Although the vast majority of older adults (87 percent) see physicians regularly, their service providers estimate that 40 percent of those who are at risk do not self-identify or seek services for substance abuse problems on their own (Raschko, 1990). Moreover, they are unlikely to be identified by their physicians despite the frequency of contact. Because most older adults live in the community and fewer than 5 percent older than 65 live in nursing or personal care homes, training supervisors in such residences does not offer a reasonable strategy for increasing problem identification. To ensure that older adults receive needed screening, assessment, and intervention services, stepped-up identification efforts by health care providers and multitiered, nontraditional case-finding methods within the community are essential (Raschko, 1990; DeHart and Hoffmann, 1995).
Most older adults see a medical practitioner several times per year, often for conditions that lend themselves to collateral discussion of the patients' drinking habits. Thus the primary care setting provides an opportunity for screening that is currently underutilized, as is the hospital (Adams et al., 1992). Home health care providers have unparalleled opportunities to observe isolated, homebound seniors for possible problems and, if substance abuse is suspected, administer a nonthreatening screen.
Identification of substance abuse among older adults should not be the purview of health care workers alone. Friends and family of older adults and staff of senior centers, including drivers and volunteers who see older adults on a regular basis, are intimately acquainted with their habits and daily routines. Frequently they are in the best position to detect those behavioral changes that signal a possible problem. Leisure clubs, health fairs, congregate meal sites, Meals-On-Wheels, and senior day care programs also provide venues in which older adults can be encouraged to self-identify. The National Council on Aging, for example, sponsors a depression awareness program for use in senior programs that features a computerized, self-administered depression test. The computer offers anonymity and immediate results. It also avoids confidentiality problems and seems to offer a feasible model for mass screening of drinking problems. See Figure 4-1 for an example of successful community case finding.
In contrast to younger substance abusers whose problems are frequently identified as a result of an action initiated by a family member, spouse, employer, school, police, or the courts, a substantial proportion of older adults' substance abuse problems remains undetected. Unless health, social service, and community service providers understand that alcohol and prescription drugs can pose serious problems for older adults and take the initiative in getting them the help they need, quality of life will be diminished, independence compromised, and physical deterioration accelerated.
Ageist assumptions, failure to recognize symptoms, and lack of knowledge about screening are among the barriers that inhibit family members, service providers, and others concerned about older adults from raising the issue of alcohol and prescription drug abuse. Although these are the two primary substances of abuse now, providers are likely to see more marijuana and other drug use among adults over 60 in the coming years.
Health care providers sometimes share the ageist attitudes discussed in Chapter 1. They may not be trained to recognize signs of substance abuse and furthermore may be unwilling to listen attentively to older patients. The latter type of provider often dismisses older patients' observations about their own symptoms and attempts at self-diagnosis and attributes all complaints or changes in health status to the aging process.
Family members also can impede problem recognition. Biases persist against perceiving older adults as alcoholics or recognizing that drinking or prescription drugs, rather than age or disease, may be a cause or chief contributor to sleep problems, mood changes, or memory deficits (Finlayson, 1995b). Another assumption inhibiting identification is the belief that older adults do not respond to treatment, a misperception flatly contradicted by studies showing that older adults are more likely to complete treatment (Linn, 1978; Cartensen et al., 1985) and have outcomes that are as good as or better than those of younger patients when treated as outpatients (Atkinson, 1995; in press).
Identifying an older abuser of alcohol or prescription drugs can also be complicated by the number of other conditions with similar symptoms. Warning signs can be easily confused with or masked by concurrent illnesses and chronic conditions. For example, sleep problems, falls, anxiety, or confusion can be attributed to a variety of nonalcohol-related diseases and disorders or dismissed as symptomatic of old age. Screeners who use amount and frequency levels appropriate for younger adults as a gauge can also miss an older adult's alcohol problem (see Chapter 2).
Finally, many health care and social service providers are unaware that effective, validated instruments are available for screening older adults or are intimidated by the prospect of using them. Many screens, moreover, take only a few minutes to administer and require little or no specialized training to score and interpret. Screening instruments are discussed in more detail below.
Ideally, every 60-year-old should be screened for alcohol and prescription drug abuse as part of his or her regular physical examination. However, problems can develop after the screening has been conducted, and concurrent illnesses and other chronic conditions may mask abuse. Although no hard and fast rules govern the timing of screening, the Panel recommends screening or rescreening if the physical symptoms listed in Figure 4-2 are present or if the older person is undergoing major life changes or transitions such as those discussed below.
As older patients undergo key life transitions or take on new and stressful roles, vulnerability to alcohol or prescription drugs may increase. Risk factor life transitions include menopause, a newly "empty nest," and approaching retirement. Assuming new roles such as caretaker for an ailing relative or custodian of young grandchildren also makes older adults more vulnerable. Any of these changes should trigger an alcohol screen.
Depending on the setting, the topic of screening can be introduced in a number of ways. Self-administered and self-scored mass screenings can be a part of a larger presentation at an American Association of Retired Persons or leisure club meeting on the topic of alcohol's effects on older adults. Self-administered but machine-scored computerized screens can be offered as part of a similar program conducted at senior centers, retirement homes, or assisted living residences with access to computers.
Visiting nurses and home health aides can integrate a brief alcohol screen into the list of health questions normally posed to patients. For example, in asking about medication, the health care provider could say, "We understand more today about the effects of even small amounts of alcohol on medication, and I want to be sure that nothing is interfering with your coumadin or affecting your overall progress in any way. Let's review how much alcohol you're drinking and take a look at all your medications."
It is preferable to use standardized screening questionnaires, but friendly visitors, Meals-On-Wheels volunteers, caretakers, and health care providers also can interject screening questions into their normal conversations with older, homebound adults. Comfort with this line of questioning will depend on the person's relationship with the older person and the responses given; however, anyone who is concerned about an older adult's drinking practices can try asking direct questions, such as
"Do you ever drink alcohol?"
"How much do you drink when you do drink?"
"Do you ever drink more than four drinks on one occasion?"
"Do you ever drink and drive?"
"Do you ever drink when you're lonely or upset?"
"Does drinking help you feel better [or get to sleep more easily, etc.]? How do you feel the day after you have stopped drinking?"
"Have you ever wondered whether your drinking interferes with your health or any other aspects of your life in any way?"
"Where and with whom do you typically drink?" (Drinking at home alone signals at-risk or potentially abusive drinking.)
"How do you typically feel just before your first drink on a drinking day?"
"Typically, what is it that you expect when you think about having a drink?" (Note: Positive expectations or consequences of alcohol use in the presence of negative affect and inadequate coping skills have been associated with problem drinking.)
If less direct questioning seems appropriate, other useful questions for identifying problematic alcohol or prescription drug use include
"Are you having any medical or health problems? What symptoms do you have? What do you think these mean? Have you felt this way before?"
"Do you see a doctor or other health care provider regularly? When was the last time? Do you see more than one? Why? Have you switched doctors recently? Why?"
"Have you experienced any negative or unwanted events that altered the way you lived (in the last 5 years)? Any since we last met? How much of an impact did the event have on the way you lived or felt? What feelings or beliefs did it cause or change? Do you believe that you are coping with the changes in a healthy fashion? How (specifically) do you manage (control) the circumstances (consequences) of the problem(s) or event(s)?"
"What prescription drugs are you taking? Are you having any problems with them? May I see them?" (This question will need to be followed by an examination of the actual containers to ascertain the drug name, prescribed dose, expiration date, prescribing physician, and pharmacy that filled each prescription. Note whether there are any psychoactive medications. Ask the patient to bring the drugs in their original containers.)
"Where do you get prescriptions filled? Do you go to more than one pharmacy? Do you receive and follow instructions from your doctor or pharmacist for taking the prescriptions? May I see them? Do you know whether any of these medicines can interact with alcohol or your other prescriptions to cause problems?"
"Do you use any over-the-counter drugs (nonprescription medications)? If so, what, why, how much, how often, and how long have you been taking them?"
Nonmedical caretakers, volunteers, and aides may opt to ask only the four CAGE questions, reproduced in Figure 4-3 and discussed in the Screening Instruments section. If the older adult answers yes to any of the four, refer to a clinician for evaluation. If the questioner suspects that prescription drug abuse may be occurring and the older adult is defensive about his or her use, confused about various prescription drugs, seeing more than one doctor, or using more than one pharmacy, a clinician should probably be notified to probe further. Other warning signs that may emerge in conversation and should prompt a more in-depth screen or an assessment include
Excessively worrying about whether prescription psychoactive drugs are "really working" to alleviate numerous physical complaints; complaints that the drug prescribed has lost its effectiveness over time (evidence of tolerance)
Displaying detailed knowledge about a specific psychoactive drug and attaching great significance to its efficacy and personal impact
Worrying about having enough pills or whether it is time to take them to the extent that other activities revolve around the dosage schedule
Continuing to use and to request refills when the physical or psychological condition for which the drug was originally prescribed has or should have improved (e.g., prescription of sleeping pills after the death of a loved one); resisting cessation or decreasing doses of a prescribed psychoactive drug
Complaining about doctors who refuse to write prescriptions for preferred drugs, who taper dosages, or who don't take symptoms seriously
Self-medicating by increasing doses of prescribed psychoactive drugs that aren't "helping anymore" or supplementing prescribed drugs with over-the-counter medications of a similar type
Rating social events by the amount of alcohol dispensed
Eating only at restaurants that serve alcoholic beverages (and wanting to know whether they do in advance)
Withdrawing from family, friends, and neighbors
Withdrawing from normal and life-long social practices
Cigarette smoking
Involvement in minor traffic accidents (police do not typically suspect older adults of alcohol abuse and may not subject them to Breathalyzer_ and other tests for sobriety)
Sleeping during the day
Bruises, burns, fractures, or other trauma, particularly if the individual does not remember how and when they were acquired
Drinking before going to a social event to "get started"; gulping drinks, guarding the supply of alcoholic beverages, or insisting on mixing own drinks
Changes in personal grooming and hygiene
Expulsion from housing
Empty liquor, wine, or beer bottles or cans in the garbage or concealed under the bed, in the closet, or in other locations.
Screening questions should be asked in a confidential setting and in a nonthreatening, nonjudgmental manner. Many older adults are acutely sensitive to the stigma associated with alcohol and drug abuse and are far more willing to accept a "medical" as opposed to a "psychological" or "mental health" diagnosis as an explanation for their problems. Prefacing questions with a link to a medical condition can make them more palatable. For example, "I'm wondering if alcohol may be the reason why your diabetes isn't responding as it should," or, "Sometimes one prescription drug can affect how well another medication is working. Let's go over the drugs you're taking and see if we can figure this problem out." It is vitally important to avoid using stigmatizing terms like alcoholic or drug abuser during these encounters.
Another technique that may help when talking with older adults is active listening (Egan, 1994). The four components of active listening are (1) observing and reading the person's nonverbal behavior - posture, facial expressions, movement, and tone of voice; (2) listening to and understanding the person's verbal communication; (3) listening in context, that is, to the whole person in the context of the social settings of his or her life; and (4) listening to sour notes, that is, things the person says that may have to be challenged. Motivational interviewing techniques also can be applied when screening older adults. Essentially this approach, which is described in more detail in Chapter 5, assumes that the patient is both capable of and responsible for initiating needed changes. Motivational interviewing is nonconfrontational, egalitarian, and supportive.
When screening anyone, especially older adults, empathy is crucial. However, in attempting to be nonconfrontational and circumspect, it is also important to avoid using euphemisms that minimize the problem. Older adults with alcohol and prescription drug problems are just as likely to engage in denial and rationalization as younger adults; those who are inadvertently misusing a prescription drug or who are unaware that their customary drink before dinner may now be causing problems are unlikely to be defensive about acknowledging the need to change.
Impaired cognition interferes with screening, making it difficult to obtain complete and accurate answers. Although it is important to respect the older adult's autonomy, collateral participation from family members or friends may be necessary in situations where a coherent response is unlikely. In this case, the screener should first ask for the older adult's permission to question others on his or her behalf. If possible, the screen should be administered to collaterals in private, using a nonconfrontational approach. "I'm concerned about your father's deteriorating condition and wonder if his use of alcohol may be having a negative impact. Have you or anybody else in the family had any concerns about his drinking?" Because circumstances differ within families, family members may not know or may be unwilling to respond honestly to that query. Another question that skilled clinicians find useful in collateral screening is, "Has anybody in your family ever had a problem with drinking?" A positive response suggests that a problem may exist and that more in-depth questioning should follow.
Sometimes collateral screening unleashes a family member's simmering anger toward the older adult for both past and current alcohol-related behavior. It is important to be alert to this possibility and to be prepared to work with the family member to discourage a confrontation with the older adult when the screen concludes.
The CAGE Questionnaire (Ewing, 1984) and the Michigan Alcoholism Screening Test_Geriatric Version (MAST-G) (Blow et al., 1992a) are two well-known alcohol screening instruments that have been validated for use with older adults. One of the most widely used alcohol screens, the CAGE consists of four questions, can be self-administered even by those with low literacy reading skills (see Figure 4-3), and can be modified to screen for use of other drugs. Positive responses on the CAGE are for lifetime problems, not current ones. Before administering the CAGE, the MAST-G, or any other screen, ascertain that the person does currently drink alcohol and that the questions that are endorsed are for problems that they have experienced recently, usually within the last year.
Although two or more positive responses are considered indicative of an alcohol problem, a positive response to any one of these questions should prompt further exploration among older adults. The CAGE is most effective in identifying more serious problem drinkers, including those with abuse and dependence, and less effective for women problem drinkers than their male counterparts.
The MAST-G was developed specifically for older adults (see Figure 4-4) and has high sensitivity and specificity among older adults recruited from a wide range of settings, including primary care clinics, nursing homes, and older adult congregate housing locations.
Although the Alcohol Use Disorders Identification Test (AUDIT) (Babor et al., 1992) has not been evaluated for use with older adults, it has been validated cross-culturally. Because there are few culturally sensitive screening instruments, the AUDIT (in the opinion of the Consensus Panel) may prove useful for identifying alcohol problems among older members of ethnic minority groups (see Appendix B).
Laboratory tests are generally used only to supplement the screens detailed above (Beresford et al., 1990; Finlayson and Hurt, in press). Some researchers have found, however, that certain abnormalities associated with alcoholism appeared more often among alcoholics older than 64 than among younger alcoholics. Those abnormalities appeared in tests of mean corpuscular volume, uric acid, serum albumin, mean corpuscular hemoglobin, and aspartate aminotransferase (Hurt et al., 1988).
To ease the process of communicating positive screening results to older patients, the Panel recommends the following approach:
Describe the impact that alcohol or prescription drug abuse is having on the older adult's health or functional status: "The screening results indicate that alcohol may be having a negative effect on your blood pressure."
Immediately follow up by noting: "This is very treatable. Cutting down on the amount you drink" or "giving up drinking altogether" or "reducing your use of chlordiazepoxide (Librium)" or "using other methods to help you sleep . . . will help you maintain your independence" or "help keep you out of a nursing home" or "decrease the likelihood of future hip fractures" or "keep you from getting so confused." In other words, spell out how reduction or cessation of use will improve the person's life. Most problem drinkers cannot address their problems by reducing use, so emphasize the importance of abstinence by saying something like: "Though I strongly recommend you stop altogether, cutting down is a good start."
Present the options for addressing the problem: If the problem seems severe, "I'd like to do a complete assessment (or refer you to someone for assessment) so we know how to proceed"; or if the problem appears to be in the early stages of development, "I'd like to see you change your drinking habits to no more than one beer (drink) per day. We'll monitor your progress over the next few weeks and see if this will help with your hypertension." This is a good time to explore the patient's willingness to change by adding, for example, "Would you be willing to change your drinking habits if the other problems we have discussed improve?"
Occasionally, a situation may appear dire, and the clinician suspects that the older adult needs to be detoxified. In this case, admission to an inpatient unit for detoxification may be the most prudent choice. Referral to an outpatient detoxification center that can monitor the person daily is appropriate if there is social support at home.
Before discussing results with an older adult, clinicians must be prepared with information about community resources available to assist in coping with this problem (e.g., meeting dates, times, and locations of Alcoholics Anonymous and other self-help recovery groups whose membership is largely 55 and older; contact and eligibility information for treatment programs that respond to the special needs of older adults); the older adult's available supports (e.g., Is transportation available? Is the recommended program affordable or covered by insurance?); and the older adult's special needs (e.g., Is the program bilingual or wheelchair accessible?). See Chapter 5 for more on treatment options. In addition, a strategy for responding to denial or refusal to follow through with a plan of action should be in place. With the agreement of an older adult involved in a self-help group or treatment program, clinicians can broker an introduction to a peer "who's been there." Frequently, these "veterans" will accompany prospective members to meetings and mentor them through the treatment process.
For some older adults coming to grips with an alcohol or prescription drug problem, repeated contacts will be necessary before they are willing to cooperate with a referral. Clinicians have observed that this process is akin to planting and nurturing a seed. Bringing the seed to fruition, however, ultimately depends on the older adult.
Scoring: Five or more "yes" responses are indicative of an alcohol problem. For further information, contact Frederic C.
Blow, Ph.D., at University of Michigan Alcohol Research Center, 400 E.
Eisenhower Parkway, Suite A, Ann Arbor, MI 48108; (734) 998-7952.
Source: Blow, F.C.; Brower, K.J.; Schulenberg, J.E.; Demo-Dananberg, L.M.; Young, J.P.; and Beresford, T.P. The Michigan Alcoholism Screening Test - Geriatric Version (MAST-G): A new elderly-specific screening instrument. Alcoholism: Clinical and Experimental Research 16:372, 1992.
_ The Regents of the University of Michigan, 1991.
The process of conveying negative screening results provides an important opportunity to reinforce healthy practices and educate older adults about the impact that alcohol and prescription drugs have on aging systems. However, even older adults who have had negative screening results may need screening repeated in the future. As discussed previously, life events render older adults vulnerable to developing problems; as the changes occur, screening questions should be asked again and the benefits of maintaining healthy habits reemphasized.
For older adults with positive screens, an assessment is needed to confirm the problem, to characterize the dimensions of the problem, and to develop an individualized treatment plan. For purposes of insurance or other funding resources, the assessment should follow criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association, 1994) or other relevant criteria, bearing in mind that these criteria may not apply directly to planning older adults' treatment. The unqualified application of such criteria is problematic in older adult populations because the symptoms of other medical diseases and psychiatric disorders overlap to a considerable extent with substance-related disorders.
In addition, as discussed in Chapter 2, the altered social roles and circumstances of older adults may further reduce the applicability of the criteria. For example, interference with occupational activities or work obligations may no longer be relevant as a manifestation of maladaptive functioning, although the emphasis for a retired person can still be placed on maintaining a dwelling, managing finances, or participating in social or recreational activities. "Recurrent substance use in situations in which it is physically hazardous," a substance abuse criteria in the DSM-IV (American Psychiatric Association, 1994, p. 183), need not mean driving drunk: Climbing a ladder, crossing a street, or taking a bath while impaired by alcohol is dangerous for a frail, older person.
With respect to tolerance - one of the DSM-IV criteria for a diagnosis of substance dependence - the aging process itself, as well as other concurrent medical diseases commonly found in older patients, lowers the threshold for onset of physiological dependence on prescription drugs. The presence of tolerance among older adults is not necessarily characteristic of substance-related psychological dependence. Conversely, the absence of tolerance to alcohol does not necessarily mean that an older adult does not have a drinking problem. To be useful in assessing older adults, the DSM-IV criteria must be interpreted age-appropriately. (See Figure 2-3, which presents the DSM-IV criteria for substance dependence as they apply to older adults with alcohol problems.)
Because the assessment process can be time-consuming and expensive, the Institute of Medicine (IOM) recommends (and the Panel supports) a sequential approach that looks at various dimensions of an older adult's suspected problem in stages so that unnecessary tests are not conducted (Institute of Medicine, 1990).
Although informed clinical judgment is essential for a sound assessment, validated substance abuse assessment instruments can provide a useful structured approach for many clinicians as well as a convenient checklist of items that should be consistently evaluated during the assessment. In general, specialized assessment is conducted by treatment program personnel or specially trained health care providers. As described by the IOM, structured assessment interviews "possess (at least potentially) the desired qualities of quantifiability, reliability, validity, standardization, and recordability" (Institute of Medicine, 1990, pp. 267-268).
Based on their experience, the Consensus Panelists recommend the use of two structured assessments with older adults: the Structured Clinical Interview for DSM-III-R (SCID) (Spitzer and Williams, 1985) and the Diagnostic Interview Schedule (DIS) for DSM-IV (Robins et al., 1981).
The SCID is a multimodule assessment that covers
Substance use disorders
Psychotic disorders
Mood disorders
Anxiety disorders
Somatoform disorders
Eating disorders
Adjustment disorders
Personality disorders.
It takes a trained clinician approximately 30 minutes to administer the 35 SCID questions that probe for alcohol abuse or dependence.
The DIS is a highly structured interview that does not require clinical judgment and can be used by nonclinicians. The DIS assesses both current and past symptoms and is available in a computerized version. It has been translated into a number of languages including Spanish and Chinese.
For some older adults, it may be impossible to understand the true impact of their alcohol and drug use or to recommend appropriate treatment services without a full assessment of their physical, mental, and functional health.
Functional health refers to a person's capacity to perform two types of everyday tasks: activities of daily living (ADLs), which include ambulating, bathing, dressing, feeding, and using the toilet, and instrumental activities of daily living (IADLs), which include managing finances, preparing meals, shopping, taking medications, and using the phone. Limitations in these domains, sometimes referred to as disabilities, can result in an inadequate diet, mismanagement of medications or finances, or other serious problems. These disabilities are major risk factors for institutionalization and are more likely than physical illness or mental health problems to prompt older adults to seek treatment.
Impairments in functional abilities are common in older adults with medical and psychiatric disorders. For instance, 90 percent of adults over the age of 65 require the use of glasses and 50 percent of adults over 65 have some degree of hearing loss (Hull, 1989; Plomp, 1978). Sensory impairments affect older adults in subtle ways that are not always immediately obvious to health practitioners but need to be anticipated, identified, and incorporated into treatment practices. Clinicians should ensure that older patients, for example, can read their prescriptions or hear what is said in a group therapy session. When not considered and compensated for, functional impairments can obstruct treatment. For example, it would be futile to enroll an older patient who is obese and has limited mobility in a program housed in a facility with steep flights of stairs and no elevator. Likewise, it makes little sense to recommend an evening program to older adults who cannot drive at night and do not have someone else to drive them.
Alcohol use can diminish IADLs and ADLs. Although alcohol-related functional impairments are potentially reversible, they should be considered when planning a treatment regimen. There are known complications of and differences between alcohol use in men and women related to compromised functional abilities and ADLs. In a recent study of older adults with a former history of alcohol abuse, impairment in ADLs was twice as common in women as in men (Ensrud et al., 1994). In addition, alcohol use was more strongly correlated with functional impairment than were smoking, age, use of anxiolytics, stroke, or diminished grip strength.
To identify functional impairments, the Panel recommends measuring the ADLs and the IADLs with the instruments in Appendix B. Another useful instrument is the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36), a self-report questionnaire that measures health-related quality of life, including both ADLs and IADLs (McHorney et al., 1994). Although this instrument is more comprehensive, it is also more difficult to use because of complex scoring of the various subscales. The SF-36 does provide, however, a comprehensive assessment of health and not just functional abilities. These instruments can be used by health care providers in a range of settings.
The relationship between alcohol use and a coexisting physical or mental disorder can take many different forms. At one extreme, medical and psychiatric problems can coexist with alcohol use with no specific relationship to drinking. Alternatively, those problems may be precipitating or maintenance factors for drinking. The use of alcohol to anesthetize pain is an example of a maintenance factor; alcohol use can then become its own problem or cause drug interaction problems with prescribed pain medications. Medical or psychiatric problems such as alcoholic cirrhosis or cognitive deficits are other possible consequences of drinking. Even when the link is not so direct, alcohol use can worsen other conditions such as hypertension or congestive heart failure.
The existence of comorbid medical and psychiatric disorders will influence treatment choice and priorities and will affect treatment outcome. Frail or medically compromised alcohol abusers, for example, may require more intensive monitoring during the detoxification period of treatment than their more robust peers. When disorders such as uncontrolled hypertension or depression are detected, reducing alcohol consumption becomes a priority; until drinking is curbed, medication prescribed for those conditions will not work effectively. In contrast, for older adults suffering from chronic pain, the priority would be to identify an effective painkiller, then taper the amount of alcohol consumed.
Studies have shown that the most common health problem among alcohol-dependent older adults is alcoholic liver disease. Chronic obstructive pulmonary disease, peptic ulcer disease, and psoriasis also are found much more frequently in older alcoholics than in older adults with no alcohol problems. Alcohol also appears to be a risk factor for myopathy, cerebrovascular disease, gastritis, diarrhea, pancreatitis, cardiomyopathy, sleep disorders, HIV/AIDS-related diseases, and both intentional and unintentional injuries (Tobias et al., 1989).
Malnutrition among older adults may be due to such conditions as poverty or a cognitive dysfunction and is especially important to diagnose and correct. Older substance-abusing adults on fixed incomes frequently have to choose among buying food, the prescriptions they need to manage illness, or the substance they abuse. If malnutrition is caused by economic conditions, it is appropriate for social service agencies or private food-related programs to be brought into the equation to help alleviate the problem.
Poor nutrition also may stem from a life change such as a spouse dying: An older person may stop preparing meals if he or she no longer has someone to cook for or eat with; a bereaved or frail person may not have the energy to shop or cook. Many adults with alcohol problems, however, "drink their calories" instead of eating food. Along these same lines, a provider should determine whether or not the older person is dehydrated, another possible indicator of alcohol problems.
Acute alcohol withdrawal syndrome is more protracted and severe in older adults than in younger adults (Brower et al., 1994; Liskow et al., 1989). Because there is no research on the recent practice of outpatient detoxification for older adults, very careful assessment is warranted before detoxification from any drug; outpatient detoxification may not be appropriate for older adults who are frail or who have a comorbidity.
Data from the Epidemiologic Catchment Area (ECA) study have strengthened support for a possible link between alcohol use and abuse and the development of other psychiatric illnesses (Regier et al., 1990). Adults with a lifetime diagnosis of alcohol abuse or dependence had nearly three times the risk of being diagnosed with another mental disorder. Comorbid disorders associated with alcohol use include anxiety disorders, affective illness, cognitive impairment, schizophrenia, and antisocial personality disorder (Finlayson et al., 1988; Blow et al., 1992b; Blazer and Williams, 1980; Saunders et al., 1991; Oslin and Liberto, 1995; Wagman et al., 1977). According to one study, older alcohol abusers are more likely to have triple diagnoses_alcohol, depression, and personality disorders - whereas younger substance abusers are more likely to have diagnoses of schizophrenia (Speer and Bates, 1992).
The presence of cognitive impairment or dementia significantly alters treatment decisions. It is particularly important to distinguish between dementia and delirium, which are often mistaken for each other by clinicians diagnosing older patients (see Figure 4-5).
Dementia is a chronic, progressive, and generally irreversible cognitive impairment sufficient to interfere with an individual's daily living. Dementia will also limit an individual's ability to interact in traditional group settings. Common causes of dementia include Alzheimer's disease, vascular disorders (e.g., multi-infarct dementia), and alcohol-related dementia. Dementia also makes it more difficult to monitor outcomes of drinking (patients may forget they drank), to get into treatment, and to benefit from the treatment.
Delirium is a potentially life-threatening illness that requires acute intervention - usually hospitalization. The cognitive losses experienced with delirium, unlike the effects of dementia, can often be reversed with proper medical treatment.
Changes in cognition are not unusual as people age, and they increase in frequency with each decade. Such changes, which are experienced in varying degrees, include minor short-term memory loss and difficulty with certain mathematical functions. However, significant memory loss, impaired abstract thinking, confusion, difficulty communicating, extreme emotional reactions and outbursts, and disorientation to time, place, and person are signs of cognitive impairment and are not part of the normal aging process.
Dementia can range from a mild level of cognitive impairment that is easily managed to a severe stage that may require intensive treatment and nursing home care. Common symptoms of dementia are presented in Figure 4-5. Symptoms described may not be equally present in all older adults experiencing dementia. The most common causes of dementia in older adults are Alzheimer's disease and vascular dementia.
Screening for significant cognitive dysfunction can be accomplished easily by any of a number of screening instruments. Patients who have been medically detoxified should not be screened for several weeks after detoxification. Until they are fully recovered, they may exhibit some reversible cognitive impairment. The Panel recommends two screens: the Orientation/Memory/ Concentration Test (Katzman et al., 1983), which is simple and can be completed in the office, and the Folstein Mini-Mental Status Exam (MMSE) (Folstein et al., 1975), which is an acceptable alternative. It should be noted that in the assessment of older problem drinkers who have recently (in the past 30 to 60 days) attained sobriety in an outpatient setting, the MMSE can be insensitive to subtle cognitive impairments. Furthermore, because the MMSE is weak on visual-spatial testing, which is likely to show some abnormality in many recent heavy drinkers, and does not include screening tests of abstract thinking and visual memory, the Panel recommends using the "draw-a-clock task" (Watson et al., 1993) and the Neurobehavioral Cognitive Status Examination (NCSE) (Kiernan et al., 1987) as supplements.
Delirium, also known as acute confusional state and acute brain syndrome, is an alteration of mental status that can usually be reversed with medical treatment. Figure 4-5 presents the characteristics of this syndrome and its common causes. Symptoms presented may occur in any combination and may be intermittent. In addition to the causes listed in Figure 4-5, benzodiazepine use prior to hospitalization has been demonstrated to be a significant risk factor for the development of delirium among hospitalized older adults. This suggests that these individuals had classical withdrawal delirium from the benzodiazepines or that mild withdrawal in addition to other risk factors greatly increases the incidence of delirium. The Confusion Assessment Method (CAM) (Inouye et al., 1990) is widely used as a brief, sensitive, and reliable screening measure for detecting delirium. The Panel recommends that a positive delirium screen be followed by careful clinical diagnostics based on DSM-IV criteria and that any associated cognitive impairment be followed clinically using the MMSE.
Alcohol abuse and dependence are directly correlated with other potential causes of cognitive impairment, including trauma from falls, motor vehicle crashes or other accidents, and the development of Wernicke-Korsakoff syndrome (Smith and Atkinson, 1997). The latter is clinically characterized by cognitive deficits (especially anterograde memory deficits), gait ataxia, and nystagmus. Its pathophysiology usually involves the lack of the vitamin thiamine. It is important to screen for Wernicke-Korsakoff syndrome because it is a potentially reversible cause of cognitive impairment (Victor et al., 1989; Grant, 1987).
The extent to which alcohol use interferes with performance on neuropsychological testing has been well reviewed (Victor et al., 1989; Grant et al., 1984). Several studies have demonstrated acute effects of alcohol on abstraction and visual-spatial problems but not on verbal skills. Less is known about the role of alcohol use in causing permanent cognitive changes. Studies have demonstrated that among nondemented alcoholics, abstinence leads to marked improvement in cognitive deficits (Brandt et al., 1983; Grant et al., 1984). However, Brandt and colleagues demonstrated that among subjects with prolonged periods of abstinence, there were long-term deficits in learning novel associations (Brandt et al., 1983). It should be noted that most of these patients were moderate consumers of alcohol, and all were healthy with no history of dementia. A more recent epidemiologic study of older African-American men found that increasing amounts of alcohol consumption were associated with worsening performance on dementia screening scales (Hendrie et al., 1996).
Affective disorders, common in older patients, also influence treatment choices. For example, a patient with an affective disorder who takes psychotropic drugs requires a treatment program with a staff familiar with these medications. Suicidal patients require intensive inpatient programs and an immediate intervention. Significant depressive symptoms, which are a common reaction after detoxification, can be worse in older adults than in younger patients and may require prescribed medicines to alleviate the depression before the abuse or addiction therapy is resumed. As noted below, research in the area of mental health comorbidities supports these findings.
Comorbid depressive symptoms are not only common in late life, but are also an important factor in the course and prognosis of psychiatric disorders. Depressed alcoholics have been shown to have a more complicated clinical course of depression with an increased risk of suicide and more social dysfunction than nondepressed alcoholics (Conwell, 1991; Cook et al., 1991). Moreover, they were shown to seek more treatment. However, relapse rates for alcoholics did not appear to be influenced by the presence of depression. Alcohol use prior to late life has also been shown to influence treatment of late-life depression. Cook and colleagues found that a prior history of alcohol abuse predicted a more severe and chronic course for depression (Cook et al., 1991).
Screening instruments for depression can be extremely useful as methods of detecting significant affective illness and for monitoring changes in affective states. The Geriatric Depression Scale (GDS) Short Form (Sheikh and Yesavage, 1986) and the Center for Epidemiological Studies_Depression Scale (CES-D) (Radloff, 1977), reproduced in Appendix B, have been validated in older age groups although not specifically in older adults with addiction problems. The Panel recommends the CES-D for use in general outpatient settings as a screen for depression among older patients.
As discussed in Chapter 2, sleep disorders and sleep disturbances represent another group of comorbid disorders associated with excessive alcohol use and with aging (Oslin and Liberto, 1995; Wagman et al., 1977; Moeller et al., 1993). Older adults sometimes self-medicate their sleep disturbances with alcohol (Wagman et al., 1977): Panel members had all heard older patients say that drinking helps them sleep.
The Panel recommends that sleep history be recorded in a systematic way in order to both document the changes in sleep problems over time and heighten the awareness of sleep hygiene. The Pittsburgh Sleep Quality Index (Buysse et al., 1988) is useful as both a research and screening scale but is difficult for clinicians to interpret and cumbersome to use. Clinicians may opt to carefully document sleep patterns and disturbances themselves rather than use this instrument (Nitcher et al., 1993).
There are other psychiatric disorders (e.g., schizophrenia, obsessive and compulsive behaviors) that complicate the treatment of abuse and addiction. In these instances, treatment options must be evaluated on a case-by-case basis, although all programs considered for referral should include medical and mental health personnel skilled in responding to those disorders.
Although suicide is not a specific psychiatric disorder, the Panel believes that there is a significant relationship among aging, alcohol use, and suicide. People older than 65 account for 25 percent of the national suicide rate (Conwell, 1991). Patients who attempt suicide require immediate and intensive inpatient therapy for as long as the illness persists. Providers must be alert to the possibility of major depression, which is common in older adults, evolving into suicidal tendencies. It helps if family and significant others, clergy, social workers, and home health care providers are knowledgeable about the warning signs for suicide, because these symptoms are more frequently manifested in nonclinical settings.
After determining that an older adult may benefit from a reduction in or complete abstention from alcohol use, the clinician must next assess the patient's understanding of this benefit. Many older adults may not know that their alcohol use is affecting their health. Because patient understanding and cooperation are essential both in eliciting accurate information and following through on the treatment plan prescribed, clinicians should use the assessment process as an opportunity to educate the older adult and to motivate him or her to accept treatment.
Many health care professionals rarely interact with older adults. To facilitate the assessment process with this population, the Consensus Panel recommends that clinicians adhere to the following guiding principles:
Areas of concern most likely to motivate older substance abusers are their physical health, the loss of independence and function, financial security, and maintenance of independence.
Assessment and treatment decisions must include the patient in order to be successful. This is particularly relevant for older adults, who may be very uncomfortable in formalized addiction treatment programs that do not include many of their peers or address their specific developmental and health needs.
Depending on an individual's particular situation, it may be important to include family members in treatment or intervention discussions (understanding that children may vacillate between a desire to help and denial and that patient confidentiality must always be respected).
Addiction is a chronic illness that ebbs and flows. Thus, patients' needs will change over time and will require different types and intensities of treatment.
Because many older adults have several health care providers (e.g., visiting nurses, social workers, adult day care staff, religious personnel), it is important to include this network as a resource in assessment and in providing treatment.
Given the complex health needs of older adults, health care providers may need assistance from experienced nonmedical personnel to adequately assess the totality of treatment issues and choices. Providers should be aware of their limitations both in providing addiction treatment and in assessing and treating mental or physical health needs.
All treatment strategies must be culturally competent and, to the extent possible, incorporate appropriate ethnic considerations (e.g., rituals).
Overarching continuity of care issues and considerations should be identified and addressed, especially in rural and minority communities where emergency room staff function as primary care providers.
The next chapter builds on these guiding principles in describing referral and treatment options for older adults with substance abuse problems.
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