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

Supplements

Formal Specialized Treatment

 

 Abstinence

Low-Risk Use

At-Risk Use

Problem Use

Abuse/
Dependence

Formal Specialized Treatment

          

For some older adults, pretreatment approaches may prove quite effective. This is especially true for late-onset drinkers and prescription drug abusers with strong social support and no mental health comorbidities. Followup brief interventions and empathic support for positive change may be sufficient for continued recovery. There is, however, a subpopulation of older adults who will need more intensive treatment.

Despite the resistance that some older problem drinkers or drug abusers exert, treatment is worth pursuing. Studies show that older adults are more compliant with treatment and have treatment outcomes as good as or better than those of younger patients.1,2 In determining a formal course of treatment, some important considerations include:

Types of treatment include:

Not every approach will be necessary for every client. Instead, the program leaders can individualize treatment by choosing from this menu to meet the needs of the particular client. Planning information comes from:

Cognitive-Behavioral Approaches

As a prelude to cognitive-behavioral therapy, a therapist might use motivational counseling. This is a more intense process than the motivational interviewing that may take place during a brief intervention. Motivational counseling acknowledges differences in readiness to change and offers an approach for "meeting people where they are."

Motivational counseling has proven effective with older adults.3 An understanding and supportive counselor:

Motivational counseling is an intensive process that enlists patients in their own recovery by:

This process also can help offset the denial, resentment, and shame invoked during an intervention.3 It falls somewhere between brief interventions and pretreatment interventions.

Types of Cognitive-Behavioral Approaches

There are three broad categories of cognitive-behavioral approaches: behavior modification/therapy, self-management techniques, and cognitive-behavioral therapies. Behavior modification applies learning and conditioning principles to modifying overt behaviors, which are those behaviors obvious to everyone around the client.4,5 Self-management refers to teaching the client to modify his or her overt behaviors as well as internal or covert patterns. Cognitive-behavioral therapy involves altering covert patterns or behaviors that only the client can observe.

Cognitive-behavioral techniques teach clients to identify and modify self-defeating thoughts and beliefs.6,7 This is intended to improve mood and reduce the probability of drinking as a method of coping, especially in the face of relapse pressures. These pressures include negative emotional states, such as depression, anger, and frustration; peer pressure; and interpersonal conflicts with spouse, family, a boss, and others.

The Drinking Behavior Chain

The cognitive-behavioral model offers an especially powerful method for targeting problems or treatment objectives that affect drinking behavior. Together, provider and client analyze the behavior itself, constructing a "drinking behavior chain." The chain is composed of:

When exploring the latter, it is particularly important to note the positive consequences of use: those that maintain abusive behavior. Cognitive-behavioral therapy is ideally suited to individuals who are slow to learn because of residual impairment of cognitive functioning. This is because this method breaks down information into small manageable units and repeats them until understanding is ensured.

Researchers have developed an instrument that can elicit by interview the individual’s drinking or drug use behavior chain.8 Immediate antecedents to drinking include feelings such as anger, frustration, tension, anxiety, loneliness, boredom, sadness, and depression. Circumstances and high-risk situations triggering these feelings include marital or family conflict, physical distress, and unsafe housing arrangements, among others. Many older adults drink excessively in response to perceived losses and changes associated with aging and their affective and behavioral response to those losses. Alcohol use is often a form of "self-medication," a means to soften the impact of unwanted change and feelings.

For the patient, new knowledge of his or her drinking chain often clarifies for the first time the relationship between thoughts and feelings and drinking behavior. This method provides insight into individual problems, demonstrates the links between psychosocial and health problems and drinking, and provides the data for a rational treatment plan and an explicit individualized prevention strategy.

Breaking drinking behavior into the links of a drinking chain serves treatment in other ways, too. It suggests elements of the community service network that may be helpful in establishing an integrated case management plan to resolve antecedent conditions (e.g., housing, financial, medical problems). Involvement from the community may be needed beyond the treatment program (see Case Management section).

Behavioral Treatment in Group Settings

Behavioral treatment can be used with older adults individually or in groups, with the group process particularly suited to older adults (see Group-Based Approaches). Equipped with the knowledge of the individual’s drinking or drug abuse behavior chain, the group leader:

The behaviors are rehearsed within the treatment program until a level of skill is acquired. The patient is then asked to try out the behaviors in the real world as "homework." For example, a client who has been practicing ways to overcome loneliness or social isolation may receive a community-based assignment in which to carry out the suggested behaviors.

After practicing, the individual reports to the group. Then the therapist and group members provide feedback and reinforce the individual’s attempt at self-management (whether or not the outcome was a success). This process continues until the individual develops coping skills and brings the antecedents for abuse under self-control or self-management. Typically, as patients learn to manage the conditions (thoughts, feelings, situations, cues, urges) that prompt alcohol abuse, abstinence can be maintained.

Posttreatment Issues

Defining drinking behavior antecedents is also useful for determining when a client is ready for discharge. When the individual can successfully use coping behaviors specific to his or her drinking antecedents, the treatment team might assist the person in gradually phasing out of the program. Discharge that takes place before the client has acquired specific coping behaviors is almost certain to result in relapse, probably very soon after discharge.

Studies comparing early- and late-onset older problem drinkers showed great similarity between these two groups’ antecedents to drinking and treatment outcomes.9 Another study described a behavioral regimen that included psychoeducation, self-management skills training, and marital therapy. A followup study of 16 male inpatients, ages 65 to 70, undertaken 2 to 4 years after discharge, indicated that half were abstaining, two had reduced their drinking, and the remaining patients’ drinking was destructive.10 These studies recommend that treatment focus on:

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Group-Based Approaches

Group experiences are particularly helpful to older adults in treatment. They provide the arena for:

Perhaps the most beneficial aspect of groups for older adults is the opportunity to learn self-acceptance through accepting others and in return being accepted. Guilt and forgiveness are often best dealt with in groups, where people realize that others have gone through the same struggles.

Special groups may also deal with the particular problems of aging. The group format can help patients learn skills for coping with many of the life changes that can put one at risk for substance abuse, including:

Self-paced learning is best for older adults. To allow clients to set their own pace in a group setting, the leader can give individualized or take-home assignments. Clients who have not reached the needed level of expertise on a topic can receive an individualized "booster session" while remaining in the group.

Older clients also should get more than one opportunity to integrate and act on new information. For example, information on bereavement can be presented in an educational session, then reinforced in therapy. To help participants integrate and understand material, it may even be helpful to expose them to all units of information twice.

Groups help create a sense of camaraderie and high morale. Research on group work with older adults suggests that older adults bond into groups at a faster pace than younger adults do.12 One successful treatment program made use of this phenomenon by assigning each person to another client who served as a "buddy." The buddy explained and facilitated the day’s events. Some of the most effective types of groups are socialization, therapy, educational, and self-help or support groups.

Socialization Groups

Groups may focus on socialization skills. They may teach clients skills for meeting new people and interacting better with peers and give them opportunities to practice. These skills are honed whenever clients gather together, whether in recreation, on coffee breaks, or at lunch. This type of activity is particularly valuable for those who live with loneliness or who have become socially isolated.

Many older adults keep in touch with friends they made during treatment, especially if the treatment program sponsored social activities. Some treatment programs sponsor an evening a week when clients can socialize. This helps them rebuild or expand their social contacts in the community.

Therapy Groups

Therapy groups can be effective ways to provide peer support, particularly if AA meetings are not accessible. They focus on building new social and coping skills. They also encourage connections with peers or others, adding to the social network. Social contacts outside of formal meetings are usually encouraged.

Some therapy groups engage in behavioral interaction, others in more psychodynamic therapy. Both types of groups allow clients to test the accuracy of their interpretations of social interactions, measure the appropriateness of their responses to others, and learn and practice more appropriate responses. Groups provide each client with feedback, suggestions for alternative responses, and support as the individual tries out and practices different actions and responses.

Some people may need help in entering the group, particularly if they are used to isolation. This help could include individual counseling sessions in which the counselor explains how a group works. The counselor could also answer the client’s questions about confidentiality.

The client’s entry into the group may be eased by joining in stages, at first observing, then over time moving into the circle. The counselor may formally introduce the new person to the members of the group so that upon entering the group, he or she is at least somewhat familiar with them.

Older adults grew up before psychological terms had been integrated into everyday language. Therefore, therapy groups for older adults should avoid the use of jargon, acronyms, and "psychspeak." If leaders do use such terms, they should begin by teaching the group their meanings. If a participant uses an unfamiliar term, the leader should explain it. It may be helpful to develop a vocabulary list on a chart and for any individual notebooks.

Similarly, many older individuals were raised not to "air their dirty laundry." Therefore, they should never be pressured to reveal personal information in a group setting before they are ready. Nor should older patients be pressured into role-playing before they are ready.

Educational Groups

Educational groups are an integral part of addiction treatment. Patients need information about addiction, the substances, their use, and their impact. Older adults also benefit from shared information about:

Educational units can be designed to teach practical skills for coping with any aspect of daily life, such as nutrition, household management, and exercise.

Some basic principles for designing educational groups follow:

Alcoholics Anonymous and Other Self-Help Groups

Many treatment programs refer patients to Alcoholics Anonymous (AA) and other self-help groups as part of aftercare. AA is a grassroots peer-assistance approach that has had the greatest impact on the treatment of chemical dependency. It addresses living without alcohol through working a Twelve Step program.

AA requires attending regularly scheduled meetings. This may be a problem for older individuals who have transportation needs, although a sponsor in the chapter may be able to assist. Chapters specifically for older adults may be more effective.

Providers should warn older patients that these groups might seem confrontational and alienating. The referring program should tell patients exactly what to expect. Group discussions may include profanity and younger members’ accounts of their antisocial behavior.

To orient clients to these groups, the treatment program may ask that local AA groups provide an institutional meeting as a regular part of the treatment program. Other options are to help clients develop their own self-help groups or to facilitate the development of independent AA groups for older adults in the area.

Older people may have trouble internalizing the notion of being "alcoholic" and needing to remain sober. Avoiding future problem drinking may depend on continuing affiliation with a recovering peer group. Some model programs have created volunteer alumni groups to allow continued affiliation after requirements for treatment, such as court supervision, end.

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Individual Counseling

Because of current interpersonal conflicts and the underlying feelings of shame, denial, guilt, or anger, psychotherapy may be appropriate. It can occur in conjunction with other treatment methods such as AA or hospital-based treatment programs. Grief counseling can support the process of healing losses.

Individual counseling is especially helpful to the older substance abuser in treatment’s beginning stages, but the counselor often must overcome clients’ worries about privacy. Subjects that many older adults are loath to discuss include their relationships with their spouses, family matters and interactions, sexual function, and economic worries.

It is essential to assure the client that the sessions are confidential. In addition, the therapist should conduct the sessions in a comfortable, self-contained room where the client can be certain the conversation will not be overheard.

Older clients often respond best to counselors who behave in a nonthreatening, supportive manner and whose demeanor indicates that they will honor the confidentiality of the sessions. Clients frequently describe the successful relationship in familial terms: "It is like talking to my son," or, "It is as though she were my sister." Older clients value spontaneity in relationships with the counselor and other staff members. A counselor’s appropriate self-disclosure often enhances or facilitates a beneficial relationship with the patient.

Because receiving counseling may be a new experience for the client, the provider should explain the basics of counseling and clearly present the responsibilities of the counselor and the client. Summarizing at the beginning of each session helps to keep the session moving in the appropriate direction. Summarizing at the end of a session and providing tasks to be thought about or completed before the next session help reinforce any knowledge or insights gained. They also contribute to the older client’s feeling that he or she is making progress.

In individual sessions, counselors can help clients prepare to participate in a therapy group, building their understanding of how the group works and what they are expected to do. Private sessions can also be used to clarify issues when the individual is confused or is too embarrassed to raise a question in the group. As the client becomes more comfortable in the group setting, the counselor may decide to taper the number of individual counseling sessions. Likewise, the client may prepare for discharge by reducing the frequency or length of sessions, secure in the knowledge that more time is available if needed.

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Medical and Psychiatric Approaches

In some cases, medication may be prescribed to lessen compulsion and chemical craving. Some experts on alcohol abuse among older adults do not typically prescribe disulfiram (Antabuse) as a drinking deterrent. They do not think the risks (serious cardiovascular alcohol-disulfiram reaction, hepatotoxicity of disulfiram) outweigh the benefits, especially in light of the high compliance rates patients achieve without the drug.

Naltrexone (ReVia), an opioid antagonist, is prescribed to treat alcohol dependence and narcotic addiction. It appears to be well tolerated by older persons.1 Evidence suggests a reduction in drinking relapses in naltrexone-treated patients.

Acamprosate (Campral), a glutaminergic drug, has shown considerable success in reducing drinking in younger alcoholics in European controlled trials.14 It is also effective in maintaining abstinence and reducing relapse severity.15 Acamprosate has not been specifically studied with older adults.

Treating Health Problems

Older substance-abusing clients differ from their younger counterparts in the number and complexity of associated health problems. These problems need to be recognized and corrected or stabilized. Otherwise, the patient’s participation in substance abuse treatment will be compromised and chances for recovery diminished.

Especially in older adults, health problems interact with and impair social and psychological function. This adds to the complex causes of the patient’s dysfunction and disability. When prescribing medications to modify drinking behavior in older adults, clinicians must consider age- and disease-related increases in vulnerability to toxic drug side effects. They also need to be aware of possible adverse interactions with other prescribed medications.

Visual and hearing problems compromise effective coping and the accomplishment of tasks of daily living. They also interfere with social functioning and may prevent effective participation in substance abuse treatment. Accordingly, initial medical assessment of older adults should routinely include screening for visual and auditory problems. Any problems discovered should be corrected as quickly as possible.

Many older alcoholics do without needed health care; linking them to a health care provider can be a profoundly valuable service. Staff of substance abuse treatment programs should consider, whenever possible, educating older clients on such health promotion themes as desirable diet and nutrition, daily exercise, sleep hygiene, and the benefits of routine health checks.

Conducting Medical Evaluations

A thorough, age-specific medical evaluation should be completed for each patient at entry into alcoholism treatment if it was not done by the referring source. The evaluation can be completed in-house in larger programs that have a primary care provider on staff, by a consulting provider, or by the patient’s personal physician.

Trained nonmedical staff can easily do portions of the evaluation, such as screening for age-related macular degeneration, a leading cause of blindness in older adults. Positive results would indicate the need for further evaluation by a professional (e.g., referral to an ophthalmologist). The treatment program should review this evaluation.

The medical evaluation should always include an assessment of medication use because of the potential for medication and alcohol interactions. To determine the medication use of older adults, the "brown bag approach" is helpful.16 The practitioner can ask older adults to bring a brown paper bag with every medication they take. This could include all medications prescribed by a doctor; all medications, vitamins, etc., they got at the drugstore; and any herbs that anyone gave them to try. This will provide an opportunity to better determine potential medication interaction problems.

Handling Mental Illnesses

Chronic mental illness such as depression, bipolar and recurrent major depressive disorders, chronic schizophrenia, and severe anxiety disorders will require ongoing care. Research suggests that some patients with schizophrenia cannot manage the interpersonal intensity of group therapy for addictions. They are more suitably managed on a one-to-one basis with an addictions counselor who consults with a psychiatrist.17

Some patients with severe disorders, including some with dementia, may be better managed in a mental health or long-term care setting than in a substance abuse program. However, it is crucial that a geriatric psychiatrist be involved, at least for consultation.

Researchers estimate that between 10 and 30 percent of older alcoholics have long-lasting or recurrent depressive symptoms.18 Some fulfill criteria for major depressive disorder, dysthymic disorder, or cyclothymic disorder. Others do not meet criteria for any of these diagnoses but suffer from depressive symptoms that fall under the category of subsyndromal depression.

Depression for several days or longer immediately following a prolonged drinking episode does not necessarily indicate a true comorbid disorder or the need for antidepressant treatment in most cases.19-21 When depressive symptoms persist several weeks after drinking stops, specific antidepressant treatment is indicated.22

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Family Involvement and Therapy

If there is a family with whom the older substance abuser still interacts and there is evidence of conflict or estrangement, family therapy can be crucial in recovery. Family therapy can enhance treatment by focusing on rebuilding the social support network.

Involving Family Members in Treatment

Gathering detailed information about the client’s relationships from family members is key in evaluating the client and planning treatment. This information will affect treatment planning whether or not family members share a home or remain involved in each other’s lives, as past events may bear upon the substance abuse. On the basis of the individual’s drinking antecedents, the treatment team can decide whether family or marital therapy is appropriate.

Family members, including adult children, can play a critical role in the older client’s treatment.23-25 Married older alcoholics are more likely to comply with treatment if their spouses also become involved in the treatment process.26

The types of individuals who are appropriate to involve in the client’s treatment will vary among clients. Some older clients may be out of touch with family members or may live far away from relatives. Dupree and colleagues found that, on average, late-onset alcoholics had a total of four friends and four family members with whom they were in contact.27 Daily contacts averaged less than one a day.

The person who is closest to the client may be a golfing partner, a housemate, a caseworker or health provider, the bank trustee of the person’s estate, or a private social service worker hired by the bank. Some older adults cohabit in longstanding common-law relationships without marrying, out of concern for grandchildren’s opinions or for financial or other reasons. Such nontraditional family members may be considered "family" for purposes of treatment.

Eliciting family information requires sensitivity and skill. Older adults are less willing than younger adults to discuss "family business." The client’s family may close ranks as well and choose not to disclose events that they fear could hurt or disturb the client. In working with family issues or family groups, a provider should emphasize airing and bringing closure to past conflicts and concerns and negate any blame.

Treatment staff need to be cautious in deciding what information to share, with which family members, and when (if at all). For example, the role of adult children in the client’s life can be problematic. Although adult children may have new responsibilities for taking care of the patient, they may also be problem drinkers who collude in the client’s drinking, supply the client with alcohol, or help the client rationalize the drinking problem.

Family and Marital Therapy

The dynamics of a marriage can change drastically as couples grow older. These changes stem from retirement, the deaths of friends, and health issues that affect marital relationships, such as changes in sexual function or the need for caregiving. Any of the issues typically experienced by older adults can affect the stability of the marital relationship and place additional stress on the client in treatment. These include financial concerns and fear of the death of a spouse.

The best setting for providing counseling to substance-abusing older patients with marital problems may be individual couple counseling or in a group setting with other couples of similar age. Counseling the couple separately from the group is advisable for addressing very personal concerns such as sexual problems or other highly sensitive issues that could be damaging to the couple’s marriage.

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Case Management, Community-Linked Services, and Outreach

Case management is the coordination and monitoring of the varied social, health, and welfare services needed to support an older adult’s treatment and recovery. Case management starts at the beginning of treatment planning and continues through aftercare. One person, preferably a social worker or nurse, should link all staff who play a role in the client’s treatment. This person should also coordinate with other important individuals in the client’s social network.

The case/care manager develops the treatment plan, reviews progress, and revises the treatment plan as needed. There is a process for monitoring success in achieving the goals of treatment. The case manager serves as an advocate, representative, and facilitator of links to other agencies to procure services for the client.

The multiple causes of older adults’ problems require multiple linkages to community services and agencies. The treatment program that seeks to be the sole source of all services for its older clients is likely to fail. Even in very isolated areas, programs can strengthen their services for older adults through linkages to local resources such as the faith community.

The case manager will likely refer the client to a combination of several community resources in response to the issues associated with the substance abuse problem. Case managers must have strong linkages through both formal and informal arrangements with community agencies and services such as:

If a program includes outreach services, case management may offer the best means of providing them.28,29 Case managers may, for example, initiate outreach services for homebound clients, although it is important to maintain continuity and assign only one case manager to an older client. If clients in a treatment program become seriously ill or dysfunctional and temporarily require services at home, a case manager may be the ideal staff person to broker services on their behalf.

Many older substance abusers are shut in, either by frailty or by choice. Treatment must be brought to them, at least initially, in the place where they live. Although problems may be serious, many of these shut-ins deny their substance problems and refuse to consider treatment. They only deal with problems they themselves perceive as important, which may be financial, housing-related, or medical. Coordination of care and concern with assertive outreach are key elements in successful treatment intervention.

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References

  1. Oslin, D.W.; Pettinati, H.; Volpicelli, J.R.; et al. "Enhancing treatment compliance in elderly alcoholics: A new psychosocial intervention model." Paper presented at the annual meeting of the Gerontological Society of America, Washington, DC, November 1997.
  2. Atkinson, R.M. Treatment programs for aging alcoholics. In: Beresford, T., and Gomberg, E., eds. Alcohol and Aging. New York: Oxford University Press, 1995, pp.186-210.
  3. Miller, W.R., and Rollnick, S. Motivational Interviewing. New York: Guilford Press, 1991.
  4. Powers, R.B., and Osborne, J.G. Fundamentals of Behavior. New York: West Publishing Co., 1976.
  5. Spiegler, M.D., and Guevremont, D.C. Contemporary Behavior Therapy. Pacific Grove, CA: Brooks/Cole, 1993.
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  7. Scott, J.; Williams, J.M.G.; and Beck, A. Cognitive Therapy in Clinical Practice: An Illustrative Casebook. London, UK: Routledge, 1989.
  8. Dupree, L., and Schonfeld, L. Assessment and Treatment Planning for Alcohol Abusers: A Curriculum Manual. FMHI Publication Series, Number 109. Tampa: Florida Mental Health Institute, University of South Florida, 1986.
  9. Schonfeld, L., and Dupree, L.W. Antecedents of drinking for early- and late-onset elderly alcohol abusers. Journal of Studies on Alcohol 1991, 52:587-592.
  10. Carstensen, L.L.; Rychtarik, R.G.; and Prue, D.M. Behavioral treatment of the geriatric alocohol abuser: A long-term follow-up study. Addictive Behaviors 1985, 10(3):307-311.
  11. Schonfeld, L., and Dupree, L. Older problem drinkers: Long-term and late-life onset abusers: What triggers their drinking? Aging 1990, 361:5-9.
  12. Finkel, S.I. Group psychotherapy with older people. Hospital and Community Psychiatry 1990, 41:1189-1191.
  13. Myers, J.E., and Schwiebert, V. Competencies for Gerontological Counseling. Alexandria, VA: American Counseling Association, 1996.
  14. Litten, R.Z.; Allen, J.; and Fertig, J. Pharmacotherapies for alcohol problems: A review of research with focus on developments since 1991. Alcoholism: Clinical and Experimental Research 1996, 20:859-876.
  15. Tempesta, E.; Janiri, L.; Bignamini, A.; et al. Acamprosate and relapse prevention in the treatment of alcohol dependence: A placebo-controlled study. Alcohol and Alcoholism 2000, 35(2):202-209.
  16. Finch, J., and Barry, K.L. Substance use in older adults. In: Fleming, M., and Barry, K., eds. Addictive Disorders. St. Louis, MO: Mosby/Yearbook Medical Publishers, 1992, pp. 270-286.
  17. Finlayson, R.E. Comorbidity in elderly alcoholics. In: Beresford, T., and Gomberg, E., eds. Alcohol and Aging. New York: Oxford University Press, 1995, pp. 56-69.
  18. Blazer, D.; Hughes, D.C.; and George, L.K. The epidemiology of depression in an elderly community population. Gerontologist 1987, 27(3):281-287.
  19. Atkinson, R.M., and Ganzini, L. Substance abuse. In: Coffey, C.E., and Cummings, J.L., eds. Textbook of Geriatric Neuropsychiatry. Washington, DC: American Psychiatric Press, 1994, pp. 297-321.
  20. Brown, S.A., and Schuckit, M.A. Changes in depression among abstinent alcoholics. Journal of Studies on Alcohol 1988, 49(5):412-417.
  21. Schuckit, M.A. Alcohol and depression: A clinical perspective. Acta Psychiatra Scandinavica Supplement 1994, 337:28-32.
  22. Brown, S.A.; Inaba, R.K.; Gillin, J.C.; et al. Alcoholism and affective disorders: Clinical course of depressive symptoms. American Journal of Psychiatry 1995, 152:45-52.
  23. Dunlop, J. Peer groups support seniors fighting alcohol and drugs. Aging 1990, 361:28-32.
  24. Dunlop, J.; Skorney, B.; and Hamilton, J. Group treatment for elderly alcoholics and their families. Social Work in Groups 1982, 5:87-92.
  25. Myers, J.E. Adult Children and Aging Parents. Alexandria, VA: American Counseling Association, 1989.
  26. Atkinson, R.M.; Tolson, R.L.; and Turner, J.A. Factors affecting outpatient treatment compliance of older male problem drinkers. Journal of Studies on Alcohol 1993, 54:102-106.
  27. Dupree, L.W.; Broskowski, H.; and Schonfeld, L. The Gerontology Alcohol Project: A behavioral treatment program for elderly alcohol abusers. Gerontologist 1984, 24:510-516.
  28. Graham, K.; Saunders, S.J.; Flower, M.C.; et al. Addictions Treatment for Older Adults: Evaluation of an Innovative Client-Centered Approach. New York: Haworth Press, 1995.
  29. Fredriksen, K.I. North of Market: Older women's alcohol outreach program. Gerontologist 1992, 32:270-272.
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