The Use of Brief Interventions for At-Risk Drinking in Older Adults

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The Use of Brief Interventions for At-Risk
Drinking in Older Adults

• Kristen L. Barry, PhD
• Research Professor
• University of Michigan Department of Psychiatry
• and Department of Veterans Affairs National
  Serious Mental Illness Treatment Research and
  Evaluation Center (SMITREC)

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Aspects of Effective Brief Interventions

• Feedback
• Responsibility
• Advice
• Menu
• Empathy
• Support Self-efficacy
• 
  Miller and Rollnick, 1993

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Settings for Brief Interventions

• Primary Care
• Emergency Department
• Hospitals
• Community
• Workplace
• Home Health Care
• Substance Abuse Treatment Programs

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Who Can Conduct Brief Alcohol Interventions?

• Physicians
• Nurses/Nurse Practitioners
• Physician Assistants
• Social Workers
• Psychologists
• Health Educators
• Home Health Workers
• Other Allied Health Providers

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Confrontation vs. MI
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Steps in Brief Alcohol Intervention

• Identifying future goals
• Summary of health habits
• individualized feedback on health, drinking, med
  use, consequences
• Standard drinks
• Types of Older Drinkers
• Consequences of At-Risk drinking
• Reasons to quit or cut down
• Drinking agreement and plan
• controlled drinking vs. abstinence goal
• Risky situations/Alternatives

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Brief Intervention Steps
Identifying future goals

• Participants are asked to identify their goals
• Physical and mental health
• Social lives/relationships
• Finances, etc.
• This makes certain issues affected by alcohol
  salient, and may assist in developing a
  discrepancy between current drinking and valued
  goals during the course of the intervention.

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Brief Intervention Steps
Summary of health habits

• Participants provide information regarding
• physical and mental health functioning
• health habits, nutritional issues, tobacco use
• alcohol consumption
• This is an opportunity for the interventionalist
  to give individualized Feedback, and facilitates
  self-reflection regarding health status and
  alcohol use.

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Brief Intervention Steps
Standard Drinks and Types of Older Drinkers

• Participants are introduced to the concept of
  standard drinks
• Participants are shown how their level of alcohol
  consumption compares to other older adults
• This assists participants in understanding that
  the effects of alcohol are similar across
  beverage groups and puts their drinking in
  perspective.

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Brief Intervention Steps
Reasons to Quit or Cut Down

• Participants are asked to identify positive and
  negative aspects of their alcohol use
• Participants are asked to identify benefits of
  change and barriers to change
• This assists participants in weighing the issues,
  and hopefully tipping the decisional balance in
  favor of changing drinking habits.

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Brief Intervention Steps
Drinking Agreement and Plan

• Participants are asked to choose a drinking goal
  (reduction vs. abstinence), their start date for
  addressing their drinking, their rate of
  reduction, and target date
• This provides a MENU of options to participants.
  Intervention staff may offer additional
  Feedback/Advice. Goal choice increases a sense
  of personal Responsibility.

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Brief Intervention Steps
Risky Situations/Alternatives are identified

• Participants are asked about the situations and
  environmental cues that may trigger drinking
• Increases insight into consumption, allows
  participants to identify their own strategies for
  cutting down. Staff are trained in Empathic
  techniques and to Support Self-efficacy.

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Practical Summary

• Assess both consumption and consequences
• Consider possible goals (engage in
  treatment/quit or reduce drinking)
• Use the FRAMES/Motivational Enhancement Approach

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If a Follow-up Intervention Session is Needed
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Follow-up Sessions

• The timing of these sessions are flexible
• Clients should receive a follow-up session at 6
  and 12 weeks after the initial session
• The purpose is multifaceted
• Assess progress
• Show concern and empathy
• Provide support and advice

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Differences from Initial Session

• There is a greater focus on alcohol use and the
  consequences of the alcohol use
• More time is available to discuss consequences of
  use and strategies for changing behavior
• The individual has had a chance to try and change
  their behavior based upon prior visit(s) and thus
  you have the opportunity to discuss successes and
  shortfalls

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Special Circumstances/Issues
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Medical Issues to Consider for Brief
Interventions

• Alcohol can cause or exacerbate the following
  health problems
• malnutrition, stomach problems, liver disease,
  stroke, cardiac problems, pancreatitis,
  hypertension, insomnia, cognitive
  problems/dementia, falls, depression, cancer,
  chronic pain, adverse medication
  effects/interactions, etc.

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Lifetime Prevalence () of Substance Use
Disorders for Various Psychiatric Disorders
ANY SUBSTANCE PSYCHIATRIC DISORDER
ABUSE/DEPENDENCE

• General population 16.7
• Schizophrenia 47.0
• Any affective disorder 32.0
• Any bipolar disorder 56.1
• Major depression 27.2
• Dysthymia 31.4
• Any anxiety disorder 23.7
• OCD 32.8
• Phobia 22.9
• Panic 35.8

Regier et al, 1990
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Factors Associated with Dual Diagnosis in Older
Adults

• Compared to older adults with psychiatric illness
  alone, those with dual diagnoses
• DD more likely in males, Minority populations
• More likely to have dementia
• Less likely to have schizophrenia or PTSD
• No difference in rate of major depression or
  bipolar disorder
• Prigerson, et al., 2001
• Compared to older adults with SA alone
• DD more likely in women, Caucasians
• Brennan, et al., 2002

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Impact of Co-occurring Disorders in Older Adults

• Higher rates of active suicidal ideation compared
  to persons with depression or alcohol use alone
• Higher health care utilization
• Psychiatric services
• Substance abuse services

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Factors Associated with Dual Diagnosis in Older
Adults (Cont.)

• Prevalence of lifetime alcohol abuse and
  dependence
• 1.5 times higher among persons with cognitive
  impairment
• George, Landeman, Blazer, Anthony, 1991

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Suicide

• Highest rates of suicide occur in late life among
  men
• Depression causes a 5.8 fold increase in risk of
  suicide compared to death from other causes
• Heavy drinking (3 drinks/day) causes a 8.9 fold
  increase in risk of suicide compared to death
  from other causes
• Moderate drinking (1-2 drinks/day) causes a 10.6
  fold increase in risk of suicide compared to
  death from other causes

Grabble, et al. 1997
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Effects of Treating Both Alcohol Abuse and
Depression

• Importance of treating both depression and
  alcohol abuse
• Combination of depression treatment and reduced
  alcohol use was beneficial in significantly
  reducing depression
• Oslin, et al., 2000

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Depression Treatment Outcomes in Older Adults
with Alcohol Use Disorders

• Inpatients treated for depression
• Improved Geriatric Depression Scores (GDS)
• Across light, moderate, and heavy alcohol
  consumers
• Among patients drinking at admission
• 80 reduced drinking by 90
• History of alcohol-related problems
• Not predictive of discharge outcomes
• 3 to 4 months post-discharge outcomes
• Improved social functioning and energy
• Oslin, et al., 2000

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The Spectrum of Interventions for Older Adults
Prevention/ Education
Brief Advice
Brief Interventions
Pre-Treatment Intervention
Formal Specialized Treatments
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Conclusion

• A brief intervention is one of the effective
  tools for working with older adults across a
  range of issues related to alcohol misuse and
  abuse.