Substance Abuse Prevention, Screening and Identification, and Assessment for Older Adults Frederic C

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Substance Abuse Prevention, Screening and
Identification, and Assessment for Older Adults
Frederic C. Blow, Ph.D. Associate Professor
and Research Associate Professor University of
Michigan, Department of PsychiatryDirector,
Serious Mental Illness Treatment Research
Evaluation Center Department of Veterans Affairs
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Presentation Overview

• Prevention Issues
• Diagnostic Criteria
• Barriers to Identification
• Signs and Symptoms
• Psychosocial Manifestations
• Screening Instruments
• Special Assessments
• Future Research Directions

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Prevention Issues
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Lifetime Patterns of Substance Use and Abuse
Focus for Prevention Strategies
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Prevention of Substance Abuse Among Older Adults
Conceptual Issues

• Age group definitions
• Life course variations in consumption
• Sensible/appropriate use of alcohol and
  prescription drugs
• Diagnostic criteria for abuse/dependence
• Risk profiles for specific subpopulations
• Prevention goals

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Prevention Strategies Effective with Youth
Relevance to Older Adults

• Individual-Focused education, skills
  development, alternate behaviors, health
  behaviors
• Families/Social Support spousal interventions,
  family supports, caregivers
• Peer Norms network of friends, perceptions
• Organizations health care organizations, AARP,
  other policy changes
• Social Environment social norms and policies,
  availability and sanctions

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Prevention of Substance Abuse Among Older
Adults Additional Issues

• Access to target populations
• Optimal modality for materials
• Appropriateness and acceptability of content
• Delivery systems
• Program-driven vs. research-initiated
  interventions
• Policy interventions
• Role of drinking, prescription drugs in late life

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Risk and Protective Factors
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Prevention of Substance Abuse Among Older Adults
Risk Factors

• Male
• Racial/Ethnic Minority Status
• Psychiatric Comorbidity
• Higher SES
• Lower Social Supports
• Previous History of Problems
• History of Using Substances as Coping Strategy

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Prevention of Substance Abuse Among Older Adults
Protective Factors

• Female
• Higher Religiosity
• Fewer Mental/Physical Health Problems
• Lower SES
• Positive Coping Styles
• More Social Supports

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Diagnosis Issues
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Problems with Definitions

• Substance Misuse
• At-risk or Hazardous Use
• Problem Use
• Substance Abuse
• Substance Dependence

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Diagnostic Criteria for Substance Dependence
in Older Adults

• The Treatment Improvement Protocol
• (TIP 26) Consensus Panel determined

• DSM-IV criteria for substance abuse
• and dependence may not be
• adequate to diagnose older adults
• with substance use problems

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DSM-IV Dependence Criteria

• Tolerance
• Withdrawal
• Use in larger amounts or for longer than
  intended
• Desire to cut down or control use
• Great deal of time spent in obtaining substance
• or getting over effects
• Social, occupational, or recreation activities
• given up or reduced
• Use despite knowledge of physical or
• psychological problem

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Applying DSM-IV Criteria to Older Adults
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Screening
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Practitioner Barriers to Identification

• Ageist assumptions
• Failure to recognize symptoms
• Lack of knowledge about screening
• Physician discomfort with substance abuse topic
• - 46.6 of primary care physicians found it
  difficult to discuss prescription drug abuse with
  their patients
• (CASA, 2000)

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Individual Barriers to Identification

• Attempts at self-diagnosis
• Description of symptoms attributed to aging
  process or disease
• Many do not self-refer or seek treatment
• - Although most older adults (87 percent) see
  physicians regularly, an estimated 40 percent of
  those who are at risk do not self-identify or
  seek services for substance abuse
  (Raschko, 1990)

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Signs and Symptoms of Substance Use Problems in
Older Adults

• Anxiety
• Blackouts, dizziness
• Depression
• Disorientation
• Mood swings
• Falls, bruises, burns
• Family problems
• Financial problems
• Headaches
• Incontinence

• Increased tolerance
• Legal difficulties
• Memory loss
• New problems in decision making
• Poor hygiene
• Seizures, idiopathic
• Sleep problems
• Social isolation
• Unusual response to medications

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Symptom Identification

• Applying quantity and frequency levels
  appropriate for younger adults to elders may
  cause failure to identify substance use problems
• Warning signs can be confused with or masked by
  concurrent illnesses and chronic conditions, or
  attributed to aging
• Sleep problems associated with chronic
  conditions, particularly cardiovascular disease
  and pain
• Falls attributed to poor lower body strength,
  poor balance, or vision limitations
• Anxiety attributed to psychosocial concerns
• Confusion/memory problems associated with
  Alzheimers disease or other dementias

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Psychosocial Manifestations of Mild/Moderate Drug
Disorders

• Psychological/Behavioral
• Agitation, irritability, dysphoria, difficulty in
  coping, mood swings, hostility, violence,
  psychosomatic symptoms, hyperventilation,
  generalized anxiety, panic attacks, depression,
  psychosis
• Family
• Chronic stable family dysfunction, marital
  problems, anxiety and depression in family
  members, divorce, abuse and violence
• (Brown, 1992)

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Psychosocial Manifestations of Mild/Moderate Drug
Disorders

• Social
• Alienation and loss of old friends, gravitation
  toward others with similar lifestyle
• Legal
• Arrests for disturbing the peace or driving while
  intoxicated, stealing, drug dealing
• Financial
• Borrowing or owing money, selling personal or
  family possessions
• (Brown, 1992)

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Screening Instruments

• Modified CAGE for drug abuse
• Examined for older populations (50 and over)
• Excellent sensitivity, poor specificity
• (Hinkin et al., 2001)
• Conjoint two-item screen
• "In the past year, have you ever drunk or used
  drugs more than you meant to?"
• "Have you felt you wanted or needed to cut down
  on your drinking or drug use in the past year?"
• Ages 50-59 Sensitivity 73.9, Specificity 84.8
• (Brown et al., 2001)
• Drug Abuse Screening Test (DAST-10, 20, 28)

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Drug Abuse Screening Test (DAST-20)

• Have you used drugs other than those required for
  medical reasons?
• Have you abused prescription drugs?
• Do you abuse more than one drug at a time?
• Can you get through the week without using drugs
  (other than those required for medical reasons)?
• Are you always able to stop using drugs when you
  want to?
• Have you had "blackouts" or "flashbacks" as a
  result of drug use?
• Do you ever feel bad or guilty about your drug
  use?
• Does your spouse (or parents) ever complain about
  your involvement with drugs?
• Has drug abuse created problems between you and
  your spouse or your parents?
• Have you lost friends because of your use of
  drugs?

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Drug Abuse Screening Test (DAST-20)

• Have you neglected your family because of your
  use of drugs?
• Have you been in trouble at work because of drug
  abuse?
• Have you lost a job because of drug abuse?
• Have you gotten into fights when under the
  influence of drugs?
• Have you engaged in illegal activities in order
  to obtain drugs?
• Have you been arrested for possession of illegal
  drugs?
• Have you ever experienced withdrawal symptoms
  (felt sick) when you stopped taking drugs?
• Have you had medical problems as a result of your
  drug use (e.g., memory loss, hepatitis,
  convulsions, bleeding, etc.)?
• Have you gone to anyone for help for a drug
  problem?
• Have you been involved in a treatment program
  specifically related to drug use?

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Assessment
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Special Assessments

• Functional Abilities
• Activities of Daily Living (ADLs)
• Instrumental Activities of Daily Living (IADLs)
• SF-36
• Comorbidities
• Physical
• Psychiatric
• Affective disorders
• Suicide risk
• Sleep Disorders

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Special Assessments

• Cognitive Impairments
• Dementia
• Orientation/Memory/Concentration Test
• Folstein Mini-Mental Status Exam (MMSE)
• Delirium
• Confusion Assessment Method (CAM)
• Other cognitive impairments
• Trauma from falls, MVA, accidents
• Wernicke-Korsakoff syndrome

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Screening and Assessment Recommendations for
Older Adults

• Every person over 60 should be screened for
  alcohol and drug abuse as part of regular
  physical examination
• Brown Bag Approach
• Screen or re-screen if certain physical symptoms
  are present or if the older person is undergoing
  major life transitions

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Screening and Assessment Recommendations for
Older Adults

• Ask direct questions about concerns
• Preface question with link to medical conditions
  of health concerns
• Do not use stigmatizing terms (i.e. drug addict)

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Future Directions

• Risk and Protective Factors/Prevention/Early
  Identification
• Drug of Choice
• Illicit, Prescription, Alcohol
• Patterns of use
• Drug use trajectories
• Re-emergence of addiction in late life
• Late-life onset of substance use disorder
• Screening, Assessment and Diagnosis
• Identification and treatment of psychiatric
  comorbidities

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Contact Information

• Frederic C. Blow, Ph.D.
• Director
• Serious Mental Illness
• Treatment Research Evaluation Center
• Department of Veterans Affairs
• Associate Professor/Research Associate Professor
• University of Michigan Department of Psychiatry
• 400 E. Eisenhower Parkway, Suite 2A
• Ann Arbor, MI 48108
• Phone [phone] Fax
  734/761-2617
• email fredblow_at_umich.edu