Tip 26 Mental Health and Substance Abuse Treatment Older Adults

Dr. Dawn-Elise Snipes, PhD, LMHC, CRC, NCC

Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC

Abuse of alcohol and prescription drugs among adults

60 and older is one of the fastest growing health
problems facing this country.
In the United States, it is estimated that 2.5 million

older adults have problems related to alcohol.
Adults age 65 and older consume more prescribed and

over-the-counter (OTC) medications than any other
age group.
Treating older adults for substance use disorders is

worthwhile.
Alcohol or substance abuse problems can be

successfully treated in older adults.

 Three age-related changes significantly affect
the way an older person responds to alcohol:
1) The normal decrease in body water that comes
with age means:
 the same amount of alcohol that previously had little effect can
now cause intoxication
 increased sensitivity and decrease tolerance to alcohol
2) The decrease in the rate of metabolism of
alcohol in the gastrointestinal tract means:
 blood alcohol level remains raised for a longer time
 an increased strain is placed on the liver


3) Age-related changes, combined with alcohol
consumption, can trigger or worsen serious
problems including :
 heart problems
 risk of stroke
 cirrhosis and other liver diseases
 gastrointestinal bleeding
 depression, anxiety, and other mental health problems


Many older adults’ medications can interact negatively

with alcohol
Older adults can become dependent on psychoactive

medications without realizing it
Older patients are more likely to misunderstand

directions for appropriate use of medicines
Older adults often receive multiple prescriptions from

different doctors without coordination
Unintentional misuse can progress into abuse if

medication is used for the desirable effects it provides


Psychoactive substance use, even at therapeutic

doses, has been associated with a variety of negative
central nervous system effects.
Indications of problematic psychoactive substance use:

• diminished psychomotor performance
• impaired reaction time
• loss of coordination
• falls
• excessive daytime drowsiness
• confusion
• aggravation of emotional state
• amnesia
• dependence


 Emotional and Social Problems
• Bereavement and sadness
• Losses
 spouse, friends, family members
 social status
 occupation and sense of professional identity
 hopes for the future
 ability to function
• Social isolation and loneliness
• Reduced self-regard or self-esteem
• Family conflict and estrangement
• Problems in managing leisure time/boredom
• Loss of physical attractiveness

 Medical Problems
• Loss of hearing or sight
• Chronic pain
• Physical disabilities and handicapping conditions
• Reduced mobility
• Insomnia
• Cognitive impairment and change
 Practical Problems
• Impaired self-care
• Dislocation from housing
• Reduced coping skills
• Loss of income or increased health care costs


 Other issues to watch for
• Older men when their wives die
• High rates of alcoholism reported in medical
settings
• Substance use disorder earlier in life
• Mood disorders
• Family history
• Psychoactive prescription drug use


 All adults age 60 and over as part of their
annual physical
 If the person undergoes a major life
transition
 If the person develops physical symptoms
not expected or explained by other medical
issues


 The following physical symptoms may alert
to the development of an addiction:
• Sleep-related problems
• Cognitive difficulties
• Seizures, malnutrition, muscle wasting
• Liver function abnormalities
• Persistent irritability and altered
mood, depression, or anxiety
• Unexplained complaints about chronic pain
• Incontinence, urinary retention, difficulty urinating


• Poor hygiene and self-neglect
• Unusual restlessness and agitation
• Complaints of blurred vision or dry mouth
• Unexplained nausea and vomiting
• Changes in eating habits
• Slurred speech
• Tremors, poor motor coordination, shuffling gait
• Frequent falls or unexplained bruising


 Can hamper screening by the presence of a
severe cognitive impairment
 Withdrawal from psychoactive drugs can
induce delirium and is a medical emergency
 Signs of delirium include:
• Disorientation
• Impaired attention, concentration, and memory
• Anxiety, suspicion, and agitation
• Misinterpretation, illusions, or hallucinations
• Delusions, speech abnormalities


Dementia is generally a chronic, progressive, and

irreversible cognitive impairment.
Dementia makes it more difficult to:

• monitor outcomes of drinking
 clients may forget they drank
• get clients into treatment
• benefit from treatment

Signs of dementia include :

• Impairments in short- and long-term memory, abstract
thinking, and judgment
• Language disorder
• Personality change or alteration
• Mood disturbances

 Indications inpatient hospital supervision is
needed for withdrawal from a prescription
drug include:
1) A high potential for developing dangerous
abstinence symptoms, such as a seizure or
delirium, due to:
 dosage of a benzodiazepine or barbiturate has been
particularly high or prolonged
 dosage has been discontinued abruptly
 patient has experienced these serious symptoms at
any time previously


Indications for inpatient withdrawal cont…

2) Suicidal ideation or threats
3) The presence of other major psychopathology
4) Unstable or uncontrolled co-morbid medical
conditions requiring 24-hour care or parenterally
administered medications (e.g., renal
disease, diabetes)
5) Mixed addictions, including alcohol
6) A lack of social supports in the living situation or
living alone with continued access to the abused
drug(s)


Should be non-confrontational and supportive

because of shame issues
Provide customized feedback on drinking patterns

and other health habits

Provide information about sensible drinking limits

based on age, health, medications

Explore reasons for drinking


Explore consequences of drinking:

physical, psychological, or social functioning

Discuss key motivators to cut down or quit

drinking
• Maintaining independence
• physical health
• financial security
• mental capacity
Identify sensible ways to cut down or quit

• Developing social opportunities that do not involve alcohol
• Getting reacquainted with hobbies and interests from
earlier in life
• Pursuing volunteer activities

Develop a drinking agreement in the form of a

prescription

 Brainstorm methods for coping with risky
situations
• Social isolation
• Boredom
• Negative family interactions

 Should end with a summary of the session


 Feedback of personal risk or impairment as
derived from the screening
 Responsibility for change
 Advice to change
 Menu of options
 Empathic counseling style
 Support self-efficacy and ongoing follow-up

 Inpatient
• 24-hour, primary medical/psychiatric/nursing inpatient
care in
• medically managed and monitored intensive treatment
settings
 Patients who need this level of care:
• brittle, frail, acutely suicidal, medically unstable or
• need constant one-on-one monitoring
• older people who are dependent on psychoactive
prescription drugs should be served in
flexible, community-oriented programs with case
management services


 6 Features
1) Age-specific group treatment that is supportive and
non-confrontational; aims to build or rebuild the
patient's self-esteem
Focus on coping with depression, loneliness and loss
2)
(e.g., death of a spouse, retirement)
Focus on rebuilding the client's social support
3)
network
Pace and content of treatment appropriate for the
4)
older person
Staff members who are interested and experienced in
5)
working with older adults
Linkages with medical services, services for the aging
6)
and institutional settings for referral into and out of
treatment; as well as case management

5 Principles
1) Treat older people in age-specific settings where
feasible
Create a culture of respect for older clients
2)
Take a broad, holistic approach to treatment that
3)
emphasizes age-specific psychological, social
and health problems
Keep the treatment program flexible
4)
Adapt treatment as needed in response to
5)
client’s gender


 Cognitive-behavioral/ Motivational Approaches
• Help to identify the negative consequences of use
• Help to shift perceptions about the impact of use
• Empower the client to generate insights and
solutions
• Express belief in the person's capacity for change
• Help offset the denial, resentment and shame
• Focus on:
 rebuilding the social support network
 self-management approaches for overcoming
depression, grief or loneliness
 general problem solving

Group-based Approaches

• Contain both an educational/theoretical component and a
personal/practical application component
• Provide a clear statement of the goal and purpose of the
session; outline the content to be covered
Cover topics sequentially ; “building block” style
•
• Begin sessions with a review of previously presented materials
• Groups should use as many of the clients' senses as possible
• Group sessions should last no longer than about 55 minutes
• Area should be well lit without glare, interruptions and noise
• Superfluous material should be kept to a minimum


 Individualcounseling
 Medical/psychiatric approaches
 Marital and family involvement/family
therapy
 Case management/community-linked
services and outreach


 Whenever possible, employ staff who have
completed training in gerontology
 Employ staff who like working with older
adults
 Provide training in empirically
demonstrated principles effective with
older adults to all staff who will interact with
these clients


 There are many issues unique to treating
elders
 Substance abuse treatment is both
necessary and worthwhile in this
population
 Treatment in peer settings, by persons
sensitive to gerontological issues and by
clinicians of similar ages may help clients
feel more at ease


RESOURCES

AARP

• 601 E Street, NW
• Washington, DC 20049
• (202) 424-2277
• (202) 434-2562 (fax)
• www.aarp.org
National Center on Addiction and Substance Abuse at Columbia University

• 152 West 57th Street
• New York, NY 10019
• (212) 841-5200
• (212) 956-8020 (fax)
• www.casacolumbia.org
Join Together

• 441 Stuart Street
• Boston, MA 02116
• (617) 437-1500
• (617) 437-9394 (fax)
• www.jointogether.org
National Aging Information Center, U.S. Administration on Aging

• 330 Independence Avenue, SW, Room 4656
• Washington, DC 20201
• (202) 619-7501
• (202) 401-7620 (fax)
• http://www.aoa.gov/naic


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