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)

Brief Interventions

	Low-Risk Use	At-Risk Use	Problem Use	Abuse/ Dependence
Brief Interventions

A brief intervention involves one or more counseling sessions. The sessions may include:

• Motivation-for-change strategies
• Patient education
• Assessment and direct feedback
• Contracting and goal setting
• Behavior modification techniques
• Use of written materials such as self-help manuals¹

Brief intervention techniques have been used to reduce alcohol use in several groups. These include adolescents, adults under age 65 who are nondependent problem drinkers, and most recently, older adults.^2,3 All of these activities can be conducted by trained clinicians, home health care workers, psychologists, social workers, and professional counselors. A video about brief interventions is available at this Web site.

Brief intervention strategies range from relatively unstructured counseling and feedback to more formal structured therapy. They rely heavily on concepts and techniques from the motivational psychology and behavioral self-control training literature.^4-7

The goal is to motivate the problem drinker to change behavior, not to assign blame. Therefore, drinking goals should be flexible. The individual should be allowed to choose drinking in moderation or abstinence.

Brief interventions have been shown to be effective in a variety of subjects over the past two decades. Between 10 and 30 percent of nondependent problem drinkers reduce their drinking to moderate levels after a brief intervention by a physician or other clinician.^8-10 Several ongoing studies of brief alcohol interventions are addressing older adults.

Older adults present unique challenges to those applying brief intervention strategies for reducing alcohol consumption. Because many older at-risk and problem drinkers are ashamed about their drinking, intervention strategies need to be especially nonconfrontational and supportive.

Research indicates that confrontation is particularly problematic with older adults who may be experiencing shame and guilt about their drinking. Furthermore, a confrontational approach is not a necessary aspect of alcohol intervention or treatment. It may actually increase defensiveness, denial, or treatment dropout.

In addition, the consumption level that constitutes at-risk drinking is lower than that for younger individuals.¹¹ Even low levels can be dangerous.

Chronic medical conditions may make it more difficult for clinicians to recognize the role of alcohol in decreased functioning and quality of life. These issues must be kept in mind during brief interventions with this vulnerable population.

Following identification of at-risk or problem drinkers through screening techniques (see Module 4), a semistructured brief intervention can be conducted. An older adult-specific brief intervention should include the following steps:

• Identify future goals (e.g., What are some of your goals over the next 3 months regarding your physical and emotional health, hobbies and activities, relationships and social life, and finances?).
• Provide customized feedback in the form of a health profile related to drinking patterns and other health habits.
• Discuss the types of drinkers in the United States and where the client fits into the norms for his or her age group. For example, "National guidelines recommend no more than seven drinks per week or one drink per day. Your consumption exceeds this level and puts you at risk."
• Introduce the concept of a standard drink.
• Discuss the reasons for drinking, weighing the pros and cons and the reasons to cut down or quit. For example, "I’m concerned that the amount you’re drinking could be making your health problems worse."
• Ask the person to consider changing, quitting, or cutting down.
• Discuss sensible drinking limits and strategies for cutting down or quitting. These include alcohol-free social gatherings and hobbies.
• Get a signed drinking agreement in the form of a "prescription."
• Discuss and develop strategies for coping with risky situations, such as negative family interactions.
• Summarize the session.

Positive change is more likely when older adults are motivated to take action on their own behalf. The following are key to inspiring motivation in older adults:

• The clinician's caring style
• Willingness to view the older adult as a full partner in his or her recovery
• The capacity to provide hope and encouragement as the older adult progresses through the referral, treatment, and recovery process

Motivational interviewing is a way to help people recognize their problems and increase their motivation to make changes. It is especially useful in resolving ambivalence. It is a supportive, respectful approach that is persuasive without being coercive.

This approach is particularly relevant in working with older persons. Understanding the conditions for persuading alcoholics to seek treatment and messages alcoholics must hear can help.

A knowledgeable, positive, determined, hopeful orientation toward alcoholism and its treatment is indispensable in persuading older adults to overcome denial and shame and seek help. One useful model for understanding motivation is FRAMES.⁷

The acronym FRAMES stands for six key elements that have been shown to be effective in assisting persons with at-risk or problem drinking in changing their drinking behavior:

• F eedback
• R esponsibility
• A dvice
• M enu
• E mpathy
• S elf-efficacy

Motivational interviewing differs in a number of ways from many traditional approaches to modifying problem behaviors. Motivational interviewing:

• Deemphasizes the use of labels such as "alcoholic"
• Emphasizes personal choice and responsibility for change
• Focuses on eliciting patients’ own concerns
• Understands that the role of the clinician can affect the level of resistance in the patient
• Uses reflection to meet resistance
• Negotiates drinking goals and strategies, rather than prescribing

Motivational interviewing is an approach that can avoid certain aspects of interpersonal interactions that can sidetrack a discussion or reinforce resistance to change.

A critical aspect of the brief intervention is eliciting motivational statements from patients. It is the clinician’s task to facilitate patients’ expression of their reasons to change their drinking as well as their resolve to change. Motivational statements tend to fall into four categories:

1. Problem recognition
2. Expression of concern
3. Openness to change
4. Optimism

It is important to reinforce these statements that indicate a willingness to consider change. Using "evocative questions" can help elicit motivational statements and enhance commitment to change. Each motivational statement may further help patients realize that the benefits of changing outweigh the costs.

References

1. Fleming, M.F.; Barry, K.L.; Manwell, L.B.; Johnson, K.; and London, R. Brief physician advice for problem alcohol drinkers: A randomized controlled trial in community-based primary care practices. Journal of the American Medical Association 1997, 277:1039-1045.
2. Blow, F.C. The spectrum of alcohol interventions for older adults. In: Gomberg, E.S.L.; Hegedus, A.M.; and Zucker, R.A., eds. Research Monograph No. 33. Alcohol Problems and Aging. NIH Publication No. 98-4163. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism, 1998.
3. Fleming, M.F.; Manwell, L.B.; Barry, K.L.; et al. Brief physician advice for alcohol problems in older adults: A randomized community-based trial. Journal of Family Practice 1999, 48(5):378-384.
4. Miller, W.R., and Taylor, C.A. Relative effectiveness of bibliotherapy, individual and group self-control training in the treatment of problem drinkers. Addictive Behaviors 1980, 5:13-24.
5. Miller, W.R., and Hester, R.K. Inpatient alcoholism treatment: Who benefits? American Psychologist 1986, 41: 794-805.
6. Miller, W.R., and Munoz, R.F. How To Control Your Drinking. Englewood Cliffs, NJ: Prentice-Hall, 1976.
7. Miller, W., and Rollnick, S. Motivational Interviewing: Preparing People to Change Addictive Behavior. New York: Guilford Press, 1991.
8. Kristenson, H.; Ohlin, H.; Hulten-Nosslin, M.B.; Trell, E.; and Hood, B. Identification and intervention of heavy drinking in middle-aged men: Results and follow-up of 24-60 months of long-term study with randomized controls. Alcoholism: Clinical and Experimental Research 1983, 7(2):203-209.
9. Wallace, P.; Cutler, S.; and Haines A. Randomized controlled trial of general practitioner intervention in patients with excessive alcohol consumption. British Medical Journal 1988, 297(6649):663-668.
10. Babor, T.F., and Grant, M. Project on Identification and Management of Alcohol-Related Problems. Report on Phase II: A Randomized Clinical Trial of Brief Interventions in Primary Health Care. Geneva, Switzerland: World Health Organization, 1992.
11. Chermack, S.T.; Blow, F.C.; Hill, E.M.; et al. The relationship between alcohol symptoms and consumption among older drinkers. Alcoholism: Clinical and Experimental Research 1996, 20(7):1153-1158.

See Module 7, Treatment for information on other types of treatment.

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