U.S. Bureau of the Census, 1996), and an these substances; adverse effects associated with estimated 83 percent of adults over 65 take at consumption of psychoactive medications; and least one prescription drug (Hazelden uses for, effects of, and alternatives to different Foundation, 1991; Ray et al., 1993). In fact, 30 categories of prescription drugs. percent of those over 65 take eight or more prescription drugs daily (Sheahan et al., 1989). Evolution of Psychoactive A large share of prescriptions for older adults Prescribing are for psychoactive, mood-changing drugs that carry the potential for misuse, abuse, or Since their introduction in the late 1950s, dependency. In 1983, one-fourth of community benzodiazepines have become the most widely dwelling older adults used psychotherapeutic prescribed anxiolytics and hypnotics in medical drugs on a regular basis for sleep disorders or practice. Their growing use throughout the chronic pain as well as for anxiety and labile 1960s prompted many to ask whether the mood (Finlayson, 1995b). Approximately 25 to United States was becoming an overmedicated 28 percent of older adults reported use of a society in which people would take a pill for any 52 29 Chapter 3

physical or emotional pain rather than exert interactions and the importance of medication some simple self-control. Some researchers compliance for positive therapeutic outcomes. feared that use of prescribed psychoactive drugs More specifically, benzodiazepines witha for a vast array of conditions would inexorably lower addiction potential and fewer adverse lead to irresponsible recreational useor interactions with other medications have physiological dependence on licit or illicit replaced many of the older barbiturates, substances. Others thought that prevalence of bromides, meprobamate, and neuroleptics for associated psychosocial problems would rise management of anxiety, especially acute along with the prescription drug use (Baiter, situational anxiety, generalized anxiety disorder, 1973; Manheimer et al., 1973; Cooperstock and and associated transient insomnia. Similarly, in Parnell, 1982). the 1960s, the benzodiazepine flurazepam Yet studies of older populations conducted (Dalmane) replaced many of the barbiturates over the past 20 years have generally found that and nonbarbiturates routinely used for sleep most adults who take psychoactive medications disorders and insomnia complaints. Displaced do not intend to abuse them. The drugs usually drugs included such barbiturates as are obtained with an appropriate prescription pentobarbital (Nembutal), secobarbital from a primary care physician for a specific (Seconal), and the combination aprobarbital and health-related purpose and are primarily used in secobarbital (Tuinal), as well as the conjunction with a physical condition or to nonbarbiturates chloral hydrate, ethchlorvynol alleviate symptoms of emotional stress (Pi land, (Placidyl), and glutethimide (Doriden) (Fouts 1979; Guttmann, 1977; Cooperstock and Parnell, and Rachow, 1994; Finlayson, 1995b; Rickels and 1982). In fact, there has been a steady Schweizer, 1993). Sales reports and pharmacy improvement in prescribing practices and safe prescription audits reflect the overall decline in and appropriate medication use in the last 25 the numbers of stimulant and barbiturate years. prescriptions, with minor tranquilizers and/or Misuse and abuse of prescriptions have sedatives exceeding other classes since the 1980s dwindled over that time for several reasons: (1) (Cooperstock and Parnell, 1982). Prescriptions safer drugs with fewer undesirable side effects for the popular arixiolytic benzodiazepines have are constantly being developed by more recently shifted from diazepam (Valium) pharmaceutical companies, especially for to the shorter acting compounds, particularly common health and mental health problems; (2) alprazolam (Xanax) and lorazepam (Ativan), ever-changing Federal and State regulations and from the earlier long-acting benzodiazepine seek to protect consumers from hazardous hypnotic, flurazepam, to the shorter acting substances and to restrict undesirable provider triazolam (Halcion) and temazepam (Restoril). practices; (3) guidelines and protocols Overall, sales of benzodiazepine anxiolytics recommending best practices are being have decreased, whereas use of benzodiazepines developed and disseminated to health care as sleep-inducing hypnotics has increased or providers; (4) more physicians are receiving remained stable (Winger, 1993; Woods and training relevant to the care of older patients Winger, 1995). (from geriatric research, education, and clinical In 1996, the top 10 drugs prescribed in centers); and (5) consumers are being educated nursing homes included two selective serotonin by their physicians and other healthcare reuptake inhibitors (SSRIs), sertraline (Zoloft) providers, pharmacists, and various media and fluoxetine (Prozac), as well as the sources regarding the dangers of drug nonbenzodiazepine anxiolytic, buspirone

30 53 Prescription Drugs

(BuSpar). This represents a decrease from 1970, effects it provides, much as an abuser of any when 8 of the top 10 nursing home prescriptions drug does. were for psychoactive drugs (Prentice, 1979). Adults can become physiologically Furthermore, chronic pain from such conditions dependent on psychoactive medications without as arthritis is more frequently treated now with meeting dependence criteria. Tolerance and nonsteroidal anti-inflammatory agents rather physical dependence can develop when some than with opiate-containing drugs such as psychoactive medications (e.g., acetaminophen with codeine (Finlayson, 1995b). benzodiazepines, opioids) are taken regularly at Yet even though fewer prescriptions for the therapeutically appropriate dose for psychoactive drugs are being written for older relatively brief periods. An abstinence adults, many patients prescribed these drugs syndrome or withdrawal effects may occur if the still misuse and abuse them, and some health drug is stopped precipitously. This type of care providers continue to exhibit poor iatrogenically induced physiological judgment in their prescribing and monitoring dependence is not usually accompanied by any practices. tendency on the part of the patient to escalate dosage during or after medically supervised Patterns ®f Use withdrawal, to experience cravings after discontinuation, or to subsequently continue use The drug-taking patterns of psychoactive or addictive behavior (Woods and Winger, 1995; prescription drug users can be described as a Portenoy, 1993). In other words, adults can continuum that ranges from appropriate use for become dependent on psychoactive medications medical or psychiatric indications through without realizing it. misuse by the patient or the prescribing health care practitioner to persistent abuse and Risk Factors fori isuse dependence as defined by the American Psychiatric Association's criteria in the Any Abr =se of Diagnostic and Statistical Manual of Mental Psychoactive Drugs Disorders, Fourth Edition (DSM-IV) (American A variety of factors influence the use and Psychiatric Association, 1994) (see Figure 3-1). potential for misuse or abuse of psychoactive Because older adults are less likely to use prescription drugs and over-the-counter psychoactive medications nontherapeutically, medications by older adults. The aging process, problems with drugs generally fall into the with its physiological changes, accumulating misuse category and are unintentional. For physical health problems, and other example, older patients are more likely to psychosocial stressors, makes prescription drug misunderstand directions for appropriate use both more likely and more risky. The most usea problem that is compounded by the consistently documented correlates of multiple prescriptions they receive, often from psychoactive prescription drug use are old age, multiple physicians unaware of a colleague's poor physical health, and female gender treatments. In these circumstances, overdose, (Cooperstock and Parnell, 1982; Sheahan et al., additive effects, and adverse reactions from 1989; Finlayson, 1995b). combining drugs are more likely to occur. Unintentional misuse can, however, progress into abuse if an older adult continues to use a medication nontherapeutically for the desirable

31 54 Chapter 3

Figure 3-1 Continuum of Psychoactive Prescription Drug Use.

Proper Use

Misuse By Patient

Dose level more or less than recommended Use for contraindicated purposes Use in conjunction with other medications with undesirable interactions Skipping doses/hoarding drugs Use with alcohol

By Doctor

Prescribing unnecessarily high dose Prescribing without determining what other medication patient is taking clearly explaining regimen 3Not Abuse By Patient

Use resulting in Decline in work, school, or home performance Legal problems Use in risky situations (e.g., driving while impaired) Continued use despite adverse social or interpersonalconsequences Source: American Psychiatric Association, 1994

Dependence By Patient

Use resulting in Tolerance Withdrawal symptoms Decline in normal activities Unsuccessful attempts or a desire to cut down or controluse Use of a substance in larger amounts or for a longer period thanwas intended Use that consumes a lot of time (including time to acquire anduse the drug and to recover from its effects) Continued use despite knowledge that it has caused or aggravateda physical or psychological problem Source: American Psychiatric Association, 1994

Among older women, use of psychoactive health care system, and previous or coexisting drugs is correlated with middle- and late-life drug, alcohol, or mental health problems also divorce, widowhood, less education, poorer seem to increase vulnerability for misusing or health and chronic somatic problems, higher abusing prescribed medications. stress, lower income, and more depression and Data from the 1984 Epidemiological anxiety (Gomberg, 1995; Closser and Blow, Catchment Area (ECA) survey (Regier et al., 1993). Major losses of economic and social 1988) confirm that anxiety disorders are supports, factors related to the provider and relatively prevalent in the general population of 32 55 Prescription Drugs adults older than 65, with 7.3 percent of older Previous History of Substance respondents reporting an incidence within the Abuse or Psychiatric Disorder past month. Older women are nearly twice as Although most experts agree that nonmedical likely as older men to develop a diagnosable use or abuse of benzodiazepines is rare at any anxiety disorder. Bereavement precipitates age and household surveys indicate that anxiety in nearly one-fourth of survivors during nonmedical use is declining (Salzman, 1993b; the first 6 months following the death of a loved Barnas et al., 1992), some liability for abuse of one and in nearly two-fifths of those left behind the benzodiazepines does seem to exist in the during the second 6-month period. Anxiety is following cohorts: (1) light-to-moderate alcohol also common after a severe traumatic event drinkers who have been demonstrated to prefer (Salzman, 1993a). diazepam over placebo and may be vulnerable to the reinforcing properties of these drugs; (2) System and Environmental adults with histories of sedative abuse, abuse of Influences multiple drugs, and methadone-maintained A variety of health care system-related and clients; and (3) patients who have developed environmental factors also place older adult physiological dependence on benzodiazepines users of psychoactive prescription drugs at risk after long-term use and are experiencing acute for misuse of these substances, serious adverse withdrawal effects following abrupt effects, or abuse and dependence. Potentially discontinuation (Salzman, 1993b; Barnas et al., dangerous prescribing practices include 1992). ordering medications without adequate However, continued craving for the diagnoses or other documented indicators of medication does not seem to persist among symptoms, prescribing them for too long a time adults who fit none of the categories above and without appropriate medical monitoring of drug who have successfully been withdrawn from reactions and patient compliance with the benzodiazepines. By contrast, adults with prescribed regimen, selecting drugs known to histories of substance abuse prefer have a high potential for side effects in older benzodiazepines to placebo. They also prefer, adults at the doses given, ordering drugs however, older anxiolytics and hypnotics such without knowing or reviewing whether they as methaqualone (Quaalude) or meprobamate interact adversely with other medications the (Miltown) to benzodiazepines (Winger, 1993; patient is taking, and failing to provide adequate Woods and Winger, 1995). The benzodiazepines and comprehensible instructions for patients preferred by sedative abusers and methadone regarding how and when to take medications maintenance clients seem to be diazepam, and what side effects to expect and report. Drug lorazepam, and alprazolam (Woods and misuse also includes failure to consider the Winger, 1995). Unfortunately, little is known influence of aging on the effects of drugs in the about the risk potential for these individuals in body (see Figure 3-2). late life.

5:6 33 Chapter 3

'igure 3-2 ,f gnagoop,Response to Drug Effect Drug Action Effects of A in: 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 Vera p amil Acute antihypertensive effect Increased

Diuretics

Furosemide Latency and size of peak diuretic response Decreased

Psychotropics Diazepam Acute sedation Increased Dip henhyd rami ne Psychomotor function No change Haloperidol Acute sedation Decreased Midazolam Electroencephalographic activity Increased Temazep am 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.

34 5 7 Prescription Drugs

Data from the Mayo Clinic further suggest coordination, ataxia, falls, excessive daytime that psychiatric diagnoses may be a risk factor drowsiness, confusion, aggravation of emotional among older adults for abuse of and state, rage, and amnesia as well as the dependence on prescription drugs (Finlayson, development of physiological dependence 1995a). In this study, rates of mental disorder manifested by withdrawal effects when the diagnosis in 100 older adults hospitalized for drugs are suddenly discontinued (Fouts and prescription drug dependence included the Rachow, 1994). Psychoactive medications have following disorders: mood (32 percent), organic been implicated in 23 percent of adverse drug mental (28 percent), personality (27 percent), reactions among nursing home residents somatoform (16 percent), and anxiety (12 (Joseph, 1995). Side effects from these drugs percent). The patient group was predominantly range from constipation, dry mouth, or urinary female, and some patients had more than one difficulty to such severe reactions as hip mental disorder diagnosis. The patient group fractures from falls, withdrawal seizures or was identified as having considerable delirium, and worsened depression leading to psychopathology by several other measures as suicide attempts (American Psychiatric well (Finlayson, 1995a). Although research on Association, 1994). However, all undesirable older drug addicts is rare, at least one study reactions may be more serious in frail older indicates that older patients with substance adults and in those with multiple chronic dependence disorders are more likely than diseases and cannot be ignored (Lapane et al., younger drug addicts to have a dual diagnosis. 1995; Solomon et al., 1993). In this investigation, only 15 percent of older drug-dependent patients had a substance abuse Anxiolytics diagnosis without a coexisting psychiatric Figure 3-3 summarizes information about some disorder compared with 64 percent of younger of the anxiolytics most frequently prescribed for counterparts. These researchers concluded that acute or chronic anxiety in older adults. The older adults with a preexisting psychiatric figure depicts the generic and most usual brand disorder may be more at risk for concurrent name for these medications as well as the prescription drug dependence (Solomon et al., elimination half-life or duration of action in the 1993). body. Note that Figures 3-3 and 3-4 both contain the names of benzodiazepinestheir Adverse Effects designations as anxiolytics or sedative/hypnotics are based on properties that drive marketing The chronic administration of psychoactive decisions. Some physicians may choose, for substances to older adults, even at therapeutic example, to use lorazepam as either an doses, has been associated with a variety of anxiolytic or sedative depending on the adverse central nervous system effects, circumstances. including diminished psychomotor performance, impaired reaction time, loss of

53 35 Chapter 3

Figure 3-3 CommonlyPrescribed Anxiolytics' Class Dru Brand Name Elimination Half-Life for Older Adults Benzodiazepines Al razolam 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 Oxaze am Serax 3-25 hours Serotonin a onist Bus iron BuS ar 1-11 hours 'Refer to product information insert for each drugas to its suitability for use in older adults.

An estimated 95 percent of benzodiazepine Although most people use benzodiazepines prescriptions for older adults in this countryare for short periods of time without developing ordered for anxiety and insomnia, with only 5 problems, others take them past the point where percent used as adjuncts for general anesthesia, they are effective and thus are at risk for adverse as muscle relaxants, or as anticonvulsants (Ray effects including tolerance and abuse. By 1990, et al., 1993). Numerous studies, including the as many as a fourth of anxiolytic users had taken 1990 American Psychiatric Association Task these medications for a year or more (Winger, Force report, have concluded that the vast 1993). Several studies in the United States and majority of use of these agents is appropriate, Britain confirm that long-term users (fora year with only occasional overprescribing by or more) of benzodiazepines are likely to be physicians for some patient subgroupsor older than age 45 and female with substantial misuse by patients (Salzman, 1990, 1993b; psychological stress, dysphoric or depressive Winger, 1993; Woods and Winger, 1995). Even symptoms, and multiple chronic physical among the small group of respondents to illnesses or somatic problems (Salzman, 1993b; household surveys who have acknowledged Winger, 1993). Benzodiazepine use for longer taking benzodiazepines that were not prescribed than 4 months is of particular concern among for them (less than 6 percent), the vast majority older adults. The physiological aging process borrowed pills from significant others and used decreases the body's ability to absorb and them for symptom relief, not recreational metabolize drugs, allowing the drug to purposes. Moreover, worldwide experience accumulate more rapidly than in younger with the short-term use of benzodiazepines to people and increase the likelihood of toxicity relieve acute anxiety, situational stress, and and adverse effects. Benzodiazepines have transient insomnia indicates that these variable rates of absorption, with metabolism medications are unusually safe and efficacious, occurring primarily in the liver. Because the with very little liability for dose increases, longer acting benzodiazepines have active prolonged use, or addictive dependence metabolites, some of which have very long half- (Salzman, 1993b). livesup to 200 hours in the case of flurazepamthe duration of action is often 36 59 Prescription Drugs longer than expected. They are also more likely the withdrawal syndrome has been known to to produce residual sedation and other adverse persist for several months (Solomon et al., 1993). effects such as decreased attention, memory, The rebound effects experienced in cognitive function, and motor coordination and withdrawal usually mimic the original increased injurious falls or motor vehicle crashes symptoms for which the benzodiazepine was (Weiss, 1994; Solomon et al., 1993; Fouts and prescribed (e.g., anxiety, insomnia, panic). Rachow, 1994; Ray et al., 1993; Winger, 1993). Those effects occur in as many as one-third to By contrast, some shorter acting one half of patients after even 1 or 2 months of benzodiazepines are not as likely to produce benzodiazepine therapy, may be more intense toxic or dependence-inducing effects with than before treatment began, and are frequently chronic dosing. One reason is that these drugs misperceived by frightened patients as a return have no active metabolites. Furthermore, of the initial problem (Rickels and Schweizer, because the oxidative pathway is often impaired 1993; Salzman, 1993b). Rebound effects, in older adults and in those with liver disease, it however, are sudden and transient, whereas a is best to choose drugs that are not metabolized relapse entails a gradual but persistent return of by this pathway. Such drugs include oxazepam the original symptoms that may continue (Serax) and lorazepam. Because of these unabated unless treated again with unpleasant and potentially hazardous side benzodiazepines or other appropriate effects of many benzodiazepines, the Panel medications (Rickels and Schweizer, 1993). recommends caution in selecting the most Unfortunately, misperceived rebound effects appropriate benzodiazepine for elderly patients. may lead some patients to self-medicate by Unfortunately, both long- and short-acting supplementing doses during withdrawal unless benzodiazepines tend to result in physiological the tapering is sufficiently gradual to ameliorate dependence, even when these medications are symptoms and the patient is counseled that taken at therapeutic doses and for as short a these rebound effects are transient and to be period as 2 months (Woods and Winger, 1995). expected (Rickels and Schweizer, 1993). Unlike Many of the most unpleasant withdrawal effects withdrawing from alcohol, however, the can be alleviated by gradually tapering the dose difficulty in abstaining during the acute phase of rather than stopping it abruptly. Even if the benzodiazepine withdrawal is not followed by dose is tapered, however, withdrawal any further craving once the patient is drug-free symptoms are experienced by 40 to 80 percent of (Winger, 1993). It appears that most patients people who discontinue benzodiazepines after 4 withdrawn from benzodiazepines can maintain to 6 months of regular use (Miller et al., 1985; abstinence. Speirs et al., 1986). Such symptoms as anxiety, The question of whether the benefits agitation, lethargy, nausea, loss of appetite, outweigh the disadvantages of chronic insomnia, dizziness, tremor, poor coordination, benzodiazepine therapy is far from settled. difficulty concentrating, depersonalization, or Followup studies have found that more than confusion may occur after stopping either long half of patients (50 to 66 percent) treated with or short half-life benzodiazepines. Symptoms benzodiazepine anxiolytics or hypnotics usually peak toward the end of the tapered experience a relapse of the original symptoms discontinuation and disappear altogether within within a year of discontinuing benzodiazepine 3 to 5 weeks (Winger, 1993; Rickels and use (Atkinson et al., 1992). Half of these patients Schweizer, 1993). In a few psychiatric patients, resume use of benzodiazepines. Longer followup studies indicate that a majority

37 GO Chapter 3

eventually resume use, whether intermittently overdose. Buspirone does not have the muscle or chronically (Finlayson, 1984). The reasons for relaxant or anticonvulsant properties of discontinuation have to be examined in an benzodiazepines. However, it does have some individually calculated riskbenefit model by side effects at higher doses, and it is not weighing the linkage between untreated anxiety immediately or invariably effective in or insomnia and alcoholism, depression, and ameliorating anxiety. The efficacy of buspirone suicide (Woods and Winger, 1995). Many for older patients is still being examined; itmay researchers, moreover, argue that anxiety is precipitate some manic effects. Also, dosages undermedicated with benzodiazepines and that should be reduced for those with decreased as many as 60 percent of patients who have renal or hepatic functioning (Winger, 1993; legitimate medical or psychological reasons for Weiss, 1994; Ray et al., 1993; Bezchlibnyk-Butler high levels of stress and anxiety do not seekor and Jeffries, 1995). obtain relief for these conditions (Salzman, 1993a). Sedative/Hypnotics Salzman (1993b) makes a compelling case Sleep disturbances are a common complaint that chronic benzodiazepine use may be among older adults, occurring in approximately appropriate for patients he characterizes as half of Americans over age 65 who live at home older (but not necessarily elderly), with a and in two-thirds of those in long-term care number of chronic illnesses and compromised facilities. Complaints about insomnia, which physical and/or psychosocial functioning. This increase with advancing age, occur in group includes patients who are often in pain, conjunction with a variety of psychiatric, dysphoric, or depressed as well as anxious, medical, or pharmacological problems as well as suffering from insomnia, or willing to visit their the changing circadian rhythms that accompany physicians. Chronic users of this type may the aging process (National Institutes of Health, experience side effects from benzodiazepines or 1990; Fouts and Rachow, 1994; Mullan et al., incur mild interactions with other drugs they are 1994). taking, but they are not purposefully abusing As previously noted, benzodiazepines have psychoactive drugs or mixing them with replaced older and more toxic hypnotics (e.g., alcohol. Benzodiazepine prescriptions seem to secobarbital, ethchlorvynol, glutethimide), be clearly indicated for patients with which have a high addiction liability and overwhelming stress or anxiety that difficult-to-treat overdose potential and which compromises functioning for short periods of also tend to accumulate in older adults with time and for chronically medically ill, usually chronic dosing as their capabilities for drug older, patients (Salzman, 1993b). absorption and elimination diminish (Solomon One new drug, the serotonin agonist et al., 1993; Bezchlibnyk-Butler and Jeffries, buspirone, is a promising alternative to 1995). Nearly two out of five prescriptions for benzodiazepines for the treatment of chronic benzodiazepines (38 percent). in 1991 were anxiety with associated depressive symptoms. written for older patients (National Institutes of It apparently produces minimal sedative effects Health, 1990; Fouts and Rachow, 1994). As with and little or no impairment of cognitive or anxiolytics, the shorter acting hypnotic psychomotor functioning, is not synergistic with benzodiazepines are generally favored over most other psychoactive drugs or alcohol, and longer acting ones that tend to accumulate in has little observed potential for causing older adults and produce undesirable effects in tolerance or dependence, withdrawal, or the central nervous system. Today, the most

38 61 Prescription Drugs commonly prescribed hypnotic benzodiazepines commonly prescribed oxazepam and lorazepam are oxazepam, temazepam, triazolam, and are listed with the benzodiazepine anxiolytics. lorazepam (Fouts and Rachow, 1994). Although aging changes sleep architecture, Unfortunately, hypnotic benzodiazepines, decreasing the amount of time spent in the like the anxiolytics, also tend to be prescribed deeper levels of sleep (stages three and four) for longer than needed for efficacy, a situation and increasing the number and duration of that leads to the well-known drawbacks of awakenings during the night, these new sleep withdrawal and rebound insomnia (Fouts and patterns do not appear to bother most medically Rachow, 1994). In 1990, for example, 23 percent healthy older adults who recognize and accept of adults who used benzodiazepine hypnotics that their sleep will not be as sound or as regular (mostly the short-acting triazolam) had used as when they were younger (National Institutes them nightly for at least 4 months (Woods and of Health, 1990; Mullan et al., 1994). Rather, Winger, 1995). insomnia complaints among older adults are Figure 3-4 displays information about some usually associated with a secondary medical or sedative/hypnotics frequently prescribed for psychiatric disorder, psychosocial changes and insomnia, listing the generic name, the common stressors, or the use of medications that interfere trade name, and the elimination half-life or with sleep (National Institutes of Health, 1990; expected duration of action in the body. The Mullan et al., 1994).

Figure 3- ;-t,-,1,; .,, 1c):,;11,-,..;, 1:4,-(. b.t, CommonlyPrescribed Sedative/Hypnotics' , . ,., ItC, -.,....1 . 1 `,0 at;I ,Y1'=.Vt .1 cr tl',1-;.;.. 1.1- iil Class Drug Brand Name Elimination Half-Life for Older Adults Benzodiazepines Flurazepam Dahnane 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 Temazep am 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 Chloral hydrate Noctec 4-8 hours (loses effect in 2 weeks) derivatives Antihistamines Hydroxyzine Atarax 1-3 hours Diphen- Benadryl 8-10 hours hydramine (over-the- counter) Doxylamine Unisom 8-10 hours (over-the- counter) 'Refer to product information insert for each drug as to its suitability for use in older adults.

64 39 Chapter 3

Among the drugs causing poor sleep drug metabolism among older patients, all patterns are the antidepressant monoamine hypnotic medications should be used with oxidase (MAO) inhibitors and SSRIs; anti- caution, especially those with long half-lives Parkinson medications; appetite suppressors; (National Institutes of Health, 1990; Fouts and the beta-blocker for hypertension, propranolol Rachow, 1994; Mullan et al., 1994). As with the (Inderal); and alcohol. Sleep apnea, in anxiolytic benzodiazepines, withdrawal effects particular, may be aggravated by the use of a signifying physiological dependence are benzodiazepine (Culebras, 1992). Insomnia has common concomitants of precipitous also been related to depression and anxiety, medication discontinuation, especially of the Alzheimer's disease, Parkinson's disease, short-acting compounds. The REM sleep cardiovascular disease, arthritis, pain, urinary rebound effects from abruptly stopping a problems, prostate disease, pulmonary disease, chronically administered benzodiazepine hyperthyroidism, and endocrinopathies. Sleep hypnotic can last 1 to 3 weeks or longer (Mullan disruption as well as anxiety commonly et al., 1994; Fouts and Rachow, 1994). accompany other psychosocial adjustments such Furthermore, sedative/hypnotics, as well as as retirement, bereavement, dislocation, or benzodiazepines, used for sleep induction may traumatic situations (National Institutes of cause confusion and equilibrium problems in Health, 1990; Mullan et al., 1994). Sleep older users who get up frequently during the complaints are also associated with female night (e.g., to go to the bathroom). When gender, living alone or in a nursing facility, treating older adults, situations likely to increase activity limitations, and sleep habits such as the incidence of falls with subsequent injury excessive daytime napping (Mullan et al., 1994). should be avoided at all costs. In addition, With respect to treatment of insomnia, a 1990 drugs taken at night for sleep induction will be National Institutes of Health consensus potentiated by any alcohol the individual has development conference statement pertaining to used during the evening. sleep disorders of older adults specifically Instead of relying on drugs as a first line of cautioned against relying on hypnotic approach, treatment should initially be directed benzodiazepines as the mainstay for managing toward any underlying disorder (e.g., insomnia (National Institutes of Health, 1990). depression, alcoholism, panic states, anxiety) Although these medications can be useful for (Mullan et al., 1994). Having the patient keep a short-term amelioration of temporary sleep sleep diary may be useful for obtaining a more problems, no studies demonstrate their long- objective clarification of sleep patterns because term effectiveness beyond 30 continuous nights, insomnia is notoriously subjective. Also, the and tolerance and dependence develop rapidly importance of good sleep hygiene cannot be (Mullan et al., 1994; National Institutes of underestimated (Mullan et al., 1994; National Health, 1990; Salzman, 1993b). In fact, Institutes of Health, 1990; Fouts and Rachow, symptomatic treatment of insomnia with 1994). Patients may need to be educated about medications should be limited to 7 to 10 days regularizing bedtime, restricting daytime naps, with frequent monitoring and reevaluation if the using the bedroom only for sleep and sexual prescribed drug will be used for more than 2 to activity, avoiding alcohol and caffeine, reducing 3 weeks. Intermittent dosing at the smallest evening fluid intake and heavy meals, taking possible dose is preferred, and no more than a some medications in the morning, limiting 30-day supply of hypnotics should be exercise immediately before retiring, and prescribed. Given the changes associated with substituting behavioral relaxation techniques

40 Prescription Drugs

(National Institutes of Health, 1990; Fouts and patients to avoid hazardous confusion and falls Rachow, 1994). (Winger, 1993; Fouts and Rachow, 1994; Ray et Withdrawal from sedative/hypnotic al., 1993; Bezchlibnyk-Butler and Jeffries, 1995). medications (as well as anxiolytics) should be Because of its recent introduction, there is carefully monitored. Withdfawal is limited information available on the possible characterized by increased pulse rate, hand undesirable effects of zolpidem for the older tremor, insomnia, nausea or vomiting, and patient. anxiety. A grand mal seizure may occur in as Several antihistamines, usually used for relief many as 20 to 30 percent of dependent persons if of allergies and available as over-the-counter withdrawal symptoms are untreated. medications, are also taken as sleeping aids Hallucinations similar to those associated with because of their sedating properties (e.g., alcoholic delirium tremens (DTs) may also be Benadryl). Antihistamines are also combined present. with over-the-counter analgesics and marketed Several precautions about particular drugs as nighttime pain medications (e.g., Tylenol should be noted. Specifically, triazolam rapidly PM). However, older adults appear to be more achieved notoriety and was banned in the susceptible to adverse anticholinergic effects United Kingdom and other European countries from these substances and are at increased risk after its 1979 introduction with accompanying for orthostatic hypotension and central nervous reports of bizarre, idiosyncratic panic and system depression or confusion. In addition, delusional reactions as well as adverse side antihistamines and alcohol potentiate one effects of confusion, agitation, and anxiety another, further exacerbating the above (Woods and Winger, 1995; Winger, 1993). More conditions as well as any problems with balance. serious side effects are still more consistently Because tolerance develops within days or and more frequently reported with triazolam weeks, these antihistamines have questionable than with temazepam, a similar short-acting efficacy and are not recommended for older hypnotic benzodiazepine (Woods and Winger, adults who are living alone (Ray et al., 1993; 1995). It appears that older patients are more Fouts and Rachow, 1994; National Institutes of likely than younger ones to experience increased Health, 1990; Bezchlibnyk-Butler and Jeffries, sedation and psychomotor impairment with this 1995). medication and to report an increased incidence of adverse behavioral reactions if the dose is Opiate/Opioid Analgesics greater than 0.125 mg (Fouts and Rachow, 1994). An estimated 2 to 3 percent of Another recently introduced but popular noninstitutionalized older adults receive hypnotic, zolpidem (Ambien), does not have the prescriptions for opioid analgesics (Ray et al., anxiolytic, muscle relaxant, or anticonvulsant 1993). Opioids are undeniably effective for properties of benzodiazepines. It has been management of severe pain such as that touted as a safer sleep medication because it occurring after surgery and serious trauma and does not disrupt physiological sleep patterns at periodically in some medical illnesses (e.g., gout, low doses and appears to have relatively mild, inflammatory bowel disease). This acute pain is dose-related adverse effects. However, usually short-lived and resolves within days to zolpidem is much more costly than the weeks at most. Opioid analgesics are also used benzodiazepines, an important consideration for to treat cancer-related pain, which is low-income older patients. Also, lower doses experienced by nearly all patients with (beginning at 5 mg) must be used in older advanced disease and by one-third-to-one-half

41 6 4 Chapter 3

of patients in earlier stages. The use of opioid least of which is fear of addiction. In addition, medications for these purposes is widely patients may believe that stoicism is virtuous, acceptable in medical practice (Portenoy, 1993). that pain is an inevitable and intractable part of In addition to the rapid development of the illness or disease, or that prescribed tolerance and physiological dependence, other medications are too costly, too complex to problems are associated with opioid manage, or likely to have numerous and prescriptions for older patients. Opioid dose undesirable side effects. Clinicians also may requirements decrease with age: The onset of underprescribe because of fear of sanctions action is slowed by the decreased rate of (Portenoy, 1993). gastrointestinal absorption of orally ingested The disagreements among clinicians narcotics, and the duration of action is longer regarding management of long-term opioid because of older patients' decreased metabolism therapy reflect different perspectives regarding and liver functioning. Older adults also have the dangers and persistence of psychological more adverse side effects because of changes in dependence following physical addiction and receptor sensitivity with age. The less potent the potential for psychosocial disintegration into opioids, codeine and propoxyphene (Darvon), an addictive, drug-abusing lifestyle. Many cause sedation and mild, dose-related researchers point out that clinical populations impairment of psychomotor performance, can be successfully withdrawn from opiates and whereas the more potent opioids, oxycodone opioids without dire consequences. One study, (Percodan) and intramuscular meperidine for example, found that only 4 of nearly 12,000 (Demerol), induce substantial impairment of patients who were prescribed morphine for self- vision, attention, and motor coordination. No administration became addicted (Chapman and apparent relation between age and sedation is Hill, 1989). Other practitioners argue that observed in patients treated with morphine and patients' quality of life improves (e.g., less pentazocine (Talwin) (Solomon et al., 1993; Ray medical care utilization) if they are kept on et al., 1993). opioids and manage pain without addiction The prescribing of opioid analgesics for (Finlayson et al., 1986a, 1986b). Also, opioid chronic nonmalignant pain (not associated with analgesics are usually contraindicated if the cancer) is a controversial issue. Although long- patient has a history of alcoholism or another term treatment of chronic pain with opiates or substance abuse or dependence disorder. opioids has not traditionally been accepted by Opioid withdrawal is accompanied by either patients or physicians, a growing body of restlessness, dysphoric mood, nausea or evidence suggests that prolonged opioid vomiting, muscle aches, tearing and yawning, therapy may be both effective and feasible. diarrhea, fever, and insomnia. Although opioid Convincing and persuasive testimony has also withdrawal is uncomfortable, it is not life- been given by a number of clinicians and threatening or particularly dangerous compared medical associations regarding the successful with untreated withdrawal from management of lengthy opioid treatment in benzodiazepines. patients with chronic nonmalignant pain Figure 3-5 displays information about some (Portenoy, 1993). of the more commonly prescribed opiate/opioid These advocates note that both acute and analgesics, listing the generic and brand names chronic pain in the United States is more usually with comments about indications and effects. under- than overmedicated for a variety of patient- and provider-related reasons, not the

42 65 Prescription Drugs

Interactionsith Other the resolution of the unfavorable reaction. The aging body is also more susceptible to adverse Drugs and With Alcohol interactions. The presence of chronic diseases Drugdrug and drugalcohol interactions are of tends to increase the number of medications increased importance in older adults for several used by older adults. Thus the risk for drug reasons. Because older adults take more interactions is increased in those for whom an prescription and over-the-counter drugs than adverse reaction would be most dangerous. younger adults and many continue to drink, the Further research is needed on specific drug potential for interactions is enhanced. An drug interactions and on drug-alcohol interaction is likely to be more problematic in an combinations that can be deadly, such as alcohol older adult because of slowed metabolic and and diazepam. clearance mechanisms, resulting in a delay in

Figure 3-5 CommonlyPrescribed opiate/OpioldAnalgesics' Class Dru Brand Name Comments Opiates Methylmorphine Common ingredient of analgesics. Mor hine Codeine e.g., Tylenol III, Common ingredient of analgesics and Robitussin A-C antitussives. Can cause sedation and mild, dose-related impairment of psychomotor coordination. Opioids Hydrocodone Lortab Can produce dose-related respiratory (synthetic) depression and irregular breathing if taken in lar:e amounts. Meperidine Demerol Contraindicated if patient is taking MAO inhibitors. Can produce psychomimetic effects and impair vision, attention, and motor coordination. Oxycodone Percodan/ Can produce substantial impairment of Percocet vision, attention, and motor coordination. Propoxyphene Darvon Can produce sedation and mild, dose-related im airment of .s chomotor coordination. Pentazocine Talwin Age does not appear to increase sedative effects. 'Refer to product information insert for each drug as to its suitability for use in older adults.

43 Chapter 3

Figure 3-6 DrugAlcohol Inte.ractions 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, Acutely ingested, alcohol can increase the hypoglycemic effect of sulfonylurea drugs; sulfonylurea chronically ingested, it can decrease hypoglycemic effect of these drugs Tolbutamide, Disulfiram-like reaction chlorpropamide 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.

44 67 Prescription Drugs

Any use of drugs and alcohol carries risk, meperidine with an MAO inhibitor can cause abuse of these substances raises the risk, and marked blood pressure fluctuations, excitability, multiple drug abuse (polypharmacy) further rigidity, hyperreflexia, hyperthermia, coma, and increases the risk. A recent study documented even death. More often, however, such the many possible unfavorable reactions interactions produce subtle or mild quantitative between prescription drugs and alcohol effects. A change in sleep, appetite, or an (Korrapati and Vestal, 1995) (see Figure 3-6). increase in anxiety may be the only sign and For example, chronic alcoholics who use even could lead a clinician to increase the dose of a therapeutic doses of acetaminophen may medication that is already contributing to the experience severe hepatoxicity. Alcohol can adverse reaction. To use psychoactive increase lithium toxicity and enhance central prescription and over-the-counter drugs wisely, nervous system depression in persons taking both physicians and consumers need to tricyclic antidepressants. High doses of understand how the aging process influences benzodiazepines used in conjunction with responses to medication and to recognize how alcohol or barbiturates can be lethal (American vulnerable older adults are both to their misuse Psychiatric Association, 1994). and abuse. Drugdrug interactions can be extremely dangerous and dramaticthe combination of

68.

45 I en-64k Sc Asee-iin011, and SSSS ent

Although the vast majority of older providers have unparalleled opportunities to adults (87 percent) see physicians observe isolated, homebound seniors for regularly, their service providers possible problems and, if substance abuse is estimate that 40 percent of those who are at risk suspected, administer a nonthreatening screen. do not self-identify or seek services for Identification of substance abuse among substance abuse problems on their own older adults should not be the purview of health (Raschko, 1990). Moreover, they are unlikely to care workers alone. Friends and family of older be identified by their physicians despite the adults and staff of senior centers, including frequency of contact. Because most older adults drivers and volunteers who see older adults on a live in the community and fewer than 5 percent regular basis, are intimately acquainted with older than 65 live in nursing or personal care their habits and daily routines. Frequently they homes, training supervisors in such residences are in the best position to detect those does not offer a reasonable strategy for behavioral changes that signal a possible increasing problem identification. To ensure problem. Leisure clubs, health fairs, congregate that older adults receive needed screening, meal sites, Meals-On-Wheels, and senior day assessment, and intervention services, stepped- care programs also provide venues in which up identification efforts by health care providers older adults can be encouraged to self-identify. and multitiered, nontraditional case-finding The National Council on Aging, for example, methods within the community are essential sponsors a depression awareness program for (Raschko, 1990; De Hart and Hoffmann, 1995). use in senior programs that features a Most older adults see a medical practitioner computerized, self-administered depression test. several times per year, often for conditions that The computer offers anonymity and immediate lend themselves to collateral discussion of the results. It also avoids confidentiality problems patients' drinking habits. Thus the primary care and seems to offer a feasible model for mass setting provides an opportunity for screening screening of drinking problems. See Figure 4-1 that is currently underutilized, as is the hospital for an example of successful community case (Adams et al., 1992). Home health care finding.

47 Chapter 4

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 Gatekeepersapartment managers, meter readers, bank personnel, postal carriers, utility repair personnel, and othersare 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).

In contrast to younger substance abusers Health care providers sometimes share the whose problems are frequently identified as a ageist attitudes discussed in Chapter 1. They result of an action initiated by a family member, may not be trained to recognize signs of spouse, employer, school, police, or the courts, a substance abuse and furthermore may be substantial proportion of older adults' substance unwilling to listen attentively to older patients. abuse problems remains undetected. Unless The latter type of provider often dismisses older health, social service, and community service patients' observations about their own providers understand that alcohol and symptoms and attempts at self-diagnosis and prescription drugs can pose serious problems attributes all complaints or changes in health for older adults and take the initiative in getting status to the aging process. them the help they need, quality of life will be Family members also can impede problem diminished, independence compromised, and recognition. Biases persist against perceiving physical deterioration accelerated. older adults as alcoholics or recognizing that drinking or prescription drugs, rather than age Screening for Alcohol and or disease, may be a cause or chief contributor to Prescription Drug Abuse sleep problems, mood changes, or memory deficits (Finlayson, 1995b). Another assumption inhibiting identification is the belief that older Barriers to Screening adults do not respond to treatment, a Ageist assumptions, failure to recognize misperception flatly contradicted by studies symptoms, and lack of knowledge about showing that older adults are more likely to screening are among the barriers that inhibit complete treatment (Linn, 1978; Cartensen et al., family members, service providers, and others 1985) and have outcomes that are as good as or concerned about older adults from raising the better than those of younger patients when issue of alcohol and prescription drug abuse. treated as outpatients (Atkinson, 1995; in press). Although these are the two primary substances Identifying an older abuser of alcohol or of abuse now, providers are likely to see more prescription drugs can also be complicated by marijuana and other drug use among adults the number of other conditions with similar over 60 in the coming years. symptoms. Warning signs can be easily confused with or masked by concurrent illnesses 48 d0 Identification, Screening, and Assessment

and chronic conditions. For example, sleep his or her regular physical examination. problems, falls, anxiety, or confusion can be However, problems can develop after the attributed to a variety of nonalcohol-related screening has been conducted, and concurrent diseases and disorders or dismissed as illnesses and other chronic conditions may mask symptomatic of old age. Screeners who use abuse. Although no hard and fast rules govern amount and frequency levels appropriate for the timing of screening, the Panel recommends younger adults as a gauge can also miss an older screening or rescreening if the physical adult's alcohol problem (see Chapter 2). symptoms listed in Figure 4-2 are present or if Finally, many health care and social service the older person is undergoing major life providers are unaware that effective, validated changes or transitions such as those discussed instruments are available for screening older below. adults or are intimidated by the prospect of As older patients undergo key life transitions using them. Many screens, moreover, take only or take on new and stressful roles, vulnerability a few minutes to administer and require little or to alcohol or prescription drugs may increase. no specialized training to score and interpret. Risk factor life transitions include menopause, a Screening instruments are discussed in more newly "empty nest," and approaching detail below. retirement. Assuming new roles such as caretaker for an ailing relative or custodian of Who and When To Screen young grandchildren also makes older adults Ideally, every 60-year-old should be screened for more vulnerable. Any of these changes should alcohol and prescription drug abuse as part of trigger an alcohol screen.

Figure 4-2 Physital Syniptom 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 Fresuent falls and unex .lained bruisin: 74 49 Chapter 4

Introducing the Topic of Screening "Does drinking help you feel better [or get to sleep more easily, etc.]? How do you feel the Depending on the setting, the topic of screening day after you have stopped drinking?" can be introduced in a number of ways. Self "Have you ever wondered whether your administered and self-scored mass screenings drinking interferes with your health or any can be a part of a larger presentation at an other aspects of your life in any way?" American Association of Retired Persons or oi"Where and with whom do you typically leisure club meeting on the topic of alcohol's drink?" (Drinking at home alone signals at- effects on older adults. Self-administered but risk or potentially abusive drinking.) machine-scored computerized screens can be "How do you typically feel just before your offered as part of a similar program conducted first drink on a drinking day?" at senior centers, retirement homes, or assisted "Typically, what is it that you expect when living residences with access to computers. you think about having a drink?" (Note: Visiting nurses and home health aides can Positive expectations or consequences of integrate a brief alcohol screen into the list of alcohol use in the presence of negative affect health questions normally posed to patients. For and inadequate coping skills have been example, in asking about medication, the health associated with problem drinking.) care provider could say, "We understand more If less direct questioning seems appropriate, today about the effects of even small amounts of other useful questions for identifying alcohol on medication, and I want to be sure that nothing is interfering with your coumadin or problematic alcohol or prescription drug use include affecting your overall progress in any way. Let's review how much alcohol you're drinking "Are you having any medical or health and take a look at all your medications." problems? What symptoms do you have? It is preferable to use standardized screening What do you think these mean? Have you questionnaires, but friendly visitors, Meals-On- felt this way before?" Wheels volunteers, caretakers, and health care "Do you see a doctor or other health care providers also can interject screening questions provider regularly? When was the last time? into their normal conversations with older, Do you see more than one? Why? Have you homebound adults. Comfort with this line of switched doctors recently? Why?" questioning will depend on the person's "Have you experienced any negative or relationship with the older person and the unwanted events that altered the way you responses given; however, anyone who is lived (in the last 5 years)? Any since we last concerned about an older adult's drinking met? How much of an impact did the event practices can try asking direct questions, such as have on the way you lived or felt? What feelings or beliefs did it cause or change? Do "Do you ever drink alcohol?" you believe that you are coping with the "How much do you drink when you do changes in a healthy fashion? How drink?" (specifically) do you manage (control) the m "Do you ever drink more than four drinks on circumstances (consequences) of the one occasion?" problem(s) or event(s)?" "Do you ever drink and drive?" "What prescription drugs are you taking? "Do you ever drink when you're lonely or Are you having any problems with them? upset?" May I see them?" (This question will need to

50 7 2 Identification, Screening, and Assessment

be followed by an examination of the actual great significance to its efficacy and personal containers to ascertain the drug name, impact prescribed dose, expiration date, prescribing Worrying about having enough pills or physician, and pharmacy that filled each whether it is time to take them to the extent prescription. Note whether there are any that other activities revolve around the psychoactive medications. Ask the patient to dosage schedule bring the drugs in their original containers.) O Continuing to use and to request refills when "Where do you get prescriptions filled? Do the physical or psychological condition for you go to more than one pharmacy? Do you which the drug was originally prescribed has receive and follow instructions from your or should have improved (e.g., prescription doctor or pharmacist for taking the of sleeping pills after the death of a loved prescriptions? May I see them? Do you one); resisting cessation or decreasing doses know whether any of these medicines can of a prescribed psychoactive drug interact with alcohol or your other Complaining about doctors who refuse to prescriptions to cause problems?" write prescriptions for preferred drugs, who "Do you use any over-the-counter drugs taper dosages, or who don't take symptoms (nonprescription medications)? If so, what, seriously why, how much, how often, and how long Self-medicating by increasing doses of have you been taking them?" prescribed psychoactive drugs that aren't "helping anymore" or supplementing Nonmedical caretakers, volunteers, and aides prescribed drugs with over-the-counter may opt to ask only the four CAGE questions, medications of a similar type reproduced in Figure 4-3 and discussed in the ES Rating social events by the amount of alcohol Screening Instruments section. If the older adult dispensed answers yes to any of the four, refer to a Ell Eating only at restaurants that serve alcoholic clinician for evaluation. If the questioner beverages (and wanting to know whether suspects that prescription drug abuse may be they do in advance) occurring and the older adult is defensive about Ell Withdrawing from family, friends, and his or her use, confused about various neighbors prescription drugs, seeing more than one doctor, E Withdrawing from normal and life-long or using more than one pharmacy, a clinician social practices should probably be notified to probe further. Cigarette smoking Other warning signs that may emerge in Involvement in minor traffic accidents conversation and should prompt a more in- (police do not typically suspect older adults depth screen or an assessment include of alcohol abuse and may not subject them to Excessively worrying about whether BreathalyzerTM and other tests for sobriety) prescription psychoactive drugs are "really Sleeping during the day

working" to alleviate numerous physical Eg Bruises, burns, fractures, or other trauma, complaints; complaints that the drug particularly if the individual does not prescribed has lost its effectiveness over time remember how and when they were (evidence of tolerance) acquired Displaying detailed knowledge about a Drinking before going to a social event to specific psychoactive drug and attaching "get started"; gulping drinks, guarding the

'7 51 Chapter 4

supply of alcoholic beverages, or insisting on changes. Motivational interviewing is mixing own drinks nonconfrontational, egalitarian, and supportive. Changes in personal grooming and hygiene When screening anyone, especially older Expulsion from housing adults, empathy is crucial. However, in Empty liquor, wine, or beer bottles or cans in attempting to he nonconfrontational and the garbage or concealed under the bed, in circumspect, it is also important to avoid using the closet, or in other locations. euphemisms that minimize the problem. Older adults with alcohol and prescription drug Asking Screening Questions problems are just as likely to engage in denial Screening questions should be asked in a and rationalization as younger adults; those confidential setting and in a nonthreatening, who are inadvertently misusing a prescription nonjudgmental manner. Many older adults are drug or who are unaware that their customary acutely sensitive to the stigma associated with drink before dinner may now be causing alcohol and drug abuse and are far more willing problems are unlikely to be defensive about to accept a "medical" as opposed to a acknowledging the need to change. "psychological" or "mental health" diagnosis as Cognition and Collateral Reporting an explanation for their problems. Prefacing questions with a link to a medical condition can Impaired cognition interferes with screening, make them more palatable. For example, "I'm making it difficult to obtain complete and wondering if alcohol may be the reason why accurate answers. Although it is important to your diabetes isn't responding as it should," or, respect the older adult's autonomy, collateral "Sometimes one prescription drug can affect participation from family members or friends how well another medication is working. Let's may be necessary in situations where a coherent go over the drugs you're taking and see if we response is unlikely. In this case, the screener can figure this problem out." It is vitally should first ask for the older adult's permission important to avoid using stigmatizing terms like to question others on his or her behalf. If alcoholic or drug abuser during these encounters. possible, the screen should be administered to Another technique that may help when collaterals in private, using a nonconfrontational talking with older adults is active listening approach. "I'm concerned about your father's (Egan, 1994). The four components of active deteriorating condition and wonder if his use of listening are (1) observing and reading the alcohol may be having a negative impact. Have person's nonverbal behaviorposture, facial you or anybody else in the family had any expressions, movement, and tone of voice; (2) concerns about his drinking?" Because listening to and understanding the person's circumstances differ within families, family verbal communication; (3) listening in context, members may not know or may be unwilling to that is, to the whole person in the context of the respond honestly to that query. Another social settings of his or her life; and (4) listening question that skilled clinicians find useful in to sour notes, that is, things the person says that collateral screening is, "Has anybody in your may have to be challenged. Motivational family ever had a problem with drinking?" A interviewing techniques also can be applied positive response suggests that a problem may when screening older adults. Essentially this exist and that more in-depth questioning should approach, which is described in more detail in follow. Chapter 5, assumes that the patient is both Sometimes collateral screening unleashes a capable of and responsible for initiating needed family member's simmering anger toward the 52 74 Identification, Screening, and Assessment older adult for both past and current alcohol- Although two or more positive responses are related behavior. It is important to be alert to considered indicative of an alcohol problem, a this possibility and to be prepared to work with positive response to any one of these questions the family member to discourage a should prompt further exploration among older confrontation with the older adult when the adults. The CAGE is most effective in screen concludes. identifying more serious problem drinkers, including those with abuse and dependence, Screening Instruments and less effective for women problem drinkers The CAGE Questionnaire (Ewing, 1984) and the than their male counterparts. Michigan Alcoholism Screening TestGeriatric The MAST-G was developed specifically for Version (MAST-G) (Blow et al., 1992a) are two older adults (see Figure 4-4) and has high well-known alcohol screening instruments that sensitivity and specificity among older adults have been validated for use with older adults. recruited from a wide range of settings, One of the most widely used alcohol screens, the including primary care clinics, nursing homes, CAGE consists of four questions, can be self- and older adult congregate housing locations. administered even by those with low literacy Although the Alcohol Use Disorders reading skills (see Figure 4-3), and can be Identification Test (AUDIT) (Babor et al., 1992) modified to screen for use of other drugs. has not been evaluated for use with older adults, Positive responses on the CAGE are for lifetime it has been validated cross-culturally. Because problems, not current ones. Before there are few culturally sensitive screening administering the CAGE, the MAST-G, or any instruments, the AUDIT (in the opinion of the other screen, ascertain that the person does Consensus Panel) may prove useful for currently drink alcohol and that the questions identifying alcohol problems among older that are endorsed are for problems that they members of ethnic minority groups (see have experienced recently, usually within the Appendix B). last year. Laboratory tests are generally used only to supplement the screens detailed above Figure 4-3 (Beresford et al., 1990; Finlayson and Hurt, in The CAGE Questionnaire press). Some researchers have found, however, 1. Have you ever felt you should cut down on that certain abnormalities associated with your drinking? alcoholism appeared more often among 2. Have people annoyed you by criticizing your alcoholics older than 64 than among younger drinking? alcoholics. Those abnormalities appeared in 3. Have you ever felt bad or guilty about your tests of mean corpuscular volume, uric acid, drinking? serum albumin, mean corpuscular hemoglobin, 4. Have you ever had a drink first thing in the and aspartate aminotransferase (Hurt et al., morning to steady your nerves or to get rid 1988). of a hangover (eye opener)? Scoring: Item responses on the CAGE are scored Communicating Positive 0 for "no" and 1 for "yes" answers, with a Screening Results higher score an indication of alcohol problems. A total score of 2 or greater is considered To ease the process of communicating positive clinically significant. screening results to older patients, the Panel Source: Ewing, 1984. recommends the following approach: 7 5 53 Chapter 4

Describe the impact that alcohol or needs to be detoxified. In this case, prescription drug abuse is having on the admission to an inpatient unit for older adult's health or functional status: detoxification may be the most prudent "The screening results indicate that alcohol choice. Referral to an outpatient may be having a negative effect on your detoxification center that can monitor the blood pressure." person daily is appropriate if there is social o Immediately follow up by noting: "This is support at home. very treatable. Cutting down on the amount Before discussing results with an older adult, you drink" or "giving up drinking clinicians must be prepared with information altogether" or "reducing your use of about community resources available to assist in chlordiazepoxide (Librium)" or "using other coping with this problem (e.g., meeting dates, methods to help you sleep... will help you times, and locations of Alcoholics Anonymous maintain your independence" or "help keep and other self-help recovery groups whose you out of a nursing home" or "decrease the membership is largely 55 and older; contact and likelihood of future hip fractures" or "keep eligibility information for treatment programs you from getting so confused." In other that respond to the special needs of older words, spell out how reduction or cessation adults); the older adult's available supports (e.g., of use will improve the person's life. Most Is transportation available? Is the recommended problem drinkers cannot address their program affordable or covered by insurance?); problems by reducing use, so emphasize the and the older adult's special needs (e.g., Is the importance of abstinence by saying program bilingual or wheelchair accessible?). something like: "Though I strongly See Chapter 5 for more on treatment options. In recommend you stop altogether, cutting addition, a strategy for responding to denial or down is a good start." refusal to follow through with a plan of action Present the options for addressing the should be in place. With the agreement of an problem: If the problem seems severe, "I'd older adult involved in a self-help group or like to do a complete assessment (or refer treatment program, clinicians can broker an you to someone for assessment) so we know introduction to a peer "who's been there." how to proceed"; or if the problem appears Frequently, these "veterans" will accompany to be in the early stages of development, "I'd prospective members to meetings and mentor like to see you change your drinking habits them through the treatment process. to no more than one beer (drink) per day. For some older adults coming to grips with We'll monitor your progress over the next an alcohol or prescription drug problem, few weeks and see if this will help with your repeated contacts will be necessary before they hypertension." This is a good time to explore are willing to cooperate with a referral. the patient's willingness to change by Clinicians have observed that this process is adding, for example, "Would you be willing akin to planting and nurturing a seed. Bringing to change your drinking habits if the other the seed to fruition, however, ultimately problems we have discussed improve?" depends on the older adult. Occasionally, a situation may appear dire, and the clinician suspects that the older adult

54 76 Identification, Screening, and Assessment

Figure 4-4- Michigan Alcoholism Screening TestGeriatric Version; (MAST-C)

1. After drinking have you ever noticed an increase in your heart rate or beating in your chest? YES NO 2. When talking with others, do you ever underestimate how much you actually drink? YES NO 3. Does alcohol make you sleepy so that you often fall asleep in your chair? YES NO 4. After a few drinks, have you sometimes not eaten or been able to skip a meal because you didn't feel hungry? YES NO 5. Does having a few drinks help decrease your shakiness or tremors? YES NO 6. Does alcohol sometimes make it hard for you to remember parts of the day or night? YES NO 7. Do you have rules for yourself that you won't drink before a certain time of the day? YES NO 8. Have you lost interest in hobbies or activities you used to enjoy? YES NO 9. When you wake up in the morning, do you ever have trouble remembering part of the night before? YES NO 10. Does having a drink help you sleep? YES NO 11. Do you hide your alcohol bottles from family members? YES NO 12. After a social gathering, have you ever felt embarrassed because you drank too much? YES NO 13. Have you ever been concerned that drinking might be harmful to your health? YES NO 14. Do you like to end an evening with a nightcap? YES NO 15. Did you find your drinking increased after someone close to you died? YES NO 16.In general, would you prefer to have a few drinks at home rather than go out to social events? YES NO 17. Are you drinking more now than in the past? YES NO 18. Do you usually take a drink to relax or calm your nerves? YES NO 19. Do you drink to take your mind off your problems? YES NO 20. Have you ever increased your drinking after experiencing a loss in your life? YES NO 21. Do you sometimes drive when you have had too much to drink? YES NO 22. Has a doctor or nurse ever said they were worried or concerned about your drinking YES NO 23. Have you ever made rules to manage your drinking? YES NO 24. When ou feel lonel,does havin: a drink helm? 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 TestGeriatric 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.

77 55 Chapter 4

for a retired person can still be placed on Communicating Negative maintaining a dwelling, managing finances, or Screening Results participating in social or recreational activities. "Recurrent substance use in situations in which The process of conveying negative screening it is physically hazardous," a substance abuse results provides an important opportunity to criteria in the DSM-IV (American Psychiatric reinforce healthy practices and educate older Association, 1994, p. 183), need not mean adults about the impact that alcohol and driving drunk: Climbing a ladder, crossing a prescription drugs have on aging systems. street, or taking a bath while impaired by However, even older adults who have had alcohol is dangerous for a frail, older person. negative screening results may need screening With respect to toleranceone of the DSM- repeated in the future. As discussed previously, IV criteria for a diagnosis of substance life events render older adults vulnerable to dependencethe aging process itself, as well as developing problems; as the changes occur, other concurrent medical diseases commonly screening questions should be asked again and found in older patients, lowers the threshold for the benefits of maintaining healthy habits onset of physiological dependence on reemphasized. prescription drugs. The presence of tolerance among older adults is not necessarily Assessment characteristic of substance-related psychological dependence. Conversely, the absence of For older adults with positive screens, an tolerance to alcohol does not necessarily mean assessment is needed to confirm the problem, to that an older adult does not have a drinking characterize the dimensions of the problem, and problem. To be useful in assessing older adults, to develop an individualized treatment plan. the DSM-IV criteria must be interpreted age- For purposes of insurance or other funding appropriately. (See Figure 2-3, which presents resources, the assessment should follow criteria the DSM-IV criteria for substance dependence as in the Diagnostic and Statistical Manual of Mental they apply to older adults with alcohol Disorders, Fourth Edition (DSM-IV) (American problems.) Psychiatric Association, 1994) or other relevant Because the assessment process can be time- criteria, bearing in mind that these criteria may consuming and expensive, the Institute of not apply directly to planning older adults' Medicine (IOM) recommends (and the Panel treatment. The unqualified application of such supports) a sequential approach that looks at criteria is problematic in older adult populations various dimensions of an older adult's because the symptoms of other medical diseases suspected problem in stages so that unnecessary and psychiatric disorders overlap to a tests are not conducted (Institute of Medicine, considerable extent with substance-related 1990). disorders. In addition, as discussed in Chapter 2, the Substance Abuse Assessment altered social roles and circumstances of older Instruments adults may further reduce the applicability of Although informed clinical judgment is essential the criteria. For example, interference with for a sound assessment, validated substance occupational activities or work obligations may abuse assessment instruments can provide a no longer be relevant as a manifestation of useful structured approach for many clinicians maladaptive functioning, although the emphasis as well as a convenient checklist of items that 56 78 Identification, Screening, and Assessment should be consistently evaluated during the Assessing Functional Abilities assessment. In general, specialized assessment Functional health refers to a person's capacity to is conducted by treatment program personnel or perform two types of everyday tasks: activities specially trained health care providers. As of daily living (ADLs), which include described by the IOM, structured assessment ambulating, bathing, dressing, feeding, and interviews "possess (at least potentially) the using the toilet, and instrumental activities of desired qualities of quantifiability, reliability, daily living (IADLs), which include managing validity, standardization, and recordability" finances, preparing meals, shopping, taking (Institute of Medicine, 1990, pp. 267-268). medications, and using the phone. Limitations Based on their experience, the Consensus in these domains, sometimes referred to as Panelists recommend the use of two structured disabilities, can result in an inadequate diet, assessments with older adults: the Structured mismanagement of medications or finances, or Clinical Interview for DSM-III-R (SCID) (Spitzer other serious problems. These disabilities are and Williams, 1985) and the Diagnostic major risk factors for institutionalization and are Interview Schedule (DIS) for DSM-IV (Robins et more likely than physical illness or mental al., 1981). health problems to prompt older adults to seek The SCID is a multimodule assessment that treatment. covers Impairments in functional abilities are Substance use disorders common in older adults with medical and Psychotic disorders psychiatric disorders. For instance, 90 percent of Mood disorders adults over the age of 65 require the use of Anxiety disorders glasses and 50 percent of adults over 65 have Somatoform disorders some degree of hearing loss (Hull, 1989; Plomp, Eating disorders 1978). Sensory impairments affect older adults Adjustment disorders in subtle ways that are not always immediately Personality disorders. obvious to health practitioners but need to be anticipated, identified, and incorporated into It takes a trained clinician approximately 30 treatment practices. Clinicians should ensure minutes to administer the 35 SCID questions that older patients, for example, can read their that probe for alcohol abuse or dependence. prescriptions or hear what is said in a group The DIS is a highly structured interview that therapy session. When not considered and does not require clinical judgment and can be compensated for, functional impairments can used by nonclinicians. The DIS assesses both obstruct treatment. For example, it would be current and past symptoms and is available in a futile to enroll an older patient who is obese and computerized version. It has been translated has limited mobility in a program housed in a into a number of languages including Spanish facility with steep flights of stairs and no and Chinese. elevator. Likewise, it makes little sense to recommend an evening program to older adults Special Assessments who cannot drive at night and do not have For some older adults, it may be impossible to someone else to drive them. understand the true impact of their alcohol and Alcohol use can diminish IADLs and ADLs. drug use or to recommend appropriate Although alcohol-related functional treatment services without a full assessment of impairments are potentially reversible, they their physical, mental, and functional health. should be considered when planning a 57

Q o Chapter 4

treatment regimen. There are known can worsen other conditions such as complications of and differences between hypertension or congestive heart failure. alcohol use in men and women related to The existence of comorbid medical and compromised functional abilities and ADLs. In psychiatric disorders will influence treatment a recent study of older adults with a former choice and priorities and will affect treatment history of alcohol abuse, impairment in ADLs outcome. Frail or medically compromised was twice as common in women as in men alcohol abusers, for example, may require more (Ensrud et al., 1994). In addition, alcohol use intensive monitoring during the detoxification was more strongly correlated with functional period of treatment than their more robust impairment than were smoking, age, use of peers. When disorders such as uncontrolled anxiolytics, stroke, or diminished grip strength. hypertension or depression are detected, To identify functional impairments, the Panel reducing alcohol consumption becomes a recommends measuring the ADLs and the priority; until drinking is curbed, medication IADLs with the instruments in Appendix B. prescribed for those conditions will not work Another useful instrument is the Medical effectively. In contrast, for older adults Outcomes Study 36-Item Short Form Health suffering from chronic pain, the priority would Survey (SF-36), a self-report questionnaire that be to identify an effective painkiller, then taper measures health-related quality of life, including the amount of alcohol consumed. both ADLs and IADLs (McHorney et al., 1994). Although this instrument is more Physical comorbidities comprehensive, it is also more difficult to use Studies have shown that the most common because of complex scoring of the various health problem among alcohol-dependent older adults is alcoholic liver disease. Chronic subscales. The SF-36 does provide, however, a comprehensive assessment of health and not just obstructive pulmonary disease, peptic ulcer functional abilities. These instruments can be disease, and psoriasis also are found much more used by health care providers in a range of frequently in older alcoholics than in older settings. adults with no alcohol problems. Alcohol also appears to be a risk factor for myopathy, Assessing Comorbid Disorders cerebrovascular disease, gastritis, diarrhea, The relationship between alcohol use and a pancreatitis, cardiomyopathy, sleep disorders, coexisting physical or mental disorder can take HIV/AIDS-related diseases, and both many different forms. At one extreme, medical intentional and unintentional injuries (Tobias et and psychiatric problems can coexist with al., 1989). alcohol use with no specific relationship to Malnutrition among older adults may be due drinking. Alternatively, those problems may be to such conditions as poverty or a cognitive precipitating or maintenance factors for dysfunction and is especially important to drinking. The use of alcohol to anesthetize pain diagnose and correct. Older substance-abusing is an example of a maintenance factor; alcohol adults on fixed incomes frequently have to use can then become its own problem or cause choose among buying food, the prescriptions drug interaction problems with prescribed pain they need to manage illness, or the substance medications. Medical or psychiatric problems they abuse. If malnutrition is caused by such as alcoholic cirrhosis or cognitive deficits economic conditions, it is appropriate for social are other possible consequences of drinking. service agencies or private food-related Even when the link is not so direct, alcohol use programs to be brought into the equation to help alleviate the problem. 58 0 Identification, Screening, and Assessment

Poor nutrition also may stem from a life Cognitive impairments change such as a spouse dying: An older person The presence of cognitive impairment or may stop preparing meals if he or she no longer dementia significantly alters treatment has someone to cook for or eat with; a bereaved decisions. It is particularly important to or frail person may not have the energy to shop distinguish between dementia and delirium, or cook. Many adults with alcohol problems, which are often mistaken for each other by however, "drink their calories" instead of eating clinicians diagnosing older patients (see Figure food. Along these same lines, a provider should 4-5). determine whether or not the older person is Dementia is a chronic, progressive, and dehydrated, another possible indicator of generally irreversible cognitive impairment alcohol problems. sufficient to interfere with an individual's daily Acute alcohol withdrawal syndrome is more living. Dementia will also limit an individual's protracted and severe in older adults than in ability to interact in traditional group settings. younger adults (Brower et al., 1994; Liskow et Common causes of dementia include al., 1989). Because there is no research on the Alzheimer's disease, vascular disorders (e.g., recent practice of outpatient detoxification for multi-infarct dementia), and alcohol-related older adults, very careful assessment is dementia. Dementia also makes it more difficult warranted before detoxification from any drug; to monitor outcomes of drinking (patients may outpatient detoxification may not be appropriate forget they drank), to get into treatment, and to for older adults who are frail or who have a benefit from the treatment. comorbidity. Delirium is a potentially life-threatening illness that requires acute interventionusually Psychiatric comorbidities hospitalization. The cognitive losses Data from the Epidemiologic Catchment Area experienced with delirium, unlike the effects of (ECA) study have strengthened support for a dementia, can often be reversed with proper possible link between alcohol use and abuse and medical treatment. the development of other psychiatric illnesses Dementia (Regier et al., 1990). Adults with a lifetime Changes in cognition are not unusual as people diagnosis of alcohol abuse or dependence had age, and they increase in frequency with each nearly three times the risk of being diagnosed decade. Such changes, which are experienced in with another mental disorder. Comorbid varying degrees, include minor short-term disorders associated with alcohol use include memory loss and difficulty with certain anxiety disorders, affective illness, cognitive mathematical functions. However, significant impairment, schizophrenia, and antisocial memory loss, impaired abstract thinking, personality disorder (Finlayson et al., 1988; Blow confusion, difficulty communicating, extreme et al., 1992b; Blazer and Williams, 1980; emotional reactions and outbursts, and Saunders et al., 1991; Os lin and Liberto, 1995; disorientation to time, place, and person are Wagman et al., 1977). According to one study, signs of cognitive impairment and are not part of older alcohol abusers are more likely to have the normal aging process. triple diagnosesalcohol, depression, and Dementia can range from a mild level of personality disorderswhereas younger cognitive impairment that is easily managed to a substance abusers are more likely to have severe stage that may require intensive diagnoses of schizophrenia (Speer and Bates, treatment and nursing home care. Common 1992). symptoms of dementia are presented in Figure

59 8.1. Chapter 4

4-5. Symptoms described may not be equally the Folstein Mini-Mental Status Exam (MMSE) present in all older adults experiencing (Folstein et al.,1975),which is an acceptable dementia. The most common causes of alternative. It should be noted that in the dementia in older adults are Alzheimer's disease assessment of older problem drinkers who have and vascular dementia. recently (in the past30to 60 days) attained Screening for significant cognitive sobriety in an outpatient setting, the MMSE can dysfunction can be accomplished easily byany be insensitive to subtle cognitive impairments. of a number of screening instruments. Patients Furthermore, because the MMSE is weak on who have been medically detoxified should not visual-spatial testing, which is likely to show be screened for several weeks after some abnormality in many recent heavy detoxification. Until they are fully recovered, drinkers, and does not include screening tests of they may exhibit some reversible cognitive abstract thinking and visual memory, the Panel impairment. The Panel recommends two recommends using the "draw-a-clock task" screens: the Orientation/Memory/ (Watson et al.,1993)and the Neurobehavioral Concentration Test (Katzman et al.,1983),which Cognitive Status Examination (NCSE) (Kiernan is simple and can be completed in the office, and et al.,1987)as supplements.

Figure 4-5 CoMparison of Dementia and Delirium: Characteristics andCauses Dementia Delirium

Characteristics Impairments in short- and long-term Inability to appreciate and respond memory, abstract thinking, and normally to the environment, often with judgment altered awareness, disorientation, inability Aphasia (language disorder) to process visual and auditory stimuli, and Apraxia (inability to carry out motor other signs of cognitive dysfunction activities despite intact comprehension Potentially life-threatening and motor function) Acute onset Agnosia (inability to recognize or identify Clouding of consciousness items despite intact sensory function) Reduced wakefulness Constructional difficulty (inability to copy Disorientation to time and space three-dimensional figures, assemble Increased motor activity (e.g., restlessness, blocks, or arrange sticks in specific plucking, picking) designs) Impaired attention and concentration Personality change or alteration and Impaired memory accentuation of premorbid traits Anxiety, suspicion, and agitation Mood disturbances Variability of symptoms over time Loss of self-care abilities Misinterpretation, illusions, or hallucinations Disrupted thinking, delusions, speech abnormalities

60 86. Identification, Screening, and Assessment

Figure 4-5 (Continued)

Dementia Delirium

Causes Most Common Causes Common Intracranial Causes Alzheimer's disease Infections (e.g., meningitis, encephalitis) Vascular dementia Seizures Alcohol-related dementia Stroke Common Metabolic/Toxic Causes Subdural hematomas Chronic drug-alcohol-nutritional abuse Tumors (e.g., Wernicke-Korsakoff syndrome) Common Extracranial Causes Organ system failure Anesthesia Anoxia Drugdrug or alcoholdrug interactions Folic acid deficiency Intoxication and/or withdrawal from Hypothyroidism alcohol or drugs (particularly psychoactive Bromide intoxication drugs) Hypoglycemia Toxic effects of prescribed or over-the- counter drugs Common Infectious Causes Giant cell arteritis (a chronic inflammatory Neurosyphilis paresis (a syphilitic process involving the extracranial arteries) infection manifested as dementia, Hip fracture seizures, and problems walking and standing) Hydrocephalus (increased fluid in the brain) AIDS/HIV-related disorders Hypercapnia (reduced ventilation often associated with chronic obstructive Meningitis pulmonary disease) Encephalitis Infections Other Common Causes Dehydration Huntington's Chorea Malnutrition Parkinson's disease Metabolic disturbances (e.g., liver or kidney Jakob-Creutzfeldt disease failure, electrolyte disturbances, hyper- or hypoglycemia, diabetes, thyroid disorders) Lewy body's dementia Myocardial infarction (heart attack) Sudden environmental changes Depression

Delirium characteristics of this syndrome and its common Delirium, also known as acute confusional state causes. Symptoms presented may occur in any and acute brain syndrome, is an alteration of combination and may be intermittent. In mental status that can usually be reversed with addition to the causes listed in Figure 4-5, medical treatment. Figure 4-5 presents the benzodiazepine use prior to hospitalization has 61 83 Chapter 4

been demonstrated to be a significant risk factor were long-term deficits in learning novel for the development of delirium among associations (Brandt et al., 1983). It should be hospitalized older adults. This suggests that noted that most of these patients were moderate these individuals had classical withdrawal consumers of alcohol, and all were healthy with delirium from the benzodiazepines or that mild no history of dementia. A more recent withdrawal in addition to other risk factors epidemiologic study of older African-American greatly increases the incidence of delirium. The men found that increasing amounts of alcohol Confusion Assessment Method (CAM) (Inouye consumption were associated with worsening et al., 1990) is widely used as a brief, sensitive, performance on dementia screening scales and reliable screening measure for detecting (Hendrie et al., 1996). delirium. The Panel recommends that a positive delirium screen be followed by careful clinical Affective disorders diagnostics based on DSM-IV criteria and that Affective disorders, common in older patients, any associated cognitive impairment be also influence treatment choices. For example,a followed clinically using the MMSE. patient with an affective disorder who takes psychotropic drugs requires a treatment Other cognitive impairments program with a staff familiar with these Alcohol abuse and dependence are directly medications. Suicidal patients require intensive correlated with other potential causes of inpatient programs and an immediate cognitive impairment, including trauma from intervention. Significant depressive symptoms, falls, motor vehicle crashes or other accidents, which are a common reaction after and the development of Wernicke-Korsakoff detoxification, can be worse in older adults than syndrome (Smith and Atkinson, 1997). The in younger patients and may require prescribed latter is clinically characterized by cognitive medicines to alleviate the depression before the deficits (especially anterograde memory abuse or addiction therapy is resumed. As deficits), gait ataxia, and nystagmus. Its noted below, research in the area of mental pathophysiology usually involves the lack of the health comorbidities supports these findings. vitamin thiamine. It is important to screen for Comorbid depressive symptoms are not only Wernicke-Korsakoff syndrome because it is a common in late life, but are also an important potentially reversible cause of cognitive factor in the course and prognosis of psychiatric impairment (Victor et al., 1989; Grant, 1987). disorders. Depressed alcoholics have been The extent to which alcohol use interferes shown to have a more complicated clinical with performance on neuropsychological testing course of depression with an increased risk of has been well reviewed (Victor et al., 1989; Grant suicide and more social dysfunction than et al., 1984). Several studies have demonstrated nondepressed alcoholics (Conwell, 1991; Cook et acute effects of alcohol on abstraction and al., 1991). Moreover, they were shown to seek visual-spatial problems but not on verbal skills. more treatment. However, relapse rates for Less is known about the role of alcohol use in alcoholics did not appear to be influenced by the causing permanent cognitive changes. Studies presence of depression. Alcohol use prior to late have demonstrated that among nondemented life has also been shown to influence treatment alcoholics, abstinence leads to marked of late-life depression. Cook and colleagues improvement in cognitive deficits (Brandt et al., found that a prior history of alcohol abuse 1983; Grant et al., 1984). However, Brandt and predicted a more severe and chronic course for colleagues demonstrated that among subjects depression (Cook et al., 1991). with prolonged periods of abstinence, there

62 84 Identification, Screening, and Assessment

Screening instruments for depression can be health personnel skilled in responding to those extremely useful as methods of detecting disorders. significant affective illness and for monitoring Although suicide is not a specific psychiatric changes in affective states. The Geriatric disorder, the Panel believes that there is a Depression Scale (GDS) Short Form (Sheikh and significant relationship among aging, alcohol Yesavage, 1986) and the Center for use, and suicide. People older than 65 account Epidemiological StudiesDepression Scale for 25 percent of the national suicide rate (CES-D) (Radloff, 1977), reproduced in (Conwell, 1991). Patients who attempt suicide Appendix B, have been validated in older age require immediate and intensive inpatient groups although not specifically in older adults therapy for as long as the illness persists. with addiction problems. The Panel Providers must be alert to the possibility of recommends the CES-D for use in general major depression, which is common in older outpatient settings as a screen for depression adults, evolving into suicidal tendencies. It among older patients. helps if family and significant others, clergy, social workers, and home health care providers Sleep disorders are knowledgeable about the warning signs for As discussed in Chapter 2, sleep disorders and suicide, because these symptoms are more sleep disturbances represent another group of frequently manifested in nonclinical settings. comorbid disorders associated with excessive alcohol use and with aging (Os lin and Liberto, Moving the Older Adult 1995; Wagman et al., 1977; Moeller et al., 1993). Older adults sometimes self-medicate their sleep Into Treatment disturbances with alcohol (Wagman et al., 1977): After determining that an older adult may Panel members had all heard older patients say benefit from a reduction in or complete that drinking helps them sleep. abstention from alcohol use, the clinician must The Panel recommends that sleep history be next assess the patient's understanding of this recorded in a systematic way in order to both benefit. Many older adults may not know that document the changes in sleep problems over their alcohol use is affecting their health. time and heighten the awareness of sleep Because patient understanding and cooperation hygiene. The Pittsburgh Sleep Quality Index are essential both in eliciting accurate (Buysse et al., 1988) is useful as both a research information and following through on the and screening scale but is difficult for clinicians treatment plan prescribed, clinicians should use to interpret and cumbersome to use. Clinicians the assessment process as an opportunity to may opt to carefully document sleep patterns educate the older adult and to motivate him or and disturbances themselves rather than use this her to accept treatment. instrument (Nitcher et al., 1993). Interacting With Older Adults Other psychiatric disorders There are other psychiatric disorders (e.g., Many health care professionals rarely interact schizophrenia, obsessive and compulsive with older adults. To facilitate the assessment behaviors) that complicate the treatment of process with this population, the Consensus abuse and addiction. In these instances, Panel recommends that clinicians adhere to the treatment options must be evaluated on a case- following guiding principles: by-case basis, although all programs considered Areas of concern most likely to motivate for referral should include medical and mental older substance abusers are their physical

63 85 Chapter 4

health, the loss of independence and network as a resource in assessment and in function, financial security, and maintenance providing treatment. of independence. Given the complex health needs of older Assessment and treatment decisions must adults, health care providers may need include the patient in order to be successful. assistance from experienced nonmedical This is particularly relevant for older adults, personnel to adequately assess the totality of who may be very uncomfortable in treatment issues and choices. Providers formalized addiction treatment programs should be aware of their limitations both in that do not include many of their peers or providing addiction treatment and in address their specific developmental and assessing and treating mental or physical health needs. health needs. Depending on an individual's particular All treatment strategies must be culturally situation, it may be important to include competent and, to the extent possible, family members in treatment or intervention incorporate appropriate ethnic discussions (understanding that children considerations (e.g., rituals). may vacillate between a desire to help and Overarching continuity of care issues and denial and that patient confidentiality must considerations should be identified and always be respected). addressed, especially in rural and minority Addiction is a chronic illness that ebbs and communities where emergency room staff flows. Thus, patients' needs will changeover function as primary care providers. time and will require different types and intensities of treatment. The next chapter builds on these guiding principles in describing referral and treatment Because many older adults have several options for older adults with substance abuse health care providers (e.g., visiting nurses, problems. social workers, adult day care staff, religious personnel), it is important to include this

8 6 64 5 Ref rrol Treat Araches

Once screening and assessment have Least Intensive Options identified a problem, the clinician and patient must choose the most Brief Intervention for At-Risk appropriate treatment. The Consensus Panel Drinkers recommends that the least intensive treatment options be explored first: brief intervention, Research has shown that 10 to 30 percent of nondependent problem drinkers reduce their intervention, and motivational counseling. Although these three approaches can be drinking to moderate levels following a brief sufficient to address the problem for some older intervention by a physician or other clinician. A patients, for others they will function as brief intervention is one or more counseling pretreatment strategies. These less intensive sessions, which may include motivation-for- options will not resolve the latter type of change strategies, patient education, assessment patients' alcohol or other drug problems but can and direct feedback, contracting and goal move them into specialized treatment by setting, behavioral modification techniques, and helping them overcome resistance to and the use of written materials such as self-help ambivalence about changing their drinking manuals (Fleming et al., 1997b). Brief intervention techniques have been used to behavior. Like treatment itself, pretreatment activities reduce alcohol use in adolescents, in adults in some cases may be conducted best in the under age 65 who are nondependent problem client's home and can be coupled with other drinkers, and most recently, in older adults (Blow, in press; Fleming et al., 1997a). All of personal or social services (Fredriksen, 1992; these activities can be conducted by trained Graham et al., 1995b) or with home-based detoxification services (Cooper, 1995). This clinicians, home health care workers, approach is ideal for the large number of at-risk psychologists, social workers, and professional older individuals who are homebound; it can be counselors (e.g., physicians, nurses, physicians' conducted by visiting nurses, housing assistants). authorities, and social workers. Community Brief intervention strategies range from health services often have staff designated to relatively unstructured counseling and feedback make visits to older adults in their homes, and to more formal structured therapy and rely some in-home treatment programs have a heavily on concepts and techniques from the motivational psychology and behavioral self- visiting nurse who identifies and treats substance abuse in the home. control training literature (Miller and Taylor, 65 87 Chapter 5

1980; Miller and Hester, 1986; Miller and clinicians to recognize the role of alcohol in Munoz, 1976; Miller and Rollnick, 1991). The decreases in functioning and quality of life. goal is to motivate the problem drinker to These issues must be kept in mind during brief change his behavior, not to assign blame. interventions with this vulnerable population. Drinking goals accordingly should be flexible, Following identification of at-risk or problem allowing the individual to choose drinking in drinkers through screening techniques (see moderation or abstinence. Chapter 4), a semistructured brief intervention In a trial conducted in Malmo, Sweden, in can be conducted. An older adult-specific brief the late 1970s, non-older adult subjects (all intervention should include the following steps: under age 65) were advised in a series of health 1. Customized feedback on patient's responses education visits to reduce their alcohol use. to screening questions about drinking They subsequently demonstrated significant patterns and other health habits such as reductions in gamma-glutamyl transferase smoking and nutrition. levels and health care utilization for up to 5 2. Discussion of types of drinkers in the United years after the brief intervention (Kristenson et States and where the patient's drinking al., 1983). The Medical Research Council trial, patterns fit into the population norms for his conducted in 47 general practitioners' offices in or her age group. Great Britain, found significant reductions in 3. Reasons for drinking. This is particularly alcohol use by the intervention group compared important because the practitioner needs to with the control group 12 months after the understand the role of alcohol in the context intervention (Wallace et al., 1988). The World of the older patient's life, including coping Health Organization trial, conducted in 10 with loss and loneliness. countries, found similar differences in alcohol 4. Consequences of heavier drinking. Some use between the two groups (Babor and Grant, older patients may experience problems in 1992). Meta-analyses found an effect size of 20 physical, psychological, or social functioning to 30 percent in studies conducted in health care even though they are drinking below cutoff settings (Bien et al., 1993; Kahan et al., 1995). levels. There are several ongoing studies of brief 5. Reasons to cut down or quit drinking. alcohol interventions for older adults, one of Maintaining independence, physical health, which is described below on page 94. financial security, and mental capacity can be Conducting brief interventions with key motivators in this age group. older adults 6. Sensible drinking limits and strategies for Older adults present unique challenges to those cutting down or quitting. Strategies that are applying brief intervention strategies for useful in this age group include developing reducing alcohol consumption. Because many social opportunities that do not involve older at-risk and problem drinkers are ashamed alcohol, getting reacquainted with hobbies about their drinking, intervention strategies and interests from earlier in life, and need to be especially nonconfrontational and pursuing volunteer activities, if possible. supportive. In addition, as discussed in Chapter 7. Drinking agreement in the form of a 2, the consumption level that constitutes at-risk prescription. Agreed-upon drinking limits drinking is lower than that for younger that are signed by the patient and the individuals (Chermack et al., 1996), so even low practitioner are particularly effective in levels can be dangerous. Chronic medical changing drinking patterns. conditions may make it more difficult for 66 88 Referral and Treatment

8. Coping with risky situations. Social process begins before the intervention and isolation, boredom, and negative family includes a progressive interaction between the interactions can present special problems in counselor and the family or friends for at least 2 this age group. days before meeting with the patient. During 9. Summary of the session. this time, the counselor not only helps plan the intervention but also educates the family about One approach devised to facilitate brief substance abuse and its prevention (Johnson, interventions is known by the acronym 1973). Participants are coached about offering FRAMES. This approach emphasizes information in an emotionally neutral, factual laFeedback of personal risk or impairment as manner while maintaining a supportive, derived from the assessment nonaccusatory tone, thus presenting Personal responsibility for change incontrovertible evidence to the loved one that a Clear advice to change problem exists. A menu of change options to increase the When using this approach with older adults, likelihood that an individual will find a Panel members recommend some modifications. responsive treatment (although multiple No more than one or two relatives or close attempts may be necessary) associates should be involved along with the An empathic counseling style counselor; having too many people present may Enhanced client self-efficacy and ongoing be emotionally overwhelming or confusing for followup (Miller and Sanchez, 1994). the older person. The most influential person to Panel members agree that when older adults include in interventions or any other are motivated to take action on their own behalf, pretreatment activity may be a spouse, the prognosis for positive change is extremely cohabitant, caregiving son or daughter, clergy favorable. Key to inspiring motivation is the member, or visiting nurse or caseworker, clinician's caring style, willingness to view the depending on the particular social network of older adult as a full partner in his or her the client. Inclusion of grandchildren is recovery, and capacity to provide hope and discouraged: Panel members report that many encouragement as the older adult progresses older alcoholics describe long-lasting resentment through the referral, treatment, and recovery and shame about the airing of their problems in process. the presence of much younger relatives. Because denial is as much a part of Intervention and Motivational psychoactive prescription drug dependence as it Counseling is of alcoholism and addiction to illicit drugs, an If the older problem drinker does not respond to intervention may help move psychoactive drug the brief intervention, two other approaches abusers toward detoxification or other formal intervention and motivational counseling treatment, although extra caution is advisable. should be considered. Both the diagnosis of abuse or dependence and the need for treatment are particularly difficult Intervention for older patients to accept because their initial In an intervention, which occurs under the use of psychoactive prescription drugs was, in guidance of a skilled counselor, several almost all cases, originally sanctioned by a significant people in a substance abuser's life health care provider and prescribed as a remedy confront the individual with their firsthand for a legitimate medical problem or complaint. experiences of his or her drinking or drug use As a group, older adults tend to have even (Johnson, 1973; Twerski, 1983). The formalized 67 89 Chapter 5

greater disdain for "drug addicts" than the the alcohol field (Di Clemente and Hughes, 1990; general population: Any implied linkage with Prochaska et al., 1992). the criminalized population of illicit drugusers Motivational counseling acknowledges is unnecessarily stigmatizing and appropriately differences in readiness and offers an approach resented. Such labels as addict, alcoholic; and for "meeting people where they are" that has drunkard should be avoided. proven effective with older adults (Miller and Motivational counseling Rollnick, 1991). In this approach, an As a result of the work pioneered by Prochaska understanding and supportive counselor listens and Di Clemente, clinicians now understand that respectfully and accepts the older adult's people may respond quite differently to perspective on the situation as a starting point, recommendations to alter or give up helps the individual identify the negative longstanding or previously pleasurable consequences of drinking and prescription drug abuse, helps him or her shift perceptions about behaviors. Reactions depend, to a great extent, on an individual's readiness to change the impact of drinking or drug-taking habits, (Prochaska et al., 1992). For example, the empowers the individual to generate insights screening or assessment findings may confirm about and solutions for his or her problem, and one individual's suspicions about the negative expresses belief in and support for the older adult's capacity for change. Motivational effect of alcohol on personal health and may counseling is an intensive process that enlists prompt an immediate commitment to abstain or begin tapering off. For others, the assessment patients in their own recovery by avoiding may be a revelation that must be processed over labels, avoiding confrontation (which usually results in greater defensiveness), accepting time before they can effect any changes. Still others may be unconvinced by the findings and ambivalence about the need to change as the need to make any changes at all. normal, inviting clients to consider alternative Research on stages of change, initially ways of solving problems, and placing the applied to smoking cessation studies, has responsibility for change on the client. This process also can help offset the denial, demonstrated that smokers enrolled in treatment trials fall into one of five stages: resentment, and shame invoked during an intervention and can serve as a prelude to precontemplation, contemplation, ready for action, action, and maintenance (Prochaska and cognitivebehavioral therapy (Miller and Rollnick, 1991). Di Clemente, 1986). Categorizing smokers this way helps predict who is most likely to succeed in quitting smoking and what kinds of Specialized Treatment of interventions work best with smokers in Older Problem Drinkers different stages (Di Clemente et al., 1991; And Substance Abusers Prochaska and Di Clemente, 1985; Velicer et al., 1992). More recently, it has been suggested that For some older adults, especially those who are research on brief interventions for problem late onset drinkers or prescription drug abusers drinkers could examine stages of change as a with strong social supports and no mental means of tailoring interventions to an health comorbidities, pretreatment approaches individual's readiness (Hodgson and Rol "nick, may prove quite effective, and followup brief 1992). Studies have already begun to examine interventions and empathic support for positive readiness for change as predictor of outcome in change may be sufficient for continued recovery.

68 00 Referral and Treatment

There is, however, a subpopulation of older Language barriers, illiteracy, and different adults who will need more intensive treatment. cultural views of and customs surrounding Despite the resistance that some older substance abuse add to the complex of factors problem drinkers or drug abusers exert, required to assess functional abilities in older treatment is worth pursuing. Studies show that adult patients. To help ensure optimal benefits older adults are more compliant with treatment for older adults, the Consensus Panel and have treatment outcomes as good as or recommends that treatment plans weave age- better than those of younger patients (Os lin et related factors into the contextual framework of al., 1997; Atkinson, 1995). the ASAM criteria. Patient Placement and Patient Levels of Treatment Matching Triage refers to the process of organizing and Services prioritizing treatment service. Typically, The following section provides an overview of decisions regarding triage are made up of two treatment services from the most to the least components: patient placement and patient intensive, with examples demonstrating how matching. various circumstances may affect the level of Patient placement describes a process by care at which a service is offered. which a recommendation is made for placement in a specific level (intensity) of care, which Inpatient/Outpatient Detoxification ranges from medically managed (high intensity) Treatment inpatient services to outpatient services (low One of the first issues to consider for an older intensity). The most commonly used patient patient with a substance dependence diagnosis placement criteria are found in the American is whether detoxification management is Society of Addiction Medicine (ASAM) Patient necessary and, if so, whether it should be Placement Criteria for the Treatment of Substance- undertaken in an inpatient hospital-based Related Disorders, Second Edition (ASAM-PPC-2) setting or managed on an outpatient basis. No (American Society of Addiction Medicine, 1996). studies or reports specifically assess the Figure 5-1 shows the six problems or potential risks or benefits of outpatient assessment dimensions that ASAM-PPC-2 uses detoxification among older adults, but to make patient placement decisions both detoxification is generally seen as medically among and within levels of service. riskier for an older person. Until more research The answers to these questions should help is available, best clinical judgment must guide the health care provider assess the severity of such decisions. For more information on the problem and the intensity of the services detoxification, see TIP 19, Detoxification From required. For older adults, the triage process is Alcohol and Other Drugs (CSAT, 1995a). Medical often greatly influenced by factors other than the safety and potential access to the abused drugs severity of a drinking or prescription drug are primary considerations when deciding problem. For example, physical accessibility of whether an older patient's withdrawal from facilities will influence treatment choices for prescription drugs requires supervision in a wheelchair-bound patients; hearing-impaired hospital. Factors indicating the need for patients will need programs with individual inpatient detoxification include therapy and/or modified small group therapy.

1, 9 69 Chapter 5

Figure 5-1

ASAM-PPC-2.Assessment, Dimensions Dimension 1Acute 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 alcoholor other drug use? Are there current signs of withdrawal? Does the patient have supports to assist in ambulatory detoxification, if medically safe? Dimension 2Biomedical Conditions and Complications Are there current physical illnesses, other than withdrawal, that need to be addressedor that may complicate treatment? Are there chronic conditions that affect treatment? Dimension 3Emotional/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? Doany 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 4Treatment 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 ina self-motivated way about his or her alcohol/other drug use problems? Dimension 5Relapse/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 tocope 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 touse, and skills to control impulses to use? Dimension 6Recovery 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.

A high potential for developing dangerous patient has experienced these serious abstinence symptoms such as a seizure or symptoms at any time previously delirium because (1) the dosage of alcohol or giSuicidal ideation or threats drug has been particularly high or prolonged The presence of other major and has been discontinued abruptly or (2) the psychopathology

70 92 Referral and Treatment

Unstable or uncontrolled comorbid medical withdrawal also is needed. Short-acting conditions requiring 24-hour care or benzodiazepines (e.g., oxazepam, lorazepam) parenterally administered medications (e.g., are customarily used as detoxification agents renal disease, diabetes) because alcohol-addicted patients are cross- Mixed addictions, (e.g., alcohol, tolerant to these substances. The use of sedative/hypnotic drugs) oxazepam or lorazepam is warranted in patients A lack of social supports at home or living with severe liver disease. Metabolism of these alone with continued access to the abused benzodiazepines does not depend on substance(s) hydroxylation by the liver, and thus they do not A failure to respond to outpatient treatment. accumulate in the liver and cause adverse effects (Brower et al., 1994). The benzodiazepine Older patients detoxifying from psychoactive dosage is decreased daily over the course of the prescription drugs on an inpatient basis should not be stabilized on high doses of detoxification process. Medications such as clonidine and methadone for opiate withdrawal benzodiazepines or barbiturates with a long or and phenobarbitol for barbiturate withdrawal intermediate half-life. These drugs can should be used more cautiously than with accumulate and result in toxicity and some younger patients. persisting cognitive impairment after hospital In general, older patients require lower doses discharge, which can interfere with functional of many medications, and the principle of capabilities in general and also hamper any starting at a lower dose and titrating at a slower immediate participation in continuing rate should be followed for detoxification. In treatment. The choice of drug and drug addition to treating acute withdrawal schedule should also be guided by the length of symptoms, clinicians are reminded that the hospitalization. If a long-acting drug such as alcoholic patients require supplemental doses of clonazepam (Klonopin) or an intermediate- thiamine, folate, and multivitamins to acting one such as chlordiazepoxide is used to counteract the vitamin depletion that is often detoxify an older patient, the hospitalization associated with excessive alcohol use. will likely be extended. An additional risk is that the patient will exhibit no signs of the Inpatient Rehabilitation abstinence syndrome until days or even weeks Patients who are brittle, frail, acutely suicidal, or after leaving the hospital. In general, the initial medically unstable or who need constant one- dose of a drug for suppression and management on-one monitoring, should receive 24-hour of withdrawal symptoms should be one-third to primary medical/psychiatric/nursing inpatient one-half the usual adult dose, sustained for 24 to care in medically managed and monitored 48 hours to observe reactions and then gradually intensive treatment settings. Recent changes in tapered with close attention to clinical responses the health care system have dramatically (Finlayson, 1995b). reduced the availability of this level of care. The clinician overseeing detoxification from Inpatient rehabilitation (traditional 14- , 21- , or alcohol or presCription drugs must decide on the 28-day programs) are not readily available and level of care necessary to maintain abstinence. often no longer reimbursed by health care Patients with high relapse or withdrawal insurers. Because of these reimbursement gaps, potential and patients with severe medical or inpatient care may have to be arranged on a psychiatric comorbidity will require medical or psychiatric unit of an acute care hospitalization. Regular monitoring of the hospital. patient's vital signs and objective symptoms of 71 Chapter 5

Residential Rehabilitation structured programs have the expertise to deal Residential programs provide a slower paced, with comorbidities in an intensive outpatient more repetitive treatment approach for older setting. patients. Services range from high to low If an older patient needs more help and intensity and can be delivered in specialized structure than is readily available, an care settings (e.g., halfway house, group home individually tailored, case-managed approach for people with addiction problems, board and may work well for coordinating outpatient care facilities, domiciliary facilities for veterans) treatment. This would entail professional and in nonspecialized settings (e.g., extended assessment of the patient's problems and care facilities, life care programs, subacute strengths, assistance with the development of a nursing homes where primary care doctors realistic treatment plan in the context of known make rounds and visiting nurses attend and reasonably available resources in the occasionally). Specialized rehabilitation community, and linkage with the identified programs include those designed for individuals programs. Usually the patient's primary who are cognitively impaired by chronic illness physician and his or her team will be the chief or traumatic injuries. These facilities work well players in ongoing case management. Providers for patients who lack significant social resources of primary drug dependence treatment should (such as family) or have no social network and not overlook the physicianwho will prescribe for those with no mobility to stabilize care all medicationsin their planning. The Panel (which justifies the expense of this treatment recommends drawing the physician into the option). treatment planning process and enrolling him as a player in the recovery network. Without the Outpatient Services physician's knowledgeable participation, the Specialized outpatient programs vary greatly in entire plan may unravel. the intensity of treatment. Partial The Panel also recommends serving older hospitalization/day treatment programs require adults who are dependent on psychoactive patients to attend day-long treatment 5 days per prescription drugs in flexible, community- week, whereas intensive outpatient programs oriented programs with case management are sometimes hospital-based and provide 2 to 3 services rather than in traditional, stand-alone hours of treatment each day. Finally, traditional substance abuse treatment facilities with low-intensity outpatient care normally provides standardized components. Case management is for one group session per week and one discussed in more detail below. individual session per month. Specialized outpatient treatment generally Nonspecialized, nonresidential services are includes psychiatric consultation and provided by many partial day treatment individualized or group psychotherapy. programs structured for outpatient care. These Outpatient programs frequently encourage include community-based drop-in centers and patients to attend regular meetings of self-help senior centers, generally less available in rural groups such as Alcoholics Anonymous, areas. These facilities are good for people Alcoholics Victorious, Rational Recovery, or waiting for inpatient care and who require a Narcotics Anonymous and often assign a level of interim care, for people with no family proactive case manager to help an older patient at home on a daily basis, and for retirees who connect with an appropriate group. After a need a structured daily regimen to keep the patient's release from the formal and time- focus on their addiction. Some of these limited outpatient substance abuse treatment 72 94 Referral and Treatment program, a case manager plays an important 6. Linkages with medical services, services for aftercare role by coordinating community-based the aging, and institutional settings for support and monitoring to reinforce gains made referral into and out of treatment, as well as during treatment and prevent or minimize the case management. impact of slips. Building from these six features, the Although the success of treatment for older Consensus Panel recommends that treatment adults has been documented, the literature on programs adhere to the following principles: substance abuse lacks empirically derived, proven methods for treating older alcoholics Treat older adults in age-specific settings and substance abusers. Instead, individual where feasible practices borrow heavily from what is known in Create a culture of respect for older clients the general fields of addictions treatment, Take a broad, holistic approach to treatment geriatric medicine and psychiatry, and social that emphasizes age-specific psychological, gerontology, as well as the cumulative social, and health problems experience of existing programs that have Keep the treatment program flexible specialized in treating older alcoholics Adapt treatment as needed in response to (Atkinson, 1995; Schonfeld and Dupree, 1996). clients' gender. Before referring an older adult to a community- Age-Specific Treatment based treatment program, health care providers should carefully consider the program's Age-specific treatment is group treatment in philosophy and practices regarding older which older individuals come together clients. exclusively with their peers. Such treatment can be provided in one of two formats. The first is a Program Philosophy and discrete program designed for older alcoholics and substance abusers in which the entire Basic Principles program provides age-specific services and all Based on a review of the older adult-specific of the patients are older. The second option is alcohol treatment literature, the Panel age-specific groups within an all-ages treatment recommends incorporating the following six program. features into treatment of the older alcohol In contrast, mixed-age treatment and abuser (Schonfeld and Dupree, 1996): mainstreaming integrate adults of all ages with similar substance abuse problems in the same 1. Age-specific group treatment that is program. The question of whether older adults supportive and nonconfrontational and achieve better outcomes in age-specific aims to build or rebuild the patient's self- treatment has not received adequate study, but esteem there is some evidence that age-specific 2.A focus on coping with depression, treatment improves older adults' compliance loneliness, and loss (e.g., death of a spouse, and outcomes (Kashner et al., 1992; Kofoed et retirement) al., 1987; Thomas-Knight, 1978). 3. A focus on rebuilding the client's social Treatment works best when the issues dealt support network with are congruent with the life stage of the 4. A pace and content of treatment appropriate client. Younger and older adults' problem for the older person drinking can usually be traced to different types 5. Staff members who are interested and of problems, even when the emotional responses experienced in working with older adults 9 5 73 Chapter 5

to the problems seem similar. For example, the older adults. In mixed-age settings, case drinking of younger and older clients may both management can provide an effective means of be attributed to depression, but the causes of addressing age-specific themes. that depression may be as different as being unable to find one's first job and facing the A Culture of Respect prospect of retirement. Older adults will Treatment programs should cultivate a culture recognize the problems of younger adults but of respect for older clients. Nurturing clients' may no longer find them particularly relevant. self-esteem and reawakening their sense of Younger adults, with no knowledge of what it's themselves as valuable, competent human like to grow old, may lack empathy and become beings are central to the process. Older adults impatient with older adults. The design of frequently enter treatment depleted physically, educational groups, the skills clients need to socially, and emotionally, convinced that their acquire, and the linkages that need to be made situation is hopeless. Adding the stigma of through case management are all different for addiction to the stigma of aging can compound older adults than for younger adults. For all of their despair. They may have been disowned by these reasons, treating the older client in an age- their families and rejected by friends because of specific setting is preferable. their drinking or drug abuse. If they seek help Of course, this is not always possible, outside the family, their experiences with particularly for prescription drug abusers. agencies are often impersonal, dehumanizing, Because very few older adults with prescription and humiliating. drug problems seek treatment or are referred for To increase clients' self-esteem, staff care, most drug treatment facilities do not have members should express confidence in each specialty "older adult track" programming. If client's ability to participate, persevere, and specialized treatment is not available, older succeed in treatment. Staff members need to adults can at least be grouped with younger state this confidence frequently and at each people whose lifestyles and problems are most phase in the treatment process in a way that is compatible and with whom they feel most upbeat but not patronizing. They should avoid comfortable. It is difficult to treat older adults acting overly helpful and implying that the who have only abused prescription drugs individual is impaired and helpless, at the same together with consumers of illicit substances, or time recognizing he or she, does need help with even alcoholics who have "hit bottom." the substance abuse problem. Managing his or Some clinicians argue that commonality in her own life helps an older client regain self- the drug of choice is the most important factor esteem. Treatment providers should take care to in grouping patients. Because lifestyles vary treat all their clients with an unconditional dramatically among different drug cultures, it positive regard, whether they are wealthy or on may be more important to group older patients welfare. with other patients who also have a primary Many actions and speaking manners problem with legal drugs rather than by age demonstrate respect in ways the older client will cohort, gender, or socioeconomic status understand: (Finlayson, 1995b). Abide by the manners that the older client If circumstances preclude treatment in an sees as customary (e.g., do not swear). age-specific setting, a program can still address Ask the individual how he or she would like the age-specific themes of older clients by hiring to be addressed and introduced to others. at least one person specializing in work with 74 96 Referral and Treatment

Use surnames and formal terms of address Holistic Treatment Based on Age- until given permission to be more familiar. Specific Problems El Avoid condescending or patronizing Treatment programs are generally advised to behavior. take a broad, holistic approach. In treating the m Speak directly to the client, not the client's older substance abuser in particular, it is spouse or adult child, when the client is necessary to focus on more than just the present. drinking or substance abuse problem. As m Recognize the client's privacy and personal people age, the likelihood of multiple space. If making home visits or entering the antecedent conditions for problem behavior client's personal space at the treatment increases. In other words, the individual's facility, acknowledge the client's ownership psychological and health problems tend to of the space. Knock and gain permission to become more complex, multiply determined, enter, ask where the person would like you and interactive. Recent research suggests that to sit, and respond graciously to any offer of older adults with alcohol problems often drink hospitality, whether accepting the offer or in response to loneliness, depression, and poor not. Make adequate provision for personal social support networks (Schonfeld and Dupree, privacy and the security of the person's 1995). Researchers have also noted chronic pain possessions, in both inpatient, and outpatient as a high-risk condition for substance abuse. settings. A number of interrelated emotional, social, m Talk to the client. Interacting spontaneously medical, spiritual, and practical problems or communicates appreciation for the person as changes characterize the older adult's an individual. Honoring the client's pain, experiences (see Figure 5-2). Some of these can needs, and joys validates the person in his or precipitate abuse of alcohol or other drugs. her attempt to process life's experiences in Those that initiate, sustain, or interact with the sobriety. substance abuse problem provide the focus of a m Fulfill the client's request to speak to his or holistic treatment approach tailored to the needs her clinician, immediately if possible. of the individual. m In a treatment program, a number of shorter, Discussing life changes with patients can informal sessions, particularly in response to help them develop insight into the causes of a patient's request, may be more valuable their substance abuse problems. For example, than a longer, scheduled session. Honoring a while discussing salient nondrinking problems patient's requests sends the message, "You with an older adult, the drinking problem often are important." emerges naturally as a topic of discussion. m Respect the client's spiritual concerns and Although the problems associated with aging desire to discuss meaning and purpose in can be overwhelming, patients need not accept life. Spiritual issues may be addressed by them passively. They can develop a self-care professional counselors or pastoral skill or positive attitude and can obtain counselors in addition to ministers or other appropriate help, such as the pharmacological mental health professionals trained in alleviation of pain, management of grief, or existential interventions. Often, older adults skills for improving relationships. have a need to discuss these issues, and alcohol misuse may be a symptom of a deeply felt lack of purpose in life.

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

Emotional and Social Problems Bereavement and sadness Consequent sense of being a "nonperson" Loss of Social isolation and loneliness Friends Reduced self-regard or self-esteem Family members Family conflict and estrangement Social status Problems in managing leisure time/boredom Occupation and sense of professional Loss of physical attractiveness (especially identity important for women) Hopes for the future Ability to function

Medical Problems Physical distress Sensory deficits Chronic pain Hearing Physical disabilities and handicapping Sight conditions Reduced mobility Insomnia Cognitive impairment and change

Practical Problems Impaired self-care Dislocation Reduced coping skills Move to new housing, or family moves away Decreased economic security or new poverty Homelessness status due to Inadequate housing Loss of income Increased health care costs

adjustments may be needed in recognition of the Program Flexibility fatigue levels of older clients. The setting of The goals, setting, and duration of treatment treatment may need to shift from clinic to home may well be different for each client. The first during a period of convalescence from a hip step toward ending problem drinking may fracture or an illness. One client may need twice involve finding safe, affordable housing for one as many treatment sessions to master steps client, resolving depression for a second, or toward self-sufficiency as another client. One improving relationships with a caregiving individual may need to continue treatment for 2 daughter for a third. Elements of treatment, years to meet the goals another client reaches such as work assignments or exercise programs, within 6 months. will need to be tailored for the individual patient. Gender Issues It may be necessary to stop treatment when Some women patients may be better served by illnesses or hospitalization intervene. Schedule all-female treatment groups and facilities, 76 98 Referral and Treatment although studies comparing the effectiveness of issue among older women. Some studies report single-sex and mixed-gender programs are that older men are prescribed antidepressants as lacking. Panel members have observed that often as or more often than women, but it is not many older women defer to men and may take known whether this is a function of greater use subservient roles in a treatment group. These of medical services by aging men or a difference women could be less likely to become leaders in in the diagnosis of depression among older the group or to build their self-esteem, although adults (Gomberg, 1992a, 1995). a talented group therapist can turn the roles of men and women in the group into therapeutic Treatment Approaches assets. Both women and men may have personal The Consensus Panel recommends the following issues related to their drinking that they would general approaches for effective treatment of be reluctant to discuss with, or in the presence older adult substance abusers: of, members of the opposite sex. This reluctance Cognitivebehavioral approaches is likely to be greater for older adults, because Group-based approaches many have a heightened need for privacy that Individual counseling discourages open discussions of personal issues Medical/psychiatric approaches and socialization with members of the opposite Marital and family involvement/family sex. In response, programs involving group therapy treatment might afford opportunities for Case management/community-linked separate meetings of males and females on an services and outreach. as-needed basis without disrupting the larger Not every approach will be necessary for program. Such meetings may never be every client. Instead, the program leaders can necessary, or take place intermittently, individualize treatment by choosing from this depending on the group members' needs or menu to meet the needs of the particular client. preferences to discuss certain topics in same-sex Planning information comes from interviews; settings. mental status examinations; physical Although most problem drinkers are men, examinations; laboratory, radiological, and more women misuse prescription drugs, and psychometric tests; and social network there are more women than men overall in the assessments, among others. aging population. Women use more Figure 5-3 lists the major treatment objectives psychoactive drugs than men do (Falvo et al., that the Panel recommends for older substance 1990; Ostrom et al., 1985; Venner et al., 1980; abusers and the approaches that can best Gomberg, 1995), and some researchers consider accomplish them. prescription drug abuse a major substance abuse

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Figure 5 -3 Treatment Qhjectives and Approaches General Objectives/ General Approaches/Examples Examples Eliminate or reduce substanceCognitivebehavioral (group or individual) abuse Alcohol (drug) effects 19 Relapse prevention Stress management Group approaches Alcohol (drug) effects education Medical Naltrexone, acamprosate (alcohol) Safely manage intoxication Medical episodes during treatment Remove patient from activities and observe Link and refer to detoxification program Enhance relationships Cognitivebehavioral (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 11 Family therapy Case management Linkage to community social programs Home visitation Individual counseling Focus on psychodynamic issues in relationships Promote health Medical Improve sleep habits Provide primary medical care Improve nutrition Cognitivebehavioral (group or individual) Increase exercise Self-management skills training Reduce tobacco use Group approaches Reduce stress C Health education iliEducation on nutrition, diet, cooking, shopping IN Sleep hygiene Stabilize and resolve Medical comorbidities E Consultation and special assessments, including medication assessment Medical Primary and specialized medical care Psychiatric (e.g., Psychiatric care for chronic mental disorders (by geriatric psychiatrist, if depression, anxiety) possible) IISensory deficits ilPain management for chronic pain disorders Antidepressants, antianxiety medication Cognitivebehavioral (group or individual) I Relaxation training

111 Depression

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or family conflict, physical distress, or unsafe CognitiveBehavioral Approaches housing arrangements, among others. Many There are three broad categories of cognitive- older adults drink excessively in response to behavioral approaches: behavior perceived losses and changes associated with modification/therapy, self-management aging and their affective and behavioral techniques, and cognitive-behavioral therapies. response to those losses. Alcohol use is often a Behavior modification applies learning and form of "self-medication," a means to soften the conditioning principles to modifying overt impact of unwanted change and feelings. For behaviorsthose behaviors obvious to everyone the patient, new knowledge of his or her around the client (Powers and Osborne, 1976; drinking chain often clarifies for the first time Spiegler and Guevremont, 1993). Self- the relationship between thoughts and feelings management refers to teaching the client to and drinking behavior, a discovery one Panel modify his or her overt behaviors as well as member calls "taking the mystery out of internal or covert patterns. Cognitive-behavior drunkenness." This method provides insight modification involves altering covert patterns or into individual problems, demonstrates the links behaviors that only the client can observe. between psychosocial and health problems and Cognitive-behavioral techniques teach drinking, and provides the data for a rational clients to identify and modify self-defeating treatment plan and an explicit individualized thoughts and beliefs (Dobson, 1988; Scott et al., prevention strategy. 1989). The cognitive-behavioral model offers an Breaking drinking behavior into the links of a especially powerful method for targeting drinking chain serves treatment in other ways, problems or treatment objectives that affect too. It suggests elements of the community drinking behavior. Together, provider and service network that may be helpful in client analyze the behavior itself, constructing a establishing an integrated case management "drinking behavior chain." The chain is plan to resolve antecedent conditions (e.g., composed of the antecedent situations, housing, financial, medical problems) that thoughts, feelings, drinking cues, and urges that necessitate involvement from the community precede and initiate alcohol or drug use; the beyond the treatment program (see Case drinking or substance-abusing behavior (e.g., Management section). pattern, style); and the positive and negative Behavioral treatment can be used with older consequences of use for a given individual. adults individually or in groups, with the group When exploring the latter, it is particularly process particularly suited to older adults (see important to note the positive consequences of Group-Based Approaches section below). use: those that maintain abusive behavior. Equipped with the knowledge of the Researchers have developed an instrument individual's drinking or drug abuse behavior that can elicit by interview the individual's chain, the group leader begins to teach the client drinking or drug use behavior chain (Dupree the skills necessary to cope with high-risk and Schonfeld, 1986). Immediate antecedents to thoughts or feelings. The leader teaches the drinking include feelings such as anger, older person to initiate alternative behaviors to frustration, tension, anxiety, loneliness, drinking, then reinforces such attempts. The boredom, sadness, and depression. leader may demonstrate through role-playing Circumstances and high-risk situations alternative ways to manage high-risk situations, triggering these feelings might include marital permitting the client to select coping behaviors

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that he or she feels willing and able to acquire. frustration, depression and grief, tension and The leader may also ask for feedback from the anxiety, lack of social support, passivity, and an group and use that feedback to work gradually unstructured life. GAP staff were encouraged to toward a workable behavioral response specific teach skills at a slower pace than might be used to the individual. with younger adults and to limit the amount of The behaviors are rehearsed within the information taught per session by following treatment program until a level of skill is written curriculum manuals. These teaching acquired. The patient is then asked to try out guides provided age-specific examples and the behaviors in the real world as "homework." maintained consistency in teaching. For example, a client who has been practicing Confrontation was not permitted. This ways to overcome loneliness or social isolation facilitated more open discussion between staff may receive a community-based assignment in and clients, encouraging clients to report which to carry out the suggested behaviors. The instances when they slipped. This information individual reports back to the group, then the was used in the group to help both the person therapist and group members provide feedback who slipped and other clients. Each slip was and reinforce the individual's attempt at self- diagrammed in terms of that person's drinking management (whether the outcome was a behavior chain, with the antecedent conditions success or not). This process continues until the and consequences, in order to teach group individual develops coping skills and brings the members how to avoid or manage their own antecedents for abuse under self-control or self- high-risk situations. The group engaged in management. Typically, as patients learn to exercises or rehearsals of the necessary actions manage the conditions (thoughts, feelings, and cognitions to prevent one drink (a slip) from situations, cues, urges) that prompt alcohol becoming a full relapse. A 1-year followup of abuse, abstinence can be maintained. clients completing GAP indicated a high rate of Defining drinking behavior antecedents is success. Seventy-five percent of clients also useful for determining when a client is maintained their drinking reduction goals and ready for discharge. When the individual has increased the size of their social support acquired and can successfully use coping networks (Dupree et al., 1984). behaviors specific to his or her antecedents for Later studies comparing early and late-onset drinking, the treatment team might begin to older problem drinkers showed great similarity assist the person in gradually phasing out of the between these two groups' antecedents to program. Discharge that takes place before the drinking and treatment outcomes (Schonfeld client has acquired specific coping behaviors is and Dupree, 1991). Another study described a almost certain to result in relapseprobably behavioral regimen that included very soon after discharge. psychoeducation, self-management skills One older adult-specific treatment program training, and marital therapy. A followup study that has used these cognitivebehavioral and of 16 male inpatients, ages 65 to 70, undertaken self-management approaches is the Gerontology 2 to 4 years after discharge, indicated that half Alcohol Project (GAP) (Dupree et al., 1984). The were abstaining, two had reduced their program assessed antecedents on a typical day drinking, and the remaining patients' drinking of drinking for each person entering treatment. was destructive (Carstensen et al., 1985). These Group treatment involved skill acquisition in studies recommend (and the Panel concurs) that order to cope with problems such as anger and treatment focus on teaching skills necessary for

80 I,0 Referral and Treatment rebuilding the social support network; self- program made use of this phenomenon by management approaches for overcoming assigning each person to another client who depression, grief, or loneliness; and general served as a "buddy," explaining and facilitating problem solving (Schonfeld and Dupree, 1990, the day's events. 1991). Some of the most effective types of groups are socialization, therapy, educational, and self- Group-Based Approaches help or support groups. Group experiences are particularly beneficial to older adults in treatment. They provide the Socialization groups arena for giving and sharing information; Groups may focus on socialization skills: practicing skills, both new and long-unused; teaching clients skills for meeting new people, and testing the clients' perceptions against interacting better with peers, and giving them reality. Perhaps the most beneficial aspect of opportunities to practice. These skills are honed groups for older adults is the opportunity to whenever clients gather together, whether in learn self-acceptance through accepting others recreation, on coffee breaks, or at lunch. This and in return being accepted. Guilt and type of activity is particularly valuable for those forgiveness are often best dealt with in groups, who live with loneliness or who have become where people realize that others have gone socially isolated. through the same struggles. Special groups may Panel members report that many older adults also deal with the particular problems of aging; keep in touch with friends they made during the group format can help patients learn skills treatment, especially if the treatment program for coping with any of the life changes identified sponsored social activities. Some treatment in Figure 5-2. programs sponsor an evening a week where Self-paced learning is best for older adults. clients can socialize, which helps them rebuild To allow clients to set their own pace in a group or expand their social contacts in the setting, the leader can give individualized or community. take-home assignments. Clients who have not Therapy groups reached the needed level of expertise on a topic Some therapy groups engage in behavioral can receive an individualized "booster session" interaction, as discussed above, others in more while remaining in the group. Older clients also psychodynamic therapy. Both types of groups should get more than one opportunity to allow clients to test the accuracy of their integrate and act on new information. For interpretations of social interactions, measure example, information on bereavement can be the appropriateness of their responses to others, presented in an educational session, then and learn and practice more appropriate reinforced in therapy. To help participants responses. Groups provide each client with integrate and understand material, it may even feedback, suggestions for alternative responses, be helpful to expose them to all units of and support as the individual tries out and information twice. practices different actions and responses. Groups help create a sense of camaraderie Some people may need help in entering the and high morale. Research on group work with group, particularly if they are accustomed to older adults suggests that older adults bond into isolation. This help could include individual groups at a faster pace than younger adults do counseling sessions in which the counselor (Finkel, 1990). One successful treatment explains how a group works and answers the

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client's questions regarding confidentiality. The Older adults can receive, integrate, and recall client's entry into the group may be eased by information better if they are given a clear joining in stages, at first observing, then over statement of the goal and purpose of the time moving into the circle. The counselor may session and an outline of the content to be formally introduce the new person to the covered. The leader can post this outline and members of the group so that upon entering the refer to it as she moves through the session. group, he or she is at least somewhat familiar The outline may also be distributed for use in with them. personal note-taking and as an aid in review Older adults grew up before psychological and recall. Courses and individual sessions terms had been integrated into the everyday should be conceived as building blocks that language. Therefore, therapy groups for older are added to the base of the older adult's life adults should avoid the use of jargon, acronyms, experience and needs. Each session should and "psychspeak." If leaders do use such terms, begin with a review of previously presented they should begin by teaching the group their materials. meanings. If a participant uses an unfamiliar Members of the group may range in term, the leader should explain it. It may be educational level from being functionally helpful to develop a vocabulary list on a chart illiterate to possessing advanced degrees. and for any individual notebooks. Similarly, Many older adults are adept at hiding a lack because many older individuals were raised not of literacy skills. These individuals need to to "air their dirty laundry," they should never be helped in a way that maintains their self- be pressured to reveal personal information in a respect. Group leaders should choose group setting before they are ready. Nor should vocabulary carefully to comply with clients' older patients be pressured into "role-playing" communication skills. before they are ready. Groups should accommodate clients' sensory Educational groups decline and deficits by maximizing the use of as many of the clients' senses as possible. Educational groups are an integral part of Simultaneous visual and audible addiction treatment. Patients need information presentation of material, enlarged print, about addiction, the substances, their use, and voice enhancers, and blackboards or flip their impact. Older adults also benefit from charts can be helpful. An overhead projector shared information about the developmental allows the leader to display written material tasks of the later stages of life, support systems, on a screen while facing and speaking to the medical aspects of aging and addiction, the group. Group members may also take home concepts and processes of cognitivebehavioral supplemental audiotapes and videotapes for techniques, and experiences they are likely to be review. facing, such as retirement, loss, partner's illness, and family concerns. Educational units can be It is important to recognize clients' physical designed to teach practical skills for coping with limitations. Group sessions should last no any aspect of daily life, such as nutrition, longer than about 55 minutes. The area should household management, or exercise. be well lighted without glare, and interruptions, Some basic principles for designing noise, and superfluous material should be kept educational groups follow: to a minimum. Distractions generally interfere

104 82 Referral and Treatment more with learning for older patients than for like talking to my son," or, "It is as though she younger ones (Myers and Schwiebert, 1996). were my sister." Older clients value spontaneity Alcoholics Anonymous and other in relationships with the counselor and other staff members; a counselor's appropriate self- self-help groups disclosure often enhances or facilitates a Many treatment programs refer patients to beneficial relationship with the patient. Alcoholics Anonymous (AA) and other self-help Because receiving counseling may be a new groups as part of aftercare. Providers should experience for the client, the provider should warn older patients that these groups might explain the basics of counseling and clearly seem confrontational and alienating. The present the responsibilities of the counselor and referring program should tell patients exactly the client. Summarizing at the beginning of what to expectthat the group discussions may each session helps to keep the session moving in well include profanity and younger members' the appropriate direction. Summarizing at the accounts of their antisocial behavior. To orient end of a session and providing tasks to be clients to these groups, the treatment program thought about or completed before the next may ask that local AA groups provide an session help reinforce any knowledge or insights institutional meeting as a regular part of the gained and contribute to the older client's treatment program. Other options are to help feeling that she is making progress. clients develop their own self-help groups or In individual sessions, counselors can help even to facilitate the development of clients prepare to participate in a therapy group, independent AA groups for older adults in the building their understanding of how the group area. works and what they are expected to do. Individual Counseling or Short- Private sessions can also be used to clarify issues Term Psychotherapy when the individual is confused or is too embarrassed to raise a question in the group. As Individual counseling is especially helpful to the the client becomes more comfortable in the older substance abuser in treatment's beginning group setting, the counselor may decide to taper stages, but the counselor often must overcome the number of individual counseling sessions. clients' worries about privacy. Subjects that Likewise, the client may prepare for discharge many older adults are loath to discuss include by reducing the frequency or length of sessions, their relationships to their spouses, family secure in the knowledge that more time is matters and interactions, sexual function, and available if needed. economic worries. It is essential to assure the client that the sessions are confidential and to Medical/Psychiatric Approaches conduct the sessions in a comfortable, self- Older substance-abusing clients differ from their contained room where the client can be certain younger counterparts in the number and the conversation will not be overheard. complexity of associated health problems. Older clients often respond best to Unless these problems are recognized and either counselors who behave in a nonthreatening, corrected or stabilized, the patient's supportive manner and whose demeanor participation in substance abuse treatment will indicates that they will honor the confidentiality be compromised and chances for recovery of the sessions. Clients frequently describe the diminished. Especially in older adults, health successful relationship in familial terms: "It is problems interact with and impair social and

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psychological function, adding to the complex of desirable diet and nutrition, daily exercise, sleep causes for the patient's dysfunction and hygiene and the benefits of routine health disability. checks. Medications used to modify drinking A thorough, age-specific medical evaluation behavior in older adults must take into account should be completed for each patient at entry age- and disease-related increases in into alcoholism treatment if it was not done by vulnerability to toxic drug side effects, as well as the referring source. The evaluation can be possible adverse interactions with other completed in-house in larger programs that prescribed medications. Disulfiram is not have a primary care provider on staff, by a generally recommended by the Panel for use in consulting provider, or by the patient's personal older patients because of the hazards of the physician. Trained nonmedical staff can easily alcoholdisulfiram interaction, as well as the do portions of the evaluation, such as screening toxicity of disulfiram itself. for age-related macular degeneration (AMD), a Naltrexone, an opioid receptor blocker with leading cause of blindness in older adults. mild opioid agonist actions, has been shown to Positive results would indicate the need for reduce drinking in younger alcoholics in further evaluation by a professional (e.g., controlled studies. A controlled pilot study of referral to an opthalmologist). The treatment its use among older men under age 70 found program should review this evaluation. that these patients tolerated the drug well (Os lin The medical evaluation should always et al., 1997). Moreover, there was suggestive include an assessment of medication use, evidence for reduction in drinking relapses in because of the potential for medication and naltrexone treated patients. Acamprosate, a alcohol interactions. To determine the glutaminergic drug, has shown considerable medication use of older adults, the "brown bag success in reducing drinking in younger approach" is helpful (Finch and Barry, 1992). alcoholics in European controlled trials (Litten et The practitioner can ask older adults to bring al., 1996). Acamprosate has not been specifically every medication they take in a brown paper studied with older adults. bag (e.g., all medications prescribed by a doctor; Visual and hearing problems compromise all medications, vitamins, etc., they got at the effective coping and the accomplishment of the drugstore; any herbs that anyone gave them to tasks of daily living, interfere with social try). This will provide an opportunity to better functioning, and may prevent effective determine potential medication interaction participation in substance abuse treatment. problems. Accordingly, initial medical assessment of older Chronic mental illness such as depression, adults should routinely include screening for bipolar and recurrent major depressive visual and auditory problems, and any disorders, chronic schizophrenia, and severe problems discovered should be corrected as anxiety disorders will require ongoing care. quickly as possible. Research suggests that some patients with Many older alcoholics do without needed schizophrenia cannot manage the interpersonal health care; linking them to a health care intensity of group therapy for addictions and are provider can be a profoundly valuable service. more suitably managed on a one-to-one basis The substance abuse treatment program should with an addictions counselor who consults with consider, whenever possible, educating older a psychiatrist (Finlayson, 1995a). Some patients clients on such health promotion themes as with severe disorders, including some with

84 1 0 (3 Referral and Treatment dementia, may be better managed in a mental Schuckit, 1988; Schuckit, 1994). When health or long-term care setting than in a depressive symptoms persist several weeks substance abuse program, provided a geriatric following cessation of drinking, specific psychiatrist is involved, at least for consultation. antidepressant treatment is indicated (Brown et The epidemiology of depression among older al., 1995). adults is controversial (Weiss, 1994). According to the Epidemiologic Catchment Area Study, Family Involvement and Therapy depressive symptoms occur in an estimated 15 Involving family members in percent of community residents over the age of treatment 65. Estimates of major depression among the The Panel recommends gathering detailed same age group are usually less than 3 percent. information about the client's relationships from Rates of major or minor depression among older family members in the evaluative and planning adults seeking care from primary care clinicians phases of treatment. This information will affect or residing in nursing homes range from 15 to 25 treatment planning whether or not family percent (National Institutes of Health, 1991). members currently share a home or remain Among those hospitalized for physical illnesses, involved in each other's lives, as past events approximately 10 percent suffer from a major may bear upon the substance abuse. On the depressive disorder, whereas an estimated 30 basis of the individual's drinking antecedents, percent experience minor depressions (Koenig the treatment team can decide whether family or and Blazer, 1996). Despite expectations that marital therapy is appropriate. rates of depression among older adults would Family members, including adult children, be high, studies have not generally confirmed can play a critical role in the older client's this view. One reason for this failure may be treatment (Dunlop, 1990; Dunlop et al., 1982; that "many depressions in this age group are Myers, 1989). Married older alcoholics are more subsyndromal and do not fit well into the likely to comply with treatment if their spouses current nomenclature" (Koenig and Blazer, 1996, also become involved in the treatment process p. 417). Another explanation may be that (Atkinson et al., 1993). symptoms "are often lost amid 'real' medical The types of individuals who are appropriate problems of the aged" (Weiss, 1994, p. 5). to involve in the client's treatment will vary Researchers estimate that between 10 and 30 from one client to the next. Some older clients percent of older alcoholics have long-lasting or may be out of touch with family members or recurrent depressive symptoms (Blazer et al., may live far away from relatives. Dupree and 1987b). Some fulfill criteria for major depressive colleagues found that, on average, late onset disorder, dysthymic disorder, or cyclothymic alcoholics had a total of four friends and four disorder. Others do not meet criteria for any of family members with whom they were in these diagnoses yet suffer from depressive contact (Dupree et al., 1984). Daily contacts symptoms that fall under the category of averaged less than one a day. The person who is subsyndromal depression. Depression for closest to the client may be a golfing partner, a several days or longer immediately following a housemate, a caseworker or health provider, the prolonged drinking episode does not necessarily bank trustee of the person's estate, or a private indicate a true comorbid disorder or the need for social service worker hired by the bank. Some antidepressant treatment in most cases older adults cohabit in long-standing common- (Atkinson and Ganzini, 1994; Brown and

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law relationships without marrying out of from the group is advisable for addressing very concern for grandchildren's opinions or for personal concerns such as sexual problems or financial or other reasons. Such nontraditional other highly sensitive issues that could be family members may be considered "family" for damaging to the couple's marriage. purposes of treatment. Eliciting family information requires Case Management, Community- sensitivity and skill: Older adults are less Linked Services, and Outreach willing than younger adults to discuss "family Case management is the coordination and business." The client's family may close ranks monitoring of the varied social, health, and as well and choose not to disclose events that welfare services needed to support an older they fear could hurt or disturb the client. In adult's treatment and recovery. Case working with family issues or family groups, a management starts at the beginning of treatment provider should emphasize airing and bringing planning and continues through aftercare. One closure to past conflicts and concerns and negate person, preferably a social worker or nurse, any blame. should link all staff who play a role in the Treatment staff need to be cautious in client's treatment as well as key family members deciding what information to share, with which and other important individuals in the client's family members, and when (if at all). For social network. example, the role of adult children in the client's The multiple causes of older adults' life can be problematic. Although adult children problems require multiple linkages to may have new responsibilities for taking care of community services and agencies. The the patient, they may also be problem drinkers treatment program that seeks to be the sole who collude in the client's drinking, supply the source of all services for its older clients is likely client with alcohol, or help the client rationalize to fail. Even in very isolated areas, programs the drinking problem. can strengthen their services for older adults through linkages to local resources such as the Family and marital therapy faith community. The dynamics of a marriage can change The case manager will likely refer the client drastically as couples grow older. These to a combination of several community changes stem from retirement, the deaths of resources in response to the issues associated friends, and health issues that affect marital with the substance abuse problem. Case relationships, such as changes in sexual function managers must have strong linkages through or the need for caregiving. Any of the issues both formal and informal arrangements with typically experienced by older adults, such as community agencies and services such as financial concerns or fear of the death of a spouse, can affect the stability of the marital Medical practitioners, particularly mental relationship and place additional stress on the health providers, geriatricians, and geriatric client in treatment. counselors The best setting for providing counseling to E Medical facilities for detoxification and other substance-abusing older patients with marital services problems may be individual couple counseling Home health agencies. or in a group setting with other couples of similar age. Counseling the couple separately

86 108 Referral and Treatment

Housing services for specialized housing setting, may be an important adjunct to therapy (i.e., wheelchair-accessible housing, for individuals who feel more comfortable congregate living) addressing their concerns in a religious context. Public and private social services providing Many older adults are concerned about their in-home support for housekeeping, meals, spiritual preparation for death, even when it is etc. not imminent, and welcome opportunities to Faith community (e.g., churches, explore that topic. synagogues, mosques, temples) Substance abuse treatment providers are Transportation services moving toward a greater recognition of the role Senior citizen centers and other social of spirituality in recovery, and providers should activities not hesitate to build on the religious belief Vocational training and senior employment systems of older clients, when appropriate. programs From its inception, Alcoholics Anonymous has Community organizations that place clients spoken of "a higher power," and much of its in volunteer work effectiveness may derive from its spiritual Legal and financial services aspects. One caution: Older adults who have The Area Agency on Aging (funded under never subscribed to a religious belief system Title 20). may not be ideal candidates for spiritually oriented therapy or referral to 12-Step If a program includes outreach services, case fellowship programs. management may offer the best means of One Panelist observed that spirituality is providing them (Graham et al., 1995b; often a key element in brief interventions, Fredriksen, 1992). Case managers may, for especially in minority communities. Programs example, initiate outreach services for that specialize in the treatment of a particular homebound clients, although it is important to ethnic or racial group may adopt strategies maintain continuity and assign only one case specific to that group (e.g., the use of tribal manager to an older client. If clients in a rituals in the treatment of Native American treatment program become seriously ill or substance abusers). A variety of nontraditional dysfunctional and temporarily require services methods for tension reduction (e.g., therapeutic at home, a case manager may be the ideal staff massage, meditation, acupuncture) have been person to broker services on their behalf. suggested as applicable to older adults, (Comprehensive case management for substance although these methods remain largely abuse treatment will be described in detail in a untested. forthcoming TIP to be published in 1998.) Other Adjunctive Approaches Discharge Plans and Aftercare Effective discharge planning is essential to A number of other treatment approaches are case management for older clients because their useful in responding to older substance abusers. social networks may have shrunk as a result of Generally, however, they work best when they their substance abuse problems, physical complement the major approaches already limitations, or the loss of family members and discussed. friends. In this context, it is vitally important for Spiritual or religious counseling with a clients' counselors or case managers to help clergy member, either in a group or individual them tap into available community resources by

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assisting them in identifying ongoing needs programs have begun this process of network (e.g., income maintenance, housing), scheduling building by publicizing their services to other services (e.g., Homemakers, eye care, hearing local agencies and health care facilities. Prior tests, financial planning), and obtaining consultation with the local Office on Aging and equipment (e.g., large-number telephones, home other resources in the community that target banking systems, walkers and other devices). older adults helps to ensure that the resulting As part of the discharge process, a counselor network is responsive to their special needs. In or case manager also develops an aftercare rural areas, treatment programs serving older program with the client. For older adults, this adults face additional challenges. In these may entail arranging transportation to follow- settings, collaboration among health and social up appointments and reminders to note dates service programs is crucial to resolve problems and times on the calendar, as well as fulfilling posed by geography, lack of public more traditional functions like monitoring transportation, sparse and distant services, and progress to prevent or reduce the negative social isolation. CSAT's Technical Assistance impact of relapse. Standard features of most Publications Rural Issues in Alcohol and Other discharge plans for older adults include Drug Abuse Treatment (CSAT, 1996), Treating Alcohol and Other Drug Abusers in Rural and Age-appropriate Alcoholics Anonymous, Frontier Areas (CSAT, 1995b), and Bringing Pills Anonymous, Rational Recovery, Excellence to Substance Abuse Services In Rural and women's or other support groups Frontier America (CSAT, 1997) have more Ancillary services needed to maintain information on surmounting these barriers. independence in the community Ongoing medical monitoring Specialized Treatment Involvement of an appropriate case manager if needed to advocate for the client and Issues for Prescription ensure needed services are provided. Drug Abuse Aftercare and recovery services for older Because so many problems with prescription clients differ in some respects from those drug abuse stem from unintentional misuse, typically offered by some substance abuse approaches for responding to these clients differ treatment programs where fraternization is in some important respects from treatment for discouraged. Programs oriented to older clients alcohol abuse and dependence. Issues that need often sponsor socialization groups or weekly to be addressed as part of treatment include treatment alumnae meetings run by long-sober educating and assisting patients who misuse peer counselors. Others allow clients to return prescribed medications to comply consistently to the program to participate in group theiapy. with dosing instructions, providing informal or Still others initiate a network of contacts for brief counseling for patients who are abusing a older clients and teach them how to expand it. prescribed substance with deleterious Some communities have established, consequences, and engaging drug-dependent integrated social service networks that enable patients in the formal treatment system at the clients to receive coordinated care. However, appropriate level of care. In addition, it is stand-alone programs in communities without important for providers to understand how defined networks may have to initiate linkages practitioners' prescribing behavior contributes with other services themselves. Some treatment

88 110 Referral and Treatment to the problem so they can address it both with medicine, or (4) the patient cannot afford the clients and uninformed health care practitioners drug and tries to do without from time to time in the community. so that she will have a supply available when she feels she needs it. Misuse by the Patient If the patient's noncompliance is due to Some experts estimate that as many as 70 economic considerations, then teaching her how percent of depressed older patients fail to take to manage medications by separating them into 25 to 50 percent of their medications, producing container compartments for each day of the wide fluctuations in blood levels and week (or hour of the day) will not be helpful. jeopardizing the efficacy of therapy (National That strategy might be appropriate, however, Institutes of Health, 1991). Such widespread for another patient who has suffered a stroke misuse of prescriptions requires intensive efforts and has real difficulty with short-term memory. to determine the reasons for noncompliance and Medication noncompliance may take the to educate patients about medication following forms: management. In general, the causes of Omitting doses or changing the frequency or noncompliance with a prescribed medication timing of doses regimen can be categorized as Doubling up on the dosage after forgetting to A lack of judgment or misconceptions about take the previous dose the drugs Taking the entire day's medications in the An inability to manage the medication morning for fear of forgetting to take all the regimen, either because it is complex or the doses of all the medications as prescribed patient has persistent memory problems and Increasing doses or dosing frequency will need regular supervision Taking the wrong drugs Insufficient resources for purchasing or Borrowing or sharing drugs storing the medications Supplementing prescribed drugs with other Intentional misuse to obtain results other over-the-counter medications or "leftover" than for those prescribed (e.g., pain pills to medicines from an earlier illness sleep, relax, soften negative affect). Continuing to use alcohol or other contraindicated drugs or foods while taking Unless patient interventions address the real reasons for noncompliance, they are not likely to the prescribed medicines be effective. If initial observations and questions Engaging in contraindicated activities while about prescription drug use suggest misuse, taking the medications (e.g., driving motor vehicles, spending time in the sun) more information will be needed so that remedies can be appropriately targeted. For Failing to tell the prescribing physician about all the other medications (prescribed and example, if a 73-year-old woman is skipping over-the-counter) being used or to report doses of her blood pressure medication, the significant or unexpected side effects or provider needs to learn whether this happens adverse reactions because (1) the patient only takes the medicine Storing medications improperly (not when she feels ill rather than on the prescribed refrigerating those that require a continued schedule, (2) the medicine sometimes makes her cold temperature) or using prescriptions feel unpleasantly dizzy, (3) the patient frequently forgets whether she took the with expired expiration dates.

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The patient and the health care practitioner is to determine whether misuse continues share responsibility for ensuring that the patient despite all attempts to correct underlying understands all dosing instructions, the reasons for noncompliance. If the patient purposes of the medications prescribed, and the appears to be knowingly noncompliant, the unpleasant side effects or adverse reactions that behavior is characteristic of abuse. should be reported to the doctor. However, The intervention for this behavior will providers can also instruct patients to take depend on an accurate and in-depth assessment advantage of pharmacists' services in providing of the social, medical, and psychological personal advice and computer-generated problems that may be driving the substance instructions regarding specific drugs, side abuse (e.g., depression, bereavement,a medical effects of varying intensity and seriousness, condition, social isolation, physical pain, contraindications for use, and when beneficial insomnia). Assessment results then provide the effects can be anticipated. Many materials have basis for an individualized treatment plan that already been developed and are widely includes and ranks mechanisms for addressing available for educating older adults and others each issue. Unless the abuse has resulted ina about medication compliance strategies and serious crisis, it is usually appropriate to try their importance. These can be obtained from, psychosocial approaches first, including grief numerous sources, including home health care therapy, sleep management training, relaxation agencies, State and local offices on aging, the techniques, socialization (day care)programs, Substance Abuse and Mental Health Services psychotherapy, and acupuncture. Administration (through the National Once treatment begins to resolve the Clearinghouse for Alcohol and Drug underlying issues, the provider must confer Information), the National Council on Aging, with the health care practitioner to determine and the American Association of Retired whether the older adult should remain on the Persons. problematic drug at a reduced dose, discontinue Treatment providers can help empower older use altogether, or switch to an alternative adults to ask more questions and optimize the prescription with less addictive potential. The benefits of their contacts with medical choice will depend on what optionsare professionals. Older patients with some available and the severity of the problems cognitive or sensory impairment may not be experienced as a result of the substance abuse. able to adhere to complicated medication The Panel recommends an open discussion of regimens. In these cases, treatment providers these issues with the patient, substance abuse can identify and educate family members or treatment provider, and health care practitioner. other professional or volunteer advocates and caregivers about the need to assist the older Misuse (Misprescribing) by the adult with this task. Health Care Provider Once the substance abuse treatment provider Health care professionals need to keep abreast identifies a medication misuse problem, of current information about appropriate arrangements should be made for an initial but prescribing practices for older patients as well as intensive monitoring of the patient's use of the new drugs with less hazardous profiles. Older problematic drug. Monitoring may be adult-specific protocols must stress medication undertaken by visiting or public healthnurses assessments for all patients; lower initial doses or other designated medical staff. The objective and time-limited dosing patterns for

1 Referral and Treatment

psychoactive and other agents; use of new and IsProviding Continuing Education Units for less complex drugs with simple metabolic attending workshops at medical conferences pathways and less dangerous side effects; and other health care professional meetings avoidance of more hazardous substances with on prescription drug use and abuse among long half-lives that cannot easily be absorbed or older patients eliminated by older adults; and appropriate, Training primary care physicians and other consistent monitoring of patients' reactions to health care providers to consult more prescribed drugs. frequently with pharmacists, psychiatrists, Health care professionals also need to be and other psychopharmacologists regarding reminded of ways to convey information that the risk and benefit profiles of the are easily understood and used by older patients psychoactive drugs they prescribe rather (e.g., written as well as spoken, disseminated to than relying on outdated materials or their family caregivers and advocates as well as the own authority patient). When prescribing medications for Empowering older patients and their older adults, it is also useful to consider the advocates to ask health care providers family situation. Are other family members questions about the rationale for all proffered likely to share their medication with the patient prescription medications as well as dosing or use it themselves? Is there a family member protocols, schedules, expected and who will help the older patient track his dangerous side effects, and interactions with medications, comply with the practitioner's other medications or food request to bring unused medications to the Ensuring that any attempts to restrict practitioner, remind the patient to discard prescribing practices through legislation and expired medication, or remove the medication at regulations do not encourage prescriptions of the practitioner's request? Family members can more hazardous substances or make be important allies in preventing problems from legitimately needed medications even more developing or escalating. difficult for patients to obtain. Some ways in which health care professionals might be motivated to adopt "best" prescribing practices for older patients Staffing Considerations include The Consensus Panel recommends that the Making relevant publications such as this TIP following principles guide staffing choices in and other resources easily available on the substance abuse treatment programs: Internet and widely disseminated through Whenever possible, employ staff who have medical societies, other health-related completed training in gerontology professional groups, and health care Employ staff who like working with older practitioner training programs adults Adding or updating older adult-specific Provide training in empirically demonstrated information in the Physician's Desk Reference principles effective with older adults to all and other pharmacist-approved publications staff who will interact with these clients. regarding psychoactive prescription drugs with abuse potential

91 Chapter 5

Credentials and Training for do so and should havesome knowledge of the Program Staff developmental tasks of aging,even if this is Staff working with older adults need to gained through experience rather than formal understand the developmental tasks of aging education. Wherever feasible,programs that and the basic principles of educational have no appropriately trained staff should gerontologyhow older adults learn and encourage at least one staff member to attain process material. For this reason, Panel certification. members believe that any program thattreats Programs with linkages to layers of even a few older adults should have at least one serviceslarge addictionsprograms or staff person who is trained in the specialization programs linked to hospitals, health care of gerontology within his or her discipline. This systems, or multiservice agenciesarecommon training should consist of at least a graduate in urban settings. The following professionals certificate program (6 to 12 months) in the should ideally be available toa treatment subfield of aging commonly called social program, whether as members of the program's gerontology. Staff with professional degrees treatment teams or as resources available should have a specialization in gerontology, through the program's linkages with other geriatrics, or psychogeriatrics. If staff lack services: appropriate credentials, it can be difficult for the A geriatrician program to receive reimbursement from A geriatric psychiatrist insurance companies or funding from other I A geropsychologist funding streams. A gerontological counselor Any program that seeks to serve older adults EA nutritionist should also have a registered nurseon staff. An activities director or recreational therapist Ideally, this nurse would have a background in (to make home visits, increase socialization, physical health, addictions, and gerontology. In teach activities to fill leisure time) freestanding programs that assign onlyone A chaplain or other member of the clergy person to older clients (common in rural areas), Occupational therapists a master's degree in nursing with a specialty in Social workers (clinical, community, gerontology is preferred. administrative) Large programs with interdisciplinary teams Peer counselors (particularly valuable should include a registered nurse,a social because they have many life experiences in worker, and chemical dependency counselors. common with clients). All staff should have master's-level training with specialties in gerontology. The social Orientation and training of all staff isa worker should be prepared to carry outcase necessity. Staff should understand and believe management roles including liaison to that the prognosis for recovery for adults inthis community agencies. age group is favorable. They should understand The Panel recognizes that someprograms in that older adults can learn and change, and they isolated areas may serve onlya few older adults should be capable of showing respect to their in a mixed-age setting and may be unableto older clients. Special trainingon counseling retain staff members with optimal training. In skills and their application with older adults such instances, the staff person chosento work should be available to peer counselors and other with older clients should havea strong desire to program clinicians on an ongoing basis.

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Attributes and Personal Traits experience of growing older. With this Facilities should project the attitude that they understanding comes a willingness to listen and want to serve older adults. When centers offer to be patient with the older adult's pace of age-specific programs with staff experienced in movement and speech. A sense of humor is also aging issues and interested in working with important. Nonconfrontational personalities older adults, use by older adults increases typically work better with older adults. People (Fleming et al., 1984; Lebowitz, 1988; Lebowitz who prefer an emotional or confrontational et al., 1987; Light et al., 1986). Similarly, in the approach to therapeutic interaction are not treatment of alcohol abuse, research suggests appropriate candidates for work with older that age-specific programs may be more adults. Staff should be able to work in groups as attractive and effective (Atkinson, 1995; Kofoed trainers or teachers. Staff who work with older et al., 1987). adults also need to be flexible and willing to It is important that all staff who work with carry out tasks that may not be considered older clients actually like adults of this age "professional." group. When hiring, program staff should try to Staff members and volunteers need to be determine how older adults fit into the open to multiple avenues to recovery. If applicant's life. Does the applicant interact with recovering staff see their own route to recovery an older person by choice, as a friend? Does he as superior or the only way, it may limit their or she interact with older family members on a ability to work effectively with older adults, regular basis? Does he or she interact with older who tend to require more flexible approaches in adults on a regular basis through volunteer order to find their path. Effective treatment for activities or other activities in the community? the older adult is more holistic, more Staff need a sense of the issues involved in supportive, and often a great deal more aging. This understanding can be gained complicated than standard addiction treatment. through training, empathy, or the personal

93 6 Outcomes and Cost Issues in Alcohol Treatment for 01 er Adults

Outcomes research is concerned not only issues are discussed, and the chapter ends with with results of studies but also with recommendations for future research. determining what exactly should be studied. For alcohol treatment among older Spectrum of Alcohol adults, for example, should the measure of Treatment Outcomes success be treatment compliance? Amount of alcohol consumed? Level of physical health? Psychological well-being? This chapter reviews Brief Intervention Outcomes compliance studies and prospective studies on Randomized controlled trials in other countries treatment for older adults and examines the have demonstrated that brief interventions can measures used. Because there have been few reduce alcohol use and related problems in at- systematic studies of alcoholism treatment risk or nondependent problem drinkers under outcome (Atkinson et al., 1993) or the costs of age 65 (Saunders et al., 1993; Anderson and treatment (Institute of Medicine, 1990) for older Scott, 1992; Persson and Magnusson, 1989; adults, this chapter also applies more general Wallace et al., 1988; Kristenson et al., 1983). (For studies to that population. There are virtually a more complete discussion of brief no outcome studies of prescription drug use interventions, see Chapter 5.) Brief intervention treatment for older adults, so this chapter studies have been conducted in health care addresses alcohol use only. settings ranging from hospitals and primary The chapter also provides an overview of health care locations (Chick et al., 1988; Wallace instruments for measuring various treatment et al., 1988; Babor and Grant, 1992a; Fleming et outcomes, instruments that are more important al., 19976) to mental health clinics (Harris and than ever as the health care system moves Miller, 1990). The first randomized controlled toward managed care. Payers increasingly are U.S. trial in community-based primary care reimbursing only treatment approaches that practices, the Trial for Early Alcohol Treatment have been validated by outcome studiesin (Project TREAT), which studied adults age 65 particular, studies that quantify resource and younger (Fleming et al., 19976), found that savings. Treatment costs and reimbursement brief intervention for alcohol problems in

95 Ltd Chapter 6

primary care patients reduced both alcohol provide services to few older adults, sample size consumption and consequences. issues have been a barrier to studying treatment A study of brief physician advice with at-risk outcomes for older alcoholics. The development drinkers age 65 and over, Guiding Older Adult of elder-specific programs in recent years has, Lifestyles (Project GOAL), also found positive however, yielded sufficient data on older changes in drinking patterns of the experimental alcoholics to permit more comprehensive (n = 158) compared with the control group (n= studies of this population (Atkinson, 1995). 71) (Fleming et al., 1997a). At the time of the 12- Previous research on alcoholism treatment in month followup, there was a significant older adults can be divided into two broad reduction in 7-day alcohol use (t = 3.77; p < .001), categories: compliance studies and outcomes episodes of binge drinking (t = 2.68; p < .005), studies. and frequency of excessive drinking (t= 2.65; p < .005). The results indicated that brief physician Studies of treatment compliance advice made a difference in the drinking Most treatment outcome research on older patterns of older at-risk and problem drinkers. alcoholics has focused on compliance with Most studies of alcohol brief interventions treatment program expectations, in particular have only included patients early in their the patient's fulfillment of prescribed treatment drinking careers, explicitly excluding dependent activities and goals, including drinking behavior drinkers with significant withdrawal symptoms. (Atkinson, 1995). Results from compliance The rationale for this practice has been that studies have shown that age-specific alcohol-dependent individuals or those affected programming improved treatment completion most severely by alcohol should be referred to and resulted in higher rates of attendance at formal specialized alcoholism treatment group meetings than did mixed-age treatment programs because their conditions are not likely (Kofoed et al., 1987). Studies also show that to be amenable to a low intensity intervention older alcoholics were significantly more likely (Institute of Medicine, 1990; Babor, 1994). than younger patients to complete treatment However, only one study to date has addressed (Schuckit, 1977; Wiens et al., 1982/1983). the validity of this assumption. Sanchez-Craig Atkinson and colleagues also found that, and colleagues found that when comparing the proportionately, twice as many older male 12-month treatment outcomes of men whowere alcoholics completed treatment than younger severely dependent and men who were not, men (Atkinson et al., 1993). both receiving brief treatment, there wereno Age of onset of alcohol problems has been a significant differences in "successful" outcomes major focus of research for older adult treatment as measured by rates of abstinence or moderate compliance studies. In one study using a drinking (Sanchez-Craig et al., 1991). matched-pairs, post hoc design, rates of completion of 6-month day treatment for 23 Alcohol Treatment Outcomes older men and women alcoholics (age 55 and The study of treatment outcomes for older older) whose problem drinking began before adults who meet criteria for alcohol abuse or age 50 (early onset) were compared with 23 who dependence has become a critical issue because began problem drinking after age 50 (late onset) of older adults' unique needs for targeted (Schonfeld and Dupree, 1991). interventions. Because traditional residential In another study of 132 male alcoholic alcoholism treatment programs generally veterans age 60 and older, the sample was

96 117 Outcomes and Cost Issues divided into three subgroups: early onset (age alcoholics, address the methodological 40 and younger, n = 50), midlife onset (age 41 to limitations inherent in compliance studies. 59, n = 62), and late onset (age 60 and older, n = Prospective studies of treatment 20) (Atkinson et al., 1990). Age of onset was outcomes related to program completion and to weekly Although it is important to examine the factors group therapy meeting attendance, with the late related to completion of treatment, studies thus onset subgroup showing the best compliance in far have inherent selectivity bias and provide no bivariate analyses. However, a subsequent information on treatment dropouts or on short- multivariate analysis of 128 men age 55 and or long-term outcomes of treatment. Other older in alcoholism treatment found that sampling issues may limit the applicability of drinking relapses during treatment were such studies to larger groups, such as the unrelated to age of onset (Atkinson et al., 1993). exclusion of women in some studies and the use Furthermore, age of onset did not predict of varying age cutoffs that sometimes place program completion but was related to individuals as young as 45 in the "older" attendance rate at scheduled visits (Atkinson et category. al., 1993). The studies on the effect of age of Problems with previous outcome studies onset on treatment compliance have therefore extend beyond sampling to study methods. The yielded mixed results. majority of studies used relatively unstructured In a study of treatment matching, Rice and techniques for assessing drinking patterns and colleagues compared drinking outcomes for alcohol-related symptoms. Furthermore, the randomly assigned male and female alcoholics 3 assessment of outcomes has been narrow in months after beginning one of three mixed-age focus. Most studies have dichotomized outpatient cognitivebehavioral treatment treatment outcome (abstention vs. relapse) conditions scheduled to last for 4 months (Rice based solely on drinking behavior. Given et al., 1993). The sample included 42 individuals evidence from numerous studies that heavy or age 50 and older, 134 patients age 30 to 49, and binge drinking is more strongly related to 53 patients age 18 to 29. There were no alcohol consequences than average alcohol significant effects of age or treatment condition consumption (Anda et al., 1988; Chermack et al., on treatment compliance. However, there were 1996; Kranz ler et al., 1990), there may be significant age group-by-treatment condition important differences in outcome for effects. For older patients, the number of days nonabstinent individuals depending on whether abstinent was greatest and the number of heavy binge drinking was part of the posttreatment drinking days fewest among those treated with pattern. Current recommendations include a focus on self-efficacy rather than a focus on categorizing nonabstinent drinking outcomes occupation or family issues. along dimensions, such as whether drinkers Major limitations remain in the treatment ever drink to the point of intoxication (Heather compliance literature, including lack of drinking and Tebbutt, 1989). Furthermore, most studies outcome data, failure to report on treatment have not addressed other relevant domains that dropouts, and variations in definitions of may be positively affected by treatment, such as treatment completion. Few carefully controlled physical and mental health status and prospective treatment outcome studies, even psychological distress. those with sufficiently large numbers of older

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One reason for the lack of prospective physical and emotional health functioning, and treatment outcome studies is that studying older psychological distress. Followup was alcoholics during and after treatment is so conducted 6 months after discharge. This study complex. One exception is a study of 137 male also examined a range of different drinking veterans (age 45 to 59 years, n = 64; age 60 to 69 outcomes, including abstinence, nonbinge years, n = 62; age 70 years and older, n = 11) drinking, and binge drinking. with alcohol problems who were randomly Adults over the age of 55 in the treatment assigned after detoxification to age-specific program (n = 90) were interviewed. The treatment or standard mixed-age treatment physical health functioning of the sample was (Kashner et al., 1992). Outcomes at 6 months similar to that reported by seriously medically ill and 1 year showed that elder-specific program inpatients in other studies, whereas patients compared with mixed-age group psychosocial functioning was significantly patients were 2.9 times more likely at 6 months worse. Nearly one-third of the sample had one and 2.1 times more likely at 1 year to report or more comorbid psychiatric disorders, with abstinence. The two treatment groups, however, anxiety disorders and major depression most could not be adequately compared at baseline common. because baseline alcohol consumption and Participants who completed the 6-month alcohol severity data were not included in the followup assessment (n = 68; 76 percent of the study. original sample) were classified into the Recognizing that older individuals have been following outcome groups: abstainers (n = 38), underrepresented in standard alcoholism nonbinge drinkers (who never exceeded four treatment programs (Booth et al., 1992; Higuchi drinks on any drinking day during the followup and Kono, 1994), as well as in treatment period; n = 12), binge drinkers (who had one or outcome studies (Atkinson, 1995), the Institute more days in which they consumed five or more of Medicine published a special report calling drinks; n = 18), and noncompleters (who did not for specific longitudinal studies focused on complete the 6-month followup assessment; n = factors associated with more successful 22). These groups did not differ significantly on treatment outcomes in older adults (Institute of demographic variables, pretreatment drinking Medicine, 1990). patterns and symptoms, age of onset of alcohol Blow and colleagues conducted a study to problems, psychiatric comorbidity, or length of determine outcomes for older adults receiving stay in treatment. For all groups who completed specialized elder-specific inpatient alcoholism the 6-month followup, there were improvements treatment (Blow et al., 1997). A range of in general health. Psychological distress treatment outcomes was assessed using a decreased significantly between baseline and prospective longitudinal design. To address followup for abstainers and nonbinge drinkers. limitations of previous studies, this study used However, binge drinkers did not show a decline validated techniques to assess baseline alcohol in psychological distress and were significantly symptoms and psychiatric comorbidity, age of more distressed at 6-month followup than both onset of alcohol problems, drinking patterns, the abstainers and nonbinge drinkers.

98 119 with an outpatient program to maximize the Measurement of effect of inpatient treatment. Multidimensional A review of the literature on patients receiving substance abuse treatment indicated Outcomes for Older that 60 to 80 percent of people who relapse do so Adults within 3 to 4 months (McLellan et al., 1992). Older adults who comply fully with and Consumption levels are not the only measure of complete the intervention or treatment, success: Drinking patterns, alcohol-related however, are more likely than younger adults to problems, physical and emotional health positively change their drinking behavior (Finch functioning, and quality of life can also be used and Barry, 1992). Therefore, outpatient to assess alcohol intervention and treatment outcomes should be assessed no sooner than 3 outcomes with populations of older adults. It is months and possibly as long as 12 months after particularly important to use benchmarked treatment (McLellan and Durell, 1996). For all methods to assess older adults to determine types of intervention and treatment, ongoing whether treatment regimens are effective. Older outcome evaluation is important since the adults have unique issues based on changes in course of alcohol problems in older adults is physical functioning, changes in tolerance to dynamic and changes over time with alcohol, and internal (e.g., hearing, eyesight) and circumstances. Additional life stressors can external (e.g., death of spouse, retirement) losses change the pattern of alcohol use in this age requiring a multidimensional approach to group. assessment and outcome evaluation to In response to the rising costs of treatment ameliorate potential reasons for relapse or a and concerns about the effectiveness of alcohol return to hazardous drinking. treatment for both younger and older adults, the Outcome assessment is invaluable from both demand to evaluate and demonstrate the quality a management and a referral perspective. The of a variety of treatment options has also grown. providers of treatment, the clinicians and For the purposes of this section, outcome agencies referring patients, and patients measurement will include methods to measure themselves need to have information regarding alcohol use and alcohol-related problems, the likely outcomes of treatment. Because physical and emotional health functioning, and treatment options range from brief interventions quality of life and well-being. to structured outpatient and inpatient treatment programs, evaluation is recommended at Measures of Alcohol Use varying points in the treatment process Drinking patterns can be assessed using (McLellan and Durell, 1996). Initial evaluation approximations such as average number of in any setting should take place at the beginning drinking days per week and average number of of the intervention or treatment to obtain drinks per occasion or day. Two of the baseline data. McLellan and Durell recommend instruments assessing average consumption are conducting first followup evaluations 2 weeks to the Alcohol Use Disorders Identification Test 1 month after the patient leaves the inpatient (AUDIT) (Babor et al., 1992b) and the Health setting. The short time frame reflects the need to Screening Survey (HSS) (Fleming and Barry, determine if the patient is engaged in aftercare 1991), both of which are reproduced in Appendix B. The AUDIT, which has been

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validated internationally and with populations instruments provides clinicians, programs, and under age 65 in the United States, assesses referral agencies with measurements regarding quantity and frequency of alcohol use as wellas the nature and severity of problems presented alcohol-related problems (Babor et al., 1987; by persons who abuse alcohol. Fleming et al., 1991; Barry and Fleming, 1993; An important multidimensional screening Schmidt et al., 1995). instrument for use specifically with older adults The HSS, originally developed by Wallace is the Michigan Alcoholism Screening Test and Haines and adapted by Fleming and Barry, Geriatric version (MAST-G) (Blow et al., 1992a) measures average quantity and frequency of (See Figure 4-4). This tool was developed alcohol use in the previous 3 months (Wallace because many of the screening measures did not and Haines, 1985; Fleming and Barry, 1991) and identify alcoholism among older adults as includes parallel questions about weight, reliably as among younger populations. The exercise, and smoking. It has been validated in MAST-G was validated using criteria for alcohol people under 65 in primary care settings in the dependence in the Diagnostic and Statistical United States (Fleming and Barry, 1991) and has Manual of Mental Disorders, Third Edition, been used with older adults as part of a brief Revised (American Psychiatric Association, intervention trial (Fleming et al., 1997a). 1987) as the gold standard on 305 older adults The most accurate method used to assess including (1) persons currently meeting alcohol current alcohol consumption is the Time Line dependence criteria but not in treatment, (2) Follow Back (TLFB) procedure. TLFB is a those currently in treatment, (3) those witha structured interview that uses calendar cues previous history of alcoholism but in recovery, (e.g., holidays, family events, trips) to quantify (4) social drinkers, and (5) abstainers. daily alcohol use over a period of time ranging The MAST-G is a 24-item scale (sensitivity= from 7 days to a number of months (Sobell et al., 0.94; specificity = 0.78) in which a score of five or 1988, 1996). Researchers have used this method more "yes" responses indicates an alcohol to obtain up to 1 year of drinking data. This problem. Scores do not discriminate between method has shown high test-retest reliability in current and past problems, although some items a variety of drinking populations ranging from address the current situation and others address normal drinkers to heavy drinkers to persons problems in the past. Tolerance is not measured participating in inpatient or outpatient in light of data indicating that older adults with treatment. Fleming and colleagues used this even low consumption can experience alcohol- procedure to assess 7-day alcohol use with related problems due to physiological changes adults age 65 and older as part of the initial that occur with age. assessment in a clinical trial to test the The Addiction Severity Index (ASI) effectiveness of brief physician advice with older (McLellan et al., 1985; McLellan et a1.,1990) was at-risk and problem drinkers (Fleming et al., developed specifically to assess over time the 1997a). alcohol-related problems and the severity of Measures of Alcohol Problems symptoms of patients in treatment for alcohol and drug abuse and dependence. The ASI is a It is necessary but not sufficient to determine semistructured interview that provides quantity and frequency of alcohol use for initial information about aspects of the patient's life and followup assessments in older adults. The that may contribute to the substance abuse use of multidimensional screening and outcome syndrome. The focus of the interview is on

100 1 Outcomes and Cost Issues seven functional areas that have been shown to health, limitations in role functioning due to be affected by substance abuse: medical status, emotional problems, vitality, and general health employment and support, drug use, alcohol use, perceptions. The SF-36 has published norms for legal status, family and social status, and these various subscales over distinct age groups, psychiatric status. Each area is assessed including older adults (McHorney et al., 1993). individually for past and present (last 30 days) In addition to the subscales addressed in the status. Each area has a 10-point interviewer- SF-36, other measures of psychological distress determined severity rating of lifetime problems are useful in alcohol outcomes assessment with and a multi-item composite score indicating older adults. The Symptom Checklist -90- severity of the problems in the last 30 days. Revised (SCL-90-R) (Derogatis, 1994b) is a self- The ASI is targeted to all adult populations report symptom inventory designed to measure in substance abuse treatment or in treatment for psychological distress. The Brief Symptom co-occurring psychiatric and substance abuse Inventory (BSI) is a brief form of the SCL-90-R disorders. The ASI has good interrater (Derogatis and Melisaratos, 1983). These tests reliability as well as good predictive, concurrent, provide an overview of a patient's symptoms and discriminant validity (McLellan et al., 1985). and identify the level of distress that a patient is Although it has not been widely used or experiencing during a specific time period (e.g., validated with older patients and is not "the last 7 days"). Both the SCL-90-R (90 items) generally used with patients who are at-risk or and the BSI (53 items) measure nine symptom problem drinkers in primary care or dimensions: somatization, obsessive- community-based settings, it is included in this compulsiveness, interpersonal sensitivity, review because it is a standard measure in the depression, anxiety, hostility, phobic anxiety, field and can provide important information paranoid ideation, and psychoticism. Each of regarding older adults in treatment settings, the tests also has three global measures of particularly in areas of greatest concern with distress, a measure of the intensity of distress, this populationmedical status, alcohol use, and a measure of the total number of patient family and social status, and psychiatric status. symptoms. Depending on the population being assessed, Measures of Physical and Emotional the internal consistency for the SCL-90-R ranges Health from 0.77 to 0.90; for the BSI, from 0.71 to 0.85. One of the most widely used measures of Test-retest reliability ranges from 0.80 to 0.90 for physical and emotional health is the Medical the SCL-90-R (with a 1-week interval between Outcomes Study 36-Item Short Form Health tests) and from 0.61 to 0.91 for the BSI. When Survey (SF-36). This instrument was originally used for outcome measurement, these measures developed for use with adults as a 20-item scale are often administered at intake, during for the Medical Outcomes Study (MOS) (Ware treatment, at discharge, and at followup and Sherbourne, 1992; Tar lov et al., 1989; intervals (Smith, 1996). Stewart et al., 1988) from more detailed measures used in the Rand Health Experiment. Measures of Quality of Life It was subsequently expanded to 36 items that Quality of life measures have most frequently measure physical functioning, limitations in been used for outcomes assessment in mental functioning due to physical health problems, health treatment. One of the most widely used social functioning, bodily pain, general mental instruments is the Quality of Life Interview

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(QLI) (Lehman, 1988). Research suggests that users of medical care in the United States. quality of life, as perceived by the patient, is an Persons with alcohol dependence, who important factor in maintaining optimal represent between 3 and 14 percent of the U.S. functioning. The quality of life measure is population, consume more than 15 percent of constructed to include a single-item measure of the national health care budget (Rice et al., general well-being and seven dimensions of 1993). Although a number of cost studies have well-being. The constructs and dimensions in examined drinking in younger adults (Holder et this scale are applicable to the alcohol treatment al., 1991; Holder and Blose, 1992; Finney and field, particularly in outcomes assessment with Monahan, 1996), few studies have separated the older adults for whom concerns about housing, costs of alcohol disorders for older adults or leisure, family, social relationships, health, even included older adults in cost analyses. In a safety, and finances are salient factors in study of Federal employees, one half of whom functioning and relapse. were over age 60, Holder and Blose analyzed 4 Internal consistency reliabilities range from years of claims data (Holder and Blose, 1986). 0.79 to 0.88 for the life satisfaction scales and They found that alcohol treatment contributed from 0.44 to 0.82 for the objective quality of life to sustained reductions in total health care scales. Normative data are available for various utilization and costs and that reductions in subgroups of patient populations, and the life posttreatment costs appeared to be sustained satisfaction items can be compared with national into the fourth and fifth years following norms in the general population. treatment. In a review of studies of alcohol treatment Costs of Alcohr.1 and potential health care cost savings that Treatment included Medicare studies, Holder found that mean monthly medical care costs increased for Outcomes studies obviously can help treatment persons with alcohol problems before initiation providers and health care professionals improve of treatment, declined immediately following treatment. They also play an important role in treatment, and continued to decline 2 years paying for treatment: Third-party payers want following treatment (Holder, 1987). The oldest validated proof that the treatment approaches group in the study (age 65 and older) they are reimbursing actually work. The other experienced the highest medical care costs and side of this equation is the costto individuals, showed the least convergence to levels prior to the health care system, and society at largeof the initiation of alcohol treatment. Reasons for alcohol-related problems. If costs of treatment this might include increased general morbidity can be measured against these larger costs, it is with age and the potentially more serious health more likely that treatment will be reimbursed. problems due to a longer period of chronic The costs of alcohol abuse and dependence alcohol abuse or dependence. are estimated to be over $100 billion a year, due Among all of the economic analyses of in part to increased mortality, significant social alcohol programs, there has been little work costs, and health consequences (National regarding the cost savings of substance abuse Institute on Alcohol Abuse and Alcoholism, prevention and early intervention in managed 1995; Brower et al., 1994; Holder and Blose, 1992; care settings. One of the few recent studies of Goodman et al., 1991). Individuals who have managed care (Holder et al., 1995) estimated alcohol disorders are among the highest cost that for every $10,000 spent on brief intervention

102 Outcomes and Cost Issues for alcohol or drug abuse, $13,500 to $25,000 is consequences of alcohol disorders will yield the saved in medical spending for the managed care largest savings in a reformed American health provider. Gaps remain in the literature care system (McCrady and Langenbucher, 1996). regarding the economic effectiveness and implications of brief interventions in managed Reimbursement Issues in care settings. Filling in the gaps is particularly The Treatment of Older important because managed care providers are challenged to provide needed services with Adults fewer dollars. The barriers to care experienced by many Findings on the efficacy and cost- individuals who need intervention or treatment effectiveness of brief intervention, however, can for problems related to their alcohol use have be misleading (Heather, 1995; Pee le, 1990). been of great concern to the alcohol treatment These reviews generally do not assess costs and field. A further concern has been the needs of older adults in these settings. observation that only a small minority of those Methodologies across cost analysis studies have who need treatment has received it (Institute of not been consistent, making comparisons more Medicine, 1990). It has not always been clear if difficult. In addition, Heather points out this is due to the lack of identification and problems in interpreting the data from brief referral of those who need treatment, the lack of intervention studies because brief interventions treatment options, or financial barriers to care. are not a homogeneous entity (they vary in All of these barriers may affect older adults. length, structure, targets of intervention, and Currently, however, the financial barriers are personnel responsible for delivery), and there is changing the fastestand some of the shifts in a distinction between treatment seekers (e.g., reimbursement are alarming. persons who answer ads indicating that they Private third-party insurers are funded would like to decrease their drinking) and through premiums paid by purchasers, with nontreatment seekers (e.g., individuals with premiums adjusted based on claims made by regularly scheduled appointments for medical any subscriber group. Generally, except for self- problems who receive interventions from their insured plans, coverage minimums and health care providers) (Heather, 1995). Clear premiums are regulated by States through their delineation of the type of study and the insurance departments. Medicare is generally potential audience for the research can help to thought of as a public third-party payer for alleviate problems of misinterpretation. health care services. The benefits provided are Most economic studies of alcohol treatment authorized through legislation. have focused on hospital inpatient and The current trend, however, is for States to outpatient treatment for abuse and dependence turn their Medicare programs over to managed (Pee le, 1990; Annis, 1986). Pee le's review of the care companies. Although, since its inception in literature revealed that, although hospital 1965, Medicare has generally covered 12 days of treatment is no more effective than outpatient inpatient alcohol treatment, most managed care treatment, reimbursement systems have often companies eliminate coverage for as much supported the more costly, medically based inpatient treatment as possible and often cut inpatient treatment options (Pee le, 1990). services for alcohol treatment altogether to keep Some experts suggest that effectively treating costs down. alcoholism and reducing the social and medical

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These cuts in coverage are antithetical to all Areas Requiring Future that is known about treating older adults with alcohol problems. Coverage of 12 days of Research inpatient treatment is extremely important for As the number of older adults rises, the use of older adults because they are likely to have a mood-altering drugs such as alcohol and greater number of physical and cognitive tranquilizers by older adults is a growing area of problems than younger adults. For example, concern from a clinical and research perspective. older adults often have more prolonged and As the Baby Boom generation reaches traditional severe alcohol withdrawal than younger adults retirement age, the field of substance abuse (Brower et al., 1994), and participation in group treatment and research will be faced with both treatment is more difficult for them in the early growing numbers of individuals who have stages of treatment. They are also more likely to alcohol-related problems and emerging need more intensive outpatient care after an problems unique to the aging population, inpatient stay than younger adults. namely a potential increased prevalence of illicit Furthermore, Medicare should reimburse for drug use and drug-related problems. alcohol prevention and early intervention efforts Even though the prevalence of alcohol and in primary care settings, because research drug use decreases with age, alcohol and indicates that early intervention programs are prescription drug use continue to be important effective with a large proportion of older at-risk health problems in the current cohort of older and problem drinkers. Such initiatives will save adults. To advance the field and address the medical community money by preventing coming needs of future older adults, research more costly complications of heavier alcohol needs to be focused in some specific areas. The intake. general areas for new research initiatives are (1) With ongoing changes in the delivery of alcohol and other drug consumption, (2) alcohol treatment services from inpatient to treatment, (3) biomedical consequences, (4) outpatient settings coupled with the shifting behavioral and psychological effects, and (5) reimbursement structure from fee-for-service special issues. Medicare to managed Medicare, coverage of In the area of alcohol and other drug effective treatment is increasingly uncertain. consumption, future research directions should The changes in treatment venue and fee include structures underscore the importance of conducting multidimensional outcomes Life course variations among alcohol, illicit assessments in the context of quality drug, and prescription drug use patterns management. Convincing research is an Gender and ethnic variability important component of efforts to ensure that Reasons for changes in drinking and drug older adults who need intervention and use patterns with aging treatment for alcohol problems receive the Early and late onset of alcohol and drug appropriate level of treatment and adequate problems followup. Ongoing evaluation of patient Health care costs for older adults outcomes can help safeguard the health of at- maintaining abstinence compared with costs risk older adults and foster the development of for those who reduce their consumption innovative treatment approaches to meet the Development of valid screening instruments needs of this vulnerable population. for illicit and prescription drug use.

104 125 Outcomes and Cost Issues

Issues related to treatment have traditionally Behavioral and psychological research been studied in males and younger cohorts of initiatives may be focused in the following adults. Some of the issues requiring both new directions: and renewed study with older adults include Demographics relating to older adult alcohol Prevention and early intervention techniques and drug use and abuse (relationship The use of technology (e.g., computers, between drinking and drug use status and interactive voice recognition) in the employment, marital status, residence, treatment of substance abuse problems in education, and other variables specifically older adults affecting older adults) The effectiveness of various older adult- Older adults' reasons for changing their specific alcohol and drug treatment drinking patterns modalities Stress, coping, and adaptation, and their Alcohol and drug withdrawal issues relationship to alcohol and drug use The effect of physical and psychiatric Cognitive effects of moderate and heavy comorbidity on treatment outcomes drinking and drug use in this age group. Older subgroups (i.e., 60-65, 65- 70, 70-75, Finally, there are some special issues related to 75-80, 80+) older adult substance abuse that have been the Relationship of provider characteristics (e.g., target of clinical concern and some initial age, similarity to client) to completion of research, which needs to be expanded in order treatment to address the needs of the current and future Risk factors for drinking and drug use cohorts of older adults: relapse, including a better understanding of specific treatment needs for older adults. Elder abuse and neglect Homelessness Biomedical research can forge a new and Underrepresentation of older adults in important path in the understanding of alcohol treatment settings. use and abuse in older adults. Directions include Researchers in gerontology, substance abuse treatment, and related fields must take the lead The effects of alcohol and drugs on aging in providing the above information. Only with organisms such knowledge can clinicians and policymakers Alcohol and drug medication interactions improve the identification and treatment of Physiological reasons for increased substance use disorders among older adults. sensitivity to alcohol as people age Without the informationand the response Medical consequences of moderate and such disorders will take a greater and greater heavy drinking and illicit drug use toll on one of the most vulnerable and fastest Interactions of alcohol, nicotine, and illicit growing sectors of the population. drugs.

12G Appe ix A Legal and Ethical Issues

by Margaret K. Brooks, Esq.1

Screening any population for substance problems: How can a provider keep accurate abuse raises key legal and ethical records and communicate with others concerned concerns: how one can inquire about an about the older individual's welfare without individual's alcohol and drug use while disclosing information that may subject the continuing to respect that person's autonomy individual to scorn or create problems with and privacy. Screening of older adults for family or third-party payers? substance abuse brings these concerns into particularly sharp focuswhether the person Autonomy and the screening is a clinician, a staff member at a Provider's Mission: A senior center, a member of the clergy, an adult protective service worker, a Meals-On-Wheels Dilemma volunteer, a pharmacist, a community health Americans attach extraordinary importance to worker, an adult day care worker, or staff being left alone. We pride ourselves on having member at a long-term care facility. perfected a social and political system that limits This appendix examines how the issues of how far the governmentand otherscan autonomy and privacy (or confidentiality) affect control what we do. The principle of autonomy the way providers working with older adults is enshrined in our Constitution, and our courts may screen for substance use problems. The have repeatedly confirmed our right to make first section discusses the relationship between our own decisions for ourselves. patient or client autonomy and the provider's Most of us cherish our autonomy and fear its obligation to inform and counsel the older loss, particularly as we age. Although providers individual about the health risks of alcohol or who screen or assess for substance abuse do so other drug use. The second section concerns because they are genuinely concerned about an privacy of information about substance use individual's health or functioning, screening

I Margaret K. Brooks is an independent consultant in Montclair, New Jersey.

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means seeking very personal informationan discussion about his alternatives. If there is a unavoidable intrusion on a person's autonomy substance abuse problem, the provider can and privacy. Alert to suggestions that their supply the information and encouragement, but judgment or abilities are impaired, older adults only the person with the problem has the power may not always see a provider's effort to "help" to change what he is doing. Respecting the as benign. patient's autonomyhis right to make choices Performed insensitively, screening or is central to encouraging that change. assessment may intensify denial. A person of any age who is "in denial" may not realize, or Privacy and want to realize, that he has to cut back on or Confidentiality give up his intake of alcohol or prescription medications; an older person may view the Aside from perceived threats to autonomy, an provider's questions and suggestions as older person may also be concerned about the intrusive, threatening, and offensive. practical consequences of admitting a substance Suggestions that an older individual's complaint use problem. Such patients may find it difficult has an emotional basis may tap an underlying or impossible to obtain coverage for reluctance to acknowledge an emotional hospitalization costs if an insurer or health component to any problem and reinforce the maintenance organization (HMO) learns that individual's resistance. Because the substance their traumatic injuries were related to abuse label carries a powerful stigma, an older alcoholism. Relationships with a spouse, individual may become alarmed if a provider children, grandchildren, or friends may suffer. intimates that alcohol or drug abuse may be Adverse consequences such as these may involved. It will be tempting for the older discourage patients with substance use individual to point to the "normal" infirmities of problems from seeking treatment. old age as the source of his difficulty rather than Concern about privacy and confidentiality is acknowledge a problem with alcohol or other fueled by the widespread perception that people drugs. with substance use disorders are weak and/or How can the provider raise the question of morally impaired. For an older person, this alcohol and drug use constructively, without concern may well be compounded by an eliciting a defensive response? Should she raise apprehension that others may view the issue and then drop it at the slightest hint of acknowledgment of a substance use disorder as resistance on the part of the older individual? a sign of inability to continue living Or should she intervene more forcefullywith independently. If the individual is having argument or by involving the family? family problemswith a spouse or with To fulfill her ethical responsibility, the childreninformation about substance use provider should do more than simply raise the could have an adverse impact on resolution of issue. As the Consensus Panel suggests, most those problems. Or the individual may older adults are unaware that their metabolism experience difficulties with health insurance. of alcohol and prescription drugs changes as they age and that lower amounts of alcohol and Federal Law medicines may incapacitate them. Respect for a The concern about the adverse effects that social person's autonomy means informing him of all stigma and discrimination have on patients in relevant medical facts and engaging him in a recovery (and how those adverse effects might

108 1 2. 8 Legal and Ethical Issues

deter people from entering treatment) led the State Law Congress to pass legislation and the U.S. Although Federal rules do not restrict how most Department of Health and Human Services to providers gather and handle information about issue a set of regulations to protect information an older individual's substance abuse, there are about individuals' substance abuse. The law is other rules that may limit how such information codified at 42 U.S.C.§ 290dd-2. The may be handled. State laws offer some implementing Federal regulations, protection to medical and mental health "Confidentiality of Alcohol and Drug Abuse information about patients and clients. Most Patient Records," are contained in 42 CFR Part 2 doctors, social service workers, and clients think (Vol. 42 of the Code of Federal Regulations, Part of these laws as the "doctor-patient privilege" or 2). "social worker-client privilege" or The Federal law and regulations severely "psychotherapist-patient privilege." restrict communications about identifiable Strictly speaking, these privileges are rules of individuals by "programs" providing substance evidence that govern whether a professional use diagnosis, treatment, or referral for provider can be asked or compelled to testify in treatment (42 CFR§ 2.11). The purpose of the a court case about a patient or client. In many law and regulations is to decrease the risk that States, however, laws offer wider protection. information about individuals in recovery will Some States have special confidentiality laws be disseminated and that they will be subjected that explicitly prohibit physicians, social to discrimination and to encourage people to workers, psychologists, and others from seek treatment for substance use disorders. divulging information about patients or clients In most settings where older adults receive without consent. States often include such care or services, Federal confidentiality laws and prohibitions in professional licensing laws; such regulations do not apply.' Providers should be laws generally prohibit licensed professionals aware, however, that if a health care practice or from divulging information about patients or social service organization includes someone clients, and they make unauthorized disclosures whose primary function is to provide substance grounds for disciplinary action, including abuse assessment or treatment and if the license revocation. practice or organization benefits from "Federal Each State has its own set of rules, which assistance,"2 that practiceor organization must means that the scope of protection offered by comply with the Federal law and regulations State law varies widely. Whether a and implement special rules for handling communication is "privileged" or "protected" information about patients who may have may depend on a number of factors: substance abuse problems.3 Moreover, the fact that most providers for The type of professional provider holding the older adults are not subject to the Federal rules information and whether he or she is does not mean that they can handle information licensed or certified by the State about their clients' substance use problems in a The context in which the information was cavalier manner. Because of the potential for communicated damage, providers should always handle such The context in which the information will be information with great care. or was disclosed Exceptions to any general rule protecting information, and

109 12:9 Appendix A

ei How the protection is enforced. The context in which the information was communicated Professionals covered by the State laws vary tremendously in this area, too. "doctor-patient" or "therapist- Some States protect only the information that a client" privilege patient or client communicates to a professional Which professions and which practitioners in private, in the course of the medical or mental within each profession are covered depends on health consultation. Information disclosed to a the State where the professional practices. clinician in the presence of a third party (like a California, which grants its citizens "an spouse) is not protected. Other States, such as inalienable right to privacy" in its Constitution, California, protect all information the patient or has what may be the most extensive protections client tells the professional or the professional for medical (including mental health) gains during examination.5 California also information. California law protects protects other information acquired by the communications with a wide variety of professional about the patient's mental or professionals, including licensed physicians, physical condition, as well as the advice the nurses, and psychotherapists (which includes professional gives the patient.' When California clinical social workers, psychologists, marriage courts are called upon to decide whether a and family counselors), as well as many particular communication of information is communications with trainees practicing under privileged, State law requires them to presume the supervision of a number of these that it is. professionals. A California court has held that California affords great protection to information given to an unlicensed professional communications between patients and by an uneducated patient may be privileged if psychotherapists, a term that covers a wide the patient reasonably believes the professional range of professions. Not only are is authorized to practice medicine.' communications by and to the patient protected, Other States' laws cover fewer kinds of information communicated by a patient's professionals. In Missouri, for example, intimate family members to therapists and protection is limited to communications with psychiatric personnel7is also protected. State-licensed psychologists, clinical social California also protects information the patient workers, professional counselors, and discloses in the presence of a third party or in a physicians. group setting. Depending on their professional training Understanding what medical information is (and licensing), primary care physicians, protected requires professional providers to physician assistants, nurse-practitioners, nurses, know whether State law recognizes the psychologists, social workers, and others may be confidentiality of information in the many covered by State prohibitions on divulging contexts in which the professional acquires it. information about patients or clients. Note that even within a single State, the kind of protection Circumstances in which afforded information may vary from profession "confidential" information is to profession. Professional providers should protected from disclosure Some States protect medical or mental health learn whether any confidentiality law in the information only when that information is State where they practice applies to their sought in a court proceeding. If a professional profession. 1o 110 Legal and Ethical Issues

divulges information about a patient or client in consent, but some limit the range of disclosure any other setting, the law in those States will not for certain diseases, like HIV. Most States make recognize that there has been a violation of the some provision for communicating information individual's right to privacy. Other States to health insurance or managed care companies. protect information in many different contexts Many of the situations that physicians and and may discipline professionals who violate social service workers face dailyprocessing their patients' privacy, allow patients to sue health claims or public benefit applications, for them for damages, or criminalize behavior that exampleare covered by one of these violates patients' privacy. The diversity of State exceptions. To fully understand the "rules" rules in this area compounds the difficulty regarding privacy of medical and mental health professionals face in becoming knowledgeable information, professionals must also know about what rules apply to them. about the exceptions to those rules. Those Exceptions to State laws protecting exceptions are generally in the statute booksin medical and mental health either the sections on evidence or the information professional licensing sections, or both. The state licensing authority as well as professional Consent associations can usually help answer questions All States permit health, mental health, and about State rules and the exceptions to those social service professionals to disclose rules. information if the patient or client consents. Enforcing confidentiality protections However, each State has different requirements regarding consent. In some States, consent can The role of the courts be oral; in others, it must be written. States that To determine the "law"that is, the rule one require written consent sometimes require that must followin any particular area, an attorney certain elements be included in the consent form will search for statutes, regulations, or that everyone use a State-mandated form. administrative rulings, and court decisions. Some States have different consent forms with There is no question that in this country, the different requirements for particular diseases. courts play a large role in "making" law particularly in an area like privacy, which Other exceptions involves human behavior, shades of meaning, Consent is not the only exception. All States and intent. No legislator drafting a statute (or also require the reporting of certain infectious bureaucrat drafting a regulation) can foresee all diseases to public health authorities and some the circumstances under which it may be require the reporting of elder abuse to protective applied. When one party sues another, a court service agencies, although definitions of is forced to decide whether a provider's "infectious disease" and "elder abuse" vary. disclosure of medical information was And most States require health care appropriate or whether such information should professionals and mental health counselors to be disclosed during the lawsuit itself. report to the authorities threats patients make to For example, after a car crash, the drivers inflict harm on others. There are States that may sue each other and ask the court to order permit or require health care professionals to the disclosure of medical records. Or the victim share information about patients with other of an assault by an adolescent may sue the health care professionals without the patients' parents and seek disclosure of medical records

131 111 Appendix A

to prove they knew their child was dangerous. indiscretion is free to sue; while such cases are How a court decides whether to order disclosure difficult for clients to win, they can cause the in such cases will depend on a variety of factors, professional and the organization employing her including State law and regulation, court rules, a good deal of grieffinancial, emotional, and and the relevance of the information sought to professional. Even short of litigation, no the dispute at hand. Similarly, when a patient professional wants to acquire the reputation of or client sues a professional for releasing being thoughtless or indiscreet. information to someone without her consent, the court will be called upon to weigh a variety of Strategies for Dealing With factors to decide whether the disclosure violated Common Situations what the State recognizes as the patient's Charting substance use information privacy. One way for a professional to safeguard clients' Over time, court decisions like these add privacy and avoid breaking the rules is to flesh to the bare statutory and regulatory rules develop a charting, or record-keeping, system and suggest how those rules will be applied the that is accurate but still protects clients' rights to next time. When a difficult case arises that does privacy and confidentiality. It is important to not fit neatly within the rule of law as remember how many people could see a client's understood, it may be helpful to consult with an medical, mental health, or social service record. attorney familiar with the rules and how the A medical chart, for example, will be seen by the State's courts are likely to interpret them. medical office staff, the insurance company (or Penalties for violations HMO or managed care organization [MCO]), States differ in the ways they discipline and in the event of a referral, another set of professionals for violations of patients' or clinicians, nurses, clerical workers, and insurers. clients' privacy. In some States, violation of If the patient is involved in litigation and his confidentiality is a misdemeanor, punishable by medical or mental health is in issue, the court a fine or short jail term. In many States, the will most likely order disclosure of his chart or professional licensing agency has the power to file in response to a subpoena. bring disciplinary charges against a professional When a provider documents the results of who violates a client's privacy. Such charges substance abuse screening or assessment or flags may result in censure or license suspension or an issue to be raised the next time he sees the revocation. Finally, the State may permit the client, he should use neutral notations or aggrieved patient or client to sue the reminders that do not identify the problem as professional for damages caused by the being substance-use-related. Following are violation of his right to confidentiality. three record-keeping systems that comply with The reality is, these enforcement mechanisms the stringent Federal confidentiality regulations, are rarely used. States rarely prosecute privacy protect clients' autonomy and privacy, and can violation offenses and professional disciplinary be used in a wide variety of settings (TIP 16, committees in most States are more concerned Alcohol- and Other-Drug Screening of Hospitalized with other kinds of professional infractions. Trauma Patients, CSAT, 1995): That is not to say that violation of a patient's giThe "minimalist" approach, which relies on privacy is cost-free. A patient or client who the provider to enter only that information in thinks he has been hurt by a professional's

112 13..9 Legal and Ethical Issues

the chart that is required for accuracy and to particularly one of importance in a community, use neutral terms wherever possible. making privacy difficult to preserve. The "rubber band" approach, which Communicating with others segregates substance abuse information in a One of the trickiest issues is whether and how separate "confidential" section in the chart. providers of older adults health care should Information in this section would be shared communicate with others about their clients' with other providers only on a need-to-know substance use problems. Communications with basis, without being open to the view of others concerned about the client may confirm every staff person who picked up the chart. the provider's judgment that the client has a o The "separate location" approach, which substance use problem or may be useful in keeps sensitive information separate from persuading a reluctant client that treatment is the rest of the client's chart. The other place necessary. might be a locked cabinet or other similarly Before a provider attempts to gather secure area. A "gatekeeper" familiar with information from other sources or enlist help for the provider's record-keeping system and the a patient or client struggling with recovery, he reasons for the extra security would be should ask the older client's permission to do so. responsible for deciding when others Speaking with relatives (including children), within or outside the officewill have access doctors, or other health and mental health to this information. This approach provides, professionals not only intrudes on the client's in effect, a stronger "rubber band" than that autonomy, it also poses a risk to her right to described in the second approach.8 privacy. Gathering information (or responding The push toward computerization of medical to questions about a client's problems) from a records will complicate the problem of keeping spouse, child, or other provider can involve an sensitive information in medical records private. explicit or implicit disclosure that the provider Currently, there is protection afforded by the believes the client or patient has a substance use cumbersome and inefficient way many, if not problem. And the provider making such a most, medical, mental health, and social service disclosure may be inadvertently stepping on a records make their way from one provider to land mine. another. When records are stored in computers, Making inquiries or answering questions retrieval can be far more efficient. behind the client's back may seriously Computerized records may allow anyone with a jeopardize the trust that has developed between disc and access to the computer in which the the provider and the client and undermine his information is stored to instantly copy and carry attempt to offer help. The professional who away vast amounts of information without talks to the client's son and then confronts her anyone's knowledge. Modems that allow with their joint conclusions runs the risk that he communication about patients among different will damage his relationship with the client. components of a managed care network extend Feeling she can no longer trust the provider and the possibility of unauthorized access to anyone angry that he has shown little respect for her with a modem, the password(s), and the autonomy or privacy, the client may refuse to necessary software. The ease with which participate in any further discussions about her computerized information can be accessed can problems. lead to "casual gossip" about a client,

13 O;) Appendix A

Dealing with questions of incapacity alternatives presented. By helping the patient or Most older clients or patients are fully capable of client narrow his focus and proceed step-by- comprehending the information and weighing step, the provider may be able to assure herself the alternatives offered by a provider and that the client, despite his diminished capacity, making and articulating decisions. A small has understood the decision to be made and percentage of older patients or clients are clearly acted in his own best interest. incapable of participating in a decision-making Enlisting the help of a health or mental health process. In such cases, the older person may professional. If working with the patient or client have signed a health care proxy or may have a in a process of gradual information-gathering court-appointed guardian to make decisions in and decision-making is not making headway, his stead. the provider can suggest that together they The real difficulty arises when a provider is consult a health or mental health professional. screening or assessing an older person whose Perhaps there is someone who has known the mental capacity lies between those two patient or client for a number of years who has a extremes. The client or patient may have grasp of the client's history and better fluctuating capacity, with "good days" and "bad understanding of the obstacles to decision- days" or periods of greater or lesser alertness making. Or, the provider may suggest a depending upon the time of day. His condition specialist who can help determine why the may be transient or deteriorating. His patient is having difficulty and whether he has diminished capacity may affect some parts of his the capacity to make this kind of decision. ability to comprehend information but not Enlisting the help of family or close friends. others. Another approach is for the provider to suggest How can the provider determine whether the to the patient or client that they call in a family patient or client understands the information member or close friend who can help them she is presenting, appreciates the implication of organize the information and sort through the each alternative, and is able to make a "rational" alternatives. Asking the client who he thinks decision, based on his own best interests? There would be helpful may win his endorsement of is no easy answer to this question. One can, this approach. however, suggest several approaches. When the client cannot grasp the information or Maximizing autonomy. The provider can help come to a decision. If the provider's efforts to the patient or client who appears to have inform the patient or client and help him reach a diminished capacity through a gradual decision are unsuccessful, she might seek his information-gathering and decisionmaking permission to consult a family member or close process. Information the client needs should be friend to discuss the problem. If the client presented in a way that allows the patient or consents, the provider should lay out her client to absorb it gradually. The provider concerns for the family member or friend. It should clarify and restate information as may be that the client has already planned for necessary and may find it helpful to summarize the possibility of his incapacity and has signed a the issues already covered at regular intervals. durable power of attorney or a health care Each alternative and its possible consequences proxy. should be laid out and examined separately. Guardianship. A guardian9 is a person Finally, the provider can help the client identify appointed by a court to manage some or all his values and link those values to the aspects of another person's life. Anyone seeking

114 134 Legal and Ethical Issues appointment of a guardian must show the court Communications with insurers, (1) that an individual is disabled in some way by HMOs, and other third-party payers disease, illness, or senility, and (2) that the The structure of health, mental health, and disability prevents him from performing the ancillary social service care for older adults is tasks necessary to manage an area or areas of his changing rapidly. Of course, older adults are life. covered by Medicare, but many have Each state handles guardianship proceedings supplementary insurance or have joined HMOs differently, but some principles apply across the or are entitled to government-sponsored social board: Guardianship is not an all-or-nothing services because of particular medical, physical, state. Courts generally require that the person or mental disabilities. How should the seeking appointment of a guardian prove the professional provider communicate with these individual's incapacity in a variety of tasks or different types of entities? areas. Courts may apply different standards to Traditional health insurance programs different life tasksmanaging money, offering reimbursement to patients for health managing a household, making health care care expenditures typically require patients to decisions, entering contracts. A person may be sign claim forms containing language found incompetent to make contracts and consenting to the release of information about manage money but not to make his own health their care. The patient's signature authorizes the care decisions (or vice versa), and the practitioner to release such information. guardianship will be limited accordingly. Although HMOs do not require patients to Guardianship diminishes the older adult's submit claim forms, both practitioners and autonomy and is an expensive process. It patients understand that the HMO or MCO can should, therefore, be considered only as a last review clinical records at any time and may well resort. review records if it has questions about the Making referrals to substance abuse patient's or client's care. treatment programs Should the provider rely on the patient's signed consent on the health insurance form or The provider has persuaded the patient or client the HMO contract and release what she has in to try outpatient treatment and knows the her chart (or a neutral version of that director of an excellent program in the information)? Or should she consult the immediate area. Rather than simply picking up patient? the phone and letting the director know she has The better practice is for the provider to referred the patient, she should consult the frankly discuss with the patient what patient about the specific treatment facility. information she intends to disclose, the Though it may seem that consent to treatment is alternatives open to the client (disclosure and the same as consent to referral to a particular refusal to disclose), and the likely consequences facility, it takes very little time to get the of those alternatives. Will the information the patient's consent, demonstrates respect for the provider sends explicitly or implicitly reveal the client or patient, and protects the provider if, nature of the patient's problem? Does the say, the treatment program's director is a client's chart contain a substance abuse relative or has some other connection to the diagnosis? Once again, the provider confronts client. the question of how such information should be recorded. Has she balanced the need for

135 115 Appendix A

accuracy with discretion and a respect for As in so many other areas involving patients' patients' privacy? Finally, even if the chart or privacy, it is best to follow two simple rules: file contains explicit information about the First, keep notations and documentation as client's substance use problem, can the provider neutral as possible while maintaining characterize the information and her diagnosis professionally acceptable standards of accuracy. in more neutral terms when releasing Second, consult the client and let the client information to the third-party payer? decide whether to agree to the disclosure. Once the client understands what kind and amount of information the provider intends to Communicating with the legal send a third-party payer, he can decide whether system to agree to the disclosure. The provider should If a doctor, psychologist, social worker, or other explain that if she refuses to comply with the provider gets a call from a lawyer asking about a third-party payer's request for information, it is patient or client, or a visit from a law likely that at least some related services will not enforcement officer asking to see records, or a be covered. If the client expresses concern, she subpoena to testify or produce medical records, should not mislead him, but confirm that once a what should he or she do? As in other matters of third-party payer learns he has had a substance privacy and confidentiality, (1) consult the use problem, he could and may lose either some patient, (2) use common sense, and (3) as a last of his insurance coverage or parts of other resort, consult State law (or a lawyer familiar with State law). entitlements and be unable to obtain other coverage.10 Responding to lawyers' inquiries. Say a lawyer calls and asks about Emma Bailey's medical, The final decision should be the client's. He may well decide to pay out of pocket. Or he mental health, or social service history or may agree to the limited disclosure and ask the treatment. As a first approach to the question, provider to inform him if more information is the provider could tell the lawyer, "I don't know requested. that I have a client with that name. I'd have to As managed care becomes more prevalent check my records "" or tell the caller that he throughout the country, medical and mental must consult with his client before having a health providers are finding that third-party conversation about her: "I'm sure you payers demand more and more information understand that I am professionally obligated to about patients and about the treatment provided speak with Emma Bailey before I speak with to those patients in order to monitor care and you." It will be hard for any lawyer to disagree with this statement. contain costs. Providers need to be sensitive The provider should then ask the client if she about the amount and kind of information they disclose because there is a risk that this knows what information the caller is seeking and whether the client wants him to disclose information may be used to deny future benefits that or any other information. He should leave to the client. Chart notes may also contain the conversation with a clear understanding of detailed and very personal information about family life that may be unnecessary for a third- the client's instructionswhether he should party payer to review in order to determine disclose the information, and if so, how much whether and what kind of treatment should be and what kind. It may be that the lawyer is covered. representing the client in a case and the client wants the provider to share all the information

116 130 Legal and Ethical Issues he has. On the other hand, the lawyer may subpoena duces tecumrequires a person to represent someone with whom the client has a appear with the records listed in the subpoena. dispute. There is nothing wrong with refusing Depending on the State, a subpoena can be to answer a lawyer's questions.12 signed by a lawyer or a judge. Unfortunately, it If the lawyer represents the client and the cannot be ignored. client asks the provider to share all information, In this instance, the provider's first step the provider can speak freely with the lawyer. should be to call Emma Baileythe client about However, if the provider is answering the whom he is asked to testify or whose records are questions of a lawyer who does not represent the soughtand ask what the subpoena is about. It client (but the client has consented to the may be that the subpoena has been issued by or disclosure of some information), the provider on behalf of Emma's lawyer, with Emma's should listen carefully to each question, choose consent. However, it is equally possible that the his words with care, limit each answer to the subpoena has been issued by or on behalf of the question asked, and take care not to volunteer lawyer for an adverse party. If that is the case, information not called for. the provider's best option is to consult with Visits by law enforcement. A police officer, Emma's lawyer to find out whether the lawyer detective, or probation officer who asks a will objectask the court to "quash" the provider to disclose medical, mental health, or subpoenaor whether the provider should social service information about a client or a simply get the client's consent to testify or turn client's case records can usually be handled in a over her records!' An objection can be based on similar manner:13 The provider can safely tell the a number of grounds and can be raised by any officer, as he might a lawyer, "I'm sure you party as well as by the person whose medical understand that I am professionally obligated to information is sought. If the provider is covered speak with my patient before I speak to you."" by a State statutory privilege, he may be able to The provider should then speak with the assert the client's privilege for her. client to find out whether she knows the subject of the officer's inquiry, whether she wants the Conclusion provider to disclose information and if so, how much and what kind. The caretaker might end It is essential for those who work with older the conversation by asking whether there are adults to respect their clients' autonomy and any particular areas the client would prefer he rights to privacy and confidentiality if they are not discuss with the officer. to be effective in screening and assessing clients When a law enforcement officer comes for substance use disorders and persuading armed with a search warrant, the answer is them to cut down their use or enter treatment. different. In this case, the provider has no In most situations, providers can follow these choice but to hand over the records listed in the simple rules: (1) consult the client, (2) let the warrant. client decide, and (3) be sensitive to how Responding to subpoenas. Subpoenas come in information is recorded or disclosed. It is only two varieties. One is an order requiring a as a last resort that the provider will have to person to testify, either at a deposition out of consult State law or a lawyer. court or at a trial. The otherknown as a

137 117 Appendix A

the Medicare Program, authorizationto Endnotes conduct a methadone maintenancetreatment For many years, there was confusion about program, or registration to dispense a drug that is regulated by the Controlled whether general medical care settings suchas Substances Act to treat alcohol primary care clinics or hospitalemergency or drug abuse; rooms were subject to the Federal law and regulations because they provided substance Programs supported by any federal department or agency of the United States, abuse diagnosis, referral, and treatmentas part even when the federal support does not of their services. In 1995, DHHS revisedthe directly pay for the alcoholor drug abuse definition of the kinds of "programs" subjectto the regulations that made it clear that the diagnosis, treatment, or referral activities; Programs conducted by Stateor local regulations do not generally apply toa general medical care facility unless that facility (or person) government units that are supported by holds itself out as providing, and provides, Federal funding that could be (but isnot necessarily) spent for the substance abuse alcohol or drug abuse diagnosis, treatment,or treatment program; referral for treatment... (42 CFR§ 2.11). The full text of § 2.11 now reads: Tax-exempt programs. Program means: 42 C.F.R.§ 2.12(b). (a) An individual or entity (other thana general medical care facility) who holds itself For a full explanation of the Federal law and regulations, see TIP 8, Intensive Outpatient out as providing, and provides, alcoholor drug abuse diagnosis, treatment, or referral for Treatment for Alcohol and Other Drug Abuse treatment; or (CSAT, 1994) and TAP 13, Confidentiality of Patient Records for Alcohol and Other Drug (b) An identified unit withina general medical Treatment (CSAT, 1994). facility which holds itself outas providing and

provides, alcohol or drug abuse diagnosis, 4 treatment, or referral for treatment; or Luhndorff v. The Superior Court of Tulare County, 166 CA 3d 485, 212 Cal. Rptr. 516 (5thDistrict, (c) Medical personnel or other staff ina 1985). Interestingly, Luhndorff general medical care facility whose primary was a criminal case in which the prosecution sought the records function is the provision of alcoholor drug of an unlicensed social worker who abuse diagnosis, treatment, or referral for interviewed treatment and who are identified as such the defendant, diagnosed his problem, providers. (See § 2.12(e)(1) for examples.) determined the appropriate treatment, and treated him for 3 months. The social worker 60 Federal Register 22,297 (May 5, 1995). was working under a licensed individual's supervision. The defendant thought the social 2 The regulations provide that"federally worker was a psychiatrist. assisted" programs include:

Programs run directly by or under contract 'Section 451 of the CaliforniaEvidence Code for the Federal government; codifies the doctor-patient privilege. See Programs carried out under a Federal license, Grosslight v. Superior Court of Los Angeles, 42 CA certification, registration, or other 3d 502, 140 Cal. Rptr. 278 (1977), in which the authorization, including certification under court held that information communicated by

118 138 Legal and Ethical Issues the parents of a minor psychiatric patient to her a private organization and supported by the doctor and his secretary was privileged, even industry. though the parents were being sued by someone the child injured on the theory that the parents In fact, in some States, depending on the knew their child was a danger to others. provider's profession, the identity of patients or clients as well as their records are protected. 6Note that the breadth of the protection may Therefore, professionals should find out vary according to the clinician's profession. whether disclosing a patient's name or acknowledging that the individual about whom 7 Gross light v. Superior Court of Los Angeles, 72 the lawyer is inquiring is a client would be Cal. App. 3d 502, 140 Cal. Rptr. 278 (1977), considered a violation of the client's right to interpreting Section 451 of the California confidentiality. Evidence Code (see footnote 5). 12A firm, but polite, tone is best. If confronted 8The Consensus Panel for TIP 16 noted: by what could be characterized as "Physical separation of clinical information is "stonewalling," a lawyer may be tempted to not unusual. Patient charts from past years are subpoena the information he is asking for, and generally kept in a separate location. Physicians more. The clinician will not want to provoke the routinely request charts to be sent to them from lawyer into taking action that will harm the this location so that they can review historical patient. clinical information about the patient. In addition, nurses are quite accustomed to 13The only exception to this advice would be if keeping some medications locked up and the provider knew the patient was a fugitive accessible only to designated personnel." (TIP being sought by law enforcement. In that case, 16, CSAT, 1995, p. 76) in some States, a refusal to assist or give officers information might be a criminal offense. 9In some States, a guardian is referred to as a fiduciary, conservator, or committee. The 14As noted above, in those States where the person who has a guardian is generally called a identity of clients or patients as well as their "ward" or an "incapacitated person." medical or mental health records are protected, the professional should give a noncommittal ioSome States prohibit insurance companies response, such as "I'll have to check my records from discriminating against individuals who to see whether I have such a patient." have received substance abuse treatment; however, these kinds of discriminatory practices 15In most instances, the provider is not legally continue. Insurance companies routinely share required to notify the client or get his consent to information about applicants for life and release records that have been subpoenaed. disability insurance through the Medical However, notifying the client shows respect for Information Bureaua data bank maintained by his autonomy and privacy and gives him an opportunity to object to the subpoena.

139 119 Appendix

Appendix B contains the following items: o The Alcohol Use Disorders Identification Test (AUDIT) O Index of Activities of Daily Living (Index of ADLs) O Instrumental Activities of Daily Living (IADL) Scale o Geriatric Depression Scale (GDS) Short Form o Center for Epidemiologic StudiesDepression Scale (CES-D) o Health Screening Survey (HSS), Revised.

140 121 Appendix B

The Alcohol Use Disorders IdentificationTest (AUDIT)

The following guidelines, questions, and scoring instructionsare excerpted from Babor, T.F.; de la Fuente, J.R.; Saunders, J.; and Grant, M. AUDIT: The Alcohol Use Disorders Identification Test: Guidelinesfor 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 primarycare settings by persons who have different kinds of training and professional backgrounds. Thecore AUDIT is designed to be used as a brief structured interview or self-report survey thatcan easily be incorporated into a general health interview, lifestyle questionnaire, or medical history. When presented in thiscontext by a concerned and interested interviewer, few patients will be offended by the questions. Theexperience of the WHO collaborating investigators (Saunders and Aasland, 1987) indicated that AUDIT questionswere 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 referspecifically to alcohol use and problems. Some patients may be reluctant to confront their alcoholuse or to admit that it is causing them harm. Individuals who feel threatened by revealing this informationto 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 healthstatus 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 questionnairemay be more useful. Alternatively, health workers may also use AUDIT to guide an interview witha concerned friend, spouse, or family member. In some settings (suchas waiting rooms), AUDIT may be administered as a sell-report questionnaire, with instructions for the patient to discuss themeaning 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 requiringemergency 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 alcoholon 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, thena transitional statement will be needed when the AUDIT questions are asked. The bestway to introduce the AUDIT questions

122 14 1 Tools

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 certainmedications), 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 aregular 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 periodof the past year, making note of the fact that this may be atypical or transitoryfor 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.

142 123 Appendix B

The AUDIT Questionnaire Circle the number that comes closest to the patient'sanswer.

1. How often do you have a drink containing alcohol?

(0) Never (1) Monthly or (2) Two to four (3) Two to three (4) Four or more less times a month times a week times a week

2. How many drinks containing alcohol doyou have on a typical day when you are drinking? [Code number of standard drinks.')

(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 drinkson one occasion?