Older Adults: “Why Bother…They’re Gonna Die Anyway!”

Carol S. D’Agostino

LCSW, MA, BCD, CASAC

Robert Wood Johnson Fellow

(Developing Leadership in Reducing Substance Abuse)

“The difficulty lies, not in the new ideas,

But in escaping from the old ones.”John Maynard Keynes

Remember…

Nothing about your client’s drinking may have changed

BUTEverything associated with their aging has.

More individuals 65+ are admitted to hospitals for ETOH-related problems than for heart attacks!

Donna – Case Study

Client Solution?

Borrows 2 cups vodka from a neighbor Refusal of all recommendations (higher level of care,

Guardianship for finances, out-of-county detox, MH day program, companion services)

Where do the ethical/moral responsibilities lie?

Hospital? Insurer? Senior Living?

PCP? Family? Adult Protective?

HHC? Client? County/State?

Older Adult Substance Abuse:A National Epidemic

National Perspective>30 million 60+17.7% suffer from substance misuse

New York State Perspective>1/2 million NYers 60+1996 only 3.8% of 250,000 admits were 55+

Monroe County Perspective~16,000 currently suffering 65+Only one geriatric-specific licensed programNo licensed medical detox beds

1996 CASA Physician Study…

Miss or Misdiagnose

94%

Patients Lie

58%

“Very Prepared”

20%

Time Constraints

35%

Treatment is Effective

4%

Never Diagnosed

43%

Complex Profile

Alcoholism

Aging Depression

Dementia

Confusion Confusion Confusion Confusion

Tremors Tremors Tremors Tremors

Malnutrition Malnutrition Malnutrition Malnutrition

Depression Depression ***** Depression

Memory Loss

Memory Loss

Memory Loss

Memory Loss

Co-occurring Disorders

Depression 20-30%Anxiety disorders 10-20%Cognitive loss 10-40%

Dementia/Alcohol Cycle

Malnutrition

Acceleration Of cycle

Loss ofSelf-esteem

Alcohol Use(Alleviate Stress)

Medication Mismanagement

Arthritis 50-70% Diabetes 40-50%

Asthma 20-40% Epilepsy 30-50%

Cholesterol 40-50% HTN 22-50%

Depression 50% Antibiotics 25-50%

Community Barriers

Advocacy!

Advocacy!

Advocacy!

Complex Client Profile

C u ltu ra l Issu es C h ro n ic D ise a se /P re sc rip tio n M e ds

A g ing S u b sta nce A b u se M e n ta l H e a lth

C o m p re h e n s iveE va lua tion

Need For A New Clinical Pathway

Aging Network

CLIENT

HealthcareSenior Living Communities

Mental HealthAddiction Treatment

Geriatric Co-occurring Disorders Model(Lifespan, Rochester, NY)

Community outreach model—not treatment/not licensed

Utilize a stratified geriatric care management approach Collaboration between aging, MH/CD and healthcare

networks Clients 55+, no court mandates, no homeless Minimal fee for service/Funding from local foundations Data collections on first 120 (Journal of Dual Disorders,

in print) Clinical evaluation (Un. of Michigan/Dr. Frederic Blow)

Broadening the Clinical Toolkit: Traditional + Risk Reduction

Medical model Abstinence model Non-compliance=“not

ready,” “hit bottom” Client has to reach out

first Strong cognitive

component

Public health model Non-abstinence model Health, safety,

functioning focus Holistic treatment plan Linkage/support Redefines success Slower pace

Focus on Medical Concerns

The relationship between alcohol consumption and risk (stroke, HTN, cancer, depression, etc.)

The interaction of alcohol + prescription meds (HTN, ulcers)

Concerns regarding health, safety, functioning Use “at risk” or “misuse” vs. Alcoholic

Ask Alcohol Relationship QuestionsAdapted from A. Weil and W. Rosen, 1993From Chocolate to Morphine: Everything You Wanted to Know About Mind-Active Drugs

Do you recognize that ETOH is a drug? Do you have an awareness of what it does to

your body? Do you experience any useful effects? Can you easily separate from your use? Are you free from adverse effects on your

health, functioning, or behavior?

THINK OUTSIDE OF THE BOX!

Don’t follow “recommended” drink charts Don’t condone alcohol for health reasons

(heart, blood, anxiety, etc.) Screen for insomnia (ETOH + ?) Utilize support at healthcare appointments Brown bag assessments Aging + ETOH = “Sicker Quicker”

Transitional Care Management:Direct Intervention/Linkage

Assessment Motivational enhancement techniques 12 Step/AA – Grey AA Crisis intervention skills mandatory Powerful brokerage with CD facilities Geriatric care management thru CD treatment

Supportive Care Management:Risk Reduction Model

Clinical evaluation Risk reduction strategies/psychotherapy Motivational enhancement techniques Powerful integration with aging and mental

health networks Linkage to CD treatment when appropriate Geriatric care management (can be intensive) Crisis intervention skills mandatory

Intensive Care Management:Environmental Treatment Model

Medically/mentally fragile Dementia Never going to be appropriate for tx –sole focus on

health, safety, functioning Intensive geriatric care management Crisis intervention skills mandatory Use of senior living communities—Step Down Geriatric Neuropsychiatric evaluations Guardianship

What are we learning?

Use has not changed, client profile has! Average age of clients b/t 75-85 >40% of referrals from families/caregivers in crisis Common threads: self-neglect, isolation, and

medication mismanagement Only 10% of clients have any previous CD tx Over 40% of clients have some form of dementia ~20% involve some form of elder abuse ~15% of clients die annually

What else?

Inpatient Linkage

--w/o motivational enhancement, 57%

completion rate

--w/motivational enhancement, 80% Outpatient Linkage

--w/o motivational enhancement, 10%

completion rate

--w/motivational enhancement, 40%

G.A.P. Program Expansion

Monroe County Geriatric Substance Abuse CoalitionMonroe County Dept. of Human/Health ServicesMonroe County Office for the AgingMonroe County Office of Mental HealthMonroe County Medical SocietyUnited WayExcellus/BlueCrossBlueShieldNational Council on Alcohol and Drug DependenceAlzheimer’s AssociationSenior Living Communities

Monroe County Coalition, cont.

Direct Service Subcommittee

1. Surveying Senior Living Committees

2. Surveying Licensed CD Tx Facilities

3. Design of a new clinical pathway:

Step Down Model

4. Ethnic Outreach

Monroe County Coalition, cont.

Public Policy Subcommittee

1. Lack of licensed medical detox beds in

Monroe County hospitals for high-risk, frail

elderly

Monroe County Coalition, cont.

Knowledge Management Subcommittee

1. Monroe County Senior Action Plan—

Geriatric Mental Health Specialist

Training Program

2. Consultation: 5 Counties in NYS

3. Contracts: Urban Healthcare Clinics