CONTENTS

Table of Contents
Introduction

1. Overview
2. Recognizing Alcohol Misuse and Abuse in Older Adults
3. Alcohol and Aging
4. Diagnosing Alcohol Problems in Older Adults
5. Recognizing Other Forms of Substance Abuse
6. Prevention and Early Intervention Strategies
7. Treatment
8. Outcomes and Cost Issues in Alcohol Treatment for Older Adults
9. Legal and Ethical Issues

Supplements
Resources

At Any Age, It Does Matter:
Substance Abuse and Older Adults (for Professionals)

Asking Screening Questions

Screening is a sensitive area and needs to be treated as such. Some guidelines follow:

1. The interviewer needs to be friendly, nonthreatening, and nonjudgmental.
2. The purpose of the questions should be clearly related to the patient’s health status.
3. The patient should be alcohol free at the time of the screening. For patients requiring emergency treatment or who are temporarily impaired, it is best to wait until their condition has stabilized and they have become accustomed to the health setting where the interview will take place. Signs of alcohol or drug intoxication should be noted.
   
   Patients who have alcohol on their breath or who appear intoxicated give unreliable responses, so consideration should be given to conducting the interview at a later time. If this is not possible, findings and conditions of the interview should be noted in the medical record.
   
   The patient should also be lucid at the time of screening and using only the proper dosages of any prescribed medications.
4. If the questions are embedded in a longer health interview, a transitional statement is needed to move into the alcohol- or drug-related questions. The best way to introduce such questions is to give the patient a general idea of the content of the questions, their purpose, and the need for accurate answers. This statement should be followed by a description of the types of alcoholic beverages typically consumed or the types of prescription drugs of interest.
   
   If necessary, clinicians may include a description of beverages that may not be considered alcoholic (e.g., cider, low-alcohol beer). Determinations of alcohol consumption are based on standard drinks.
5. The patient should be informed that the information he or she provides will be kept confidential.
6. The questions need to be easy to understand.

Many older adults are acutely sensitive to the stigma associated with alcohol and drug abuse. They are far more willing to accept a "medical" as opposed to a "psychological" or "mental health" diagnosis as an explanation for their problems.

Prefacing questions with a link to a medical condition can make them more palatable. For example, "I’m wondering if alcohol may be the reason your diabetes isn’t responding as it should." Or "Sometimes one prescription drug can affect how well another medication is working. Let's go over the drugs you're taking and see if we can figure this problem out." It is vitally important to avoid using stigmatizing terms such as alcoholic or addict during these encounters.

Active Listening

Another technique that may help when talking with older adults is active listening.³⁵ The four components of active listening are:

1. Observing and reading the person’s nonverbal behavior—posture, facial expressions, movement, and tone of voice
2. Listening to and understanding the person’s verbal communication
3. Listening in context, that is, to the whole person in the context of the social settings of his or her life
4. Listening to sour notes, that is, things the person says that may have to be challenged

Motivational Interviewing

Motivational interviewing techniques also can be applied when screening older adults. Essentially this approach assumes that the patient is both capable of and responsible for initiating needed changes. Motivational interviewing is nonconfrontational, egalitarian, and supportive.

When screening anyone, especially older adults, empathy is crucial. However, in attempting to be nonconfrontational and cautious, it is also important to avoid using euphemisms that minimize the problem. Older adults with alcohol or drug problems are just as likely to engage in denial and rationalization as younger adults. Those who are unaware that their customary drink before dinner may now be causing problems are unlikely to be defensive about acknowledging the need to change. Neither are persons who are inadvertently misusing a prescription drug.

Settings for Screening

Depending on the setting, the topic of screening can be introduced in a number of ways. Self-administered and self-scored mass screenings can be part of a larger presentation about alcohol’s effects on older adults. These presentations can be given at an American Association of Retired Persons or leisure club meeting. Self-administered but machine-scored computerized screens can be offered as part of a similar program at senior centers, retirement homes, or assisted living residences with access to computers.

Visiting nurses and home health aides can integrate a brief alcohol screen into the list of health questions normally posed to patients. For example, in asking about medication, the health care provider could say:

"We understand more today about the effects of even small amounts of alcohol on medication, and I want to be sure that nothing is interfering with your Coumadin or affecting your overall progress in any way. Let’s review how much alcohol you’re drinking and take a look at all your medications."