Addressing issues related to geropsychiatry and the well-being of older adults
Mr. Kenneth “Bubba” Levesque, age 43, was admitted to a nursing home in Massachusetts for help in learning how to walk with a prosthetic limb after an amputation of his lower left leg. Before his amputation, he had spiraled between addiction and recovery many times over the years but told his family that while in the nursing home, he would finally “get clean.” During the 7 months in the nursing home, however, he received increasing doses of opioid medications and no substance abuse counseling. After learning to walk with his prosthesis, he was discharged. Three days later he was dead from an opioid overdose (Lazar, 2016).
Nursing home is often used as a generic term to include a variety of services, such as assistance with daily living, rehabilitation, hospice, or skilled care (Patrick, n.d.). Mr. Levesque received treatment at a nursing home that offered rehabilitation services. In summer 2016, state inspectors in Massachusetts stated that patients at two nursing homes, including the one that Mr. Levesque was discharged from, were in “immediate jeopardy” because of serious violations, such as lack of treatment for substance use disorders and inadequate staff training (Lazar, 2016, para. 6). These concerns signal a new awareness of the critical need to study problems of substance use in long-term care (LTC) settings. Despite intense concern with substance use disorders in communities across the United States, a focus on this problem in nursing homes, where potent pain medications are administered routinely, has been missing (Lazar, 2016). The lack of awareness and inadequate treatment for substance use disorders may impact nursing home residents of any age. With older adults comprising a large percentage of the residents in these facilities and receiving many potentially addictive medications, it is important to focus on problems of substance use in this population.
Although most of the literature related to this problem refers to it as substance abuse, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) no longer uses the terms “substance abuse” and “substance dependence” (Substance Abuse and Mental Health Services Administration [SAMHSA], 2015). The new DSM-5 terminology refers to substance use disorders, which occur when the recurrent use of alcohol and/or drugs causes significant clinical or functional impairment, such as health problems, disability, and failure to meet major responsibilities in daily life (SAMHSA, 2015). A diagnosis of substance use disorder is based on evidence of impaired control, social impairment, risky use, and pharmacological criteria. The most common substance use disorders in the United States are related to alcohol, tobacco, cannabis, and hallucinogen, opioid, and stimulant drugs (e.g., amphetamines, methamphetamine, cocaine). Because most of the literature related to substance use disorders in LTC settings relates to alcohol and drug addiction, that is the primary focus for the current article.
Context of the Problem
Substance use disorder among older adults is a complex problem that is growing as the aging population increases. The problem often goes undiagnosed, or is misdiagnosed, and is often insufficiently treated when it is identified (Plotkin, 2015). Symptoms of alcoholism and drug dependency in older adults sometimes mimic symptoms of other medical and behavioral problems that are common in this population, such as dementia and depression (National Council on Alcoholism and Drug Dependence [NCADD], 2015). In addition, health care providers are often not adequately trained to screen older adults for substance use disorders and may have a bias that these disorders are not worth treating in this population (NCADD, 2015). Until recently, the problem of substance use disorders in older adults has received little attention by government agencies and is often unrecognized by health care providers (Gray, 2014; Span, 2014). Government agency strategies for addressing substance use disorders have focused primarily on young adults, who are the most visible and socially disruptive users (Gray, 2014). Older adults who have a substance use disorder are often not seen as a threat to society.
It has been estimated that 2.5 million older adults in the United States have a substance use disorder; abuse of alcohol and drugs in this population, especially prescription drugs, is one of the fastest growing health problems in the country (NCADD, 2015). Many older adults struggle with lifelong addictions or become addicted to prescription drugs that they take for coping with physical or psychological pain (Span, 2014). Although individuals 65 and older comprise only 13% of the population, they account for approximately 30% all prescribed medications in the United States, placing them at increased risk for problems with abuse and addiction (NCADD, 2015). Cognitive changes and medical conditions that are common in older adults may be exacerbated by substance use disorders; these changes may account for more than twice the number of hospital readmissions as older adults without addiction issues (Plotkin, 2015). Alcohol use disorders may not have caused significant problems in young adulthood, but in older adults, alcohol is metabolized differently and can interact with many of their medications (Blow & Barry, 2014).
Researchers in two studies in nursing homes reported that 29% to 49% of residents had a lifetime diagnosis of substance use disorders (Blow & Barry, 2014). Approximately 50% of nursing home residents have alcohol-related problems (NCADD, 2015). As Baby Boomers age, they are likely to begin entering nursing homes in increasing numbers. This population has demonstrated historically high levels of drug use and the possibility that many may continue to misuse drugs suggests that the critical gap in caring for older adults with substance use disorders is likely to grow unless effective measures are brought to bear on the problem (White et al., 2015).
Experts believe that many problems with substance use disorders in LTC settings stem from inadequate training and chronic understaffing (Goodwin, 2014). Pressure from pharmaceutical companies to market their products may also contribute to inappropriate use of medication (Goodwin, 2014). Most nursing homes are not prepared to identify and treat residents with a history of substance use disorders; resources and programs to care for these patients have not typically been a priority (Lazar, 2016). When an older adult is abusing drugs that have been prescribed by a health care provider, the problem may be difficult to identify (Gray, 2014). Nursing home leaders are looking to state health regulators for guidance on how best to care for the rapidly growing number of older adults being admitted with drug addictions (Lazar, 2016).
The nursing home setting provides complex challenges for staff and administrators attempting to provide safe and high-quality care for a vulnerable patient population (Gurwitz, 2012). Older adults in nursing homes often have multiple chronic medical conditions, functional impairments, and cognitive deficits. They also are often taking large numbers of medications so that they may be at special risk for drug-related harm. In addition, there is often little physician involvement, especially in view of the severity and complexity of care that residents need. Communication is also a problem. Many medical decisions are made over the telephone in brief conversations between the nursing staff and physician or nurse practitioner. Transitions between the nursing home, emergency department, and hospital are common and add to increasing risk of medication errors and preventable adverse drug events. These factors contribute to making the nursing home environment one of the most complicated and challenging clinical settings and place older adults at substantial risk of iatrogenic injury (Gurwitz, 2012).
Measures for Addressing the Problem
This is a critical time for clinicians to develop the skills and strategies needed to deal with the range of substance use disorders that will be present in LTC settings in the future (Blow & Barry, 2014). Administrators and staff in these settings need to be educated about substance use disorders in older adults and how to deal with them. Physicians often fail to identify substance use disorders in this population because they are not trained to recognize it, are reluctant to screen older adults for addiction, and do not understand how addiction can exacerbate the medical problems of older adults (Plotkin, 2015). Physicians and nurse practitioners who prescribe medications for residents in LTC settings need to be more aware of drug addiction and inappropriate use of addictive substances. The Massachusetts Medical Society is establishing panels to help physicians better understand what is needed to address problems with substance use for patients in nursing homes (Lazar, 2016). Nursing home administrators worry about visitors giving patients opioid and other drugs without the knowledge of nursing staff (Lazar, 2016). The Massachusetts State Health Department has also begun training nursing home inspectors about substance use disorders in nursing homes to help them recognize whether appropriate care is being provided for patients with addiction (Lazar, 2016).
Screening instruments need to be developed for substance use disorders in older adults to assess the severity of the problem and identify the appropriate level of intervention (Blow & Barry, 2014). Two examples of screening instruments that can be used by staff in LTC settings are the Florida Brief Intervention and Treatment for Elders (BRITE) project (White et al., 2015) and the Screening, Brief Intervention, and Referral to Treatment (SBIRT) tool (SAMHSA, 2016). Both instruments are designed to screen for prescription drug and alcohol abuse among older adults. There is a need for further development and testing of screening tools that could be used by staff in LTC settings, as well as education of staff on how to use these tools.
Policies need to be developed in LTC institutions for dealing with problems of substance use. White et al. (2015) found in a survey of 40 administrators of licensed skilled nursing facilities in Kentucky that less than one third of the institutions had formal policies to manage substance use disorders. Nurses are important resources for developing these policies. White et al. (2015) noted that an important issue to address in these new policies is the use of medical marijuana.
Synergy Health Centers, the New Jersey organization that owns 11 Massachusetts nursing homes, including the one where Mr. Levesque was a patient, has implemented procedures to identify and treat substance use disorders for patients in all of its nursing homes (Lazar, 2016). These procedures include identifying any residents who are at risk for substance use disorders and referring them for treatment. Synergy Health is also educating nursing home staff about chronic pain, opioid drug use, and addiction. Other changes include providing residents with weekly support meetings run by specialists (Lazar, 2016).
A New Model of Treatment
New models of care in LTC settings are needed to address the problem of substance use disorders for older adults. One promising initiative is being piloted by The New Jewish Home, one of the largest not-for-profit geriatric health and rehabilitation institutions in the United States, to help older adults with addiction find appropriate care. In New York State, the fastest growth rate of substance use disorders, 24% per year, is among older adults; therefore, a new approach to care for this population is critical (Plotkin, 2015). The Jewish Home Lifecare, launched in the Bronx in 2014, is the first nursing home to implement a rehabilitation program focused on helping patients recover from their medical and addiction problems (Span, 2014). Mr. Poole-Dayan, administrator of the program, noted, “We've always had people with substance abuse problems in nursing homes. We either haven't known it, or we haven't done anything about it” (Span, 2014, para. 17).
Patients in the Lifecare program receive thorough screening, individual and group therapy, access to Alcoholics Anonymous® (AA) meetings, talk therapy, counseling on how to prevent relapses, and care by specialists who replace potentially addictive drugs with non-addictive medications (Lazar, 2016; Span, 2016). A team-focused treatment plan involves the family and coordinates care among the physical and occupational therapy staff; mental health, addiction, and social services professionals; and organizations such as AA (Plotkin, 2015). Staff members monitor patients' discharge carefully to ensure that they have adequate support, including outpatient therapy and home visits.
Administrators of the Lifecare program have not yet calculated costs per patient but are committed to continuing it because of the impressive preliminary results. In the first 2 years, approximately two thirds of patients who began in the program reported no relapse 1 month after discharge (Lazar, 2016). Administrators anticipate that Medicare and Medicaid will help cover costs as they expand treatment options. The average length of stay for patients in the program is 25 days and program administrators are trying to determine if this is adequate to make sustained progress. They are also exploring what types of additional training the staff will need (Span, 2014).
Implications for Nursing
Nurses working in LTC settings can have a direct impact on the care of older residents with substance use disorders by helping draft policies for the organization that address the problem and implementing evidence-based strategies to ensure safe medication practices. The current article has focused on the problem of substance use disorders but strategies for addressing medication safety related to other types of drugs are also needed.
Inappropriate administration of anti-psychotic medication to older adults in nursing homes is a long-standing, yet preventable, problem (Goodwin, 2014). It has been estimated that as many as one in five patients in U.S. nursing homes receive antipsychotic drugs that are not only unnecessary, but are dangerous (Goodwin, 2014). Antipsychotic drugs are designed for treatment of individuals with severe mental illness, such as patients with schizophrenia or bipolar disorder, but are dangerous when used for older adults with Alzheimer's disease or dementia, where they may trigger agitation, anxiety, confusion, disorientation, and even lead to death (Goodwin, 2014).
Nurses can be instrumental in improving medication safety in LTC settings through interventions for enhanced inter-provider communication, improved procedures for medication reconciliation, and use of computer entry systems that incorporate essential clinical information (Gurwitz, 2012). Structured communication strategies such as SBAR (Situation, Background, Assessment, and Recommendation) can be helpful in guiding telephone discussions between nursing home staff and off-site prescribers. This approach has been demonstrated to have a positive impact on the quality of warfarin management in nursing homes (Gurwitz, 2012).
Nurses working in hospitals and the community need to be sensitive to the possibility of older adults being addicted to alcohol or drugs and engage them in conversations that reveal habits and rituals in their life patterns (Gray, 2014). Advanced practice nurses can play an important role in helping screen patients for substance use disorders and facilitate treatment for older adults. Nurse educators can help bring awareness to the need for further education and training for staff who are caring for this population. Nurse researchers can make important contributions by developing simple and reliable screening tools. All nurses can be effective advocates for health care policies that focus on the need for evidence-based programs and resources that address the problem of substance use disorders for older adults in LTC settings.
Unfortunately, changes implemented by Synergy Health Centers came too late for Mr. Levesque and his family, who repeatedly asked nurses about the powerful narcotics he was receiving. They were rebuffed when they expressed concern that Mr. Levesque was being discharged onto the street with no addiction counseling. They were told, “I don't know what to tell you. Go to the emergency room” (Lazar, 2016, para. 21). The use of multidisciplinary teams comprising physicians, nurse clinicians, advanced practice nurses, clinical pharmacists, and other health professionals has the potential to implement new models and educate staff on the increasing problem of substance use disorders for older adults in LTC settings. These changes are needed now.
- Blow, F.C. & Barry, K.L. (2014). Substance misuse and abuse in older adults: What do we need to know to help?Generations, 38(3), 53–67.
- Goodwin, J. (2014). Antipsychotics in nursing homes. Retrieved from http://www.aarp.org/health/drugs-supplements/info-2014/antipsychotics-overprescribed.html
- Gray, M.T. (2014). Habits, rituals, and addiction: An inquiry into substance abuse in older adults. Nursing Philosophy, 15, 138–151. doi:10.1111/nup.12041 [CrossRef]
- Gurwitz, J. (2012). Medication safety in nursing homes. What's wrong and how to fix it. Retrieved from https://psnet.ahrq.gov/perspectives/perspective/126/medication-safety-in-nursing-homes-whats-wrong-and-how-to-fix-it
- Lazar, K. (2016, September10). Tragic consequences when nursing homes neglect substance abuse. Retrieved from https://www.bostonglobe.com/metro/2016/09/10/neglected-peril-substance-abuse-nursing-homes/XpTd53Hl1b7Sx6csij8GVJ/story.html
- National Council on Alcoholism and Drug Dependence. (2015). Alcohol, drug dependence and seniors. Retrieved from https://www.ncadd.org/about-addiction/seniors/alcohol-drug-dependence-and-seniors
- Patrick, W. (n.d.). Nursing home care. Retrieved from http://www.caregiver.com/channels/ltc/articles/nursing_home_care.htm
- Plotkin, A.F. (2015, January21). Jewish Home launches first in nation nursing home based geriatric substance abuse program. Retrieved from http://jewishhome.org/news-and-events/press-releases/jewish-home-launches-first-in-nation-nursing-home-based-geriatric-substance-abuse-program
- Span, P. (2014, August15). The addict down the hall. Retrieved from http://newoldage.blogs.nytimes.com/2014/08/15/the-addict-down-the-hall/?_r=0
- Substance Abuse and Mental Health Services Administration. (2015). Substance use disorders. Retrieved from http://www.samhsa.gov/disorders/substance-use
- Substance Abuse and Mental Health Services Administration. (2016). Screening, brief intervention, and referral to treatment (SBIRT). Retrieved from http://www.samhsa.gov/sbirt
- White, J.B., Duncan, D.F., Bradley, D.B., Nicholson, T., Bonaguro, J. & Abrahamson, K. (2015). Substance abuse policies in long-term care facilities: A survey with implications for education of long-term care providers. Educational Gerontology, 41, 519–525. doi:10.1080/03601277.2014.986400 [CrossRef]