Transcript Screening and Brief Motivational Intervention for At

Patricia Pullins, LMSW, LCDC
The Council on Alcohol and Drugs Houstonsm
Presents
Baby Boomer Seniors: Bracing for Changing Patterns
in Substance Abuse Among Older Adults
TIPSS 2011
303 Jackson Hill  Houston, Texas 77007  281-200-9329  Fax 713-400-6684
Presentation Objectives
• Gain knowledge about current findings and the
latest research on substance use among older
adults
• Understand how an older person’s physiology
differs from that of a younger person
• Understand the many factors that may influence
the use and potential for misuse or abuse of
substances among Boomers
• Develop an awareness of Baby Boomer attitudes,
beliefs and expectations toward drug use
• Learn what you can do to help
Changing Demographics and Needs
• The oldest Baby Boomers turned 65 in 2011
• The number of seniors ( 65+) in Texas is growing:
2011: 2,647,792 (10.2%) of population
2020: 3,846,891 (12.4%) of population
2030: 5,647,647 (15.1%) of population
• Older adults are increasingly abusing substances other than alcohol
• Up to 17% of older Americans misuse alcohol and prescription
drugs
• 25% of all emergency room admissions of seniors may involve
alcohol- medication interactions
• Older adults with alcohol use problems are not recognized by many
professionals
General Issues for
Older Adults
•Loss (status, people,
vocation, health, etc.)
•Complex medical
issues
•Social isolation, loneliness
•Multiple medications
•Major financial problems
•Sensory deficits
•Housing changes
•Reduced mobility
•Family concerns
•Cognitive impairments
•Time management burden
•Impaired self-care, loss
of independence
Facts About Physiological
Changes with Age:
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Decrease in physical strength
Decline in efficiency of body organs
Loss of bone mass
Slower reflexes
Takes longer to return to equilibrium
Decline in the senses
Older Adults & Alcohol Use
• Increased risk of stroke (with overuse)
• Impaired motor skills (e.g. driving) at low
level use
• Increased risk of injury (falls, accidents)
• May result in sleep disorders
• Increased risk of suicide
• Interacts with dementia symptoms
Older Adults & Alcohol Use
• Higher blood alcohol concentration (BAC) from dose
• More impairment from a high BAC
• Potential interactions/increased side effects with
medications and/or compromised metabolizing (especially
psychoactive medications, benzodiazepines, barbiturates,
antidepressants, dioxin, warfarin)
Drinking Guidelines
• Should not exceed 1 drink per day
• Never more than 2-3 drinks on any drinking
day (binge drinking)
• Limits for older women should be somewhat
less than for older men
(NIAAA, 1995; DuFour & Fuller, 1995)
Drinking Guidelines (continued)
• Recommendations consistent with data on
benefits/risks of drinking in this age group
• Lower limits for older adults because:
-increased alcohol sensitivity with age
-greater use of contraindicated medications
-less efficient liver metabolism
-less body mass/fat increases circulating levels
Potential Alcohol Problems in Older
Adults: Signs
•Anxiety, depression, excessive mood •New difficulties in decision
making
swings
•Blackouts, dizziness, idiopathic
seizures
•Poor hygiene
•Disorientation
•Sleep problems
•Falls, bruises, burns
•Family problems
•Headaches
•Financial problems
•Incontinence
•Legal difficulties
•Memory loss
•Social isolation
•Unusual response to medications
•Increased alcohol tolerance
•Poor nutrition
Defining Alcohol Use Patterns
• Abstinence: no alcohol for past year
• Low risk: use alcohol with not problems
• At-risk: alcohol use with increased chance of
problems/complications
• Problem drinking: experiencing adverse
consequences
• Dependent: loss of control, drinking despite
problems, physiological symptoms (tolerance,
withdrawal)
If You Drink, Recommended Level
For 60+
• No more than one drink per day or seven
drinks per week
• Maximum of two drinks on any drinking
occasion
• Somewhat lower levels for older women
The Substance Abuse and Mental Health Services
Administration/Center on Substance Abuse
Prevention Consensus Panel for TIP #26 –
Substance Abuse Among Older Adults
What Conditions May Be Caused
or Worsened by Alcohol Abuse?
• 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
Risk Factors for Alcohol Problems
Risk factors make people more vulnerable to alcohol
and medication misuse problems
• Death of spouse, friends, and other family members
• Loss of job and related income, social status, and
sometimes self-esteem ___ as a result of retirement
• Loss of mobility ( inability to drive, problems
walking)
• Impaired vision and hearing, insomnia and memory
problems
Co-morbid Conditions
Co-morbidity is a serious, common concern
among older adults using alcohol:
• Impaired Activities of Daily Living (ADLs)
• Psychiatric symptoms, mental disorders
• Alzheimer’s Disease
• Sleep disorders
“Medications are probably the
single most important health
care technology in preventing
illness, disability, and death in
the geriatric population.”
Avorn J. Medication use and the elderly: current status and
opportunities. Health Affairs 1995, Spring.
17
“Any symptom in an elderly
patient should be considered a
drug side effect until proved
otherwise.”
J Gurwitz, M Monane, S Monane, J Avorn
Brown University Long-term Care Quality Letter 1995.
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Why are Seniors at Greater Risk
for Medication-Related Problems?
• Physiological Changes with Aging
• Number of Medications
– 5.8 prescription medications
– 3.2 over-the-counter medications
• Poor adherence
• Types of medications prescribed, e.g.,
psychoactive medications
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Why are Seniors at Greater Risk
for Medication-Related Problems
• Self medication, alcohol use
• Multiple chronic diseases
• Under-representation in clinical
trials, particularly those over age
75
• Shortage of trained professionals
in geriatric pharmacotherapy
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Polypharmacy
• Use of many medications either
concurrently or sequentially
• 2x ADR risk when number of
medications increases from 1 – 4
• 14x ADR risk in older adults who use 7
medications
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Continuum of Psychoactive Medication
use
• Proper use
• Misuse—Most Common
– By Patient
– By Doctor
• Abuse
– By Patient
• Dependence
– By Patient
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Protective Factors
Protective factors increase resistance to alcohol and
medication misuse by promoting healthy behavior:
• Education ( wise use of medications) and skills
• Access to resources
• Availability of support networks and social bonds
• Supportive family relationships
Variation in Use
• Substantial changes exist in the patterns of substance
use and abuse over different age cohorts, particularly
among those born post-WWII.
• Mean alcohol consumption appears to remain higher
over time for the midlife group (including the Baby
Boom generation) than for other age groups.
– Baby Boom generation, as it ages, may maintain a higher level
of alcohol consumption than in previous older cohorts
(Blow et al., 2003)
World View of Which Group
of Older Adults
• Maxims
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Don’t air your dirty laundry
Pick yourself up by your bootstraps
Put your best foot forward
If you don’t have anything good to say…
Put on a happy face
Boomer Lore
• Is 40 really the new 30?
• Instead of measuring aging by how long
people have lived so far, scientists have
factored in how many more years people can
still look forward to.
• They effectively are behaving as if they were
younger.
• As people have more and more years to live
they have to save more and plan more.
Boomer Lifestyle
• Purchase 57% of health-care insurance ($75 billion)
• Represent 58% of all health-care spending ($152
billion)
• Purchase 67% of all prescription drugs ($37 billion)
• Account for 61% of all over-the-counter drug
purchases
• Purchase 41% of all personal care products and
services ($24 billion)
• Purchase 50% of all reading material ($8 billion)
Leading-Edge Boomers Shared an
Intense and Captivating Coming-ofAge Period
• Created many common values
• Unique generational values
• Shared life experiences
Fountain of Youth
“They’re still youthful, and they have plenty of
money” - Ken Dychtwald, President and CEO of Age Wave
• “Old” rules no longer apply
• “Hip” and “cool” don’t equate just with
“young” anymore
• Do not like association with aging metaphors
• Many view themselves as younger than the
calendar
– As much as twelve years or more
Brent Green, “Marketing to Leading-Edge Baby Boomers:
Perceptions, Principles, Practices, Predictions”
Medical Marijuana
AARP Poll
• 72% of adults aged 45+ support the use of
medical marijuana for:
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Multiple Sclerosis
Glaucoma
Arthritis
Parkinson’s Disease
Alzheimer’s Disease
Join Together Online, 5/9/2005
Wonder Drugs
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Steroids
Viagra
Crystal Meth
Marijuana
Amphetamines
Cialis
Emotional Needs In Later Life
• One’s emotional needs remain the same throughout life.
• Too often, just because older people look different on the
outside, they are assumed to feel differently on the inside.
• Emotional needs do not go away as people age, but sometimes
they may not be nurtured as well. It also may become more
difficult for the older person to meet his or her emotional
needs as family and friend die, or health or inability to drive
decreases.
• There is a tendency in working with older adults to focus on
meeting the physical and health needs. Psychological needs
are often not given the same attention.
Sexual Needs in Later Life
There is no subject in our society that is associated with
more myths and misinformation than that of sexual
intimacy and the elderly.
How an older adult views himself or herself can
be important in determining overall well being.
An older person who views the slowing of sexual
response as “normal aging” is going to respond
quite differently than the individual who views
the slowing as “sexual warning, or “ I’m less of a
man or woman.”
Myths About Aging
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Is what I have observed really the problem?
Is it symptomatic of “aging”?
Could it be related to chronic health problems?
Or is what I have observed actually a symptom
of the problem?
Patients in older-adult services at HanleyHazelden, a treatment center in West Palm
Beach, Fla., stated,
“Our whole lives are about loss. We lose
our hair, hearing, teeth, and eyesight. We
lose our loved ones and our friends”.
Join Together Online, 7/21/2003
Intervention with Older Adults
• Preventive education for abstinent, low-risk
drinkers
• Brief, preventive intervention with at-risk and
problem drinkers
• Alcoholism treatment for abusing/dependent
drinkers
Screening
• Who?
-Every person aged 60 or over
-If physical signs are present
-Undergoing major life changes
• What?
-Screen for alcohol and prescription drug use/abuse
• How?
-In any regular services
-Brown bag approach
-Ask direct questions
-Avoid stigmatizing terms
Screening
Goal of screening for
alcohol use problems in
older adults is to:
Rationale of screening for
alcohol use problems among
older adults:
•Identify at-risk drinkers,
problem drinkers, and
persons with alcoholism
•Incidence is high enough to
justify costs
•Determine need for
further diagnostic
assessment
•Adverse quality/quantity of
life effects are significant
•Effective treatment exists
•Valid & cost-effective
screening exists
Screening Instruments
• Short Michigan Alcohol Screening TestGeriatric Version (SMAST-G)
• Health Screening Survey, includes other health
behaviors (nutrition, exercise, smoking,
depressed feelings); includes quantity and
frequency questions
• CAGE (Cut down, Annoyed by others, feel
Guilty, need Eye opener)
SMAST-G
• Two or more “yes” responses is indicative of
alcohol problem (0-10 possible)
• 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?
SMAST-G (continued)
3. Does having a few drinks help
decrease your shakiness or tremors?
4. Does alcohol sometimes make it hard
for you to remember parts of the day or
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?
SMAST-G (continued)
7. Have you ever increased your drinking
after experiencing a loss in your life?
8. Has a doctor or nurse ever said they
were worried or concerned about your
drinking?
9. Have you ever make rules to manage
your drinking?
10. When you feel lonely, does having a
drink help?
Quantity/Frequency Screen
Eight or more drinks/week or two or more
occasions of binge drinking in last month are
indicative of alcohol use problems.
1. In the last three months, on average, how many days a
week have you been drinking alcohol?
2. On a day when you have had alcohol to drink, how many
drinks have you had?
3. In the last three months, how many times have you had 3
or more drinks on an occasion?
Who Seeks Treatment?
Treatment Seeking
• Age-related factors may deter treatment seeking by
older patients
• Among medically ill veterans age 55 or older
– Expressed interest in treatment and attendance at
pretreatment evaluation was associated with younger age
and higher CAGE (Cut down, Annoyed by others, feel Guilty, need
Eye opener
– Being unmarried and drug use (in addition to alcohol) was
associated with treatment interest
• Adults ages 55+ ‘More Receptive’
– Because they’ve bottomed out more
(Satre et al., 2003a)
Special Populations
Barriers to effective identification exist for:
•Women
•Certain minority group members
• Lack of culturally competent tools and
interventions
•Individuals with physical disabilities,
co-morbidities
•Homebound
Factors that might influence who
seeks treatment
• Social & personal factors- support from family
& friends
• Cognitive status
• Functional health
• Self- esteem
• Personality styles
• Locus of control (belief that events in his/her life
result from personal actions, fate or powerful
others) .
Medicare
• A federal health insurance program for:
65 or older
Under 65 with certain disabilities
Any age with End-State Renal Disease
(permanent kidney failure)
• Has four different types to cover different
services: Part A, B, and D.
• Part C is Medicare Advantage that gives
benefits through private insurance.
Medicare and Substance Abuse
• In Texas, Medicare covers substance abuse
based on mental health services on outpatient
basis.
• Pay 50% of Medicare-approved amount and
separate copayment amount for facility
service.
• Part B Benefit.
• Must pay annual $155 deductible for Part B
services.
Referral Pathways
• Admissions aged 55 or older were more likely
than younger admissions to enter treatment
through self-referral
• Elders less likely to be referred through the
criminal justice system
• Few referred by health care providers in both
young and older samples
(OAS, SAMHSA, 2004)
Effective Approaches For Older
Adults
• Brief alcohol interventions
• Home and community-based mental health
outreach
• Integration of substance abuse, mental health,
and primary care services
• Geriatric mental health consultation and
treatment teams in nursing homes
• Support interventions for families and
caregivers of persons with dementia
Effective Approaches For Older
Adults
• A variety of pharmacological and
nonpharmacological interventions
• Cognitive-behavioral approaches
• Group-based approaches
Demographic projections indicate that the aging of the “baby boom” generation will increase the proportion of persons over age 65 from
Take Home Message
• If we are to help- We must be sensitive to the
values and beliefs held by older adults
• If we are to help- We must be sensitive to the
values and beliefs of family members
• If we are to help-We must examine our values
and beliefs
Sources
Get Connected! Toolkit: Linking Older Adults With Medication, Alcohol, and Mental Health
Resources: http://www.samhsa.gov/Aging/docs/GetConnectedToolkit.pdf
Older Americans Substance Abuse and Mental Health Technical Assistance Center:
http://www.samhsa.gov/OlderAdultsTAC/index.aspx
Treatment Improvement Protocol (TIP) Series 26: Substance abuse among older adults.
(1998). Rockville, MD: U.S. Department of Health and Human Services, Public Health
Service, Substance Abuse and Mental Health Services Administration, Center for Substance
Abuse Treatment.
Older Adults and Alcohol Problems. University of Michigan Department of Psychiatry, and
Associate Director, Department of Veterans Affairs National Serious Mental Illness
Treatment Research and Evaluation Center (SMITREC). Kristen L. Barry, PhD, Research
Associate Professor.
Population Projections for Texas: Years 2000-2040 by Gender and Race/Ethnicity:
http://www.hhsc.state.tx.us/research/dssi/PopStats/ProjectionsTX_GenderRace.html
Texas Population Projections for Older Adults Age 60-Plus: Years 2000 – 2040:
http://www.hhsc.state.tx.us/research/dssi/PopStats/ProjectionsTX_AgeGrpsElderly.html