Brief Intervention for At-Risk Drinkers

Research has shown that 10 to 30 percent of nondependent problem drinkers reduce their drinking to moderate levels following a brief intervention by a physician or other clinician. A brief intervention is one or more counseling sessions, which may include motivation-for-change strategies, patient education, assessment and direct feedback, contracting and goal setting, behavioral modification techniques, and the use of written materials such as self-help manuals (Fleming et al., 1997b). Brief intervention techniques have been used to reduce alcohol use in adolescents, in adults under age 65 who are nondependent problem drinkers, and most recently, in older adults (Blow, in press; Fleming et al., 1997a). All of these activities can be conducted by trained clinicians, home health care workers, psychologists, social workers, and professional counselors (e.g., physicians, nurses, physicians' assistants).

Brief intervention strategies range from relatively unstructured counseling and feedback to more formal structured therapy and rely heavily on concepts and techniques from the motivational psychology and behavioral self-control training literature (Miller and Taylor, 1980; Miller and Hester, 1986; Miller and Munoz, 1976; Miller and Rollnick, 1991). The goal is to motivate the problem drinker to change his behavior, not to assign blame. Drinking goals accordingly should be flexible, allowing the individual to choose drinking in moderation or abstinence.

In a trial conducted in Malmo, Sweden, in the late 1970s, non-older adult subjects (all under age 65) were advised in a series of health education visits to reduce their alcohol use. They subsequently demonstrated significant reductions in gamma-glutamyl transferase levels and health care utilization for up to 5 years after the brief intervention (Kristenson et al., 1983). The Medical Research Council trial, conducted in 47 general practitioners' offices in Great Britain, found significant reductions in alcohol use by the intervention group compared with the control group 12 months after the intervention (Wallace et al., 1988). The World Health Organization trial, conducted in 10 countries, found similar differences in alcohol use between the two groups (Babor and Grant, 1992). Meta-analyses found an effect size of 20 to 30 percent in studies conducted in health care settings (Bien et al., 1993; Kahan et al., 1995). There are several ongoing studies of brief alcohol interventions for older adults, one of which is described below.

Intervention and Motivational Counseling

If the older problem drinker does not respond to the brief intervention, two other approaches - intervention and motivational counseling - should be considered.

Patient Placement and Patient Matching

Triage refers to the process of organizing and prioritizing treatment service. Typically, decisions regarding triage are made up of two components: patient placement and patient matching.

Patient placement describes a process by which a recommendation is made for placement in a specific level (intensity) of care, which ranges from medically managed (high intensity) inpatient services to outpatient services (low intensity). The most commonly used patient placement criteria are found in the American Society of Addiction Medicine (ASAM) Patient Placement Criteria for the Treatment of Substance-Related Disorders, Second Edition (ASAM-PPC-2) (American Society of Addiction Medicine, 1996).

Figure 5-1 shows the six problems or assessment dimensions that ASAM-PPC-2 uses to make patient placement decisions both among and within levels of service.

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Figure 5-1: ASAM-PPC-2 Assessment Dimensions.

The answers to these questions should help the health care provider assess the severity of the problem and the intensity of the services required. For older adults, the triage process is often greatly influenced by factors other than the severity of a drinking or prescription drug problem. For example, physical accessibility of facilities will influence treatment choices for wheelchair-bound patients; hearing-impaired patients will need programs with individual therapy and/or modified small group therapy.

Language barriers, illiteracy, and different cultural views of and customs surrounding substance abuse add to the complex of factors required to assess functional abilities in older adult patients. To help ensure optimal benefits for older adults, the Consensus Panel recommends that treatment plans weave age-related factors into the contextual framework of the ASAM criteria.

Inpatient/Outpatient Detoxification Treatment

One of the first issues to consider for an older patient with a substance dependence diagnosis is whether detoxification management is necessary and, if so, whether it should be undertaken in an inpatient hospital-based setting or managed on an outpatient basis. No studies or reports specifically assess the potential risks or benefits of outpatient detoxification among older adults, but detoxification is generally seen as medically riskier for an older person. Until more research is available, best clinical judgment must guide such decisions. For more information on detoxification, see TIP 19, Detoxification From Alcohol and Other Drugs (CSAT, 1995a). Medical safety and potential access to the abused drugs are primary considerations when deciding whether an older patient's withdrawal from prescription drugs requires supervision in a hospital. Factors indicating the need for inpatient detoxification include

• A high potential for developing dangerous abstinence symptoms such as a seizure or delirium because (1) the dosage of alcohol or drug has been particularly high or prolonged and has been discontinued abruptly or (2) the patient has experienced these serious symptoms at any time previously
• Suicidal ideation or threats
• The presence of other major psychopathology
• Unstable or uncontrolled comorbid medical conditions requiring 24-hour care or parenterally administered medications (e.g., renal disease, diabetes)
• Mixed addictions, (e.g., alcohol, sedative/hypnotic drugs)
• A lack of social supports at home or living alone with continued access to the abused substance(s)
• A failure to respond to outpatient treatment.

Older patients detoxifying from psychoactive prescription drugs on an inpatient basis should not be stabilized on high doses of benzodiazepines or barbiturates with a long or intermediate half-life. These drugs can accumulate and result in toxicity and some persisting cognitive impairment after hospital discharge, which can interfere with functional capabilities in general and also hamper any immediate participation in continuing treatment. The choice of drug and drug schedule should also be guided by the length of the hospitalization. If a long-acting drug such as clonazepam (Klonopin) or an intermediate-acting one such as chlordiazepoxide is used to detoxify an older patient, the hospitalization will likely be extended. An additional risk is that the patient will exhibit no signs of the abstinence syndrome until days or even weeks after leaving the hospital. In general, the initial dose of a drug for suppression and management of withdrawal symptoms should be one-third to one-half the usual adult dose, sustained for 24 to 48 hours to observe reactions and then gradually tapered with close attention to clinical responses (Finlayson, 1995b).

The clinician overseeing detoxification from alcohol or prescription drugs must decide on the level of care necessary to maintain abstinence. Patients with high relapse or withdrawal potential and patients with severe medical or psychiatric comorbidity will require hospitalization. Regular monitoring of the patient's vital signs and objective symptoms of withdrawal also is needed. Short-acting benzodiazepines (e.g., oxazepam, lorazepam) are customarily used as detoxification agents because alcohol-addicted patients are cross-tolerant to these substances. The use of oxazepam or lorazepam is warranted in patients with severe liver disease. Metabolism of these benzodiazepines does not depend on hydroxylation by the liver, and thus they do not accumulate in the liver and cause adverse effects ( Brower et al., 1994 ). The benzodiazepine dosage is decreased daily over the course of the detoxification process. Medications such as clonidine and methadone for opiate withdrawal and phenobarbitol for barbiturate withdrawal should be used more cautiously than with younger patients.

In general, older patients require lower doses of many medications, and the principle of starting at a lower dose and titrating at a slower rate should be followed for detoxification. In addition to treating acute withdrawal symptoms, clinicians are reminded that alcoholic patients require supplemental doses of thiamine, folate, and multivitamins to counteract the vitamin depletion that is often associated with excessive alcohol use.

Inpatient Rehabilitation

Patients who are brittle, frail, acutely suicidal, or medically unstable or who need constant one-on-one monitoring, should receive 24-hour primary medical/psychiatric/nursing inpatient care in medically managed and monitored intensive treatment settings. Recent changes in the health care system have dramatically reduced the availability of this level of care. Inpatient rehabilitation (traditional 14- , 21- , or 28-day programs) are not readily available and often no longer reimbursed by health care insurers. Because of these reimbursement gaps, inpatient care may have to be arranged on a medical or psychiatric unit of an acute care hospital.

Residential Rehabilitation

Residential programs provide a slower paced, more repetitive treatment approach for older patients. Services range from high to low intensity and can be delivered in specialized care settings (e.g., halfway house, group home for people with addiction problems, board and care facilities, domiciliary facilities for veterans) and in nonspecialized settings (e.g., extended care facilities, life care programs, subacute nursing homes where primary care doctors make rounds and visiting nurses attend occasionally). Specialized rehabilitation programs include those designed for individuals who are cognitively impaired by chronic illness or traumatic injuries. These facilities work well for patients who lack significant social resources (such as family) or have no social network and for those with no mobility to stabilize care (which justifies the expense of this treatment option).

Outpatient Services

Specialized outpatient programs vary greatly in the intensity of treatment. Partial hospitalization/day treatment programs require patients to attend day-long treatment 5 days per week, whereas intensive outpatient programs are sometimes hospital-based and provide 2 to 3 hours of treatment each day. Finally, traditional low-intensity outpatient care normally provides for one group session per week and one individual session per month.

Nonspecialized, nonresidential services are provided by many partial day treatment programs structured for outpatient care. These include community-based drop-in centers and senior centers, generally less available in rural areas. These facilities are good for people waiting for inpatient care and who require a level of interim care, for people with no family at home on a daily basis, and for retirees who need a structured daily regimen to keep the focus on their addiction. Some of these structured programs have the expertise to deal with comorbidities in an intensive outpatient setting.

If an older patient needs more help and structure than is readily available, an individually tailored, case-managed approach may work well for coordinating outpatient treatment. This would entail professional assessment of the patient's problems and strengths, assistance with the development of a realistic treatment plan in the context of known and reasonably available resources in the community, and linkage with the identified programs. Usually the patient's primary physician and his or her team will be the chief players in ongoing case management. Providers of primary drug dependence treatment should not overlook the physician - who will prescribe all medications - in their planning. The Panel recommends drawing the physician into the treatment planning process and enrolling him as a player in the recovery network. Without the physician's knowledgeable participation, the entire plan may unravel.

The Panel also recommends serving older adults who are dependent on psychoactive prescription drugs in flexible, community-oriented programs with case management services rather than in traditional, stand-alone substance abuse treatment facilities with standardized components. Case management is discussed in more detail below.

Specialized outpatient treatment generally includes psychiatric consultation and individualized or group psychotherapy. Outpatient programs frequently encourage patients to attend regular meetings of self-help groups such as Alcoholics Anonymous, Alcoholics Victorious, Rational Recovery, or Narcotics Anonymous and often assign a proactive case manager to help an older patient connect with an appropriate group. After a patient's release from the formal and time-limited outpatient substance abuse treatment program, a case manager plays an important aftercare role by coordinating community-based support and monitoring to reinforce gains made during treatment and prevent or minimize the impact of slips.

Although the success of treatment for older adults has been documented, the literature on substance abuse lacks empirically derived, proven methods for treating older alcoholics and substance abusers. Instead, individual practices borrow heavily from what is known in the general fields of addictions treatment, geriatric medicine and psychiatry, and social gerontology, as well as the cumulative experience of existing programs that have specialized in treating older alcoholics (Atkinson, 1995; Schonfeld and Dupree, 1996). Before referring an older adult to a community-based treatment program, health care providers should carefully consider the program's philosophy and practices regarding older clients.

Age-Specific Treatment

Age-specific treatment is group treatment in which older individuals come together exclusively with their peers. Such treatment can be provided in one of two formats. The first is a discrete program designed for older alcoholics and substance abusers in which the entire program provides age-specific services and all of the patients are older. The second option is age-specific groups within an all-ages treatment program.

In contrast, mixed-age treatment and mainstreaming integrate adults of all ages with similar substance abuse problems in the same program. The question of whether older adults achieve better outcomes in age-specific treatment has not received adequate study, but there is some evidence that age-specific treatment improves older adults' compliance and outcomes (Kashner et al., 1992; Kofoed et al., 1987; Thomas-Knight, 1978).

Treatment works best when the issues dealt with are congruent with the life stage of the client. Younger and older adults' problem drinking can usually be traced to different types of problems, even when the emotional responses to the problems seem similar. For example, the drinking of younger and older clients may both be attributed to depression, but the causes of that depression may be as different as being unable to find one's first job and facing the prospect of retirement. Older adults will recognize the problems of younger adults but may no longer find them particularly relevant. Younger adults, with no knowledge of what it's like to grow old, may lack empathy and become impatient with older adults. The design of educational groups, the skills clients need to acquire, and the linkages that need to be made through case management are all different for older adults than for younger adults. For all of these reasons, treating the older client in an age-specific setting is preferable.

Of course, this is not always possible, particularly for prescription drug abusers. Because very few older adults with prescription drug problems seek treatment or are referred for care, most drug treatment facilities do not have specialty "older adult track" programming. If specialized treatment is not available, older adults can at least be grouped with younger people whose lifestyles and problems are most compatible and with whom they feel most comfortable. It is difficult to treat older adults who have only abused prescription drugs together with consumers of illicit substances, or even alcoholics who have "hit bottom."

Some clinicians argue that commonality in the drug of choice is the most important factor in grouping patients. Because lifestyles vary dramatically among different drug cultures, it may be more important to group older patients with other patients who also have a primary problem with legal drugs rather than by age cohort, gender, or socioeconomic status (Finlayson, 1995b).

If circumstances preclude treatment in an age-specific setting, a program can still address the age-specific themes of older clients by hiring at least one person specializing in work with older adults. In mixed-age settings, case management can provide an effective means of addressing age-specific themes.

A Culture of Respect

Treatment programs should cultivate a culture of respect for older clients. Nurturing clients' self-esteem and reawakening their sense of themselves as valuable, competent human beings are central to the process. Older adults frequently enter treatment depleted physically, socially, and emotionally, convinced that their situation is hopeless. Adding the stigma of addiction to the stigma of aging can compound their despair. They may have been disowned by their families and rejected by friends because of their drinking or drug abuse. If they seek help outside the family, their experiences with agencies are often impersonal, dehumanizing, and humiliating.

To increase clients' self-esteem, staff members should express confidence in each client's ability to participate, persevere, and succeed in treatment. Staff members need to state this confidence frequently and at each phase in the treatment process in a way that is upbeat but not patronizing. They should avoid acting overly helpful and implying that the individual is impaired and helpless, at the same time recognizing he or she does need help with the substance abuse problem. Managing his or her own life helps an older client regain self-esteem. Treatment providers should take care to treat all their clients with an unconditional positive regard, whether they are wealthy or on welfare.

Many actions and speaking manners demonstrate respect in ways the older client will understand:

• Abide by the manners that the older client sees as customary (e.g., do not swear).
• Ask the individual how he or she would like to be addressed and introduced to others. Use surnames and formal terms of address until given permission to be more familiar.
• Avoid condescending or patronizing behavior.
• Speak directly to the client, not the client's spouse or adult child, when the client is present.
• Recognize the client's privacy and personal space. If making home visits or entering the client's personal space at the treatment facility, acknowledge the client's ownership of the space. Knock and gain permission to enter, ask where the person would like you to sit, and respond graciously to any offer of hospitality, whether accepting the offer or not. Make adequate provision for personal privacy and the security of the person's possessions, in both inpatient and outpatient settings.
• Talk to the client. Interacting spontaneously communicates appreciation for the person as an individual. Honoring the client's pain, needs, and joys validates the person in his or her attempt to process life's experiences in sobriety.
• Fulfill the client's request to speak to his or her clinician, immediately if possible.
• In a treatment program, a number of shorter, informal sessions, particularly in response to a patient's request, may be more valuable than a longer, scheduled session. Honoring a patient's requests sends the message, "You are important."
• Respect the client's spiritual concerns and desire to discuss meaning and purpose in life. Spiritual issues may be addressed by professional counselors or pastoral counselors in addition to ministers or other mental health professionals trained in existential interventions. Often, older adults have a need to discuss these issues, and alcohol misuse may be a symptom of a deeply felt lack of purpose in life.

Holistic Treatment Based on Age-Specific Problems

Treatment programs are generally advised to take a broad, holistic approach. In treating the older substance abuser in particular, it is necessary to focus on more than just the drinking or substance abuse problem. As people age, the likelihood of multiple antecedent conditions for problem behavior increases. In other words, the individual's psychological and health problems tend to become more complex, multiply determined, and interactive. Recent research suggests that older adults with alcohol problems often drink in response to loneliness, depression, and poor social support networks (Schonfeld and Dupree, 1995). Researchers have also noted chronic pain as a high-risk condition for substance abuse.

A number of interrelated emotional, social, medical, spiritual, and practical problems or changes characterize the older adult's experiences (see Figure 5-2). Some of these can precipitate abuse of alcohol or other drugs. Those that initiate, sustain, or interact with the substance abuse problem provide the focus of a holistic treatment approach tailored to the needs of the individual.

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Figure 5-2: Life Changes Associated With Substance Abuse in Older Adults.

Discussing life changes with patients can help them develop insight into the causes of their substance abuse problems. For example, while discussing salient nondrinking problems with an older adult, the drinking problem often emerges naturally as a topic of discussion. Although the problems associated with aging can be overwhelming, patients need not accept them passively. They can develop a self-care skill or positive attitude and can obtain appropriate help, such as the pharmacological alleviation of pain, management of grief, or skills for improving relationships.

Program Flexibility

The goals, setting, and duration of treatment may well be different for each client. The first step toward ending problem drinking may involve finding safe, affordable housing for one client, resolving depression for a second, or improving relationships with a caregiving daughter for a third. Elements of treatment, such as work assignments or exercise programs, will need to be tailored for the individual patient.

It may be necessary to stop treatment when illnesses or hospitalization intervene. Schedule adjustments may be needed in recognition of the fatigue levels of older clients. The setting of treatment may need to shift from clinic to home during a period of convalescence from a hip fracture or an illness. One client may need twice as many treatment sessions to master steps toward self-sufficiency as another client. One individual may need to continue treatment for 2 years to meet the goals another client reaches within 6 months.

Gender Issues

Some women patients may be better served by all-female treatment groups and facilities, although studies comparing the effectiveness of single-sex and mixed-gender programs are lacking. Panel members have observed that many older women defer to men and may take subservient roles in a treatment group. These women could be less likely to become leaders in the group or to build their self-esteem, although a talented group therapist can turn the roles of men and women in the group into therapeutic assets.

Both women and men may have personal issues related to their drinking that they would be reluctant to discuss with, or in the presence of, members of the opposite sex. This reluctance is likely to be greater for older adults, because many have a heightened need for privacy that discourages open discussions of personal issues and socialization with members of the opposite sex. In response, programs involving group treatment might afford opportunities for separate meetings of males and females on an as-needed basis without disrupting the larger program. Such meetings may never be necessary, or take place intermittently, depending on the group members' needs or preferences to discuss certain topics in same-sex settings.

Although most problem drinkers are men, more women misuse prescription drugs, and there are more women than men overall in the aging population. Women use more psychoactive drugs than men do (Falvo et al., 1990; Ostrom et al., 1985; Venner et al., 1980; Gomberg, 1995), and some researchers consider prescription drug abuse a major substance abuse issue among older women. Some studies report that older men are prescribed antidepressants as often as or more often than women, but it is not known whether this is a function of greater use of medical services by aging men or a difference in the diagnosis of depression among older adults (Gomberg, 1992a, 1995).

Cognitive-Behavioral Approaches

There are three broad categories of cognitive-behavioral approaches: behavior modification/therapy, self-management techniques, and cognitive-behavioral therapies. Behavior modification applies learning and conditioning principles to modifying overt behaviors - those behaviors obvious to everyone around the client (Powers and Osborne, 1976; Spiegler and Guevremont, 1993). Self-management refers to teaching the client to modify his or her overt behaviors as well as internal or covert patterns. Cognitive-behavior modification involves altering covert patterns or behaviors that only the client can observe.

Cognitive-behavioral techniques teach clients to identify and modify self-defeating thoughts and beliefs (Dobson, 1988; Scott et al., 1989). The cognitive-behavioral model offers an especially powerful method for targeting problems or treatment objectives that affect drinking behavior. Together, provider and client analyze the behavior itself, constructing a "drinking behavior chain." The chain is composed of the antecedent situations, thoughts, feelings, drinking cues, and urges that precede and initiate alcohol or drug use; the drinking or substance-abusing behavior (e.g., pattern, style); and the positive and negative consequences of use for a given individual. When exploring the latter, it is particularly important to note the positive consequences of use: those that maintain abusive behavior.

Researchers have developed an instrument that can elicit by interview the individual's drinking or drug use behavior chain (Dupree and Schonfeld, 1986). Immediate antecedents to drinking include feelings such as anger, frustration, tension, anxiety, loneliness, boredom, sadness, and depression. Circumstances and high-risk situations triggering these feelings might include marital or family conflict, physical distress, or unsafe housing arrangements, among others. Many older adults drink excessively in response to perceived losses and changes associated with aging and their affective and behavioral response to those losses. Alcohol use is often a form of "self-medication," a means to soften the impact of unwanted change and feelings. For the patient, new knowledge of his or her drinking chain often clarifies for the first time the relationship between thoughts and feelings and drinking behavior, a discovery one Panel member calls "taking the mystery out of drunkenness." This method provides insight into individual problems, demonstrates the links between psychosocial and health problems and drinking, and provides the data for a rational treatment plan and an explicit individualized prevention strategy.

Breaking drinking behavior into the links of a drinking chain serves treatment in other ways, too. It suggests elements of the community service network that may be helpful in establishing an integrated case management plan to resolve antecedent conditions (e.g., housing, financial, medical problems) that necessitate involvement from the community beyond the treatment program (see Case Management section).

Behavioral treatment can be used with older adults individually or in groups, with the group process particularly suited to older adults (see Group-Based Approaches section below). Equipped with the knowledge of the individual's drinking or drug abuse behavior chain, the group leader begins to teach the client the skills necessary to cope with high-risk thoughts or feelings. The leader teaches the older person to initiate alternative behaviors to drinking, then reinforces such attempts. The leader may demonstrate through role-playing alternative ways to manage high-risk situations, permitting the client to select coping behaviors that he or she feels willing and able to acquire. The leader may also ask for feedback from the group and use that feedback to work gradually toward a workable behavioral response specific to the individual.

The behaviors are rehearsed within the treatment program until a level of skill is acquired. The patient is then asked to try out the behaviors in the real world as "homework." For example, a client who has been practicing ways to overcome loneliness or social isolation may receive a community-based assignment in which to carry out the suggested behaviors. The individual reports back to the group, then the therapist and group members provide feedback and reinforce the individual's attempt at self-management (whether the outcome was a success or not). This process continues until the individual develops coping skills and brings the antecedents for abuse under self-control or self-management. Typically, as patients learn to manage the conditions (thoughts, feelings, situations, cues, urges) that prompt alcohol abuse, abstinence can be maintained.

Defining drinking behavior antecedents is also useful for determining when a client is ready for discharge. When the individual has acquired and can successfully use coping behaviors specific to his or her antecedents for drinking, the treatment team might begin to assist the person in gradually phasing out of the program. Discharge that takes place before the client has acquired specific coping behaviors is almost certain to result in relapse - probably very soon after discharge.

One older adult-specific treatment program that has used these cognitive-behavioral and self-management approaches is the Gerontology Alcohol Project (GAP) (Dupree et al., 1984). The program assessed antecedents on a typical day of drinking for each person entering treatment. Group treatment involved skill acquisition in order to cope with problems such as anger and frustration, depression and grief, tension and anxiety, lack of social support, passivity, and an unstructured life. GAP staff were encouraged to teach skills at a slower pace than might be used with younger adults and to limit the amount of information taught per session by following written curriculum manuals. These teaching guides provided age-specific examples and maintained consistency in teaching.

Confrontation was not permitted. This facilitated more open discussion between staff and clients, encouraging clients to report instances when they slipped. This information was used in the group to help both the person who slipped and other clients. Each slip was diagrammed in terms of that person's drinking behavior chain, with the antecedent conditions and consequences, in order to teach group members how to avoid or manage their own high-risk situations. The group engaged in exercises or rehearsals of the necessary actions and cognitions to prevent one drink (a slip) from becoming a full relapse. A 1-year followup of clients completing GAP indicated a high rate of success. Seventy-five percent of clients maintained their drinking reduction goals and increased the size of their social support networks (Dupree et al., 1984).

Later studies comparing early and late-onset older problem drinkers showed great similarity between these two groups' antecedents to drinking and treatment outcomes (Schonfeld and Dupree, 1991). Another study described a behavioral regimen that included psychoeducation, self-management skills training, and marital therapy. A followup study of 16 male inpatients, ages 65 to 70, undertaken 2 to 4 years after discharge, indicated that half were abstaining, two had reduced their drinking, and the remaining patients' drinking was destructive (Carstensen et al., 1985). These studies recommend (and the Panel concurs) that treatment focus on teaching skills necessary for rebuilding the social support network; self-management approaches for overcoming depression, grief, or loneliness; and general problem solving (Schonfeld and Dupree, 1990, 1991).

Group-Based Approaches

Group experiences are particularly beneficial to older adults in treatment. They provide the arena for giving and sharing information; practicing skills, both new and long-unused; and testing the clients' perceptions against reality. Perhaps the most beneficial aspect of groups for older adults is the opportunity to learn self-acceptance through accepting others and in return being accepted. Guilt and forgiveness are often best dealt with in groups, where people realize that others have gone through the same struggles. Special groups may also deal with the particular problems of aging; the group format can help patients learn skills for coping with any of the life changes identified in Figure 5-2.

Self-paced learning is best for older adults. To allow clients to set their own pace in a group setting, the leader can give individualized or take-home assignments. Clients who have not reached the needed level of expertise on a topic can receive an individualized "booster session" while remaining in the group. Older clients also should get more than one opportunity to integrate and act on new information. For example, information on bereavement can be presented in an educational session, then reinforced in therapy. To help participants integrate and understand material, it may even be helpful to expose them to all units of information twice.

Groups help create a sense of camaraderie and high morale. Research on group work with older adults suggests that older adults bond into groups at a faster pace than younger adults do (Finkel, 1990). One successful treatment program made use of this phenomenon by assigning each person to another client who served as a "buddy," explaining and facilitating the day's events.

Some of the most effective types of groups are socialization, therapy, educational, and self-help or support groups.

Individual Counseling or Short-Term Psychotherapy

Individual counseling is especially helpful to the older substance abuser in treatment's beginning stages, but the counselor often must overcome clients' worries about privacy. Subjects that many older adults are loath to discuss include their relationships to their spouses, family matters and interactions, sexual function, and economic worries. It is essential to assure the client that the sessions are confidential and to conduct the sessions in a comfortable, self-contained room where the client can be certain the conversation will not be overheard.

Older clients often respond best to counselors who behave in a nonthreatening, supportive manner and whose demeanor indicates that they will honor the confidentiality of the sessions. Clients frequently describe the successful relationship in familial terms: "It is like talking to my son," or, "It is as though she were my sister." Older clients value spontaneity in relationships with the counselor and other staff members; a counselor's appropriate self-disclosure often enhances or facilitates a beneficial relationship with the patient.

Because receiving counseling may be a new experience for the client, the provider should explain the basics of counseling and clearly present the responsibilities of the counselor and the client. Summarizing at the beginning of each session helps to keep the session moving in the appropriate direction. Summarizing at the end of a session and providing tasks to be thought about or completed before the next session help reinforce any knowledge or insights gained and contribute to the older client's feeling that she is making progress.

In individual sessions, counselors can help clients prepare to participate in a therapy group, building their understanding of how the group works and what they are expected to do. Private sessions can also be used to clarify issues when the individual is confused or is too embarrassed to raise a question in the group. As the client becomes more comfortable in the group setting, the counselor may decide to taper the number of individual counseling sessions. Likewise, the client may prepare for discharge by reducing the frequency or length of sessions, secure in the knowledge that more time is available if needed.

Medical/Psychiatric Approaches

Older substance-abusing clients differ from their younger counterparts in the number and complexity of associated health problems. Unless these problems are recognized and either corrected or stabilized, the patient's participation in substance abuse treatment will be compromised and chances for recovery diminished. Especially in older adults, health problems interact with and impair social and psychological function, adding to the complex of causes for the patient's dysfunction and disability.

Medications used to modify drinking behavior in older adults must take into account age- and disease-related increases in vulnerability to toxic drug side effects, as well as possible adverse interactions with other prescribed medications. Disulfiram is not generally recommended by the Panel for use in older patients because of the hazards of the alcohol-disulfiram interaction, as well as the toxicity of disulfiram itself.

Naltrexone, an opioid receptor blocker with mild opioid agonist actions, has been shown to reduce drinking in younger alcoholics in controlled studies. A controlled pilot study of its use among older men under age 70 found that these patients tolerated the drug well (Oslin et al., 1997). Moreover, there was suggestive evidence for reduction in drinking relapses in naltrexone treated patients. Acamprosate, a glutaminergic drug, has shown considerable success in reducing drinking in younger alcoholics in European controlled trials (Litten et al., 1996). Acamprosate has not been specifically studied with older adults.

Visual and hearing problems compromise effective coping and the accomplishment of the tasks of daily living, interfere with social functioning, and may prevent effective participation in substance abuse treatment. Accordingly, initial medical assessment of older adults should routinely include screening for visual and auditory problems, and any problems discovered should be corrected as quickly as possible.

Many older alcoholics do without needed health care; linking them to a health care provider can be a profoundly valuable service. The substance abuse treatment program should consider, whenever possible, educating older clients on such health promotion themes as desirable diet and nutrition, daily exercise, sleep hygieneand the benefits of routine health checks.

A thorough, age-specific medical evaluation should be completed for each patient at entry into alcoholism treatment if it was not done by the referring source. The evaluation can be completed in-house in larger programs that have a primary care provider on staff, by a consulting provider, or by the patient's personal physician. Trained nonmedical staff can easily do portions of the evaluation, such as screening for age-related macular degeneration (AMD), a leading cause of blindness in older adults. Positive results would indicate the need for further evaluation by a professional (e.g., referral to an opthalmologist). The treatment program should review this evaluation.

The medical evaluation should always include an assessment of medication use, because of the potential for medication and alcohol interactions. To determine the medication use of older adults, the "brown bag approach" is helpful (Finch and Barry, 1992). The practitioner can ask older adults to bring every medication they take in a brown paper bag (e.g., all medications prescribed by a doctor; all medications, vitamins, etc., they got at the drugstore; any herbs that anyone gave them to try). This will provide an opportunity to better determine potential medication interaction problems.

Chronic mental illness such as depression, bipolar and recurrent major depressive disorders, chronic schizophrenia, and severe anxiety disorders will require ongoing care. Research suggests that some patients with schizophrenia cannot manage the interpersonal intensity of group therapy for addictions and are more suitably managed on a one-to-one basis with an addictions counselor who consults with a psychiatrist (Finlayson, 1995a). Some patients with severe disorders, including some with dementia, may be better managed in a mental health or long-term care setting than in a substance abuse program, provided a geriatric psychiatrist is involved, at least for consultation.

The epidemiology of depression among older adults is controversial (Weiss, 1994). According to the Epidemiologic Catchment Area Study, depressive symptoms occur in an estimated 15 percent of community residents over the age of 65. Estimates of major depression among the same age group are usually less than 3 percent. Rates of major or minor depression among older adults seeking care from primary care clinicians or residing in nursing homes range from 15 to 25 percent (National Institutes of Health, 1991). Among those hospitalized for physical illnesses, approximately 10 percent suffer from a major depressive disorder, whereas an estimated 30 percent experience minor depressions (Koenig and Blazer, 1996). Despite expectations that rates of depression among older adults would be high, studies have not generally confirmed this view. One reason for this failure may be that "many depressions in this age group are subsyndromal and do not fit well into the current nomenclature" (Koenig and Blazer, 1996, p. 417). Another explanation may be that symptoms "are often lost amid 'real' medical problems of the aged" (Weiss, 1994, p. 5). Researchers estimate that between 10 and 30 percent of older alcoholics have long-lasting or recurrent depressive symptoms (Blazer et al., 1987b). Some fulfill criteria for major depressive disorder, dysthymic disorder, or cyclothymic disorder. Others do not meet criteria for any of these diagnoses yet suffer from depressive symptoms that fall under the category of subsyndromal depression. Depression for several days or longer immediately following a prolonged drinking episode does not necessarily indicate a true comorbid disorder or the need for antidepressant treatment in most cases (Atkinson and Ganzini, 1994; Brown and Schuckit, 1988; Schuckit, 1994). When depressive symptoms persist several weeks following cessation of drinking, specific antidepressant treatment is indicated (Brown et al., 1995).

Family Involvement and Therapy

Case Management, Community-Linked Services, and Outreach

Case management is the coordination and monitoring of the varied social, health, and welfare services needed to support an older adult's treatment and recovery. Case management starts at the beginning of treatment planning and continues through aftercare. One person, preferably a social worker or nurse, should link all staff who play a role in the client's treatment as well as key family members and other important individuals in the client's social network.

The multiple causes of older adults' problems require multiple linkages to community services and agencies. The treatment program that seeks to be the sole source of all services for its older clients is likely to fail. Even in very isolated areas, programs can strengthen their services for older adults through linkages to local resources such as the faith community.

The case manager will likely refer the client to a combination of several community resources in response to the issues associated with the substance abuse problem. Case managers must have strong linkages through both formal and informal arrangements with community agencies and services such as

• Medical practitioners, particularly mental health providers, geriatricians, and geriatric counselors
• Medical facilities for detoxification and other services
• Home health agencies.
• Housing services for specialized housing (i.e., wheelchair-accessible housing, congregate living)
• Public and private social services providing in-home support for housekeeping, meals, etc.
• Faith community (e.g., churches, synagogues, mosques, temples)
• Transportation services
• Senior citizen centers and other social activities
• Vocational training and senior employment programs
• Community organizations that place clients in volunteer work
• Legal and financial services
• The Area Agency on Aging (funded under Title 20).

If a program includes outreach services, case management may offer the best means of providing them (Graham et al., 1995b; Fredriksen, 1992). Case managers may, for example, initiate outreach services for homebound clients, although it is important to maintain continuity and assign only one case manager to an older client. If clients in a treatment program become seriously ill or dysfunctional and temporarily require services at home, a case manager may be the ideal staff person to broker services on their behalf. (Comprehensive case management for substance abuse treatment will be described in detail in a forthcoming TIP to be published in 1998.)

Other Adjunctive Approaches

A number of other treatment approaches are useful in responding to older substance abusers. Generally, however, they work best when they complement the major approaches already discussed.

Spiritual or religious counseling with a clergy member, either in a group or individual setting, may be an important adjunct to therapy for individuals who feel more comfortable addressing their concerns in a religious context. Many older adults are concerned about their spiritual preparation for death, even when it is not imminent, and welcome opportunities to explore that topic.

Substance abuse treatment providers are moving toward a greater recognition of the role of spirituality in recovery, and providers should not hesitate to build on the religious belief systems of older clients, when appropriate. From its inception, Alcoholics Anonymous has spoken of "a higher power," and much of its effectiveness may derive from its spiritual aspects. One caution: Older adults who have never subscribed to a religious belief system may not be ideal candidates for spiritually oriented therapy or referral to 12-Step fellowship programs.

One Panelist observed that spirituality is often a key element in brief interventions, especially in minority communities. Programs that specialize in the treatment of a particular ethnic or racial group may adopt strategies specific to that group (e.g., the use of tribal rituals in the treatment of Native American substance abusers). A variety of nontraditional methods for tension reduction (e.g., therapeutic massage, meditation, acupuncture) have been suggested as applicable to older adults, although these methods remain largely untested.

Discharge Plans and Aftercare

Effective discharge planning is essential to case management for older clients because their social networks may have shrunk as a result of their substance abuse problems, physical limitations, or the loss of family members and friends. In this context, it is vitally important for clients' counselors or case managers to help them tap into available community resources by assisting them in identifying ongoing needs (e.g., income maintenance, housing), scheduling services (e.g., Homemakers, eye care, hearing tests, financial planning), and obtaining equipment (e.g., large-number telephones, home banking systems, walkers and other devices).

As part of the discharge process, a counselor or case manager also develops an aftercare program with the client. For older adults, this may entail arranging transportation to follow-up appointments and reminders to note dates and times on the calendar, as well as fulfilling more traditional functions like monitoring progress to prevent or reduce the negative impact of relapse. Standard features of most discharge plans for older adults include

• Age-appropriate Alcoholics Anonymous, Pills Anonymous, Rational Recovery, women's or other support groups
• Ancillary services needed to maintain independence in the community
• Ongoing medical monitoring
• Involvement of an appropriate case manager if needed to advocate for the client and ensure needed services are provided.

Aftercare and recovery services for older clients differ in some respects from those typically offered by some substance abuse treatment programs where fraternization is discouraged. Programs oriented to older clients often sponsor socialization groups or weekly treatment alumnae meetings run by long-sober peer counselors. Others allow clients to return to the program to participate in group therapy. Still others initiate a network of contacts for older clients and teach them how to expand it.

Some communities have established, integrated social service networks that enable clients to receive coordinated care. However, stand-alone programs in communities without defined networks may have to initiate linkages with other services themselves. Some treatment programs have begun this process of network building by publicizing their services to other local agencies and health care facilities. Prior consultation with the local Office on Aging and other resources in the community that target older adults helps to ensure that the resulting network is responsive to their special needs. In rural areas, treatment programs serving older adults face additional challenges. In these settings, collaboration among health and social service programs is crucial to resolve problems posed by geography, lack of public transportation, sparse and distant services, and social isolation. CSAT's Technical Assistance Publications Rural Issues in Alcohol and Other Drug Abuse Treatment (CSAT, 1996), Treating Alcohol and Other Drug Abusers in Rural and Frontier Areas (CSAT, 1995b), and Bringing Excellence to Substance Abuse Services In Rural and Frontier America (CSAT, 1997) have more information on surmounting these barriers.

Misuse by the Patient

Some experts estimate that as many as 70 percent of depressed older patients fail to take 25 to 50 percent of their medications, producing wide fluctuations in blood levels and jeopardizing the efficacy of therapy (National Institutes of Health, 1991). Such widespread misuse of prescriptions requires intensive efforts to determine the reasons for noncompliance and to educate patients about medication management. In general, the causes of noncompliance with a prescribed medication regimen can be categorized as

• A lack of judgment or misconceptions about the drugs
• An inability to manage the medication regimen, either because it is complex or the patient has persistent memory problems and will need regular supervision
• Insufficient resources for purchasing or storing the medications
• Intentional misuse to obtain results other than for those prescribed (e.g., pain pills to sleep, relax, soften negative affect).

Unless patient interventions address the real reasons for noncompliance, they are not likely to be effective. If initial observations and questions about prescription drug use suggest misuse, more information will be needed so that remedies can be appropriately targeted. For example, if a 73-year-old woman is skipping doses of her blood pressure medication, the provider needs to learn whether this happens because (1) the patient only takes the medicine when she feels ill rather than on the prescribed schedule, (2) the medicine sometimes makes her feel unpleasantly dizzy, (3) the patient frequently forgets whether she took the medicine, or (4) the patient cannot afford the drug and tries to do without from time to time so that she will have a supply available when she feels she needs it.

If the patient's noncompliance is due to economic considerations, then teaching her how to manage medications by separating them into container compartments for each day of the week (or hour of the day) will not be helpful. That strategy might be appropriate, however, for another patient who has suffered a stroke and has real difficulty with short-term memory.

Medication noncompliance may take the following forms:

• Omitting doses or changing the frequency or timing of doses
• Doubling up on the dosage after forgetting to take the previous dose
• Taking the entire day's medications in the morning for fear of forgetting to take all the doses of all the medications as prescribed
• Increasing doses or dosing frequency
• Taking the wrong drugs
• Borrowing or sharing drugs
• Supplementing prescribed drugs with other over-the-counter medications or "leftover" medicines from an earlier illness
• Continuing to use alcohol or other contraindicated drugs or foods while taking the prescribed medicines
• Engaging in contraindicated activities while taking the medications (e.g., driving motor vehicles, spending time in the sun)
• Failing to tell the prescribing physician about all the other medications (prescribed and over-the-counter) being used or to report significant or unexpected side effects or adverse reactions
• Storing medications improperly (not refrigerating those that require a continued cold temperature) or using prescriptions with expired expiration dates.

The patient and the health care practitioner share responsibility for ensuring that the patient understands all dosing instructions, the purposes of the medications prescribed, and the unpleasant side effects or adverse reactions that should be reported to the doctor. However, providers can also instruct patients to take advantage of pharmacists' services in providing personal advice and computer-generated instructions regarding specific drugs, side effects of varying intensity and seriousness, contraindications for use, and when beneficial effects can be anticipated. Many materials have already been developed and are widely available for educating older adults and others about medication compliance strategies and their importance. These can be obtained from numerous sources, including home health care agencies, State and local offices on aging, the Substance Abuse and Mental Health Services Administration (through the National Clearinghouse for Alcohol and Drug Information), the National Council on Aging, and the American Association of Retired Persons.

Treatment providers can help empower older adults to ask more questions and optimize the benefits of their contacts with medical professionals. Older patients with some cognitive or sensory impairment may not be able to adhere to complicated medication regimens. In these cases, treatment providers can identify and educate family members or other professional or volunteer advocates and caregivers about the need to assist the older adult with this task.

Once the substance abuse treatment provider identifies a medication misuse problem, arrangements should be made for an initial but intensive monitoring of the patient's use of the problematic drug. Monitoring may be undertaken by visiting or public health nurses or other designated medical staff. The objective is to determine whether misuse continues despite all attempts to correct underlying reasons for noncompliance. If the patient appears to be knowingly noncompliant, the behavior is characteristic of abuse.

The intervention for this behavior will depend on an accurate and in-depth assessment of the social, medical, and psychological problems that may be driving the substance abuse (e.g., depression, bereavement, a medical condition, social isolation, physical pain, insomnia). Assessment results then provide the basis for an individualized treatment plan that includes and ranks mechanisms for addressing each issue. Unless the abuse has resulted in a serious crisis, it is usually appropriate to try psychosocial approaches first, including grief therapy, sleep management training, relaxation techniques, socialization (day care) programs, psychotherapy, and acupuncture.

Once treatment begins to resolve the underlying issues, the provider must confer with the health care practitioner to determine whether the older adult should remain on the problematic drug at a reduced dose, discontinue use altogether, or switch to an alternative prescription with less addictive potential. The choice will depend on what options are available and the severity of the problems experienced as a result of the substance abuse. The Panel recommends an open discussion of these issues with the patient, substance abuse treatment provider, and health care practitioner.

Misuse (Misprescribing) by the Health Care Provider

Health care professionals need to keep abreast of current information about appropriate prescribing practices for older patients as well as new drugs with less hazardous profiles. Older adult-specific protocols must stress medication assessments for all patients; lower initial doses and time-limited dosing patterns for psychoactive and other agents; use of new and less complex drugs with simple metabolic pathways and less dangerous side effects; avoidance of more hazardous substances with long half-lives that cannot easily be absorbed or eliminated by older adults; and appropriate, consistent monitoring of patients' reactions to prescribed drugs.

Health care professionals also need to be reminded of ways to convey information that are easily understood and used by older patients (e.g., written as well as spoken, disseminated to family caregivers and advocates as well as the patient). When prescribing medications for older adults, it is also useful to consider the family situation. Are other family members likely to share their medication with the patient or use it themselves? Is there a family member who will help the older patient track his medications, comply with the practitioner's request to bring unused medications to the practitioner, remind the patient to discard expired medication, or remove the medication at the practitioner's request? Family members can be important allies in preventing problems from developing or escalating.

Some ways in which health care professionals might be motivated to adopt "best" prescribing practices for older patients include

• Making relevant publications such as this TIP and other resources easily available on the Internet and widely disseminated through medical societies, other health-related professional groups, and health care practitioner training programs
• Adding or updating older adult-specific information in the Physician's Desk Reference and other pharmacist-approved publications regarding psychoactive prescription drugs with abuse potential
• Providing Continuing Education Units for attending workshops at medical conferences and other health care professional meetings on prescription drug use and abuse among older patients
• Training primary care physicians and other health care providers to consult more frequently with pharmacists, psychiatrists, and other psychopharmacologists regarding the risk and benefit profiles of the psychoactive drugs they prescribe rather than relying on outdated materials or their own authority
• Empowering older patients and their advocates to ask health care providers questions about the rationale for all proffered prescription medications as well as dosing protocols, schedules, expected and dangerous side effects, and interactions with other medications or food
• Ensuring that any attempts to restrict prescribing practices through legislation and regulations do not encourage prescriptions of more hazardous substances or make legitimately needed medications even more difficult for patients to obtain.

Credentials and Training for Program Staff

Staff working with older adults need to understand the developmental tasks of aging and the basic principles of educational gerontology - how older adults learn and process material. For this reason, Panel members believe that any program that treats even a few older adults should have at least one staff person who is trained in the specialization of gerontology within his or her discipline. This training should consist of at least a graduate certificate program (6 to 12 months) in the subfield of aging commonly called social gerontology. Staff with professional degrees should have a specialization in gerontology, geriatrics, or psychogeriatrics. If staff lack appropriate credentials, it can be difficult for the program to receive reimbursement from insurance companies or funding from other funding streams.

Any program that seeks to serve older adults should also have a registered nurse on staff. Ideally, this nurse would have a background in physical health, addictions, and gerontology. In freestanding programs that assign only one person to older clients (common in rural areas), a master's degree in nursing with a specialty in gerontology is preferred.

Large programs with interdisciplinary teams should include a registered nurse, a social worker, and chemical dependency counselors. All staff should have master's-level training with specialties in gerontology. The social worker should be prepared to carry out case management roles including liaison to community agencies.

The Panel recognizes that some programs in isolated areas may serve only a few older adults in a mixed-age setting and may be unable to retain staff members with optimal training. In such instances, the staff person chosen to work with older clients should have a strong desire to do so and should have some knowledge of the developmental tasks of aging, even if this is gained through experience rather than formal education. Wherever feasible, programs that have no appropriately trained staff should encourage at least one staff member to attain certification.

Programs with linkages to layers of services - large addictions programs or programs linked to hospitals, health care systems, or multiservice agencies - are common in urban settings. The following professionals should ideally be available to a treatment program, whether as members of the program's treatment teams or as resources available through the program's linkages with other services:

• A geriatrician
• A geriatric psychiatrist
• A geropsychologist
• A gerontological counselor
• A nutritionist
• An activities director or recreational therapist (to make home visits, increase socialization, teach activities to fill leisure time)
• A chaplain or other member of the clergy
• Occupational therapists
• Social workers (clinical, community, administrative)
• Peer counselors (particularly valuable because they have many life experiences in common with clients).

Orientation and training of all staff is a necessity. Staff should understand and believe that the prognosis for recovery for adults in this age group is favorable. They should understand that older adults can learn and change, and they should be capable of showing respect to their older clients. Special training on counseling skills and their application with older adults should be available to peer counselors and other program clinicians on an ongoing basis.

Attributes and Personal Traits

Facilities should project the attitude that they want to serve older adults. When centers offer age-specific programs with staff experienced in aging issues and interested in working with older adults, use by older adults increases (Fleming et al., 1984; Lebowitz, 1988; Lebowitz et al., 1987; Light et al., 1986). Similarly, in the treatment of alcohol abuse, research suggests that age-specific programs may be more attractive and effective (Atkinson, 1995; Kofoed et al., 1987).

It is important that all staff who work with older clients actually like adults of this age group. When hiring, program staff should try to determine how older adults fit into the applicant's life. Does the applicant interact with an older person by choice, as a friend? Does he or she interact with older family members on a regular basis? Does he or she interact with older adults on a regular basis through volunteer activities or other activities in the community?

Staff need a sense of the issues involved in aging. This understanding can be gained through training, empathy, or the personal experience of growing older. With this understanding comes a willingness to listen and to be patient with the older adult's pace of movement and speech. A sense of humor is also important. Nonconfrontational personalities typically work better with older adults. People who prefer an emotional or confrontational approach to therapeutic interaction are not appropriate candidates for work with older adults. Staff should be able to work in groups as trainers or teachers. Staff who work with older adults also need to be flexible and willing to carry out tasks that may not be considered "professional."

Staff members and volunteers need to be open to multiple avenues to recovery. If recovering staff see their own route to recovery as superior or the only way, it may limit their ability to work effectively with older adults, who tend to require more flexible approaches in order to find their path. Effective treatment for the older adult is more holistic, more supportive, and often a great deal more complicated than standard addiction treatment.