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Substance abuse among adults over the age of 65 yrs. is a fa

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Transcript of Substance abuse among adults over the age of 65 yrs. is a fa

Substance Abuse in the Elderly & Disabled Population
Factors that influence the rate of Substance Use
Substance abuse among adults over the age of 65 yrs. is a fast growing health issue in the country.
Not only, is it under identified, under diagnosed, under treated, and under estimated.
Research demonstrates that about 17% of older adults are suffering with alcohol and prescription drug use issues.
Often times, diagnosing an adult with substance abuse issues may be difficult because the symptoms sometimes relate to the symptoms associated with other medical and behavioral disorders common among this population, such as diabetes, dementia, and depression.
Factors Cont.
Due to previous customs and their ancestral history, there is a stigma within this community towards admitting substance abuse issues and getting the necessary treatment towards it.
There is an understanding that there is no point in treating older adults for substance abuse issues due to their age, and lack of knowledge towards different treatments.
There is a strong belief that substance abuse treatment within the elderly population turns into a waste of health care resources.

Lack of Awareness
Clinician Behavior
Substance Use Patterns and Signs/Symptoms of Addiction
How much do you know???
1. Recent census data estimates that nearly 35
million people in the United States are 65 years
or older. Substance abuse among those 60 years
and older (including misuse of prescription
drugs) currently affects about 17 percent of this
population. By 2020, the number of older adults
with substance abuse problems is expected to

2. A 2011 study by the Substance Abuse and Mental Health Services Administration found that among adults aged 50 to 59, the rate of current illicit drug use increased to 6.3 percent in 2011 from 2.7 percent in 2002.

3. Aside from alcohol, the most commonly abused
drugs were opiates, cocaine and marijuana.

4. In 2010 the best estimates are that six to eight million
older Americans — about 14 percent to 20 percent of the
overall elderly population had one or more substance
abuse or mental disorders.

5. The number of adults aged 65 and older is projected to
increase to 73 million from 40 million between 2010 and
2030, and the numbers of those needing treatment
stands to overwhelm the country’s mental health care

True or False?
Special Treatment needs for the Disabled
It does illustrate the fact that a significant number of people in this country are living with a long-term disability. Unfortunately there is only limited body of information about the relationship between physical disability and the SUDs. This is clearly seen in the fact that 62% of those people who are disabled also have an AUD (Heinmann & Fawal, 2005).

Special Treatment Needs Cont.
Unfortunately, even if a disabled person is identify as having an SUD, treatment resources for these individuals are very, very limited.
For example, if the person is hearing impaired and uses sign language, many treatment programs must rely not on professional sign language interpreters, but on friends and family members to translate questions and comments into sign language (Heinemann & Fawal, 2005).
According to Doweiko, even if treatment programs have videotapes of lectures that are closed captioned, utilize sign language interpreters to translate group therapy sessions for the hearing-impaired client, few program can provide such sign language interpreters outside of group or individual therapy sessions.
This prevent the client from participation in informal give-and-take discussions outside of group or individual psychotherapy sessions and can make the client feel isolate (Doweiko, 212, 2009).

Even when the older patient with SUD is referred to treatment, there are few specialized programs that can meet the unique needs of older patients who are substance abusers. These special needs can include:

Primary prevention
: to warn the individual of the potential dangers of alcohol or drug abuse.
Component to identify and help serve older patients who might be overlooked by traditional social services agencies.
Detoxification programs:
designed to meet the needs of the older patients with an SUD (who may required longer-than-normal periods to complete the detoxification process
Protective environments:
for older patients, including treatments component
Primary treatments:
for those people whose status would allow them to benefit from such treatment programs, and
After-care programs:
for older individuals

Substance Abuse Among Elderly Video
Special Treatment Needs Cont.
All of the aforementioned would be an addiction to access to social work support services and long-term residential care for people who have suffered medical or psychiatric damage from their substances use disorder
Given the current era of “managed care,” it is unlikely that such extended treatment programs might be developed.
In younger adult the detoxification process might be completed in 3-7 days, might require 28 days or more for the older adult with an SUD to complete (Gomberg, 2004; Mundle, 2004; Stevenson, 2005).
Even if older patients do complete the detoxification process, they will often present treatment staff with a range of sensory deficit not seen in young-adult patients and often dislike the profanity commonly encountered in mixed-age groups.
Unless these special needs are addressed older patients with SUD are unlikely to be motivated to remain in treatment or might resist a referral to treatment following relapse (Zimberg, 2005).

Video: Elderly Population

As of 2002, it was reported that 15 million of disabled adults may need substance abuse treatment; however fail to obtain it.
Disabled adults are typically 2 in 4 times more probable to developing a substance abuse disorder rather than the general population.
Persons with disabilities often have multiple risk factors such as; medication and health problems, societal enabling, a lack of identification of potential problems, and a lack of accessible and appropriate prevention and treatment services.

Factors in Substance Abuse in the Disabled Population
Other factors associated with substance abuse among the disabled are shame, lack of knowledge, and insufficient familial support.
Due to the possible present medical and health issues associated with the disabled population, there is an increase in prescription drugs prescribed by their own doctors.
Since the disabled has more accessibility to these drugs it becomes more of a factor an possibility for them to become addicted.

Factors Cont.
Video: Disabled Population
Barriers to Identifying and Treating The Elderly With Substance Abuse Problems
A term that is associated with negative stereotypes to older adults (elderly – 60 years and older) and to explain away their problems as a function of being old rather than looking for specific medical, social, or psychological causes.

Lack of awareness of the problem that is often shared by the older substance abuser, his or her loved ones, the community, and society as a whole.
A lack of awareness or denial of the signs of alcohol abuse (more common among older adults), combined with the personal or community-specific stigma of the disease, may effectively raise one or more barriers to treatment.
Many older adults are also very sensitive to the stigma associated with psychiatric disorders.
Many older adults do not accept that alcohol- or other drug-related disorders are health care problems or diseases.

Health care and older adult service providers may be as slow to spot a substance abuse problem as everyone else is: Despite its frequency, there is often a low index of suspicion for this problem. Even when there is the suspicion of a substance abuse disorder, the practitioner may have difficulty applying the diagnostic criteria to a wide variety of nonspecific symptoms.
Another clinician barrier to diagnosing alcohol problems in older adults is stereotyping. Clinicians are less likely to detect alcohol problems in women, the educated, and those with higher socioeconomic status (Moore et al., 1989).
Providers may also believe that older substance abusers do not benefit from treatment as much as younger patients, despite studies that have dispelled this persistent myth

Medical and psychiatric comorbidities present yet another challenge to the effective treatment of the older substance abuser. Comorbid conditions such as medical complications, cognitive impairment, mental disorders such as major depression, sensory deficits, and lack of mobility not only can complicate a diagnosis but can sway the provider from encouraging older patients to pursue treatment for their substance abuse problems. 

Transportation (may be available to go to a hospital but not to AA or aftercare or evening programs): This is especially problematic in rural communities that lack public transportation or in poor urban communities where accessing transportation can be dangerous (Fortney et al., 1995).
Shrinking social support network: Fewer friends to support them, participate in the treatment process, or take them places.
Time: Despite the assumption that older adults have an excess of free time, they may well have to provide 24-hour supervision to a spouse, other relative, or friend, or have to care for grandchildren while the parent works.
Lack of expertise: Few programs have specialists in geriatrics, treat many older adults, or are designed to accommodate functional disabilities such as hearing loss or ambulation problems.
Financial: The structure of insurance policies can be a barrier to treatment. The carving out of mental health services from physical health services under managed care in particular can prevent older adults from receiving inpatient substance abuse treatment.

Other Barriers to Identification and Treatment
Special Populations
The following confront more specific barriers to treatment:
Racial and Ethnic Minorities
Home bound older adults including those with physical Disabilities
Barriers to Identifying and Treating Disabled Individuals with Substance Abuse Problems
Attitudes about "disability" influence the ways non-disabled people react to people with disabilities, which can affect the latter's treatment outcomes. The stereotypes and expectations of others also influence the ways people think about their own disabilities.
Perceptions, stereotypes, or beliefs held by providers can hinder their ability to treat a person with a disability
Attitudinal Barriers
Programs can inadvertently discriminate when their policies, practices, or procedures present barriers to the treatment of people with coexisting disabilities. For example, a program may establish a discriminatory policy such as the following:
We do not serve clients who are taking medication (even if the medication is for a medical condition, such as epilepsy). (Such discrimination is also often seen against clients in opioid maintenance therapy or those who require psychoactive medications for a psychiatric condition.)
People who miss appointments must pay fines (even though disability-related problems may make it impossible for a person to make a scheduled appointment)
Fire and safety regulations require that all clients be able to walk out of the building independently (which precludes the participation of a person who uses a wheelchair).
All clients must participate in house chores such as washing dishes and mowing the lawn (which precludes the participation of people with particular physical disabilities).
Every person must read two chapters of a book per day (even if some people do not have the necessary reading skills).

Discriminatory Policies, Practices, and Procedures
Communication barriers exist when a program's communications with people with coexisting disabilities are less accessible than its communications with others. To eliminate communications barriers, programs should have available a wide range of auxiliary aids and services.

Communication Barriers
Architectural Barriers
Physical barriers include the absence of elevators or ramps, narrow hallways, poor lighting, wall telephones too high for people in wheelchairs, deep pile carpets that interfere with wheelchairs or crutches, conventional doorknobs that impede access to people with limited manual dexterity, or even a lack of transportation from the property's boundaries (where public transportation may drop off a person) to the facility's entrance. Programs should consider other types of modifications as well in order to make their buildings safer for all participants
Special Treatment Needs for the Elderly
It is imperative for treatment program staff to be aware of the age-specific stressors that older people will present when they are in a rehabilitation center setting such as bereavement, loneliness, and the efforts of physical illness (Zimberg, 2005, 1996). On a positive note, there is evidence that older adults with an SUD respond better to an age-specific treatment program that do younger substance abusers (Drew et al; 2010).
Older patients were found to remain in primary treatment longer and to respond to psychosocial intervention such as Alcoholics Ananumous (AA) with more enthusiasm, while presenting a lower risk of relapse then seen with other subgroups of drinkers (Satre et al; 2004)
It may be difficult to detect the problem of substance abuse when the elderly live alone. Consideration should be given to the presence of a drug and/or alcohol problem if there is memory loss, depression, repetitive falls and injuries, legal problems, chronic diarrhea, labile moods, malnutrition and recent isolation.
What to do?
Education for and from healthcare providers
Family’s attention
Social interactions
Clinical treatment

Special Treatment Needs Cont.
Special Treatment needs for the Disabled
In contrast to this lack of treatment resources for patients with physical disabilities, Drug dealers are quite happy to offer their services to the disabled. Some drug dealers have gone so far as to learn sign language in order to communicate with hearing-impaired clients, providing a service lacking in many rehabilitation.

Intervention and Treatment Modalities
Substance Abuse and the Elderly
Few outcome studies that focus on older patients with an SUD...few specialized programs that can meet the Unique needs of older substance abusers.
In comparison to young-adults, older adults with an SUD may take 28 days or more for completing detoxification
Evidence that older adults with an SUD respond better to age-specific treatment programs than do younger substance abusers.

A) Primary prevention to educate client of dangers and consequences of substance abuse.
B) Outreach programs to Identify and help those overlooked
C) Detoxification may need longer than normal periods to complete the detoxification process..
D) Protective environments that promote sobriety for older patients including treatment components.
E) Primary treatment adequate treatment for status of patient.
F) After-care programs for older individuals.

Special Needs to Consider
Strategies for Engaging and Retaining the Elderly Substance Abuser in Treatment
Can present sensory deficits not seen in young-adults.
May not feel comfortable with mixed age group environments.
If the aforemention needs are addressed, older patients were found to remain in primary treatment longer and to respond to psychosocial Interventions such as Alcoholics Anonymous. Show more enthusiasm and present lower risk of relapse than other groups
Care providers must be aware of age specific stressors.

Age Specific Stressors
Bereavement- Loss of loved ones and friends around them.
Loneliness- Family involvement or lack of in recovery.
Effects of Physical illness- Medical factors that inhibit recovery.

Treatment Models
Cognitive Behavioral/Self Management intervention
The treatment approach and main goals of CB/SM are clear:

To engage and support clients as they receive skills training, using CB/SM
To analyze, understand, and control the day-to-day factors that have led clients to abuse substances
Clients demonstrate mastery of these skills by being able to diagram, understand, and prevent or interrupt their individual substance use behavior chains
Using the appropriate skills learned in treatment sessions to manage high-risk situations in real life
Typically, as clients learn to manage the antecedents (i.e., situations, thoughts, feelings, cues, urges) that trigger their substance abuse, they can maintain their abstinence.
Substance Abuse and the Disabled
Treatment resources are very limited
The Hearing Impaired-Treatment programs must rely not on professionals but family and friends for interpretation.
These limitations may isolate the client due to not being able to partake in informal discussions outside of group psychotherapy sessions.
Family may feel disabled member is “entitled” to drug use and become enablers.
Treatment guidelines are lacking.

12-Step Model/ Disease Model / Minnesota Model
- AA and NA models. This model focuses on chemical dependency as the primary problem.This model is by far the most widely used treatment model.
Cognitive Behavioral Treatment Model-
Identify and reframe irrational thinking.
Bio-Psycho-Social Model/Social Model:
- social model practitioners believe that alcoholism is a multifaceted disease, one that is caused by a combination of factors: moral/spiritual, biological, psychological, and social/environmental.
Harm Reduction
- Harm reduction is a public-health approach to dealing with drug-related issues that places first priority on reducing the negative consequences of drug use rather than on eliminating drug use or ensuring abstinence. (needle exchange)
a) addictive behaviors are not all or nothing
b) Sobriety is a stepwise process
c) Sobriety is not for everyone

Therapy Models
- Identify if issue predates disability
- Financial incentives
A study of Independent Living Centers in California found that nearly two thirds of the centers do not regularly ask their clients about alcohol or other drug use (Frieden, 1990). Obviously, adequate assessment must occur before treatment commences.
Highly skilled medical staff, need awareness and skills in dealing with individuals with substance abuse problems and physical disabilities.
Family's closeness to the individual who is disabled, the family "is uniquely qualified to complement professional rehabilitation resources" Enabling and codependency are critical parts of an addictions cycle.

Strategies for Engaging and Retaining the Disabled substance abuser in treatment
People with both a substance use disorder and a coexisting disability may need assistance and individualized accommodations to
Escape from abusive situations
Learn to protect themselves from victimization
Find volunteer work or other means of gaining a sense of productivity in lieu of paid employment (although paid employment would always be preferred)
Develop pre-vocational skills such as basic grooming, dressing appropriately, using public transportation, and cooking
Learn social skills that may be missing because of both substance use disorders and disability-related problems
Learn to engage in healthy recreation
Become educated about their legal rights to accessible environments and services as well as employment
Obtain financial benefits to which they are entitled
Build new peer networks

(Center for substance abuse treatment, 1998)


Center for Substance Abuse Treatment. Substance Use Disorder Treatment For People With Physical and Cognitive Disabilities. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1998. (Treatment Improvement Protocol (TIP) Series, No. 29.) Chapter1—Overview of Treatment Issues. Available from: http://www.ncbi.nlm.nih.gov/books/NBK64885/
Center for Substance Abuse Treatment. Substance Abuse Among Older Adults. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1998. (Treatment Improvement Protocol (TIP) Series, No. 26.) Chapter 1 - Substance Abuse Among Older Adults: An Invisible Epidemic. Available from: http://www.ncbi.nlm.nih.gov/books/NBK64422/

Drew, S. M., Wilkins, K. M., & Trevisan, L. (2010). Managing medications and alcohol misuse by your older patients.
Current Psychiatry, 9(2), 21-24, 27-28, 41.
Heinmann, A W., & Rawal, P. H. (2005). Disability and rehabilitation issues. In J.H. Lowinson, P. Ruiz, R. B. Millman, & J . G. Langrod (Eds.), Substance abuse: A Coprehensive textbook (4th ed.). New York: Lippincott Williams & Wilkins.
Satre, D. D.., Mertens, J. R., Arean, P. A., & Weisner, C. (2004). Five-year alcohol and drug treatment outcomes in older adults versus middle-aged and young adults in managed care program. Addiction, 99, 1286-1297.
Zimberg, S. (1996). Treating alcoholism: An age-specific intervention that works for older patients. Geriatrics, 51(10), 45-49.
Zimberg, S. (2005). Alcoholism and substance abuse in older adults. In R. J. Frances, S. I. Miller, & A. H. Mack (Eds.), Clinical textbook of addictive disorders (3rd ed.). New York: Guilford.

Center for Substance Abuse Treatment. Substance Use Disorder Treatment For People With Physical and Cognitive . Disabilities. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1998. (Treatment . . Improvement Protocol (TIP) Series, No. 29.) Chapter1—Overview of Treatment Issues.Available from: . ………….http://www.ncbi.nlm.nih.gov/books/NBK64885
Guthmann, D. Models of alcohol and other drug treatment for consideration when working with deaf and hard of hearing i inndividuals. Minnsota CHemical Dependancy Program for Deaf and Hard of Hearing Individuals. Retrieved from . . http://www.mncddeaf.org/articles/models_ad.htm
Menniger, J. A. (2002). Assessment and treatment of alcoholism and substance-related disorders in the elderly. Bulletin of the Menninger Clinic, 66(2), 166-83. Retrieved from http://ezproxy.barry.edu/login?url=http://search.proquest.com/docview/200490139?accountid=27715

6. A 2011 National Survey on Drug Use and Health found
that 8.3 percent of adults 65 and older reported binge
drinking, defined as having four or five drinks on one
occasion in the past month, while the rate of heavy
drinking was 2 percent.

7. If you are curious if an elderly person might have a drinking
problem you can administer a quick screening test called the

The MAST-G (Michigan Alcoholism Screening Test Geriatric
Version) varies from the MAST in that the questions highlight
the special employment and social situations of someone who
is retired and how that can relate to alcohol abuse. The tool
consists of 24 Questions (see handout).

8. Some studies estimate that up to 10 percent of the
elderly misuse prescription drugs with serious abuse
potential, most often anti-anxiety benzodiazepines like
Klonopin, sleeping pills like Ambien and opiate painkillers
like Oxycodone.

9. Women far out number men when it comes to
nonmedical use of prescription medication: 44 percent of
women versus 23 percent of men.

1. Researcher have found out that the baby boomer generation has not turned away from drug or alcohol abuse, as evidenced by the fact that an estimated 1.7 million people over the age of 50 are addicted to a drug(s), a number that is expected to reach 4.4 million by the year 2020(Kluger, 2006).

2. Researchers believe that 1% of the elderly have used an illicit drug in the past 30 days and that between 13% and 19% of the men and 9% of women over the age of 60 have an established AUD ( Brust, 2004; Gwinnell & Adamec, 2006).

3. Fifteen percent of older drinkers also have a concurrent drug abuse disorder (Greenfield, 2007)

4. Hazardous alcohol use is now defined as more than three drinks in one sitting or more than seven drinks in a 7-day period (Drew et al., 2010).

Scope of the Problem
5. As a group, the elderly population use one-third of prescription medications and one-half of all over- the –counter medications sold each year in the United States (Gross, 2008; “U.S. Face of Drug Abuse Grows Older,”2006).

6. Nineteen percent of older individuals who drink alcohol will experience at least one adverse alcohol-drug interaction (Brust, 2004). If the individual were to also have an SUD, the risk of an adverse drug interaction is multiplied, possibly with fatal results (Gwinell & Adamec, 2006; Stevenson, 2005; Zimbert, 2005).

7. 25-30% of the men and 5-12% of women who are hospitalized are thought to have and AUD ( Stevenson, 2005).


Elderly Substance Abuse PSA Video
Different Patterns of Alcohol/Drug Abuse in the Elderly
The problem of SUDs in the elderly is complicated by the issue of age
Older Drinkers (between ages of 50 and 74) are more likely to misjudge their level of impairment at low to moderate levels of intoxication than younger adults.

Late-onset alcoholism
Individuals who had no evidence of AUD in young or middle adulthood, but who did develop an AUD in late adulthood
Late-onset exacerbation
Individuals who had intermittent problems with alcohol in young and middle adulthood, but who developed a more chronic pattern of alcohol abuse in late adult hood
Early-onset alcoholism
Individuals with alcohol problems in young adulthood, which continued through middle adulthood into late adult years.

Subtypes of Older People with Alcohol Use Problems
Prescription misuse is often the most commonly overlooked aspect of the elderly
Mixture of alcohol and prescribed medications
Intentional overuse of a prescribed compound
Intentional under use of a prescribed medication, often to extend the duration between refills
Erratic use of a prescribed medications
The failure of the attending physician to obtain a complete drug history, including that of over-the-counter medications, resulting in dangerous combinations of various compounds.
Under utilization of prescribed medications is the most common form of medication misuse, usually reflecting the patients inability to afford medication.

Forms of Drug Misuse
Signs and Symptoms of Addiction in the Elderly
Older adults tend to have more medical problems than do younger adults and in earlier stages of SUDs often mimic the symptoms of other disorders, making the differential diagnosis very difficult for the physician.

Why is it so difficult to detect SUDs within the Elderly?
Abusers tend to attribute physical complications caused by their SUD to the aging process, form of denial aided by physicians, who rarely inqure about possible substance abuse in older people
Physicians fail to look for SUD in an older patient, based on assumption that person deserves to use
Some physicians believe that older person with an AUD is unlikely to respond to treatment, they do not look for SUDs in their patients
Social Isolation; especially if person lives alone
Rarely demonstrate the traditional warning signs
Ex. Substance related legal, social, or occupational problems found in younger adults
Missing work is explained as age-related problems or of taking care of sick spouse
Familial shame: demand that the issue stay hidden

Symptoms and Signs of Abuse in the Disabled Population
Signs and symptoms of substance abuse in the disabled population is very hard to detect.

Why is it so hard to detect SUD within the disabled population?

Many symptoms related to substance use also can represent everyday challenges associated with developmental disability.
Mimics a wide range of mental illnesses such as:
Mood disorders, all the way to
Symptoms such as:
slurred speech
Impaired judgment
Awkward or unsteady walk
This complicates diagnosis of SUD and further for treatment
Full transcript