Transcript Strengthening Aging and Gerontology Education for Social

Working with Older
Adults with Substance
Use Issues
Judy Fenster, Ph.D., LCSW
Maurice Lacey, LMSW
Field Instructor Symposium
Friday, February 20, 2009
Adelphi University
School of Social Work
Acknowledgements
 The development of this field instructor
seminar was made possible through a
Gero-innovations grant from the CSWE
Gero-Ed Center’s Master’s Advanced
Curriculum (MAC) Project and the John A.
Hartford Foundation.
 Adelphi University Project Team: Judy
Fenster (Principal Investigator), Philip
Rozario, Patricia Joyce, and Bradley
Zodikoff.
 CSWE’s Gero-Ed Center, funded by
John A. Hartford Foundation
 2007: Enhance capacity of Advancedyear MSW students to serve older
adults in health, mental health, and
substance abuse treatment settings.
Gero-Innovations Grant (GIG)
Goal: Provide MSW students enrolled in advancedyear non-gerontology courses with knowledge
about working with older adults.
How? Through:
 Coursework
 Fieldwork
Seminar Learning Objectives
Participants will increase their:
 awareness of the need for knowledge re: working
with older adults with substance use problems.
 understanding of “competencies” in working with
older adults with substance use issues.
 strategies for preparing their agencies to work with
older adults.
 strategies for developing field assignments for
students working with older adults.
I. Why Focus on Working with
Older Adults with Substance Use
Disorders?
Growth in Elderly Population
Percentage of population age 65+ in the U.S.
1900 – 4%
2006 – 13%
2030 - 20% (predicted)
Also: Number of people aged 85> will
double by 2030
Long Island Profile: Projected 60+
population (2000-2015)
370000
308788
320000
270000
283957
256925
Nassau 60+ will grow
11% by 2015
224799
220000
170000
Suffolk 60+ to increase
120000
37% by 2015
70000
20000
Nassau
Suffolk
2000
2015
New York State Department for the Aging, Year 2015 Study
Long Island Profile: Projected 85+
population (2000-2015)
50000
 Nassau 85+ to
36,597
40000
increase 65% by 2015
34757
30000
22,209
20002
20000
 Suffolk 85+ to
10000
0
Nassau
Suffolk
2000
increase 74% by 2015
2015
New York State Department for the Aging, Year 2015 Study
Baby Boomers use more AODs
than their parents – will this
trend continue with age?
II. What are Competencies for
Advanced Practice with Older
Adults?*
Involves applied knowledge of
complex situations and skills to making
differential diagnosis and intervention
with and on behalf of older adults.
Requires knowledge of intra- and
inter-group diversity as it relates to
aging and late-life outcomes.
Applied to effective intervention
with older adults and their families, as
well as to aging programs and policies.
Specific Competencies for
Geriatric SW Practice
 6.1 Engage, maintain rapport,
and sustain effective working
relationships with a wide range of
older adults (including those with
behavior problems, mental illness
and dementia) and their family
and caregivers.
 6.9 Conduct assessment and
intervention strategies for
substance/drug/alcohol abuse in
later life.
Competencies in Action
S. Abuse Assessment: Differential
Diagnosis
Should we use methods normed on younger
adults to diagnose/assess older adults?
DSM Criteria for Substance Abuse:
Recurrent use resulting in failure to fulfill role
obligations
Recurrent use in hazardous situations (DWI,
operating heavy machinery)
Recurrent use-related legal problems
Competencies in Action
S. Abuse Treatment
Competency: Conduct assessment and
intervention strategies for
substance/drug/alcohol abuse in later life
 Should we intervene when an older adult is
having substance use problems?
 Are drinking guidelines similar for younger and
older adults?
 What’s the best place to refer an older person
with substance use issues: a regular treatment
program, or an “elder specific program”?
 Does the traditional confrontational approach
work well with older adults with substance use
problems?
III. What Do We Know About
Substance Use Among Older
Adults?
Alcohol and illicit drug use ↓ with age;
Prescription drug use ↑ with age.
Most common substance issue for older
adults = Alcohol Use.
Prevalence depends on definition of problem:
3-15% of older adults are at-risk or
problem drinkers.
3-8% misuse or abuse prescription, overthe-counter, or illicit drugs.
Is Prevalence Underestimated?
Substance misuse in
older adults often goes
unrecognized by
professionals (and
others)
Few older adults with
substance use problems
(only about 10-15%)
seek help in specialized
addiction treatment
settings
Drinking Guidelines for Older
Adults
1 (or fewer) standard drinks per day
< 7 drinks per week
< 3 drinks on any single occasion
 Limits for older women should be

somewhat less than for older men.
Drinking and using drugs that interact with
alcohol is not advised.
(Source: NIAAA, 1995; Dufour & Fuller, 1995)
Why are the limits lower for older
adults?
With age comes:
-Greater use of medications → higher potential
for bad reactions (antiarthritics,
anticoagulants, diuretics)
-Less efficient liver metabolism → poorer
alcohol elimination
-Less muscle/more fat → higher BAC
-Stronger effects at the same BAC (↓
coordination, ↑ alcohol sensitivity,
↓ tolerance)
Defining Substance Use Patterns
Among the Elderly
Caveats to using DSM criteria:
 Criteria for abuse might not fit
 Tolerance and withdrawal may look
different in older adults
 Cognitive deficits and prescription drug
interactions can make it harder to
recognize the substance use as the
problem
Defining Substance Use Patterns
Abstinence
No alcohol/drug use for past
year
Low risk
Substance use with no problems
At-risk
Substance use with increased
chance of problems
Problem
Experiencing adverse
consequences
Dependent
Loss of control, drinking/using
despite problems, physiological
symptoms (tolerance,
withdrawal)
So What’s the Problem? Ethics
of intervening with the Elderly
AOD use in older adults is associated with ↑ risk of:
Stroke (with overuse)
Impaired motor skills (e.g., driving) at low level
use
Injury (falls, accidents)
Sleep disorders
Suicide
Interaction with dementia symptoms
AOD Use - effects, cont’d.
- Higher blood alcohol concentrations
(BAC) & more impairment from dose
 Medication effects:
 Potential interactions
 Increased side effects
 Compromised metabolizing*
(especially psychoactive medications,
benzodiazepines, barbiturates,
antidepressants, digoxin, warfarin)
Comparing Older and Younger
Adults with SUDs
Older adults with SUDs tend to be less
severely addicted, and suffer fewer
family/social consequences of their
substance abuse.
Compared to “youngers”, older adults:
 Are ____ likely to seek treatment for SUD.
 Are ____likely to complete treatment.
Treatment Need
SAMHSA: By 2020 the number of
older people who need substance
abuse treatment will increase
from 1.7 million to 4.4 million.
This represents a 70% increase
in the rate of treatment need.
(Source: Gfoerer, Penne, Pemberton & Folsom, 2003).
General Issues for Older Adults
Loss (status, people,
vocation, routine, health)
Role changes
Social isolation
Loneliness
Complex medical
issues (pain)
Multiple meds
Sensory deficits
Reduced mobility
Cognitive changes
Financial problems
Impaired self-care
Housing changes
Loss of independence
New caregiving role
Unstructured time
Signs of Potential Substance Use
Problems
Anxiety, depression,
excessive mood swings
Blackouts, dizziness
Disorientation
Falls, bruises, burns
Headaches
Incontinence
Memory loss
Unusual response to
medications
Decision-making difficulties
Poor self-care
Poor nutrition
Sleep problems
Family problems
Financial problems
Social isolation
Increased alcohol
tolerance
Screening for Alcohol Use
Problems in Older Adults
Goals:
Identify at-risk, problem and dependent
drinkers
Determine the need for further diagnostic
assessment & treatment
Screening for Alcohol Problems
1. Ask: “How often do you have a drink
containing alcohol?”
2. If any usage, follow up with:
 “How many days per week do you
drink?”
 “How many drinks per day?”
 “How often do you have 3> drinks on
one occasion?”.
Then:
Screening Instruments: Alcohol
Use
 Michigan Alcohol Screening Test Geriatric Version (MAST-G)
1992)
(Blow et al.,
 Short Version of MAST-G: S-MAST-G
(University of Michigan, 1991)
 CAGE (Ewing, 1984)
CAGE
1. “Have you ever felt you ought to CUT down on
your drinking?”
2. “Have you ever felt ANNOYED at someone for
criticizing your drinking?”
3. “Have you ever felt GUILTY about your drinking
or about something that happened while you were
drinking?”
4. “Ever felt the need for an EYEOPENER (drink to
steady your nerves or get rid of hangover) the next
morning?”
For older adults, ONE positive response could
indicate an alcohol use problem.
MAST-G
(Short Version)
Yes or no answers to:
1. “When talking with others, do you ever
underestimate how much you actually drink?”
2. “After a few drinks, have you sometimes not
eaten or been able to skip a meal because
you don’t feel hungry?”
3. “Does having a few drinks help decrease your
shakiness or tremors?”
MAST-G
(continued)
4. “Does alcohol sometimes make it hard for
you to remember parts of the day/night?”
5. “Do you usually take a drink to relax or
calm your nerves?”
6. “Do you drink to take your mind off your
problems?”
7. “Have you ever increased your drinking
after experiencing a loss in your life?”
MAST-G
(continued)
8. “Has a doctor or nurse ever said they were
worried or concerned about your drinking?”
9. “Have you ever made rules to manage your
drinking?”
10. “When you feel lonely, does having a drink
help?”
TWO or more positive responses = possible
alcohol problem.
Comprehensive Assessment
Physical Examination and Laboratory tests
can help confirm diagnosis:
 Skin color changes (e.g., jaundice), skin
legions, cardiac arrhythmias, liver
enlargement, and malnutrition are all
connected to alcohol misuse
 Neurological assessment can evaluate
balance and provide a mental status
 Lab tests can also help evaluate usage
Diagnostic Case Study: Mr. V
77-year-old male admitted to the hospital following a fall
and resulting rib fracture.
Medical history: MD reports no current concerns. Mr. V has
arthritis, which he treats with Tylenol. Had insomnia
for 1 yr following death of wife of 40 years. Recently
lost 5 pounds, which he attributes to having no one to
cook for him at home. Feels lonely living alone in big
house, especially since daughter moved away 6 months
ago. Has seen friends less often lately, and has
stopped attending church group.
Substance Usage: Tylenol, vitamins. Routine used to be
one martini before dinner. However, for the past
several months, he has added a glass of wine with
lunch, and one additional martini before bedtime, for
arthritis and insomnia.
(Adapted from: Boyle & Davis, 2006)
Discussion of Mr. V
 Would you categorize Mr. V’s alcohol
use as low-risk, at-risk, problem
usage, or dependence?
 How would he score on the:
CAGE? MAST-G?
 What else should you assess before
making a diagnosis?
Screening for Other Drug Use
Drug Abuse Screening Test (DAST-10)
(Skinner,
1982)
 “Have you used drugs other than those
required for medical reasons?”
 “Do you ever feel bad or guilty about your drug
use?”
Ask about dosages of prescription, over-thecounter, and herbal drugs, and about dosing
practices.
Ask about drug-on-drug and drug/alcohol
interaction effects.
Prescription and OTC Drug
Use, Misuse and Abuse
 Difference between Misuse and Abuse
 Most abused drug among elderly =
Benzodiazepines (used for anxiety,
insomnia & pain). 17-23% of drugs
prescribed to older adults are Benzos.
 Women more likely than men to
misuse or abuse psychoactive drugs,
and also more likely to mix alcohol
with prescription psychoactive drugs.
Screening for Prescription
Drug Abuse
Signs:
 Loss of motivation
 Memory loss
 Family discord
 Trouble sleeping
 “Doctor shopping”

Drug-seeking behavior
Intervention with Older Adults
1.Preventive education
for abstinent, low-risk
users
2.Brief, preventive
intervention with
at-risk and problem
users
3.Substance abuse
treatment for
abusing/dependent
older adults
Brief Intervention
 Time-limited (5 mins, 2-5 brief sessions)
 Targeted at a specific behavior
 Goal directed
 Reducing or eliminating substance
misuse, and/or
 Facilitating entry into treatment
 Relies on negotiated goals
 Empirical support with younger drinkers
across multiple settings
Brief Intervention
(cont’d)
Empirical studies with older adult alcohol users
Project GOAL (Guiding
Older Adult Lifestyles)
Health Profile Project
University of Wisconsin
(n= 156)
University of Michigan
(n= 454)
— Brief physician advice
for drinkers (age 65+)
— Two 10-15 minute
sessions, followed up
with clinic phone calls
— Reduced consumption at
12 months by 35-40%
—Elder-specific
motivational enhancement
session
—Preliminary findings:
reduced at-risk drinking at
12 months
Brief Protocols with Older Adults
 Brief intervention and MET are
effective approaches
 Accepted well by older adults
 Can be conducted at home or in
clinic
 Reduces substance use & related
harm*
 Reduces health care utilization
Other Treatment
Approaches
Cog-behavioral
Marital and family
Group counseling
Case management
Relapse Training
Formalized
therapy
Medical and
psychiatric
approaches
involvement
substance abuse
treatment
Elder-Specific Intervention*
Differs from mixed-age treatment in that it:
 Also deals with issues of relevance to older
adults -- loss, isolation, prescription drug
use, interaction effects, health problems.
 Utilizes a less confrontational, less
hierarchical, and more supportive approach
 Relies heavily on motivational interviewing
and CBT approaches
Studies of Elder-Specific
Models
 Both mixed-age and age-specific
treatments have been found effective.
 There’s some evidence that elder-
specific treatment is even more
effective, in terms of treatment
initiation, length of stay, treatment
completion, and long-term outcome.
(Kashner et al., 1992)
Model Program:
Older Adults Technology Services
(OATS)
Nonprofit org - Engages, trains and supports older
adults in using technology to improve their quality of
life. Offered at 26 senior centers in NYC.
 Engages older adults in learning about digital devices
and how they can improve their lives.
 Trains them to use computers and other technology
tools in a relaxed, senior-friendly environment.
 Supports seniors in using technology to connect to
family and friends, improve health care, get needed
services, earn and manage money, and enjoy a
higher standard of living.
OATS (continued)
 Intergenerational training program:
trains high school students to teach
computers to older adults.
 “Senior Planet” website: digital
community that connects older adults
to resources, events, commentary and to each other - through a website
and education training program.
Innovations
Computer-assisted AOD Screening:
Accuracy equal to in-person and paperand-pen versions.
► Advantages: Privacy, Literacy, Immediacy
► Disadvantages?
Telephone Counseling: Can increase
access to treatment for seniors with
mobility or health problems.
Conclusions
 Screening for substance use problems
among older adults is effective
 Brief interventions are effective
 Additional interventions complete a
spectrum of effective approaches
 Treatment approach depends on client
background; assessment of needs, goals,
resources; and preferences
Conclusions
(continued)
 Older adults benefit from screening,
assessment, referral, prevention, and
intervention delivered by social
workers who are sensitive to elder
issues:
 Non-judgmental approach
 Motivational
 Supportive approach
 Age-appropriate goals: Improve
health status, rebuild social
supports, improve enjoyment of life
IV: Preparing Your Agency to be
Open to Working with Older Adults
 Create a culture of respect
 Age-specific group treatment that is
supportive and non-confrontational and
aims to rebuild the client’s self-esteem.
 A focus on coping with depression,
loneliness, loss, and rebuilding the client’s
social support network.
 Social work groups based specifically on a
mutual aid approach.
 Treatment staff that is interested and
experienced in working with older adults.
IV: Preparing Your Agency to be
Open to Working with Older Adults
 Linkages should be made with medical and
mental health services.
 Treatment be provided in age-specific
settings, to create a culture of respect for
older clients; to take a broad, holistic
approach to treatment that emphasizes agespecific psychological, social, and health
problems; to
 Keep the treatment program flexible
 Adapt treatment as needed in response to
client gender, medical conditions, and care
giving responsibilities.
 Use holistic treatment models that take into
account broader issues.
IV: Preparing Your Agency to be
Open to Working with Older Adults
 Assess agency’s capacity to serve older
adults
 On going In-Service trainings
V. Helping Students Attain
Competency in Working with Older
Adults
 Encourage and Expose students to data and literature
related to serving older adults.
 Create student lead “Special Project” i.e. agency
survey research, community presentation
 Connect Field Work experience with older adults to
classroom learning.
 Allow student to co-lead groups with older adults.
 Field visits to other treatment providers.
 Use process recording as tool to gauge skills and
competencies in working with older adults.
Connecting Classroom Knowledge
and Field Assignments
Focus students to assess whether existing
programs and interventions are inclusive of
age diversity in addition to other dimensions
of diversity.
Example with group work:
Will an older man who is having trouble
adjusting to retirement and is newly
mourning the death of his wife feel
comfortable attending a substance use group
at a treatment center where most of the
other participants are between ages 20-40?
Your Turn
 Are you expecting growth in aging
populations in your agency?
 What challenges do you foresee?
 Do you have any thoughts re: how to
prepare your agency for these changes?
 Any thoughts re: working with students
to help effect this change?
Acknowledgements &
References

Illustrations: Microsoft Corporation, 2002

Selected slides: NIAAA Social Work Curriculum on Alcohol Use Disorders (Audrey
Begun, Editor), Module 10C

CSWE/John A. Hartford Foundation – Gero-Ed Center
REFERENCES:
Blow, F.C., Brower, K.J., Schulenberg, J.E., Demo-Dananberg, L.M., Young, J.P. &
Beresford, T.P. (1992). The Michigan Alcohol Screening Test-Geriatric Version
(MAST-G): A new elderly-specific screening instrument. Alcoholism: Clinical and
Experimental Research, 16, 372.
Center for Substance Abuse Treatment: Substance Use Among Older Adults. Treatment
Improvement Protocol (TIP) Series, Number 26. DHHS Publication No. (SMA) 073918. Rockville, MD: Substance Abuse and Mental Health Services, 1998.
Cloud, R.N., & Peacock, P.L. (2001). Internet screening and interventions for problem
drinking: Results from the www.carebetter.com pilot study. Alcoholism Treatment
Quarterly 19(2), 23–44.
Amodeo, M., & R.Schofield (Eds). (1997). Social Work Approaches to Alcohol and Other
Drug Problems: Case Studies and Teaching Tools. Washington, D.C.: Council on
Social Work Education.
Dufour, M. & Fuller, R. K. (1995). Alcohol in the elderly. Annual Review of Medicine, 46,
123-32.
References, continued
Ewing, J.A. (1984). Detecting alcoholism: The CAGE questionnaire. Journal of the
American Medical Association, 252, 1905-1907.
Gfoerer J., Penne, M., Pemberton, M., & Folsom, R. (2003). Substance abuse
treatment need among older adults in 2020: the impact of the baby-boom cohort.
Drug and Alcohol Dependence, 69, 127-135.
Kashner, T.M., Rodell, D.I., Ogden, S.R., Guggenheim, F.G., & Karson, C.N. (1992).
Outcome and costs of two VA inpatient treatment programs for older alcoholic
patients. Hospital Community Psychiatry, 43, 985-989.
Lessler, J.T., Caspar, R.A., Penne, A., & Barker, P.R. (2000). Developing Computer
Assisted Interviewing (CAI) for the National Household Survey on Drug Abuse.
Journal of Drug Issues, 30(1), 9–34.
National Institute on Alcohol Abuse and Alcoholism. (1995). Diagnostic criteria for
alcohol abuse and dependence. Alcohol alert no. 30 (PH 359) (pp. 1-6). Rockville,
MD: U. S. Department of Health and Social Services, Public Health Service,
National Institutes of Health, NIAAA.
Regents of the University of Michigan (1991). Short Form: Michigan Alcohol
Screening Test – Geriatric version (S-MAST-G).
Skinner, H. (1982). The drug abuse screening test. Addictive Behavior, 7(4), 363371.
Resources
AARP
601 E Street, NW, Washington, DC 20049
www.aarp.org
National Center on Addiction and Substance Abuse
152 West 57th Street, New York, NY 10019
www.casacolumbia.org
Join Together
441 Stuart Street. Boston, MA 02116
www.jointogether.org
National Aging Information Center/U.S. Admin. on Aging
330 Independence Avenue, Washington, DC 20201
www.aoa.gov/naic
Resources, Cont’d.
SAMHSA’s National Clearinghouse for Alcohol and Drug
Information (NCADI)
P.O. Box 2345, Rockville, MD 20847-2345
www.samhsa.gov
National Council on the Aging
409 3rd Street, Washington, DC 20024
www.ncoa.org
National Institute on Aging, Public Information Office
Bldg. 31, Rm. 5C2, 31 Center Dr., Bethesda, MD 20892-2292
www.nih.gov/nia/