Substance abuse and the elderly: unique issues and concerns. (Substance Abuse and the Elderly).Substance use, abuse, and dependence are elusive constructs when it comes to assessing problem behavior among individuals who are elderly (defined as individuals over the age of 65 for this article). While it is clear that drug and alcohol use, abuse, and dependence occur among this age cohort, the extent, types and outcome of use, abuse, and dependence are speculative, at best. Individuals over the age of 65 make up roughly 12.4% of the total U.S. population (about 35 million people) and they represent the fastest growing age cohort; by 2030 this group will nearly double in size to over 70 million individuals and will represent 20% of the U. S. population (Administration on Aging The Administration on Aging (AoA) is an agency of the United States Department of Health and Human Services. AoA awards annual grants (computed by formulas) to State government agencies on aging and Native American tribal organizations to support programs mandated by the Congress , 2002). Various sources of data suggest that alcohol problems are ordinary events, but largely unrecognized in this population and estimates of the prevalence of heavy drinking
The rehabilitation, substance abuse, and gerontology gerontology: see geriatrics. literature pay scant attention to alcohol problems of the elderly and largely ignore drug problems all together. Several reasons have been suggested for this lack of information and attention. First, drug abuse/dependence research tends to be driven by the federal agenda and the popularity of drugs at a given time, to the exclusion of other drugs and other drug related behaviors. Initially, research centered on the problems created by dependence on illicit narcotic narcotic, any of a number of substances that have a depressant effect on the nervous system. The chief narcotic drugs are opium, its constituents morphine and codeine, and the morphine derivative heroin.
See also drug addiction and drug abuse. drugs with recent shifts in attention to cocaine and illicit stimulant drugs. As aging individuals are thought to be among the least likely to use these drug types, little information is known about incidence or prevalence or about the effects of these drug on the elderly population.
Second, as Winnick (1962) suggested, individuals "age out of" drug use and relatively few individuals maintain illicit drug illicit drug Street drug, see there use beyond his or her thirties or forties. Peterson (1988) reported that individuals who begin substance abuse after age 65 are more likely to abuse alcohol and rarely turn to illicit drugs.
Third, stemming from the massive drug problems that began in the 60s, the emphasis in the literature and treatment has been on drug and alcohol problems presented by adolescents and young adults. Indeed, some have argued that the substance abuse treatment system and treatment literature have been strongly biased towards young males to the neglect of not only the elderly, but women, some minorities, and people with disabilities (Benshoff & Janikowski, 2000). As a consequence, little is known or empirically reported about the unique needs presented by individuals who are elderly and experiencing drug and alcohol problems.
Finally, Levin and Kruger (2000) called substance abuse among older adults an "invisible epidemic" (p. 1) noting that older adults, relatives, and caregivers tend to downplay the existence of substance abuse problems in this population. Levin and Kruger asserted that the symptoms of alcohol and drug abuse are often mistaken for the symptoms of aging problems such as dementia, depression, or other problems commonly seen in older adults.
Extensive data exist about prescription and over the counter drug use by the elderly. Although elderly individuals make-up 12.4% of the population, they consume 25% to 30% of all prescription drugs (Ondus et al., 1999). On a daily basis elderly adults consume more over-the-counter and prescription drugs than any other age group and are more likely to consume psychoactive drugs Psychoactive drugs
Any drug that affects the mind or behavior. There are five main classes of psychoactive drugs: opiates and opioids (e.g. heroin and methadone); stimulants (e.g. cocaine, nicotine), depressants (e.g. with a potential for misuse, abuse, and addiction (Levin & Kruger, 2000). In 1985 Vestal vestal (vĕs`təl), in Roman religion, priestess of Vesta. The vestals were first two, then four, then six in number. While still little girls, they were chosen from prominent Roman families to serve for 30 (originally 5) years, during which and Dawson (as cited in Crandall, 1991) listed the most frequently used drug types as analgesics Analgesics Definition
Analgesics are medicines that relieve pain.
Analgesics are those drugs that mainly provide pain relief. (used by 67% of the population), cardiovascular drugs (34%), laxatives Laxatives Definition
Laxatives are products that promote bowel movements.
Laxatives are used to treat constipation—the passage of small amounts of hard, dry stools, usually fewer than three times a week. (31%), vitamins (29%), antacids Antacids Definition
Antacids are medicines that neutralize stomach acid.
Antacids are used to relieve acid indigestion, upset stomach, sour stomach, and heartburn. (26%), and anti-anxiety medications (22%). More recently Ondus et al. noted that elderly individuals are 2-3 times more likely than younger individuals to be prescribed psychoactive drugs, most notably benzodiazepines Benzodiazepines Definition
Benzodiazepines are medicines that help relieve nervousness, tension, and other symptoms by slowing the central nervous system.
Benzodiazepines are a type of antianxiety drugs. . Notably. Levin and Kruger (2000) reported that benzodiazepines make up 17% to 23% of drugs prescribed for older adults.
Drug use appears to negatively affect the health of the elderly at a higher rate than other populations. Data suggest detrimental drug reactions occur 3 to 7 times more often for older adults (Crandall, 1991) and 12% to 17% of acute hospital admissions for adverse drug reactions adverse drug reaction,
n a detrimental outcome from a drug. Two types of ADRs exist: Type 1 results from dosage mismatch and Type 2 from rare conditions often as a consequence of a small dose. See also risk or sensitive type. occur in this population (Crandall, 1991). Similarly, Adams, Zhong, Barboriak, and Rimm reported that 11% to 20% of acute care hospital admissions among the elderly were alcoholism related (1993). Intentional abuse of prescription medications to get high is thought to be rare, but overuse overuse Health care The common use of a particular intervention even when the benefits of the intervention don't justify the potential harm or cost–eg, prescribing antibiotics for a probable viral URI. Cf Misuse, Underuse. does occur among this population. Often this over-use is related to multiple chronic health conditions being treated by several physicians. For example, an individual may be seeing a family practice physician for general health needs and specialists for specific diseases or illnesses. If these physicians are not communicating, the patient can be over-medicated and end up in serious difficulty. A more common adverse drug event among elderly persons who are poor is the under use of medication. Many individuals living at or below the poverty level and without a prescription drug plan may not have funds to purchase needed medication. This, of course, is a common scenario among individuals with disabilities who are poverty stricken.
Alcohol use, abuse, and dependence among the elderly population tend to occur at lower rates than in the general population; however data vary widely by study. Adams, Zhong, Barboriak, and Rimm (1993) reported that the prevalence of alcohol related problems in this population range from 1.4% of the elderly cohort to as high as 22%. The most recent National Household Survey on Drug Abuse revealed the over 65 years of age cohort has the lowest rates of alcohol use among any adult cohort, and by far the lowest rates of binge drinking binge drinking An early phase of chronic alcoholism, characterized by episodic 'flirtation' with the bottle by binges of drinking to the point of stupor, followed by periods of abstinence; BD is accompanied by alcoholic ketoacidosis–accelerated lipolysis and and heavy alcohol use (Substance Abuse and Mental Health Services Administration The Substance Abuse and Mental Health Services Administration (SAMHSA), an operating division of the Health and Human Services Department (HHS), was established in 1992 by the Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act (Pub. L. No. 102-321). , 2002). Alcohol use among the elderly is common with declines seen with advancing age (Rigler, 2000), but alcohol related problems are a significant cause of acute-care hospitalization hospitalization /hos·pi·tal·iza·tion/ (hos?pi-t'l-i-za´shun)
1. the placing of a patient in a hospital for treatment.
2. the term of confinement in a hospital. in this group (Rigler, 2000; Adams et al., 1993).
It is difficult to adequately ascertain rates of abuse, use, and dependence among this group for several reasons. First, the elderly cohort tends to be a "hidden" population, isolated from contact with traditional gatekeepers to treatment. They may not drive and thus are not likely to be arrested for driving under the influence; members of this cohort are usually retired and consequently do not experience alcohol-related job problems. Second, this is an age cohort more likely to view alcohol problems as a moral failing and may be less willing to report alcohol problems. Finally, the isolation imposed by failing health may reduce participation in social activities, but may not preclude drinking at home.
Early and Late Onset of Abuse
Traditionally, substance abusers over the age of 65 have been identified as early onset or late onset abusers (Benshoff & Roberto, 1987). More recently these categorizations have been conceptualized as chronic or situational (National Institute on Aging The National Institute on Aging is a division of the U.S. National Institutes of Health, located in Bethesda, Maryland.
Formed in 1974, NIA's mission is to improve the health and well-being of older Americans through research. It is the primary U.S. , 2002). Early onset abusers began drinking or drugging behavior before the age of 65 and continued to consume thereafter. Jung (1994) asserted early onset abusers frequently have significant physical and mental health problems, usually associated with their substance abuse history. Rigler (2000) reported that about two-thirds of elderly individuals with alcoholism problems are early onset drinkers, noting those individuals who survive the rigors of alcoholism problems in earlier life often have significant mental and physical health complications. Some individuals undoubtedly survive into old age because of genetics. Others probably survive because they have learned to moderate consumption to remain functional in the community and to maintain a semblance of good health. A common aphorism aphorism (ăf`ərĭz'əm), short, pithy statement of an evident truth concerned with life or nature; distinguished from the axiom because its truth is not capable of scientific demonstration. among aircraft pilots is that there are old pilots and bold pilots, but no old, bold pilots. The same may be true of the elderly cohort: there may be old drinkers and bold drinkers, but no old, bold drinkers.
Late onset abusers typically are individuals who begin their substance abuse after 65 usually in response to a negative life situation or event such as retirement, death of a spouse, decline in status in the community, or health setbacks. It is unclear, however, if a causal relationship exists (Rigler, 2000). For example, do individuals begin drinking after the loss of a spouse because of grief, or because the death resulted in the loss of a control mechanism? Does increased drinking after retirement result from despair in the change of life status or an inability to manage unstructured free time? Does a significant health crisis trigger increased alcohol consumption as a coping mechanism coping mechanism Psychiatry Any conscious or unconscious mechanism of adjusting to environmental stress without altering personal goals or purposes or as a way to supplement pain medication? Importantly, Peterson (1988) noted that adoption of illicit drug abuse in the later years is a rare phenomenon. Nearly all newly acquired substance abuse problems are alcohol related in the over 65 years old cohort.
Brennan and Moos (1996) reported that, in contrast to early onset drinkers, late onset drinkers typically have fewer physical and mental health problems. They also have stronger societal connections (e.g., they are more likely to be in a marital relationship Noun 1. marital relationship - the relationship between wife and husband
family relationship, kinship, relationship - (anthropology) relatedness or connection by blood or marriage or adoption and less likely to have been in a correctional facility) and are less likely to have ever been in drug or alcohol treatment. Consequently, late onset drinkers tend to have a better prognosis for recovery because they have not suffered the physical and psychological ravages rav·age
v. rav·aged, rav·ag·ing, rav·ages
1. To bring heavy destruction on; devastate: A tornado ravaged the town.
2. of long-term alcohol and drug problems (Brennan & Moos, 1996).
Unique Issues: Moderating and Exacerbating Factors
Individuals in the age cohort comprising the over 65 population today have had life experiences that may moderate against drug and alcohol abuse. The older members of this cohort lived through the prohibition years in America and during the era when temperance Temperance
Alcoholics Anonymous (AA)
organization founded to help alcoholics (1934). [Am. Culture: EB, I: 448]
provides protection against drunkenness; February birthstone. was popular. In addition, nearly all of the members of this age cohort lived during a time when drug use was frowned upon by mainstream society and when the availability of drugs of abuse was limited. Individuals over the age of 65 were not exposed to illegal drug use at the same rates as the general population during their adolescent and young adult years, typically the time of greatest drug exploration. Alcohol use was more tightly controlled for this population, also, and additionally was stigmatized (National Institute on Alcohol Abuse and Alcoholism The National Institute on Alcohol Abuse and Alcoholism (NIAAA), as part of the U.S. National Institutes of Health, supports and conducts biomedical and behavioral research on the causes, consequences, treatment, and prevention of alcoholism and alcohol-related problems. , 1998). Many states had "blue laws blue laws, legislation regulating public and private conduct, especially laws relating to Sabbath observance. The term was originally applied to the 17th-century laws of the theocratic New Haven colony, and appears to originate in " on the books, supported by prohibitionist pro·hi·bi·tion·ist
1. One in favor of outlawing the manufacture and sale of alcoholic beverages.
2. often Prohibitionist A member or supporter of the Prohibition Party. or temperance movements temperance movements, organized efforts to induce people to abstain—partially or completely—from alcoholic beverages. Such movements occurred in ancient times, but ceased until the wide use of distilled liquors in the modern period resulted in increasing . These morality-based laws tended to restrict alcohol sales in terms of time and place. For example, many public venues were not permitted to sell alcohol and it was common for alcohol to be prohibited at sporting events, fairs, and other social gatherings. The vestiges of these laws and the prohibitionist and temperance movements are seen in the "dry" communities and counties that continue to exist in many states. As a consequence of their life experiences and societal events, many older adults view substance abuse as a moral failing (Marks, 2002).
In addition, this is an age cohort that has seen a lesser emphasis on legal drugs to treat illness and disease. For many years the wonder drugs of today did not exist and the drugs in use were not advertised in the Sunday supplement or on television.
As a consequence of the aforementioned life influences, it is probable that the current 65 and over age cohort is less likely to abuse drugs or alcohol. It will be interesting to examine drug and alcohol use and abuse rates in the forthcoming age cohort to determine if exposure to different levels of drug and alcohol availability will have a positive, neutral, or negative influence on drug or alcohol abuse.
Individuals on a low fixed-income may not have the funds for discretionary or luxury expenses, categories into which the purchase of drugs and alcohol may fall. However, financial status may be an exacerbating factor. Individuals on a low fixed-income who spend money for alcohol or drugs may do so at the neglect of more basic needs such as adequate food or medication. Consequently, alcohol or drug abuse may wreak greater havoc because of poor nutrition and lack of medical care. In addition, higher rates of alcohol consumption are reported among the affluent elderly residing in retirement communities (Atchley, 1997).
Frail health has been cited as a reason for discontinuing alcohol and drug use among the elderly population (Atchley, 1997). Declining health may impede individuals from leaving home to acquire drugs and alcohol, or may result in placement in a nursing home or similar long-term care facility long-term care facility
See skilled nursing facility. where drug or alcohol access is prohibited. Additionally, evidence suggests that individuals in poor health may be more likely to consume medications that negatively interact with alcohol or mood-altering illicit drugs. Consequently, they may discontinue alcohol or drug use.
Perhaps the largest exacerbating factor contributing to substance abuse in the elderly is family, caregiver, and clinician complicity in the abuse process, a factor Benshoff and Roberto (1987) labeled the nice little old man/lady syndrome. Families may view the older adult's drinking or drug abuse as an irritant ir·ri·tant
Causing irritation, especially physical irritation.
A source of irritation.
n 1. an agent that causes an irritation or stimulation.
2. , but not a problem; they may actively engage in a codependency process which fosters the continuation of abuse, rationalizing that the abuse cannot be that harmful. They may view alcohol use as one of the few pleasures left to the older individual, and attribute problems more to the deficits related to aging. Ondus et al. (1999) asserted that:
Factors contributing to the clinician's lack of awareness of substance abuse in the elderly include lack of awareness of substance abuse as a potentially important problem for older adults, failure to obtain and/or record accurate drug histories, reluctance to ask potentially embarrassing questions and lack of initiation of any action regarding an older adult's substance use. (p. 28)
In short, the substance abusing elderly individual may be seen as a nice little old man/lady who could not possibly have a drug or alcohol problem.
Physiological/Psychological Concomitants of Substance abuse in the Elderly
The physiological changes that occur naturally with aging result in increased sensitivity and decreased tolerance to alcohol and drugs in older individuals (Ondus et al. 1999; Norton, 1998). In addition, many older adults lose body mass, and consequently smaller amounts of drugs and alcohol have more profound effects. One of the major problems for older adults is the decreased absorption rate in the gastrointestinal system gastrointestinal system: see digestive system. , thought to occur as a result of decreased blood flow to the GI system (Crandall, 1991). As a result, drugs and alcohol remain in the body longer and at higher rates of concentration.
The elimination of drugs and alcohol from the body occurs primarily through excretion and metabolism. Excretion is principally a function of the nephritic nephritic /ne·phrit·ic/ (ne-frit´ik) pertaining to or affected with nephritis.
Of, relating to, or affected with nephritis.
1. system in which blood-borne drugs and alcohol are transferred from the circulatory system circulatory system, group of organs that transport blood and the substances it carries to and from all parts of the body. The circulatory system can be considered as composed of two parts: the systemic circulation, which serves the body as a whole except for the to the urine via the kidneys. Nephritic function slows down with aging, resulting in slower excretion of drugs and alcohol and increased and prolonged drug or alcohol concentration in the body (Ondus et al., 1999).
Metabolism is the major mechanism by which drugs and alcohol are eliminated from the body. Metabolism occurs primarily in the liver and individuals with age-related or disease related change in liver function will experience slowed metabolism and increased amounts of the drug in the body for longer periods of time. In addition, the mortality rate for cirrhotic cir·rho·sis
1. A chronic disease of the liver characterized by the replacement of normal tissue with fibrous tissue and the loss of functional liver cells. liver disease Liver Disease Definition
Liver disease is a general term for any damage that reduces the functioning of the liver.
The liver is a large, solid organ located in the upper right-hand side of the abdomen. is about twice the mortality rate for the general population (Alcoweb, 2002).
Aging tends to result in a reduction in body muscle mass, total body water and lean body mass, and an increase in total body fat (Crandall, 1991). Consequently, the concentration of alcohol and the resultant sensitivity to alcohol is increased because alcohol is a water-soluble substance. Conversely, Ondus et al. (1999) pointed out that concentrations of lipid soluble drugs, particularly the benzodiazepines, are increased, thus prolonging and increasing their effects. For many older adults the decrease in body mass is so significant that the typical adult dose of a medication, particularly a sedative-hypnotic medication, may be far too high.
The increased presence of substances in the body at higher concentration levels suggests that older adults may be significantly more susceptible to substance abuse problems at low dosage levels. The threshold between use and abuse for the average adult may be simply too high for the aging adult.
Injuries related to falls are a significant cause of hospitalization, nursing home placement, or decreased mobility among older adults (Lord, McLean, & Stathers, 1992), accounting for about 40% of accidental injuries in this population (Adams & Jones, 1998). Lord et al. found that, among older people living in the community, a significant relationship existed between falls and psychoactive drug psychoactive drug Substance abuse An agent that provides pleasure or ameliorates pain, and may cause physical dependence and tolerance, with a tendency to ↑ dose in order to achieve the same effect; use of non-prescribed psychoactive agents may be 'social' or use. They attributed the association to reduced cognitive awareness and reduced neural transmission speed. In a literature-based study, Adams and Jones (1998) outlined the presence of a plausible link between alcohol consumption and falls. Both studies, however, noted that a number of confounding variables exist when examining drug or alcohol-related falls and injuries including age and activity level of the participants, gender, and the presence of age related disorders.
Psychological co-morbidity of substance abuse and mental health problems is frequently mentioned in the literature (National Institute on Alcohol Abuse and Alcoholism, 1998; Norton, 1998). Mood disorders The mood or affective disorders are mental disorders that primarily affect mood and interfere with the activities of daily living. Usually it includes major depressive disorder (MDD) and bipolar disorder (also called Manic Depressive Psychosis). , and anxiety disorders Anxiety disorders
A group of distinct psychiatric disorders characterized by marked emotional distress and social impairment, including generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, and posttraumatic stress disorder. are cited as common mental health problems in older adults (Hegel, Stanley, & Arean, 2002), and both may be exacerbated by alcohol or drug use. One of the realities of aging is the phenomenon of loss: loss of a spouse, loss of a job and status through retirement, loss of health, and loss of friendships and social opportunities (Norton, 1998). Depression is a frequent outcome of the losses related to aging and is also common consequence of alcohol problems among older adults (Doweiko, 1999). Indeed, loss and the resulting grief and depression can be a trigger for substance misuse/abuse in the elderly so that persons who have no previous substance problems may progress rapidly into problematic use.
Additionally, existing substance use disorders may be exacerbated by events such as the loss of a loved one or the onset of an age related disability. For this reason careful screening must include a thorough review of any factors that may be directly affecting substance use (Bleechem, 2002). Moore and Wolkstein (1996) suggested that determining whether substance abuse precedes another disability, co-occurs with another disability, or follows another disability can be critical in evaluating the impact of the alcohol and other drug abuse (AODA AODA Alcohol and Other Drug Abuse (treatment programs)
AODA Ancient Order of Druids in America
AODA American Overseas Dietetic Association
AODA Administrative Office of the District Attorneys (New Mexico) ) disorder on the consumer as well as influencing potential choices for intervention. Evidence suggests that elderly individuals who are heavy drinkers are significantly more likely than nondrinkers to die of suicide, a depression related phenomenon (National Institute on Alcohol Abuse and Alcoholism, 1998).
Barriers to Successful Identification
The identification of substance abuse disabilities within the elderly population presents several distinct challenges. Among these challenges are societal beliefs about the population, denial/resistance among the consumers, complications due to other coexisting disabilities, and unique patterns of onset. When these issues are not accounted for during intervention any of them may present significant barriers to effective identification and screening of substance abuse disabilities.
Attitudes, beliefs, and values toward persons with substance abuse disorders substance abuse disorder
Any of a category of disorders in which pathological behavioral changes are associated with the regular use of substances that affect the central nervous system. significantly influence the approach to dealing with these disorders (Koch, 2002). Examples of stereotypes influencing professional failure to identify substance abuse disorders might include pessimism about treatment efficacy for elderly persons or the erroneous belief Noun 1. erroneous belief - a misconception resulting from incorrect information
misconception - an incorrect conception that all persons with these disorders belong to a lower socio-economic class Noun 1. socio-economic class - people having the same social, economic, or educational status; "the working class"; "an emerging professional class"
social class, stratum, class (all persons with substance abuse disorders live on skid row skid row
a run-down area frequented by alcoholics. [Am. Culture: Misc.]
See : Alcoholism
district of down-and-outs and bums. [Am. Usage: Brewer Dictionary, 1008]
See : Failure ) which leads to a failure to screen middle or upper-class consumers (Menninger, 2002). Professionals may also fail to investigate problems that may be indicative of an substance abuse disorder (forgetfulness Forgetfulness
See also Carelessness.
Absent-Minded Beggar, The
ballad of forgetful soldiers who fought in the Boer War. [Br. Lit.: “The Absent-Minded Beg-gars” in Payton, 3]
absent-minded professor , emotional instability, or physical illness) due to making the assumption that problems are a natural part of "aging" (Norton, 1998). Additionally, they might assume that elderly consumers deserve to be able to over-consume alcohol as part of their right to a blissful retirement (Bleechem, 2002).
As with any population of persons experiencing substance abuse disorders, consumer denial can be a significant barrier to treatment (Bleechem, 2002; Miller & Rollnick, 1991). Persons who have been consuming alcohol or other drugs "successfully" for a long period of time may have difficulty recognizing the increasingly negative consequences of their use. Alternatively, they may perceive their substance use problems as being the result of aging rather than comprehending the relationship between their substance consumption and their physical/mental health. In both situations, individuals may be resistant to entering and participating in treatment.
Screening for substance abuse problems can also be complicated by the presence of other disabilities that are a natural part of the aging process or which may be induced by drugs or alcohol. Norton (1998) cautioned that professionals must rule out the potential that substance misuse may be creating disorders such as delirium delirium
Condition of disorientation, confused thinking, and rapid alternation between mental states. The patient is restless, cannot concentrate, and undergoes emotional changes (e.g., anxiety, apathy, euphoria), sometimes with hallucinations. , dementia, mood disorders, sexual dysfunction sexual dysfunction
Inability to experience arousal or achieve sexual satisfaction under ordinary circumstances, as a result of psychological or physiological problems. , and personality problems that might be presumed to be "age-related." Likewise, professionals need to be aware that other medical problems such as elevated liver enzymes, hepatitis, pancreatitis pancreatitis
Inflammation of the pancreas, associated with alcohol, trauma, or pancreatic-duct obstruction. Activated enzymes escaping into pancreatic tissues cause irritation and inflammation. , hypertension, arrhythmia arrhythmia (ārĭth`mēə), disturbance in the rate or rhythm of the heartbeat. Various arrhythmias can be symptoms of serious heart disorders; however, they are usually of no medical significance except in the presence of , and a variety of pulmonary problems may be indicative of substance abuse (Menninger, 2002).
Screening for substance abuse typically involves broad-based questionnaires designed to determine if consumers may be experiencing substance use disorders. No screening instrument described in this section will provide data sufficient to make a clinical diagnosis. However, they may help to determine if it is necessary to recommend a more thorough assessment by a fully trained substance abuse professional. Several traditional screening instruments have been utilized with the population of elderly individuals including the CAGE, the Michigan Alcohol Screening Test (MAST), and the Alcohol Use Disorders Identification Test The Alcohol Use Disorders Identification Test (AUDIT) is a simple ten-question test developed by the World Health Organization to determine if a person's alcohol consumption may be harmful. (AUDIT).
The CAGE is an easy to use, four question, interview that may be included as part of the initial intake as well as during the assessment/evaluation process. The CAGE is an easily administered instrument that has been identified as the most widely promoted standard screening test for clinical practice (Hester & Miller, 1995). The CAGE questions are: (a) Have you ever tried to cut down on your drinking?; (b) Do you become annoyed when others ask you about your drinking?; (c) Do you ever feel guilty about your drinking?; and (d) Have you ever used alcohol in the morning taking an "eye-opener." When consumers answer yes to any of the CAGE questions, further exploration of their use is indicated. Although, Norton (1998) suggested that some caution may be needed in using this instrument due to the paucity of reliability/validity data for its use with the elderly population, the CAGE represents a means by which any professional may initiate discussion about substance use.
The MAST and AUDIT are paper and pencil screening instruments that provide more detailed description of alcohol use. The MAST consists of 23 questions to which the consumer responds with either yes or no answers. Questions explore negative consequences related to alcohol use including legal, family, social, vocational, and medical/psychiatric problems. A version of the Michigan Alcohol Screening Test for use with elderly individuals has been developed (The MAST-G) and purports to measure elderly specific consequences and behaviors related to alcohol consumption (Menninger, 2002; Zimberg, 1996). The AUDIT is a 10-item survey that measures negative alcohol related consequences as well as allowing for a limited description of total alcohol consumption. Research has demonstrated that the MAST and the CAGE have comparable sensitivity for identifying alcoholism in elderly individuals while the AUDIT is somewhat less sensitive (Menninger, 2002). In addition, Rigler (2000) cautioned that the MAST and CAGE fail to distinguish between current and past drinking behaviors. All three of these instruments rely on client self-report and should be viewed with the usual skepticism. Prior to using any of these instruments, professionals should review Menninger's suggestions for adapting these instruments for use with the elderly population.
When making treatment referrals several pitfalls can occur including: (a) lack of individualized in·di·vid·u·al·ize
tr.v. in·di·vid·u·al·ized, in·di·vid·u·al·iz·ing, in·di·vid·u·al·iz·es
1. To give individuality to.
2. To consider or treat individually; particularize.
3. treatment approaches; (b) lack of accessibility; and (c) over-reliance on the self-help model. Koch and Rubin (1997) cautioned that substance abuse treatment providers have had a history of providing "one size fits all" treatment that may not effectively meet the needs of individual consumers. Before making a referral, rehabilitation professionals are ethically bound to ensure the program they are utilizing will be specialized enough to meet the needs of consumers from the older age cohort. Norton (1998) recommended that psycho-educational, peer support, family interventions, and cognitive-behavioral interventions may be effectively tailored to meet the needs of the elderly population and that treatment becomes more efficacious when it is not generic.
Substance abuse treatment professionals often provide several "levels of care" for consumers with substance abuse disorders. These levels of care include: outpatient care where consumers may receive 1-3 hours of group and individual counseling per week; intensive outpatient counseling where consumers may receive 9-20 hours of individual and group counseling per week; residential care with medical monitoring consisting of 24 hour supervision by substance abuse professionals and access to medical/psychiatric treatment; and medically managed care where services may be provided in a medical setting such as a psychiatric hospital psychiatric hospital
A hospital for the care and treatment of patients affected with acute or chronic mental illness. Also called mental hospital. . Typically services will be provided in the least restrictive environment As part of the U.S. Individuals with Disabilities Education Act, the least restrictive environment is identified as one of the six principles that govern the education of students with disabilities. based on the seriousness of the substance abuse disorders, however, when consumers present with medical and/or psychiatric complications they may quickly be referred to the most restrictive settings even though they may have less severe substance abuse diagnoses. However, rehabilitation professionals are obligated ob·li·gate
tr.v. ob·li·gat·ed, ob·li·gat·ing, ob·li·gates
1. To bind, compel, or constrain by a social, legal, or moral tie. See Synonyms at force.
2. To cause to be grateful or indebted; oblige. to advocate for the consumer's right to receive appropriate services given their individual needs.
Finally, rehabilitation professionals may tend to be too reliant on peer self-help approaches for dealing with substance abuse disorders. Koch and Benshoff (2002) found that rehabilitation professionals tended to refer all of their consumers to Alcoholics Anonymous Alcoholics Anonymous (AA), worldwide organization dedicated to the treatment of alcoholics; founded 1935 by two alcoholics, one a New York broker, the other an Ohio physician. (AA) and to require participation in this program even though the individuals making the referral had very little insight into the program. This lack of awareness about the strengths and weaknesses of AA combined with the fact that many consumers may not benefit from participation in AA (Koch & Rubin, 1997) can produce unfortunate results. Older individuals may believe they do not fit into the group or have differing concerns from younger members. In addition, they may have age-related mobility or hearing problems that prevent participation in peer self-help groups. Norton (1998) suggested that elderly individuals do better in self-help groups composed of same-age peers. Finally, peer self-help groups can be an excellent treatment adjunct, but they are not a substitute for professional intervention.
For various reasons substance abuse in the elderly population has not been viewed as a serious or widespread problem. Researchers have rarely addressed the unique issues faced by this group of individuals, traditional care providers have been slow or reluctant to identify problems and few elderly-specific treatment resources have been developed. To adequately provide services for the elderly with substance abuse problems practitioners should be aware of the pathways of development of substance abuse and the influences that perpetuate the disorder. These influences include cohort effects, socioeconomic status socioeconomic status,
n the position of an individual on a socio-economic scale that measures such factors as education, income, type of occupation, place of residence, and in some populations, ethnicity and religion. , frail health, discretionary income Discretionary Income
The amount of an individual's income available for spending after the essentials have been taken care of.
Essentials are things like food, clothing, and shelter. , status as a hidden population, and caregiver complicity. Additionally, it is important to be aware of the physiological and concomitant effects of alcohol and other substances. Life events such as the loss of loved ones loved ones npl → seres mpl queridos
loved ones npl → proches mpl et amis chers
loved ones love npl , the onset of age-related health problems, and the failure of caregivers to recognize and confront drug and alcohol may contribute to the development and continuation of the abuse. Finally, appropriate screening instruments can be used in identifying substance use, abuse, and dependence in the elderly and therefore increase the likelihood of developing an effective treatment plan. Above all, future research should center on unique, elderly-specific identification, intervention and treatment strategies.
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The scientific study of the biological, psychological, and sociological phenomena associated with old age and aging.
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A scientific discipline, such as sociology, anthropology, or psychology, in which the actions and reactions of humans and animals are studied through observational and experimental methods. approach (2nd ed.). New York New York, state, United States
New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of : McGraw-Hill.
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A physical and psychological habituation to a mood- or mind-altering drug, such as alcohol or cocaine.
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1. Causing or tending to cause injury; harmful: eating habits that are injurious to one's health.
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John J. Benshoff, Ph.D., CRC (Cyclical Redundancy Checking) An error checking technique used to ensure the accuracy of transmitting digital data. The transmitted messages are divided into predetermined lengths which, used as dividends, are divided by a fixed divisor. , Rehabilitation Counselor Training, Rehabilitation Training Institute-Mailcode 4609, Southern Illinois University Southern Illinois University, main campus at Carbondale; state supported; coeducational; est. 1869, opened 1874 as a normal school, renamed 1947. It has a center for archaeological investigation and a fisheries research laboratory. There is also a campus at Edwardsville. at Carbondale, Carbondale, IL 62901-4609. Email: firstname.lastname@example.org
John J. Benshoff Laura K. Harrawood Southern Illinois University at Carbondale Darwin Shane Koch University of North Texas