Older Adults with Substance Use Disorders
Providers of substance abuse services are increasingly aware that large numbers of older adults will require specialized substance abuse services as they begin moving into older age. The aging of the U.S. population and the arrival into older age of the Baby Boomers—the generation born between 1946 and 1964—are focusing attention on the “invisible epidemic” of older adults with substance use disorders.
By 2030, citizens over 65 will number 71 million, increasing to more than 20 percent of the country’s population. Of that 71 million, 16 percent (11 million people) will be in need of substance abuse services.
When substance-related problems are identified, Baby Boomers are significantly more open to seeking professional mental health assistance and substance abuse counseling than were previous cohorts. Increased demand and higher expectations will have a significant impact on the existing service delivery system.
In the older adult population, as in other age groups, substances include alcohol, street and recreational drugs, and both prescribed and over-the-counter medications. Particularly dangerous in older adults is potential interaction between alcohol and other drugs, including legitimately prescribed and appropriately used medication. The most widespread pattern of abuse among older adults, however, is the misuse of prescriptions and over-the-counter medications coupled with continued or increased consumption of alcohol.
Frequently substance abuse in older adults mimics symptoms of other health problems (e.g., confusion and agitation), or its signs are perceived as normal aspects of aging (e.g., unsteadiness and falls). It is recommended that all adults age 60 and over be screened for alcohol and prescription drug abuse as part of regular physical examinations.
Since screening, assessment, and referral to age-appropriate treatment, if warranted, are essential, providers dealing with older adults need to be aware of:
- Evidence-based Programs (EBPs) for Older Adults with Substance Use Disorders
- Reimbursement for Services
- Screening Tools That Are Effective with Older Adults
- Special Considerations in Working with Older Adults
- Vulnerability of Older Adults to Misuse of Substances
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- Aging individuals are especially vulnerable to misuse of mind-altering substances. Research has identified some of the psychosocial stressors facing older persons, including depression, bereavement, retirement, loneliness, strained personal relationships, economic hardships, and physical illnesses.
- Alcohol, which may have been a source of comfort, as well as an integral part of an individual’s social life through the years, can become, through misuse, a serious hazard to an aging person’s physical and mental health. An aging person’s body and mind will become more vulnerable to the cumulative effects of alcohol’s habitual use.
- The physical, psychological, behavioral, and social effects of untreated substance abuse on older adults are, in fact, profound. From worsening medical conditions, falls, injuries and accidents to personality changes, depression and increased anxiety to isolating behaviors and deteriorating relationships, an older person’s quality of life is greatly diminished by substance use disorders.
- To be prepared to respond to this challenge, providers must focus on targeted programs and specialized services to meet the needs of older adults with substance use disorders. As resources become even more limited, it will be increasingly difficult to make a case for services dedicated to the needs of older adults unless those services can be shown to be evidence-based in their design and both efficient and effective in their implementation.
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The Substance Abuse and Mental Health Services Administration (SAMHSA) suggests the following screening tools:
- The CAGE Questionnaire
- The Alcohol Use Disorders Identification Test (AUDIT)
- The Short Michigan Alcoholism Screening Test – Geriatric Version (S-MAST-G)
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The Substance Abuse and Mental Health Services Administration’s National Registry of Evidence-based Programs and Practices (NREPP) has recommended several effective programs and practices for service providers to use in working with older adults.
- Motivational Interviewing (MI), a goal-directed, client-centered counseling style for eliciting behavioral change by helping clients to explore and resolve ambivalence. The operational assumption in MI is that ambivalent attitudes or lack of resolve is the primary obstacle to behavioral change, so that the examination and resolution of ambivalence becomes its key goal.
- Motivational Enhancement Therapy (MET), an adaptation of motivational interviewing (MI) that includes one or more client feedback sessions in which normative feedback is presented and discussed in an explicitly non-confrontational manner.
- Relapse Prevention Therapy (RPT), a behavioral control program that teaches individuals with substance addiction how to anticipate and cope with the potential for relapse. RPT can be used as a stand-alone substance use treatment program or as an aftercare program to sustain gains achieved during initial substance use treatment.
- Cognitive Behavioral Therapy (CBT), which may be of particular benefit to older adults because of the emphasis on social support. A CBT/Self Management approach would include using the A-B-C’s (Antecedents-Behaviors-Consequences) of behavioral analysis in a three-stage therapeutic model:
- Develop a substance use profile to identify the client’s antecedents and consequences for substance use, and create an individualized “substance use behavior chain.”
- Teach the client how to identify the chain’s components so that s/he can understand high-risk situations for alcohol or drug use.
- Teach specific skills to address high-risk situations to prevent relapse.
- Brief Intervention is frequently successful with older adults who have scant awareness of the danger of misuse of alcohol, drugs and medications. In a limited number of sessions—three is the average—therapists use age-appropriate screening techniques to target specific health behaviors, employ motivation enhancement strategies, and offer advice and education. The goals of Brief Intervention therapy are to motivate individuals to change dangerous behaviors, to eliminate/reduce alcohol or substance use, and to use medications appropriately.
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Medicare, for which individuals 65 and older qualify, covers treatment for substance-related disorders in inpatient or outpatient settings. Coverage is available for both diagnostic and therapeutic services. Certain limits apply. To determine what kinds of coverage are provided, contact the Centers for Medicare and Medicaid Services (CMS), www.cms.gov, 1-877-267-2323.
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Because older people suffering from substance abuse are particularly stigmatized, many desiring help hesitate to discuss their problem, even with health care providers. Paradoxically, stigma against older people can result in situations in which senior services are denied due to the person’s admitted substance abuse, and substance abuse treatment is denied because the potential client is deemed “too old” to benefit from the expenditure of limited resources.
In interacting with older adults, providers should recognize the physical and mental changes that occur with aging and adjust their approaches accordingly. Older adults, for example, respond best to supportive rather than confrontational approaches. Since older adults are often uncomfortable discussing alcohol consumption or drug use, an effective screening requires privacy, safety, comfort and respect. Respect can be conveyed by actively listening to the older adult’s view of the situation and addressing concerns with empathy and encouragement.
For more information about working with older adults with substance use disorders, please contact Margaret Anne Lane (Margaret.Lane@dbhds.virginia.gov).
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