1. Substance Abuse Prevention, Screening and Identification, and Assessment for Older Adults Frederic C. Blow, Ph.D. Associate Professor and Research Associate Professor University of Michigan, Department of Psychiatry Director, Serious Mental Illness Treatment Research & Evaluation Center Department of Veterans Affairs

2. Presentation Overview  Prevention Issues  Diagnostic Criteria  Barriers to Identification  Signs and Symptoms  Psychosocial Manifestations  Screening Instruments  Special Assessments  Future Research Directions

3. Prevention Issues

4. Lifetime Patterns of Substance Use and Abuse: Focus for Prevention Strategies Older Higher

5. Prevention of Substance Abuse Among Older Adults: Conceptual Issues Age group definitions Age group definitions Life course variations in consumption Life course variations in consumption Sensible/appropriate use of alcohol and prescription drugs Sensible/appropriate use of alcohol and prescription drugs Diagnostic criteria for abuse/dependence Diagnostic criteria for abuse/dependence Risk profiles for specific subpopulations Risk profiles for specific subpopulations Prevention goals Prevention goals

6. Prevention Strategies Effective with Youth: Relevance to Older Adults Individual-Focused: education, skills development, alternate behaviors, health behaviors Individual-Focused: education, skills development, alternate behaviors, health behaviors Families/Social Support: spousal interventions, family supports, caregivers Families/Social Support: spousal interventions, family supports, caregivers Peer Norms: network of friends, perceptions Peer Norms: network of friends, perceptions Organizations: health care organizations, AARP, other policy changes Organizations: health care organizations, AARP, other policy changes Social Environment: social norms and policies, availability and sanctions Social Environment: social norms and policies, availability and sanctions

7. Prevention of Substance Abuse Among Older Adults: Additional Issues Access to target populations Access to target populations Optimal modality for materials Optimal modality for materials Appropriateness and acceptability of content Appropriateness and acceptability of content Delivery systems Delivery systems Program-driven vs. research-initiated interventions Program-driven vs. research-initiated interventions Policy interventions Policy interventions Role of drinking, prescription drugs in late life Role of drinking, prescription drugs in late life

8. Risk and Protective Factors

9. Prevention of Substance Abuse Among Older Adults: Risk Factors Male Male Racial/Ethnic Minority Status Racial/Ethnic Minority Status Psychiatric Comorbidity Psychiatric Comorbidity Higher SES Higher SES Lower Social Supports Lower Social Supports Previous History of Problems Previous History of Problems History of Using Substances as Coping Strategy History of Using Substances as Coping Strategy

10. Prevention of Substance Abuse Among Older Adults: Protective Factors Female Female Higher Religiosity Higher Religiosity Fewer Mental/Physical Health Problems Fewer Mental/Physical Health Problems Lower SES Lower SES Positive Coping Styles Positive Coping Styles More Social Supports More Social Supports

11. Diagnosis Issues

12. Problems with Definitions Substance Misuse Substance Misuse At-risk or Hazardous Use At-risk or Hazardous Use Problem Use Problem Use Substance Abuse Substance Abuse Substance Dependence Substance Dependence

13. Diagnostic Criteria for Substance Dependence in Older Adults The Treatment Improvement Protocol (TIP #26) Consensus Panel determined: DSM-IV criteria for substance abuse and dependence may not be and dependence may not be adequate to diagnose older adults with substance use problems

14. DSM-IV Dependence Criteria Tolerance Withdrawal Use in larger amounts or for longer than intended Desire to cut down or control use Great deal of time spent in obtaining substance or getting over effects Social, occupational, or recreation activities given up or reduced Use despite knowledge of physical or psychological problem

15. Applying DSM-IV Criteria to Older Adults Tolerance Even low intake may cause problems due to body changes Withdrawal May not develop physiological dependence Use in larger amounts or for longer than intended Cognitive impairment interferes with self-monitoring Desire to cut down or control use Same across life span Time in obtaining substance or getting over effects Negative effects with relatively low use Activities given up or reduced May have fewer activities Use despite knowledge of problems May not know problems are related to use

16. Screening

17. Practitioner Barriers to Identification  Ageist assumptions  Failure to recognize symptoms  Lack of knowledge about screening  Physician discomfort with substance abuse topic - 46.6% of primary care physicians found it difficult to discuss prescription drug abuse with their patients (CASA, 2000) (CASA, 2000)

18. Individual Barriers to Identification  Attempts at self-diagnosis  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)

19. Signs and Symptoms of Substance Use Problems in Older Adults Anxiety Anxiety Blackouts, dizziness Blackouts, dizziness Depression Depression Disorientation Disorientation Mood swings Mood swings Falls, bruises, burns Falls, bruises, burns Family problems Family problems Financial problems Financial problems Headaches Headaches Incontinence Incontinence Increased tolerance Legal difficulties Memory loss New problems in decision making Poor hygiene Seizures, idiopathic Sleep problems Social isolation Unusual response to medications

20. Symptom Identification Applying quantity and frequency levels appropriate for younger adults to elders may cause failure to identify substance use problems Applying quantity and frequency levels appropriate for younger adults to elders may cause failure to identify substance use problems Warning signs can be confused with or masked by concurrent illnesses and chronic conditions, or attributed to aging Warning signs can be confused with or masked by concurrent illnesses and chronic conditions, or attributed to aging –Sleep problems associated with chronic conditions, particularly cardiovascular disease and pain –Falls attributed to poor lower body strength, poor balance, or vision limitations –Anxiety attributed to psychosocial concerns –Confusion/memory problems associated with Alzheimer’s disease or other dementias

21. Psychosocial Manifestations of Mild/Moderate Drug Disorders  Psychological/Behavioral –Agitation, irritability, dysphoria, difficulty in coping, mood swings, hostility, violence, psychosomatic symptoms, hyperventilation, generalized anxiety, panic attacks, depression, psychosis  Family –Chronic stable family dysfunction, marital problems, anxiety and depression in family members, divorce, abuse and violence (Brown, 1992) (Brown, 1992)

22. Psychosocial Manifestations of Mild/Moderate Drug Disorders  Social –Alienation and loss of old friends, gravitation toward others with similar lifestyle  Legal –Arrests for disturbing the peace or driving while intoxicated, stealing, drug dealing  Financial –Borrowing or owing money, selling personal or family possessions (Brown, 1992) (Brown, 1992)

23. Screening Instruments Modified CAGE for drug abuse Modified CAGE for drug abuse –Examined for older populations (50 and over) –Excellent sensitivity, poor specificity (Hinkin et al., 2001) Conjoint two-item screen Conjoint two-item screen –"In the past year, have you ever drunk or used drugs more than you meant to?" –"Have you felt you wanted or needed to cut down on your drinking or drug use in the past year?" »Ages 50-59: Sensitivity 73.9, Specificity 84.8 (Brown et al., 2001) Drug Abuse Screening Test (DAST-10, 20, 28) Drug Abuse Screening Test (DAST-10, 20, 28)

24. Drug Abuse Screening Test (DAST-20) 1. Have you used drugs other than those required for medical reasons? 2. Have you abused prescription drugs? 3. Do you abuse more than one drug at a time? 4. Can you get through the week without using drugs (other than those required for medical reasons)? 5. Are you always able to stop using drugs when you want to? 6. Have you had "blackouts" or "flashbacks" as a result of drug use? 7. Do you ever feel bad or guilty about your drug use? 8. Does your spouse (or parents) ever complain about your involvement with drugs? 9. Has drug abuse created problems between you and your spouse or your parents? 10. Have you lost friends because of your use of drugs?

25. Drug Abuse Screening Test (DAST-20) 11. Have you neglected your family because of your use of drugs? 12. Have you been in trouble at work because of drug abuse? 13. Have you lost a job because of drug abuse? 14. Have you gotten into fights when under the influence of drugs? 15. Have you engaged in illegal activities in order to obtain drugs? 16. Have you been arrested for possession of illegal drugs? 17. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs? 18. Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.)? 19. Have you gone to anyone for help for a drug problem? 20. Have you been involved in a treatment program specifically related to drug use?

26. Assessment

27. Special Assessments Functional Abilities Functional Abilities –Activities of Daily Living (ADLs) –Instrumental Activities of Daily Living (IADLs) –SF-36 Comorbidities Comorbidities –Physical –Psychiatric »Affective disorders »Suicide risk Sleep Disorders Sleep Disorders

28. Special Assessments Cognitive Impairments Cognitive Impairments –Dementia »Orientation/Memory/Concentration Test »Folstein Mini-Mental Status Exam (MMSE) –Delirium »Confusion Assessment Method (CAM) –Other cognitive impairments »Trauma from falls, MVA, accidents »Wernicke-Korsakoff syndrome

29. Screening and Assessment Recommendations for Older Adults  Every person over 60 should be screened for alcohol and 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

30. 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. drug addict)

31. Future Directions  Risk and Protective Factors/Prevention/Early Identification  Drug of Choice Illicit, Prescription, AlcoholIllicit, Prescription, Alcohol  Patterns of use Drug use trajectoriesDrug use trajectories Re-emergence of addiction in late lifeRe-emergence of addiction in late life Late-life onset of substance use disorderLate-life onset of substance use disorder  Screening, Assessment and Diagnosis  Identification and treatment of psychiatric comorbidities

32. Contact Information Frederic C. Blow, Ph.D. Director Serious Mental Illness Treatment Research & Evaluation Center Department of Veterans Affairs Department of Veterans Affairs Associate Professor/Research Associate Professor University of Michigan Department of Psychiatry 400 E. Eisenhower Parkway, Suite 2A Ann Arbor, MI 48108 Phone: 734/761-2210 Fax: 734/761-2617 email: fredblow@umich.edu