At-Risk Alcohol Use in Older Adults: Background At-Risk Alcohol Use in Older Adults: Background on Problem, Screening, Brief Interventions, Brief on Problem, Screening, Brief Interventions, Brief

Treatments, and Mental Health ComorbiditiesTreatments, and Mental Health Comorbidities

Kristen L. Barry, PhD

Research Professor

University of Michigan Department of Psychiatry

and Department of Veterans Affairs National Serious Mental Illness Treatment Research and Evaluation Center (SMITREC)

Get Connected!

Linking Older Adults With Medication, Alcohol, and

Mental Health Resources

WWW.SAMHSA.GOV

WWW.NIAAA.GOV

The Demographic Imperative I

• 13 percent of U.S. population age 65+; expected to increase up to 20 percent by 2030

• 78 million ‘Baby Boomers’ (born from 1946-1964) in U.S. Census 2000– Second wave ‘Baby Boomers’

(now aged 40-49) contains 45 million

Alcohol Use in Older Adults

• 66% of older men, 65% of older women used alcohol

• 3% met full criteria for an alcohol use disorder

• At-risk drinking was reported in:–17% of men, 11% of women ages 50+–19% of all respondents ages 50-64–13% of all respondents ages 65+

• Binge drinking was reported in:–20% of men, 6% of women ages 50+–23% of all respondents ages 50-64–15% of all respondents ages 65+

(Blazer & Wu, 2009a)

Medication Misuse and Alcohol Interactions

• Medications with significant alcohol interactions

– Benzodiazepines

– Other sedatives

– Opiate/Opioid Analgesics

– Some anticonvulsants

– Some psychotropics

– Some antidepressants

– Some barbiturates

(Bucholz et al., 1995; NIAAA, 1998)

Estimated Prevalence of Major Psychiatric Disorders by Age Group

7

8

9

10

11

12

13

14

15

16

2000 2010 2020 2030

Mill

ions

18-29 30-44 45-64 65 >

Jeste, et al., 1999; www.census.gov

Course and Consequences of

Older Adult Alcohol Consumption

Aging, Drinking and Consequences

• Aging-related changes make older adults more vulnerable to adverse alcohol effects – Higher BAC from a given dose

– More impairment at a given BAC

– Interactive effects of alcohol, chronic illness and medication

• Implications for older adult drinkers – Moderate levels of consumption can be more risky

– More consequences from maintaining consumption

– Increased consumption may quickly result in consequences

What conditions may be caused or What conditions may be caused or worsened by alcohol use? worsened by alcohol use?

• 1 or more drinks per day1 or more drinks per day– Gastritis, ulcers, liver and pancreas problemsGastritis, ulcers, liver and pancreas problems

• 2 or more drinks per day2 or more drinks per day– Depression, gout, GERD, breast cancer, Depression, gout, GERD, breast cancer,

insomnia, memory problems, fallsinsomnia, memory problems, falls

• 3 or more drinks per day3 or more drinks per day– Hypertension, stroke, diabetes, gastrointestinal Hypertension, stroke, diabetes, gastrointestinal

diseases, cancer of many varietiesdiseases, cancer of many varieties

SBIRT MODEL

•Screening

•Brief Intervention

•Referral to Treatment

Screening Approaches

Recommended Drinking Limits for Older Adults

Recommendations must include both average daily consumption and frequency of heavy drinking

No more than 1 standard drink/day

No more than 4 standard drinks on any drinking day (Defined as Binge Episode)

(Chermack, Blow, et al., 1996)

Recommended Drinking Limits for Older Adults

Recommended limits for older women somewhat lower than those for older men

Lower than recommended levels for younger adults

Consistent with patterns shown to have potential health benefits

(Chermack, Blow, et al., 1996)

Signs and Symptoms of Alcohol Problems in Older Adults

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

• Increased tolerance to alcohol

• Legal difficulties• Memory loss• New problems in decision

making• Poor hygiene• Seizures, idiopathic• Sleep problems• Social isolation• Unusual response to

medications

Barriers to IdentificationAgeist assumptionsFailure to recognize symptomsLack of knowledge about screeningAttempts at self-diagnosis or description of

symptoms attributed to aging process or diseaseMany 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)

Alcohol Screening with Older Adults

– To identify at–risk drinkers, problem drinkers and/or persons with alcoholism

– Identify subset of clientele that need more assessment

– High enough incidence to justify cost– Adverse effects of problem drinking– Effective treatments available– Presence of valid screening techniques

Goal of Screening

Rationale for Screening

Screening Instruments and Assessment Tools

• Alcohol Consumption – Quantity, Frequency, Binge Drinking

• Alcohol Consequences– AUDIT, MAST, SMAST– Elder-Specific: MAST-Geriatric Version, SMAST-G

• Health Screening Survey – includes other health behaviors

• nutrition, exercise, smoking, depression

Screening and Assessment Recommendations for Older Adults

Every person over 60 should be screened for alcohol and prescription 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

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. alcoholic)

Brief Interventions

Low Risk At Risk Problem Dependent

None

Small

Moderate

Severe

None

Light

Moderate

Heavy

Alcohol Problems

Relationship between Alcohol Use and Alcohol Problems

Alcohol Use

Barriers to Seeking Alcoholism Treatment for Older Adults

Resistance to asking for help Disdain of labels (alcoholic, old) Lack of transportation No significant others to assist in

motivation to seek help Providers less likely to refer older adults Gaps in substance abuse, aging, and

mental health services

The Spectrum of Interventions for Older Adults

ANot

Drinking

BLight-Moderate

Drinking

CHeavy

Drinking

DAlcohol

Problems

EMild

Dependence

FChronic/Severe

Dependence

Prevention/ Education

Formal Specialized Treatments

Pre-Treatment Intervention

Brief Interventions

Brief Advice

Empirical Support for Brief Interventions with Older Adults

Physician advice for older adult at-risk drinkers led to reduced consumption at 12 months (University of Wisconsin; N=156; 35-40% change)

: Elder-specific motivational enhancement session

conducted in-home reduced at-risk drinking at 12 months (University of Michigan; N=454)

Project GOAL (Guiding Older Adult Lifestyles)Project GOAL (Guiding Older Adult Lifestyles)

Health Profile ProjectHealth Profile Project

Additional BI Studies with Older Adults

• Moore, et al, 2010- NIAAA sponsored– Brief intervention in primary care

– Follow-up health educator call

– Positive results

• Schonfeld, et al, 2010- SAMHSA sponsored– Large state-wide demonstration project in variety of

health care and senior services sites

– Positive reductions in drinking with BI

– Demonstrated that implementation in a variety of senior service sites is possible

Florida BRITE Project: SAMHSA

• Florida - only SBIRT specific to older adults

• BRITE is offered in medical, aging, psychiatric, substance abuse services

• BRITE expanded from 4 sites (4 counties) to 21 sites in 15 counties

• Challenge: Prescription drug misuse

Florida BRITE• In the first two years, 6,205 people were

screened by BRITE providers– Not all sites were “up and operating yet”

• Screening takes place in:– Hospital emergency rooms– Urgent care centers & clinics– Primary care practices– Aging services– Senior housing– Private homes

Proportion of SBIRT Services in BRITE Project

70% - Screening and feedback only

27% - Brief Advice/Brief Intervention

2% - Brief Treatment

2% - Referral for specialty services

Primary Substances Used

69.6% Alcohol

18.9% Prescription Drugs (not necessarily psychoactive meds)

7.3% Illicit drugs

4.6% Other

Results Across Reviews/Meta-Analyses

Brief Interventions (BI) can reduce alcohol use for at least 12 months among younger and older adults

Approach is acceptable to younger and older adults

Results mixed on longer-term utilization and reduction of alcohol-related harm

Special Circumstances

Alcohol Withdrawal Excessive Drinking

21+ drinks/week Benzodiazepine/Opioid Use

5+ days/week for 3+months

Brief Treatments

Types of TreatmentsExamples:

Brief Treatments

•Strengths-Based Case Management

•Motivational Enhancement Therapy (MET)

•Cognitive Behavioral Therapy (CBT)

Specialized Treatments

•Outpatient

•Inpatient **

Who Seeks Treatment?

Referral Pathways• Admissions aged 55 or older were more

likely than younger admissions to enter treatment through self-referral – What leads to self-referral?

• Elders less likely to be referred through the criminal justice system

• Few referred by health care providers in both young and older samples

(OAS, SAMHSA, 2004)

Conclusions

There are effective screening techniques Screening can bring about change Brief Interventions (BI) can reduce

alcohol use for at least 12 months among older adults

Motivational enhancement effective Approach is acceptable to older adults

and can be conducted in health clinics and in-home

Conclusions

BI and BT are effective Substance abuse treatment works PREVENTION matters!________________________We can all make a difference in the lives of

our older clients/patients who use alcohol at risk levels or combine alcohol and counter-indicated medications.