A review of existing treatments for substance abuse among the elderly and recommendations for future directions

Emotional and cognitive influences on alcohol consumption in middle-aged and elderly Tanzanians: a population-based study

Alcohol consumption in Tanzania exceeds the global average. While sociodemographic difference in alcohol consumption in Tanzania have been studied, the relationship between psycho-cognitive phenomena and alcohol consumption has garnered little attention. Our study examines how depressive symptoms and cognitive performance affect alcohol consumption, considering sociodemographic variations. We interviewed 2299 Tanzanian adults, with an average age of 53 years, to assess their alcohol consumption, depressive symptoms, cognitive performance, and sociodemographic characteristics using a zero-inflated negative binomial regression model. The logistic portion of our model revealed that the likelihood alcohol consumption increased by 8.4% (95% confidence interval [CI] 3.6%, 13.1%, p < 0.001) as depressive symptom severity increased. Conversely, the count portion of the model indicated that with each one-unit increase in the severity of depressive symptoms, the estimated number of drinks decreased by 2.3% (95% CI [0.4%, 4.0%], p = .016). Additionally, the number of drinks consumed decreased by 4.7% (95% CI [1.2%, 8.1%], p = .010) for each increased cognitive score. Men exhibited higher alcohol consumption than women, and Christians tended to consume more than Muslims. These findings suggest that middle-aged and elderly adults in Tanzania tend to consume alcohol when they feel depressed but moderate their drinking habits by leveraging their cognitive abilities.

USING MACHINE LEARNING METHODS TO ASSESS THE RISK OF ALCOHOL MISUSE IN OLDER ADULTS

The population of older adults, defined in this study as those 50 years of age or older, continues to increase every year. Substance misuse, particularly alcohol misuse, is often neglected in these individuals. To better identify older adults who might not be properly assessed for alcohol misuse, we have derived a risk assessment tool using patients from the United Kingdom Biobank (UKB), which was validated on patients in the Weill Cornell Medicine (WCM) electronic health record (EHR). The model and tooling created stratifies the risk of alcohol misuse in older adults using 10 features that are commonly found in most EHR systems. We found that the area under the receiver operating curve (AUROC) to correctly predict alcohol misuse in older adults for the UKB and WCM models were 0.84 and 0.78, respectively. We further show that of those who self-identified as having ongoing alcohol misuse in the UKB cohort, only 12.5% of these patients had any alcohol-related F.10 ICD-10 code. Extending this to the WCM cohort, we forecast that 7,838 out of 12,360 older adults with no F.10 ICD-10 code (63.4%) may be missed as having alcohol misuse in the EHR. Overall, this study importantly prioritizes the health of older adults by being able to predict alcohol misuse in an understudied population.

Improvement in quality of life among women and men aged 60 years and older following treatment for alcohol use disorder

BACKGROUND

Previous studies have yielded mixed results on the association between gender and alcohol use disorder (AUD) treatment outcomes. Thus, additional research is needed to determine the effect of gender on AUD treatment outcomes, including quality of life (QoL), particularly among older adults.

AIMS

In a clinical sample of older adults with DSM-5 AUD, we examined changes in QoL from the beginning of AUD treatment through 1 year of follow-ups. We also examined the effect of gender and explored interaction effects with gender on QoL.

METHODS

We utilized data from the "Elderly Study," a multi-national, single-blind, randomized, controlled trial of 693 adults aged 60+ with DSM-5 AUD. Alcohol use was assessed with the Form-90, and QoL with the brief version of the World Health Organization QoL measure. Information was collected at treatment initiation and at 4-, 12-, 26-, and 52-week follow-ups. Multilevel mixed-effects logistic and linear regression models were used to examine QoL changes and the effect of gender on changes in QoL.

RESULTS

Following treatment, small, but significant improvements were seen over time in overall perceived health (p < 0.05). Improvements that persisted over the 1-year follow-up period were seen in the QoL domains of physical health (β: 2.6, 95% CI: 1.4-3.9), psychological health (β: 3.5, 95% CI: 3.3-3.8), social relationships (β: 4.0, 95% CI: 2.5-5.6), and environmental health (β: 1.4, 95% CI: 0.4-2.4). No significant changes were seen over time in overall perceived QoL (p = 0.58). Gender was not associated with changes in any of the QoL outcome measures (all p ≥ 0.05).

CONCLUSIONS

Among 60+ year-old adults receiving treatment for DSM-5 AUD, improvements in QoL were achievable and maintained over time, but were not associated with gender.

Substance Use Disorders in the Geriatric Population: a Review and Synthesis of the Literature of a Growing Problem in a Growing Population

Purpose of review

Substance use disorders are becoming increasingly prevalent in the geriatric population, necessitating an updated understanding of the existing literature. This review aims to describe the epidemiology, special considerations, and management of substance use disorders in older adults.

Recent findings

PubMed, Ovid MEDLINE, and PsychINFO databases were searched from their inception through June 2022 using the following keywords: "substance use disorder," "substance abuse," "abuse," "illicit substances," "illicit drugs," "addiction," "geriatric," "elderly," "older adults," "alcohol," "marijuana," "cannabis," "cocaine," "heroin," "opioid," and "benzodiazepine." Our findings suggest an increasing trend in substance use in older adults despite medical and psychiatric consequences when using such substances. The majority of older patients admitted to substance abuse treatment programs were not referred by healthcare providers, suggesting room for improvement in the screening and discussion of substance use disorders. Our review also suggests that there should be careful consideration of COVID-19 and racial disparities when screening, diagnosing, and treating substance use disorders in the older population.

Summary

This review provides updated information on epidemiology, special considerations, and management of substance use disorders in older adults. As substance use disorders become more prevalent in older adults, primary care physicians must be prepared to recognize and diagnose substance use disorders as well as collaborate with and refer patients to geriatric medicine, geriatric psychiatry, and addiction medicine.

Mindfulness-Oriented Recovery Enhancement for Addictive Behavior, Psychiatric Distress, and Chronic Pain: A Multilevel Meta-Analysis of Randomized Controlled Trials

Objectives

Mindfulness-Oriented Recovery Enhancement (MORE) is an integrative intervention designed to ameliorate addiction, chronic pain, and psychiatric symptoms. Although multiple randomized controlled trials (RCTs) have examined the clinical efficacy of MORE, no study has quantitatively synthesized this body of research. Thus, we conducted a meta-analysis of RCTs examining the effects of MORE on addictive behaviors, craving, opioid dose, pain, and psychiatric symptoms.

Methods

Relevant manuscripts were identified through comprehensive searches of four bibliographic databases. Two- and three-level random-effects models were used to generate synthesized effect size estimates, and meta-regressions were performed to examine whether study and sample characteristics influenced the magnitude of aggregate effect sizes.

Results

Our search identified 16 manuscripts reporting data from eight RCTs (N = 816). Moderate to small effects in favor of MORE were observed for addictive behaviors (SMC =  - .54, p = .007), craving (SMC =  - .42, p = .010), opioid dose (MC =  - 17.95, p < .001), chronic pain (SMC =  - .60, p < .001), and psychiatric symptoms (SMC =  - .34, p < .001). MORE's effects on psychiatric symptoms and craving were not moderated by participant race, gender, age, or income.

Conclusions

Study findings provide empirical evidence of MORE's efficacy for a wide diversity of individuals, and as such, MORE should now be disseminated broadly throughout the healthcare system.

Meta-analysis Pre-registration PROSPERO #CRD42022319006

Supplementary Information

The online version contains supplementary material available at 10.1007/s12671-022-01964-x.

Hospital Admission Rate, Cumulative Hospitalized Days, and Time to Admission Among Older Persons With Substance Use and Psychiatric Conditions

Background

Substance use among older persons occurs with medical and psychiatric comorbidities. This study examined the associations of substance use disorder (SUD), psychiatric, and dual diagnoses with 12-month cumulative hospitalized days, hospital admission rate and number of days to first hospitalization.

Methods

The cohort of 3,624 individuals (28.2% women) aged 50 years or older was assessed for substance use severity in 65 Swedish municipalities during March 2003-May 2017. Addiction Severity Index data were linked to hospital discharge records and crime statistics. The outcomes were (a) 12-month cumulative hospitalized days; (b) Hospital admission rate, and (c) days to first hospitalization. Generalized linear regression techniques investigated associations between outcomes and SUD, psychiatric and dual diagnoses at admission.

Results

During 2003-2017, 73.5% of the participants were hospitalized. Twelve-month hospitalized days were positively associated with SUD (Incidence rate ratio (IRR) = 1.41, 95%CI: 1.26-1.58), dual diagnosis (IRR = 2.03, 95%CI: 1.74-2.36), and psychiatric diagnoses (IRR = 2.51, 95%CI: 2.09-3.01). Hospital admission rate was positively associated with SUD (IRR = 4.67, 95%CI: 4.28-5.08), dual diagnosis (IRR = 1.83, 95%CI: 1.64-2.04), and psychiatric diagnoses (IRR = 1.73, 95%CI: 1.55-1.92). Days to first hospitalization were negatively associated with SUD (IRR = 0.52, 95%CI: 0.47-0.58), dual diagnosis (IRR = 0.57, 95%CI: 0.50-0.65), and psychiatric diagnoses (IRR = 0.83, 95%CI: 0.73-0.93). The marginal effects of SUD and/or mental disorders increased with age for all outcomes, except for days to first hospitalization.

Conclusion

Three of four older persons assessed for substance use severity were later hospitalized. Substance use disorders, dual diagnoses and other mental disorders were the primary reasons for hospitalization and were associated with longer stays, earlier hospitalization, and repeated admissions. Sensitizing service providers to old age substance use and sharing data across the care continuum could provide multiple points of contact to reduce the risk of hospitalizations among older persons with problematic substance use.

Evaluation and Management of Alcohol use Disorder among Older Adults

Purpose of Review

The prevalence of alcohol use disorder (AUD) among older adults in the United States is rising, but remains underdiagnosed, underreported, and inadequately managed. This review highlights the medical, social, and cultural factors of AUD in older adults and provides guidelines for its screening, evaluation, and management.

Recent Findings

The COVID-19 pandemic has created additional challenges and barriers to care, as older adults may have disproportionate worsening of anxiety, depression, and substance use resulting from increased isolation related to physical distancing and shelter-in-place guidelines.

Summary

All older adults should be routinely screened for AUD with standardized screening tools. If a patient’s screening results are positive, a clinician should conduct a brief assessment, which may be supplemented by laboratory tests. Most older adults at risk for alcohol misuse do not need specialized SUD treatment, but most can benefit from Screening, Brief Intervention, and Referral to Treatment (SBIRT) to prevent substance misuse before it occurs. Medications for the treatment of AUD in older adults include naltrexone, acamprosate, disulfiram, gabapentin and topiramate. Psychosocial treatments, including mutual help groups, are equally important.

Safety and Persistence of Nalmefene Treatment for Alcohol Dependence. Results from Two Post-authorisation Safety Studies

Aims

Two post-authorisation studies assessed the safety and persistence of patients’ use of nalmefene.

Methods

The START study (EUPAS5678) was a non-interventional, multi-country, prospective, 18-month (8 follow-up visits) cohort study including outpatients initiating nalmefene for the first time. The multi-database retrospective cohort study (MDRC, EUPAS14083) included baseline and follow-up data from German, Swedish and UK healthcare databases. Both studies permitted ‘all comers’ without explicit exclusion criteria; predefined subgroups of interest included the elderly (≥65 years) as well as patients with significant psychiatric and/or somatic comorbidities.

Results

START study: Overall, the mean duration of nalmefene treatment was 10.3 ± 7.3 months (N = 1348), with 49.0% of patients treated for ≥1 year; frequent reasons for treatment discontinuation were ‘goal reached’ and ‘drug cost’. The most frequently reported adverse drug reactions (ADRs) were nausea (4.7%), dizziness (3.2%) and insomnia (2.0%). ADR rates appeared higher in the elderly subpopulation (18.6% reported ≥1 ADR vs. 12.0% in the total population) but were not higher in the other predefined subgroups.

MDRC study: The database follow-up analysis followed 2892 patients over 18 months for whom the duration of nalmefene treatment was between 2 and 3 months and <5% of patients used nalmefene for ≥1 year.

Conclusions

Despite the inclusion of a wider patient population (e.g. elderly patients and those with relevant co-morbidities), the safety and tolerability profile of nalmefene given in routine practice was consistent with previous clinical studies. The differing rates of persistence beyond 1 year likely reflect the different methodologies and highlight the relevance of psychosocial support at follow-up visits.

Ältere, einsame Männer mit Alkoholabhängigkeit: Systematische Literaturrecherche zum aktuellen Stand der alters- und geschlechtsspezifischen Interventionen

Der Kenntnisstand zu Prävalenzen und Krankheitsverläufen älterer, einsamer Männer, die an Alkoholstörungen leiden, ist immer noch sehr gering und damit auch das Hilfeangebot. Die vorliegende systematische Literaturrecherche identifiziert die Risikofaktoren dieser Zielgruppe, den aktuellen Wissensstand über Alkoholkonsum bei älteren, einsamen Männern sowie den aktuellen Interventionsstand. Hierfür wurden nach einem umfangreichen Suchlauf 43 einschlägige Literaturquellen zum Thema Alkohol im Alter, Einsamkeit und Interventionen einbezogen. Eindeutiges Ergebnis ist, dass es wenige alters- oder geschlechtsspezifische Suchthilfeprogramme für Männer insgesamt gibt und keines, welches sich spezifisch auf ältere und einsame Männer ausrichtet. Einsamkeit wird in den Studien zwar hin und wieder als Problem bei Suchtkranken beschrieben, aber nicht explizit untersucht. Es wurde daher ein innovatives Interventionskonzept, das auf diese Gruppe zugeschnitten ist, entwickelt. Das Programm „Viktor“ bezieht sich auf diese Problematik und bietet ein spezifisches Angebot für Männer ab 55 Jahren mit einer Alkohol- und Einsamkeitsproblematik an.

Substance use disorder and the baby boom generation: Does Berlin outpatient addiction care face a sustained change?

Introduction

The ageing of baby boomers is expected to confront addiction care with new challenges. This cohort had greater exposure to psychoactive substances in youth than earlier cohorts. In this study, we aimed to investigate whether Berlin addiction care is confronted with a sustained change in its clientele initiated by the baby boomers.

Methods

Using data from Berlin outpatient addiction care facilities, we contrasted type of primary substance use disorder and number of comorbid substance use disorders in baby boomers with an earlier and a later cohort. To isolate cohort effects, two‐level random intercept regression models were applied in the overlapping age groups of the baby boomer cohort with each of the other cohorts.

Results

Compared with the earlier cohort, alcohol use disorder lost importance whereas illicit substance use disorder gained importance in the baby boomers. Baby boomers presented a higher number of comorbid substance use disorders than the earlier cohort. Comparing baby boomers with the later cohort, these relationships pointed in the opposite direction.

Discussion and Conclusions

Outpatient addiction care faces a sustained change to more illicit and comorbid substance use disorders. With increasing life expectancy and the ageing of baby boomers marked by higher substance use than previous cohorts, older clients, who had been under‐represented in outpatient addiction care, will gain relevance. Hence, addiction care has to adapt its offers to appropriately meet the changing needs of its clientele.

A Substance Misuse Intervention Program in Postacute Care: Who Declines Participation?

OBJECTIVES

Alcohol and substance misuse has been under-acknowledged and underidentified in older adults. However, promising treatment approaches exist (e.g., brief interventions) that can support older adults with at-risk alcohol and substance use. Postacute rehabilitation settings of Skilled Nursing Facilities (SNFs) can offer such programs, but little is known about patient characteristics that are associated with the likelihood of participating in interventions offered in postacute rehabilitation care. Thus, the objective of this study was to identify individual patient characteristics (predisposing, enabling, and need-related factors) associated with participation in a brief alcohol and substance misuse intervention at a SNF.

METHODS

This cross-sectional study analyzed medical record data of postacute care patients within a SNF referred to a substance misuse intervention. Participants were 271 patients with a history of substance misuse, 177 of whom enrolled in the intervention and 94 refused. Data collected upon patient admission were used to examine predisposing, enabling, and need-related factors related to likelihood of program participation.

RESULTS

Older age and ethnic minority status were associated with a reduction in likelihood to participate, while widowhood increased the likelihood of participation.

CONCLUSION

Upon referral to a substance misuse intervention, clinicians in SNFs should be cognizant that some patients may be more likely to refuse intervention, and additional efforts should be made to engage patients at-risk for refusal.

Alcohol Screening, Brief Intervention, and Referral to Treatment (SBIRT) for Girls and Women

Females ages 12 and older are the fastest growing segment of alcohol consumers in the United States, with the past decade showing a 16% increase in alcohol use per 12-month period and a 58% increase in high-risk drinking (i.e., > 3 drinks in a day and/or > 7 drinks in a week) per 12-month period. The increase in alcohol use and risk drinking poses unique and serious consequences for women. Women have a more rapid progression to alcohol-related problems and alcohol use disorders (AUD) than men, and if pregnant, women can potentially expose the fetus to alcohol. Screening, brief intervention, and referral to treatment (SBIRT) is an evidence-based, integrated public health approach used to identify and address risky alcohol use among women in a variety of health and social service settings. This article presents the current status of SBIRT among girls ages 12 and older, women of childbearing age, and older women. Screening instruments, brief interventions, and implementation issues specific to women of all ages are described. Through this review of the current literature, care providers can determine best practices for the prevention and treatment of risk drinking in women of all ages presenting in health care settings.

The effect of legal mandates on substance use disorder treatment completion among older adults

Objective: This study seeks to determine the relationship between referral type (legally mandated versus non-mandated) and substance use disorder (SUD) treatment completion among older adults and by primary substance used.Method: We used data from the Treatment Episode Data Set - Discharges (TEDS-D) from 2011. Using data for persons age 55 and over (n = 104,747), we used propensity score matching (PSM) to address selection bias and attenuate the likelihood of a type I error. Logistic regression models estimated the effect of referral type on treatment completion based on treatment for a primary substance for five categories of substances.Results: In the matched sample, those who faced treatment mandates had 71% greater odds of completing treatment compared with those who entered treatment voluntarily (OR =1.71, 95% CI [1.64, 1.79]). Based on the primary drug used, odds of treatment completion were highest for alcohol, with 86% greater treatment completion for the mandated individuals compared with those entering treatment without a legal mandate (OR =1.86, 95% CI [1.75, 1.97]).Conclusion: These findings suggest that the motivating influence of treatment mandates may encourage completion of SUD treatment among older adults. Although the legal mandates for treatment are punitive, they may act to keep older adults with SUD engaged in treatment, an important factor as treatment completion is inversely related to relapse of a SUD.

Common substance use disorders in older adults

Substance use disorder prevalence in older adults is increasing as the baby boom generation ages. Of the different substances with concern for misuse and use disorder, alcohol, prescription drugs, and illicit drugs are the leading causes. High-risk drinking and alcohol use disorder is the leading substance use disorder in older adults. Prescription drug misuse and use disorder in older adults are the second leading cause for substance use disorder and most commonly involves prescription opioids and benzodiazepines. Illicit drug use in older adults is also increasing. Substance use disorders are difficult to recognize in older adults due to medical comorbidity, neurocognitive impairment, and functional decline. Older adults are also more susceptible to drug effects due to decreased hepatic and renal clearance of the substances. Older adults should be screened and assessed for substance use disorders, and when diagnosed, non-pharmacologic as well as pharmacologic intervention should be performed.

DSM-5 Latent Classes of Alcohol Users among Treatment Seeking Older Adults

Objective: Understanding the variation of alcohol use disorder (AUD) among a clinical sample of patients aged 60 and older, by identifying latent classes of AUD and exploring risk factors and outcomes of treatment associated with the class. Method: We used the Danish subsample (n = 341) from the Elderly Study. Latent class analysis was used to identify classes based on the 11 symptoms of DSM-5 AUD. We analyzed the associations between class membership and sociodemographic variables, alcohol consumption, and drinking-related outcome of treatment. Results: Three latent classes were identified. Individuals in the low-symptomatic class (34.85%) displayed low endorsement of DSM-5 criteria "Withdrawal", "Time Spent", "Less activities" compared to the other classes, and had fewest drinks per drinking day. Individuals in the moderate-symptomatic class (32.69%) were most likely to be intoxicated in hazardous situations, and those in the high-symptomatic class (32.47%) displayed, with a few exceptions, the highest probabilities of all DSM-5 criteria. Female gender, living alone and prior AUD treatment was associated with increased risk of being in the high-symptomatic class. No difference between classes was found with respect to years with AUD and frequency of drinking days, and latent class membership had no effect on drinking outcome after treatment, when controlling for baseline. Conclusions: Three classes of DSM-5 AUD among older adults in treatment emerged, displaying a low-moderate-high distribution, advocating for a unidimensional construct of DSM-5 AUD. Although different with respect to baseline risk factors, no strong connection between DSM-5 latent class and alcohol consumption after AUD treatment was found.HighlightsAmong 341 older alcohol use disorder (AUD) outpatients, three latent classes of DSM-5 AUD emerged.The classes of DSM-5 AUD displayed a low-moderate-high endorsement of DSM-5 AUD characteristics.The three classes had similar alcohol-related treatment outcomes.

Substance use disorders among older adults: A review of randomized controlled pharmacotherapy trials

Substance use disorders (SUDs) are a growing problem among older adults. Acamprosate, disulfiram, and naltrexone are United States Food and Drug Administration (referred to as FDA) approved for the treatment of alcohol use disorder, and buprenorphine is approved for the treatment of opiate use disorder among adults. However, the data on the use of these medications for the treatment of SUDs among older adults are unclear from randomized controlled trials (referred to as RCTs). A review of the literature indicates that there are only two RCTs that evaluated the use of pharmacologic agents for SUDs among older adults (≥ 50 years). One trial evaluated the use of naltrexone when compared to placebo for the treatment of alcohol use disorder among individuals, 50-70 years in age. The other trial evaluated the use of naltrexone or placebo as adjuncts with sertraline in the treatment of alcohol use disorder among individuals older than 55 years in age. Both trials indicated that the use of naltrexone reduced the rates of relapse among older adults with alcohol use disorder. However, we did not identify any RCTs that studied the use of buprenorphine, acamprosate, or disulfiram for SUDs among older adults. Based on available evidence, it would be safe to conclude that limited data indicate some efficacy for naltrexone in the treatment of alcohol use disorder among older adults. However, data from controlled trials on the use of other medications that are FDA approved for the treatment of SUDs among younger adults are nonexistent among older adults with SUDs.

Drink wise, age well; reducing alcohol related harm among people over 50: a study protocol

Background

Evidence suggests that the use of alcohol among older adults (defined as those aged 50+) has increased in recent years, with people aged 55–64 now more likely to exceed the recommended weekly guidelines than any other age group.

Methods/ design

This is a quasi-experimental study with a before-after design. A postal questionnaire will be sent to 76,000 people aged 50 and over registered with a general practice in five different ‘demonstration’ (intervention) and control areas in the UK. Multiple interventions will then be delivered in demonstration areas across the UK. At the end of the programme, a postal questionnaire will be sent to the same individuals who completed it pre-programme to establish if there has been a reduction in alcohol use, at-risk drinking and alcohol related problems. Qualitative interviews with clients and staff will explore how the interventions were experienced; how they may work to bring about change and to identify areas for practice improvements.

Discussion

This study protocol describes a multi-level, multi-intervention prevention-to-treatment programme which aims to reduce alcohol-related harm in people aged 50 and over.

Motivational Interviewing and Fat Consumption in Older Adults: A Meta-Analysis

Diets high in fat increase the risks for obesity and chronic diseases, even for older adults, the largest growing population in the United States. In the current study, a meta-analysis was performed to examine the effects of motivational interviewing (MI) dietary interventions on fat consumption in older adults. Electronic databases, journals, and unpublished literature were searched. Six primary studies were retrieved, providing seven comparisons between intervention and control groups and a total of 1,351 participants. MI had a moderate effect on fat intake in older adults (effect size = 0.354, p < 0.01). Studies with indicators of higher design quality showed greater MI effects. Nurses and providers can incorporate MI into health education and counseling to improve older adults' dietary health behaviors. [Journal of Gerontological Nursing, 44(11), 33-43.].

Barriers and Facilitators to Treatment Engagement Among Clients in Inpatient Substance Abuse Treatment

There is a call for drawing on client voice to provide a rich, nuanced understanding of factors influencing substance treatment engagement as to maximizing treatment benefits. We interviewed 60 clients in a short-term inpatient substance treatment program and examined facilitators and barriers to treatment engagement. Thematic analysis yielded four themes, including perceived treatment needs, trust and counselor rapport, peer inspiration, and organizational factors. Perceived treatment needs serve as both a facilitator and a barrier wherein the acknowledgment of needs led to greater treatment engagement whereas a lack of perceived needs hindered treatment engagement. The establishment of trust and counselor rapport and peer inspiration facilitated treatment engagement. Clients rated several organizational factors including a lack of treatment provision, gender-responsive treatment and infrastructure, and ineffective communication with nonclinical staff as barriers to treatment engagement. Clinical implications include enhancing treatment motivation and counselor rapport, establishing gender-responsive treatment programs, and providing trainings for staff.

Prevention and Screening of Unhealthy Substance Use by Older Adults

The number of older adults who engage in unhealthy substance use is expected to increase substantially to levels never seen before. Older adults, owing to physiologic changes in aging, are at high risk for the adverse effects of alcohol and illegal drug use. Screening and prevention can help older patients to be better informed of the risks of substance use, and reduce high-risk behaviors and its potential negative outcomes. The authors review the prevalence and trends of substance use and their potential impact on health outcomes, and discuss an approach to screening and prevention for older adults.

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.

Use of alcohol and drugs with addiction potential among older women and men in a population-based study. The Nord-Trøndelag Health Study 2006-2008 (HUNT3)

Background

Little is known about the consumption habits of older adults in Norway with respect to alcohol and the use of drugs with addiction potential, such as benzodiazepines, z-hypnotics and opioids, among regular drinkers. We studied the prevalence of self-reported consumption of alcohol on a regular basis in community-living older men and women (≥ 65 years). Furthermore, we investigated the prevalence of dispensed prescribed drugs with addiction potential in older men and women who were regular drinkers.

Methods

We used data from the Nord-Trøndelag Health Study 2006–2008 (HUNT3). Of 12,361 older adults in the HUNT3 study, 11,545 had answered the alcohol consumption item and were included in our study. Regular drinkers were defined as consuming alcohol one or more days a week. Data on dispensed drugs with addiction potential were drawn from the Norwegian Prescription Database. Addiction potential was defined as at least one prescription for benzodiazepines, z-hypnotics or opioids during one year for a minimum of two consecutive years.

Results

In total 28.2% of older Norwegian adults were regular drinkers. Men in the study were more likely to be regular drinkers than women. Drugs with addiction potential were used by 32.4% of participants, and were more commonly used by women. Nearly 12% of participants used benzodiazepines, 19% z-hypnotics and 12.4% opioids. Among regular drinkers, 29% used drugs with addiction potential, which was also more common among women. Adjusted for age, gender and living situation, use of z-hypnotics was associated with regular alcohol intake, while use of opioids was associated with no regular alcohol intake.

Conclusion

The prevalence of the use of drugs with addiction potential was high in a Norwegian population of older adults who reported regular consumption of alcohol. Strategies should be developed to reduce or prevent alcohol consumption among older adults who use drugs with addiction potential.

Uživanje alkohola med starostniki v domačem okolju: rezultati presejalnega testa SMAST-G

Uvod: Dosedanje raziskave kažejo, da je tvegano ali škodljivo uživanje alkohola med starostniki prisotno v obsegu med 5 % in 23 % te populacije. Z raziskavo smo želeli preučiti pojavnost uživanja alkohola v starosti v povezavi z demografskimi dejavniki, socialno vključenostjo in samooceno zdravja. Metode: Uporabljen je bil standardizirani vprašalnik Short Michigan Alcoholism Screening Test – Geriatric version (SMAST-G). Nenaključno so bili vključeni starostniki nad 65 let, živeči v domačem okolju, ki so razumeli besedilo. Podatke smo obdelali z opisno statistiko in testom hi-kvadrat. Rezultati: Ugotovili smo, da je med starostniki 30,0 % takšnih, ki imajo možne težave z alkoholom. Statistična značilnost večjega uživanja alkohola se je pokazala pri nižji izobrazbi (x2 = 12,255, p = 0,007) ter pri moškem spolu (x2 = 14,641, p < 0,001). Ugotovili smo statistično povezanost uživanja alkohola s samooceno zdravja (x2 = 12,085, p = 0,017) ter s posameznimi spremenljivkami socialne vključenosti, in sicer z oceno socialnih odnosov (x2 = 14,124, p< 0,001) in z (ne)obstojem osebnih ciljev za prihodnost (x2 = 12,156, p = 0,016). Diskusija in zaključek: Uživanje alkohola se pri starostnikih povezuje s slabšo kakovostjo socialnih odnosov in nižjo samooceno zdravja. Raziskava kaže na potrebo po zvišanju znanja starostnikov o vplivih uživanja alkohola na zdravje, na potrebo po njihovi integraciji v socialno okolje ter po nadaljnjem raziskovanju problema uživanja alkohola v starosti.

Characteristics of online treatment seekers interested in a text messaging intervention for problem drinking: adults 51 and older versus middle-aged and younger adults

According to the Institute of Medicine, the vast older adult population is estimated to have mental health and substance use disorders at unprecedented rates and will place high demand on an unprepared healthcare system. Online and mobile health interventions, such as text messaging, could provide an alternative form of frontline intervention that could alleviate some of the burden on the healthcare system; however, it remains unknown what are characteristics of adults over 50 who might be interested in a mobile health behavioral intervention and how they may differ from their younger counterparts. To explore the characteristics of those interested in a text messaging intervention by age, we examined screening data for a randomized controlled trial testing a text messaging intervention to reduce drinking among 1,128 hazardous and problem drinkers, aged 21-30, 31-50, and 51 and older. Participants were recruited online through website advertising on alcoholscreening.org and moderationmanagement.org. Results demonstrated that over a quarter of individuals pursuing online and/or text messaging treatment were 51 and older. These participants reported heavy drinking, with significantly greater number of days drinking and binge drinking than the younger groups, but with fewer consequences. Across age groups, a vast majority of participants were female. Findings demonstrate that a group of adult heavy drinkers 51 and older already pursue online treatment and are interested in using a text messaging intervention to help them reduce drinking, suggesting an avenue to engage this population using an alternative frontline treatment.

A pilot study of online feedback for adult drinkers 50 and older: Feasibility, efficacy, and preferences for intervention

Normative (NF) and personalized feedback (PF) are moderately effective brief interventions for at-risk drinking middle-aged and older adults. This study tested the feasibility of online feedback for drinkers 50 and older. This study's aims were to identify whether there is differential effectiveness of PF over NF in prompting drinkers 50years old and older to plan for change and to determine potential preferences for intervention among adult drinkers 50 and older with practical knowledge about computers.

METHOD

Using Amazon's Mechanical Turk, 138 male and female drinkers aged 50 to 75+ were recruited to complete an online survey that asked about their: perceptions of their drinking, quantity and frequency of drinking, and any comorbid health and/or mental health disorders/medications. They were then provided either NF or PF. NF provided information about how participants' drinking compared to their same age and gendered peers. PF provided information about level of risk to health and provided recommendations for safe levels of drinking. After feedback, participants were evaluated for their reactions (e.g., "How much does this worry you?") and their plan to change their drinking. Participants were asked about preferences for interventions.

RESULTS

80% of participants rated themselves a no or low-risk drinker, yet 52.2% were found to be at-risk drinkers. Overall, participants reported feedback was helpful, and 43.9% made some kind of plan to change. Participants in NF were significantly more likely to make a plan for change than those in PF. Participants reported that they most preferred an online (40.9%) or a brief in-person (31.8%) intervention.

CONCLUSION

Findings revealed that brief online feedback was feasible, though limited to those who are computer knowledgeable. Unexpectedly, NF outperformed PF, suggesting that peer comparisons may be more motivating for adults 50 and older than previously thought. Finally, an online intervention appears to be a preferred intervention for alcohol use among this particular group of drinkers.

A Systematic Review of Opioid and Benzodiazepine Misuse in Older Adults

OBJECTIVE

The authors assessed the prevalence of opioid and benzodiazepine prescription drug misuse in older adults, the risk factors associated with misuse, and age-appropriate interventions.

METHODS

Following PRISMA guidelines, a literature search of PubMed, PsycINFO, and EMBASE for peer-reviewed journal articles in English through April 2014 with updates through November 2015 was conducted for reports on misuse of prescription benzodiazepines and opioids in older adults. Relevant publications were reviewed that included participants age ≥65 years. Reference lists were manually searched for key identified articles and geriatric journals through April 2016. Information on the study design, sample, intervention, comparators, outcome, time frame, and risk of bias were abstracted for each article.

RESULTS

Of 4,932 reviewed reports, 15 were included in this systematic review. Thirteen studies assessed the prevalence of prescription drug misuse and included studies related to opioid shopping behavior, assessment of morbidity and mortality associated with opioid and/or benzodiazepine use, frequency and characteristics of opioid prescribing, frequency of substance use disorders and nonprescription use of pain relievers, and health conditions and experiences of long-term benzodiazepine users. One study identified risk factors for misuse, and one study described the effects of provider education and an electronic support tool as an intervention.

CONCLUSION

There is a dearth of high quality research on prescription drug misuse in older adults. Existing studies are heterogeneous, making it difficult to draw broad conclusions. The need for further research specific to prescription drug misuse among older adults is discussed.

Motivational Interviewing and Fruit/Vegetable Consumption in Older Adults

Evidence supports the relationship between fruit and vegetable consumption (FVC) and risk reduction for several illness conditions, even for older adults. Thus, we examined the effects of motivational interviewing (MI) on FVC in adults with a mean age ≥60. We chose MI because of its growing popularity as an effective behavior change strategy and because the person-centered MI principles are a good fit for older adults. We searched 10 electronic databases, several journals, and unpublished and fugitive literature. We retrieved seven primary studies, providing nine comparisons, with 1,978 participants. The overall MI effect size (ES) was .221 ( p = .002). When the percentage of women was greater, ES was lower; when interventionists had more training, ES was higher; and when sessions were longer, ES was stronger. Future researchers might test longer sessions with trained interventionists and examine gender differences. Practitioners should be well trained and offer sessions that are 30 to 40 min in length.

Alcohol-Related Diagnoses in Hospital Admissions for All Causes Among Middle-Aged and Older Adults: Trends and Cohort Differences From 1993 to 2010

OBJECTIVE

This aim of this study was to characterize trends in alcohol-related hospital admissions among middle-aged and older adults from 1993 to 2010 in relation to age, gender, race, and cohort membership.

METHOD

This study utilized repeated cross-sectional data from the Nationwide Inpatient Sample. Using alcohol-related classified admissions, yearly rates and longitudinal trends of alcohol-related inpatient hospitalizations based on age, period, birth cohort, gender, and race were estimated.

RESULTS

Among those aged 45 and older, admissions rose from an estimated 610,634 to more than 1,134,876, and rates of any alcohol-related diagnosis also increased from 1993 to 2010. Rates for men were consistently higher than women, and rates for Blacks were higher than Whites. Age was associated with decreasing rates, but post-World War II cohorts displayed higher rates over time.

DISCUSSION

Rates of alcohol-related admissions are increasing among adults above age 45, which may be a function of cohort effects. Training the health care workforce is crucial to respond to this trend.

Alcohol Use as Risk Factors for Older Adults' Emergency Department Visits: A Latent Class Analysis

INTRODUCTION

Late middle-aged and older adults' share of emergency department (ED) visits is increasing more than other age groups. ED visits by individuals with substance-related problems are also increasing. This paper was intended to identify subgroups of individuals aged 50+ by their risk for ED visits by examining their health/mental health status and alcohol use patterns.

METHODS

Data came from the 2013 National Health Interview Survey's Sample Adult file (n=15,713). Following descriptive analysis of sample characteristics by alcohol use patterns, latent class analysis (LCA) modeling was fit using alcohol use pattern (lifetime abstainers, ex-drinkers, current infrequent/light/moderate drinkers, and current heavy drinkers), chronic health and mental health status, and past-year ED visits as indicators.

RESULTS

LCA identified a four-class model. All members of Class 1 (35% of the sample; lowest-risk group) were infrequent/light/moderate drinkers and exhibited the lowest probabilities of chronic health/mental health problems; Class 2 (21%; low-risk group) consisted entirely of lifetime abstainers and, despite being the oldest group, exhibited low probabilities of health/mental health problems; Class 3 (37%; moderate-risk group) was evenly divided between ex-drinkers and heavy drinkers; and Class 4 (7%; high-risk group) included all four groups of drinkers but more ex-drinkers. In addition, Class 4 had the highest probabilities of chronic health/mental problems, unhealthy behaviors, and repeat ED visits, with the highest proportion of Blacks and the lowest proportions of college graduates and employed persons, indicating significant roles of these risk factors.

CONCLUSION

Alcohol nonuse/use (and quantity of use) and chronic health conditions are significant contributors to varying levels of ED visit risk. Clinicians need to help heavy-drinking older adults reduce unhealthy alcohol consumption and help both heavy drinkers and ex-drinkers improve chronic illnesses self-management.

Late-life psychosis: diagnosis and treatment

Psychosis is one of the most common conditions in later life with a lifetime risk of 23 %. Despite its high prevalence, late-onset psychosis remains a diagnostic and treatment dilemma. There are no reliable pathognomonic signs to distinguish primary or secondary psychosis. Primary psychosis is a diagnosis of exclusion and the clinician must rule out secondary causes. Approximately 60 % of older patients with newly incident psychosis have a secondary psychosis. In this article, we review current, evidence-based diagnostic and treatment approaches for this heterogeneous condition, emphasizing a thorough evaluation for the "six d's" of late-life psychosis (delirium, disease, drugs dementia, depression, delusions). Treatment is geared towards the specific cause of psychosis and tailored based on comorbid conditions. Frequently, environmental and psychosocial interventions are first-line treatments with the judicious use of pharmacotherapy as needed. There is an enormous gap between the prevalence of psychotic disorders in older adults and the availability of evidence-based treatment. The dramatic growth in the elderly population over the first half of this century creates a compelling need to address this gap.

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.

Feasibility and Utility of Experience Sampling to Assess Alcohol Consumption Among Older Adults

In the literature on alcohol use and aging, drinking has often been conceptualized as a means of coping with negative feelings, such as stress, yet much of the literature on older adults and drinking has utilized cross-sectional or other data ill-suited for exploring dynamic processes. Experience sampling methods have the ability to measure and analyze dynamic processes in real time, such as relations between alcohol use and mood states. Nonetheless, these approaches are intensive and may burden respondents. Therefore, this study evaluated the feasibility, acceptability, and validity of a modified daily diary to measure alcohol use and explored alternate methods of collecting diary data. Findings suggest that a modified diary was acceptable and not burdensome. Respondents were reluctant to consider technology (e.g., cellphone)-based means of data collection. Measures of alcohol use showed little within-person variation suggesting that for those who drink at all, drinking is a daily habit.