Transcript Slide 1

Older Adults:
Addictions &
Concurrent Disorders
Liz Birchall
Community Outreach Programs
in Addictions (COPA)
Agenda
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Overview
What’s different for Older Adults with
Addictions
Best Practices
Treatment and Program Approaches
Case based learning
Knowledge Transfer and Exchange
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Demographics
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In 2012, there were 810 million adults over 60 yrs in the world, making up
11.5% of the global population (The UN Population Fund in Choi & DiNitto,
2013)
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Canada’s population is aging and the proportion of those aged 65 years and
older has almost doubled in the last fifty years
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Population projections indicate that, by 2036, almost a quarter (24.5%) of
the Canadian population will be 65 years or older (Statistics Canada, 2007)
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The aging population will increase over the next thirty years; increasing from
4.2 million in 2005 to 9.8 million in 2036 (Stats Can, Portrait of Seniors,
2007).
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The baby boomer generation represents nearly one out of three Canadians;
the largest age cohort in Canada and the oldest baby boomers are now
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entering their retirement years (Statistics Canada, 2007)
Older Adults/Seniors and
Substance Use Issues
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Alcohol consumption, deaths and problems have increased in older
age groups in developed countries (USA, Australia and EU
members) (Wilson et al, 2013)
In the next 20 yrs, among health problems and burden of illness, two
areas of substance use are of concern for older adults: alcohol and
psychoactive prescription drugs (Wang & Andrade, 2013)
The prevalence of alcohol use disorder is higher than in previous
generations and is expected to increase in older adults as this
generation ages (Sacco, Kuerbis, Goge & Bucholz, in press)
Literature indicates that the current population of older adults are
continuing to use alcohol and psychoactive prescription drugs at a
higher rate than previous generations and are beginning to present
larger issues for the health care system as well as the intervention
and treatment communities (Blow, Barry, 2012)
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WHAT’S DIFFERENT FOR
OLDER ADULTS WITH
ADDICTIONS?
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Older Adults and Substance
Use
Onset of Substance Use Issues:
Late Onset
 Some older adults begin to have problems with
their substance use during times of transition or
loss (e.g. forced retirement, bereavement, new
or escalating health concerns, loss of
independence)
Early onset
 Some older adults have long standing substance
use issues
Why is substance use different
for older adults/seniors?
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Older adults, due to complex and/or chronic health conditions require pharmaceutical
medications that can interact with each other and non prescribed substances (e.g.
alcohol, marijuana)
Our bodies change as we age which can make alcohol and other drugs more potent
and subsequently more harmful
Older adults with some degree of cognitive impairment and/or functional losses are
often misdiagnosed with dementia when, in fact, there may be a substance misuse or
addictions issue
Older adults are often marginalized and isolated so they have little or no positive
social connections
Older people with chronic substance misuse may have had multiple head injuries
resulting in symptoms of acquired brain injury
The signs of substance misuse can be mistaken for sign of aging and, as a result, the
older person does not receive the interventions they need
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Alcohol and Medication
Interactions
Medication
Alcohol Interaction
Anticoagulants (Blood Thinners like
Warfarin or Coumadin)
to prevent heart attacks, strokes, and
blood clots in veins and arteries
Increased risk of internal bleeding (e.g., GI bleed)
Antidepressants of all types
Can make people sleepy which could lead to falls,
fractures
Cardiovascular Medications (i.e. Digoxin,
Nitroglycerine)
Can make people dizzy
Risk of heart problems when stopping drinking
without help from a doctor or nurse to advise on
dose and timing of heart medications
Narcotic pain relievers (i.e. Codeine)
Can make people sleepy which could lead to falls,
fractures
Increases likelihood of overdose
Risk of liver damage
Benzodiazepines (i.e., Valium,
Ativan/Lorazepam, Clonazepam)
Can make people sleepy which could lead to falls,
fractures
Increases likelihood of overdose
Can cause agitation
Older Adults and Prescription
Medication
Common Types of Medication for Older Adults:
 Benzodiazepines (e.g., Valium, Ativan/Lorazepam)
 Sedatives/Sleep (e.g., Imovane/Zopiclone)
 Analgesics/Opiates (e.g., Codeine, Oxycodone, Percocet)
Issues for Older Adults:
 Drug interactions can be dangerous, and older adults are often
taking more than one medication
 Older adults consume almost as much as 30% of prescribed
meds
 25% of hospital admissions of people over 50 are related to
misuse of prescription medication
 Older adults often take medication incorrectly– 50% use
medication inappropriately in dose and/or frequency and/or
timing
Withdrawal
Withdrawal is often only possible in a medical setting and
takes longer than in younger people:
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Older adults have more prolonged and severe withdrawal
than younger patients and are more likely to develop
complications such as delirium (Kahan, 2005)
On average, older adults need 5 to 10 days to complete the
withdrawal process, are more likely to have co-morbid
conditions and do require assistance with activities of daily
living. These factors increase the likelihood that withdrawal
will be managed either in the ER or result in hospital
admission(Kahan, 2005)
Issues of Loss and Transition
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Transition from work to retirement,
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Loss of friends, family, spouse/partner
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reduced income
Loss of meaningful occupation
Loss of social network
Social isolation
Loneliness
Boredom
Health Issues
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Loss of independence
Chronic pain
Physical limitations
Reduced mobility
Cognitive impairment and change
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BEST PRACTICES
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Best and Promising Practices
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Research shows older adults are as successful in addiction
treatment as their younger counterparts
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Health Canada (2002) states best practices identified through
research demonstrates that treatment of high need older
adults include:
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a harm reduction and holistic problem solving approach,
home visiting known as “outreach”,
intensive case management and
social and recreational programs
Clinical experts have added to these principles the need to
support those who form the “circle of care” for the older
person
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Identifying Substance Misuse
in Older Adults/Seniors
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Substance misuse is often not identified in older
adults or wrongly attributed to aging:
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Confusion
Depression
Disorientation
Unsteady gait/falls
Recent memory loss
Loss of interest in activities
Social isolation
Tremors
Irregular heart rate
Poor appetite
Stomach complaints
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Goals in an older adult specific
approach
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The end goal of abstinence is not always
necessary or realistic. Instead, a harm
reduction goal that is related to quality of life
improvement as defined by the older person
is the aim
Treatment/counseling should be focused on
what would make life better, more
comfortable and happier not on the
substance use
What is Harm Reduction?
The Centre for Addiction and Mental Health (CAMH, 2012) defines harm
reduction as:
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Although some people can overcome their addictions, there will be
those who may not, or choose not, to overcome their addictions
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Focuses on minimizing the risks and consequences of drug or
alcohol consumption
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It is an alternative method to programs that support abstinence. It
also realizes that abstinence is not a realistic goal for some people
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People shouldn't be judged based on the substances they use.
Dignity, respect and support are crucial elements when working with
people with addictions and other high-risk issues
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TREATMENT & PROGRAM
APPROACHES
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COPA: Vision, Mission &
Values
Our mission is to engage older adults with addictions, concurrent disorders and
problem gambling issues in the improvement of their quality of life.
Our vision is an empowered community where older adults with addictions,
concurrent disorders and problem gambling issues receive support and service to
enable them to achieve an optimum quality of life.
We value:
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Respect: We are committed to a non-judgmental, inclusive approach that treats
everyone fairly;
Empowerment: We are dedicated to fostering active participation in treatment and
providing the necessary information to make informed choices;
Compassion: We believe in the dignity of every person and accept people as
they are.
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COPA Model: Core
Components
Our programs are delivered in accordance with the COPA Pillars:
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Outreach - service is provided where the clients are rather than requiring clients
come to the program.
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Harm Reduction - it is not necessary for clients to acknowledge addiction
problems or reach complete abstinence in order for meaningful change to take
place.
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Independence – focus on quality of life and maintaining independence.
Modalities we use include, (but not limited to):
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Strength-based Counselling
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Harm Reduction Therapy
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Motivational Interviewing/Stages of Change
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Narrative Therapy
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Dialectical Behaviour Therapy
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Goal-directed Counselling
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Cognitive Behavior Therapy
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COPA Main Program
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COPA Main Program provides addiction(s) counselling and case
management in an outreach capacity to older adults with concurrent
disorders. In addition, the COPA Main Program serves individuals in
the 37 long term care homes within the Toronto Central LHIN as part
of the specialized Toronto psycho geriatric system.
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Initial assessment and treatment
Coordination, provision, and linkages to primary care
Comprehensive care in the community, including clients’ homes,
supportive housing sites, long term care homes, boarding homes, dropins and community centres
Client focused, strengths based counselling grounded in a harm
reduction model
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COPA Main Program
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Client Profile
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Frail, marginalized, varied income, & at risk
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Socially isolated
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Complex medical needs
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Majority of clients experiencing co-occuring mental health challenges
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20% are living in long term care homes
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30 % with complex needs / “hard” to serve & “hard” to reach
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Majority of clients struggle with alcohol and nicotine dependence
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Living with little or no formal support
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At increased risk of using ED and inpatient hospital services
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Trends we see
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Risk factors as it relates to substance misuse, such as housing, finances,
ADLs, etc.
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Undiagnosed/diagnosed dementia and fluctuating capacity
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COPA Main Program
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Cultural Competency
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COPA has been delivering our main program addiction services
in Polish for approximately 20 years.
Culturally sensitive/competent addictions treatment counselling
and case management services are provided for substance use,
concurrent and problem gambling issues.
Many of the clients struggle with co-occuring depression,
isolation and some of them are facing eviction, financial hardship,
immigration struggles and complex medical needs. Majority of
our Polish clients experience significant language barriers to
accessing essential services, requiring the case manager to
provide both translation/interpretation services.
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COPA College
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COPA College, has been successfully delivered in Toronto by
Community Outreach Programs in Addictions (COPA) since 2007 in
a variety of community settings, including shelters, long term care
homes, and supportive housing site
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Psycho-educational group sessions hosted over an eight-week period.
Groups offer an opportunity to build capacity both between the facilitator
and the group.
Topics covered include but are not limited to relapse prevention,
gambling, harm reduction and stress management.
Feedback from participants constantly helps to shape and inform COPA
College practices
In the last session a graduation ceremony is held and participants are
presented with a certificate of completion, their reflections are reviewed
and they are given feedback from the course instructors.
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COPA and Social Inclusion
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Health Promotion
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Minding our Bodies - Develop nutrition and exercise workshops that can be
delivered by front line staff are relevant and engaging for low income older
adults in a format that can be easily downloaded and used by other not for
profit agencies and health promotion organizations, Exercise, Healthy Food
and Making a Meal
Bridge to Health - A collaborative approach between COPA, Vintage
Fitness, Good Neighbours Club and John Innes Community Centre, this
project formed a bridge for marginalized older adults to access physical
recreational activities in their local community centre located in South East
Toronto
Health and Wellness Together - A health and wellness toolkit for seniors by
seniors designed to cover a variety of areas of health promotion and wellness
including, exercise, falls prevention, positive mental health, recovery and
harm reduction.
COPA: First Step To
Home
First Step to Home
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FSTH was developed by Woodgreen and launched in March 2010 as a
transitional housing support program at 650 Queen Street East in Toronto
offering safe, and secure subsidized housing for up to 4 years. The aim of the
program is to support the men in learning how to make a successful transition
from living on the streets to living in more permanent housing that reflects a
more stable, and healthier lifestyle.
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Intensive case management and treatment on site to 28 male residents
Harm reduction and addiction services
Supportive counselling
Low barrier programming
24 hour staffing
Personal support and homemaking
Weekly assistance keeping unit clean
Assistance with activities of daily living, such as grocery shopping
Nursing and medical care on site
Life skills development
Social and recreational activities
Housing support in transitioning to permanent housing
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First Step to Home
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Goal: building more community integration and programming which focuses
on enhancing our clients’ support systems. This will allow them to live
independently more successfully, and improve their overall well-being
Eligibility Criteria - 55+ years with history of chronic homelessness, streetentrenched, mental health issues and/or addictions
Client Profile
 Men, 55+ (on average in their 60s)
 Substance Use - Primarily alcohol & nicotine dependency, to a lesser
extent opioid pain medications and crack use
 Mental Health - Depression, Bipolar Disorder, Schizophrenia, Anxiety
 Physical Health - High Blood Pressure, Diabetes, Hepatitis C, COPD,
Liver and renal failure, Arthritis, Mobility issues
Clients socially isolated, with little direct support from family and/or friend
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First Step to Home
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COPA: Lansdowne Place
(ASH)
Landsdowne Place
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Addiction Supportive Housing for older adults with problematic substance use.
Funded by Toronto Central LHIN and MOHLTC and provided in partnership
with Mainstay Housing.
16 subsidized units scattered within market rent building.
Eligibility Criteria - 55+, problematic substance use, frequent hospital visits
Permanent housing
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Long-term individualized case management
Substance use counseling through a harm reduction approach
Housing support with a focus on eviction prevention
Social and recreational activities
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Landsdowne Place
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We also run the following programs for our clients:
 Safekeeping of cash, ID and important documents
 Medication pick-up
 Community Kitchen
 Urban Resiliency Garden
 COPA College, a psycho-educational support group
 Movie Matinees
 Computer Access
Trends
 Substance use: Goals range from achieving or maintaining abstinence to
harm reduction
 Concurrent mental health concerns
 Multiple physical health concerns
 History of unstable housing
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Landsdowne Place
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Landsdowne Place
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Landsdowne Place
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COPA and Social Inclusion
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Urban Resiliency Garden
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The goal is to create a safe green outdoor space for older adults/seniors to
engage in active leisure activities, learn through a series of workshops and
education sessions and to contribute to the community in which they live.
This project is a community development project that will provide a leadership
role for our steering committee of older adults/seniors in the design,
development, implementation and maintenance of an urban garden for a
large affordable housing complex.
We are excited to integrate gardening programs to increase social
interaction, establish a positive leisure space, encourage cooperation and
build a strong caring intergenerational community.
Landsdowne Place – Urban
Resiliency Garden
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Crisis Outreach Service for
Seniors
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In 2009 a partnership of agencies began providing crisis outreach services
to older adults in south east Toronto. Since then, COSS has expanded to
cover the majority of the city. COSS has been generously funded by the
Toronto Central LHIN through the Aging at Home Strategy.
Partnership includes: Woodgreen Community Services (3 FTE), COPA (3
FTE), The Good Neighbours Club (1.5 FTE) and South Riverdale
Community Health Centre (1 FTE)
COSS operates 365 days of the year from 9am-5pm
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Mobile crisis intervention and outreach service to older adults
Coordination, provision, and linkages to primary care
Short-term intensive case management to stabilize client situation and “warm
hand-off” to longer-term services when needed
Comprehensive care in the community including clients’ homes, supportive
housing sites, drop-ins and community centres
Team includes: SW, RPN, and NP
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Crisis Outreach Service for
Seniors
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Eligibility Criteria - aged 65 (or street-involved clients aged 55) and older
with mental health issues and/or addictions
We work with client on average for approx 6-8 weeks but have made
exceptions when a warm hand-off is not possible during this timeframe. We
have also had some clients with multiple readmissions
Client Profile
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frail, marginalized, low-income, & at risk
homeless or under housed
“hard” to serve & “hard” to reach
living with little or no formal support
at increased risk of using ED and inpatient hospital services
Trends we see
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Housing & Finances
Undiagnosed dementia and fluctuating capacity
Re-admissions to COSS
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CASE BASED LEARNING
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Mrs X
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Long term social use of alcohol: sherry and two glasses
of wine with dinner
Developed dementia and could no longer remember how
many drinks she had had, she was very frail so risk of
falls when walking to the liquour store
Harm reduction plan with family to have her use taxi to
get to local restaurant (fall prevention) and family to
dilute alcohol by giving her drinks of half wine and half
water
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Mr Late Onset
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Mr. X: Very successful well-travelled
business man who is financially
comfortable living in an affluent home
became ill, went into hospital for surgery
which unexpectedly resulted in leg
amputation due to complications. Drinking
significantly escalated
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Mr Early Onset
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Mr. X: Highly successful business man who
drank heavily but able to function until he had to
retire at which point he began to drink very
heavily with significant costs to his health and
family
Mr. Y: Loss of job in manufacturing in his 30’s
led to heavy drinking resulting in relationship
break down, loss of home and connection to
children; long term marginalization, living in
poverty with minimal social supports and very
limited resources/options
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KNOWLEDGE TRANSFER &
EXCHANGE
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KTE
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Geriatric Mental Health, Addictions and Responsive Behaviours Community of
Practice - A collaboration between AKE, Seniors Health Research Transfer Network
(SHRTN) and Ontario Research Coalition of Research Institutes / Centres on Health
& Aging (ORC) to bring together people, ideas, and resources to increase awareness
of the needs of seniors affected by serious mental illness, addiction, dementia or
behavioural issues.
With the support of this CoP we formed a Geriatric Addictions Subgroup to work
specifically in the area of specialized geriatric addictions.
The Geriatric Addictions Subgroup was supported through the Evidence Exchange
Network (EENet) as a Community of Interest in 2012/13 and in 2013/14
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Promote evidence based/informed practice for specialized addictions treatment
and service for older persons to community agencies, researchers and policy
makers.
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Facilitate knowledge transfer between the addiction sector and the larger seniors’
health, mental health and social service system.
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Raise awareness of the issues related to addictions treatment for older persons
to ensure inclusion in service delivery planning, policy discussions and initiatives.
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KTE
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Fact Sheets
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Fact Sheet #1: Introduction to Older Adults and Substance Use: (adopted by NICE as a
pocket guides
Fact Sheet # 2: Management of Alcohol Use Disorders in Older Adults: What Doctors
Need to Know
Fact Sheet #3: Screening for Alcohol Problems in Older Adults
Fact Sheet #4: Older Adults and Opiods
Mental health, addictions and behavioural issues
http://brainxchange.ca/Public/Resource-Centre-Topics-A-to-Z/Mentalhealth-addictions-and-behavioural-issues.aspx
Addictions: Specialized Geriatric Information and Approaches
http://brainxchange.ca/Public/Resource-Centre-Topics-A-to-Z/Mentalhealth-addictions-and-behavioural-issues/Addictions-Specialized-GeriatricInformation-and.aspx
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Thank You
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