Older Adults: Addictions &

Concurrent Disorders

Liz Birchall

Community Outreach Programs in Addictions (COPA)

Agenda

Overview What’s different for Older Adults with

Addictions Best Practices Treatment and Program Approaches Case based learning Knowledge Transfer and Exchange

2

In 2012, there were 810 million adults over 60 yrs in the world, making up 11.5% of the global population (The UN Population Fund in Choi & DiNitto, 2013)

Canada’s population is aging and the proportion of those aged 65 years and older has almost doubled in the last fifty years

Population projections indicate that, by 2036, almost a quarter (24.5%) of the Canadian population will be 65 years or older (Statistics Canada, 2007)

The aging population will increase over the next thirty years; increasing from 4.2 million in 2005 to 9.8 million in 2036 (Stats Can, Portrait of Seniors, 2007).

The baby boomer generation represents nearly one out of three Canadians; the largest age cohort in Canada and the oldest baby boomers are now entering their retirement years (Statistics Canada, 2007)

Demographics

3

Older Adults/Seniors and Substance Use Issues Alcohol consumption, deaths and problems have increased in older age

groups in developed countries (USA, Australia and EU members) (Wilson et al, 2013)

In the next 20 yrs, among health problems and burden of illness, two areas of substance use are of concern for older adults: alcohol and psychoactive prescription drugs (Wang & Andrade, 2013)

The prevalence of alcohol use disorder is higher than in previous generations and is expected to increase in older adults as this generation ages (Sacco, Kuerbis, Goge & Bucholz, in press)

Literature indicates that the current population of older adults are continuing to use alcohol and psychoactive prescription drugs at a higher rate than previous generations and are beginning to present larger issues for the health care system as well as the intervention and treatment communities (Blow, Barry, 2012)

4

WHAT’S DIFFERENT FOR OLDER ADULTS WITH

ADDICTIONS?

5

Older Adults and Substance UseOnset of Substance Use Issues:

Late Onset Some older adults begin to have problems with

their substance use during times of transition or loss (e.g. forced retirement, bereavement, new or escalating health concerns, loss of independence)

Early onset Some older adults have long standing substance

use issues

Why is substance use different for older adults/seniors? Older adults, due to complex and/or chronic health conditions require pharmaceutical

medications that can interact with each other and non prescribed substances (e.g. alcohol, marijuana)

Our bodies change as we age which can make alcohol and other drugs more potent and subsequently more harmful

Older adults with some degree of cognitive impairment and/or functional losses are often misdiagnosed with dementia when, in fact, there may be a substance misuse or addictions issue

Older adults are often marginalized and isolated so they have little or no positive social connections

Older people with chronic substance misuse may have had multiple head injuries resulting in symptoms of acquired brain injury

The signs of substance misuse can be mistaken for sign of aging and, as a result, the older person does not receive the interventions they need

7

Alcohol and Medication Interactions

Medication Alcohol Interaction

Anticoagulants (Blood Thinners like Warfarin or Coumadin)to prevent heart attacks, strokes, and blood clots in veins and arteries

Increased risk of internal bleeding (e.g., GI bleed)

Antidepressants of all types Can make people sleepy which could lead to falls, fractures

Cardiovascular Medications (i.e. Digoxin, Nitroglycerine)

Can make people dizzyRisk of heart problems when stopping drinking without help from a doctor or nurse to advise on dose and timing of heart medications

Narcotic pain relievers (i.e. Codeine) Can make people sleepy which could lead to falls, fracturesIncreases likelihood of overdoseRisk of liver damage

Benzodiazepines (i.e., Valium, Ativan/Lorazepam, Clonazepam)

Can make people sleepy which could lead to falls, fracturesIncreases likelihood of overdoseCan cause agitation

Older Adults and Prescription Medication

Common Types of Medication for Older Adults: Benzodiazepines (e.g., Valium, Ativan/Lorazepam) Sedatives/Sleep (e.g., Imovane/Zopiclone) Analgesics/Opiates (e.g., Codeine, Oxycodone, Percocet)

Issues for Older Adults: Drug interactions can be dangerous, and older adults are often

taking more than one medication Older adults consume almost as much as 30% of prescribed

meds 25% of hospital admissions of people over 50 are related to

misuse of prescription medication Older adults often take medication incorrectly– 50% use

medication inappropriately in dose and/or frequency and/or timing

Withdrawal

Withdrawal is often only possible in a medical setting and

takes longer than in younger people:

Older adults have more prolonged and severe withdrawal

than younger patients and are more likely to develop complications such as delirium (Kahan, 2005)

On average, older adults need 5 to 10 days to complete the withdrawal process, are more likely to have co-morbid conditions and do require assistance with activities of daily living. These factors increase the likelihood that withdrawal will be managed either in the ER or result in hospital admission(Kahan, 2005)

Issues of Loss and Transition Transition from work to retirement,

reduced income Loss of meaningful occupation Loss of social network

Loss of friends, family, spouse/partner Social isolation Loneliness Boredom

Health Issues Loss of independence Chronic pain Physical limitations Reduced mobility Cognitive impairment and change

11

BEST PRACTICES

12

Research shows older adults are as successful in addiction treatment as their younger counterparts

Health Canada (2002) states best practices identified through research demonstrates that treatment of high need older adults include: a harm reduction and holistic problem solving approach, home visiting known as “outreach”, intensive case management and social and recreational programs

Clinical experts have added to these principles the need to support those who form the “circle of care” for the older person

Best and Promising Practices

13

Identifying Substance Misuse in Older Adults/Seniors

Substance misuse is often not identified in older adults or wrongly attributed to aging: Confusion Depression Disorientation Unsteady gait/falls Recent memory loss Loss of interest in activities Social isolation Tremors Irregular heart rate Poor appetite Stomach complaints

14

Goals in an older adult specific approach

The end goal of abstinence is not always necessary or realistic. Instead, a harm reduction goal that is related to quality of life improvement as defined by the older person is the aim

Treatment/counseling should be focused on what would make life better, more comfortable and happier not on the substance use

What is Harm Reduction?

The Centre for Addiction and Mental Health (CAMH, 2012) defines harm

reduction as:

1. Although some people can overcome their addictions, there will be those who may not, or choose not, to overcome their addictions

2. Focuses on minimizing the risks and consequences of drug or alcohol consumption

3. It is an alternative method to programs that support abstinence. It also realizes that abstinence is not a realistic goal for some people

4. People shouldn't be judged based on the substances they use. Dignity, respect and support are crucial elements when working with people with addictions and other high-risk issues

16

TREATMENT & PROGRAM APPROACHES

17

COPA: Vision, Mission & ValuesOur mission is to engage older adults with addictions, concurrent disorders and

problem gambling issues in the improvement of their quality of life.

Our vision is an empowered community where older adults with addictions,

concurrent disorders and problem gambling issues receive support and service to

enable them to achieve an optimum quality of life.

We value:

Respect: We are committed to a non-judgmental, inclusive approach that treats everyone fairly;

Empowerment: We are dedicated to fostering active participation in treatment and providing the necessary information to make informed choices;

Compassion: We believe in the dignity of every person and accept people as

they are.

18

COPA Model: Core Components

Our programs are delivered in accordance with the COPA Pillars: Outreach - service is provided where the clients are rather than requiring clients

come to the program. Harm Reduction - it is not necessary for clients to acknowledge addiction

problems or reach complete abstinence in order for meaningful change to take place.

Independence – focus on quality of life and maintaining independence.

Modalities we use include, (but not limited to): Strength-based Counselling Harm Reduction Therapy Motivational Interviewing/Stages of Change Narrative Therapy Dialectical Behaviour Therapy Goal-directed Counselling Cognitive Behavior Therapy

19

COPA Main Program COPA Main Program provides addiction(s) counselling and case

management in an outreach capacity to older adults with concurrent disorders. In addition, the COPA Main Program serves individuals in the 37 long term care homes within the Toronto Central LHIN as part of the specialized Toronto psycho geriatric system.

Initial assessment and treatment Coordination, provision, and linkages to primary care Comprehensive care in the community, including clients’ homes,

supportive housing sites, long term care homes, boarding homes, drop-ins and community centres

Client focused, strengths based counselling grounded in a harm reduction model

20

COPA Main Program Client Profile

Frail, marginalized, varied income, & at risk Socially isolated Complex medical needs Majority of clients experiencing co-occuring mental health challenges 20% are living in long term care homes 30 % with complex needs / “hard” to serve & “hard” to reach Majority of clients struggle with alcohol and nicotine dependence Living with little or no formal support At increased risk of using ED and inpatient hospital services

Trends we see Risk factors as it relates to substance misuse, such as housing, finances,

ADLs, etc. Undiagnosed/diagnosed dementia and fluctuating capacity

21

COPA Main Program

Cultural Competency COPA has been delivering our main program addiction services

in Polish for approximately 20 years. Culturally sensitive/competent addictions treatment counselling

and case management services are provided for substance use, concurrent and problem gambling issues.

Many of the clients struggle with co-occuring depression, isolation and some of them are facing eviction, financial hardship, immigration struggles and complex medical needs. Majority of our Polish clients experience significant language barriers to accessing essential services, requiring the case manager to provide both translation/interpretation services.

22

COPA College COPA College, has been successfully delivered in Toronto by

Community Outreach Programs in Addictions (COPA) since 2007 in a variety of community settings, including shelters, long term care homes, and supportive housing site

Psycho-educational group sessions hosted over an eight-week period. Groups offer an opportunity to build capacity both between the facilitator and the group.

Topics covered include but are not limited to relapse prevention, gambling, harm reduction and stress management.

Feedback from participants constantly helps to shape and inform COPA College practices

In the last session a graduation ceremony is held and participants are presented with a certificate of completion, their reflections are reviewed and they are given feedback from the course instructors.

23

COPA and Social Inclusion

Health Promotion Minding our Bodies - Develop nutrition and exercise workshops that can be

delivered by front line staff are relevant and engaging for low income older adults in a format that can be easily downloaded and used by other not for profit agencies and health promotion organizations, Exercise, Healthy Food and Making a Meal

Bridge to Health - A collaborative approach between COPA, Vintage Fitness, Good Neighbours Club and John Innes Community Centre, this project formed a bridge for marginalized older adults to access physical recreational activities in their local community centre located in South East Toronto

Health and Wellness Together - A health and wellness toolkit for seniors by seniors designed to cover a variety of areas of health promotion and wellness including, exercise, falls prevention, positive mental health, recovery and harm reduction.

COPA: First Step To Home

First Step to Home FSTH was developed by Woodgreen and launched in March 2010 as a

transitional housing support program at 650 Queen Street East in Toronto offering safe, and secure subsidized housing for up to 4 years. The aim of the program is to support the men in learning how to make a successful transition from living on the streets to living in more permanent housing that reflects a more stable, and healthier lifestyle.

Intensive case management and treatment on site to 28 male residents Harm reduction and addiction services Supportive counselling Low barrier programming 24 hour staffing Personal support and homemaking Weekly assistance keeping unit clean Assistance with activities of daily living, such as grocery shopping Nursing and medical care on site Life skills development Social and recreational activities Housing support in transitioning to permanent housing

26

First Step to Home Goal: building more community integration and programming which focuses

on enhancing our clients’ support systems. This will allow them to live independently more successfully, and improve their overall well-being

Eligibility Criteria - 55+ years with history of chronic homelessness, street-entrenched, mental health issues and/or addictions

Client Profile Men, 55+ (on average in their 60s) Substance Use - Primarily alcohol & nicotine dependency, to a lesser

extent opioid pain medications and crack use Mental Health - Depression, Bipolar Disorder, Schizophrenia, Anxiety Physical Health - High Blood Pressure, Diabetes, Hepatitis C, COPD,

Liver and renal failure, Arthritis, Mobility issues Clients socially isolated, with little direct support from family and/or friend

27

First Step to Home

28

COPA: Lansdowne Place (ASH)

Landsdowne Place Addiction Supportive Housing for older adults with problematic substance use.

Funded by Toronto Central LHIN and MOHLTC and provided in partnership

with Mainstay Housing. 16 subsidized units scattered within market rent building. Eligibility Criteria - 55+, problematic substance use, frequent hospital visits Permanent housing

Long-term individualized case management Substance use counseling through a harm reduction approach Housing support with a focus on eviction prevention Social and recreational activities

30

Landsdowne Place We also run the following programs for our clients:

Safekeeping of cash, ID and important documents Medication pick-up Community Kitchen Urban Resiliency Garden COPA College, a psycho-educational support group Movie Matinees Computer Access

Trends Substance use: Goals range from achieving or maintaining abstinence to

harm reduction Concurrent mental health concerns Multiple physical health concerns History of unstable housing

31

Landsdowne Place

32

Landsdowne Place

33

Landsdowne Place

34

COPA and Social Inclusion

Urban Resiliency Garden The goal is to create a safe green outdoor space for older adults/seniors to

engage in active leisure activities, learn through a series of workshops and education sessions and to contribute to the community in which they live.

This project is a community development project that will provide a leadership role for our steering committee of older adults/seniors in the design, development, implementation and maintenance of an urban garden for a large affordable housing complex.

We are excited to integrate gardening programs to increase social interaction, establish a positive leisure space, encourage cooperation and build a strong caring intergenerational community.

Landsdowne Place – Urban Resiliency Garden

36

Crisis Outreach Service for Seniors In 2009 a partnership of agencies began providing crisis outreach services

to older adults in south east Toronto. Since then, COSS has expanded to cover the majority of the city. COSS has been generously funded by the Toronto Central LHIN through the Aging at Home Strategy.

Partnership includes: Woodgreen Community Services (3 FTE), COPA (3 FTE), The Good Neighbours Club (1.5 FTE) and South Riverdale Community Health Centre (1 FTE)

COSS operates 365 days of the year from 9am-5pm Mobile crisis intervention and outreach service to older adults Coordination, provision, and linkages to primary care Short-term intensive case management to stabilize client situation and “warm

hand-off” to longer-term services when needed Comprehensive care in the community including clients’ homes, supportive

housing sites, drop-ins and community centres Team includes: SW, RPN, and NP

37

Crisis Outreach Service for Seniors Eligibility Criteria - aged 65 (or street-involved clients aged 55) and older

with mental health issues and/or addictions We work with client on average for approx 6-8 weeks but have made

exceptions when a warm hand-off is not possible during this timeframe. We have also had some clients with multiple readmissions

Client Profile frail, marginalized, low-income, & at risk homeless or under housed “hard” to serve & “hard” to reach living with little or no formal support at increased risk of using ED and inpatient hospital services

Trends we see Housing & Finances Undiagnosed dementia and fluctuating capacity Re-admissions to COSS

38

CASE BASED LEARNING

39

Mrs X

Long term social use of alcohol: sherry and two glasses of wine with dinner

Developed dementia and could no longer remember how many drinks she had had, she was very frail so risk of falls when walking to the liquour store

Harm reduction plan with family to have her use taxi to get to local restaurant (fall prevention) and family to dilute alcohol by giving her drinks of half wine and half water

40

Mr Late Onset

Mr. X: Very successful well-travelled business man who is financially comfortable living in an affluent home became ill, went into hospital for surgery which unexpectedly resulted in leg amputation due to complications. Drinking significantly escalated

41

Mr Early Onset

Mr. X: Highly successful business man who drank heavily but able to function until he had to retire at which point he began to drink very heavily with significant costs to his health and family

Mr. Y: Loss of job in manufacturing in his 30’s led to heavy drinking resulting in relationship break down, loss of home and connection to children; long term marginalization, living in poverty with minimal social supports and very limited resources/options 42

KNOWLEDGE TRANSFER & EXCHANGE

43

KTE Geriatric Mental Health, Addictions and Responsive Behaviours Community of

Practice - A collaboration between AKE, Seniors Health Research Transfer Network (SHRTN) and Ontario Research Coalition of Research Institutes / Centres on Health & Aging (ORC) to bring together people, ideas, and resources to increase awareness of the needs of seniors affected by serious mental illness, addiction, dementia or behavioural issues.

With the support of this CoP we formed a Geriatric Addictions Subgroup to work specifically in the area of specialized geriatric addictions.

The Geriatric Addictions Subgroup was supported through the Evidence Exchange Network (EENet) as a Community of Interest in 2012/13 and in 2013/14 Promote evidence based/informed practice for specialized addictions treatment

and service for older persons to community agencies, researchers and policy makers.

Facilitate knowledge transfer between the addiction sector and the larger seniors’ health, mental health and social service system.

Raise awareness of the issues related to addictions treatment for older persons to ensure inclusion in service delivery planning, policy discussions and initiatives.

44

KTE Fact Sheets

Fact Sheet #1: Introduction to Older Adults and Substance Use: (adopted by NICE as a pocket guides

Fact Sheet # 2: Management of Alcohol Use Disorders in Older Adults: What Doctors Need to Know

Fact Sheet #3: Screening for Alcohol Problems in Older Adults Fact Sheet #4: Older Adults and Opiods

Mental health, addictions and behavioural issues http://brainxchange.ca/Public/Resource-Centre-Topics-A-to-Z/Mental-health-

addictions-and-behavioural-issues.aspx Addictions: Specialized Geriatric Information and Approaches http://brainxchange.ca/Public/Resource-Centre-Topics-A-to-Z/Mental-health-

addictions-and-behavioural-issues/Addictions-Specialized-Geriatric-Information-and.aspx

 

45

Thank You

46