Transcript Age Specific Approaches: Ensuring Competent Care

Substance Use Among the Aging
Population: A System-Wide Response
Aging Summit
Age-Specific Approaches: Ensuring
Competent Care
April 12th, 2016
Nicole MacFarland, PhD, LCSW-R, CASAC
Executive Director, Senior Hope Counseling, Inc.
Objectives
Gain an understanding of the prevalence and
significance of late-life addiction in New York State
and nationally.
Gain insight into critical elements of age-specific
services targeting older addicted adults by exploring
patient level characteristics in relation to outcomes.
Understand the unique needs of older addicted adults
in an outpatient setting which caters exclusively to
the 50+ population.
Overview
Older Addicted Adults: Prevalence & Significance
Theoretical Frameworks & Approaches
Treatment Overview
– Example: Senior Hope Counseling
Screening and Evaluation Tools
Overview of Presenter’s Research
Recommendations
Questions
Older Addicted Adults: Prevalence
& Significance
Projection of Substance Use Disorders
Among Seniors in the U.S.
Increased concern for those ‘baby boomers’ born
between 1946-1964 (Han, Gfroerer & Colliver,
2009).
Office of Applied Studies Data Review (2009)
rate for SUDs in 2020 for age 50-59 in U.S. is
projected to reach 5.7 million (Han, Gfroerer &
Colliver, 2009)
2015 OASAS Older Adult Admissions (55 and Older)
by Program Category
1,253
1,981
4,639
PROGRAM Category
Crisis
11,420
Outpatient
11,385
Opioid Tx
Program
Inpatient
Residential
OASAS 2016
Drinking Guidelines
Recommended Drinking Limits for Older Adults:
 No more than 1 standard drink per day.
 No more than 2 drinks on any drinking day
 Limits for older women should be somewhat less then for
older men (Merrick, E. et al., 2008).
 Lower limits for older adults because:
- Greater use of contraindicated medications
- Less efficient liver metabolism
- Increased alcohol sensitivity with age
- Less body mass/fat increases circulating levels
(Source: NIAAA, 3/04; Dufour & Fuller, 1995)
Early Onset vs. Late Onset
Early Onset:
use began <40 yrs
have used services for years
have basic understanding
Late Onset:
Use began >40 yrs
Usually healthier mentally and physically
have begun using services later in life
(Blow, Tip, 1998)
Older Adults and Alcohol Use
Increased risk of:
Stroke (with overuse)
Impaired motor skills (e.g., driving)
at low level use
Injury (falls, accidents)
Sleep disorders
Suicide
Interaction with dementia symptoms
(NIAAA, 3/04)
©2002 Microsoft
Corporation
Older Adults and Use (continued)
Other Effects:
Higher blood alcohol concentrations
(BAC) from dose
More impairment from BAC
Medication effects:
Potential interactions
Increased side effects
Compromised metabolizing
(especially psychoactive medications,
benzodiazepines, barbiturates, and
antidepressants)
(NIAAA, 3/04)
©2002 Microsoft
Corporation
Older Adults and Prescriptive Drug Abuse
Older patients are prescribed benzodiazepines more than any other age group, and
North American studies demonstrate that 17 to 23 percent of drugs prescribed to
older adults are benzodiazepines (D’Archangelo), 1993. The dangers associated with
these prescription drugs include problematic effects due to age-related changes in
drug metabolism, interactions among prescriptions, and interactions with alcohol.
(SAMHSA TIP 26)
Signs of Potential Alcohol Problems
Anxiety, depression,
excessive mood swings
Blackouts, dizziness, &
seizures
Disorientation
Falls, bruises, burns
Headaches
Incontinence
Memory loss
Unusual response to
medications
(NIAAA, 3/04)
New difficulties in making
decisions
Poor hygiene
Poor nutrition
Sleep problems
Family problems
Financial problems
Legal difficulties
Social isolation
Increased alcohol tolerance
Co-morbid Conditions
Co-morbidity is a serious,
common concern among
older adults using alcohol:
Impaired Activities of Daily Living
(ADL’s)
Psychiatric symptoms, mental
disorders
Alzheimer’s disease
Sleep disorders
(NIAAA, 3/04)
©2002 Microsoft Corporation
Co-Occurring Disorders Among
Older Adults
“Over the next 25 years, the number of older
adults with major psychiatric illnesses will more
than double from an estimated 7 to 15 million
Individuals” (Bartels et al., 2005, p.2).
Theoretical Frameworks &
Approaches
Theoretical Frameworks
& Approaches
Cognitive Behavioral Theory
Productive Aging Perspective
Motivational Interviewing
Harm Reduction
16
Cognitive Behavioral
Helps the patient overcome difficulties by identifying and
changing dysfunctional thinking behavior and emotional
responses.
Treatment focuses on:
– Symptom reduction and stabilization
– Skills training
– Teaching cognitive techniques (problem solving)
– Increasing time spent engaged in pleasant activities and
events (Coon & Devries, 2004).
17
Productive Aging Perspective
Challenges traditional perspective that
the aging adult is increasingly
unproductive over time
Instead, aging adult has a natural role
to contribute to society-for example,
through volunteering
Why is this perspective important?
(Kayne, Butler, & Webster, 2003)
18
Motivational Interviewing
Motivational interviewing enables the
clinician to address the client’s needs
from his or her perspective according to
client readiness for change.
(Miller & Rollnick, 1991)
19
Harm Reduction
Unlike traditional approaches, harm
reduction does not require an individual
to stop using but instead works on the
goal of abstinence, recognizing that not
everyone is able to abstain from
substance use during early stages of
treatment
(Erikson, Riley, Cheung, Yuet, & O’hare, 1997).
20
Treatment Overview
2008 Survey of NYS Programs
Based on a survey of 34 programs (with a 65 %) return rate, it
was found that treatment approaches and practices for older
adults dramatically differed between programs.
69% of the programs surveyed provided heterogeneous
services to seniors (meaning mixed-age groups).
– The emphasis in programs and services targeting seniors inclusive of
all programs was on Psycho- Education, Psychiatric Care, and Family
Services.
– Case management, Health & Nutrition Programming, and Grief and
Loss work were also widely utilized.
2008 Survey of NYS Programs
Of nine community service resources for Seniors, Senior
Centers were found to be the most utilized (45%).
Of the programs surveyed 80% acknowledged that the needs
of seniors are minimally met or not met at all.
Treatment Approaches
Community
Integration
Wide Range
of Services
Senior
Addiction
Treatment
ResearchInformed
Practices
Approach
(Harm
Reduction
vs.
Abstinence)
AgeTailored
Services
Treatment Approaches
Individual counseling
Group- based
counseling
Medical/psychiatric
approaches
Cognitive-behavioral
therapy
Harm Reduction
Source: NIAAA Social Work Education
Module 10C (Revised 3/04)
Marital and family
involvement/family
therapy
Case management/
community-linked
services & outreach
Formalized
substance abuse
treatment
Senior Hope Counseling
Senior Hope Counseling Inc.
Senior Hope is a nonprofit clinic catering exclusively
to the 50+population struggling with alcohol and/or
other drugs.
Founded fourteen years ago by Dr. Bill Rockwood &
his wife Adrienne.
Mission: Senior Hope Counseling provides quality,
evidence-based, comprehensive addiction services to
older adults and their families in a compassionate
setting.
Goal: promote the highest quality recovery lifestyle
possible for our clients and their families.
Services Offered: Senior Hope
Individual, family, and group services
Nursing assessments and family interventions
Non-Intensive level of outpatient services
Day and evening treatment programming
Tailored programming for addicted elders
Assessments, treatment planning, linkage, referrals, and
discharge planning
Referral Agencies
Inpatient Rehabilitations
Detoxification Facilities
Judicial System
Medical Floors of Hospitals
EAP’S
Agencies Serving Older Adults
Friends and Family
Concerns of Financial Exploitation
Among Elders
Telemarketing
Door-to-door sales
Sweepstakes
Home Improvements
Predatory Lending
Charity scams
Intervention
Payees
APS
Family Interventions
Legal Assistance
Financial Management Consultation
Individual Counseling
Senior Hope Counseling Inc.
An ACE Informed Outpatient Clinic
Examining Adverse Childhood Experiences
The Benefit of Using an ACEs Screening Tool
The Adverse Childhood Experiences
(ACE) Study
Summary of Findings:
• Adverse Childhood Experiences
(ACEs) are very common
• ACEs are strong predictors of adult
health risks and disease
• ACEs are implicated in the 10 leading causes of
death in the U.S.!
ACEs: MARC Project
Senior Hope- ACEs Project 2016 & 2017
Data Collection ACE Questionnaires
Dissemination of Knowledge
Implications for the Future
Group Offerings: Senior Hope
11 Age-Specific Groups
Trauma Survivors’ Group
Recovery Topics
Life’s Transitions Group
Relapse Prevention
Men’s Group
Anger Into Energy Group
Women’s Group
Understanding Addiction
Mental Health & Recovery
Wellness and Recovery
Goal-Oriented Action and Learning
Themes: Senior Hope
 Elders benefit from being treated with
individuals their same age and talking
about age related issues.
 Older addicted adults report that they
benefit from smaller groups that focus on
age specific topics run by professionals
with geriatric addictions and mental
health background.
Themes: Senior Hope
 Older adults have repeatedly stated they are
uncomfortable with profanity in the group
session.
 Having age related materials in the waiting
room helps older adults feel more
comfortable in the waiting room.
 Having transportation to pick up patients is
helpful.
Themes: Senior Hope
 Being sensitive to the generation
these individuals grew up in is
critical.
 We often say what type of
legacy do you want to leave
behind. Do you want to be
remembered as ‘mom’ or ‘dad’
‘grandma’ or ‘grandpa’ who
died after a fall due to being
intoxicated?
Themes: Senior Hope
 Finding meaning and purpose in later
life is so important. Often we hear from
elders that they do not feel anyone
needs them anymore and that they have
nothing to do.
 Why age specific services vs. Mixed
age group treatment. My dissertation
focused on the theme of how ‘one size
does not fit all’ when it comes to
addictions treatment.
Senior Hope: Themes
 ACE questionnaire integrated into
programming
 Trauma Survivors Group to help
older addicted adults have a safe
place to discuss the impact early
childhood trauma had on later-life
addictions, mental health and
physical wellness.
Themes: Senior Hope
 Connection of services in the
community. So often older adults
may feel too tired, disabled,
overwhelmed, and alienated to
identify what services in the
community may help them.
Themes: Senior Hope
 Older addicted and mentally ill adults are
at greater risk of financial exploitation,
emotional and/ or physical abuse by adult
children as well as predators in the
community.
Statistical Overview of Senior Hope
01/01/2010- 01/01/2016 (N=761) OASAS
Gender: 61.4% Male 38.6% Female
Age: 56+ = 69.3%, < 56= 30.7%
Mental Health= 60.4%
Primary Substance: Alcohol=71.9%
Retired: 28.6% Disabled: 35.0%
Race: White=71.4%
Black/African American=25.8%
Educ.: HS=21.8; Assoc. =8.5; BA=13.4; Grad=11.4
Impairment: Hearing=12.1%, Mobility= 32.9%
Sight: 32.6%, Other Health Conditions: 62.2%
Statistical Overview of Senior Hope
01/01/2010- 01/01/2016 (N=761) OASAS
Marital Status: 27.9% Divorced, 9.3% Widowed,
28.6% Married, 1.7% Living as Married, 24.2%
Never Married, and 9.3% Separated
ACOA/ACOSA: 6.4% with both, ACOA only:
41.4%, ACOSA only: 1.8%
ER Episodes (past six months): 36.9% had 1 or
more
Criminal Justice System: (Past six months); 27.9%
Changes In Primary Substance at Admission:
Senior Hope Counseling, Inc.
2015: Alcohol Primary Substance- 73% (N=141)
Heroin Primary Substance- 9.9%
Other Opiate/Synthetic Primary Substance- 4.3%
OxyContin Primary Substance -1.4%
2014: Alcohol Primary Substance- 72.9% (N=155)
Heroin Primary Substance- 11.0%
Other Opiate/Synthetic Primary Substance-.6%
OxyContin Primary Substance-1.3 %
2013: Alcohol Primary Substance- 69.2% (N=133)
Heroin Primary Substance- 8.3%
Other Opiate/Synthetic Primary Substance- 1.5%
OxyContin Primary Substance- 2.3%
(OASAS Statistics, 2016)
Changes In Substance Use
From 2010 to 2014, older adult (age 50
years of age and older) admissions to
outpatient treatment programs statewide
for opioids as a primary substance of
abuse have increased by 22 percent,
from 2,760 in 2010 to 3,370 in 2014.
(Provided by the New York State Office of Alcoholism and
Substance Abuse Services)
OASAS Program Performance
Report (calendar Year) 2015
Performance of our Program
Units of Service per Full-Time Employee 2,559 (per year)
Minimum Standard
1,000
% Discontinued Use
54
25
1 Month Retention Rate
77
75
3 Month Retention Rate
68
65
6 Month Retention Rate
54
40
% Completing Program or Referred
33
35
Patient to Primary Counselor Ratio
34
25
Senior Hope Counseling Inc.
Monthly Units of Service from 2002-2015
900
January
Units of Service Per Month
800
700
Februar
y
March
600
April
May
500
June
400
July
August
300
Sept.
200
Oct.
100
Nov.
Dec.
0
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Years of Operation
2012
2013
2014
2015
Screening and Evaluation Tools
CAGE
C Have you ever felt you should cut down on your drinking?
A Have people annoyed you by criticizing your drinking?
G Have you ever felt bad or guilty about your drinking?
E Eye opener: Have you ever had a drink first thing in the
morning to steady your nerves or to get rid of a hangover?
An answer of 2 or more indicates high likelihood of a substance
abuse problem. An answer Yes to one question indicates the need
for a referral for a full evaluation.
Mayfield D., McLeod G., et al. 1974, “The CAGE Questionnaire: Validation of a
New Alcoholism Instrument. “ American Journal Psychiatry 131 (10): 1121-1123.
Table 3: Short Michigan Alcoholism Screening
Test :Geriatric Version
(S-MAST-G) The Regents of the University of Michigan, 1991.
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 didn't feel hungry?
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?
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 made rules to manage your drinking?
10. When you feel lonely, does having a drink help?
TOTAL S-MAST-G SCORE (0-10)
Scoring: 2 or more "yes" responses are indicative of an alcohol problem.
Contact source: Frederic C. Blow, Ph.D., University of Michigan Alcohol Research
Center, 400 E. Eisenhower Parkway, Suite A., Ann Arbor, MI 48104, 734-998-7952
Adapted from the NIAAA Social Work Module 10C
Overview of Presenter’s Research
Methodology
An ex post facto examination of secondary data
exploring the effectiveness of geriatric addictions
treatment in community-based outpatient clinics
across NYS.
Data Sources
Survey of Providers
– Enabled the PI to identify what patients received
New York State Client Data System
– Admission Data
– Discharge Data
Sample
Purposive, non-probability sample.
Sample Size: 1,456 patients
– Discharged from 22 outpatient chemical
dependency programs across New York State
during the following time period: 1/1/200812/31/2008.
All patients ages 50 and older who had a length of
stay of 30 or more days and 4 or more treatment visits
were included.
Statistical Analyses
Program survey data (from the pilot study) and
client level data (OASAS) were combined.
Binary logistic regression analyses (exploring
changes in odds ratios) were conducted that
included the pertinent control and interaction
variables.
Final Variables and Predicted Findings
Control Variables
Age
Gender
Independent
Variables
Strong Promising
Approaches (SPA)
Dependent
Variables
Social Goal
Achievement
Strong
Community
Integration (SCI)
Race
Use Severity
Co-Occurring MH
Disorder
Legal Status
Strong AgeTailored (SAT)
Strong
Comprehensive
Services (SCS)
Strong Harm
Reduction (SHR)
Co-Occurring
Medical Condition
Strong Health
Focus (SHF)
Employment
LOS
Parental Addiction
Overall Goal
Achievement
Findings
Females were more likely to have co-occurring illness
(80%, p<.001 versus 52% for males), lower drug use
severity (19% versus 25% for males, p<.05) and less
likely to have criminal justice history (10.3% , p<.001
versus 30% for males).
Those 65 and older compared to those 50-64 years
old were less likely to have high severity of SUDs
(11% versus 26%, p<.001), more likely to have cooccurring mental illness (77% versus 57%, p<.001)
and less likely to have a criminal justice history 11%
versus 27%, p<.001) and more likely to be
unemployed (94 % versus 58%, p<.001).
Findings
Blacks when compared to all others were
significantly more likely to have severe drug use
(29%, p<.01), criminal justice history (30%, p<.001)
and alcohol/drug addicted parents 44%, p<.001).
Latinos when compared to all others were
significantly more likely to have criminal justice
history (35%, p<.001) and severe alcohol/drug use
(28%, p<.05).
Whites were significantly less likely to have high
severity of SUDs (19%, p<.001), criminal justice
history (17%, p<.001), and unemployment (38%,
p<.05).
Findings
The condition of having employment (OR=1.47,
p<.001) was associated with better odds of overall
goal achievement.
Older age (OR=2.65, p<.001) was associated with
better odds of overall goal achievement.
The condition of having parents who were
themselves substance addicted (OR=.759, p<.05) was
associated with lower odds of overall goal
achievement.
The condition of having co-occurring mental illness
(OR=.645, p<.01) was associated with overall lower
odds of overall goal achievement.
Findings
The main finding was that programs that
provided age-tailored services (SAT) for older
addicted adults had better odds of overall goal
achievement by a factor of 2.25 (p<.01)
For each increase in the number of age-tailored
services (SCS) provided, programs improved
their odds of overall goal attainment by 21.6%
(p<.001).
Findings
Strong age-tailored services were associated
with 2.3 times greater odds (p<.01) of social
functioning goal achievement.
Each increase in the number of age-tailored
services led to 16.7 percent improved odds
(p<.001) of social functioning goal
achievement.
Findings
Programs that provided strong community
integration (SCI) for older addicted adults had
better odds of overall goal achievement by a
factor of 1.7 (p<.01).
Programs that provided strong community
integration (SCI) for older addicted adults had
better odds of social goal functioning by a
factor of 1.9 (p<.01).
Findings
There was some support for the promising
approaches identified in the literature review
(including case management combined with
CBT and age-tailored groups), however this
did not reach the p<.05 (p=.103) level of
significance.
Recommendations
Recommendations
MAIN FINDING
– Mixed vs. Same-Age
– Age-Tailored Services
Grief and Loss, Psycho-Education, Health & Nutrition,
Transportation, Psychiatric Services, Case Management
& Family Services.
Strong Community Integration
– Avoid “silos”
– Locate programs that treat seniors in communities rich with
senior services.
Recommendations
Harm Reduction
Strong Health Focus
Strong Promising Approaches
– CBT (Schonfeld & Dupree, 1995; Rice et al.,
1993), age-specific services (Blow et al., 2000;
Cummings et al., 2006), and case management
services (D’Agostino et al., 2006).
Recommendations
EMPLOYMENT
– Meaning and Purpose
– Unstructured Time
OLDER AGE
– Physiological changes
– Multiple medications
– Co-Occurring MH & Medical
Recommendations
ACOA/ACOSA (Have Parents who were addicted)
– ACEs
MENTAL ILLNESS
– Rates of Mental Illness
– Implications for Programming
– Insurance Reimbursement Implications
Questions
Contact Information
Nicole MacFarland, PhD, LCSW-R, CASAC
Executive Director, Senior Hope Counseling, Inc.
Phone (518) 489-7777 Fax (518) 489-7771
Email: [email protected]
Website: www.seniorhope.org
Facebook: https://www.facebook.com/SeniorHope195059470831009/?ref=aymt_homepage_panel
Websites & Resources
WWW.Nami.Org
www.geron.org/Hartford/docfellows.htm
http://www.niaaa.nih.gov/
http://www.drugabuse.gov/OtherResources.html
http://csat.samhsa.gov/
www.ncadi.samhsa.gov
http://users.erols.com/ksciacca/
Continuing Education Training
NASW-NYS
Course Title: Geriatric Addictions
CEU Credits: 2
Member Price: $ 20.00
Non Member Price: $ 25.00
Course Description:
Recovery In The Golden Years: A Social Work Perspective By
Nicole Sarette MacFarland, LCSW-R, DCSW, CASAC
Published Article
International Journal of Aging and
Human Development
“Restorative Integral Support (RIS) for Older
Adults Experiencing Co-Occurring Disorders”
Larkin, H. & MacFarland, N.S.
Book Chapter: Schonfeld & MacFarland
Schonfeld, L. & MacFarland, N.S. (2015)
Treatment of substance abuse disorders in
older adults. In P.A. Arean (Ed.) Treatment
of late-life depression, anxiety and
substance abuse. Washington, DC:
American Psychological Association.
Chapter 28: A Social Work Perspective On Geriatric
Addictions By Nicole S. MacFarland
Thank You