Cori Robin, LCSW
Health and Aging
Rush University Medical Center
Illinois Elder Rights Conference
July 12, 2012 Session T14

Presenter Disclosures
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• Gain knowledge of current findings and prevalence of substance use/misuse in older adults
• Understand risk factors that may influence this population ’ s use/abuse/misuse
• Understand physiological differences with aging
• Learn about potential treatment efforts to imbed in current workplace environment
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Rise in Older Adults
• 13% of current U.S. population age 60 and older
• Expected to increase up to 20 % by 2030
• Each year more than 3.5 million Boomers turn 55
• Individuals aged 85 and older are the fastest growing segment of the population.
www.census.gov
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The Need for Change
• Social and human services are going to be overwhelmed with increase in older adults
• Increased need for age-sensitive substance abuse and mental health prevention and treatment
• Demand for Substance Abuse and Mental Health services is likely to increase because the Baby Boom cohort tends to:
– use these services more frequently than current older adult cohort
– be less stigmatized by seeking services.
Blow & Barry, 2011
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Substance Use in Older Adults
• #1 Most common: Nicotine (~18-22%)
• #2 Alcohol (~2-18%)
• #3 Psychoactive Prescription Medications (~2-4%)
• #4 Other Illegal Drugs (marijuana, cocaine, narcotics) (<1%)
Blow & Barry, 2011
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Levels of Drinking
World Health Organization Standards:
• Harmful drinking: Use of alcohol that causes complications
(includes abuse and dependence)
• Hazardous drinking: Use of alcohol that increases risk for complications
• Non-hazardous drinking: Use of alcohol without clear risk of complications (includes beneficial use)
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Drinking in Older Adults
• 66% of men, 65% of women used alcohol
• 3% met full criteria for an alcohol use disorder
• At-risk drinking was reported in:
– 17% of men, 11% of women ages 50+
– 19% of all respondents ages 50-64
– 13% of all respondents ages 65+
• Binge drinking was reported in:
– 20% of men, 6% of women ages 50+
– 23% of all respondents ages 50-64
– 15% of all respondents ages 65+
Blazer & Wu, 2009a
• 65+ age group binge on alcohol more frequently than any other age group
CDC, January 2012
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Substance Use in Older Adults
• Estimated one in five older adults may be affected by combined difficulties with alcohol and medication misuse.
• More patients 60 & older are admitted to hospitals for alcohol connected problems than for heart attacks
• About 1/4 of nursing home admissions occur because the patient is unable to manage their medications.
• Psychoactive medication use indirectly causes up to 14% of hip fractures in older adults 60+
Hazlett and Schonfeld, 2011
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Prescription Medication Use
• Older Adults are the largest consumers of psychoactive medications
• 85% of older adults take a prescription medication
• 76% use more than one medication daily
• Older adults constitute 13% of the population & use 1/3 of the prescriptions
• 20% use tranquilizers daily
• Factors associated with prescription drug abuse in older adults:
– female sex, social isolation, history of a substance-use or mental health disorder, and medical exposure to prescription drugs with abuse potential
Simoni-Wastila & Yang, 2006; Blow & Barry, 2011
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Prescription Medication Use (Cont)
• At least 1 in 4 older adults use psychoactive medications with abuse potential
• By 2020, non-medical use of prescription drugs among adults age 50 and over will increase dramatically
• Older adults average 2-3 serious medication errors per month
• An estimated 125,000 older adults ’ deaths can be attributed to medication noncompliance at a cost of
$100 billion in the US alone
Wolstenholme, 2011; Simoni-Wastila & Yang, 2006
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Interactions: Medication and Alcohol
Medications with significant alcohol interactions
• Benzodiazepines
• Other sedatives
• Opiate/Opioid Analgesics
• Some anticonvulsants
• Some psychotropics
• Some antidepressants
• Some barbiturates
Blow & Barry, 2011; NIAAA, 1998
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Physiological Aging
• Decrease in percent of body weight composed of water
• Changes in digestion
• Changes in liver function
• Changes in kidney function
• Other medical factors associated with aging
(multiple medications, sensory issues)
Barry & Blow, 2004
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Medical Risks
1 or More Drinks per Day
Gastritis, ulcers, liver and pancreas problems
2 or More Drinks per Day
Depression, gout, GERD, breast cancer, insomnia, memory problems, falls
3 or More Drinks per Day
Hypertension, stroke, diabetes, gastrointestinal diseases, cancer of many varieties
Blow & Barry, 2011
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Signs/Symptoms
• Anxiety
• Blackouts
• Dizziness
• Depression
• Disorientation
• Mood swings
• Falls, bruises, burns
• Family problems
• Financial problems
• Headaches
• Incontinence
• Increased tolerance to alcohol
Blow & Barry, 2011
• Legal difficulties
• Memory Loss
• Problems in decision making
• Poor hygiene
• Seizures
• Sleep problems
• Social isolation
• Unusual response to medications
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Unique Aspects with Older Adults
Medical & Psychosocial Issues with Aging
• Loss (loved ones, employment, driving, social or economic status)
• Financial problems
• Transitions in housing
• Social isolation
• Caregiving for loved ones
• Complex medical problems
• Multiple medications
• Reduced mobility
• Cognitive impairment or loss
• Sensory deficits
Blow, 2007
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Risk for Psychiatric Illness
Older adults are three times as likely to develop a mental illness with a lifetime diagnosis of alcohol abuse.
Common “Dual Diagnoses” include:
• Depression (20-30%)
• Cognitive loss (10-40%)
• Anxiety disorders (10-20%)
Blow & Barry, 2011
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Barriers to Identification
• Assumptions with age
• Lack of awareness
• Difficulty in recognizing symptoms
• Symptoms attributed to other causes
• Cultural/social context
• Many do not self-refer or seek help
Hazlett and Schonfeld, 2011
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Recommended Drinking Limits
Centers for Disease Control and Prevention:
• Drinking Limits: no more than one drink per day on average for older men or less than one drink per day on average for older women
• Binge drinking: drinking four or more drinks during a single occasion (drinking day) for men or three or more drinks during a single occasion for women
CDC, 2011
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Standard Drink
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SBIRT Intervention
Intervention to identify non-dependent substance use or prescription medication issues and to provide effective service strategies prior to their need for more extensive or specialized substance abuse treatment
• Prescreen quickly identifies older adults who use alcohol and/or the psychoactive medications targeted for this intervention (opioid analgesics for pain and sedative hypnotics: benzodiazepines and barbiturates for sleep, anxiety, nerves, agitation)
• Screening quickly assesses the severity of substance use and identifies the appropriate level of education and/or treatment needed for the individual (primary prevention).
• Brief intervention focuses on increasing insight and awareness regarding substance use and motivation for behavioral change (secondary prevention).
• Referral to Treatment provides access to specialty substance abuse assessment and care, if needed.
• Six Month Follow-up uses same screening questionnaire and can help determine if clients have changed their alcohol and/or psychoactive medication use, or need additional assistance with their alcohol and/or psychoactive medication use.
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Prescreen Questions
1) In general, would you say your health is:
__ Excellent __ Very Good ___ Good __ Fair
2) Do you visit your primary care physician at least one time per year? __Yes __No
__ Poor
3) Please review the list of medications on back of this page. During the past 3 months, have you used any of these prescription medications for pain for problems like back pain, muscle pain, headaches, arthritis, fibromyalgia,
__Yes __No etc.?
4) During the past 3 months, have you used any prescription medications to help you fall asleep or for anxiety or for your nerves or feeling agitated?
__Yes __No
5) In the last 3 months, have you felt you should: a. lose some weight: b. cut down or stop smoking: c. cut down or stop drinking: d. do more to keep fit:
___No
___No
___No
___No e. better manage medications: ___No
___Sometimes
___Sometimes
___Sometimes
___Sometimes
___Sometimes
6) In the past 3 months, have you fallen or had a fear of falling?
__Yes __No
___Quite Often
___Quite Often
___Quite Often
___Quite Often
___Quite Often
___Very Often
___Very Often
___Very Often
___Very Often
___Very Often
7) In the past 3 months, have you had anything to drink containing alcohol (beer, wine, wine cooler sherry, gin, vodka or other hard liquor)?
__Yes __No
8) In the past 3 months, have you thought about changing any other things about your health?

Screening
• Screening Instruments
– Substance Consumption
– Substance Consequences
• CAGE, AUDIT, MAST, SMAST
• Older Adult Specific: MAST-G; SMAST-G
– Health Screening Survey
• Universal (not systematic) Screening
• Techniques
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Brief Intervention
After a positive identification of at-risk status, Brief Intervention is conducted:
1. Identify future goals (related to physical/mental health, social life/relationships, finances, etc)
2. Summary of health habits
3. Psycho-education on standard drinks, level of consumption and physical changes with aging and substances
4. Types of older drinkers in U.S.
5. Psycho-education on interaction of alcohol and medications
6. Consequences of at-risk drinking or medication misuse (discuss positive and negative effects)
7. Reasons to quit or cut down
8. Agreed-upon plan
9. Handling risky situations or triggers
10.Visit summary Barry, Blow & Schonfeld, 2004
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Techniques of BI
Express empathy
Roll with resistance
Support self-efficacy
Develop discrepancy
Miller & Rollnick, 2002
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When Intervening with Older Adults…
• Avoid labels (i.e. addict, alcoholic)
• Avoid confrontation or anger
• Create a culture of respect
• Acknowledge difficulty of behavior change
• Create a safe environment
• Avoid shaming language
• Be non-judgmental
• Focus on re-building coping skills and increasing support network
• Connect use and symptoms
• Connect behaviors and participants ’ emotional responses
• Relate alcohol and drug use-abuse issues to how it can effect health
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Sources
.
Barry, K.L., Blow, F.C. & Schonfeld, L. (2004). Health promotion workbook for older adults (adapted to include medication misuse).
Blazer, D.G. & Wu, L.T. (2009). The epidemiology of at-risk and binge drinking among middle-aged and elderly community adults: National survey on drug use and health. American Journal of Psychiatry, 166, 1162-1169.
Blow, F.C. (2007). Substance abuse screening and interventions for older adults: Evidence-Based Approaches. Presented at American Society on
Aging, San Francisco, CA: June 21, 2007.
Blow, F.C. & Barry, K.L. (2011). Substance use disorders among older adults. Presented at SAMHSA/Substance Abuse Prevention Older Americans
Technical Assistance Center Training, Chicago, IL.
Get Connected! Toolkit: Linking Older Adults With Medication, Alcohol, and Mental Health Resources: http://www.samhsa.gov/Aging/docs/GetConnectedToolkit.pdf
Hazlett, RW. & Schonfeld, L. (2011). The use and abuse of alcohol, drugs and prescription medication in vulnerable adults. 2011 Florida
Conference on Aging.
Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people to change addictive behavior (2nd ed.). New York: Guilford Press.
Older Americans Substance Abuse and Mental Health Technical Assistance Center: http://www.samhsa.gov/OlderAdultsTAC/index.aspx
Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. (1998). Substance Abuse Among Older
Adults: A Guide for Social Service Providers. Treatment Improvement Protocol (TIP) Series 26. Department of Health and Human Services
Publication No. (SMA) 98-3179. Rockville, MD
Simoni-Wastila, L., & Yang, H. K. (2006) Psychoactive drug abuse in older adults. American Journal of Geriatric Pharmacothery, 4: 380–394.
Wolstenholme, B. (2011). Medication-related problems in geriatric pharmacology. Aging Well, 4(3), 8.
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Contact Information
Cori Robin, LCSW
Rush University Medical Center
(312) 942-6087
Cori_B_Robin@rush.edu
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