elderlyaddiction

This is a paper I wrote for Social Work General Practice I (GPI) concerning Alcohol and Drug Addiction and the Elderly:

*while you may read and use my material for reference, I ask that you do not re-cycle this paper to use as your own.

INTRODUCTION Although a largely hidden problem, alcohol and drug dependency among the elderly is statistically growing in epidemic proportions. This report, Alcohol and Drug Abuse Among the Elderly, explores this problem facing the elderly population as well as health care professionals in the field of aging. Principles from the Generalist Intervention Model will be applied. According to the Connecticut Clearinghouse funded by the Federal Department of Mental Health and Addiction Services, between 2 and 10 percent of people over the age of 55 have chemical dependency problems (Connecticut Clearinghouse, 1998). Further, though this age range accounts for only 11 percent of the population, theses older adults account for 25 to 33 percent of the prescription drugs used each year (Connecticut Clearinghouse, 1998). In 1991, an estimated 70 percent of hospital admissions of older adults were directly linked to alcohol-related problems with widowers over the age of 75 having the highest rate of alcoholism in the country (Barber, 1996). Diagnosis of chemical dependency in older adults often goes undetected due to factors such as lack of appropriate screening tools, denial of family and community, and medical complications often related to and directly resulting from an alcohol-induced illness (Gurnack, Atkinson, & Osgood, 2002). Prescribed care for the elderly in cases of substance abuse is coming more to the forefront of care giving professionals. Community coalitions, federal research and medical advisory boards all contribute to the best diagnosis strategies and treatment of this growing issue. RECOGNITION AND ASSESSMENT Aging tends to be associated with increased problems with disease and ill health. However, association to the impact of drinking and the ill health of the aging adult is not always considered. Heavy drinking may be a cause for such health problems such as liver disease, raised blood pressure, and some forms of cancer (Institute of Alcohol Studies, 1997). In many cases, an older adult may need several prescription medications to handle one or more ailments or chronic illnesses during their later adult life and the use of alcohol in addition to medications negatively impact the older adult. Alcohol also despresses brain activity disabling proper functioning in older adults. Further, prescribed medication in conjunction with alcohol may further impair the individual (Institute of Alcohol Studies, 1997). Therefore, Social Workers and other health care professionals must be aware that many health-related illnesses may be a direct result of alcohol consumption used in conjunction with prescription and non-prescription medications. Further, health care professionals need to be aware of not only the symptoms of such co-morbid effects, but also know the extent to which an older individual may be addicted. For this purpose, three types of elderly drinkers have been identified (Institute of Alcohol Studies, 1997). They are: early-onset drinkers, late-onset drinkers, and intermittent drinkers (Institute of Alcohol Studies, 1997). Early-onset drinkers or ‘Survivors’ are those people have a continuing problem with alcohol-abuse resulting from early life habits. Statistics show that nearly two thirds of elderly problem drinkers are a result of an early- life drinking problem (Institute of Alcohol Studies, 1997). Late-onset drinkers or ‘Reactors’ begin drinking as a result of or in response to a traumatic life experience such as a death of a loved one, loneliness, pain, or insomnia (Institute of Alcohol Studies, 1997). Intermittent drinkers or ‘Binge’ drinkers on the other hand, drink on occasion or socially. Late-onset drinkers or intermittent drinkers have the best chance of managing and/or treating their alcohol consumption (Institute of Alcohol Studies, 1997). The physical effects of alcohol may also be easily misinterpreted. These effects include: impaired mental alertness, judgment, physical coordination and reaction time, and an increase to the risk of falls. Over time, drinking may cause permanent damage to the brain and central nervous system and may manifest itself in the form of cardiovascular pain, kidney, and stomach related illness (Barber, 1996). Beyond DSM-IV criteria and evaluation for substance abuse and dependence, there is the need for detailed diagnostic evaluation of the older adult (Gurnack, Atkinson, & Osgood, 2002). Not only does the clinician need to define the type of drinker the older individual may be, the clinician must also consider the types of prescribed medications that the individual is taking on a daily basis and if that drug is considered an ‘at risk’ medication when mixed with alcohol. APPLIED GENERALIST MODEL The following case study gives an example of how a social worker might apply principles from the Generalist Intervention Model for the engagement, assessment and planning phases: Mrs. Jones is a 72-year old widow. Her husband died 12 years ago due to heart failure. As a couple, they were involved with many social organizations in the community and Mrs. Jones continues to enjoy her occasional social drink with friends. She enters the hospital for two weeks after a fall which broke her hip. She is ready to be discharged and on the recommendation of her primary care physician and family, has decided to enter a long-term care facility for rehabilitation. She is anticipating release from the facility after she undergoes some physical therapy and plans to return home to continue to live her life independently. During the engagement phase, the social worker will want to build trust in the individual by discussing her recent decision to move to a long-term care facility. The worker will ask the client how she feels about the placement, what concerns she has about the decision and assure her of the expected outcome to alleviate or at least minimize early apprehension. The worker may escort the client to the placement and even introduce her to staff responsible for her care. Personal attention to the client as well as family members is important during the engagement phase for the older adult. After engaging the client and building trust, the social worker will want to make an assessment of the client. Verbal cognitive ability during this phase will determine the extent to which a worker may value the information as valid given by the older adult. In cases where alcohol consumption is implied, clinicians may best use the time-line follow-back method (TLFB) for diagnosis and assessment (Gurnack, Atkinson, & Osgood, 2002). The TLFB method is used most in research studies of treatment for addiction and has become the standard for such studies. In addition, principle assessment questionnaires such as MAST, SMAST, and CAGE may prove helpful to the worker during this phase (Kirst-Ashman & Hull, 2002). However, use of quantitative criteria sometimes presents validity issues, since the elderly have lower tolerance to alcohol and many times, shifts in weight gain and loss (ALCOWEB, 1996). Impact of social environments, family structures, and life-cycle adjustments are also important factors to consider during the assessment phase (Kirst-Ashman & Hull, 2002). In cases when the older adult is on prescribed medications, it is important to assess the extent of the alcohol consumed. That is, how much, how often. The U.S. Department of Health and Human Services has published recommendations regarding consumptions and older adults (Gurnack, Atkinson, & Osgood, 2002). Further, rationale and recommendations for treatment of at-risk drinkers are defined. Pharmaceutical data shows that benzodiazepines are prescribed more often to elderly patients (Gurnack, Atkinson, & Osgood, 2002). In addition, over the counter drugs such as sleeping pills, pain killers and antihistamines may be very dangerous to the older adult when mixed with an alcoholic drink (National Institute on Alcohol Abuse and Alcoholism, 2000). Therefore, Social Workers should assess the extent of drug use both prescribed and non-prescribed when working with older adults. Since older Americans are on the rise and there are greater possibilities for longer life-expectancy among the elderly, clinicians must consider beyond a micro approach to practice. Instead, a micro to mezzo scope should be considered with respect to this issue. In addition, since older adults are considered a more vulnerable population, strict abiding to the NASW Code of Ethics is a must. In many cases, the clinician may act as broker to the client and his/her family providing the necessary referral assistance that is needed for the circumstance. The clinician may also find that when working with older adults the need for case and cause advocacy. Health Care Reform, Medicare/Medicaid, Elder Abuse, Long-Term Care Planning are all issues to be aware of when working within this population. When working with clients in long-term care facilities, the clinician must alert the client to his/her rights and the relevance to their specific situation. PLANNING FOR THE POPULATION With the upcoming baby boom generation, and their predescribed conditions and behaviors, come a desperate need for intervention and planning for the treatment of alcohol-dependent adults. Treatment and counseling of older people needs to be based on assessment and matching of each person’s needs to the range of treatment and the services available (Institute of Alcohol Studies, 1999). One way for social workers to facilitate change is to encourage supportive family systems. Programs that reinforce skills and focus on reducing isolation may also decrease loneliness induced drinking in the older adult (Connecticut Clearinghouse, 1998). In addition, group treatment raises levels of social interactions and encourages positive support of peers. Emphasis on non-alcohol activities such as day centers and clubs show useful alternatives to social activities In addition to assisting with establishing social networks, individual case management is also an essential component in the treatment of older adults with alcohol dependence (Gurnack, Atkinson, & Osgood, 2002). After establishing a therapeutic alliance with the client, the clinician should evaluate with the client the pros and cons of drinking and together establish a treatment plan. Also, a contract with family may be a useful tool for accountability. Monitoring the clients’ moods and overall health is also a useful gauge of progress, however proper initial assessment for diagnosis is most important. Implementation of the Generalist Intervention Model would include: 1. Working with your client—the importance of relating the client to the process is vital not only to gain the trust of the older individual, but also to help the client assess his/her dependency issues and ways of empowering the individual to change. 2. Prioritize problems—older adults may not associate medical health problems with alcohol dependency. Therefore, it is up to the clinician to transition the client towards acknowledgment and admittance to this problem before planning may begin. 3. Translate problem into need—again, working with older populations, the client may assume physical problems to be their only problem. It is important that the clinician find ways to connect the dependency in ways the client can identify when translating the problem. Then, actual needs may be worked on. 4. Evaluate levels of intervention—selecting a strategy is often times difficult for the clinician. Group processes have been proven to be useful when working with the older adult. Also, supportive family networks encourage positive outcomes for the aging adult. Otherwise, the clinician may consider in-patient or out-patient networks for support. 5. Establish goals—goals clarify the treatment process. In addition, goals organize the older adult and serves to simplify the treatment process. Thus, goal oriented approaches are vital to problem resolutions. 6. Specify objectives—some older adults are cognitively impaired. During alcohol treatment, he/she may become increasingly confused as to what the clinician is trying to help with. By clearly defining objectives, the client and worker mutually agree on the terms of treatment and this also serves as a way to improve communication skills between clinician and client. 7. Specify action steps—clear definitions for the older adult is key to well-being. The client may be easily distracted or may simply forget. It is important for the clinician to use reminder strategies, give examples of the step by step processes, and ask the client to say back the action steps agreed upon. 8. Formalize a contract—this step in the model should be used at the discretion of the clinician for it may not be appropriate to use with the aging adult. Although contracts show their usefulness for adherence to agreed definitions, a formal contract may confuse the older adult and may not necessarily have the desired effect. CONCLUSION With the changing patterns of alcohol consumption, clinicians working with elderly population must consider the possibility for co-morbid diagnosis. Increasingly, Social Workers within the field of aging should be aware of the increased risk of prescription medications and their potential for abuse. Because older adults have medications more accessible to them, have the ability to self-medicate, and often use certain medications to relieve stress and/or improve their performance, there is increased risk for drug abuse and mis-use. Appropriate assessment and screening tools as well as clearly defined goals must be applied to the older alcohol-dependent adult. Clinicians should also understand the complications associated with alcohol use, addictive patterns of abuse, and approaches to solve this problem when working with the population of older adults. In conclusion, clinicians need to be aware of late-life alcoholism as an increasingly important focus for intervention strategies and construct ways of treatment using principles from the Generalist Intervention Model for practice.

(I also did a national book review on this same topic and I'll put that link here soon)