Diane (pseudonym) is 65 years old, divorced, and recently retired. Her only family is a daughter who lives 300 miles away and with whom she is in touch only sporadically. Diane started gambling in her 40s, taking trips to casinos with friends a couple of times per year. Since her traumatic divorce, she has been gambling more frequently and alone, in an effort to take her mind off her troubles. She has developed cordial relationships with the casino managers, and they have introduced her to new kinds of gambling, offering her classes in various types of poker and blackjack. She has become fascinated with the bouncing roulette ball: She watches the ball, mesmerized, forgetting the psychological pain and depression she feels most of the time. Diane receives discounts to gamble, and casino workers offer her free drinks and meals and generally treat her “just like family.” She stays longer at the casino, spending more money than she had planned. Now that she has a limited income, she worries some about having enough money for her basic needs and believes that if she gambles enough she will win a large amount—enough to set her up for the rest of her life. In a sense, she now regards her gambling as a job, visiting the local casino almost daily for stimulation and social support. Feeling deeply ashamed, Diane has avoided telling her daughter about her new occupation and credit card debt (Schlenker, 2008).
With casinos dotting the landscape of both rural and urban areas, opportunities to engage in gambling as a social activity abound; in fact, the gaming industry has become one of the fastest growing industries in the United States (Shaffer & Korn, 2002). Gambling in moderation can be an innocent recreational activity, with increasing numbers of senior centers offering trips to casinos as regularly scheduled social activities. However, for some people, especially older adults like Diane, gambling becomes problematic.
Older adults may experience unique risk factors for developing problem gambling behaviors, such as fixed incomes, loneliness, and boredom as a result of postretirement inactivity (Wiebe & Cox, 2005). Southwell, Boreham, and Laffan (2008) found that 27% of older adults (N = 414) who regularly play electronic gaming machines reported drawing on their savings to fund the activity. This is a concern because even small losses can have financial and legal implications for older adults on fixed incomes (Levens, Dyer, Zubritsky, Knott, & Oslin, 2005). The cohort of adults older than 65 has increased their participation in lifetime gambling, from 35% in 1975 to 80% in 1999 (Shaffer & Korn, 2002), in part due to increased access to gambling venues. Therefore, as the number of gambling opportunities increase, it is important for nurses to be aware of older adults’ vulnerability to gambling pathology.
Advertisements to gamble at casinos are found on state highway signs, and lottery numbers can be found in daily newspapers and on the evening news—opportunities to gamble are everywhere. One can gamble via computer, at grocery stores and gas stations, in churches, on gambling boats, and in casinos close to home. The increased use of computers by older adults has introduced a newer type of gambling, Internet gambling. Older adults can now participate in gambling from home, with only a computer and credit card number.
Trips to casinos are often sponsored by senior centers and assisted living facilities. These trips seem to be affordable and especially enticing to those on a fixed income. The outings are popular off-site activities (McNeilly & Burke, 2001), providing a trip, socialization, restaurant meal, and opportunity to be a winner. Older adults identified their motivation for gambling as relaxation, escaping boredom, passing time, and getting away for the day (McNeilly & Burke, 2001). In addition, like Diane in the individual example, many older adults now living on a fixed income may be hoping for the “big win” (Wiebe & Cox, 2005).
Activity directors at senior centers often encourage residents to take day trips to the casino for the social benefit and reasonable meal (Desai, Desai, & Potenza, 2007). In addition, some casinos provide bus service if there are enough individuals to fill the bus. This, in turn, is a benefit to the center in that it incurs no cost to provide the activity. When individuals at senior centers develop problems, the staff may not know how to identify problems, where to go for help, or what treatments are available. Because gambling problems are difficult to detect, senior center staff may unknowingly send someone with a gambling problem on a casino trip. Although activity directors would not arrange an outing to a local tavern and would not take a known alcoholic to a bar, they may not recognize a client with problem or pathological gambling and may take them to a casino.
Given the growing gaming industry, there are both increased opportunities for older adults to gamble, as well as risks for problematic gambling behaviors. Pathological gambling criteria include:
- Being preoccupied with gambling.
- Gambling with larger amounts of money.
- Trying unsuccessfully to stop gambling.
- Feeling irritable when trying to quit.
- Gambling to forget problems.
- Losing money one day then returning to win back money lost.
- Lying to others about gambling.
- Committing illegal acts to pay for gambling.
- Arguing with family about gambling.
- Borrowing from others to pay gambling debts.
Meeting three to four of the pathological gambling criteria represents problem gambling; five or more of the criteria must be met for a diagnosis of pathological gambling (American Psychiatric Association [APA], 2000; Volberg, Nysse-Carris, & Gerstein, 2006). Pathological gambling is associated with adverse consequences for the gamblers, as well as for their families and society as a whole (Shaw, Forbush, Schlinder, Rosenman, & Black, 2007). Individuals who develop severe gambling problems often experience comorbid psychiatric and medical illnesses such as alcoholism, depression (Kerber, Black, & Buckwalter, 2008), and cardiovascular disease (Morasco et al., 2006).
Assessment and Diagnosis
The first step in assessing this disorder is detection of the problem. Sullivan, Abbott, McAvoy, and Arroll (1994) found that pathological gamblers rarely disclose their mental health problems to their primary care physician. Therefore, nurses are in a unique position to assess for physical and emotional signs associated with problem and pathological gambling behavior in older adult clients. Pathological gambling may look like deteriorating health, which is common in advanced age (Fessler, 1996) and may mask the problem. Symptoms such as insomnia, gastrointestinal disorders, cardiac problems, high blood pressure, and headaches are often found in clients with problem gambling (Cunningham-Williams, Cottler, Compton, & Spitznagel, 1998). Older adults may not recognize gambling activities as problematic and may feel shame if they do (Volberg, 2003). In addition, older adults tend to avoid help due to denial or stigma associated with mental health problems (Stewart & Oslin, 2001). Therefore, clients with financial problems, alcoholism, or depression should be screened for pathological gambling (Unwin, Davis, & De Leeuw, 2000).
When assessing older adults, clinicians may begin by discussing gambling as a common recreational activity. Then clinicians can share that there is a correlation between gambling and health problems in older adults; this communicates concern without labeling (Potenza, Fiellin, Heninger, Rounsaville, & Mazure, 2002). Stewart and Oslin (2001) recommended asking clients, “What type of gambling do you do?” rather than, “Do you gamble?” If the older adult client talks about gambling, Johnson, Hamer, and Nora (1998) recommended using the Lie/Bet Questionnaire. This two-question screen has shown both sensitivity and specificity in identifying pathological gamblers. The Lie/Bet Questionnaire asks: (a) Have you ever had to lie to people important to you about how much you gamble? and (b) Have you ever felt the need to bet more and more money?
If the client answers yes to either of the Lie/Bet questions, referral to a psychiatric nurse or other mental health professional for further assessment is recommended. This follow-up assessment would include review of Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR; APA, 2000) criteria for a possible diagnosis of pathological gambling. The following pathological gambling diagnostic screens are considered tools of choice for the adult population: the South Oaks Gambling Screen (SOGS) (Lesieur & Blume, 1993) and the National Opinion Research Center DSM-IV Screen for Gambling problems (NODS) (National Opinion Research Center, 1999).
It is important to remember that some symptoms of mental illnesses are common in older adults with pathological gambling, including increased isolation, anxiety, distractibility, and depressed mood. In a sample of 40 older adult recovering pathological gamblers, Kerber et al. (2008) found an 82% prevalence rate of depression. Alcohol abuse disorders were found in 73.2% of gamblers in a national epidemiologic survey of 43,093 respondents (Petry, Stinson, & Grant, 2005). In their study of 10,563 adults older than 60, Pietrzak, Morasco, Blanco, Grant, and Petry (2007) similarly found that those with gambling disorders, compared with those without a history of regular gambling, have increased rates of alcohol use (53.2% versus 12.8%), nicotine use (43.2% versus 8%), and drug use (4.6% versus 0.7%), as well as mood (39.5% versus 11%), anxiety (34.5% versus 11.6%), and personality (43% versus 7.3%) disorders. Kerber et al. (2008) also found that 60% of their older adult participants experienced personality disorders according to the Personality Disorder Questionnaire, with obsessive-compulsive, avoidant, and depressive disorders being the most common. Depression and gambling have a significant correlation (Kerber et al., 2008); therefore, nurses should assess older adult clients for depression and suicide risk.
Further, individuals with restless leg syndrome or Parkinson’s disease should be screened for frequent gambling behaviors when taking dopaminergic drugs, such as pramipexole (Mirapex®) (Dodd et al., 2005). Pathological gambling and other impulse control disorders have been associated with the use of dopaminergic drugs (Burn & Tröster, 2004). Discontinuing the medication will potentially reverse impulse control behaviors.
Client Education and Treatment
Little research has been done to identify specific treatments for problem and pathological gambling. However, as the number of pathological gamblers grows, the interest in how best to treat this illness also increases. Inpatient treatment is available in only a few U.S. states; outpatient treatment through counseling and Gamblers Anonymous (GA) is the most common (National Research Council, 1999).
Client education for those diagnosed with pathological gambling should include providing information about GA ( http://www.gamblersanonymous.org). The GA website provides details about its recovery and unity programs, 20 questions about gambling behavior, locations of local meetings, and a link to Gam-Anon ( http://www.gam-anon.org), which offers support for individuals’ family members and loved ones.
As a 12-step program similar to Alcoholics Anonymous, GA supports abstinence as a means to recovery. A significant benefit of support groups is social connectedness. An older adult-specific program would be of significant benefit because of common issues such as loneliness, depression, isolation, and economic factors related to retirement and chronic illness. In addition, GA (a free treatment option) evidenced improved outcomes when compared with cognitive-behavioral therapy (which requires a licensed clinician) (Leung & Cottler, 2009). Individual counseling aims to change the gambler’s lifestyle and provide insight into his or her irrational or fantasy-based way of thinking (Ladouceur, Sylvain, Boutin, & Doucet, 2002). A study of effectiveness found no single method superior in treating problem gambling (Lesieur 1998); therefore, combining individual counseling with GA may provide the greatest results.
Natural recovery from addictive disorders is becoming increasingly recognized as a common occurrence (Klingemann & Sobell, 2001). Hodgins and el-Guebaly (2000) compared natural and treatment-assisted recovery from gambling problems among resolved and active gamblers. They speculated that since natural recovery from alcohol problems can occur and most smokers quit on their own, a natural recovery phenomenon can occur with gambling as well. They cited two major reasons for quitting: negative emotions (e.g., anxiety, depression, guilt) and financial constraints. The two actions taken by the natural recovery group were stimulus control (i.e., avoiding gambling activities and advertisements) and new activities to replace gambling. Slutske (2006) identified 33% to 36% of individuals with pathological gambling as recovering through natural recovery.
Given the possible negative effects of problem and pathological gambling, growing numbers of casinos are implementing self-exclusion programs (SEPs) that allow individuals to ban themselves from entering casinos (Nelson, Kleschinsky, LaBrie, Kaplan, & Shaffer, 2010). Self-exclusion programs require that a person complete a self-exclusion form. Programs vary by state and may involve one or all casinos in the state. GA is a good source for state-specific information. For the most part, individuals who have completed a SEP form and are subsequently found on a gambling site are escorted from the premises, must forfeit their winnings, and potentially face criminal trespassing charges (Rhea, 2005). SEPs are available at some multinational casino companies and at all American Gaming Association member venues (Nelson et al., 2010). Research on the effectiveness of these programs is scant, but Nelson et al. found that only one in eight (13%) self-excluders had not gambled at all since enrolling in a Missouri Voluntary Exclusion Program.
Referral and Consultation
Clients with problem gambling behaviors should be referred to an advanced practice nurse or counselors with training and/or certification in pathological gambling treatment. The National Council on Problem Gambling (n.d.) offers certification training and 2,000 hours of supervised clinical practice. Certified gambling counselors can be searched by city and state at http://www.ncpgambling.org.
Education about the problems or consequences associated with pathological gambling is the first step in reducing pathological gambling. Higgins (2001) and Gosker (1999) recommended a gambling education program for older adults, especially those living in residential communities, and suggested peers serve as sponsors on senior center-sponsored gambling trips. Nurses need to educate and assess their older adult clients with mental illness for gambling problems because this population is particularly vulnerable to gambling pathology (Ricketts & Bliss, 2003). In the older adult population, it is important for nurses to differentiate the altered cognitions seen in pathological gambling from other conditions such as depression and dementia.
Older adults may participate in recreational gambling without issue and then develop problems; when this occurs, problem gambling can be difficult to detect. As in Diane’s case, problem and pathological gambling can begin insidiously and can progress to increasing impairment, damaging the person’s ability to function socially and financially. Nurses need to be aware of the potential hazards of gambling behavior and assess for adverse effects of gambling on clients’ physical and mental health. Quick, easy-to-use assessment tools, such as the Lie/Bet Questionnaire, the SOGS, and the NODS, can help identify those with gambling problems.
Nurses in all practice areas who have contact with older adults have the opportunity to assess for potential gambling problems, as well as communicate the risks of gambling to older adults and community members. This article highlights the potential health effects associated with older adults with gambling disorders. Few articles or nursing research studies have addressed this potentially harmful issue among the older adult population, which emphasizes the need for early detection and screening of older adult clients for gambling problems.
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