TIP 26: Addiction Treatment in Older Adults
Instructor: Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery
Objectives
~ Review the data about substance abuse and gambling issues in older adults
~ Review screening for substance use and mental health disorders in the elderly
~ Identify risk factors for SA and MH issues
~ Review placement and treatment issues specific to older adults
Introduction
~ Abuse of alcohol and prescription drugs among adults 60 and older; growing fast
~ Estimated 2.5 million older adults have problems related to alcohol
~ Consume more prescribed and over-the-counter (OTC) medications
~ 2006 New Jersey study indicated 23% of citizens over 55 were disordered gamblers (New Jersey Senior Gamblers Study)
~ Seniors are fastest growing group of gamblers between 1974 and 1989 (Gambling Impact and Behavior Study 1999)
~ A 2008 study reveals that they gamble for
~ Extrinsic reasons include winning money, gaining independence, and supplementing income
~ Intrinsic reasons include entertainment/excitement, being around other people, distraction from everyday problems such as loneliness and boredom, and escaping feelings of grief and loss associated with the death of a loved one or close friend. (Arizona Compulsive Gambling Council)
Introduction
~ Among adults over 65 years of age gambling is the most frequently identified social activity (McNeilly & Burke 2001)
~ Reduced cognitive capacity can make it difficult for them to make sound decisions.
~ Older adults living on a fixed income with limited savings can’t necessarily afford the financial drain of a gambling disorder.
~ When you’re younger, maybe you’re $100,000 in debt, but you’ve got your spouse, you’ve got your children, your job; you still have some reason to get up in the morning,” Nower says
~ Because older adults tend to have less contact with friends and family, gambling-related problems may go unnoticed.
Introduction
~ Gambling should be identified as a problem when it disrupts, damages, or limits a person’s life
~ Signs of problem gambling are spending more money on gambling than intended; feeling bad, sad, or guilty about gambling; not having enough money for food, rent, or bills; being unable to account for blocks of time; experiencing social withdrawal; and experiencing anxiety or depression.
~ Older adults may try to hide or deny a gambling problem, they may feel hopeless or ashamed about the situation, or they may be unaware that help is available.
Alcohol and the Older Adult
~ Age-related changes affecting the way an older person responds to alcohol:
1) Normal decrease in body water that comes with age
~ Same amount can now cause intoxication
~ Increased sensitivity and decrease tolerance
2) Decrease in rate of GI metabolism
~ Blood alcohol level remains raised for a longer time
~ Increased hepatic workload
Alcohol and the Older Adult Cont…
~ Trigger or worsen serious problems
~ Heart problems
~ Risk of stroke
~ Cirrhosis and other liver diseases
~ Gastrointestinal bleeding
~ Depression, anxiety and other mental health problems
Prescription Drugs
~ Medications interact negatively with alcohol
~ Dependence on psychoactive medication
~ Misunderstood directions
~ Multiple prescriptions from different doctors; no coordination
~ Unintentional misuse leading to abuse
Screening
~ Psychoactive substance use associated with negative central nervous system effects
~ Indications of problematic psychoactive substance use:
~ Diminished psychomotor performance
~ Impaired reaction time
~ Loss of coordination
~ Falls
~ Excessive daytime drowsiness
~ Confusion
~ Aggravation of emotional state
~ Amnesia
~ Dependence
Risk Factors
~ Emotional and Social Problems
~ Bereavement and sadness
~ Losses
~ Spouse, friends, family members
~ Social status
~ Occupation and sense of professional identity
~ Hopes for the future
~ Ability to function
~ Social isolation and loneliness
~ Reduced self-regard or self-esteem
~ Family conflict and estrangement
~ Problems in managing leisure time/boredom
~ Loss of physical attractiveness
Risk Factors cont…
~ Medical Problems
~ Loss of hearing or sight
~ Chronic pain
~ Physical disabilities; handicapping conditions
~ Reduced mobility
~ Insomnia
~ Cognitive impairment and change
~ Practical Problems
~ Impaired self-care
~ Dislocation from housing
~ Reduced coping skills
~ Loss of income or increased health care costs
Risk Factors cont…
~ Other Issues
~ Older men are at increased risk when their wives die
~ High rates of alcoholism in medical settings
~ Substance use disorder earlier in life
~ Mood disorders
~ Family history
~ Psychoactive prescription drug use
Who and When To Screen
~ Adult annual physical
~ Major life transition
~ Unexpected / unexplained physical symptoms
Physical Symptoms
~ Potential signs of development of an addiction:
~ Sleep-related problems
~ Cognitive difficulties
~ Seizures, malnutrition, muscle wasting
~ Liver function abnormalities
~ Persistent irritability and altered mood, depression, anxiety
~ Unexplained complaints about chronic pain
~ Incontinence, urinary retention, difficulty urinating
Physical Symptoms cont…
~ Poor hygiene, self-neglect
~ Unusual restlessness, agitation
~ Complaints of blurred vision or dry mouth
~ Unexplained nausea and vomiting
~ Changes in eating habits
~ Slurred speech
~ Tremors, poor motor coordination, shuffling gait
~ Frequent falls , unexplained bruising
Delirium and Dementia
~ Presence of a severe cognitive impairment impairs screening
~ Withdrawal-induced delirium; medical emergency
~ Signs of delirium:
~ Disorientation
~ Impaired attention, concentration, memory
~ Anxiety, suspicion, agitation
~ Hallucinations
~ Delusions, speech abnormalities
Dementia
~ Chronic, progressive, irreversible cognitive impairment
~ Complicates:
~ Monitoring drinking outcomes
~ Getting clients into treatment
~ Getting benefit from treatment
~ Signs of dementia:
~ Impaired short- and long-term memory, abstract thinking, judgment
~ Language disorder
~ Personality change or alteration
~ Mood disturbances
Detoxification
~ Indications for inpatient hospitalization:
~ High potential for developing dangerous abstinence symptoms, seizure or delirium
~ High or prolonged dosage of benzodiazepine, barbiturate, alcohol
~ Abruptly discontinued
~ Positive past history
~ Suicidal ideation or threats
~ Other major psychopathology
Inpatient Detoxification cont…
~ Unstable or uncontrolled co-morbid medical conditions requiring 24-hour care or parenterally administered medications
~ renal disease
~ diabetes
~ HBP
~ Mixed addictions, including alcohol
~ Lack of social supports in the living situation; living alone
~ Continued access to the abused drug(s)
Brief Interventions
~ Non-confrontational, supportive
~ Shame issues
~ Provide customized feedback
~ Provide information
~ Based on age, health, medications
~ Explore reasons for drinking/gambling
~ Explore consequences of drinking/gambling
~ Physical, psychological, social functioning
Brief Interventions cont…
~ Discuss key motivators to cut down or quit
~ Maintaining independence
~ Physical health
~ Financial security
~ Mental capacity
~ Identify sensible ways to cut down or quit
~ Develop sober social opportunities
~ Get reacquainted with hobbies and interests
~ Pursue volunteer activities
~ Develop a drinking agreement prescription
Brief Interventions cont…
~ Brainstorm coping methods
~ Social isolation
~ Boredom
~ Negative family interactions
FRAMES Approach
~ Feedback of personal risk or impairment as derived from the screening
~ Responsibility for change
~ Advice to change
~ Menu of options
~ Empathic counseling style
~ Support self-efficacy and ongoing follow-up
Treatment Settings
~ Inpatient
~ 24-hour, primary medical/psychiatric/nursing care
~ Medically managed, monitored, intensive setting
~ Indicators:
~ Brittle, frail, acutely suicidal, medically unstable
~ Need constant one-on-one monitoring
~ Older people dependent on psychoactive prescription drugs need flexible, community-oriented programs with case management services
Treatment Approaches
~ Age-specific group treatment
~ Supportive, non-confrontational
~ Builds or rebuilds patient's self-esteem
~ Focus
~ Coping with depression, loneliness and loss from death of a spouse, retirement
~ Focus
~ Rebuilding client's social support network
~ Pace and content
~ Appropriate for the older person
Treatment Approaches cont…
~ Staff
~ Interested and experienced with older adults
~ Provide
~ Medical services, services for the aging
~ Institutional settings for referral into and out of treatment
~ Case management
Treatment Approaches cont…
~ 5 Principles
~ Treat older people in age-specific settings
~ Create a culture of respect for older clients
~ Take a broad, holistic approach to treatment; emphasize age-specific psychological, social and health problems
~ Flexible treatment program
~ Adapt treatment to client’s gender
General Approaches To Treatment
Cognitive-Behavioral/Motivational Approach
~ Identify negative consequences of use
~ Shift perceptions about the impact of use
~ Empower client to generate insights and solutions
~ Express belief in their capacity for change
~ Help offset the denial, resentment and shame
~ Focus on:
~ Rebuilding social support network
~ Self-management approaches for overcoming depression, grief or loneliness
~ General problem solving
General Approaches cont…
Group-Based Approach
~ Two components:
~ Educational/theoretical
~ Personal/practical application
~ Clearly state goal and purpose of sessions; outline content
~ Topics sequential; “building block” style
~ Begin with a review of previously presented materials
~ Incorporate all 5 senses
~ About 55 minutes
~ Well lit without glare, interruptions and noise
~ Superfluous material kept to a minimum
General Approaches cont…
~ Individual counseling
~ Medical/psychiatric approaches
~ Marital and family involvement/family therapy
~ Case management/community-linked services and outreach
Staffing
~ Gerontology training
~ Enjoy working with older adults
~ Provide training to all staff who will interact with these clients
~ Empirically demonstrated principles
~ Effective with older adults
Summary
~ Many issues unique to treating elders
~ Substance abuse treatment in this population
~ Necessary
~ Worthwhile
~ Ease clients by providing treatment:
~ In peer settings
~ By persons sensitive to gerontological issues
~ By clinicians of similar ages
~ Withdrawal from psychoactive drugs can induce delirium and is a medical emergency.
Resources
~ AARP
~ 601 E Street, NW
~ Washington, DC 20049
~ (202) 424-2277
~ (202) 434-2562 (fax)
~ www.aarp.org
~ National Center on Addiction and Substance Abuse at Columbia University
~ 152 West 57th Street
~ New York, NY 10019
~ (212) 841-5200
~ (212) 956-8020 (fax)
~ www.casacolumbia.org
~ Join Together
~ 441 Stuart Street
~ Boston, MA 02116
~ (617) 437-1500
~ (617) 437-9394 (fax)
~ www.jointogether.org
~ National Aging Information Center, U.S. Administration on Aging
~ 330 Independence Avenue, SW, Room 4656
~ Washington, DC 20201
~ (202) 619-7501
~ (202) 401-7620 (fax)
~ http://www.aoa.gov/naic
~ https://allceus.com/CE/course/view.php?id=117