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)

Cognitive Impairments

The presence of cognitive impairment or dementia significantly alters treatment decisions. It is particularly important to distinguish between dementia and delirium, which are often mistaken for each other by clinicians diagnosing older patients (see Dementia and Delirium: Characteristics and Causes).

Dementia is a chronic, progressive, and generally irreversible cognitive impairment sufficient to interfere with an individual’s daily living. Dementia can range from a mild level of cognitive impairment that is easily managed to a severe stage that may require intensive treatment and nursing home care. Symptoms described may not be equally present in all older adults experiencing dementia.

Dementia will also limit an individual’s ability to interact in traditional group settings. Common causes of dementia include Alzheimer’s disease, vascular disorders (e.g., multi-infarct dementia), and alcohol use. Dementia also makes it more difficult to monitor outcomes of drinking (patients may forget they drank), to get into treatment, and to benefit from treatment.

Changes in cognition are not unusual as people age, and they increase in frequency with each decade. Such changes are experienced in varying degrees. They include minor short-term memory loss and difficulty with certain mathematical functions.

The following are not part of the normal aging process. They are signs of cognitive impairment:

• Significant memory loss
• Impaired abstract thinking
• Confusion
• Difficulty communicating
• Extreme emotional reactions and outbursts
• Disorientation to time, place, and person

It is fairly easy to screen for significant cognitive dysfunction, using any of a number of screening instruments. Patients who have been medically detoxified should not be screened for several weeks after detoxification.

Until they have been through detoxification and have experienced a period of abstinence, patients may exhibit some reversible cognitive impairment. Two screens can be used: the Orientation-Memory-Concentration Test,⁵⁸ which is simple and can be completed in the office, and the Folstein Mini-Mental Status Exam (MMSE),⁵⁹ which is an acceptable alternative.

The MMSE has certain limitations when used to assess older problem drinkers who have recently (in the past 30 to 60 days) attained sobriety in an outpatient setting. The MMSE can be insensitive to subtle cognitive impairments.

The MMSE is also weak on visual-spatial testing. This testing is likely to show some abnormality in many recent heavy drinkers. Finally, the MMSE does not include screening tests of abstract thinking and visual memory. Therefore, the "draw-a-clock task"⁶⁰ and CogniStat (formerly the Neurobehavioral Cognitive Status Examination)⁶¹ may be desirable as supplements.