Blackburn J.A., Dulmus C.N. (Editors). Handbook of gerontology: evidence-based approaches to theory, practice, and policy

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Table 12.1

DSM-IV-TR

Criteria for Substance Abuse and Dependence

Abuse

A. A maladaptive pattern of substance use, leading to clinically significant impairment

or distress, as manifested by one (or more) of the following, occurring within a 12-

month period:

(1) recurrent substance use resulting in a failure to fulfill major role obligations at

work, school, or home (e.g., repeated absences or poor work performance related

to substance use; substance-related absences, suspensions, or expulsions from

school; neglect of children or household)

(2) recurrent substance use in situations in which it is physically hazardous (e.g.,

driving an automobile or operating a machine when impaired by substance use)

(3) recurrent substance-related legal problems (e.g., arrests for substance-related

disorderly conduct)

(4) continued substance use despite having persistent or recurrent social or interper-

sonal problems caused or exacerbated by the effects of the substance (e.g.,

arguments with spouse about consequences of intoxication, physical fights)

B. The symptoms have never met the criteria for Substance Dependence for this class

of substance.

Dependence

A. A maladaptive pattern of substance use, leading to clinically significant impairment

or distress, as manifested by three (or more) of the following, occurring at any time

in the same 12-month period:

(1) tolerance, as defined by either of the following:

(a) a need for markedly increased amounts of the substance to achieve intoxica-

tion or desired effect;

(b) markedly diminished effect with continued use of the same amount of the

substance.

(2) withdrawal, as manifested by either of the following:

(a) the characteristic withdrawal syndrome for the substance;

(b) the same (or closely related) substance is taken to relieve or avoid with-

drawal symptoms.

(3) the substance is often taken in larger amounts or over a longer period than was

intended.

(4) there is a persistent desire or unsuccessful efforts to cut down or control sub-

stance use.

(5) a great deal of time is spent in activities necessary to obtain the substance (e.g.,

visiting multiple doctors or driving long distances), use the substance (e.g.,

chain-smoking), or recover from its effects.

(6) important social, occupational, or recreational activities are given up or reduced

because of substance use.

(7) the substance use is continued despite knowledge of having a persistent or

recurrent physical or psychological problem that is likely to have been caused or

exacerbated by the substance (e.g., current cocaine use despite recognition of

cocaine-induced depression, or continued drinking despite recognition that an

ulcer was made worse by alcohol consumption).

Source: Diagnostic and Statistical Manual of Mental Disorders,

fourth edition, text revision

(pp. 110–111, 114–115), by the American Psychiatric Association, 2000, Washington, DC: Author.

316

Table 12.2

Barriers to Identifying Alcohol and Other Drug Misuse in Older Adults

Barrier Example

Beliefs about aging held by health care

providers and family members

Physicians or family members may not pay

attention to drinking or using patterns if

they think those patterns are a reaction to

the stressors of aging.

Pessimism about prognosis in older people

who drink alcohol or misuse other drugs

Health care providers or family members

may not be aware of treatment resources for

elderly alcoholics or drug addicts and the

chances of recovery.

Denial of addiction to alcohol or other drugs

Shame about alcohol or other drug use is

common among older people, and some

may believe alcoholism and other drug

addiction is a moral weakness.

Fewer social warning signs in older people There are fewer alcohol-or drug-related

legal or occupational problems.

Concurrent medical conditions skew the

clinical picture in older people

Symptoms are disguised when other ill-

nesses such as anemia, peripheral neu-

ropathy, or altered cognition are present.

Addiction may happen unknowingly

Some over-the-counter medications contain

significant amounts of alcohol.

Some common signs and symptoms of problematic use of alcohol and other

drugs in the older population are indicated in the literature. For example, Blow

et al. (2002) described the guidelines for older adults and use of alcohol. It is rec-

ommended by the National Institute on Alcohol Abuse and Alcoholism (Dufour

& Fuller, 1995) and the CSAT’s Treatment Improvement Protocol (TIP; 1998) on

older adults to limit consumption to no more than one standard drink (one 12-

ounce beer, 5-ounce glass of wine, or 1.5 ounces [one shot] of liquor) per day or

seven drinks per week. Further, it is advised that a person 65 or older should not

consume more than two standard drinks on any one occasion.

Blow et al. (2002) and Fingerhood (2000) presented signs and symptoms of po-

tential substance misuse and abuse in older adults. The list includes anxiety, in-

creased tolerance to alcohol or medications, blackouts, dizziness, legal difficulties,

depression, mood swings, memory loss, loss of motivation, disorientation, new dif-

ficulties with activities of daily living, new challenges in decision making, dimin-

ished hygiene, drug-seeking behavior, doctor shopping, falls, bruises, burns,

family or marital problems, idiopathic seizures, financial problems, sleep distur-

bance, headaches, social isolation, incontinence, and poor nutrition. A decreased

tolerance has also been noted in older adults due to the increased chemical sensi-

tivity in this population. For instance, elderly persons can consume alcohol less fre-

quently and per occasion drink a decreased amount and still experience the same

effect as do young alcoholics (Thibault & Maly, 1993).

Accurate recognition of problematic behaviors and illness must include a clear

definition of target symptoms and behavior, the principle that change in the

symptoms or behavior leads to an improved quality of life, and a description that

Substance Abuse 317

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the problems are not rare (Gurnack, Atkinson, & Osgood, 2002). Identification of

at-risk substance use and problematic behaviors and illness through careful

screening and assessment techniques is crucial to providing quality services.

Although the interview with a practitioner remains the clinician’s greatest

asset, standardized screening tools provide a rapid, sensitive, inexpensive, and

more objective perspective in the screening for problematic use to assist in focusing

suitable treatment options (Gurnack et al., 2002). There are several screening tools

being used by practitioners: CAGE, Michigan Alcohol Screening Test-Geriatric Ver-

sion (MAST-G), Short Form Michigan Alcohol Screening Test-Geriatric Version

(SMAST-G), Alcohol Use Disorders Identification Test (AUDIT), and Alcohol Re-

lated Problems Survey (ARPS).

The CAGE (Ewing, 1984; Mayfield, McLeod, & Hall, 1974) is the most widely

used alcohol-problem screening tool. It is very brief, with only four items, and is

easily administered in a nonthreatening manner in an interview. The four items

pertain to wanting to Cut down, feeling Annoyed that people criticize one’s

drinking, feeling Guilty about others criticizing one’s drinking, and having an

Eye-opener drink in the morning to get rid of a hangover or to get motivated. Two

positive responses indicate that further assessment is needed to determine an

abusive, dependent, or otherwise problematic use of alcohol (Buellens & Aert-

geerts, 2004). The typical clinical cutoff score is two positive responses; however,

some authors suggest lowering the cutoff to one positive response when screen-

ing the elderly (Buellens & Aertgeerts, 2004; Conigliaro, Kraemer, & McNeil,

2000). Buchsbaum, Buchanan, Welsh, Centor, and Schnoll (1992) reported that a

cutoff of one positive answer on the CAGE yielded a sensitivity of 86% and a

specificity of 78% in distinguishing problematic alcohol behaviors in the elderly.

The SMAST-G is the short form of the Michigan Alcoholism Screening Test—

Geriatric Version (MAST-G). This test was developed as a screen for alcohol prob-

lems in the elderly; it consists of 10 items (SMAST-G) and 24 items (MAST-G;

Blow, 1998; Blow et al., 1992; Moore, 1972). More than five positive answers indi-

cates an alcohol problem. The test has a sensitivity of 91% to 93% and a speci-

ficity of 65% to 84% when compared with DSM criteria (Blow et al., 1992; Joseph,

Ganzin, & Atkinson, 1995; Morton, Jones, & Manganaro, 1996).

The Alcohol Use Disorders Identification Test (AUDIT) is a 10-item instrument

developed to screen for alcohol use disorders and focuses on consumption

(Babor, de la Fuenta, Saunders, & Grant, 1992). Morton and colleagues (1996)

found that when using a cutoff score of 8, the AUDIT appeared useful but less

sensitivethantheCAGE.TheAUDITdemonstratedasensitivityof33%anda

specificity of 91%.

The Alcohol Related Problems Survey (ARPS) is a 10-item self-administered

reliable and valid instrument developed specifically for older adults (Fink, El-

liott, Tsai, & Beck, 2005; Fink et al., 2002; Moore, Hays, Reuben, & Beck, 2000).

This survey focuses on early detection of alcohol-related problems and is recom-

mended for use in primary care settings. There is also a computerized version

called the CARPS that has been used in a study by Fink et al. (2005) to demon-

strate that older primary care patients can effectively decrease alcohol consump-

tion and other drinking risks when given personalized information about how

their drinking affects their health.

These screening tools have shown some success in assisting with intervention

for alcohol problems in the elderly, but it is still important to consider that they

Substance Abuse 319

are only self-report measures and that urine drug screens and a comprehensive

interview by a qualified professional are crucial for a more detailed and substan-

tive clinical assessment. Urine drug screens continue to be useful as both a

screening mechanism and as a confirmation of self-report. The majority of drugs

of abuse remain detectable in a urine drug screen for 4 or more days, and there is

an option of increasing the reliability of the drug screen through ordering a chain

of custody (Barry, Oslin, & Blow, 2001).

Research literature has urged that substance abuse treatment services for older

persons should begin with screening in the primary care provider’s (PCP) setting

due to the frequency of visits made to the PCP (6 to 8 times) per year (Emlet,

Hawks, & Callahan, 2001; Fink et al., 2005; Gunter & Arndt, 2004; Saleh &

Szebenyi, 2005). It is possible that if screening and referral to appropriate sub-

stance abuse treatment were to occur as standard practice in PCP offices, urgent

visits to emergency rooms might decline.

Saleh and Szebenyi (2005) studied data from 11 states from the Healthcare Cost

and Utilization Project State Inpatient Databases (N = 2,309,872) in relation to re-

source use of elderly with alcohol-related diagnoses. This research revealed the

necessity for proper linkages between hospital emergency rooms and substance

abuse treatment facilities equipped to provide medical detoxification services for

older clients to decrease the added resource burden acquired by alcohol-related

emergency room admissions.

Emlet et al. (2001) explained that social workers acting on behalf of their older

clients have an obligation to educate family members or caregivers and other

health care providers about problematic alcohol and other drug use among the el-

derly. Due to the issues unique to older adults (i.e., historical and cultural factors

that lead to their feeling disgraced), older adults may find it increasingly difficult

to identify their drinking or using other drugs as problematic. The complexity of

identification of problem alcohol or drug use among the elderly may be further

complicated by chronic medical conditions (Blow, 1998). It is also recommended

that feedback from the screening instruments be given to the client immediately

to maximize treatment intervention opportunities.

The U.S. Department of Health and Human Services, Substance Abuse and

Mental Health Services Administration, CAST (1998) TIP Series 26 recommends a

specific way to communicate the screening and assessment results to elderly

clients. The first point is to provide a description of how the alcohol or prescrip-

tion drug abuse affects the older adult’s health or functional status. Second, the

assessor should provide concrete information about how substance abuse or de-

pendence is very treatable and explain treatment options in an effort to ulti-

mately maintain independence and improve quality of life. Third, if symptoms

appear severe, recommending further assessment to provide more information on

how to proceed with treatment is suggested. If symptoms do not appear severe,

having a discussion about monitoring progress over a few weeks and a willing-

ness to make changes is appropriate. Finally, if the situation is dire, with an ap-

parent need for detoxification, admission to an inpatient facility may be the most

prudent option.

Once the screening and assessment are completed, the treatment provider can

then make a determination about the appropriate level and intensity of care. De-

cisions about the referral of clients after the screening and assessment process

has been completed need to be guided by knowledge of available resources as

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well as appropriate levels of care that match the clinical symptoms of the particu-

lar client. Linking clients with appropriate referrals often begins with referral to

the least intensive options.

EAST

NTENSIVE

REATMENT

PTIONS

Least intensive treatment options include brief intervention, intervention, and

motivational counseling. The evidence suggests that 10% to 30% of problem

drinkers who do not meet criteria for dependence decrease their drinking to

moderate levels after a brief intervention by a physician or other clinician (CSAT,

1998). Brief intervention techniques can range from relatively unstructured coun-

seling and feedback to more formal structured therapy that relies on concepts

and applications from motivational psychology (Miller & Rollnick, 1991). If the

client does not respond to brief intervention techniques, intervention and motiva-

tion counseling are other options that can be explored.

Intervention occurs under the guidance of a skilled counselor with many sig-

nificant members of the substance abusing client’s life in an effort to be direct

about their concerns and experiences with the drinking and drug behavior (John-

son, 1973). This process is designed to break down the delusion of denial that is

pervasive in alcohol and other drug dependence.

Motivational counseling involves an acknowledgment of differences in readi-

ness for change and offers an alternative approach for meeting people where they

are (Miller & Rollnick, 1991). The skilled counselor listens respectfully to the

client and accepts the older adult’s viewpoint as a starting point toward change

and intervention. This type of intervention can serve as a prelude to other thera-

peutic interventions.

Gunter and Arndt (2004) suggest that if the patient is an at-risk drinker or

drug user, brief education can be effective in lessening the level of alcohol or

other drug intake. For late-onset substance abusers who are not in need of detox-

ification, motivational interviewing techniques may be sufficient to bring about

change. Among late-onset substance abusers (not in need of detoxification) there

may be a reactive pattern of relatively short duration to a situational stressor.

Older people who are experiencing difficulties related to drinking alcohol but

do not meet the criteria for alcohol dependence may be best served with brief in-

tervention (Fingerhood, 2000). Fleming, Barry, Manwell, Johnson, and London

(1997); Fleming et al. (2002); and Wilk, Jensen, and Havighurst (1997) reported

that brief intervention can decrease drinking to a moderate level in up to one

third of individuals. The process of providing brief intervention includes identifi-

cation of the problem, a discussion of consequences, and a determined plan of

care. This intervention is designed to take place over 2 to 3 sessions approxi-

mately 15 minutes each in a nonconfrontational and supportive style (Finger-

hood, 2000).

UTPATIENT AND

NPATIENT

REATMENT

PTIONS

Specialized outpatient programs vary tremendously in the intensity of care. Par-

tial hospitalization programs require attending 5-day, day-long treatments

within a hospital but returning home in the evenings. Intensive outpatient pro-

grams involve approximately 2 to 3 hours of treatment each day, sometimes 3 to 5

Substance Abuse 321

days a week. Traditional outpatient treatment involves weekly sessions in a low-

intensity environment.

Elderly clients who do meet the criteria for dependence need more structured

intervention; however, strategies of brief intervention may be effective in creating

a treatment plan. Structured intervention for clients with substance dependence

includes detoxification and subsequent rehabilitation.

It is crucial to consider the age-related differences in the detoxification needs

in treatment for alcohol withdrawal. For instance, older alcoholics commonly will

have a delayed onset of withdrawal symptoms, with symptoms beginning several

days after the last drink of alcohol was consumed. Kraemer, Conigliaro, and Saitz

(1999) found that confusion is often the first recognizable symptom of with-

drawal, instead of tremors, which are more readily detected in younger alco-

holics. These researchers also suggest that severity and duration of withdrawal

increases with age. With the delayed withdrawal symptoms, the family interview

becomes increasingly important for collateral information.

An inpatient treatment facility is the best option for an older person who meets

criteria for substance dependence, lacks social support, struggles with major

medical illness, failed at attempted outpatient tapering or detoxification, and has

an increased potential for morbidity with withdrawal. Coexisting medical prob-

lems increase the morbidity of substance withdrawal, which can justify the need

for medical monitoring while under detoxification (Fingerhood, 2000). In the el-

derly, it becomes increasingly important to monitor for adverse effects from phar-

macological intervention during detoxification of withdrawal symptoms, as

benzodiazepines used in this process can create difficulties in gait, cognition,

and incontinence (Fingerhood, 2000).

When making referrals to an inpatient treatment facility, it is good ethical

practice to inquire about specific interventions that the facility utilizes to meet

the needs of the elderly. Social workers and other professionals have the opportu-

nity to advocate for older clients to obtain adequate services for them.

As previously mentioned, selecting appropriate treatment services usually in-

cludes looking into the least intensive treatment options, such as brief interven-

tion, intervention, and motivational counseling. These strategies may be more

appropriate as a part of pretreatment while moving clients into more specialized

treatment by assisting to overcome resistance and ambivalence about changing

their use of chemicals. The treatment planning process should include age-specific

treatment recommendations that fit the needs of each client.

-S

PECIFIC

REATMENT

The literature suggests that treatment outcomes are improved when elderly

clients receive age-specific treatment (Benshoff & Harrawood, 2003; Blow, 1998;

Fingerhood, 2000; McInnis-Dittrich, 2005; Norton, 1998). Blow (1998) emphasized

that there are few treatment outcome studies for this population reported in the

literature, which is attributed to the challenges in follow-up after completion of

treatment and the complexity of researching elderly substance abusers.

In one notable exception, Lemke and Moos (2002) compared groups of younger

and middle-aged (55 and older) patients in inpatient alcohol treatment programs

(n = 432 in each age group). The sample included alcoholic patients in inpatient

substance abuse treatment programs in 12 Veterans Administration medical cen-

ters from varied regions in the United States. Findings suggest that when older

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clients were integrated with younger clients, the treatment outcomes were com-

parable and positive. Older clients appeared to have been well integrated in

mixed-age programs, were more likely to have a longer length of stay, and ex-

pressed high levels of satisfaction. Moreover, the older clients in this study expe-

rienced significant positive change on nearly all measures of behavior and

attitudes toward treatment. Lemke and Moos (2002) noted the possibility that

their study participants may have been selected for the treatment program using

criteria that made the different age groups more similar and easier to treat

within a mixed-age context. These researchers made it clear that their data could

not address the question of whether the older clients might have shown better

outcomes if they had been in programs that were specifically tailored to their

needs. However, the findings do suggest that there were no gross age inequities

in the mixed-age treatment programs and that there were similarities in treat-

ment interventions across the age range.

Another notable exception is a study of 137 male veterans with alcohol prob-

lems who were randomly assigned after detoxification to age-specific treatment

or standard mixed-age treatment (Kashner, Rodell, Ogden, Guggenheim, & Kar-

son, 1992). Treatment outcomes at 6 months and 1 year demonstrated that age-

specific program clients were 2.9 times more likely at 6 months and 2.1 times

more likely at 1 year to report abstinence when compared with mixed-age group

clients.

The results of these studies show that the question of whether older adults ac-

tually achieve better treatment outcomes in age-specific treatment has not re-

ceived adequate study. However, treatment programs should cultivate a culture of

respect for older clients to reduce the stigma of addiction and the stigma of aging.

Norton (1998) recommended that psychoeducational, peer support, family, and

cognitive-behavioral interventions tailored to meet the needs of elderly clients

make for efficacious approaches. Benshoff and Harrawood (2003) and McInnis-

Dittrich (2005) suggest that intervention with older clients calls for a slower pace

in combination with a supportive, nonconfrontational style in individual and

group settings composed of same-age peers. Elderly clients can do well in 12-step

support groups as an adjunct to 12-step facilitated and other types of professional

intervention. Professionals referring clients to 12-step groups need to be well in-

formed about the strengths and shortcomings of these groups, such as Alcoholics

Anonymous and Narcotics Anonymous, to effectively connect older clients with

these groups.

EVIDENCE-BASED PRACTICE GUIDELINES

The Consensus Panel (CSAT, 1998) advises that treatment programs for older

adults focus on more than just the substance abuse problems, due to the complex-

ity of the aging process and associated conditions. Individual psychological and

health-related issues tend to become more complicated with age (CSAT, 1998).

These challenges call for flexibility when setting goals and determining appro-

priate plans of care. For example, interruptions in treatment for substance abuse

may occur due to necessary hospitalizations due to illnesses. Also, adjustments

to substance abuse treatment related to fatigue or various physical limitations

may be needed.

Substance Abuse 323

ENDER

SSUES

Gender issues may also play an important role in treating older clients for sub-

stance abuse. The Consensus Panel (CSAT, 1998) observed many older women de-

ferring to men in treatment groups; they were also less likely to become leaders or

to build self-confidence. A seasoned therapist could assist in turning these gen-

der roles around to enhance the therapeutic group relationships.

Satre and Arean (2005) found that older women were more likely to decrease

their problematic drinking when it was associated with a serious health condi-

tion. These results may assist practitioners with interventions for older women

specific to identifying factors related to health that may be a catalyst for drinking

cessation.

In a study by Brennan, Kagay, Geppert, and Moos (2000), findings showed that

many women constitute elderly Medicare inpatients with substance use disor-

ders (N = 22,768; 37% were women). These researchers reported that these pa-

tients often had prior substance-related hospitalizations, coexisting psychiatric

conditions, accidents involving poisoning, adverse drug reactions, and falls. This

study purports that elderly women may benefit from treatment that focuses on

their psychiatric disorders and accidental risks as well as their substance abuse.

Personal issues related to substance abuse may be difficult for group members

to discuss in the presence of members of the opposite sex. Older adults may have

an increased need for privacy, which may provide barriers to self-disclosure

(CSAT, 1998). The Consensus Panel recommends that in these situations, separate

gender-specific groups be made available.

REATMENT

PPROACHES

As previously described, brief interventions in the form of educational sessions

and motivational counseling have shown positive results in the research litera-

ture to date (Bartels et al., 2002; CSAT, 1998; Hanson & Gutheil, 2004). In addition

to these less intensive therapeutic approaches, the Consensus Panel (CSAT, 1998)

recommends several treatment approaches that have been effective with older

substance-abusing clients. These approaches include cognitive-behavioral, group-

based, individual-based, medical and psychiatric care, family therapy, case man-

agement services, and specialized treatment for issues with prescription drug

abuse. Each of these approaches are described next.

Cognitive-behavioral approaches, specifically behavior modification, self-

management techniques, and cognitive-behavioral therapies, are recommended

to assist with eliminating or decreasing substance abuse (CSAT, 1998; Morin

et al., 2004). These techniques can be applied to individual and group sessions to

identify and make changes to self-defeating thought patterns and beliefs. The

cognitive-behavioral approaches establish a method for focusing on specific

problems that affect substance-abusing behavior. By exploring thoughts and

feelings, triggers to abusing substances, and the positive and negative conse-

quences associated with substance abuse, an improvement in insight, awareness,

thinking, and behavior can occur.

Group-based approaches are also recommended as particularly beneficial to

substance-abusing clients. Because social isolation is a pervasive problem among

older adults who abuse substances, involvement in group therapy can provide a

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healing experience. Group approaches may take many forms (e.g., educational,

socialization, therapy, support), depending on the needs of the clients. Group ex-

periences can provide an opportunity to share with and gain acceptance from

group members and alleviate issues with excessive guilt and shame. Groups can

focus on specific aging issues and incorporate new coping skills. The literature

suggests that older adults bond into groups at a more rapid pace than do younger

adults (CSAT, 1998; Finkel, 1990).

Individual therapy has been shown to be helpful to older adults with substance

abuse, especially in the beginning stages (CSAT, 1998). Therapists who approach

the sessions in a nonthreatening, supportive way and with genuine respect for

confidentiality can create a successful therapeutic relationship. A clear explana-

tion of confidentiality is paramount to the building of trust and rapport. Private

sessions with older adults can assist in clarifying issues to bring forward in a

group therapy setting as well as to process complicated issues that they may be

too embarrassed to discuss outside of an individual session.

As was previously described, the attention to medical issues, especially for the

older adult population, is critical to the successful treatment of substance abuse.

Stabilization of medical and psychiatric problems should be primary for the el-

derly in order for optimal participation in substance abuse treatment and subse-

quent recovery (CSAT, 1998). Of course, addressing the medical and mental

health needs of older clients will need to be concurrent with substance abuse

treatment once stabilized. Sometimes linking an older alcoholic or other drug ad-

dict to a health care provider can make a profound difference, as many are with-

out adequate medical services.

Involvement of family or significant others in substance abuse treatment for

older adults is recommended by the Consensus Panel (CSAT, 1998) after detailed

information is obtained about the family and the interplay of dynamics. A proper

treatment plan can be designed, which may include family therapy intervention if

the treatment providers deem that it would be helpful in the client’s situation.

Sensitivity and extensive skill are called for in eliciting family information, espe-

cially with an older population, along with the particular skills required to pro-

vide substance abuse treatment.

Case management services may be vital for substance-abusing elderly clients.

Case management involves coordinating various social, health, and welfare ser-

vices in an effort to provide supportive service to an older adult’s treatment and

subsequent recovery (CSAT, 1998). Referral to myriad services and providing

multiple linkages to community outreach programs that the older adult may have

not been aware of prior to treatment may make a significant difference in the

quality of life of these clients.

Specialized treatment for older adults struggling with prescription drug abuse

is imperative due to the many difficulties that stem from unintentional misuse. It

is paramount that treatment providers grasp the dangers of how practitioners’

prescribing behavior contributes to the prescription drug abuse problems in

order to effectively advocate for and empower elderly clients and properly ad-

dress the issues with uninformed health care providers (CSAT, 1998).

Educating older adults and their family members about medication compliance

strategies can be accomplished through using materials already published and in

community settings such as home health care agencies and state and local offices

of aging. Brief educational sessions devoted to increasing awareness can make

Substance Abuse 325

positive contributions in the overall health of older adults. Thorough assessment

with an exploration of underlying issues is recommended, as well as open discus-

sions about issues related to prescription drug abuse with the client, the sub-

stance abuse treatment provider, and the health care provider (CSAT, 1998).

Case Study and Evidence-Based Practice Application

Raymond R is a 74-year-old Caucasian male who lives with his wife of 49 years in

a single-family residence. He is a retired school teacher who earned a master’s

degree in education and is Methodist. Raymond was a participant in a program

designed to provide evidence-based services to community-dwelling older adults

(age 65 and older) in medically underserved areas to ensure access to quality

geriatric assessment and self-management intervention services. This program

was funded by Health Resources and Services Administration as a research study

to improve health outcomes of older adults in medically underserved areas. The

overarching goal of the program was to improve the health of older adults by pro-

viding as many resources as possible so that they could remain in their own

homes as long as possible. The program provided an in-home assessment and a

self-management plan of care by a social worker and a physical therapist. Recom-

mendations were provided to Raymond in an effort to improve his health. Brief

interventions in the form of telehealth with supportive health-related phone calls

were delivered at random to clients in the experimental group. Other clients (in

the control group) were given the plan of care with individualized recommenda-

tions and were to manage the plan of care on their own until a follow-up in-home

assessment at 12 weeks.

Raymond voluntarily enrolled into the program by responding to an ad in the

community newspaper. He was provided with a full explanation of the program

and signed informed consent and HIPAA forms in order for treatment services to

be provided. The social worker and physical therapist provided an evidence-

based assessment, which involved administering multiple instruments represent-

ing both disciplines over a 2-session period.

The assessment instruments used by both disciplines included multiple ques-

tionnaires determined by the evidence-based search to be best practice for assess-

ing well to mildly impaired community-dwelling older adults. Instruments used

in the assessment process included but were not limited to questionnaires per-

taining to health history, current health status, medications, nutrition, health

care providers, coping styles, fatigue and pain level estimates, confidence about

doing things, personal and home hygiene, resources used to manage health, the

CAGE screening tool (Ewing, 1984; Mayfield, McLeod, & Hall, 1974), Geriatric

Depression Scale (5/15; Weeks, McGann, Michaels, & Penninx, 2003), Lubben’s

(1988) Family Network Scale, the Mini-Cog (Tuokko, Hadjistavropoulos, Miller,

& Beattie, 1992), the Functional Reach Test (Duncan, Weiner, Chandler, & Stu-

denski, 1990), the Sit to Stand Test (Jones, Rikli, & Beam, 1999), and the Timed

Get Up and Go Test (Podsiadlo & Richardson, 1991).

Raymond’s score on the CAGE was a 3 out of 4, which indicates problematic

use of alcohol with a potential for alcohol abuse or dependence. He answered yes

to feeling he ought to cut down on his drinking, that his wife annoyed him by

criticizing his drinking, and feeling bad or guilty about his drinking. He de-

scribed drinking only one “cocktail” per day.