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)

Guidelines for Intervention, Education, and Treatment of Older Adults

Establish a Supportive Relationship

A supportive relationship is vital to treatment and recovery. However, creating intergenerational trust may be more difficult for young professionals. The mnemonic device PEARLS can help anyone make statements of support:

P	Partnership. "We’ll work together on this."
E	Empathy. "This seems upsetting to you."
A	Assurance. Statements that predict a positive outcome (e.g., "Our experience has shown a high success rate.")
R	Respect. "You seem to be dealing with this problem very well."
L	Legitimation. "Giving up your substance abuse is very difficult to do."
S	Support. "I’ll be available to you during treatment."

Additional suggestions include:

• Talk with care and concern, not in terms that judge overall behavior. Don’t blame or criticize.
• Use "I messages." Phrases such as "I noticed" or "I am worried" keep blame out of the discussion.
• When referring the person to an intervention specialist or treatment center, continue support with followup contact.
• Understand that effective treatment often means increased contact with the staff or counselor. As one person said, "They sometimes just need to touch base a lot."

Recognize Values and Attitudes and Address Beliefs and Fears

Values, attitudes, beliefs, and fears can affect a person’s openness and successful recovery. Among older adults, a stigma is attached to alcoholism and addiction. Therefore, they are less likely to acknowledge they have a problem, reach out for help, or self-refer for treatment.

Consider the effects of traditional male and female roles. Many older males have been taught to "take charge" in their lives and they do so in treatment and group work. Older women, on the other hand, may carry an attitude of "trying to please."

Examples of values, attitudes, beliefs, and fears that can affect recovery include:

• Reluctance to seek help and share help with others
• Privacy issues ("Personal problems are to be kept private.")
• Belief that alcohol problems are a sign of a character defect—moral weakness, sin, or lack of willpower
• Feeling like a "survivor who’s made it this far without help"
• Personal "future time perspective"—not much time left anyway
• Fear of "mental illness" label
• Fear of loss of control
• Fear of being placed in a nursing home
• Personal interpretation of "referral"
• Spiritual beliefs (Is there difficulty making the transition from religion to the concept of spirituality and a Higher Power?)
• Cultural orientation

Treat With Dignity and Respect

Low self-esteem and feelings of guilt and remorse are common among older persons with alcohol problems. Because of the powerful stigma associated with alcoholism and addiction, exposing an alcohol or other drug problem can be particularly threatening to an older person’s self-image. Approaches used in education, intervention, and treatment must:

• Build self-worth.
• Identify and build on the person’s strengths.
• Empower the older person. The message needs to be given that the person is in charge of his or her recovery.
• Value the person’s life experience.

Generally, when a person feels respect rather than blame, resistance and denial will decrease. Start by talking about concerns where there is less or no stigma attached, for example, the loss of friends, difficulty with housing, or money.

Use language that is nonthreatening and nonaccusatory. Also, show respect by using the person’s title (Mr., Mrs., Dr.) unless asked to call the person by his or her first name. In addition, give choices and make compromises in negotiating a plan of action.

Tips for using nonthreatening language include:

• Avoid terms like "alcoholic," "drunk," or "addict." These are often charged with negative feelings. "Addicted" may be equated with criminal activity. "Alcoholic" may be associated with being weak-willed or sinful.
• Terms such as "alcohol (or other drug) problem" or "problem with drinking" or "alcohol consumption" are less threatening.
• Using the label "alcoholic" before educating the person about the disease concept can have negative effects—increase denial, increase resistance, and reinforce feelings of low self-worth.

Emphasize the Disease Concept

Alcoholism as a disease is a concept many older people do not understand or accept. Thus, they often need to be educated about the disease concept and that alcohol problems can affect anybody.

Use an Educational Approach

Address changes in the body due to aging and the added impact of alcohol and drugs. Many older people are not aware of how aging affects tolerance for alcohol or that their physical symptoms may be caused by their drinking. Many clinicians feel that a major motivator for getting people into treatment is a physician who points out the medical problems drinking is creating.

Be Positive and Optimistic

It is critical that treatment staff and counselors believe in and convey the message to the person that recovery is possible and will enhance quality of life. Older people also need to know that life can be better without alcohol. It can be helpful to provide the person with ways to recognize success. For example:

• Establish manageable goals.
• Be specific about ways to recognize success (e.g., "When you reach…, you will feel/experience…").

Be Sensitive to Physical Limitations

It’s important to consider any health problems and physical limitations, such as reduced stamina, mobility problems, and speech, hearing, vision, and cognitive impairments. However, be careful not to make allowances that will be enabling. Sensory changes and mental functioning can affect the quality of information obtained. Considerations include the following:

• Build rest periods into the schedule.
• Pace to the person. This means that presentation of information, activities, and the transition from one setting or level of care to another generally will need to be slower than for a younger population.
• Be sure the environment is well lit, quiet, free of other distractions, comfortable, and accessible.
• Use a multisensory approach to teaching.
• Be sure print materials can be read by the visually impaired person and that the hearing-impaired person can understand (sign language interpretation or amplification devices may be needed).
• Arrange for transportation, if needed.
• Make sure your expectations in regard to a person’s progress are realistic and not based on a healthy, younger population.

Use an Age-Specific Treatment Approach

Intervention and treatment must be sensitive to and responsive to the special needs of older persons. Many older people benefit from mixed-age group treatment programs. However, it’s important to be aware that:

• Some older people have problems identifying with and relating to polyaddicted younger people. Profanity and stories of antisocial behavior are especially distressing to older adults.
• If an older person cannot relate to the problems of younger adults, that may only increase the person’s denial.
• Some older adults may be uncomfortable when there is strong emotional expression or vigorous psychological interpretation or confrontation by group members and leaders.
• When older adults are part of a mixed-age treatment program, it can be helpful to have a special track tailored to the needs of older persons.
• Issues and concerns that older adults face generally are quite different from those of younger people with alcohol and drug problems.

Regardless of group setting, some older people will find it difficult to give feedback because they don’t want to be hurtful or negative. They also may be uncomfortable when a peer discloses a personal issue or feels "the secret" shouldn’t be discussed.

Identify and Build a Support System

Successful recovery from alcohol or other drug problems depends, in part, on the support provided by family, friends, and caregivers. Some older persons need assistance with activities of daily living. It’s essential that their caregivers are involved in the intervention, treatment, and aftercare process.

A significant question to answer is "Who is part of the older person’s life?" It may be difficult to locate key people to be involved. Reasons include:

• Some people may have few, if any, family members or friends available due to death, illness, disability, alienation, distance, or chemical dependency.
• The "key" people may not be family, e.g., health care provider, in-home care providers, senior center or senior housing staff, other residents in senior housing, neighbors, and clergy.
• Family may live far away.

Some potential support persons may have attitudes that keep them from being supportive. For example:

• They view late-life alcohol or drug problems as incurable, with no hope for change or recovery.
• They justify the person’s drinking: "He has a right to enjoy a few drinks at this time of life." "She’s not hurting anyone." "It’s the only friend he has." "He’s happy."
• They do not view treatment as a worthwhile investment. "He’s old and doesn’t have that much time left anyway."

Some family and friends may need proof of serious effort on the part of the older person before they will be supportive of treatment. They may also need help in processing their own feelings of anger, betrayal, guilt, and sadness. Family dynamics and the response of family members will be related to:

• Roles and values previously assumed by family members
• Interactions among family members
• Age of onset of alcohol/drug problem
• Feelings held: loss, guilt, anger, resentment
• Personal experience with alcohol and drugs

Understanding the family history and relationship dynamics is necessary if treatment of the older person is to be successful.

• Each family develops its own myths, secrets, and patterns of sharing and avoidance.
• Roles and values of the older generation concerning marriage affect the roles and attitudes a person will assume during the treatment of a spouse.
• Feelings and behaviors of family members range from abuse to indifference to being highly codependent to love and concern.
• Family response tends to be related to whether the older person’s problems with drinking were early onset, late onset, or intermittent use.

The table below summarizes family dynamics related to different stages of drinking behavior.

Early Onset
Roles of Family Members	Ways of Coping	Emotional Reaction
When under stress, will generally revert to old roles. Caregivers (often the spouse and oldest child) usually try to hold things together while trying to fix the problem. A caregiver who has experienced years of hurt (or abuse) may take advantage of the older person’s vulnerability and be verbally and physically abusive; more likely if the caregiver is also an alcoholic.	If avoided facing the problem in the past, will continue to focus elsewhere and let others take over. Some or all may have given up trying and are literally out of reach. If chemically dependent, will find any focus on alcohol and drugs very threatening. Spouse has usually tried many ways to cope—from trying to be a drinking partner to being indifferent. Some, especially the wife, may develop somatic complaints.	All tend to lack insight into their own feelings and problems. Female spouse often grows more empty, angry, and lonely while continuing to perform duties. Male spouse often withdraws physically and emotionally, feeling angry and betrayed, especially if he has been a good provider.
Late Onset
Roles of Family Members	Ways of Coping	Emotional Reaction
Often continue to function as if there is no problem, waiting for stress or event that precipitated alcohol/drug use to subside. May be reluctant to accept a diagnosis of alcoholism. Once accepts diagnosis, usually will intervene and be supportive.	May not recognize the need for help, thinking the problem will resolve itself once the stress is alleviated. Often seeks medical help to ease symptoms of current stress.	Not prepared for sudden change in behavior. May react with confusion and disbelief.
Intermittent
Roles of Family Members	Ways of Coping	Emotional Reaction
When under the stress of drinking behavior, revert to old roles typical of an alcoholic family. Attempt to "hold things together" until the drinking stops. When the drinking stops, tend to resume everyday roles, acting as if the abstinence is the normal behavior.	Tend to focus on each new crisis as the main issue that needs attention, rather than on the ongoing pattern of intermittent drinking. Often misinterpret times of abstinence as normal, not seeing the need for help.	Often vigilant, watching for the types of stresses that trigger drinking episodes. "Walk on eggshells" because they cannot predict whether the person will be drinking or sober.

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