Transcript by older adults - ncaddwestchester.org

The Psychedelic Age Continues:
Drugs, Boomers and Older Adults
Juan Harris MBA, MS, CAP, CAPP, SAP, CET, CMHP, CGAC, ICADC
Program Director Center for Older Adult Recovery
CARON / HANLEY Inc., West Palm Beach, FL
1
Aging is Changing
• 1400 average life span
– 33 years of age
• 1900 average life span
– less than 49
• 2000 statistical
– 50 year old can expect to live another
30 years
2
Myths About Aging
• Majority of persons are senile or demented
• Majority of older persons feel miserable
most of the time.
• Most older people cannot work as
effectively as younger persons.
• Most old persons are unhealthy and need
assistance with daily activities.
• Majority of older persons are socially
isolated and lonely.
Who’s Old?
• Aging is :
– Discovery of the real
self… (Cicero)
– Metamorphosis of the
soul with aging that allow
for the emergence of
precursors of wisdom and
the discovery of new
values and meanings not
possible by younger
generations…(Plato)
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6
What does the research tell us?
7
Baby Boomers
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Boomers won’t go quietly!!
Youthquake shake-up
Emotional Retirement Planning
Treatment differences
Increase of illicit drugs?
8
Drug Use
Use of any of the following in past year:
1. Marijuana?
2. Cocaine?
3. Crack?
4. Heroin?
5. Hallucinogens (such as LSD, PCP)?
6. Substances - sniffed or inhaled?
Recorded by interviewer - YES/NO format. Any YES
responses results in a Flag for further
assessment.
Baby Boomers “Come of
Age”
• Current Problem: lack of knowledge of substance use in
elders
• Substance use in elders will be a huge problem in < 20
years b/c boomers:
– Accepting of alcohol and drug use
• Used more in youth
• Use more NOW
– Use more psychoactive Rx drugs now
– 3-4x more emotional disorders
10
Substance Use - Type by
Gender – 50 and Older
80.0
71.1
70.0
60.0
50.0
58.1
57.7
42.3
41.9
40.0
28.9
30.0
20.0
10.0
0.0
Any Illicit Use
Marijuana
Male
Prescription
Female
11
The need to
screen for
illicit drug use.
An increasing
trend among
older adults?
Statistics
• In 1992, the number of older Americans admitted to treatment facilities
was near 6.6% of all admissions nationwide;
• By 2008, the number of admissions from this age group reached
12.2%.
• Statistically, alcohol addiction has remained the primary substance
abuse disorder for people age 50 and older, and this still holds true
today.
• However, seniors are now abusing more illicit substances—such as
cocaine, heroin, and marijuana—and legal prescription drugs than
before.
Statistics
• In 1992, admissions for prescription drug abuse involving older
adults were at 0.7%, yet this figure jumped to 3.5% by 2008.
• Marijuana abuse admissions rose from 0.6% in 1992 to 2.9% in
2008.
•
Heroin abuse admissions more than doubled—from 7.2% of
admissions in 1992 to 16.0% in 2008.
• Most significantly, cocaine abuse admissions almost quadrupled,
from 2.9% in 1992 to 11.4% in 2008.
• While these substances of abuse increased among older adults,
alcohol abuse saw a decline in admissions among this age group.
Statistics
• Older adult admissions involving alcohol as the primary
substance of abuse were once 84.6% of admissions in
1992, but fell to 59.9% by 2008.
• This shift in primary substances of abuse has caused
alarm among the health community,
• Not only in regards to treatment for the current generation
of older Americans, but also in terms of preparing for the
onset of the aging Baby Boomers.
Statistics
• In 1992, 13.7% of older adult admissions to treatment facilities were
experiencing multiple substance abuse disorders.
• In 2008, this figure tripled to 39.7% of older adult admissions.
• Researchers state that this incline is mostly due to the rise of
cocaine addiction among this age group.
• In 1992, the percentage of older American admissions involving
cocaine as the primary substance of abuse in comorbid cases was
at 5.3%, but by 2008 this more than tripled to 16.2%.
statistics
• Cocaine abuse was also responsible for the rise in
addictions that occurred within the last five years.
• About 26.2% of addictions started in the last five years
among older adults involved cocaine as the primary
substance of abuse, with prescription drug abuse following
close behind at 25.8% of recent addictions.
• Even though almost 75% of older adults admissions still
pertain to an addiction that began before the age of 25,
addictions that were initiated within the last five years
among this age group grew—most involved illicit
substances.
Diagnosis and Assessment
RAISING THE ISSUE
• Describe what you see (e.g., “I’ve noticed you’ve been
having difficulty walking.” “As far as I can tell, you’ve
eaten only biscuits this week. Is there a problem with
your meals?”).
• Avoid saying that the person’s problems will go away if
they stop drinking.
• Try saying, “You don’t seem to be your old self these
days. How are you feeling? Would you be interested in
having someone to talk to about it?”
Diagnosis and Assessment
HARM REDUCTION
• If you are worried about yourself or someone else there
are things you can do to reduce the harm:
– talk to a professional about your concerns
– always eat before you drink, alternate alcoholic drinks with soft
drinks and don’t mix different types of alcohol
– be aware of the facts about alcohol
– never tell a long term drinker to just stop drinking - alcohol is a
physically addictive substance and sudden withdrawal can be
fatal
Do you help them “cope”?
• What may be appropriate at a younger age
may not work with older adults.
• Coping may be your strategy. Surviving may
make sense to you.
• Older adults may no longer see the necessity
of living at any cost.
• Older adults may have a sense of urgency
about making things right.
• The transgenerational dilemma: your
development issues may be in conflict with
theirs.
Signs and Symptoms of Substance Use
Problems in Older Adults
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Anxiety
Blackouts, dizziness
Depression
Disorientation
Mood swings
Falls, bruises, burns
Family problems
Financial problems
Headaches
Incontinence
Nesting
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Increased tolerance
Legal difficulties
Memory loss
New problems in decision
making
Poor hygiene
Seizures, idiopathic
Sleep problems
Social isolation
Unusual response to
medications
Decline in ADLs
Symptom Identification
• Applying quantity and frequency levels appropriate for younger
adults to elders may cause failure to identify substance use
problems
• Warning signs can be confused with or masked by concurrent
illnesses and chronic conditions, or attributed to aging
– Sleep problems associated with chronic conditions,
particularly cardiovascular disease and pain
– Falls attributed to poor lower body strength, poor balance, or
vision limitations
– Anxiety attributed to psychosocial concerns
– Confusion/memory problems associated with Alzheimer’s
disease or other dementias
Diagnosis and Assessment
• Early Onset Alcoholism
– Long history chronic alcoholism
– Started drinking age 14 – 20
– Gradual increase tolerance
– Multiple attempts to quit
– Multiple treatment or detox experiences
23
Diagnosis and Assessment
• Late Onset Alcoholism
–Started age 50+
–Losses
–Toxic effects
–Shame
–Grief
24
Diagnostic Criteria
for Substance Dependence
in Older Adults
The Treatment Improvement Protocol
(TIP #26) Consensus Panel determined:
DSM-IV criteria for substance abuse
and dependence may not be
adequate to diagnose older adults
with substance use problems
DSM-IV Dependence Criteria
Tolerance
 Withdrawal
 Use in larger amounts or for longer than intended
 Desire to cut down or control use
 Great deal of time spent in obtaining substance
or getting over effects
 Social, occupational, or recreation activities
given up or reduced
 Use despite knowledge of physical or
psychological problem

Applying DSM-IV Criteria
to Older Adults
Tolerance
Even low intake may cause
problems due to body changes
Withdrawal
May not develop physiological
dependence
Use in larger amounts or for
longer than intended
Cognitive impairment interferes
with self-monitoring
Desire to cut down or control use Same across life span
Time in obtaining substance or
getting over effects
Negative effects with relatively
low use
Activities given up or reduced
May have fewer activities
Use despite knowledge of
problems
May not know problems are
related to use
Diagnosis and Assessment
• Assessment tools
– Geriatric Depression Scale
– MAST-G
– S-MAST-G
– CAGE
– Folstein MMSE
– Millon MCMI II
– Audit
28
Diagnosis and Assessment
• Blood / Alcohol Content
– 1.5 oz Liquor
– 12 oz Beer
– 5 oz Wine or
– 12 oz Winecooler
29
Diagnosis and Assessment
• Initial Screening
– Physical condition
– Emotional status
– Personal care / cognitive functioning
– Available support system
– Motivation for accepting help
30
Diagnosis and Assessment
• Information collected from
– Older adult
– Spouse
– Sons and daughters
– Physician
– Clergy
– Friends
31
Diagnosis and Assessment
• Methods of collecting information
– Older adult interview
– Older adult self-reporting
– Family and significant others
– Interviews / Documentation
– Medical records
32
Diagnosis and Assessment
• Problems Assessing Older Adults
– Beliefs
– Attitudes
– Perspectives
– Differential diagnosis
– Assessment tools
– Prolonged effects
– Age = specific criteria
33
Diagnosis Issues
Assessment Challenges
Clinicians and physicians not trained in gerontology and
substance abuse,
Combined with the care giver’s lack of training and knowledge of
healthy behaviors of older adults
Creates a defense known as “double denial” (Kagan & Shafer,
2001).
These combined factors may hinder recognizing older adults at
risk, or may
Create a perception of substance use as normal for coping with
trauma issues and psychosocial stressors common in this
stage of life (Colleran, 2002.
Problems with Definitions
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Substance Misuse
At-risk or Hazardous Use
Problem Use
Substance Abuse
Substance Dependence
Special Assessments
• Functional Abilities
– Activities of Daily Living (ADLs)
– Instrumental Activities of Daily Living (IADLs)
– SF-36
• Comorbidities
– Physical
– Psychiatric
• Affective disorders
• Suicide risk
• Sleep Disorders
Special Assessments
• Cognitive Impairments
– Dementia
• Orientation/Memory/Concentration Test
• Folstein Mini-Mental Status Exam (MMSE)
– Delirium
• Confusion Assessment Method (CAM)
– Other cognitive impairments
• Trauma from falls, MVA, accidents
• Wernicke-Korsakoff syndrome
Suicide Risk Items *
1. Has anyone in your family ever committed
suicide?
2. If yes, who in your family committed suicide?
3. Have you ever thought about taking your life?
4. How recently have you thought about killing
yourself?
5. Do you have a plan for doing this? (response
selected from list of plans provided)
6. Have you ever been in the care of psychiatrist,
psychologist, or other professional because of
severe depression or mental problems?
7. Do you keep firearms in the house?
8. If yes, ask how many guns are in the house?
*
Adapted from Brown & Bongar (2004) Assessing risk for completed suicide in elderly
patients: Psychologists' views of critical risk factors. Professional Psychology: Research
and Practice.
40
Short - Geriatric Depression Scale
Scoring:
5-9 = mild to moderate
1. Are you basically satisfied with your life?
depression
2. Have you dropped many of your activities
10+ = serious levels of
and interests?
depression
3. Do you feel that your life is empty?
4. Do you often get bored?
5. Are you in good spirits most of the time?
6. Are you afraid that something bad is going to happen to you?
7. Do you feel happy most of the time?
8. Do you often feel helpless?
9. Do you prefer to stay at home, rather than going out and
doing new things?
10. Do you feel you have more problems with memory than most?
11. Do you think it is wonderful to be alive now?
12. Do you feel pretty worthless the way you are now?
13. Do you feel full of energy?
14. Do you feel that your situation is hopeless?
15. Do you think that most people are better off than you are?
Screening and Assessment
Recommendations for Older
Adults
 Every person over 60 should be
screened for alcohol and drug abuse as
part of regular physical examination
 “Brown Bag Approach”
 Screen or re-screen if certain physical
symptoms are present or if the older
person is undergoing major life
transitions
Medication Misuse –
“Brown Bag” Review
Interviewer's impressions of the person
after completing the "Brown Bag Review" of
prescriptions:
1. Does not correctly recall the purpose of one or more medications
2. Reports the wrong dose/amount of one or more medications
3. Takes one or more medications for the wrong reasons or symptoms
4. Needs education and/or assistance on proper medication use
Medication Use: Client Interview
Items
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Takes more than one type of prescribed medication
Difficulty remembering how many meds to take
Prescriptions from two or more doctors
Felt worse soon after taking meds
Taking meds to help sleep
Uses up meds too fast
Takes meds for nervousness or anxiety
Doctor/nurse expressed concern about use of meds
Take pain relieving meds
Take pills to deal with loneliness, sadness
Saving old medications for future use
Chooses between cost of meds and other necessities
A family member reminds them to take pills
Uses dispenser or other method to help remind
Fails to take meds supposed to
Borrow someone else's meds
Feel groggy after taking certain medications
OTC Medication Use – Client Interview Items
1. Do you frequently take aspirin, Tylenol, Advil, or other
non-prescription pills for pain?
2. Do you ever tell your physician about the type of nonprescription pills you buy?
3. Do you use herbal pills such as Ginkgo, Saw Palmetto,
St. John's Wort?
4. Do you take non-prescription pills or remedies for
improving your memory?
5. Have you ever felt worse soon after taking over-the
counter remedies?
6. Are you taking medications to help you sleep?
7. Do any of the non-prescription pills you take make you
feel groggy?
8. Do you use plants or herbs to make your own remedies such as
garlic, or aloe?
Practitioner Barriers
to Identification
Ageist assumptions
Failure to recognize symptoms
Lack of knowledge about screening
Physician discomfort with substance
abuse topic
- 46.6% of primary care physicians found it
difficult to discuss prescription drug abuse
with their patients
(CASA,
2000)
Individual Barriers
to Identification
Attempts at self-diagnosis
Description of symptoms attributed to
aging process or disease
Many do not self-refer or seek treatment
- Although most older adults (87 percent) see
physicians regularly, an estimated 40 percent of
those who are at risk do not self-identify or seek
services for substance abuse
(Raschko, 1990)
Screening and Assessment
Recommendations for Older
Adults
 Ask direct questions about concerns
 Preface question with link to medical
conditions of health concerns
 Do not use stigmatizing terms (i.e. drug
addict)
Future Directions
 Risk and Protective Factors/Prevention/Early
Identification
 Drug of Choice
• Illicit, Prescription, Alcohol
 Patterns of use
• Drug use trajectories
• Re-emergence of addiction in late life
• Late-life onset of substance use disorder
 Screening, Assessment and Diagnosis
 Identification and treatment of psychiatric
comorbidities
The Alcoholic Brain
• Smaller, lighter and more shrunken.
• More extensive shrinkage in cortex.
• Vulnerability to shrinkage greater with age.
– Enlargement of the ventricle system.
– Reduced weight and volume.
• Decreased blood flow and metabolism.
• Women may be more vulnerable.
51
Normal Brain SPECT Images
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ALCOHOL
17 Years of Heavy weekend use
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Alcohol
44 year old with 18 years of
daily use; underside
surface view; marked
overall decreased activity
45 year old with 25 years
history of daily use;
underside surface view;
marked overall decreased
activity
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Cocaine
Methamphetamine
~ 24 year old ~
2 years use
~ 28 year old ~
8 years use
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Marijuana
~ 18 year old ~
3 years use
4 times a week
59
Heroin
~ 40 year old ~
7 years methadone use
10 years heroin use
60
Before and After Recovery
Active substance abuse
One year alcohol and
drug free
61
Before and After Recovery
Active substance
abuse
One year alcohol and
drug free
62
FACTORS INFLUENCING
OUR BELIEFS
Cohort Effect
Historical Events
63
Generational Experiences
Today’s OA
Baby Boomers
Gen X
Depression
Rap
WWI/WWII
Sexual
Openness
Vietnam/Gulf
Prohibition
Illicit Drugs
Raves
Advent TV
Advent PC’s
Advent Web
Antibiotics
Transplants
Cloning
Automobile
Air Travel
Space
Gen War
64
Intervention
Are all interventions
SUCCESSFUL?
65
INTERVENTION
Presenting reality as a united
front
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Dysfunctional Families Are
Blindfolded
– don’t see
Gagged
– don’t talk
Ear muffed
– don’t hear
Handcuffed
– don’t touch
Lassoed
– don’t reach out
Shackled – don’t step out of line
Hobbled
– don’t go for help
68
The Five Freedoms
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Seeing and hearing what is
Saying what you feel and think
Feeling what you feel
Asking for what you want
Taking risks on your own behalf
69
Sandwich Generation
Group of adult
children and others
who are responsible
for three or more
generations of
people
70
Accidental Addicts
• Possible problems with patient medical
condition
– Requires drug therapy / not receiving drug
– Wrong drug taken
– Too little / much of correct drug taken
– Result of adverse drug-reaction
– Result of drug / drug, drug / food, drug / lab.
Int
– Result of drug for not valid indication
71
Accidental Addicts
• Patient – Doctor Communication
Questions
– What drug have I been prescribed?
– How does this drug work?
– Why am I taking this drug?
– What are the side-effects of this drug?
– How long should I take this drug?
72
Factors Influencing our Beliefs
• If we are to help…
– We must be sensitive to the values and
beliefs held by older adults
– We must be sensitive to the values and
beliefs of family members
– We must examine our values and beliefs
73
Factors Influencing our Beliefs
• When grandma got ‘tipsy’ we all thought it
was ‘cute’
• Let him drink, he’s not hurting anybody.
• What difference does it make at his age
• It’s okay for Grandpa to get ‘drunk’ but not
Grandma
74
Factors Influencing our Beliefs
• Myths
– Older people can’t learn
– Reconstructive surgery
– Too old to be depressed
– It is worth it
– Last remaining friend
75
Factors Influencing our Beliefs
• Stereotypes
– Man under bridge
– Town drunk
– Daily drinker
– Younger person
– Skid row bum
76
Older Adult Treatment
• Older adult facts
– Age specific treatment most effective
– Highest rate of recovery
– Tendency to follow direction
77
Older Adult Treatment
• Special Treatment Needs
– Extended / Appropriate Detox
– Slower transition
– Speech, hearing, vision, nutrition
– Medical, Psychological, Psychiatric
– Grief, loss, rest periods, recreation
– Treating Whole Person
78
Older Adult Treatment
• Special Issues for Older Adults
– Denial
– Alcoholics Anonymous
– Women’s Issues
– Men’s Issues
79
Older Adult Treatment
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Groups for Older Adults
Grief
Life Transition
Relapse
Women / Men Alumni
Support
• Sober Seniors
• Nutrition
• Continuing Care
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Dual Diagnosis
Wellness
Storytime
Meditation
AA / Big Book
Nicotine
RET
Regular Group Therapy
80
Continuing Care
• Components of Continuing Care
– Health Care Concerns
– Coping Mechanisms
– Spirituality
– Living Situation
– Support System
– Community Resources
– Alumni or AA Contact
81
Prevention of Substance Abuse
Among Older Adults: Protective
Factors
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Female
Higher Religiosity
Fewer Mental/Physical Health Problems
Lower SES
Positive Coping Styles
More Social Supports
Thank You
For more information, please contact…
Hanley Center
933 45th Street
West Palm Beach, FL 33407
(Office) 561-841-1136
Email: [email protected]
Website: hanleycenter.org
Toll Free: 866-4HANLEY