1. 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)

2. Get Connected!
Linking Older Adults With Medication, Alcohol, and Mental Health Resources

4. 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 ) in U.S. Census 2000
Second wave ‘Baby Boomers’ (now aged 40-49) contains 45 million

5. 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)

6. 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)

7. Estimated Prevalence of Major Psychiatric Disorders by Age Group
Jeste, et al., 1999;

8. Course and Consequences of Older Adult Alcohol Consumption

9. 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

10. 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

11. SBIRT MODEL
Screening
Brief Intervention
Referral to Treatment

12. Screening Approaches

13. 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)

15. 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)

16. 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

17. 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)

18. 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

19. 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

20. 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

21. 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)

22. Brief Interventions

23. 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

24. 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

25. 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

26. 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

27. Additional BI Studies with Older Adults
Moore, et al, NIAAA sponsored
Brief intervention in primary care
Follow-up health educator call
Positive results
Schonfeld, et al, 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

28. 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

29. 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

30. 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

31. Primary Substances Used
69.6% Alcohol
18.9% Prescription Drugs (not necessarily psychoactive meds)
7.3% Illicit drugs
4.6% Other

32. 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

33. Special Circumstances
Alcohol Withdrawal
Excessive Drinking
21+ drinks/week
Benzodiazepine/Opioid Use
5+ days/week for 3+months

34. Brief Treatments

35. Types of Treatments Examples: Brief Treatments
Strengths-Based Case Management
Motivational Enhancement Therapy (MET)
Cognitive Behavioral Therapy (CBT)
Specialized Treatments
Outpatient
Inpatient **

36. Who Seeks Treatment?

37. 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)

38. 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

39. 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.