|
WHO ARE THEY?
Seniors abusing substances span all cultures and economic strata. They may be our family, friends or neighbors.
Demographics
Because of the major increase in numbers of persons over 65, we must prepare to adjust services to meet the needs of this group. The present population over 60 years old is 35 million, representing 13 percent of the population. This figure is expected to be 20 percent by the year 2030. Specifically, more than 1 million seniors are estimated to be alcoholics or drug abusers (over-the-counter and/or prescription medications). This estimate is considered to be very low; other statistics reveal that up to 17 percent of seniors suffer ongoing consequences due to the use and abuse of alcohol and other drugs.
Lack of Knowledge
One of the most serious aspects of the rising use of chemicals in the senior population is that few are aware that the problem exists. In general, except for those who work in the field of chemical dependency, there is a lack of knowledge among both healthcare providers and the general public. Symptoms of alcohol or drug problems frequently mimic symptoms and behaviors associated with the aging process, complicating diagnosis.
Physicians are not informed about where to refer older adults for treatment, so they may question if they should bother with a referral. This problem can cost the nation millions of dollars annually for multiple hospitalizations, exacerbated chronic illness, loss of independent life styles and a general decline in quality of life available to the older population. Healthcare providers, as well as society in general, tend to attribute mental and physical symptoms of alcohol and/or medication abuse as part of the aging process.
Eighty-seven percent of older adults see a physician regularly, but it is estimated that 40 percent of those who are at risk are not diagnosed. Alcoholism is often misdiagnosed or under-diagnosed because symptoms are misattributed to 1) common geriatric syndromes including falls, incontinence or dementia, 2) diseases common in older age such as congestive heart failure, hypertension or osteoporosis, 3) an age-biased view of older adults such as poor sleep patterns, diminished sex drives or memory deficits.
Barriers to Recovery
Several barriers to recovery for older adult/users include:
- detachment from the mainstream; not easily identified.
- can experience multiple losses such as spouse, family
members, health, active lifestyle and income.
Plagued by these myths:
- Addiction is untreatable.
- Most people become confused and forgetful as they age.
- Drinking may be an older person's last remaining
pleasure.
- It's okay because the doctor prescribed it.
- He/she may have nothing else to do with the time.
- Alcoholism is a moral weakness.
- Alcohol is good for altering an older person's mood.
- He/she should be left alone because he/she is not
hurting anybody.
- Older folks are too frail to deal with a recovery program.
Addiction is definitely treatable in older adults. The reality is that without treatment and intervention, addictions will become worse. Ultimately, one fall, a spike in blood pressure leading to a stroke or one more intoxication can result in nursing home placement, the
very thing that the patients and all of the people in their lives are trying to avoid, the loss of independence.
Family Attitudes
A final barrier to recovery is family attitude. They are not interested in helping or supporting; they are tired of the problem. The other scenario is a family member tries to control the person's use by doing shopping and overseeing social activities. There is a need for family education.
Medical Sequelae
Older adults are more vulnerable to the effects of alcohol because of their unique physiology. Aging increases alcohol sensitivity primarily because older tissues hold less water than younger tissue. As people age, the amount of lean body mass decreases, and the proportion of fatty tissue increases. Consequently, a given amount of alcohol is more potent, and medications given in the usual "adult dose" are more concentrated. Slowing of the GI track and a decrease in liver and kidney functions may give rise to an accumulation of drugs as metabolism slows. The result is a greater potential for intoxication, drug interactions and side effects in the older adult.
Chronic Conditions and Medications
Normal age-related changes are often exacerbated by disease; in fact, chronic health problems often have a greater impact than aging itself. Approximately 80 percent of older people have a chronic condition, and many have multiple conditions. As "old age" lasts longer, more people are living with chronic illnesses for a longer time. The risk of adverse reactions increases with each additional drug, whether that means taking a dose twice or forgetting a dose. When eight to nine chemicals are ingested, the risk of drug-to-drug reaction is 100 percent. Most people over age 65 regularly take between two and seven medications daily. Alcohol can interact with at least half of the 100 most commonly prescribed drugs as well as with many over-the counter medications. Ten percent of hospital admissions in those over 65 are primarily for drug-drug interaction.
Psychological Disorders
Excessive alcohol consumption is associated with depression, a common problem among the elderly. Physiologically, levels of serotonin and norepinephrine are altered in the brain as people get older. Symptoms of depression may result from physical illnesses such as diabetes, thyroid disorders or Parkinson's disease. Depression can result from side effects of medications used to treat these diseases. After age 65, drinkers are 16 times more likely to die of suicide, which is often precipitated by depression. Older adults have a higher suicide rate than any other subgroup.
Making the Diagnosis
Because symptoms can be so similar for alcoholism, diseases of later life and adverse drug reactions, it is important to develop diagnostic procedures. No one sign is indicative of alcoholism in the elderly, but several indicators, especially in multiples, are highly suspicious. On physical exams, remember to note bruises, abrasions and scars that can suggest frequent falls. Cigarette burns on the fingers can suggest falling asleep or passing out. The general medical history needs to include not only medication regimes (prescription and OTC), but also various doctors and pharmacy patterns. Lab values need to be compared with elderly patients that are not alcoholic. A thorough mental status exam is necessary to evaluate cognitive functioning, emotional affect and recent memory.
Important Points to Consider When Assessing Clients
_ complete geriatric assessment and neurological work-up
_ detoxification should be a primary consideration
_ knowing all substances, including alcohol, prescribed
and over-the-counter meds taken in the last 24 hours,
48 hours and last two weeks
_ assessment at a slower pace than usual, maybe during
two visits
_ all physical or cognitive impairments considered
_ collaboration with another person
_ sensory needs
_ assessment tools such as C.A.G.E., Geriatric Mast, a
M.M.S.E. (Mini/Mental Status Exam), E.A.S.T. (Elderly
Alcoholic Screening Test)
Important Points to Consider When Choosing the Treatment Center
Multiple considerations are these:
- What are the financial resources?
- Do they need a long-term/in-patient setting - or detox
and out-patient setting?
- Who is their support?
- Does the facility offer age-appropriate programs?
- Does the facility utilize any older adults as
sponsors/helpers?
- Are workers sensitive to some of the issues and special
needs previously mentioned?
- Do they provide transportation?
- Do they provide small groups, shorter sessions?
- Utilization of community services
In Home Assessments
Home visits are a real plus in the whole picture of assessing and treating adults for chemical issues. The atmosphere is more private and relaxed; they are not so threatened by
self-disclosure. Simultaneously, we are able to assess the client's environment and family interactions, factors that help greatly in choosing appropriate services.
Conclusion
It is clear that we as clinicians in the field of chemical dependency have a responsibility in helping society to become more educated and understanding with heightened awareness regarding chemical dependency issues. The goal is for elders to achieve the highest quality of life and maintain independence whenever possible.
Ms. Nancy Pelletier received her diploma from Massachusetts General Hospital and has specialized in the field of chemical dependency nursing for over 12 years. Her present experience as Chemical Dependency Coordinator for the Visiting Nurse Association of Cleveland has allowed her to have extensive clinical and administrative involvement as well as a community focus. Most recently, her efforts have been on older adults and chemical use.
Ms. Christine Pickens is with the Visiting Nurse Association of Cleveland, Ohio and is currently specializing in the area of in-home behavioral health and chemical dependency, focusing on assessments, teaching and referrals. Her nursing experience includes background in medical nursing, roles in management, supervision, teaching positions and nurse consultant for research in early alcohol detection. She is presently working toward counseling credentialing.
References
1. American Medical Association. "Alcoholism and the Elderly: Diagnosis, Treatment, Prevention." Guidelines for Primary Physician Care. (1997).
2. Beresford, T.P. & Gomberg, ESL., (eds). Alcohol and Aging. Oxford University Press; (1994).
3. Case Western Reserve Geriatric Education Center. Alcoholism & Elders: A Matter of Substance. A Training Manual for Professional Community Social Services, Health and Mental Health Care System. (1997).
4. Campbell, J.W. "Alcoholism in the Elderly." Hamr, Sloane, P., (eds). Primary Care in Geriatrics: A Case Based Approach. 2nd Edition, (1992).
5. Lowinson, Joyce M.D., Ruiz, Pedro M.D., Millman, Robert M.D., & Langford, John M.D. Substance Abuse. A Comprehensive Textbook. 2nd Edition, (1992).
|
