Michigan Older Adult Substance Abuse Network

Made possible through funding by the Michigan Department of Community Health - Division of Substance Abuse Quality and Planning - Michigan Older Adult Substance Network Grant

Growth at Any Age

Section 1 - History of Michigan's Older Adult Substance Abuse Program Networking

Contents

The Governor's Task Force

In early 1977, Representatives David Hollister and Senator Joseph Snyder held several meetings with service providers concerned about substance abuse problems among their senior clientele. Out of these meetings grew support developed for the formation of a statewide task force to investigate the nature and extent of older adult substance abuse problems and to make recommendations about needed program and policy changes. In June, 1977, Governor William G. Milliken appointed the Seniors and Substance Abuse Task Force, charging them to:

The Task Force was comprised of thirteen members -- teachers, pharmacists, law enforcement representatives, substance abuse prevention and treatment specialists, aging service providers, older adult volunteers, and older adults.

The Task Force collected information, held public hearings, heard professional testimony, and commissioned a research group to conduct interviews, prepare a mail survey, and assemble the results of these efforts. Nearly 400 older adults were interviewed, the results of 1750 surveys mailed to health care and human service providers were compiled, data from the state's Medicaid system was reviewed, and testimony from public hearings was assessed.

Findings. According to the Task Force report:

It was evident that not only did extensive numbers of older adults use a variety of prescription and non-prescription substances, but many used multiple substances.

It was determined that an estimated 7%, or 91,000 Michigan Seniors, were experiencing some form of alcohol related/ medication misuse problem. Many reported consuming 5 or more drinks of alcohol per day.

The Governor's Task Force submitted twenty specific proposals focused upon six areas of need:

Implementation of the Task Force Recommendations

Creation of the Satellite Staff. In order to carry out the recommendations of the Task Force, the Office of Services to the Aging requested and was granted funding by the Federal Administration on Aging for two years (beginning in 1979) in the amount of $181,000. This funding was granted for the purpose of stimulating program planning and policy development for seniors in both the Office of Substance Abuse Services and the Department of Mental Health through the use of experts loaned to these agencies by the Office of Services to the Aging. These individuals became known as the Satellite Staff, and provided consultation and technical assistance not only to the state agencies to which they were assigned, but to local communities as well.

Development of substance abuse model projects. The State Legislature appropriated $150,000 to the Office of Services to the Aging in Fiscal Year 1989 for the development of model projects. A request for proposals sent to the thirty substance abuse coordinating agencies resulted in the submission of seventeen proposals. Five sites were chosen for funding as pilot programs - Marquette, the western Upper Peninsula, Kent, Kalamazoo, and Macomb Counties.

In fiscal year 1979 - 1980, each project site developed a local interagency coordination committee, assessed training needs for agency personnel, and developed and conducted training for service providers and health professionals. Projects also assessed local aging and substance abuse service delivery systems. The focus of these projects was to strengthen the abilities of the existing substance abuse and aging networks' capacities to respond to older adults with potential or actual substance abuse problems, rather than developing a new level of services aimed solely at older adults. The Satellite Staff provided consultation and technical assistance to these projects.

Assessing the impact of these projects in 1980, it was decided by the Office of Services to the Aging and the Office of Substance Abuse Services that they were successful and should continue. In August of 1980, the Office of Substance Abuse Services requested that the five sites develop formal plans for implementing continuums of prevention, case finding, and treatment services for older adults. This request required the model projects to build on the first year efforts, focusing the second year of operations on direct service delivery.

As development continued, each of the five projects hired one full-time professional with clerical and consultation support to provide direct services to older adults in the community. Specific older adult target populations were identified, and plans were prepared in which the older adult substance abuse counselor would "fill the gap" in the existing continuum of services. As the outreach/case finding service delivery began, it was at once apparent that the gaps between the community agencies were much greater than anticipated. Budgetary problems created funding delays, and each of the pilot programs were hampered as they initiated the projects. The one person staff capacity of these projects was in no way sufficient to meet the extent of the need.

A shift in emphasis became the focus of the Pilot Projects as they entered their third year of services. When they began, each was targeted on the medication use/misuse which had been identified as a significant older adult issue. However, alcohol problems began to emerge as the predominant older adult problem. The focus of the aging programs was shifted to alcohol problems, and the service expectations were narrowed to Outreach, Case finding and Outpatient Care.

Good News, Bad News

Assessment of the recommendations of the 1978 Task Force. The Satellite Staff, headed by Mary James at the Office of Services to the Aging (OSA), and Joseph E. Resch, Jr., the Aging and Substance Abuse Specialist on permanent assignment to the Office of Substance Abuse Services (OSAS) worked with the Governor's Advisory Group on Seniors and Substance Abuse to publish a report, Good News, Bad News: Progress and problems in carrying out the recommendations of the 1978 Task Force on Seniors and Substance Abuse. This document, published in February, 1981, chronicled efforts at implementing the recommendations of the 1978 Task Force, not only in the five model project sites, but throughout the State of Michigan. Considerable progress had been made in recognizing the needs of older adults, developing interagency approaches, and initiating services to older adults with substance abuse problems. (Good News, Bad News, 1981)

Expanding older adult services - identifying community needs. Among the recommendations developed in Good News, Bad News: Progress and Problems in Carrying Out the Governor's Task Force on Seniors and Substance Abuse were:

It was clear that the continued development of the existing programs, as well as the implementation of similar model programs through Michigan would require a commitment of state and community resources. During the remaining years of the decade, as the economic forecast remained tentative and as the older adult population continued its steady increase in numbers, the OSAS funded programs specializing in older adult substance abuse services made slow progress. However, with the availability of some additional funding came an increase in the number of programs and, for some programs, expansion of services. Case finding activities developed into outpatient care and prevention services were expanded.

By 1985, the direction and support of the existing programs were shifting, as planned, from the "start-up" support provided by OSA to the maintenance of that effort by funds from OSAS. This process and transition were deliberate, requiring the coordination of these state offices as well as the involvement of the pilot programs across Michigan. The Satellite staff of OSA was concluding its more direct involvement and focusing its attention on the preliminary organization and planning of the Older Adult Substance Abuse Information Network, which had been outlined in the earlier documents to the Governor.

Substance Abuse Network Grant

In an effort to create a means to coordinate and promote information exchange among existing older adult substance abuse providers, encourage the development of additional older adult services, and provide ongoing networking activity, the Office of Services to the Aging, in conjunction with the Office of Substance Abuse Services funded a project to network older adult substance abuse activities throughout the State of Michigan. The initial Substance Abuse Network Grant was awarded to Gerontology Network for fiscal year 1988. Activities of that initial grant included the identification of older adult programs, as well as the publication of a directory which outlined the range of services provided by these organizations. Programs were included in the 1988 Directory based upon responses to an Older Adult Substance Abuse Resources Inventory developed at that time. Additional older adult substance abuse service providers were identified as the first Network Conferences were held at Ann Arbor and Grand Rapids, where the interactive networking and information sharing by programs became a reality.

In 1989, the premiere edition of the Network Profile newsletter was in print, an effort to provide regular information to providers on developments in older adult substance abuse services. A Leadership Council was formed as a representative working group of older adult substance abuse service providers from all regions of the state to continue development of older adult initiatives and promote networking and information sharing among older adult providers.

Gerontology Network continues its role of coordinating state efforts at networking in conjunction with the Bureau of Substance Abuse Services/Michigan Department of Community Health (BSAS/MDCH) and the Leadership Council. This ongoing focus on networking, information sharing and advocacy is critical to the ongoing support and development of substance abuse services for Michigan's older adult population. Current efforts include the publication of a newsletter three times yearly, sponsorship of state and regional conferences for older adult service providers, technical assistance throughout the state, coordination of a Leadership Council, a Web page on older adult substance abuse, and advocacy for service and policy development.

The Future

The number of older adults continues to grow. With this growth comes increased needs for services. However, as in the early 1980's, when older adult substance abuse programs began to be promoted and developed, the late 1990's are also a time of change and challenge in the State of Michigan. Managed care, changes in reimbursement, and the potential of funding cuts threaten the stability, growth, and even the continued existence of specialized older adult substance abuse services.

Renewed emphasis on local networking and resource development are critical. Ongoing creativity and innovation in programming, resource development, and service provision will become essential to ensure the continuation of services to this population. This local effort, coupled with the continued support of BSAS/MDCH, as well as supportive efforts such as the Substance Abuse Network Grant are needed to carry older adult substance abuse services through the 1990's and into the next century.

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Section 2 - Older Adult Substance Use

Contents

Cultural Context

The Aging of America

For the first time in history, large numbers of individuals are living into their eighties, nineties, and even reaching one hundred years of age. The growth of this group of older adults is continuing, with an increasing impact on our culture and economy.

As individuals age, the number of physical health problems they experience increases, and the number of prescription medications used by this group rises as well. This population growth will have significant impact on the health care sectors of our economy, with increasing numbers of older adults needing and receiving help to be able to stay in community settings. The number of moderately to severely disabled older adults is projected to grow from 5.1 million in 1986 to 22.6 million in 2040, an increase of 350 percent, while the older adult population will grow by only 175 percent. (AOA, 1997)

Michigan's Older Adults

Patterns of growth of Michigan's older adult population parallel national trends. The Michigan Office of Services to the Aging, reported in 1998:

In keeping with national trends, Michigan's older adult population is becoming older, more predominately female, and likely to be living alone. Programs need to be designed with these realities in mind.

It should be remembered that older adults are not a single, unitary group. Rather, this population is a collection of diverse individuals and groups ranging from people who are living independently managing the changes which come with aging, and providing assistance to others to individuals who are homebound and isolated, to those placed in a dependent care setting. The demographic characteristics described previously have some strong implications for accessing older adults to provide needed substance abuse services.

In attempting to provide substance abuse services to older adults, it should be remembered that:

Older Adults and Substance Misuse/Abuse - Epidemiology

Like the rest of our society, older people use coffee, tobacco, alcohol, prescription and over-the-counter drugs and, to a lesser extent, illicit drugs.

Prescription medications

The impact of drug misuse also puts older adults at higher risk of other problems.

Over-the-counter medications

It is estimated that 35 percent of older adults treat health concerns with non-prescription drugs, including antacids, analgesics, sleep aids, antihistamines, decongestants, laxatives, and vitamins. Nationally, over $5 billion dollars is spent annually on over-the-counter products, with older adults being major consumers.

In a nation-wide study of the use of over-the-counter drugs, older adults reported experiencing 4.2 everyday health problems during a two-week period. Of these problems, 35 percent were not treated at all, 11 percent were treated with home remedies, a physician or dentist was consulted for 13 percent of the problems, a previously prescribed medication was used 15 percent of the time, and 35 percent of the time over-the-counter medications were used. (Evashwick, 1991)

Many older adults do not consider over-the-counter drugs as medications, do not report using them to physicians, and drug interactions can easily occur. In a survey of patients with cancer at the Moffitt Cancer Center, 47 percent of the older adults were taking nonprescription drugs, but did not report them as medications. (Cancer Center)

Tobacco

Smoking is the major cause of preventable death in the United States today. It is estimated that smoking is responsible for one out of three deaths due to coronary heart disease and one out of five cancer-related deaths. Older adult smokers, many of whom have smoked for years, are the group most likely to experience the cumulative health conditions associated with, or exacerbated by, smoking.

Tobacco smoking is the cause of one out of every five deaths in America today. (U.S.Preventive Services Task Force, 1996)

Alcohol

Alcohol misuse is a serious, often undetected and under treated problem of older adults. Culturally, the use of alcohol with older adults is often hidden, and many families do not want to even consider the possibility of alcohol problems with older adult family members. The effect of alcohol on older adults, however, is a significant and costly problem.

To understand the substance abuse problems of older adults, it is important to develop an understanding of the process of aging, cultural influences on the individual, and special challenges facing this population. Without this, effective intervention is not possible.

The Cultural Experience of Aging

Generational perspectives

America has been a youth-centered culture. With a history of only slightly more than 200 years, American culture is still strongly rooted in conquest of the frontier, with great value placed on independence, freedom, self-sufficiency, and strength. These values are especially reflective of the generation of older adults living today who grew up at a time these values were widely accepted.

Being dependent on others for care, loss of self-sufficiency, and decreased personal autonomy are doubly difficult for many members of this generation. Not only must these older adults adapt to changed levels of functioning, many feel this need for assistance is not merely a result of the aging process, but also reflects on their worth and integrity. This may result in a reluctance to seek help from others. Generationally, there is also a strong value placed on the family taking care of its own problems. Many older adults feel a stigma related to experiencing substance abuse problems. Thus, talking with professionals is something this generation often is reluctant to do. These value and generation based tendencies, coupled with the denial inherent in substance abuse problems, make older adults a difficult population for substance abuse providers to reach.

Aging as an individualized process

Each individual ages in a manner unique to him/her. Aging is not solely a physical process, rather it happens as a result of the interplay between physical changes, the individual's attitudes and beliefs about aging, and social/cultural beliefs, norms, and values.

Physical changes inevitably occur as the body ages. However, with an ongoing program of adequate health care, older adults can adapt to these changes, and their impact on functioning can be minimized. An exercise program adapted to the individual's physical capabilities can maintain or enhance endurance, stamina, and cardio-vascular functioning. Recent studies with older adults and resistance conditioning have shown significant increase in lean muscle mass for older adults participating in these programs.

Adaptation of diet to the nutritional needs and special considerations of older adults can ensure proper nutrition and prevent many problems associated with improper nutrition such as obesity, malnutrition, anemia, etc.

A program of regular medical care, including an annual physical exam, monitoring and treatment of chronic conditions, and timely response to acute problems can do much to prevent or postpone loss of functioning or the development of serious physical problems.

An individual's attitudes and beliefs about his/her aging are a critical component of the aging process. The attitudes and approach to life that an individual has as a younger adult tend to remain as s/he ages. Older adults who have interests and involvement in addition to their work and family roles, and who remain actively engaged in life, tend to age more slowly. Conversely, older adults who disengage, become sedentary and conceive of themselves only in work or family roles, tend to age more quickly. Aging, although inevitable, takes many forms and progresses at variable rates based on some factors such as attitude and involvement which are under the control of the older adult.

Aging as a cultural process

Cultural stereotypes, norms, and beliefs about aging also affect the aging process of older adults and the social context in which they age. As a youth-centered culture, America tends to hold youth as an ideal. This cultural valuing of youth is reflected in ideals of physical attractiveness based on young bodies, portrayals of older adults in less than flattering lights, and advertising approaches which idealize young adulthood as the most desirable life style. Even the design of furniture, lighting of public areas, and design of public transport (e.g. buses with steps difficult for older adults to negotiate) are based on physical attributes of the young. The message overtly and covertly sent to older adults is that they are not capable of adequately negotiating the physical environment, they are not attractive, and they are not as valuable as younger people. As the number of older adults continues to grow, these cultural norms are beginning to change. However, cultural biases and beliefs about older adults still constitute an environment of ageism with which older adults must cope. As with younger populations, these negative messages and beliefs impact the self-confidence and self-esteem of older adults, making them more vulnerable to the use of substances to deal with feelings that have been developed in response to these messages.

Aging as a developmental process

From the perspective of human development, the older adult years provide an opportunity for the final stages of development. Erik Erikson identified eight stages of human life, each with its own particular developmental task (Erickson, 1950). The eighth stage allows the opportunity for review of accomplishments, failures, losses, and successes leading to either acceptance and integration or to despair.

In addition to this review and resolution of the past, older adults also must decide how they will continue to live out the remainder of their lives. Critical to a healthy transition is the older adult's ability to redefine a role beyond work and parental roles. If this does not occur, the future is not open. Similarly, individuals whose self-esteem and self-concept are strongly tied to their physical attractiveness or stamina and strength often have difficulty adapting to the aging process, unless other sources of identity and esteem can be defined. Finally, a key to older adult development is the decision and ability to become involved in the needs of others or community interests rather than focusing strictly on oneself. If these areas can be successfully negotiated, older adults remain vital and involved. If not, individuals disengage, withdraw, and may engage in self-defeating or self-destructive patterns of behavior.

Adaptation to loss and change

With increasing age come increasing losses and the necessity to adapt to ongoing change. By the time the human body is 40 years old, measurable decreases in functioning begin to occur. By the time individuals reach their sixties, seventies, and eighties these changes are easily identified and often significantly impact functioning. Older adults must adapt to these changes and losses in physical functioning.

When individuals retire, they often face a dual set of losses and adjustments. Work role and identity are lost. Also, with retirement generally come diminished life style options. If expensive health care becomes necessary, retirement income and savings can be radically affected reducing older adults to poverty level incomes.

Losses of spouse, friends and relatives are also part of the aging process. In addition to the need to mourn these losses, older adults often experience, as a result of the loss of significant others, diminished social contacts and support networks. Thus, at a time when friends and relatives are needed to help older adults deal with loss, these people are often not available.

Older adults experience significantly more health problems than younger groups. With chronic health conditions such as arthritis, cardio-vascular conditions, and hearing loss often come decreased levels of independence and self-sufficiency. These, too, constitute changes and losses to which older adults must adjust.

Finally, changes in family roles must be accommodated. In some cases, due to failing health, role reversals may occur with older adults requiring care from their adult children. These changes cause stress to family systems and again constitute another set of losses and adjustments.

With increasing losses and adjustments, and with diminished physical, social, and economic resources upon which to draw, older adults become a high risk group for substance misuse and abuse.

The Aging Process and its Impact on Substance Use

The Physical Process of Aging

As we age, physical changes occur which significantly impact how our bodies are affected by alcohol, prescription medications, over-the-counter (OTC) drugs, and other substances we may ingest. The aging process gradually results in a loss of elasticity and resiliency of many tissues and systems in the body, resulting in decreased effectiveness of system functioning. Basal metabolism declines with aging. The body takes longer to adjust to stresses and come back to a level of homeostasis. Examples of this decreased level of functioning can be seen in many body systems and organs:

Cardio-vascular system
Blood flow is usually reduced due to loss of blood vessel elasticity and reduced cardiac output. Older adults may tire more easily as a result. Heart valves may become less flexible and more rigid resulting in the decreased effectiveness of cardiac output.
Digestive system
Food is not as effectively digested. The chemical composition of saliva changes. Peristalsis, the process of moving food through the digestive system, slows down. Stomach and pancreatic secretions decrease, resulting in less effective digestion and absorption. Absorption of some vitamins and nutrients is decreased. Decreased muscle tone in the large intestine may result in constipation or fecal impaction.
Integumental system (the skin)
With aging the skin becomes thinner, with less actively growing layers. It is less elastic and injuries to the skin such as tears or bruises occur more easily.
Sensory organs/systems
The eye loses its ability to accommodate (adjust from light to dark, or close to far vision) as quickly. Bi-focals may be needed. Aging-related hearing loss may occur, especially of higher tones. The older adult may experience difficulty in discriminating between conversation and background noise. Acuity of touch is decreased. Decreased taste sensation and smell may lead to decreased appetite.
Musculoskeletal system
As aging continues, muscle cells atrophy, the percentage of body mass composed of lean muscle tissue decreases, and muscle tissue is replaced by fat. Muscular strength and endurance decrease. Additionally, due to loss of elasticity of muscle tissue, aging results in loss of flexibility and increased stiffness. Loss of calcium, with a resultant thinning of bones, may occur, increasing the possibility of fractures.
Respiratory system
With decreased elasticity of respiratory tissues comes decreased capacity of the lungs and decreased strength for breathing or coughing. Infections, respiratory disorders, or other unusual stresses may result in insufficient oxygen for the body's needs. Feelings of exhaustion, confusion and disorientation can occur as a result of the decreased oxygen flow.
Genitourinary system
As aging continues, the kidneys become less effective in filtering wastes from the bloodstream. By the time an older adult reaches the age of 70 to 80, the kidneys filter at half the rate they did when the individual was 30. (Hogstel, l981). Wastes tend to stay longer in the body and the potential for drugs reaching toxic levels increases as an older adult ages. As muscle tone is lost in the ureters and bladders, the bladder may not empty completely, resulting in increased risk of urinary tract infections. Many older women may experience some degree of urinary incontinence. Older men experience increased frequency of urination.
Endocrine system
Hormone production remains unchanged with the exception of estrogen and testosterone. The incidence of diabetes mellitus increases with aging, although there is not agreement as to the cause of this increased prevalence.
Immunologic system
Older adults experience a delayed immune response to infections and the response of the immune system is not as effective as in younger adults. Thus, infections have the potential of being more serious than with younger adults. Some authorities believe there is an increased incidence of autoimmune diseases such as arthritis due to an increased production of antibodies which do not recognize the body's tissues and attack them.
Neurologic system
The speed of transmission of nerve impulses decrease with aging, resulting in slowed reaction time, a slowed startle response, somewhat slower voluntary movement, and slower decision making. Intelligence, the ability to reason and learn, as well as memory and thought processes remain intact. (Hogstel, 1981) Sleeping patterns are affected by the aging process, with older adults spending less time in deep sleep and in rapid eye movement sleep. This may result in older adults feeling tired and reporting inadequate rest. Due to neurologic and other physical changes, older adults may be more susceptible to heat stroke or hypothermia than younger adults.

The physical changes described occur as a part of the normal aging process. Attention to health and a proactive focus on developing healthy practices related to diet, exercise, and self-care can in many cases promote optimal functioning of the older adult, decreasing or preventing some aging related conditions from developing. The physical changes related to aging need to be recognized and considered when assessing and treating older adults for substance related concerns.

The Pharmacokinetics of Older Adults and Substances

Changes in metabolism of substances

When a substance is taken orally, absorption from the stomach or intestines into the bloodstream occurs more slowly than in younger adults. Due to decreased enzyme activity, it takes longer for the older adult's digestive system to act on the substance and transform it into a form usable by the body. The liver transforms substances into components the body uses and ones which will be discarded. Since the metabolism rate usually decreases with age, it takes longer to clear drugs from the bloodstream. This delay also means the drug level in the bloodstream remains higher for a longer period of time.

Changes in absorption and action of substances

When a substance is taken orally, absorption from the stomach or intestines into the bloodstream occurs more slowly than in younger adults. Due to decreased enzyme activity, it takes longer for the older adult's digestive system to act on the substance and transform it into a form usable by the body. The liver transforms substances into components the body uses and ones which will be discarded. Since the metabolism rate usually decreases with age, it takes longer to clear drugs from the bloodstream. This delay also means the drug level in the bloodstream remains higher for a longer period of time.

Some substances, particularly psychotropic agents, are drawn to and stored in body fat tissue. With the aging process the percentage of body fat increases, replacing muscle tissue. This increase in body fat has two results: there is an increase in the amount of stored substance, resulting in the substance remaining for a longer period of time in the body; and there is a decrease in the amount of the drug available to act at the receptor site (where the drug action is intended to act). This results in drugs being less effective for the reasons described while at the same time having prolonged effects due to their presence for a longer period of time in the body. Depressants and sedatives are an exception to this. Their effect increases due to the aging of the central nervous system.

The central nervous system is the most sensitive part of the body in terms of aging-related drug responses. The cellular changes in the brain and other central nervous tissues affect the nervous system's reaction to drugs. The results vary. For example, stimulants usually have less effect and depressants have a greater effect. When the central nervous system is severely impaired by a disease, the drug effect is less predictable. An opposite reaction to the normal response, also known as a paradoxical response, may even occur. For example, a medication prescribed to reduce anxiety may result in high levels of agitation. The incidence of these paradoxical responses in older adults is higher than in younger populations.

Changes in elimination/excretion of substances

As indicated earlier, the liver is instrumental in transforming substances so that they can be used by the body, with waste products separated so that they can be eliminated by the kidneys. With slower metabolism and less effective functioning, substances remain longer in the body and act longer on physical and mental functioning. Since the kidneys, responsible for the elimination of most substances, become less effective with aging, this also increases the danger of drug toxicity.

Implications for Use of Medications and Assessment of Medication Action With Older Adults

Chronic health conditions

The average older adult over 65 has four or more chronic health conditions which require medications. This increased incidence of physical health conditions, coupled with physical changes related to the aging process, make older adults as a group especially susceptible to problems with medications. (Southwick, 8/8/88)

Greater susceptibility to medications

Older adults generally are affected by lower dosages of medications than younger adults. Although it generally takes longer for medications to affect conditions for which they have been prescribed, it generally takes lower dosages of medications to treat conditions. Due to decreased levels of protein binding of medications with older adults, higher levels of medications are available for acting on the body. Also, because more of the older adult's body is composed of fat rather than muscle, fat (lipid) soluble medications are retained for longer periods of time in the bodies of older adults, so the time medications act in the body is prolonged.

Greater incidence of paradoxical effects

Older adults tend to experience greater rates of paradoxical effects with medications than younger populations. Medications prescribed for treatment of anxiety, such as Valium or Librium, may produce increased agitation rather than promoting lower levels of anxiety. It is imperative to carefully monitor the effects medications are having.

Increased incidence of drug interactions

Older adults are at greater risk of experiencing drug interactions and interaction effects than younger populations. Since older adults are often taking multiple medications, using over the counter drugs, and may be using alcohol as well, their risk of experiencing drug interactions is higher than that of younger individuals. It is estimated alcohol-medication interactions may be a factor in at least 25 percent of all Emergency Room admissions. (Holder, 1992) Drug interactions may occur when two or more prescription drugs are combined, or when a drug is combined with alcohol or certain foods. Drug interactions may intensify the effects of one or both of the drugs, block or reduce the effects of one or both of the drugs, or cause a totally different, combined effect. For example, laxatives, antibiotics, and thyroid products interfere with the effect of digitalis preparations; diuretics and Vitamin D increase their effect.

Side effects

Side effects are any effects a drug has other than the intended therapeutic effects. Older adults tend to experience more frequent side effects than younger populations. Since the physical systems of older adults are not working as efficiently as those of younger individuals, side effects tend to be more serious. Since older adults tend to use more medications and over the counter drugs than younger adults, this further increases the frequency and severity of side effects experienced. Some side effects are known and unavoidable, e.g. antihistamines may cause drowsiness. Some medications can produce side effects which include lethargy, depression, memory deficits, and profound disorientation. These side effects can make assessment of the older adult very difficult, since it is often unclear whether it is a physical health condition, a side effect, mental health, or substance abuse related condition which is causing the particular behaviors observed. If the medication must be continued because of serious health concerns, side effects are sometimes treated with other medications. These in turn may produce other side effects.

Higher incidence of adverse drug reactions

Older adults experience a higher incidence of adverse drug reactions than younger adults. Research has demonstrated older adult hospitalizations due to adverse drug reactions comprise 17 percent of all older adult admissions, a figure six times higher than that of the general population. Hospitalization due to inappropriate drug use costs about $20 billion annually. (Nananda et al., 1990) Another study estimated 32,000 older adults suffer hip fractures annually as a result of adverse drug reactions. (Wayne et al., 1987) A study related to driving revealed that 16,000 automobile related accidents resulting in injury each year can be attributed to adverse drug reactions of older adults. (Wayne et al., 1992)

An adverse drug reaction is any response to a drug which has a harmful or unintended effect and which is not the result of deliberate drug abuse. Sometimes a drug reacts negatively in a certain person, producing an idiosyncratic effect. Adverse drug reactions may be caused by a dosage that is too high for an individual or by the cumulative effects of drug combinations. The symptoms vary based on the medications involved, but can include such conditions as dizziness, fatigue, diarrhea, constipation, confusion, agitation, vomiting, or increased blood pressure.

Tardive Dyskinesia is an adverse drug reaction which appears in a significant portion of older adults who have been treated over a number of years with neuroleptic medications, including antipsychotic drugs, major tranquilizers, etc. Symptoms include involuntary limb, tongue, facial, and trunk movements. Ninety percent of patients over 60 experience early symptoms during the first ten weeks of drug administration. (Paez, 1980) Tardive Dyskinesia is irreversible in 50 to 70 percent of the cases. Lowered drug dosages with frequent assessment of medication effect can reduce the incidence of Tardive Dyskinesia.

Confusion as a reaction to medications

Confusion, disorientation, memory loss, and a variety of disturbances resembling dementia or intoxications may be reactions to medications. Due to the decreased effectiveness of physical system functioning medications, over the counter drugs, and alcohol can significantly impact the mental status of older adults. Even when medication or substance use is discontinued, it takes a longer period of time for a normal level of functioning (homeostasis) to occur with older adults than with younger populations. This return to normal functioning may be further delayed if medications are fat (lipid) soluble due to their longer retention in the body.

Common Patterns of Older Adult Substance Misuse and Abuse

Alcohol Misuse and Abuse

Late onset vs. early onset alcohol problems

Alcohol abuse among older people generally follows two major patterns. The first is the early onset, or chronic drinker. Two-thirds of older alcoholics now in treatment are early onset "survivors", many of whom have been problem drinkers for 30 or more years. Many have been treated before and have had numerous relapses. They are likely to have been regarded as "hopeless cases". Many have alienated their families by their behavior; although some have been able to survive because of an alcoholic family support system. Early onset alcoholics usually have multiple health problems. (Giordano, 1985)

Early onset alcoholics often have coexisting mental health conditions, especially major affective disorders. (Schonfeld and Dupree, 1991)

The other pattern of alcohol misuse and abuse is comprised of the late onset alcoholics, reactive drinkers. Research suggests about one-third of older adults with alcohol problems are late onset drinkers. (Liberto and Oslin, 1995) Reactive drinkers develop an alcohol problem late in life, often in their 50's or 60's, in response to stressful situations such as death of a spouse, retirement, health problems, and ongoing losses. Life crises, loss, isolation, and a lack of meaningful activity are common conditions among reactive drinkers. Their drinking histories vary from seldom drinking, or moderate social drinking, to having an earlier drinking problem that has surfaced again in later years. These late-onset drinkers tend to have a lower incidence of marked antisocial behaviors, more limited psychiatric histories, and fewer lifestyle disruptions than individuals with lifelong problems. (Blow, 1998)

Whether late onset or lifelong drinkers, studies and research tend to demonstrate that in both groups of older adults most drank daily, alone at home, and when feeling sad, depressed, lonely or bored. Many lived alone, were retired, and had few natural support systems. (Schonfeld, 1990)

Older adult physiology and alcohol problems

For an older adult, alcoholism can develop quickly. It may take two or three years or only a matter of months. The transformation can be startling. Aging related changes, illnesses, and medication use decrease the time it takes to develop physical dependency. Due to aging related physical changes, the older adult's ability to manage alcohol changes. Tolerance for alcohol decreases with age. As the liver and kidneys function less effectively, alcohol remains for longer periods of time in the body. Due to the body's decreased ability to process alcohol, older adults drinking the same amount of alcohol they did when younger will be more impacted by the effects. (Pacific Northwest Extension, 1989) Detoxification of older adults may take longer and be complicated by other medical problems.

Older adult women are affected even more profoundly than older adult men. It takes less alcohol to cause intoxication in a woman than a man of the same size and weight. For each drink consumed by a woman, her body absorbs approximately 30 percent more alcohol than a man. Women's bodies contain less water and more fat than do men's. Thus, alcohol is not as diluted as in a man's body. Studies have also revealed that women possess less of the enzyme alcohol dehydrogenase. This enzyme, produced in the stomach, reduces the amount of pure alcohol entering the bloodstream through the small intestine. For women who are alcoholic, none of the enzyme is produced, and therefore no reduction of the alcohol going into the bloodstream occurs.

Women alcoholics experience alcohol related medical complications sooner and with lower levels of alcohol consumption than men. Women who abuse alcohol also experience a higher probability of death from alcoholism than men, and their mortality rate is increased. The life expectancy of women alcoholics is 15 years less than women who do not drink. (Gateway Recovery, 1990) With the growing numbers of widowed women, and the greater acceptance of women drinking in the generation of women now becoming older adults, the alcohol misuse and abuse problems of older adult women can be expected to rise.

Identification of alcohol misuse and abuse of older adults

Compared to younger populations, the identification of alcohol related problems is often more difficult with older adults. Indicators of problems, such as loss of job, loss of driver's license, and loss of social support systems, which are signals of potential problems with younger populations, are often considered a consequence of the aging process with older adults. Other physical indicators, such as increased rates of accidents, problems with sleep, problems with sexual functioning, memory loss, trembling, etc. are often considered by family or significant others as consequences of aging.

In identifying potential alcohol misuse/abuse problems, the following may be considered possible indicators of problem drinking:

As evident in reviewing the list, the same set of behaviors and conditions can be indicators of problems ranging from vision losses, infections, and problems with equilibrium to dementia, depression, and a functional grieving process. Societal attitudes toward aging and older adults can also be barriers to identification of problems. It is difficult for many to accept their parents or grandparents could be abusing alcohol. For others, the attitude that "Drinking is all the person has left, so why take it away?" can prevent action.

It is important in attempting to identify causes of problems with older adults, that access to adequate medical examination and care occur in order to treat or rule out physically based disorders. Also, many older adults often feel more comfortable in accessing medical health care professionals to discuss problems of a personal nature, since these individuals are generally accepted as having access to those areas of the older adult's life. Family and significant others often have valuable information related to history and current functioning and should be involved if possible.

Effects of alcohol misuse/abuse on older adults

Since the body of the older adult has diminished effectiveness in metabolizing and eliminating alcohol, the effects of alcohol on the older adult are more severe than with younger populations. The existence of physical health problems, such as cardio-vascular disease, diabetes, and central nervous system disorders or deterioration further compound alcohol problems. Medications used to treat physical health conditions can interact with alcohol causing other complications. Even without co-existing physical conditions, the list of alcohol effects and problems on older adults is extremely significant:

In combination with prescription drugs or over the counter medications, the effects of alcohol abuse or misuse become more pervasive, more complicated to assess and treat, and more destructive to the older adult.

Medication Use, Misuse, and Abuse by Older Adults

As discussed previously, older adults, due to the number of chronic health conditions they experience, use larger numbers of medications, both prescription and over the counter. Problems with medications occur due to aging related physical changes experienced by older adults, the drug interactions that occur when taking multiple medications, and problems with compliance and self-administration.

Physiologically based problems

Previous sections have explored in some detail the aging related changes experienced by older adults, and how these changes affect the manner in which substances act on their bodies. Several of these areas especially affect medication use and compliance related to older adults.

Geriatric dosages

Most standard dosages of medications are based on testing with younger subjects, Older adults, because of aging related physical changes often should not receive the same dosage as younger adults. If chronic illnesses affecting the body's functioning are involved, it is even more likely that medication dosages will need to be adjusted. Some physicians may not be aware of the need to adjust dosage levels until an appropriate level of medication can be determined, and, thus, some older adults may be over medicated.

Prescribing medications for side effects of other medications

At times drugs are prescribed to address the undesirable side effects of other medications. These undesirable effects may continue to increase as the number of medications increases. This practice further complicates the medication-related problems of older adults.

Poor health status

An older person with multiple health problems is more likely to be taking multiple medications to address these problems than younger adults. Increased medication use is directly correlated to the potential for increased medication misuse or abuse. Multiple drug regimens are more difficult to follow than a single drug schedule. The likelihood of side effects, drug interactions, and adverse reactions to drugs is also increased. For older adults with chronic health problems, these reactions to drugs are sometimes regarded as further health problems or an exacerbation of existing conditions with little thought given to the possibility of adverse reactions to medications.

Poor health status

An older person with multiple health problems is more likely to be taking multiple medications to address these problems than younger adults. Increased medication use is directly correlated to the potential for increased medication misuse or abuse. Multiple drug regimens are more difficult to follow than a single drug schedule. The likelihood of side effects, drug interactions, and adverse reactions to drugs is also increased. For older adults with chronic health problems, these reactions to drugs are sometimes regarded as further health problems or an exacerbation of existing conditions with little thought given to the possibility of adverse reactions to medications.

Problems in compliance and self-administration

Problems in compliance and self-administration. Problems with medications may also be the result of confusion about medications, a lack of understanding of drug regimens, or other social and environmental factors which result in medication misuse by the older adult.

The nature and effects of the medication itself

Some older adults tend to take more of medications they experience as pleasurable or beneficial, and less of medications they do not enjoy. For example, diuretics, which tend to increase urination, may be avoided at times the older adult will be away from home, for fear of embarrassment due to the need for frequent urination or the fear of incontinence. Thus, less than therapeutic dosages may be consumed.

On the other hand, some medications which reduce anxiety may be taken in greater quantities than prescribed, with some older adults ascribing to the theory that if one pill is good, two might be better. This increased dosage can also result when older adults do not experience the relief they formerly did from the medication, or if the condition for which the medication was prescribed worsens.

Some older adults are so concerned about becoming addicted to, or dependent on, medications, once they discover the potential that the drug is "habit forming" they do not fill the prescription, do not take it, or take it only sporadically.

Communication with health care professionals

Many older people experience difficulty in communicating their health problems and health care needs to their physicians. Many are confused by the complexity of medical care today; do not understand the roles of nurses, nurse practitioners, and physicians' assistants; and minimize their problems, due to their own fears related to aging, hospitals, and death.

People are usually anxious about a doctor's visit, especially if it is a new doctor or a specialist to whom they have been referred. The world inside a doctor's office can be intimidating and the resultant stress can dramatically affect memory, the ability to listen, to comprehend, and to remember the information provided later. If an older adult is ill or frail, the exertion of going to the doctor's office can further reduce the ability to communicate, remember, and understand what is being conveyed.

Older adults also have many myths about health care. Physicians are often respected without question. Hospitals may be regarded as places where people go to die. Medications may be regarded as "wonder drugs", too complex to be understood, and since prescribed by the physician, certainly nothing which would cause harm or distress to the older patient.

Since many older adults assume the physician knows everything about their health needs and health care, many are passive as patients. As a result, older adults may not share complete information with the physician, assuming what they have to say is unimportant, or not worth the physician's time. Older adults may assume some conditions or changes in functioning, such as dizziness, impaired mobility, or memory loss, are part of the normal aging process, and not discuss them with the physician. At times, decreased functioning is not shared with the physician, with the older adult fearing placement in an institutional setting may result. Often, information related to changes in appetite, functioning, medication use, over the counter medications, drinking, or diet are not communicated. Examinations or appointments may be rushed, not allowing time for a complete check-up with each visit, in which some of these areas could be explored or discovered by the physician.

At times, physicians themselves may contribute to communication problems with older adults. With some patients, they may not share possible side effects of medications, fearing they may confuse their patients, or unnecessarily alarm them. Communication problems of older adults, such as hearing loss, or speech problems, may require that much more time be spent in communication, with some physicians not spending sufficient time to communicate at the slower pace required. Such communication difficulties can result in misdiagnosis, non-compliance of the older adult with drug regimens, and an inability of the older adult to recognize side effects or paradoxical effects of medications.

The high cost of medications

The high cost of medications is one of the main reasons older adults do not comply with a prescribed regimen. Older adults may not fill prescriptions once they aware of costs, they may wait until Social Security checks arrive, or reduce the amount of medication taken in an effort to extend the prescription without incurring additional cost. They may save unused medication, hoping to be able to use it in the future and self-medicate if similar symptoms develop.

Improper medication storage

Proper storage of medications is essential to maintain properties of the drugs. Medications stored in the bathroom may be damaged by the effects of moisture. Medications kept at the bedside may be taken at the wrong times, multiple times, or not at all due to confusion at night or in the morning. At times, the wrong medication may be taken due to visual difficulties experienced by the older adult. Medications may be taken from their containers and stored with other medications. If exposed to sunlight or high temperatures, the effects of some medications may be diminished or may change. Improper medication storage may result in improper medication use by the older adult.

Lack of understanding of medications

With the ever-expanding development of new medications with complex names and difficult to understand actions, properties, and side effects, many older adults have very little understanding of the medications they are consuming and the properties of these medications. Often medication is monitored by older adults based on color, size, and the shape of the pills themselves. If generic drugs are substituted, this adds even more to the confusion. Thus, for some older adults, medication usage and compliance becomes not so much a matter of following directions, but rather, of putting together the pieces of a puzzle.

Over the Counter Medications

Older adults experience a wide variety of chronic and acute health conditions. For some of these, they see physicians and may receive prescription medications. For others, they medicate themselves, believing such conditions are a normal part of the aging process and they should not complain about them to others. A variety of studies have indicated that 70 percent of illnesses are treated with self-prescribed medications. Over 300,000 over the counter (OTC) products are currently available to treat self-diagnosed problems. Unfortunately, symptoms of many conditions are similar, and such self-diagnosis and self-treatment can be dangerous.

Many older adults believe OTC drugs are safe, and not dangerous even if taken in dosages greater than recommended. They are unaware that OTC's combined with alcohol, prescription medications, or other OTC drugs can be dangerous. They are also often not aware of the side effects or adverse effects these medications may have themselves. They do not consider these drugs medicine, and often even if asked by the physician, do not report them as medications currently being taken.

Arthritis, gastro-intestinal problems, headaches, and allergies are often treated by OTC medications. Aspirin, used to relieve pain and inflammation, may cause gastro-intestinal problems and bleeding. At times, allergic reactions, including asthma attacks may even result.

Older adults treating "indigestion" and "heart burn" with antacids or baking soda can cause a rise in the alkalinity of the stomach. This in turn can affect the effectiveness and absorption of other drugs including some antibiotics, iron, and acidic based drugs. Antacids containing sodium can promote edema and be problematic in certain cardio-vascular conditions, such as congestive heart failure. Constant use of laxatives can create laxative dependency, further compromising an aging gastro-intestinal system.

Over-use of vitamins can also be problematic, with fat soluble vitamins such as Vitamins A, D, E, and K retained in the body to a level where toxic reactions can occur. Vitamin C, much touted as a preventative for colds, can cause diarrhea and even precipitate formation of uric acid crystals in the urine.

In addition to the active ingredients in over the counter medications, inert materials, such as dyes, alcohol, binders, flavors, and preservatives may produce allergic reactions or sensitivity. (Perspectives in Health Promotion and Aging, 1990) It should be stressed that OTC drugs, whether used alone, or in combination with other medications or alcohol, can be dangerous to the health of older adults.

Promoting Effective Use of Medications

In working with older adults with substance abuse problems, it is important to address medications currently in use by older adults, and assist them in developing approaches to using medications properly. The first step is to determine medications that are being used, and assessing the manner in which they are actually being used. One method of making this determination is to ask the older adult to show you all the medications s/he is currently using. It is important to see the actual medication bottle with the directions on it, and to remember to ask the older adult to also include all over the counter medications s/he is using as well.

In helping the older adult use medications properly, it is important to:

  1. Identify the purpose the medication was prescribed.
  2. Review dates to determine if prescriptions are outdated.
  3. Determine with the older adult if the reason or condition for which the medication was prescribed still exists.
  4. Determine if the older adult is using the medication in the manner in which it is prescribed. Ask the older adult to describe it to you, not just read the label. At times, especially with medications that have been taken for long periods of time, the older adult may have changed the manner in which s/he is taking the medication.

If questions arise, either on your part, or the part of the older adult, the older adult's physician should be contacted for clarification. It is important that medication usage not be determined or changed either by you or the older adult, bit rather that the physician make those determinations.

Help older adults become more informed consumers of medications by:

  1. Encouraging an ongoing program of health care including regular visit to the physician
  2. Encouraging older adults to contact physicians if they have concerns about medications, or experience side effects or unanticipated effects
  3. Reminding them that over the counter drugs are medications, and that if they are using prescription drugs as well, or frequently use an over the counter medication, they should contact their physician to determine if the drug is safe for them to use
  4. Reminding older adults that if they see specialists it is a good idea to take along their medications, or at least a list of them, so the specialist can be aware of medications they are using and will not prescribe drugs which may interact or be contra-indicated
  5. Reminding older adults to contact the physician if they experience increased symptoms or levels of difficulty, not to adjust medication dosages or stop taking medications on their own
  6. Reminding older adults that alcohol should not be consumed when taking some medications. It is important that they let the physician know they drink, if they do, and pay attention to warning labels
  7. Encouraging older adults to establish a system of reminders or monitors so they can remember and keep track of medications they have taken
  8. Encouraging older adults to consult with their pharmacist to discuss questions about medications, over-the-counter drugs, and potential drug interactions.

Through education and support older adults can become more informed consumers of medications, and decrease the danger of being adversely affected by the medications prescribed for their health.

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Section 3 - Older Adult Prevention / Health Promotion

Contents

Prevention - Maintaining and Further Developing Healthy Approaches to Aging

The History of Prevention - From Disease Prevention to Healthy Lifestyles

Substance abuse prevention approaches have developed from roots in the information giving and scare tactics of the 1960's to an emphasis on health promotion and wellness in the 1990's. Early prevention efforts, in attempting to deter individuals from substance use and abuse by presenting information which highlighted and sometimes sensationalized the negative effects of substances, were often unsuccessful in deterring substance abuse, and at times produced more informed and sophisticated substance abusers. In the 1970's and 1980's it was recognized that merely providing information did not change behavior, and some studies indicated that information giving actually resulted in increased substance use. Research and practice demonstrated that to affect lasting change in behavior, prevention needed not only to deal with information, but with attitudes, values, relationships, environmental factors, and social conditions. The 1990's has brought to prevention a focus not only on deterring self-destructive or harmful behaviors, but in promoting health and wellness.

During the 1980's specialized older adult prevention activities began to be developed. Community based "Brown Bag" programs in which seniors were asked to bring medications they were using to be reviewed by a health care professional, and "Talk to Your Doctor" programs assisted older adults in safely using medications. Prevention programs in the 1990's continued to emphasize the safe use of medication and alcohol while promoting wellness and healthy aging. Medical care staff and aging service providers increasingly recognized and encouraged patient information and education programs. "Over the past decade, prevention and health promotion have received increased attention as a means of increasing quality of life and controlling the cost of health care." (German, 1994)

Providing a Comprehensive Array of Services

The range of prevention services for older adults begins with "preventing or delaying the occurrence of disease" (World Health Organization, Definition of Primary Prevention). These initiatives educate seniors and caregivers through information and training in wellness, self-esteem, and the development of life skills for successful aging.

Primary Prevention strategies
Primary Prevention programs focus on improvement of health habits, helping older adults avoid alcohol abuse, stop smoking, exercise, eat and sleep well, and prevent injury related to home safety and medication use. (German and Fried, 1989)
Health screening
Health screening for hypertension, cancer, diabetes, dental conditions, foot care, sensory impairment, poor nutrition, depression, medication side effects, and fall risks cover the level of prevention needed to insure safety and avoid functional disabilities. Vaccines against pneumonia and influenza also keep healthy older adults within the disease free population. Although most of these activities fall outside the scope of services provided directly by the substance abuse professional, encouraging and networking with others to see they are available can do much to promote health and prevent substance abuse.
Targeted prevention for older adults
Targeted prevention is directed toward groups and individuals where the risk of alcohol and medication disorders is greatest. These initiatives enhance the protective factors which promote positive behavior, health, and well-being. (FADAA, 8/97)
Strategies for targeted prevention include specific risk reduction programs, peer support activities, companionship programs, in-home health and chore services, safety assessments, self-help groups, and various primary prevention initiatives. Communication skills, problem solving, anger and stress management, finance and budgeting support, and retirement planning programs are examples of training services included in both primary and targeted prevention services for seniors.
Systems focused approaches
In addition to the group and individuals efforts to promote health among older adults, systems prevention work is needed to ensure the improvement of services for seniors, including housing, outreach programs, employment programs, and family support services.

System Focused Approaches

Basic assumptions related to older adult prevention

Older adult health promotion and substance abuse prevention efforts are built on the belief that older adults can continue to learn, to change, and to grow. Although most prevention funding and programming are directed to children and youth, older adult prevention, with its emphasis on wellness and health, is grounded in the belief that aging is not a deterioration of functioning, but a developmental stage with its own dynamics and life tasks. (Berg and Cassells, 1990)

For an older adult prevention program to be effective, it must address the entire range of older adult lifestyles and aging related issues. Topics included in health promotion are reflective of the opportunities and challenges of older adults in day to day living, and include:

Not a series of single isolated events, older adult substance abuse prevention is an organized strategy of community, agency, and individual efforts which promote health by assisting older adults in recognizing and utilizing their physical, mental, emotional, and spiritual resources. A goal of prevention is to assist senior citizens in effectively dealing with age-related losses, illness, and change without resorting to substance misuse or abuse. Health Promotion approaches reinforce healthful behaviors, attitudes, and environmental practices, thereby preventing the need for older adults to turn to medication or alcohol abuse out of lack of information or the attempt to deal with pain and loss.

Prevention Strategies

Prevention for older adults involves the development, preparation, coordination, presentation, and evaluation of health promotion activities, such as:

These strategies, implemented to promote wellness among older adults, can become the fundamental elements of individual and community health, as well as reinforcing the prevention efforts targeted to other populations. As society breaks through its denial of aging, the awareness of older adult health and related issues will provide a solid foundation for community growth.

Types of Prevention Programs

Information services.
Information services provide older adults, family members, care providers, and members of community organizations and groups with current, accurate information relating to aging, health, and safe use of alcohol and medications. These information services often take the form of presentations focusing on a particular topic such as "Older Adult Services in the Community", "Aging and Substance Abuse", or "Planning for Lifelong Living". Although Information Services are not, in themselves, an effective means of promoting lasting behavioral change, they are an important component of prevention services in that they help older adults and the community develop awareness of older adult issues, programs, and services. Informational presentations often are the first services requested by groups or organizations which later express an interest in strategies which promote more lasting change.
Educational services.
These structured prevention activities focus upon the relationships between aging and effective lifestyle adaptations. It is common for these services to be presented to small groups and require several sessions. Educational programs, to be effective, utilize a variety of techniques, building upon the knowledge and life skills of the participants. Didactic presentations, opportunity for dialogue and group discussion, use of audio-visuals (e.g. handouts, videos, and films), and question and answer sessions are components of educational services. The goal of such approaches is not merely information sharing, but facilitating the opportunity for participants to review their own values, lifestyles, and practices in order to consider the possibility of adapting their current lifestyles to more effective, healthier approaches.
Training of older adults and care providers.
The need for increased services specializing in the care of older adults has resulted in skill training for the development of these individuals. Such training programs prepare professional and volunteer care givers to work directly with seniors and their families. By improving and enhancing the skills of these individuals, the aging population will benefit as their needs are more effectively addressed. In developing training programs, as in educational services, it is important to use a variety of methods. In addition to the previously mentioned, case studies, role plays and skill practice sessions are valuable tools in ensuring skill mastery and application of new learning by participants.
Promotion of creative alternatives.
Prevention focuses on the development and reinforcement of healthful behaviors. The development of creative alternatives to substance misuse or abuse is, thus, a focus in all prevention approaches, as the individual is supported and encouraged in the practice of healthy approaches to dealing with stress, loss, and change. At times, the development and promotion of creative alternatives for groups of older adults may also be a specific strategy, seeking to promote creative applications of abilities, resources, and materials. Focused on participatory initiatives, these creative ventures develop self-assurance, build self-confidence, nurture self-awareness, and healthful interdependence. Examples of such activities include volunteer work to serve those in need, excursions, and a variety of activities involving older adults in areas of interest. Often such activities are not funded through substance abuse program channels, but are available in the community, offering a valuable resource to the older adult, the community, and the substance abuse professional.
Coalition building for older adult advocacy.
As small groups and individuals share their concerns and develop common goals, they add strength, legitimacy, and credibility to their individual areas of concern. Encouraging and supporting such coalition efforts is a worthwhile prevention strategy addressing areas of community and social concern which transcend the needs of individual older adults. An example of the impact of such an approach is found in various senior coalitions in Michigan which join together to share information, plan community activities for resource networking, and organize to address local and regional needs of the senior population.
Development of public policy on aging.
In a time of diminishing public sector resources, without an adequate policy base older adult substance programs and program funding become especially vulnerable to cuts and diminished levels of support. The policy base provides direction, rationale and a commitment to older adult services by those responsible for allocation of funds. Public policy also serves to educate other sectors of the population about the needs of older adults and services essential to address those needs. Shared policy and direction provide a unifying force among older adult providers and interest groups, permitting issues too large or complex to be dealt with effectively by any one group, to be addressed as a shared concern. Thus, prevention resources need to be directed toward generation, adoption, and support of such policy to enhance the probability that older adult substance abuse services remain a focus and priority, and that issues of a complex and far-reaching nature continue to be addressed.

Elements Of Effective Older Adult Prevention Programs

Although variations exist in the form and practice of older adult prevention programming, there are several characteristics shared by most. These reflect the nature of the group served, the issues addressed, and the problems faced by seniors.

Outreach.
Prevention services involve going to older adult centers, residential settings, and other congregate sites. Programs offered at the substance abuse offices are generally not as well attended due to a variety of factors such as problems with transportation, mobility impairments, and the stigma associated with substance abuse services by many older adults.
Peer support.
Peers provide the valuable perspective of someone who has shared a similar life experience - who has "been there". This often creates a special bond, an increased level of comfort, and access at a level the substance abuse professional may not have. Use of other older adults can often break through age related barriers, as many substance abuse professionals are younger than the older adults with whom they work. If it is not possible to use peers, it becomes especially important to allow older adult participants the opportunity to interact, creating a peer support element within the prevention activity.
Interdisciplinary approaches.
Service providers from several disciplines combine to bring the prevention message to the older adult community. This can be especially helpful when dealing with the complex medical, financial, legal, and social aspects of the lives of many older adults. If such resources are available, the difference in presentation styles, communication approaches, and life experiences can also be helpful in maximizing areas of access to the older adult. The Michigan Pharmacists Association (MPA) regularly provides local members to assist in establishing and conducting "Brown Bag" programs for the assessment and evaluation of prescription and non-prescription medications both in pharmacies and at community based locations.
Life skills training.
Learning new ways to adapt to the natural changes involved with aging can enhance the quality of life for older adults. Such training builds on a lifetime of skills and experience. It is important to recognize the existing strengths of individuals as the basis for such training, and not assume there is one way for particular problems to be handled. The trainer serves as a resource, helping individuals adapt their own approaches and life skills to situations they may be facing for the first time, and does not prescribe a certain method for older adults to adopt.
Age-appropriate materials.
Prevention materials for seniors should focus on the needs and characteristics of the older adult population, both in terms of content areas as well as style of presentation. Content areas such as aging, coping with change, retirement, medication, financial management, memory, and dealing with loss can be of interest to older adults. In using printed materials, larger type, attractively formatted materials, and use of ink and paper with high contrast compensate for aging related vision changes.
Growth opportunities.
For older adults, new learning and reinforcement of previous learning enhance a sense of accomplishment and purpose. In addition, learning of new skills and approaches to life problems can assist older adults in successfully managing life changes. At a deeper level, such growth opportunities clearly communicate to the older adult s/he is competent, able to change and grow, and is still a vital part of the community.
Commitment to healthy aging.
Recognition that aging is a natural, healthy process and that wisdom and integrity are individual achievements central to healthy aging are important philosophical foundations of older adult prevention programming. Effective prevention programs dispel the stereotypes and biases commonly associated with the aging experience.
Family and care provider involvement.
Recognition of the relationship of family members and other care providers, as well as involvement with the existing family/care support systems, are important components of effective older adult prevention programs. Many otherwise isolated older adults maintain contacts with family and/or professional care providers, who can be invaluable in reaching older adults unable or unwilling to attend prevention activities. These individuals, often have strong trust relationships with older adults, and may, thus, provide instant credibility to a substance abuse prevention message, as well as access to the individual senior.
Independence and interdependence.
Prevention activities should provide older adults with opportunities to express their needs for independence and interdependence. With declining physical functioning, a greater incidence of chronic health problems and, for many older adults, the need to subsist on a fixed income, most older adults experience a diminished ability to live as independently as they did previously. Thus, it is important to help older adults develop an understanding and approach to accepting the help of others while maintaining their self-esteem and sense of personal competency.

Older Adult Learning

Principles of Older Adult Learning and Their Application to Program Design

Since older adult prevention programming and activity are based on the assumption that older adults can learn, change, and grow, it is important to understand the older adult as a learner when developing approaches to this population.

Ability to learn.
Older adults do not lose their ability to learn as part of a healthy aging process. Reaction time is slowed, and it takes longer for the older adult to change from one activity or mode of thought to another, however, the ability to learn remains. On the other hand, adults tend to compensate for slower psychomotor functioning by being more accurate and making fewer trial and error mistakes than younger populations.
In designing activities for older adults, it is important to develop approaches which do not rapidly shift from one type of activity to another, and to allow enough time for participants to complete steps before moving on. The training or presentation may be more stimulating for the presenter if it rapidly shifts focus, is complex, or unusual but this can be difficult for some older adults to follow, and can result in a less effective prevention activity. In dealing with older adults with some degree of cognitive impairment or loss, frequent shifts in focus can cause confusion in participants.
Sensory losses.
As discussed previously, many older adults experience varying degrees of sensory loss as a normal part of aging. Hearing loss, especially in the higher tones, is common. Visual changes result in older adults needing more light than younger people to see clearly, and needing more time for the eyes to accommodate for changes from near to distance vision. Additionally, older adults experience some loss of ability to distinguish between shades of colors, especially blues and greens. Diminished vision may result in difficulty reading small print, compressed text, and materials printed with ink and paper which do not have strong contrasts.
Since many older adults experience some degree of sensory loss, it is especially important to use a multi-sensory approach, and not rely solely on one avenue of communication. Verbal presentations need to be easily heard, without distracting background noises. Printed materials should be printed on paper which contrasts with the ink used. Larger, simple type styles can make reading easier. If the presenter writes on newsprint, a chalkboard, or overhead projector, care should be taken that what is written is clearly readable from a variety of locations throughout the room.
Research has demonstrated that even with individuals not experiencing sensory loss, a multi-sensory approach is much more effective in promoting effective learning.
Wide variations in older adult groups.
With lifetimes of experience, older adults tend to be a more diverse, less homogeneous group than younger populations. A wide range of values, life experiences, life styles, and life problems often exist within older adult groups.
Prevention efforts which assume older adults are one group are often not effective, since they address the needs and situations of only a portion of the group. Materials and activities need to be designed to accommodate a wide variety of values, life styles, and personalities. It is important to avoid approaches which indicate there is "one right way" to either view an issue, or deal with it. It is more effective to identify some principles upon which approaches can be developed, and then use the resources of the group to brainstorm a variety of ways to deal with the issue at hand. For example, in dealing with the role of isolation in reinforcing denial and continuing unhealthy patterns of substance use, it is helpful to enlist the group in identifying life factors which lead to isolation, and discuss effective means for overcoming it.
Life changes and learning.
Adults often seek out new learning experiences to assist them in coping with specific life changes. They tend to be less interested in very broad topic areas and more interested in something more targeted, more practical, and more able to assist them in dealing with a specific challenge. New approaches must be integrated with past experiences and beliefs. Thus, learning is seen as a means to an end, and must become part of the person's existing experience base, be integrated into an existing value system, and practiced in order to affect change in the person's life.

Older adults are adults.

We all tend to learn best from experiential rather than didactic approaches. We also tend to learn best in environments in which we have control of the learning experience. This is especially true of adults. The more closely the learning environment matches the learning style of the individual, the more likely the learning will be successful, and the more effective the learning becomes. Older adults have a wealth of life experiences from which to draw.

For individuals designing prevention services, the implications are clear. The more involved older adults become in planning, designing, and carrying out the learning activities, the more likely those activities will be in producing the desired learning experience. Since many older adults associate prevention activities with "school", they are often reticent at first to be verbal in front of their peers, expecting the presenter to lecture and provide information. There are a variety of approaches to helping older adults become more involved comfortably in prevention activities, including small group discussions, voluntary sharing, structured activities which provide individual choices on topics, etc. Older adults often respond very well to experiences or approaches shared by peers, and the group is a valuable resource for the substance abuse professional.

In designing activities, it is important for the substance abuse staff person to consider what approaches would work well with him/herself. This can be a valuable guide to designing prevention activities for other adults.

Summary

In developing older adult activities, it is helpful to keep in mind the following:

Prevention work with older adults is an investment in the future not only of those individuals, but ourselves as well. As we all age, and face the issues they face today, what is shared and discovered by older adults can provide for us a valuable guide to our own futures and the challenges we will face.

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Older Adult Treatment Approaches

Table of Contents

Casefinding - Early Intervention

Casefinding can be broadly defined as identification of individuals with substance abuse problems and the actions taken to assist them in accessing appropriate treatment services. Casefinding has both an individual and community focus. Individual casefinding involves assisting particular older adults in accessing treatment services through a process of screening, assessment, referral and follow-up. A more systems-wide approach focuses on intervening with organizations which may then more effectively identify individuals with substance abuse problems and direct them to appropriate treatment.

No matter what form it takes, casefinding has as its goal breaking through the isolation that insulates the individual from the help s/he needs. Isolation, a result of substance abuse problems for individuals of any age, becomes even more pronounced and problematic with older adults. Multiple factors contribute to this increased isolation and resultant difficulties in assisting older adults in accessing services.

Elements of the Isolation of Older Adults With Substance Abuse Problems

Retirement

Many older adults are not actively engaged in the work force. This lack of regular contact with co-workers and lack of predictable structure in which to assess functioning, make it difficult to evaluate the impact of substance use or misuse on functioning. Retirement, for many, results in increased isolation. (Robertson, 1992)

Mobility problems/health problems

Health and mobility problems also lead to the isolation of many older adults as the individual may be physically unable to leave his/her residence. For less debilitated individuals, working or stair climbing, although possible, can be a painful or exhausting process. (Raschko, 1990)

Lack of transportation/income

For many older adults the lack of private transportation and a lack of information, physical capability, or discretionary income for public transportation may limit mobility and increase isolation. Especially in rural settings where public transportation may be non-existent or very limited, this can be a substantial factor in isolation. (Shipman, 1990)

Crime

Many older adults fear the victimization they may experience due to increased crime in their neighborhoods. This may be especially true of inner city older adults remaining in their family homes in older neighborhoods which have deteriorated. (NIA, 1996)

Cultural diversity

Older adults living in areas of high concentration of a particular ethnic or cultural sub-group may be resistant to leaving their neighborhoods to access services in other areas. Some older adults are reluctant to deal with substance abuse staff having other cultural origins. This factor also, then, leads to increased isolation. (TIP # 26)

Values and attitudes related to drinking

Some older adults growing up in the era of Prohibition retain strong negative attitudes about drinking and about those who drink. Drinking may be viewed by these individuals as a sign of moral weakness. Negative attitudes and judgments are compounded when someone drinks excessively, or is seen by these older adults to have problems related to drinking. Strong values, moral prohibitions against drinking, and fear of the judgments of others further isolate older drinkers experiencing substance abuse problems.

As a result of these factors and others, older adults experiencing substance abuse problems can be a very difficult population to identify and get into treatment. Thus, the methods used to identify and motivate these individuals into treatment must address the particular characteristics and needs of these seniors.

Principles for Older Adult Casefinding Services

Use multiple approaches

Since older adults are a varied population, it is important that casefinding efforts utilize a variety of approaches, including mass media, organizational development, referral source development, peer approaches and individual substance abuse staff casefinding.

Plan and evaluate approaches

Older adults with substance abuse problems are often a very difficult group to reach. In order to target casefinding resources most effectively it is necessary to analyze and build on approaches that demonstrate success. Such analysis also provides information with which it is possible to identify older adult groups which are not being reached. Particular approaches for these groups can then be developed and evaluated.

Use recovering older adults to assist

Involvement of older adults who are in recovery to assist in casefinding has dual benefits. These older adults have a great deal of credibility with peers and are modeling a recovery process for them. Their endorsement of the program and its value in their recovery often has a credibility which is difficult, if not impossible, to surpass. The involvement of recovering older adults in casefinding efforts can also be of great value to their own personal recovery process.

Be persistent

Organizational credibility is not attained overnight. In many casefinding efforts, the individuals approached may need multiple contacts to overcome the fear and denial which isolate them and interfere with their access to services. Similarly, a variety of approaches may be needed, and may need to be repeated over time, in order to generate ongoing referrals for services. Casefinding is not a one-time effort; it is an ongoing process of development.

Use older adults' existing links to the community

Many older adults, because of increasing health care needs and declining levels of independent functioning, are involved with a variety of care providers. These care providers can be invaluable in identifying older adults potentially in need of substance abuse services, and in facilitating access to services. They already have established relationships and have developed a level of trust which would take a stranger considerable time to cultivate. With training and information, care providers can become very skilled at identifying older adults in need of treatment and at motivating them to seek services. Family care providers are also a valuable resource in helping older adults obtain needed services. As with the use of other recovering older adults, this approach broadens casefinding resources in a cost-effective manner.

Each community has a variety of care providers to access. Examples of individuals include:

Health Care Personnel

Human Services Personnel

Other Organizations

In approaching any of these organizations for collaborative casefinding efforts, it is important to keep in mind the mission, priorities, norms, and values of these systems. This level of assessment, prior to attempting actual networking and casefinding efforts, will reduce the possibility erroneous assumptions by older adult substance abuse providers. It is important in both establishing and maintaining such efforts that the needs of both parties are clearly identified, addressed, and met in the casefinding activity. Otherwise, it is easy for collaborative endeavors to fall apart. (DeHart and Hoffman, 1995)

Casefinding with Individual Older Adults

Whether older adults seek treatment after hearing of services through mass media, peers, or other providers, the point is reached at which the older adult's needs are assessed by the professional substance abuse provider as a precursor to treatment. In performing this assessment, the following approaches can be helpful.

Involvement of the referral agent

If the older adult is referred, it is often helpful to have the person making the referral part of the initial approach to the potential client. This person already has some relationship with the older adult and likely has access to that individual at a deeper level than you, as a stranger, will have. Referrals in which the significant other first broaches the need for treatment with the older adult, and perhaps is present for part of the first session, are much more likely to be successful than "cold" approaches by the substance abuse professional.

Generational differences

Modify your language and approach to be sensitive to the older adult, his/her generational values and attitudes, and style of communication. Generally, younger population groups find it much easier to discuss matters of a personal nature with professional care providers than do older adults, who have been taught as a generation that they should be able to handle problems themselves and that family or personal matters are not discussed outside the family. Additionally, many of these individuals grew up during the era of Prohibition, when drinking was seen as a moral weakness. This area, then, has a special sensitivity and often requires a slower approach in assessing substance related problems.

Terms such as "alcoholism" and "substance abuse" often have strong emotional connotations for individuals of this generation and may make the assessment of need much more difficult as defenses increase. This reaction can also be exacerbated depending on personal religious views related to the use of alcohol. It tends to be much more productive initially to use language that is not as emotionally loaded and to begin the assessment discussing life problem areas and the possible connection to drinking. An aggressive approach with this population is likely to produce resistance.

Persistence

In individual interviews it is important to keep coming back to information which is vague or unclear, in a manner not perceived as threatening by the older adult. Similarly, in outreach work, it may be necessary to approach the older adult repeatedly to assist him/her in reaching the point where s/he can identify a need for treatment. Again, the key is not an aggressive approach, rather an ongoing presence in which reality is brought back again and again, with the older adult sensing that the professional is someone who cares enough to be present and who conveys a consistent message.

Comprehensive assessment

In determining the needs of older adults for services, it is important that a comprehensive, holistic assessment be completed. Although the assessment that occurs in casefinding is generally not as in-depth as the assessment which is part of treatment, it is, nevertheless, critical that a holistic assessment of the older adult occurs. Many physical health conditions, life situations and medications can cause symptoms which mimic substance abuse, or can exacerbate substance related symptoms. Thus, a comprehensive, holistic assessment is essential.

Understanding treatment resources

Help the older adult develop an accurate understanding of treatment resources. Especially with older adults for whom substance abuse has not been a lifelong problem, a lack of understanding and many misconceptions may exist about treatment of substance abuse problems. Inpatient and outpatient substance abuse treatment programs were not a part of many older adults' life experiences, since both are of relatively recent origin. Similarly, many have little understanding of Alcoholics Anonymous or of the basic functions of self help groups. Ensuring a clearer understanding of what comprises treatment can address the fears which prevent involvement.

Developing hope

Assist the older adult in developing hope that real change can occur. Coupled with the normal losses and challenges of aging, a substance abuse problem may seem insurmountable to the older adult. It is important to help that individual develop hope that change can actually occur. This hope is often tied to some unfinished business or some dream for the future in which they still can invest. The substance abuse professional may be the only individual in that older adult's world who will express the hope, and support the older adult in achieving the dream.

Community support systems

Engage community supports to break through isolation and mobilize a support and monitoring group for the older adult. As with other older adults, these individuals may experience a variety of aging related changes which result in decreased independence and a need for assistance to continue functioning independently. It is helpful to assist the older adult in obtaining needed services, e.g. Visiting Nurses, Meals on Wheels, Chore Services, etc. in order to break through the isolation which insulates them from the help they need. (Shipman, 1990) These providers then can access and assist in providing a healthy support system for the older adult, reinforcing his/her recovery.

With older adults, casefinding is rarely a single appointment resulting in a referral. It is generally a process through which the older adult gradually recognizes the need for, and willingness to become involved with, treatment.

Assessment of the Older Adult With Substance Abuse Problems

Factors Contributing to the Complexity of Older Adult Assessment

Assessing the older adult for substance abuse problems is a much more complex process than assessing younger populations due to several factors:

Health and aging related changes
Many aging related changes, chronic physical health conditions, and disease processes can cause symptoms which may easily be interpreted as symptoms of substance abuse. For example, tremors, problems with balance and coordination, disorientation, and memory loss, which may indicate substance abuse problems in younger populations, may also be indicative in older populations of physical health conditions.
Ongoing losses
Due to retirement, decline in physical functioning, and changing roles in the family, there are fewer external indicators of the older adult's ongoing stable level of functioning. These changes constitute losses which must be factored in as variables in assessing the older adult's use of substances and of their effect on his/her life.
Drug interactions and paradoxical effects
With increased physical health problems and chronic conditions, an increased number of medications, the increased likelihood of drug interactions, and increased paradoxical reactions of drugs the assessment of medication misuse becomes very complex. Add to this the prevalent use of over-the-counter medications and alcohol use by older adults and the assessment process is further complicated.
Generational differences and substance abuse stigma
As mentioned previously, aging related stigmas about drinking, sharing private concerns with strangers, and generational differences in values can confound the evaluation, especially when a younger adult is attempting to assess the older person. While some older adults feel a stigma related to using alcohol, others consider alcohol use an irrefutable privilege.
Sensory losses
Sensory losses (sight and hearing) complicate the communication process, making it difficult for some older adults to understand what is being said, or questions asked on printed forms. Older adults may be reluctant to admit they are experiencing these difficulties, and attempt to respond to what they think is being asked. If the substance abuse professional is not aware this is occurring, inaccurate information may be gathered and faulty conclusions drawn. This makes the assessment process much more difficult.
Cognitive losses
Cognitive losses which the individual may be experiencing due to dementia can further cloud the diagnostic picture, as the older adult is unable to provide accurate information due to memory loss, or fully understand what is being asked. It is difficult to determine if the cognitive losses are a result of substance abuse, and are perhaps reversible, or are a result of another condition being experienced by the older adult.

Areas of Assessment and Special Considerations

Outline of assessment areas

As a result of the factors discussed above, the assessment of the older adult is a process which tends to take longer than assessments of individuals from younger age groups. It becomes especially important with older adults that a holistic approach to assessment is taken and that all possible sources of information are consulted. An assessment of an older adult for a substance abuse problem should include at least the following areas:

Assessment of health

A physical examination by a physician, as well as access to health records of the individual, are significant components of a comprehensive assessment of the older adult. It is also important to assess medication usage, including over-the-counter drugs, and concomitant use with alcohol. With the older adult's permission, family members, spouses, siblings, etc. can be valuable sources of information. These individuals may have a better recollection of the history of the individual, may provide helpful perspectives on his/her functioning, and may be able to fill in some missing pieces of the assessment puzzle. If resources are available, occupational therapy, physical therapy, psychiatric assessment, and psychological testing can also provide useful information for the assessment process. If these additional resources are not available, it is important that the substance abuse professional assess these areas on at least a basic level. (Blow, 1998)

Sensory loss

Since many older adults experience some sensory loss, it is important that this be taken into consideration when assessing a potential substance abuse problem. Aging related vision changes can make completion of forms and questionnaires difficult. Also, many older adults did not complete high school and may have problems in reading or understanding instruments and forms designed for younger populations. Potential difficulty should be assessed prior to giving older adults these instruments or forms. Forms and instruments can be administered verbally with the older adult.

Difficulties with reading
If reading is required as part of the assessment process, bright non-glaring light is necessary to compensate for aging related vision changes. Interviewers should be careful not to sit where glare from windows or lights makes it difficult for the older adult to see them clearly, since many older adults experiencing hearing loss read lips to assist them in comprehending what is being said. It is important to offer visual cues to promote improved communication.
Hearing loss
Also, with individuals experiencing hearing loss, the staff person may need to speak at a higher volume. If attempting to do this, it is important to remember that hearing loss generally begins with higher tones, so speaking in a lower tone of voice can make communication with the older adult more understandable.

Pace of assessment

Due to factors related to the discomfort of some older adults in sharing personal information with others, talking about drinking or substance abuse, and needing to seek professional help, it is important that the assessment process not be hurried or rushed. Rushing tends to create increased defensiveness and limits the validity and scope of the information obtained. It may take two or three sessions to complete an evaluation or assessment of the older adult.

Building a relationship

These sessions can provide a valuable opportunity for relationship development and a time to work through some of the denial and defensiveness, as well as the fear associated with entering treatment. This additional time spent in the assessment phase pays worthwhile dividends later, since studies indicate that, compared to younger populations, more older adults who enter treatment complete those treatment programs. This initial assessment stage is a time of assessment not only of the older adult, but also by the older adult of the individual with whom s/he will be working (Atkinson, 1997).

Specialized Older Adult Treatment or an Integrated Approach?

Factors In Determining Specialized vs. Integrated Approaches

A variety of studies have addressed the question of whether specially focused older adult treatment is more effective than integrated treatment with younger populations. (Chaney, 1978; Brown, 1986; Janik, 1983; Atkinson, 1985; Kofoed, 1987) Conclusions of these studies vary. In a recent study, Kashner found evidence that age specific group treatment improved older adult compliance and outcomes.(Kashner, 1992) The question of a specialized vs. an integrated approach is an important one for program developers and clinical staff as well. In attempting to address it, several factors need to be kept in mind.

Multiple older adult populations

Older adults are often thought of as a single group sharing common characteristics. However, they tend to be one of the most diverse of all groups. Although they share a chronological age span, have lived through the same period of history, and have experienced the physical changes which come with aging, each of them has had a unique set of life experiences over an extended period of time. As a result, there is a broad range of attitudes toward aging, methods of dealing with change, lifestyles, and individual life circumstances. Thus, using age as a singular indicator of the treatment approach lacks depth and soundness.

Special needs of older adults

Whether an integrated or an age-specific approach is used, treatment programs should be adapted to the special needs of older adults. This requires that integrated programs demonstrate flexibility and creativity in modifying existing programs to meet the needs of older adults. To be effective, both age-specific and integrated programs must address older adult developmental issues, adapt pace and methodology to aging-related physical changes, and be sensitive to generational issues. These considerations have been described in other sections of this document.

Cost considerations

Cost considerations are often the deciding factor in choices about age-specialized or integrated treatment. For example, the small number of older adults using inpatient services, the lack of private insurance or sufficient income of these individuals to pay for such services, and the longer period needed for inpatient treatment of this group may slow or prohibit the development of specialized inpatient services.

Special Considerations in the Treatment of Older Adults

The advantages of specialized treatment developed to address the needs of older adults include:

Whether integrated or specialized, to be effective with older adults, treatment programs and methodologies need to be sensitive to the distinctive needs of this population.

Alternatives to confrontation

Confrontational approaches used with younger populations can be counter-productive with older adults. For confrontation to be effective, a relationship of trust needs to be developed. Confrontation should be less aggressive, and spread over a longer time span. The substance abuse professional should avoid judgmental, blaming statements or confrontations delivered in language which may be unfamiliar to the older adult. A factual approach in which the substance abuse professional presents his/her concerns based on information shared by the older adult, helping him/her realize the destructiveness of the substance abuse/misuse is more helpful. Effective confrontation is often not a one-time experience, but a series of deepening confrontations as the relationship develops. (Hinrichsen, 1990)

Stabilization / Detoxification

Due to aging related physical changes, detoxification often requires a longer period of time for older adults. Since physical systems of older adults function less effectively than those of younger individuals due to the effects of aging, recovery from the effects of alcohol or other substances takes longer. Similarly, the recovery from the impact of a substance on cognitive functioning is also a more lengthy process. This detoxification period should be carefully monitored medically due to the higher incidence of physical health problems in the older adult population. To adequately address the needs of older adults, detoxification programs need the ability to accommodate varying lengths of stay. (Dunlop, 1990)

Health conditions and medications

The prevalence of chronic and acute health conditions and the greater incidence of medications taken by older adults to treat these conditions complicates the treatment process. Health and medication use can dramatically affect the cognitive abilities of older adults and, thus, impact the rate of treatment progress. Health problems and the stress they produce can further complicate the recovery process for older adults. Treatment services need to address these conditions and the medications for their management on an ongoing basis. (Blow, 1998)

Reminiscence

Reminiscence can be a valuable tool in the treatment of older substance abusers. The use of life review and reminiscence allows individuals to share their stories, address unresolved conflicts and, based on a process of reassessment, determine future direction. In group situations such sharing can create bonds between individuals, increase levels of trust, and break through the defenses of others. With older adults there may be a need to return several times to the same stories in an attempt to resolve past life experiences. It is important in facilitating a healthy use of reminiscence to focus on feelings and the relationship of feelings and substance abuse. In group settings dialogue between members around stories that have been shared can be helpful to all concerned. (Ruyle, 1988) (Kaminsky, 1984)

Family work

Family work can be a complicated, long term process in working with adult children of older adult substance abusers. For older adults who have had life long problems related to substance abuse there are lengthy histories of family dysfunction and family conflict. Patterns with such extended duration can be very difficult to confront and change. In addition, the adult children themselves may be attempting to deal with the effect of childhood experiences on their current functioning. Years of unexpressed anger, rage, and fear can seem overwhelming. (Dunlop, 1990)

Motivating factors

There is often an absence of motivating factors for older adults to engage in treatment. Since older adults are less likely to have legal system involvement than are younger populations, this coercive force for treatment is often not present. Since many older adults have retired and do not have the role of family provider to maintain, this motivating factor is also often missing. Similarly, with children growing up and leaving home, the death of close friends and relatives, and decreased social contact, the powerful impetus for treatment provided by significant others may be missing or diminished. It is important to identify what motivating factors exist for the older adult to seek treatment, e.g. fears of loss of independence and of placement in dependent care settings, friends and family, pets, etc. These often may be different than motivating factors used with younger populations. (Blow, 1998)

Length of treatment

As with casefinding and assessment, treatment of older adults with substance problems takes longer than treatment of younger adults. For a large set of reasons discussed previously, including changing lifetime patterns of behavior, aging related physical conditions, longer periods required for detoxification, cognitive losses of some older adults, as well as increased losses and unresolved grieving processes, recovery is a more long term process.

Age differences

Differences in age between older adults with substance abuse problems and individuals providing treatment can complicate the treatment process. Older adults may feel younger substance abuse professionals do not have an appreciation or understanding of age related issues. Younger substance abuse professionals may feel uncomfortable in confronting older adults. They also may find seniors reminding them of their parents and awakening unresolved issues related to their own families, which in turn may interfere with the treatment process. (King, 1986)

Losses and loss of alcohol

Older adults, already experiencing multiple and increasing losses, must deal with another loss - the loss of the substance they have been abusing. It is important this loss be identified and discussed as a loss experience with the older adult in order to facilitate a healthy grieving process and promote recovery. It is also important, however, that this loss not become the major focus of treatment, especially early in the recovery process, or treatment progress can be undermined or impeded. The possibilities resulting from a recovery process should balance the grieving process and provide direction and reason for the loss. (Sumberg, 1985)

Treatment Services

As with younger populations, treatment options need to be chosen based on the particular needs of the older adults. Often the socio-economic status of older adults, a lack of insurance coverage, and physical health conditions limit treatment options available to this population. Many of the special considerations for older adults discussed earlier can be provided through a variety of treatment modalities including detoxification, intensive inpatient treatment, outpatient services, day care, half-way houses, peer support and aftercare.

Inpatient services/intensive outpatient services

Inpatient Services can be provided effectively in both integrated and specialized settings. It should be remembered that in addition to the longer period often required for detoxification of older adults, they may experience greater confusion, depression, and memory loss than younger groups. These conditions are often reversible and require a slower, more supportive approach than is used with younger adults. Additional rest periods or breaks can facilitate return to normal levels of functioning for older adults with less endurance than younger individuals. The use of a "buddy system" in which more functional individuals assist more debilitated older adults in learning and adapting to the new environment can be helpful. Elective lectures, specialized older adult sessions, and use of peers in the treatment process can also increase the effectiveness of inpatient treatment for older adults. These same considerations also apply to intensive outpatient/day treatment services as well.

Outpatient services

Outpatient services should allow for home based services to older adults. The level of comfort may be greater for the older adult who feels stigmatized by generational values and attitudes when coming into a substance abuse treatment center. Additionally, more comprehensive and accurate assessments may be made of the older adult's daily functioning, the impact of substance abuse on his/her life, and current life style. It may also be easier to involve significant others in support of treatment goals by engaging them in the living situation of the older adult. Home based services are more costly than office based services due to travel time associated with visits. Substance abuse staff may find themselves, at times, in situations which are less controlled than the office setting. However, home based services can provide insights and accesses to older adults unavailable in the office milieu.

Follow-up and aftercare

Follow-up and aftercare are especially important when working with older adults. As discussed earlier, by nature of income, retirement status, changed family roles, health conditions and mobility problems, older adult substance abusers tend to return to more isolated situations than younger individuals. These conditions tend to increase the likelihood of relapse. Follow-up and aftercare efforts need to be structured around the particular needs of the older adult being served. Use of, and coordination with existing care providers can maximize chances for a successful recovery process. Peer involvement and support in specialized groups or on a one-to-one basis are also valuable tools in combating the isolation which may make the recovery process a difficult one. (Dunlop et al., 1990)

Recovery is an ongoing process for older adults as with all individuals. The process is complicated by the ongoing losses of aging and physical changes which affect every aspect of the older adult's life. Perhaps the greatest challenge facing the substance abuse professional is to creatively deal with barriers, complications and setbacks without losing hope that recovery can happen and to convey this hope and commitment to the older adults we serve.

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