Treatment approaches for older problem drinkers

Professionals' perspectives on interventions to reduce problematic alcohol use in older adults: a realist evaluation of working elements

OBJECTIVES

This study set out to understand how (which elements), in what context and why (which mechanisms) interventions are successful in reducing (problematic) alcohol use among older adults, from the perspective of professionals providing these interventions.

DESIGN

Guided by a realist evaluation approach, an existing initial programme theory (IPT) on working elements in alcohol interventions was evaluated by conducting semistructured interviews with professionals.

SETTING AND PARTICIPANTS

These professionals (N=20) provide interventions across several contexts: with or without practitioner involvement; in-person or not and in an individual or group setting. Data were coded and links between contexts, elements, mechanisms and outcomes were sought for to confirm, refute or refine the IPT.

RESULTS

From the perspective of professionals, there are several general working elements in interventions for older adults: (1) pointing out risks and consequences of drinking behaviour; (2) paying attention to abstinence; (3) promoting contact with peers; (4) providing personalised content and (5) providing support. We also found context-specific working elements: (1) providing personalised conversations and motivational interviewing with practitioners; (2) ensuring safety, trust and a sense of connection and a location nearby home or a location that people are familiar with in person and (3) sharing experiences and tips in group interventions. Furthermore, the mechanisms awareness and accessible and low threshold participation were important contributors to positive intervention outcomes.

CONCLUSION

In addition to the IPT, our findings emphasise the need for social contact and support, personalised content, and strong relationships (both between client and practitioner, and client and peers) in interventions for older adults.

Opioid-Induced Hearing Loss and Neonatal Abstinence Syndrome: Clinical Considerations for Audiologists and Recommendations for Future Research

Purpose Over the last two decades, the number of Americans misusing opioids has reached epidemic levels. With such drastic increases in opioid misuse, audiologists are more likely to have patients with opioid-induced hearing loss or neonatal abstinence syndrome (NAS) than in previous years. More attention is needed on how these increases might influence clinical practice and such a discussion could be useful for audiologists. The goal of this article, therefore, is to summarize what is currently known regarding the relationship between opioid misuse and audiology to help guide hearing health care providers (with a particular focus on opioid-induced hearing loss and NAS). This article (a) summarizes the overlap in opioid misuse and hearing loss populations, (b) describes the evidence linking opioid misuse to hearing loss, (c) discusses clinical implications that opioid-induced hearing loss and NAS have for practicing audiologists, and (d) recommends directions for future audiological research on opioid-induced hearing loss and NAS. Conclusions There is considerable overlap between populations at-risk for hearing loss and opioid misuse. Additionally, compelling evidence exists linking opioid misuse to hearing loss, but the specific causal mechanisms remain unclear, indicating a need for additional research. This article attempts to fill a gap in the audiological literature and has the potential to serve as a guide for hearing health care providers to make more informed clinical decisions regarding patients with opioid-induced hearing loss and NAS. Clinicians may wish to consider the concerns raised in this article before intervening with such concerns, especially in the absence of best practice protocols.

Interventions in individuals with specific needs

With the growing understanding of substance use problems among special populations like women, gender minority groups, as well as in the geriatric population, there is a drive to develop sensitive interventions catering to their unique needs. This chapter is a short review of psycho-social interventions targeted towards these individuals with specific needs.

Comparing daily drivers of problem drinking among older and younger adults: An electronic daily diary study using smartphones

BACKGROUND

By 2030, numbers and proportions of older adults with substance-use problems are expected to increase. While risk factors for problem drinking in late life have been identified, it remains unknown whether these factors drive daily drinking among older problem drinkers. This study examined the daily drivers of drinking among problem drinkers, moderated by age, utilizing ecological momentary assessment (EMA).

METHOD

Participants (N = 139), ages 20-73, received daily EMA online surveys completed via a smartphone prior to initiation of treatment. Multilevel modeling tested the moderating impact of age on within- and between-person relationships between drinking and focal predictors (mood, loneliness, boredom, stress, poor sleep, social factors, alcohol salience, commitment and confidence not to drink heavily).

RESULTS

Older adults reported greater alcohol consumption when daily boredom levels were higher. Heavier drinking among younger adults was associated with poorer sleep quality. Greater daily confidence, daily commitment and daily alcohol salience did not impact drinking to the same extent for older adults as for younger adults. Greater person-level commitment predicted reduced drinking equivalently across age, but low person-level commitment predicted greater drinking among older adults compared to their younger counterparts.

CONCLUSION

Older adults may have unique daily drivers of drinking that are not fully realized in current research and intervention efforts. Addressing the growing substance-use treatment needs among this population will require identifying the unique drivers of drinking among older adults, such as boredom, when compared to younger adults.

Alcohol use disorders in elderly people: fact or fiction?

The number of older people is increasing in populations throughout the world. Alcohol use disorders in elderly people are a common but underrecognised problem associated with major physical and psychological health problems. Owing to the negative attitudes and inadequate training of healthcare professionals, alcohol misuse is not always being detected or effectively treated. Current diagnostic criteria and common screening instruments for alcohol use disorders may not be appropriate for elderly people. Older people are as likely to benefit from treatment as younger people and the basic principles of treatment are much the same. Better integrated and outreach services are needed. Training of healthcare professionals in this area and pragmatic research should be prioritised to improve detection, treatment and service provision for this vulnerable and neglected population.

Retirement, Social Support, and Drinking Behavior: A Cohort Analysis of Males with a Baseline History of Problem Drinking

Although previous research examining drinking behaviors among older adults suggests that significant life events are likely to have their strongest alcohol-related effects among those with a history of heavy or problematic drinking, to date researchers have not directly examined the association between such events and the drinking behavior of such individuals. Consequently, using longitudinal data, we examine the link between retirement as a significant life event and the severity of problem drinking behavior of retirement-eligible males employed in blue-collar occupations and having a history of problem drinking. We find that while retirement had no significant impact on the problem drinking behavior of a control sample of 236 retirement-eligible blue-collar males with no history of problem drinking, retirement was associated with a net decline in the severity of drinking problems among those 71 retirement-eligible blue-collar males with a history of problem drinking. Much of this effect is explained by the consolidation of the latters' retirement-related social networks, suggesting that for those with a problem drinking history, retirement may provide a kind of “relief” from permissive drinking environments potentially encouraging problem drinking behaviors.

Substance abuse among older adults

Although the myth that older adults do not use mood-altering substances persists, evidence suggests that substance use among older adults has been underidentified for decades. The baby boom generation is unique in its exposure to, attitudes toward, and prevalence of substance use-causing projected rates of substance use to increase over the next twenty years. Given their unique biological vulnerabilities and life stage, older adults who misuse substances require special attention. Prevalence rates of substance use and misuse among older adults, methods of screening and assessment unique to older adults, and treatment options for older adults are reviewed.

Functioning of alcohol use disorders criteria among middle-aged and older adults: implications for DSM-5

This study explored dimensionality and rank-order severity of the Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV) alcohol use disorder (AUD) criteria among adults 50+ years old. Secondary analysis was performed on data from individuals 50+ (N = 3,412) from the 2009 National Survey of Drug Use and Health. Confirmatory factor analyses (CFA) and item response theory (IRT) analyses were performed on the 11 AUD criteria. DSM-IV and DSM fifth edition (DSM-5) classifications were compared. CFA revealed a one-factor model. IRT analyses revealed that AUD criteria identify only severe cases of AUD. Overall, 5.8% met criteria for a DSM-IV AUD; 7.5% met criteria for DSM-5 AUD.

BAP updated guidelines: evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP

The British Association for Psychopharmacology guidelines for the treatment of substance abuse, harmful use, addiction and comorbidity with psychiatric disorders primarily focus on their pharmacological management. They are based explicitly on the available evidence and presented as recommendations to aid clinical decision making for practitioners alongside a detailed review of the evidence. A consensus meeting, involving experts in the treatment of these disorders, reviewed key areas and considered the strength of the evidence and clinical implications. The guidelines were drawn up after feedback from participants. The guidelines primarily cover the pharmacological management of withdrawal, short- and long-term substitution, maintenance of abstinence and prevention of complications, where appropriate, for substance abuse or harmful use or addiction as well management in pregnancy, comorbidity with psychiatric disorders and in younger and older people.

Substance abuse treatment for older adults in private centers

By 2020, an estimated 4.4 million older adults will require substance abuse treatment compared to 1.7 million in 2000-01. This study examined the availability of special services for older adults, adoption of recommended treatment approaches, and organizational characteristics of centers that offer special services. Data were collected via face-to-face interviews with administrators and/or clinical directors from a nationally representative sample of 346 private treatment centers participating in the 2006-07 National Treatment Center Study. Results indicated that only 18% provided special services for older adults; age-specific recommendations were generally adopted; more older adult-specialty centers offered prescription drug addiction treatment, primary medical care, and housing assistance. The proportion of patients with Medicare payment predicted availability of special services. As more older adults will seek help with a myriad of substance use disorders (SUDs) over the next decade, treatment centers need to get ready for a plethora of challenges as well as unique opportunities for growth.

Interaction effects of age and contingency management treatments in cocaine-dependent outpatients

As the American population ages, older adults are accounting for a larger percentage of the drug-abusing population, but little attention has been given to this age group especially in regards to evaluating responsivity to different treatment modalities. Contingency management (CM) is a highly effective behavioral treatment that provides positive tangible reinforcers for objective evidence of behavior change. The purpose of this study was to examine main and interactive effects of age on outcomes in cocaine-dependent patients receiving CM with standard care (SC) or SC alone. Patients (N = 393) participating in 1 of 3 randomized trials of CM for cocaine dependence were divided into young, middle, and older age cohorts. Baseline characteristics and outcomes were compared across the age groups. The oldest age group had more medical problems than the youngest and middle age groups but had fewer legal difficulties and psychiatric symptoms. The oldest age group remained in treatment significantly longer than the other age groups, regardless of the type of treatment received. Although all age groups benefited from CM in terms of retention and longest duration of abstinence achieved, a significant age by treatment interaction effect emerged, with the older cohort improving relatively less from CM than the younger age groups. These findings demonstrate that age may play a role in moderating intervention outcomes, and tailoring CM to the needs of older and middle-aged substance abusers may be important for improving outcomes in this growing population.

The baby boomer effect: changing patterns of substance abuse among adults ages 55 and older

Between now and 2030, the number of adults aged 65 and older in the United States will almost double, from around 37 million to more than 70 million, an increase from 12% of the U.S. population to almost 20%. It was long held that, with only a few isolated exceptions, substance abuse simply did not exist among this population. In light of the impact of the baby boom generation, this assumption may no longer be valid. The authors examined admissions of persons 55 years and older (n = 918,955) from the Treatment Episode Data Set (1998-2006). Total admissions with a primary drug problem with alcohol have remained relatively stable over this time. Admissions for problems with a primary drug other than alcohol have shown a steady and substantial increase. Clearly, data from the Treatment Episode Data Set indicate a coming wave of older addicts whose primary problem is not alcohol. The authors suspect that this wave is led primarily by the continuing emergence of the baby boomer generation.

Substance abuse

Alcohol abuse poses special risks for increased morbidity and mortality among older adults, contributing to the heightened use of medical resources and the related increase in medical costs. Although the prevalance of alcohol use disorders in the older adults is generally less than that found in younger groups, it is expected to increase with the aging of the "baby-boom" generation. In spite of this, little attention has focused on developing, and evaluating the efficacy of, treatment programs for older adults with alcohol related disorders. This article discusses the availability of effective treatment strategies for older alcohol abusers and reviews the epidemiological and outcomes research literatures related to alcohol abuse and older adults. The few empirical studies that examine outcomes associated with the treatment of older substance abusers reveal positive outcomes, especially when "age-specific," cognitive-behavioral, and less confrontational treatment approaches are employed.

Screening older, blue-collar workers for drinking problems: an assessment of the efficacy of the drinking problems index

The authors examine the performance of the Drinking Problems Index (DPI) as a screening instrument for the identification of drinking problems among older blue-collar workers. Performance was assessed using a random sample of 1055 retirement-eligible blue-collar workers with the CAGE as a problem-drinking criterion. The authors also assessed the relative performance of the DPI versus the CAGE on the basis of each instrument's sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC) with regard to other alcohol-related criteria. DPI was found to offer reasonable levels of sensitivity and specificity, although its sensitivity varied by age. Moreover, for older, blue-collar workers, the DPI was found to more effectively screen for problematic patterns of alcohol consumption than the CAGE.

Evidence-based practices in geriatric mental health care: an overview of systematic reviews and meta-analyses

At least 20% of people over the age of 65 suffer from mental disorders. It is anticipated that the number of older Americans with psychiatric disorders will double over the next 30 years. There is, however, substantial unmet need. The recent Surgeon General's Report on Mental Health, a Report on Mental Health from the Administration on Aging, and an expert consensus statement underscore the need to plan for the challenge of providing services for elderly people with major mental disorders. Among the greatest challenges is the expertise gap that affects clinicians practicing in routine clinical settings. This gap reflects inadequate training in geriatrics and a failure to incorporate contemporary clinical research findings and known evidence-based practices (EBPs) into usual care. This article provides an overview of the emerging evidence-base supporting the efficacy of empirically-validated geriatric mental health interventions for major geriatric mental health disorders, including systematic EBP reviews, meta-analytic studies, and expert consensus statements. Cautions and limitations regarding the reliance on randomized, controlled trials, meta-analyses, and systematic reviews also are presented.

Psychotherapies and older adults

OBJECTIVE

To confirm clinical experience which suggests that older people are offered psychotherapies significantly less often than younger ones. For those who are able to access psychotherapeutic help the outcome is comparable, sometimes better, than for younger patients.

METHOD

Contemporary and older seminal literature was reviewed for psychodynamic, cognitive-behavioural, reminiscence and systemic family therapies treating older patients.

RESULTS

The main findings supported the experience of staff in old age psychiatry that if the reluctance of referrers and sometimes of older patients themselves can be overcome this type of work is valuable and effective.

CONCLUSIONS

Each patient is unique. Generalizations are not always appropriate, however, with advancing years some common themes emerge in therapeutic work. It may be necessary to make modifications to the therapeutic technique to accommodate the difficulties experienced by people in later life but also to use their strengths. Staff working in this field need to have the capacity to be aware of and to understand their own feelings and prejudices about the second half of life. For patients not offered formal therapy a psychotherapeutic approach will nevertheless enhance their psychiatric care. Although the body of research is growing, more work needs to be done in evaluating all of the psychotherapies offered to older people.

Alcohol, drugs and much more in later life

Elderly adults are greater consumers of prescription and 'over the counter' medications than any other age group and polypharmacy, including the co-use of alcohol, is common in this group. Age related physiological changes which influence drug concentrations, metabolism, polypharmacy and interaction of other drugs with alcohol can negatively influence functional capacity, psychomotor ability, and cognition, including attention and memory, placing the older person at greater risk of accident, injury, isolation and ultimately institutionalisation. It is argued that DSM-IV criteria used to define "abuse" or "dependence" are of limited value to the majority of elderly 'problem' alcohol or drug users, with ICD-10 criteria that identify those who are experiencing 'a risk' of or where use "is actually" causing "early" harm, more appropriate. Impediments to psychiatrists and other medical practitioners identifying 'problem' alcohol and other drug use, and appropriate assessment and intervention procedures are briefly discussed. The potential for decreasing the incidence and severity of physical and psycho/social events following a reduction or cessation in problem alcohol or other drug use means that assessment and intervention should be one cornerstone of management practice for this often disenfranchised and vulnerable group.

Prognosis of older patients in mixed-age alcoholism treatment programs

Older patients were compared with matched groups of younger and middle-aged patients in inpatient alcohol treatment programs (N=432 in each age group). Compared with other patients, older patients had poorer physical health and lower cognitive status at treatment entry, but they were drinking less and reported fewer drinking-related problems, fewer psychological symptoms, more social support, more adaptive coping, and fewer barriers to abstinence. Older patients had positive views of the programs and, except for less family therapy and problem-focused counseling, received comparable treatment to that received by other patients. At discharge, older patients showed significant change in most areas targeted for treatment. Better initial status was the strongest predictor of better discharge functioning. Patients with higher cognitive functioning and stronger treatment motivation and those who experienced more interpersonal support and who received more specialized treatment services showed better-than-expected improvement. The age groups showed similar outcomes, prognostic factors, and response to different treatment orientations.

Follow-up to the statewide model detection and prevention program for geriatric alcoholism and alcohol abuse

A follow-up study was conducted to investigate the long term consequences of a statewide geriatric alcoholism detection and prevention effort in Virginia. High levels of knowledge had been retained seven years after the initial training. Quantitative and qualitative data provided by 64 of the volunteers, who were trained to conduct workshops in their communities, verified the program's ability to: 1) encourage further training or study in the area, 2) enhance the detection of alcohol problems, and 3) increase the incidence of assistance to individuals with alcohol problems. Ancillary data revealed the program's effects on personal drinking habits.

Age differences in HIV risk behaviors and drug treatment utilization among drug users in Kentucky

The purpose of this study was to (1) profile demographic and other characteristics of two age groups, younger aged 30 to 39 (N = 643), and older aged 40 to 49 (N = 395), (2) examine and identify differences in lifetime drug use patterns and age of drug use initiation, (3) examine HIV risk behaviors: drug use and sexual practices, (4) compare drug user treatment utilization between the two age groups, and (5) examine barriers to drug is treatment utilization by gender. The study sample (N = 1038) was drawn from individuals recruited into the NIDA Cooperative Agreement in Kentucky. The median age in the study sample was 38, the majority were male (72%), and African-American (81%). Results indicate that older subjects initiated drug use at a later age than younger subjects. Compared to the younger age group, significantly more subjects in the older group reported having ever used any of the 10 drugs examined. Injection drug use patterns and lifetime sex exchange practices were more prevalent in the older age group. Older subjects also were more likely to utilize drug user treatment, specifically methadone maintenance treatment. When barriers to drug user treatment were examined, significantly more women than men did not qualify for treatment, and they did not have enough money for treatment. Implications for interventions are discussed.

Clients speak: participatory evaluation of a nonconfrontational addictions treatment program for older adults

OBJECTIVES

To describe the important aspects of the Lifestyle Enrichment for Senior Adults (LESA) program from the clients' perspective and why these aspects were important to them.

METHODS

The study used a participatory approach. Researchers collaborated with counselors and clients to develop an evaluation that (a) respected the experiences and knowledge of people in the program and (b) provided an accurate assessment of the important aspects of the program from the clients' perspective. One-to-one interviews were conducted with 52 clients.

RESULTS

Clients' relationships with counselors, the positive emotions experienced during individual and group counseling, and the program's flexibility were of key importance. Allowing clients to choose their level of involvement and the general acceptance of drinkers also contributed to perceived benefits of the program.

DISCUSSION

The benefits of client-centered addictions therapy warrant closer examination. Senior adults' motivation for behavior change may be highly sensitive to the relational aspects of the treatment approach.