Patricia Pullins, LMSW, LCDC The Council on Alcohol and Drugs Houston sm Presents Baby Boomer Seniors: Bracing for Changing Patterns in Substance Abuse Among Older Adults TIPSS Jackson Hill  Houston, Texas   Fax

Presentation Objectives Gain knowledge about current findings and the latest research on substance use among older adults Understand how an older person’s physiology differs from that of a younger person Understand the many factors that may influence the use and potential for misuse or abuse of substances among Boomers Develop an awareness of Baby Boomer attitudes, beliefs and expectations toward drug use Learn what you can do to help

Changing Demographics and Needs The oldest Baby Boomers turned 65 in 2011 The number of seniors ( 65+) in Texas is growing: 2011: 2,647,792 (10.2%) of population 2020: 3,846,891 (12.4%) of population 2030: 5,647,647 (15.1%) of population Older adults are increasingly abusing substances other than alcohol Up to 17% of older Americans misuse alcohol and prescription drugs 25% of all emergency room admissions of seniors may involve alcohol- medication interactions Older adults with alcohol use problems are not recognized by many professionals

General Issues for Older Adults Loss (status, people, vocation, health, etc.) Social isolation, loneliness Major financial problems Housing changes Family concerns Time management burden Complex medical issues Multiple medications Sensory deficits Reduced mobility Cognitive impairments Impaired self-care, loss of independence

Facts About Physiological Changes with Age: Decrease in physical strength Decline in efficiency of body organs Loss of bone mass Slower reflexes Takes longer to return to equilibrium Decline in the senses

Older Adults & Alcohol Use Increased risk of stroke (with overuse) Impaired motor skills (e.g. driving) at low level use Increased risk of injury (falls, accidents) May result in sleep disorders Increased risk of suicide Interacts with dementia symptoms

Older Adults & Alcohol Use Higher blood alcohol concentration (BAC) from dose More impairment from a high BAC Potential interactions/increased side effects with medications and/or compromised metabolizing (especially psychoactive medications, benzodiazepines, barbiturates, antidepressants, dioxin, warfarin)

Drinking Guidelines Should not exceed 1 drink per day Never more than 2-3 drinks on any drinking day (binge drinking) Limits for older women should be somewhat less than for older men (NIAAA, 1995; DuFour & Fuller, 1995)

Drinking Guidelines (continued) Recommendations consistent with data on benefits/risks of drinking in this age group Lower limits for older adults because: -increased alcohol sensitivity with age -greater use of contraindicated medications -less efficient liver metabolism -less body mass/fat increases circulating levels

Potential Alcohol Problems in Older Adults: Signs Anxiety, depression, excessive mood swings Blackouts, dizziness, idiopathic seizures Disorientation Falls, bruises, burns Headaches Incontinence Memory loss Unusual response to medications New difficulties in decision making Poor hygiene Poor nutrition Sleep problems Family problems Financial problems Legal difficulties Social isolation Increased alcohol tolerance

Defining Alcohol Use Patterns Abstinence: no alcohol for past year Low risk: use alcohol with not problems At-risk: alcohol use with increased chance of problems/complications Problem drinking: experiencing adverse consequences Dependent: loss of control, drinking despite problems, physiological symptoms (tolerance, withdrawal)

If You Drink, Recommended Level For 60+ No more than one drink per day or seven drinks per week Maximum of two drinks on any drinking occasion Somewhat lower levels for older women The Substance Abuse and Mental Health Services Administration/Center on Substance Abuse Prevention Consensus Panel for TIP #26 – Substance Abuse Among Older Adults

What Conditions May Be Caused or Worsened by Alcohol Abuse? 1 or more drinks per day –Gastritis, ulcers, liver and pancreas problems 2 or more drinks per day –Depression, gout, GERD, breast cancer, insomnia, memory problems, falls 3 or more drinks per day –Hypertension, stroke, diabetes, gastrointestinal diseases, cancer of many varieties

Risk Factors for Alcohol Problems Risk factors make people more vulnerable to alcohol and medication misuse problems Death of spouse, friends, and other family members Loss of job and related income, social status, and sometimes self-esteem ___ as a result of retirement Loss of mobility ( inability to drive, problems walking) Impaired vision and hearing, insomnia and memory problems

Co-morbid Conditions Co-morbidity is a serious, common concern among older adults using alcohol: Impaired Activities of Daily Living (ADLs) Psychiatric symptoms, mental disorders Alzheimer’s Disease Sleep disorders

17 “Medications are probably the single most important health care technology in preventing illness, disability, and death in the geriatric population.” Avorn J. Medication use and the elderly: current status and opportunities. Health Affairs 1995, Spring.

18 “Any symptom in an elderly patient should be considered a drug side effect until proved otherwise.” J Gurwitz, M Monane, S Monane, J Avorn Brown University Long-term Care Quality Letter 1995.

19 Why are Seniors at Greater Risk for Medication-Related Problems? Physiological Changes with Aging Number of Medications –5.8 prescription medications –3.2 over-the-counter medications Poor adherence Types of medications prescribed, e.g., psychoactive medications

20 Why are Seniors at Greater Risk for Medication-Related Problems Self medication, alcohol use Multiple chronic diseases Under-representation in clinical trials, particularly those over age 75 Shortage of trained professionals in geriatric pharmacotherapy

21 Polypharmacy Use of many medications either concurrently or sequentially 2x ADR risk when number of medications increases from 1 – 4 14x ADR risk in older adults who use 7 medications

22 Continuum of Psychoactive Medication use Proper use Misuse—Most Common –By Patient –By Doctor Abuse –By Patient Dependence –By Patient

Protective Factors Protective factors increase resistance to alcohol and medication misuse by promoting healthy behavior: Education ( wise use of medications) and skills Access to resources Availability of support networks and social bonds Supportive family relationships

Variation in Use Substantial changes exist in the patterns of substance use and abuse over different age cohorts, particularly among those born post-WWII. Mean alcohol consumption appears to remain higher over time for the midlife group (including the Baby Boom generation) than for other age groups. –Baby Boom generation, as it ages, may maintain a higher level of alcohol consumption than in previous older cohorts ( Blow et al., 2003)

World View of Which Group of Older Adults Maxims –Don’t air your dirty laundry –Pick yourself up by your bootstraps –Put your best foot forward –If you don’t have anything good to say… –Put on a happy face

Boomer Lore Is 40 really the new 30? Instead of measuring aging by how long people have lived so far, scientists have factored in how many more years people can still look forward to. They effectively are behaving as if they were younger. As people have more and more years to live they have to save more and plan more.

Boomer Lifestyle Purchase 57% of health-care insurance ($75 billion) Represent 58% of all health-care spending ($152 billion) Purchase 67% of all prescription drugs ($37 billion) Account for 61% of all over-the-counter drug purchases Purchase 41% of all personal care products and services ($24 billion) Purchase 50% of all reading material ($8 billion)

Leading-Edge Boomers Shared an Intense and Captivating Coming-of- Age Period Created many common values Unique generational values Shared life experiences

Fountain of Youth “They’re still youthful, and they have plenty of money” - Ken Dychtwald, President and CEO of Age Wave “Old” rules no longer apply “Hip” and “cool” don’t equate just with “young” anymore Do not like association with aging metaphors Many view themselves as younger than the calendar –As much as twelve years or more Brent Green, “Marketing to Leading-Edge Baby Boomers: Perceptions, Principles, Practices, Predictions”

Medical Marijuana AARP Poll 72% of adults aged 45+ support the use of medical marijuana for: –Multiple Sclerosis –Glaucoma –Arthritis –Parkinson’s Disease –Alzheimer’s Disease Join Together Online, 5/9/2005

Wonder Drugs Steroids Viagra Crystal Meth Marijuana Amphetamines Cialis

Emotional Needs In Later Life One’s emotional needs remain the same throughout life. Too often, just because older people look different on the outside, they are assumed to feel differently on the inside. Emotional needs do not go away as people age, but sometimes they may not be nurtured as well. It also may become more difficult for the older person to meet his or her emotional needs as family and friend die, or health or inability to drive decreases. There is a tendency in working with older adults to focus on meeting the physical and health needs. Psychological needs are often not given the same attention.

Sexual Needs in Later Life There is no subject in our society that is associated with more myths and misinformation than that of sexual intimacy and the elderly. How an older adult views himself or herself can be important in determining overall well being. An older person who views the slowing of sexual response as “normal aging” is going to respond quite differently than the individual who views the slowing as “sexual warning, or “ I’m less of a man or woman.”

Myths About Aging Is what I have observed really the problem? Is it symptomatic of “aging”? Could it be related to chronic health problems? Or is what I have observed actually a symptom of the problem?

Patients in older-adult services at Hanley- Hazelden, a treatment center in West Palm Beach, Fla., stated, “Our whole lives are about loss. We lose our hair, hearing, teeth, and eyesight. We lose our loved ones and our friends”. Join Together Online, 7/21/2003

Intervention with Older Adults Preventive education for abstinent, low-risk drinkers Brief, preventive intervention with at-risk and problem drinkers Alcoholism treatment for abusing/dependent drinkers

Screening Who? -Every person aged 60 or over -If physical signs are present -Undergoing major life changes What? -Screen for alcohol and prescription drug use/abuse How? -In any regular services -Brown bag approach -Ask direct questions -Avoid stigmatizing terms

Screening Goal of screening for alcohol use problems in older adults is to: Identify at-risk drinkers, problem drinkers, and persons with alcoholism Determine need for further diagnostic assessment Rationale of screening for alcohol use problems among older adults: Incidence is high enough to justify costs Adverse quality/quantity of life effects are significant Effective treatment exists Valid & cost-effective screening exists

Screening Instruments Short Michigan Alcohol Screening Test- Geriatric Version (SMAST-G) Health Screening Survey, includes other health behaviors (nutrition, exercise, smoking, depressed feelings); includes quantity and frequency questions CAGE (Cut down, Annoyed by others, feel Guilty, need Eye opener)

SMAST-G Two or more “yes” responses is indicative of alcohol problem (0-10 possible) Yes or no answers to: 1. When talking with others, do you ever underestimate how much you actually drink? 2. After a few drinks, have you sometimes not eaten or been able to skip a meal because you don’t feel hungry?

SMAST-G (continued) 3. Does having a few drinks help decrease your shakiness or tremors? 4. Does alcohol sometimes make it hard for you to remember parts of the day or night? 5. Do you usually take a drink to relax or calm your nerves? 6. Do you drink to take your mind off your problems?

SMAST-G (continued) 7. Have you ever increased your drinking after experiencing a loss in your life? 8. Has a doctor or nurse ever said they were worried or concerned about your drinking? 9. Have you ever make rules to manage your drinking? 10. When you feel lonely, does having a drink help?

Quantity/Frequency Screen 1.In the last three months, on average, how many days a week have you been drinking alcohol? 2.On a day when you have had alcohol to drink, how many drinks have you had? 3.In the last three months, how many times have you had 3 or more drinks on an occasion? Eight or more drinks/week or two or more occasions of binge drinking in last month are indicative of alcohol use problems.

Who Seeks Treatment?

Treatment Seeking Age-related factors may deter treatment seeking by older patients Among medically ill veterans age 55 or older –Expressed interest in treatment and attendance at pretreatment evaluation was associated with younger age and higher CAGE (Cut down, Annoyed by others, feel Guilty, need Eye opener –Being unmarried and drug use (in addition to alcohol) was associated with treatment interest Adults ages 55+ ‘More Receptive’ –Because they’ve bottomed out more (Satre et al., 2003a)

Special Populations Barriers to effective identification exist for: Women Certain minority group members Lack of culturally competent tools and interventions Individuals with physical disabilities, co-morbidities Homebound

Factors that might influence who seeks treatment Social & personal factors- support from family & friends Cognitive status Functional health Self- esteem Personality styles Locus of control (belief that events in his/her life result from personal actions, fate or powerful others).

Medicare A federal health insurance program for: 65 or older Under 65 with certain disabilities Any age with End-State Renal Disease (permanent kidney failure) Has four different types to cover different services: Part A, B, and D. Part C is Medicare Advantage that gives benefits through private insurance.

Medicare and Substance Abuse In Texas, Medicare covers substance abuse based on mental health services on outpatient basis. Pay 50% of Medicare-approved amount and separate copayment amount for facility service. Part B Benefit. Must pay annual $155 deductible for Part B services.

Referral Pathways Admissions aged 55 or older were more likely than younger admissions to enter treatment through self-referral Elders less likely to be referred through the criminal justice system Few referred by health care providers in both young and older samples (OAS, SAMHSA, 2004)

Effective Approaches For Older Adults Brief alcohol interventions Home and community-based mental health outreach Integration of substance abuse, mental health, and primary care services Geriatric mental health consultation and treatment teams in nursing homes Support interventions for families and caregivers of persons with dementia

Effective Approaches For Older Adults A variety of pharmacological and nonpharmacological interventions Cognitive-behavioral approaches Group-based approaches

Take Home Message If we are to help- We must be sensitive to the values and beliefs held by older adults If we are to help- We must be sensitive to the values and beliefs of family members If we are to help-We must examine our values and beliefs Demographic projections indicate that the aging of the “baby boom” generation will increase the proportion of persons over age 65 from 13 percent currently, to 20 percent by the year By the year 2030, the number of older adults with substance abuse or mental illness is expected to more than double to an estimated 15 million individuals. 11,16 As the “baby boom” cohort ages, the extent of alcohol and medication misuse is predicted to significantly increase due to the combined effect of the growing population of older adults and cohort-related differences in lifestyle and attitudes. 16,17 Based on these projections, the associated need for treatment services of substance use disorders in older persons is estimated to increase by 70 percent. 18 Increases in the need and the demand for mental health services are expected as well. The demand for mental health services is likely to increase as the baby boom cohort has tended to utilize mental health services more frequently than the current older adult cohort and has tended to be less stigmatized by seeking mental health care. 11,19,20 Population growth and cohort-specific characteristics indicate a future of increasing pressure on all health care resources and treatment systems but particularly for substance abuse and mental health services. 21

Sources Get Connected! Toolkit: Linking Older Adults With Medication, Alcohol, and Mental Health Resources: Older Americans Substance Abuse and Mental Health Technical Assistance Center: Treatment Improvement Protocol (TIP) Series 26: Substance abuse among older adults. (1998). Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. Older Adults and Alcohol Problems. University of Michigan Department of Psychiatry, and Associate Director, Department of Veterans Affairs National Serious Mental Illness Treatment Research and Evaluation Center (SMITREC). Kristen L. Barry, PhD, Research Associate Professor. Population Projections for Texas: Years by Gender and Race/Ethnicity: Texas Population Projections for Older Adults Age 60-Plus: Years 2000 – 2040: