University of Michigan Department of Psychiatry At-Risk Alcohol Use in Older Adults: Background on Problem, Screening, Brief Interventions, Brief Treatments, 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 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 worsened by alcohol use? 1 or more drinks per day Gastritis, ulcers, liver and pancreas problems 2 or more drinks per day Depression, gout, GERD, breast cancer, insomnia, memory problems, falls 3 or more drinks per day Hypertension, stroke, diabetes, gastrointestinal diseases, 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 Identification Ageist assumptions Failure to recognize symptoms Lack of knowledge about screening Attempts at self-diagnosis or description of symptoms attributed to aging process or disease Many 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 Goal of Screening 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 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

Relationship between Alcohol Use and Alcohol Problems None Light Alcohol Use Moderate Heavy Low Risk At Risk Problem Dependent Severe Moderate Small Alcohol Problems None

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 Not Drinking B Light-Moderate C Heavy D Alcohol Problems E Mild Dependence F Chronic/Severe Prevention/ Education Brief Advice Brief Interventions Pre-Treatment Intervention Formal Specialized Treatments

Empirical Support for Brief Interventions with Older Adults Project GOAL (Guiding Older Adult Lifestyles) 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) Health 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 Treatments Examples: 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.