Alcohol and drug abuse among the elderly has received relatively little attention from both clinical and research perspectives.1·2 Recent contributions, however, suggest that the elderly do have significant problems associated with the misuse and abuse of alcohol and prescription drugs,3·4 and the efficacy of rehabilitation for the aging chemically dependent person is proving favorable.5-6
The exact percentage of the older population that is adversely affected by alcohol and other drugs is unknown.
The overall incidence of alcoholism in older adults is lower than among younger people, but it is more often thought to be a hidden phenomena in the aging person because most older problem drinkers are retired or live alone.7·8 ï&mily members, friends, and employers are not available to notice changes in work patterns, behavior, and personality, which is frequently how younger chemically dependent persons are identified.
The evidence available in the literature offers variable percentages for the incidence of chemical abuse in the elderly. One study indicated 10% of men and 2% of women over age 60 are chemically dependent.9 Another study, conducted by household surveys, indicated an incidence between 10% and 20%.'° Hospital admissions to psychiatric units range from 15% to 60%, with studies indicating as high as 60% of men admitted and 43% of women admitted having some form of chemical dependency.11·12 The National Institute on Alcohol Abuse and Alcoholism examined several clinical studies and concluded that older persons in hospitals who exhibit illness or other serious consequences of alcohol abuse range from 7.5% to 70%.4-13 Problems with alcohol do not necessarily decrease with age, yet it is almost impossible to identify the incidence of chemical abuse among the elderly outside of a hospital or other treatment setting for reasons already mentioned.14
Recognizing chemical dependency in the elderly presents a special case. It is often difficult to differentiate between chemical dependency and other physical, mental, and social disturbances that accompany aging. Although no one factor is sufficient for an accurate diagnosis of an alcohol or drug problem, Figure 1 lists common identifying factors that present in the elderly chemically dependent person. These symptoms are frequently labeled by healthcare practitioners as normal signs of aging, when in reality they are a direct result of alcohol or other drug abuse and are reversible once the abuse is stopped.
In theory, there are two types of geriatric chemical dependencies.15 Some observers distinguish between the early onset problem drinker and the late onset drinker. The early onset abuser is the individual who has frequently experienced problems with alcohol over a lifetime and continues to abuse alcohol in old age. The late onset drinker often presents no history of drinking difficulties, but develops an abusive pattern of chemical use in response to the stresses of aging. Such stresses may include the loss of friends, spouse, and employment, along with the loss of a sense of purpose and identity. In a study conducted at the Mayo Clinic for Alcoholism and Drug Dependency, 41% of persons over the age of 65 reported symptoms of alcoholism that began after age 60. l6
Chemical dependency in the older adult may be difficult to identify because the criteria often used in the screening and diagnosis of abuse and dependency is inappropriate for this population. Many scales used to diagnose alcoholism or drug dependency measure prevalence of legal, social, and job related problems.4·10 These are not always appropriate for diagnosing the elderly because many have retired, do not drive, and are isolated from family and friends.
A review of the literature indicated only one study that evaluated assessment tools used to screen the elderly. l7 Willenbring and Spring concluded that the 25-item Michigan Alcoholism Screening Test (MAST) appears to have an excellent sensitivity to and specificity in elderly men. TTiis short screening tool allows the practitioner to explore the nature of an individual's drinking habits and how they affect daily relationships. It can easily be incorporated into nursing assessments as a screening tool (Figure 2).
SIGNS AND SYMPTOMS
Once an older person has been identified as having a chemical dependency, treatment options depend on what is available in the community and the attitudes and values of the health-care professional. The following obstacles have been identified for the older person seeking treatment: elderly drinkers are labeled as a poor risk and are often turned down for treatment programs if a younger client presents first19; agebased prejudice prevails in many hospital treatment programs20; the older alcoholic is often regarded as non-productive and useless to society, and the preference is to use shrinking financial resources on a younger population4'18; poor training and misinformation revealed in the fact that medical professionals (physicians and nurses) receive little or no training or formal education related to geriatric alcoholism3·15; and problems of the elderly that have been labeled as a function of their age and psychological stress have often been observed as acceptable behavior. People are too quick to assume that the signs and symptoms of chemical dependency are normal aging symptoms.21
The prognosis for recovery of the aging chemically dependent person is excellent once the problem is identified and the person is provided with direction and support for re-entering mainstream life.4-5 Recovery rates are similar to those for younger alcoholics, and a high rate of completion of treatment programs indicates motivation to change, contrary to general medical thinking.12 Elderly alcoholics may see this time of their lives as a case of "now or never": they may wish to take responsibility for themselves and strive for change, or think they may undo some of the patterns of their lives. It is important for the clinician to recognize that hope for future change is the greatest source of strength in enduring difficulties brought about by recovery. Although the clinician may not see the elderly as having many years left in which to direct their hope, the decisive factor is the individual's own perception of the time left and how that time shall be used. The clinician becomes instrumental in assisting chemically dependent persons in finding better ways of living for the short span of life left to them.22
MICHIGAN ALCOHOLISM SCREENING TEST18
The best setting for rehabilitation of the chemically dependent aging person is controversial, and more research is recommended to support a clinical hypothesis that treatment programs devoted solely to older patients are more beneficial than mixed treatment programs where young and older chemically dependent persons attend treatment sessions together. The model for treatment where chemically dependent persons of all ages go through treatment together is most common in this country.5 Presently, alcoholism treatment facilities that work primarily with elderly alcoholics are almost nonexistent.1
Regardless of whether separate treatment programs are offered for the elderly chemically dependent person or not, there are some important differences between elderly alcoholics and their younger counterparts in the same treatment program. To deny that these differences exist is to make the program less effective in maintaining the sobriety for each of the age groups involved.19
Lack of personal resources and insurance benefits sufficient to secure the available services the aged person requires, lack of experience and training among staff members for dealing with problems specific to the elderly, and the shortage of community facilities that accommodate the physical needs of the aging person are all considerations when assessing treatment needs of the elderly. Sherose (1983) adds that the elderly person typically requires much more time for detoxification from alcohol and other drugs than the younger person, and insurance companies, including Medicare, have misunderstood the basic physiological need for the aging person to remain hospitalized for a longer period of time.13
Other differences noted in the literature are: older persons generally have multiple medical problems that require attention19; modifications of regimens used for detoxification and long-term management should be made with specific attention paid to avoiding overmedicating for withdrawal and remembering that disulfiram is contraindicated in patients with cardiac arrhythmias and pulmonary disease23; aging issues such as retirement, grief, abandonment, physical losses, and isolation are unique to the elderly and require separate attention in group therapy2,5,i9. physiological changes in the elderly require more frequent rest times, large print material for education and homework, minimal writing for those suffering from arthritis of the hands, and structured supervised exercise programs to enhance emotional and physical well-being.
Considering the types of therapies offered to the elderly, a group treatment format offers many advantages.24 Groups enable participants to receive positive reinforcement from peers, provide increased opportunity to model both peer and leader behavior, provide an opportunity for social interaction (especially important for aging persons for whom loneliness and isolation are common problems), and provide an opportunity to draw on the experiences of others who have had similar problems.
Inpatient and outpatient programs for recovering alcoholics and drug dependency should accommodate these separate needs of the elderly by creating elderly-specific treatment groups. Specific needs to be addressed may include discussions about normal physical changes that occur with age, how to deal with losses, grief therapy, reminiscence therapy, assertiveness training, familiarization with social support agencies, or field trips to places of interest to the aging person. If done by a skilled counselor or nurse who is familiar with geriatrics and chemical dependency, this may be enough in a mixedage treatment facility to accommodate the specific needs for treatment of the elderly.
A small survey (N= 12), conducted by the author, of recovering chemically dependent persons whose length of sobriety ranged from 1 month to 7 years, provided responses consistent with the current literature. Results indicated that group therapy was thought to be more beneficial than individual therapy, and elderly-specific groups were more beneficial to the participants than mixed groups. Other suggested treatment recommendations were to provide the elderly client with large-print reading material, to allow extra time for projects and homework assignments, to provide tape recorders for older persons to perform homework assignments instead of having to write, to provide a structured, supervised exercise program, and, in Une with Alcoholics Anonymous advice, to "keep it simple."
Chemical abuse and dependency in the elderly is an ever present problem that frequently goes unrecognized. The primary health-care provider is in a unique position to identify problems by assessing for alterations in physical and emotional behaviors. One must consider the special risks that alcohol and other drugs pose for older adults and make recommendations for treatment to aid the chemically dependent elderly person in recovery. Types of treatment available for the older chemically dependent person will vary depending on the community, but evidence indicates that once treatment is obtained, different needs and responses are present for the elderly. Treatment programs, whether impatient or outpatient, must recognize that when the elderly are provided direction and support, the prognosis for recovery is excellent.6 With time, patience, caring, and commitment, an improved quality of life can be achieved for the elderly chemically dependent person.
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