Transcript Document
At-Risk Alcohol Use in Older Adults: Background
on Problem, Screening, Brief Interventions, Brief
Treatments, and Mental Health Comorbidities
Kristen L. Barry, PhD
Research Professor
University of Michigan Department of Psychiatry
and Department of Veterans Affairs National Serious Mental
Illness Treatment Research and Evaluation Center (SMITREC)
Get Connected!
Linking Older Adults With
Medication, Alcohol, and
Mental Health Resources
WWW.SAMHSA.GOV
WWW.NIAAA.GOV
The Demographic Imperative I
• 13 percent of U.S. population
age 65+; expected to increase
up to 20 percent by 2030
• 78 million ‘Baby Boomers’
(born from 1946-1964) in
U.S. Census 2000
– Second wave ‘Baby Boomers’
(now aged 40-49) contains 45
million
Alcohol Use in Older Adults
• 66% of older men, 65% of older women used
alcohol
• 3% met full criteria for an alcohol use disorder
• At-risk drinking was reported in:
–17% of men, 11% of women ages 50+
–19% of all respondents ages 50-64
–13% of all respondents ages 65+
• Binge drinking was reported in:
–20% of men, 6% of women ages 50+
–23% of all respondents ages 50-64
–15% of all respondents ages 65+
(Blazer & Wu, 2009a)
Medication Misuse
and Alcohol Interactions
• Medications with significant alcohol interactions
– Benzodiazepines
– Other sedatives
– Opiate/Opioid Analgesics
– Some anticonvulsants
– Some psychotropics
– Some antidepressants
– Some barbiturates
(Bucholz et al., 1995; NIAAA, 1998)
Estimated Prevalence of Major
Psychiatric Disorders by Age Group
16
15
14
Millions
13
12
11
10
9
8
18-29
30-44
45-64
65 >
7
2000
2010
2020
2030
Jeste, et al., 1999; www.census.gov
Course and
Consequences of
Older Adult Alcohol
Consumption
Aging, Drinking and Consequences
• Aging-related changes make older adults more
vulnerable to adverse alcohol effects
– Higher BAC from a given dose
– More impairment at a given BAC
– Interactive effects of alcohol, chronic illness and
medication
• Implications for older adult drinkers
– Moderate levels of consumption can be more risky
– More consequences from maintaining consumption
– Increased consumption may quickly result in
consequences
What conditions may be caused or
worsened by alcohol use?
• 1 or more drinks per day
– Gastritis, ulcers, liver and pancreas problems
• 2 or more drinks per day
– Depression, gout, GERD, breast cancer,
insomnia, memory problems, falls
• 3 or more drinks per day
– Hypertension, stroke, diabetes, gastrointestinal
diseases, cancer of many varieties
SBIRT MODEL
• Screening
• Brief Intervention
• Referral to Treatment
Screening Approaches
Recommended Drinking Limits
for Older Adults
Recommendations must include both average
daily consumption and frequency of heavy
drinking
No more than 1 standard drink/day
No more than 4 standard drinks on any
drinking day (Defined as Binge Episode)
(Chermack, Blow, et al., 1996)
Recommended Drinking Limits
for Older Adults
Recommended limits for older women
somewhat lower than those for older men
Lower than recommended levels for younger
adults
Consistent with patterns shown to have
potential health benefits
(Chermack, Blow, et al., 1996)
Signs and Symptoms of Alcohol
Problems in Older Adults
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•
•
•
•
•
•
•
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Anxiety
Blackouts, dizziness
Depression
Disorientation
Mood swings
Falls, bruises, burns
Family problems
Financial problems
Headaches
Incontinence
• Increased tolerance to
alcohol
• Legal difficulties
• Memory loss
• New problems in decision
making
• Poor hygiene
• Seizures, idiopathic
• Sleep problems
• Social isolation
• Unusual response to
medications
Barriers to Identification
Ageist assumptions
Failure to recognize symptoms
Lack of knowledge about screening
Attempts at self-diagnosis or description of
symptoms attributed to aging process or disease
Many do not self-refer or seek treatment
– Although most older adults (87 percent) see physicians
regularly, an estimated 40 percent of those who are at risk
do not self-identify or seek services for substance abuse
(Raschko, 1990)
Alcohol Screening with
Older Adults
Goal of Screening
– To identify at–risk drinkers, problem drinkers
and/or persons with alcoholism
– Identify subset of clientele that need more
assessment
Rationale for Screening
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High enough incidence to justify cost
Adverse effects of problem drinking
Effective treatments available
Presence of valid screening techniques
Screening Instruments
and Assessment Tools
• Alcohol Consumption
– Quantity, Frequency, Binge Drinking
• Alcohol Consequences
– AUDIT, MAST, SMAST
– Elder-Specific: MAST-Geriatric Version, SMAST-G
• Health Screening Survey
– includes other health behaviors
• nutrition, exercise, smoking, depression
Screening and Assessment
Recommendations for Older Adults
Every person over 60 should be screened
for alcohol and prescription drug abuse as
part of regular physical examination
“Brown Bag Approach”
Screen or re-screen if certain physical
symptoms are present or if the older person
is undergoing major life transitions
Screening and Assessment
Recommendations for Older Adults
Ask direct questions about concerns
Preface question with link to medical
conditions of health concerns
Do not use stigmatizing terms (i.e. alcoholic)
Brief Interventions
Relationship between Alcohol Use and Alcohol Problems
None
Light
Alcohol Use
Moderate
Heavy
Low Risk
At Risk
Problem
Dependent
Severe
Moderate
Small
None
Alcohol Problems
Barriers to Seeking Alcoholism
Treatment for Older Adults
Resistance to asking for help
Disdain of labels (alcoholic, old)
Lack of transportation
No significant others to assist in
motivation to seek help
Providers less likely to refer older adults
Gaps in substance abuse, aging, and
mental health services
The Spectrum of Interventions for
Older Adults
A
B
Not
Light-Moderate
Drinking
Drinking
Prevention/
Education
Brief Advice
Brief
Interventions
Pre-Treatment
Intervention
Formal Specialized Treatments
C
Heavy
Drinking
D
Alcohol
Problems
E
Mild
Dependence
F
Chronic/Severe
Dependence
Empirical Support for Brief
Interventions with Older Adults
Project GOAL (Guiding Older Adult Lifestyles)
Physician advice for older adult at-risk drinkers led to
reduced consumption at 12 months
(University of Wisconsin; N=156; 35-40% change)
:Health Profile Project
Elder-specific motivational enhancement session
conducted in-home reduced at-risk drinking at 12
months
(University of Michigan; N=454)
Additional BI Studies with Older
Adults
• Moore, et al, 2010- NIAAA sponsored
– Brief intervention in primary care
– Follow-up health educator call
– Positive results
• Schonfeld, et al, 2010- SAMHSA
sponsored
– Large state-wide demonstration project in variety of
health care and senior services sites
– Positive reductions in drinking with BI
– Demonstrated that implementation in a variety of senior
service sites is possible
Florida BRITE Project: SAMHSA
• Florida - only SBIRT specific to older
adults
• BRITE is offered in medical, aging,
psychiatric, substance abuse services
• BRITE expanded from 4 sites (4 counties)
to 21 sites in 15 counties
• Challenge: Prescription drug misuse
Florida BRITE
• In the first two years, 6,205 people were
screened by BRITE providers
– Not all sites were “up and operating yet”
• Screening takes place in:
–
–
–
–
–
–
Hospital emergency rooms
Urgent care centers & clinics
Primary care practices
Aging services
Senior housing
Private homes
Proportion of SBIRT Services
in BRITE Project
70%
27%
2%
2%
-
Screening and feedback only
Brief Advice/Brief Intervention
Brief Treatment
Referral for specialty services
Primary Substances Used
69.6% Alcohol
18.9% Prescription Drugs (not necessarily
psychoactive meds)
7.3% Illicit drugs
4.6% Other
Results Across Reviews/MetaAnalyses
Brief Interventions (BI) can reduce alcohol
use for at least 12 months among younger
and older adults
Approach is acceptable to younger and older
adults
Results mixed on longer-term utilization
and reduction of alcohol-related harm
Special Circumstances
Alcohol Withdrawal
Excessive Drinking
21+ drinks/week
Benzodiazepine/Opioid Use
5+ days/week for 3+months
Brief Treatments
Types of Treatments
Examples:
Brief Treatments
• Strengths-Based Case Management
• Motivational Enhancement Therapy (MET)
• Cognitive Behavioral Therapy (CBT)
Specialized Treatments
• Outpatient
• Inpatient **
Who Seeks Treatment?
Referral Pathways
• Admissions aged 55 or older were more
likely than younger admissions to enter
treatment through self-referral
– What leads to self-referral?
• Elders less likely to be referred through the
criminal justice system
• Few referred by health care providers in
both young and older samples
(OAS, SAMHSA, 2004)
Conclusions
There are effective screening techniques
Screening can bring about change
Brief Interventions (BI) can reduce
alcohol use for at least 12 months among
older adults
Motivational enhancement effective
Approach is acceptable to older adults
and can be conducted in health clinics
and in-home
Conclusions
BI and BT are effective
Substance abuse treatment works
PREVENTION matters!
________________________
We can all make a difference in the lives of
our older clients/patients who use alcohol at
risk levels or combine alcohol and counterindicated medications.