Drug and Alcohol Treatment Outcomes in Older Adults

1
Drug and Alcohol Treatment Outcomes in Older
Adults

• Derek D. Satre, Ph.D.
• Jennifer Mertens, M.A.
• Sujaya Parthasarathy, Ph.D.
• Constance Weisner, Dr.PH., M.S.W.
• University of California, San Francisco and
• Kaiser Permanente Division of Research

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Study Support

• Studies were supported by the National
  Institute on Drug Abuse (R01 DA08728 and R37
  DA10572) and the National Institute on Alcohol
  Abuse and Alcoholism (R37 AA10359).
• The first author was supported by a National
  Institute on Drug Abuse training grant (T32
  DA07250) and center grant (P50 DA09253).
• The Drug and Alcohol Research Team at the Kaiser
  Division of Research and the staffs of the Kaiser
  Chemical Dependency Recovery Programs provided
  essential support for these studies.

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Key Older AdultTreatment Research Gaps

• Clinical needs of older adults in treatment
• Studies of private programs
• Factors associated with treatment success
• Gender differences
• Long term outcomes
• Cost impacts

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Research Questions

• How are older patients different from others at
  baseline and at 6-month follow-up?
• How do older patients differ by gender?
• How are 5-year outcomes of older adults in
  treatment different from those of other patients?
• How do health service utilization and cost offset
  associated with treatment differ by age group?

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Sample

• 1204 patients at Kaiser completed CD treatment
  intakes at outpatient facilities in Sacramento,
  from 1994 to 1996. (Day Hospital Study)
• -Weisner et al., 2000
• Drug testing was used to validate self-report
• 80 of patients completed six-month follow-up
• response rate increased with age 77 of younger,
  83 of middle-aged, and 91 of older adults

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Treatment Program

• Randomized to day hospital outpatient or
  lower-intensity outpatient care
• Abstinence-based, 12-step informed, group format
  included education, relapse prevention and
  family-oriented therapy
• Individual counseling and physician appointments
  were available as needed

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Theoretical Framework for Analyses

• Treatment outcome is determined by
• Individual characteristics
• Treatment
• Extra-treatment factors
• How are older adults different from other
  patients in these domains that influence outcome?

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Analyses

• Compared three age groups
• 736 patients ages 17-39, mean age 30.4 (sd
  6.3)
• 379 patients ages 40-54, mean age 45.1 (sd
  3.8)
• 89 patients ages 55-81, mean age 61.6 (sd
  6.0)
• Examined gender differences within the older
  adult group
• Tested predictors of abstinence using logistic
  regression

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Key Baseline Age Differences

• Older adults (55-81)
• Married, Caucasian, retired
• ASI score means (vs. younger adults)
• Higher alcohol severity
• Lower drug severity
• Greater medical problems
• Fewer social and family problems
• Less psychiatric distress (ASI and SCL-66)
• More likely to have abstinence goal
• -Satre et al., 2003

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Length of Stay in Treatment

• Treatment length was measured in days
• Older and middle-aged stayed longer than younger,
  p

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Abstinence Rates at Six Months

• Significant overall age group differences,
  p .03

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Factors Associated with Greater Age, and with
Abstinence at Six Months

• Being married
• Dependence criteria not met
• Less hostility on SCL-66
• Abstinence goal
• Greater length of stay
• (Age was NS)

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Implications

• Older adults bring several strengths to treatment
  that younger adults lack, such as lower hostility
  and greater abstinence motivation, and they stay
  in treatment longer
• However, these advantages do not translate into
  substantially higher abstinence rates

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Why Study Older Women?

• Fastest growing segment of the population
• Heavy users of health services
• Concerns about prescription drug use
• May be more sensitive to alcohol or drugs than
  men
• May have different treatment needs and access
  issues

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Gender Differences in Six-Month Outcome

• N 92 (29 women and 63 men)
• Alcohol dependent adults age 55 and over
• Data drawn from two outcome studies (Day Hospital
  Study and Integrated Care Study) to increase
  sample size -Weisner et al., 2000, 2001.

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Baseline Characteristics of Older Women versus
Older Men

• Lower income (53 vs. 33 earn under 40K)
• Not married (38 vs. 62 married)
• Later onset of heavy drinking (5) (age 35 vs.
  28)
• Comparable baseline alcohol consumption (16 days
  per month of 5 drinks)
• Comparable tranquilizer use (25 vs. 29)
• Perhaps more distress (78 vs. 60 anxiety, NS)
• Comparable abstinence goal (100 vs. 90)
• -Satre et al., 2004a

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Length of Stay by Gender

• Older women stayed an average of 24 days longer
  in treatment than older men (NS)

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Abstinence at Six Months by Gender

• 79 of older women abstinent at six months, vs.
  54 of older men (p

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Clinical Implications for Older Women

• Strengths
• Abstinence goal
• Length of stay
• Good abstinence outcomes
• Special needs
• Social support (living alone)
• Economic support
• Depression and anxiety treatment

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Day Hospital Sample at Five Years

• 77 of the sample completed 5-year follow-up
• Older adults more likely to maintain Kaiser
  membership (91 vs. 80, 59)
• Mortality by age group
• 1 of younger
• 5 of middle-aged
• 11 of older
• -Satre et al., 2004b

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Five Year Outcomes

• Older adults had lower legal and family/social
  ASI scores than younger adults
• No difference on other ASI scores
• Higher 30-day and 1-year abstinence rates than
  younger adults (all substance diagnoses)
• No age difference in abstinence among those only
  dependent on alcohol

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30-day Abstinence Rates at Five Years by Age Group

• Significant overall age group differences, p
  .02

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30-day Abstinence at Five Years by Age and Gender
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Age Differences in Social Networks
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Predictors of Abstinence at Five Years

• Female gender
• Length of stay
• Nobody encouraged drinking or drug use
• Not significant
• Age group
• CD diagnosis
• Treatment intensity
• Married at year five
• Kaiser membership at year five

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Five-Year Study Key Points

• Older women have the best outcome
• Greater length of stay in treatment has long-term
  benefits
• Older adults show strengths and weakness in
  social networks

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Proposed Intervention

• Based on profile of social networks
• Lower AA use in older adults
• Activate or expand informal support
• Supplement mixed-age program
• Age-specific interpersonal psychotherapy group (K
  award study)

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Medical Conditions

• Study compared CD patients in treatment to
  demographically matched control from the Kaiser
  membership
• One third of medical conditions examined were
  more prevalent in CD patients, especially
• Hypertension, liver cirrhoses, COPD, asthma,
  injuries, lower back pain, arthritis, headache,
  depression, anxiety, psychosis
• 
  -Mertens et al., 2003

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Medical Conditions in Patients Age 55 and Over

• CD patients had higher rates than age- and
  sex-matched controls
• Ischemic heart disease
• Depression
• Anxiety

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Health Care Utilization and Cost

• Records of CD patients were examined 18 months
  pre- and post-intake
• Compared to utilization and cost records in a
  non-patient control group, using automated health
  plan records
• Examined age group differences
• 
  -Parthasarathy et al., 2001

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Utilization and Cost Findings

• Greater age was positively associated with
  pre-treatment cost in both samples
• Post-treatment, decline in cost was larger in the
  treatment sample than in the matched sample for
  those aged 40 to 49, but not in older age groups

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Areas for Further Investigation in Older Adults

• Improving outpatient CD treatment
• Social network intervention
• 9 and 11 year Day Hospital study follow-up
• Remission, alcohol vs. drug use
• How CD (and treatment) affects health
• Health conditions and psychiatric disorders
• Services utilization and cost
• Primary care study
• Dual diagnosis study funded by RWJF

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References

• Mertens, J. R., Lu, Y. W., Parthasarathy, S.,
  Moore, C., Weisner, C. (2003). Medical and
  psychiatric conditions of alcohol and drug
  treatment patients in an HMO. Archives of
  Internal Medicine, 163, 2511-2517.
• Parthasarathy, S., Weisner, C., Hu, T.W.,
  Moore, C. (2001). Association of outpatient
  alcohol and drug treatment with health care
  utilization and cost Revisiting the offset
  hypothesis. Journal of Studies on Alcohol, 62,
  89-97.
• Satre, D. D., Mertens, J. R., Areán, P. A.,
  Weisner, C. (2003). Contrasting outcomes of older
  versus middle-aged and younger adult chemical
  dependency patients in a managed care program.
  Journal of Studies on Alcohol, 64, 520-530.
• Satre, D. D., Mertens, J. R., Weisner, C.
  (2004a). Gender differences in older adult
  treatment outcomes for alcohol dependence.
  Journal of Studies on Alcohol, 65, 638-642.

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References (cont.)

• Satre, D. D., Mertens, J. R., Areán, P. A,
  Weisner, C. (2004b). Five-year alcohol and drug
  treatment outcomes of older adults versus
  middle-aged and younger adults in a managed care
  program. Addiction, 99, 1286-1297.
• Weisner, C., Mertens, J., Parthasarathy, S.,
  Moore, C., Hunkeler, E. M., Hu, T.-W. Selby, J.
  V. (2000) The outcome and cost of alcohol and
  drug treatment in an HMO day hospital versus
  traditional outpatient regimens. Health Services
  Research, 35, 791-812.
• Weisner, C., Mertens, J., Parthasarathy, S.,
  Moore, C., Lu, Y. (2001) Integrating primary
  medical care with addiction treatment a
  randomized controlled trial. Journal of the
  American Medical Association, 286, 1715-1723.
• Contact Derek Satre, Ph.D., UCSF, 401
  Parnassus, Box 0984-OVS, San Francisco, CA 94143.
  Email dereks_at_lppi.ucsf.edu