Identifying Barriers to Care for Older Adults with Substance Use Disorders and Cognitive Impairments

Article (PDF Available)inAlcoholism Treatment Quarterly 30(2):211-223 · March 2012with37 Reads
DOI: 10.1080/07347324.2012.663302
Some substance use disorders in older adults may be better conceptualized as hazardous use that is sometimes unintentional and affected by other mental health conditions, including dementia. This study identified (1) the types of substances older adults are abusing, (2) how the disorders are linked to dementia and other mental health issues, and (3) barriers to screening and treatment. Focus groups with inpatient and outpatient treatment teams and a review of medical records were completed. Screenings for substance use disorders and other geriatric syndromes (e.g., depression, dementia) are not widely done and is an area in which improvements can be made.

Full-text (PDF)

Available from: Christine J Jensen, Mar 18, 2015
This article was downloaded by: [Christine Jensen]
On: 16 April 2012, At: 08:01
Publisher: Routledge
Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered
office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Alcoholism Treatment Quarterly
Publication details, including instructions for authors and
subscription information:
Identifying Barriers to Care for Older
Adults with Substance Use Disorders and
Cognitive Impairments
Christine J. Jensen
, Herman R. Lukow II
& Andrew L. Heck
The Center for Excellence in Aging and Geriatric Health,
Williamsburg, Virginia, USA
The College of William & Mary, Williamsburg, Virginia, USA
Piedmont Geriatric Hospital, Burkeville, Virginia, USA
Available online: 13 Apr 2012
To cite this article: Christine J. Jensen, Herman R. Lukow II & Andrew L. Heck (2012): Identifying
Barriers to Care for Older Adults with Substance Use Disorders and Cognitive Impairments, Alcoholism
Treatment Quarterly, 30:2, 211-223
To link to this article:
Full terms and conditions of use:
This article may be used for research, teaching, and private study purposes. Any
substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,
systematic supply, or distribution in any form to anyone is expressly forbidden.
The publisher does not give any warranty express or implied or make any representation
that the contents will be complete or accurate or up to date. The accuracy of any
instructions, formulae, and drug doses should be independently verified with primary
sources. The publisher shall not be liable for any loss, actions, claims, proceedings,
demand, or costs or damages whatsoever or howsoever caused arising directly or
indirectly in connection with or arising out of the use of this material.
Alcoholism Treatment Quarterly, 30:211–223, 2012
Copyright © Taylor & Francis Group, LLC
ISSN: 0734-7324 print/1544-4538 online
DOI: 10.1080/07347324.2012.663302
Identifying Barriers to Care for Older Adults
with Substance Use Disorders and
Cognitive Impairments
The Center for Excellence in Aging and Geriatric Health, Williamsburg, Virginia USA
The College of William & Mary, Williamsburg, Virginia USA
Piedmont Geriatric Hospital, Burkeville, Virginia USA
Some substance use disorders in older adults may be better con-
ceptualized as hazardous use that is sometimes unintentional
and affected by other mental health conditions, including demen-
tia. This study identified (1) the types of substances older adults
are abusing, (2) how the disorders are linked to dementia and
other mental health issues, and (3) barriers to screening and
treatment. Focus groups with inpatient and outpatient treatment
teams and a review of medical records were completed. Screenings
for substance use disorders and other geriatric syndromes (e.g.,
depression, dementia) are not widely done and is an area in which
improvements can be made.
KEYWORDS Older adult, cognitive impairment, hazardous use,
co-occurring disorders, screening
This project was made possible in part by funding from a bequest designated for research
by the Ruth Jennings Family, which is administered by Piedmont Geriatric Hospital (Burkeville,
Virginia). The Project Team would like to acknowledge the hospital’s generous support
in awarding us use of these funds to complete this study. The staff members in Health
Information Management at this hospital were extremely helpful to the medical record review
process. Members of the project’s Advisory Council were also instrumental to the successful
completion of this study. Advisory Council members represented community-based agencies,
health systems, local government, state government, a psychiatric hospital, and academic
Address correspondence to Christine J. Jensen, PhD, The Center for Excellence in Aging
and Geriatric Health, 3901 Treyburn Dr. Suite 100, Williamsburg, VA 23185. E-mail: cjensen@
Downloaded by [Christine Jensen] at 08:01 16 April 2012
212 C. J. Jensen et al.
Substance use disorders (SUDs) in older adults with cognitive impairments
are a hidden but substantial problem. Screening and detection as well as
treatment remain challenging. This project assessed issues of SUDs as they
related to memory loss and mental health in older adults. An evidence-
based framework guided the project. The objectives for this project included
seeking answers to the following:
1. What framework is most helpful for understanding the relationship be-
tween memory loss and SUDs in older clients?
2. How frequently is a dual diagnosis of dementia and SUD made?
3. What are the warning signs and predictors for older adults with a dual
diagnosis of dementia and SUD?
4. What unique barriers exist for older adults seeking treatment?
Hazardous Alcohol and Substance Use
Currently, there are more than 38 million adults older than age 65. In 20 years
that number will double and the number of people age 85 years or older will
quadruple (U.S. Census Bureau, 2005). In addition to the current older adult
population, there are an estimated 76 million Baby Boomers, persons born
between 1946 and 1964, who are now turning 65. Maples and Abney (2006)
cited general differences of the Baby Boomer cohort from the preceding
cohort. Baby Boomers are physically healthier; have vastly different quality-
of-life expectations given their higher level of education; possess expanded
worldviews because of technological advances in media, communications,
and travel; and have not experienced the challenges of previous generations
(e.g., Great Depression, World War II). However, aging Boomers also face
a unique set of life stressors that their parents did not face. Boomers will
likely be working into later age because of economic downturns, and they
are experiencing a delay in being able to collect Social Security and rising
health care costs (Maples & Abney, 2006). They will also be dealing with the
effects of an increased number of divorces and blended families that affect
work and child-rearing responsibilities and may place a greater demand on
mental health services and supports.
Up to 20 million older adults misuse, many times unintentionally, alco-
hol, over-the-counter drugs, and prescription medications (Substance Abuse
and Mental Health Services Administration [SAMHSA], 2003). Between one
fifth and one fourth of all prescribed drugs to older adults are benzodi-
azepines, typically used to treat anxiety. The Center for Substance Abuse
Treatment (CSAT; 2004) reported that the interaction between alcohol and
over-the-counter medications causes more problems than any other SUD.
SAMHSA (2005) reported that for every year from 1995 to 2005, alcohol
was the most frequently reported substance of abuse upon admission to
treatment centers for persons age 65 years and older. During this same time
Downloaded by [Christine Jensen] at 08:01 16 April 2012
Overcoming Barriers to Care for Older Adults 213
period, admissions to treatment facilities for opiate abuse increased from
6.6% to 10.5%. Adults age 65 to 69 made up the largest proportion of the
SUD treatment population of all adults age 65 and older, increasing from 56%
in treatment in 1995 to 59% in 2005 (Drug and Alcohol Services Information
System, 2007).
A number of physiological changes accompany age including a decrease
in the body’s volume of water, reduced renal functioning, and a reduced rate
of metabolism. In addition, older adults tend to experience a decrease in lean
body mass, which results in increased sensitivity and decreased tolerance
to alcohol (CSAT, 2005; Culberson, 2006a). Compounding these issues are
higher rates of chronic diseases and increased prescription drug use to treat
pain, sleep, anxiety, and depression experienced by older adult populations
(Culberson, 2006a). Some of the serious conditions that alcohol can either
activate or exacerbate include hypertension, cardiac arrhythmia, hemorrhagic
stroke, cirrhosis of the liver, and gastrointestinal bleeding (Atkinson, 1994).
Alcohol use also depresses the immune system reducing the body’s capacity
to fight infections. In addition, alcohol use causes decreased bone density
and may increase the chances of malnutrition, sleep disturbances, and the
development of mental health problems (Atkinson, 1994). Other problems
associated with use include increased risk of falls resulting in injuries, in-
cluding traumatic brain injuries, and impairment in the ability to engage in
activities of daily living (Culberson, 2006a). Because of these age-related
effects, older adults are more vulnerable to the negative effects of alcohol
use; and, therefore, even the smallest amount of alcohol may compound
or complicate a wide variety of physical and/or mental health challenges.
In light of these challenges, the National Institute on Alcohol Abuse and
Alcoholism (NIAAA; 1998) proposed ‘‘recommended sensible drinking limits’’
of no more than one alcoholic drink per day for men older than age 65 and
‘‘somewhat less’’ than this level for women. Yet, at present, 15% of men and
12% of women older than age 60 years regularly exceed this limit (Culberson,
2006a, 2006b; NIAAA, 1998; Oslin & Holden, 2002).
There is limited substance-related research that focuses on older adults.
Late onset of problematic alcohol use is described as developing problem
alcohol use later in life. Some researchers define the age of late onset as age
55 and older (Fick et al., 2003; Myers, Dice, & Dew, 2000) and others set the
age of late onset at 45 (Wetterling, Veltrup, John, & Driessen, 2003). One third
of problematic drinkers older than age 55 develop late-onset patterns and the
remaining two thirds are chronic users (Myers et al., 2000). When compared
to chronic users, late-onset drinkers tend to be women who report less family
history of problem use, lower consumption amounts, fewer psychological
or legal problems, and who demonstrate a less severe pattern of use and
respond better to treatment efforts (Culberson, 2006a; Fick et al., 2003; Myers
et al., 2000; Wetterling et al., 2003). Those who develop late-onset patterns
generally are higher functioning and in better health than the chronic drinker
Downloaded by [Christine Jensen] at 08:01 16 April 2012
214 C. J. Jensen et al.
who may be attempting to mask long-term or chronic use of alcohol (Fick
et al., 2003). ICD-10 criteria also noted that late-onset drinkers have less
preoccupation with drinking, less impairment in controlling drinking, less
desire and compulsion to drink, and reduced withdrawal effects (Wetterling
et al., 2003). Social risk factors for late-onset harmful alcohol use include a
lack of available social support networks, loss of a life partner, and familial
risk factors including family history of alcohol abuse, family dysfunction,
hostility, and patronizing attitudes (Myers et al., 2000) toward older family
Alcohol and Dementia
Most SUD research examining the relationship between substance misuse
and memory loss relates to the effects of alcohol, in particular. Tyas (2001)
noted that it is challenging to study the relationship between alcohol use and
the development of Alzheimer’s disease (AD) because of similarities between
alcoholic dementia and AD, such as a shared substrate of brain damage in
the two respective disorders and the lack of standard diagnostic criteria for
alcoholic dementia. Tyas also noted that the research suggests that past or
present alcohol abuse is a valuable predictor of the rate of cognitive decline
for those diagnosed with AD but that further research is warranted. Research
found that, excluding probable AD, occurrence of all types of dementia and
mortality risk was significantly higher for participants age 65 years or older
who abused alcohol (Thomas & Rockwood, 2001).
Oslin, Katz, Edell, and Ten Have (2000) estimated that approximately
one in four persons with dementia have alcohol problems. There is a grow-
ing body of evidence that alcohol consumption may actually be negatively
correlated with AD; that is, that moderate alcohol consumption may mitigate
the onset of AD and improve overall health (Lang & Melzer, 2009; Ruitenberg
et al., 2002; Solfrizzi, Colacicco, Gagliardi, Santamato, & Panza, 2007). These
findings may serve to minimize the risks (e.g., falls, malnutrition, interaction
with medications, isolation) that alcohol consumption can pose for older
adults (Thomas & Rockwood, 2001).
Ruitenberg and colleagues (2002) hypothesized that because vascular
disease appears to be linked to dementia and moderate alcohol intake is
linked with vascular health, alcohol may mitigate dementia risk. In their study
of 3,395 participants they found that consumption of one to three alcoholic
beverages per day was significantly associated with a lower risk of all forms
of dementia. However, other researchers noted that the differential effect of
wine could be due to nonalcoholic components of wine such as polyphenol
antioxidants (Luchsinger, Tang, Siddiqui, Shea, & Mayeux, 2004). Research
into lifestyle-related factors suggests a potential benefit of moderate alcohol
intake, specifically for wine (Solfrizzi et al., 2007). However, cognitive status
may influence the amount of alcohol individuals consume, their understand-
Downloaded by [Christine Jensen] at 08:01 16 April 2012
Overcoming Barriers to Care for Older Adults 215
ing of standard amounts, and their understanding of the associated health
implications. Other research into the effects of continued alcohol use among
individuals diagnosed with alcohol-related dementia suggest that abstinence
may be of clinical value in treating patients with dementia and alcohol
dependence (Oslin & Cary, 2003).
Co-Occurring Disorders
The actual prevalence of older adults with concurrent SUDs and mental dis-
orders varies greatly by population and is affected by a variety of contextual
factors. It is estimated that between 7% and 38% of those with a psychiatric
illness also experience SUDs. Conversely, between 21% and 66% of those
who have SUDs face mental health challenges (Blow, Bartels, Brockmann,
& Van Critters, 2005). The most commonly referenced co-occurring disor-
ders involve depression and alcohol use (Blow et al., 2005). In one study,
researchers found at least one psychiatric diagnosis in 31.1% of participants
age 55 and older admitted to a SUD inpatient treatment program; anxiety
disorders were most common, and major depression was the only mood
disorder found (Blow, Walton, Chermack, Mudd, & Brower, 2000). In their
study of the treatment of depression among older adults who used alcohol,
Oslin et al. (2000) noted that comorbidity of alcohol use and depression
was routinely uncovered. They found that treatment and recovery from
depression was not complicated by alcohol use. However, there was strong
evidence that abstinence imposed by hospitalization resulted in significant
positive outcomes for depression. This suggests that patients who are older
and depressed with SUDs may be better served by undergoing addiction
treatment rather than treatment targeted to depression. Even when SUDs are
controlled, older adults with concurrent mood disorders tend to have more
mood episodes as they age (CSAT, 2008). Mood episodes include changes
in appetite or weight, disrupted sleep patterns, decreased energy, feelings
of worthlessness or guilt, difficulty concentrating, and recurrent thoughts of
death (CSAT, 2008).
Co-occurring disorders, such as depression and SUD, make it challeng-
ing to determine not only which condition is the primary disorder but also
the treatment regimen that should follow. The symptoms of intoxication or
withdrawal from alcohol, benzodiazepines, opioids, steroids, and stimulants
precipitate or mimic depression and dysthymia (CSAT, 2008); this is worth
noting for older adults because, as noted earlier, approximately one fifth
of all prescriptions for older adults are for benzodiazepines. Careful and
continuous assessment of alcohol use is essential because mood and anxiety
symptoms may result from a SUD and not underlying mental health issues
(CSAT, 2008). Some authors (Blow, 2004; SAMHSA, 2005) have suggested
that those age 60 years and older be routinely screened, perhaps during
their annual physician exam, for alcohol-related issues or problems.
Downloaded by [Christine Jensen] at 08:01 16 April 2012
216 C. J. Jensen et al.
Role of Health Care Providers
Sharp and Vacha-Hasse (2011) surveyed primary care physicians regarding
their attitudes toward older adults and toward screening for alcohol use.
Interestingly, they found that physicians are not generally compliant with
guidelines established by the American Medical Association that call for the
routine screening for alcohol use in all patients age 60 and older. They
reported screening their new patients more frequently (73%) compared to
their established patients (45%). Physicians further reported that their lower
levels of confidence in their own screening techniques affected the frequency
with which they screened their older patients for harmful alcohol use. The
majority of physicians surveyed reported positive perceptions of working
with older adults but these perceptions did not affect their screening pro-
cedures or frequency of screenings. The authors noted that several studies
have demonstrated that physicians who utilize a brief intervention with their
patients who are at risk for or are already abusing alcohol are effective in
helping their patients control their drinking. Ostensibly, educating physicians
and other health care and community education professionals regarding the
value of alcohol screening and brief interventions will be the key to our
ability to serve the growing numbers of older adults misusing and abusing
Many service providers working with older adults may be unaware of
the NIAAA-recommended alcohol consumption standards for older adults.
Highly publicized studies reporting the positive effects of alcohol (e.g., re-
duced heart disease, delayed onset of AD) (Hulse, Lautenschlager, Tait, &
Almeida, 2005; Juan et al., 2004; Luchsinger et al., 2004) may result in care
providers ignoring the associated risks of exceeding NIAAA-recommended
limits of alcohol consumption even if they are aware of those limits (Atkin-
son, 1994; Culberson, 2006a; Lang & Melzer, 2009). Blow (2004) noted
other barriers including a failure to recognize symptoms masked by ill-
nesses or chronic disease, lack of knowledge of age-related physiological
changes resulting in different recommended rates of consumption by age
and gender, and physician and family discomfort with discussing actual or
possible SUDs. Compounding the issue, Klap, Unroe, and Unutzer (2003)
found that older adults, as compared to younger adults, reported less time
spent with their primary care providers (PCPs) in addressing mental health
Screening Procedures and Instruments
Thomas and Rockwood (2001) urged physicians to screen individuals age
65 and older for alcohol abuse and encouraged family members and other
caregivers to be alert for potential alcohol abuse, which may not be obvious.
Changes in the family dynamics and family roles also confound the process
Downloaded by [Christine Jensen] at 08:01 16 April 2012
Overcoming Barriers to Care for Older Adults 217
of accurate detection (Egbert, 1993). Many screening tools for SUDs are
either not normed for an older population or may be inappropriate for
older adults who may not exhibit social, legal, and occupational conse-
quences and changing consumption patterns (Culberson, 2006b; NIAAA,
1998; O’Connell, Chin, Cunningham, & Lawlor, 2003). Culberson (2006a)
reported that adults age 65 years and older only receive an accurate alcohol-
related primary diagnosis 37% of the time, whereas the rate for those younger
than age 65 is 60%. Threats to diagnosis include faulty self-reporting be-
cause of memory impairment, poor understanding of alcohol use patterns
by clinicians, individual and familial denial, and attitudes of the primary
care physician, particularly those that subscribe to a moral model of ad-
diction and see attempts at treatment as futile (Oslin & Holden, 2002).
Other diagnostic issues include problems with definitions for clinical terms
such as ‘‘misuse,’’ ‘‘at-risk,’’ ‘‘hazardous,’’ ‘‘problem drinking,’’ ‘‘abuse,’’ and
‘‘dependence.’’ Furthermore, substance use patterns of many older adults fall
outside the parameters set forth in the Diagnostic and Statistical Manual of
Mental Disorders (DSM-IV TR; American Psychiatric Association, 2002; Oslin
& Holden, 2002). Culberson (2006b) found that older adults benefit from
a supportive screening environment versus a confrontational environment.
Reliability of self-report is enhanced when screenings are conducted in the
context of a general health and lifestyle interview as opposed to direct
questioning on drinking or substance use patterns (Crum, Puddey, Gee, &
Fried, 2002).
The researchers utilized Glicken’s (2009) evidence-based framework, a pro-
cess of self-directed learning requiring the access to and analysis of in-
formation, to guide the synthesis of various data sources. The Treatment
Improvement Protocol (TIP) series published by the CSAT (2004, 2005, 2008)
proved invaluable to understanding the uniqueness of the challenges associ-
ated with screening, brief intervention, referral, and treatment from multiple
viewpoints (e.g., medical, social services). In addition, SAMHSA’s (2003) Get
Connected Toolkit offers an excellent basis for developing a user-friendly
program that also includes screening for cognitive impairments. It provides
an educational component on alcohol and other medication use and brief
interventions and introduces self-administered screening tools for substance
use and depression.
One of the most promising projects informing this work has been
Florida’s Brief Intervention and Treatment for Elders (BRITE) program. The
BRITE program is a screening, brief intervention, referral, and treatment
(SBIRT) project funded by SAMHSA’s CSAT. The benefits of the BRITE
program that have been realized to date include the following:
Downloaded by [Christine Jensen] at 08:01 16 April 2012
218 C. J. Jensen et al.
Improved linkages among individual practitioners and community agen-
cies with specialized SUD treatment agencies.
Improved identification of SUDs, decreased alcohol and drug use, and
increased knowledge of clinical staff.
Implementation in the general health setting; recognition of the powerful
motivational influence of PCPs.
Utilization of technology support to maintain clinical focus.
Development of a range of interventions for the individual with SUD and
a system to facilitate and monitor referrals to specialized services (Hazlett,
In addition to reviewing medical records at a Mid-Atlantic psychiatric hospital
for older adults to examine prevalence of co-occurring disorders, a primary
source of data collection involved focus groups with treatment teams at
the same psychiatric hospital and an area Community Services Board. The
treatment teams consist of psychologists, psychiatrists, social workers, coun-
selors, nurses, and other direct care staff who treat older adults with mental
health issues. Representatives of this facility and agency were instrumental
in inviting and securing the participation of treatment team members for
these focus groups. The focus groups were audio-recorded and transcribed
in concert with notes taken at each session by the research team. Each focus
group lasted approximately 45 minutes and information was gathered on the
participants’ utilization of screening tools for memory and substance use, the
expected competency of staff, their perceived ability to detect the needs of
their patients/clients, and their identification of barriers to the diagnosis and
treatment of older adults with dementia and SUDs (see Table 1).
Implications and Recommendations
To address and overcome the noted barriers to caring for older adults with
SUDs, the researchers proposed a series of recommendations for the psychi-
atric hospital and community partners serving older adults.
Recommendations for Mid-Atlantic geropsychiatric hospital. Offer ad-
ditional training opportunities for members of the clinical staff to enhance
their abilities to actively engage in screening and assessment functions.
Capture the extensive knowledge that the hospital staff possesses regard-
ing nonverbal communications in order to provide a resource to share
with other professionals working in older adult settings.
Downloaded by [Christine Jensen] at 08:01 16 April 2012
Overcoming Barriers to Care for Older Adults 219
TABLE 1 Summary of Focus Groups with an Inpatient Treatment Team and an Outpatient
Geropsychiatric Hospital
Local Community
Services Board
Participants Counselors, social worker,
psychiatrist, nurse, music therapist,
activity coordinator, occupational
therapist, psychologist
Counselors, psychologist,
Typical screening
tools utilized in
clinical practice
Mini Mental Status Exam, battery of
cognitive tests (including subtests
from the Cognistat), community
living skills.
Several instruments include substance
abuse items
History, prior treatment,
legal history,
Substance Abuse
Subtle Screening
Inventory, Addiction
Severity Index
Expected competency
of staff members
Training in the fields of psychology
and psychiatry, nursing; interns
trained to administer tests
Learning specific to older
adult, job applicant
experience, qualified
substance abuse
professional, qualified
mental health
Ability to understand
and detect patients’
How patients make wishes known,
verbal vs. nonverbal interaction
(80% reported as nonverbal)
Level of alertness,
agitation, insight of
family member(s)
Barriers to screening
and to care
Family, client’s awareness of disease/
disorder, expectations; additional
training needed; support in
community upon discharge; coping
with discharge
Large number of retirees,
need to educate
caregivers; referrals to
other agencies or to
long-term care
Offer parallel psychoeducational, counseling, and support programs for
family members of hospital patients to assist them during transitions to
and from the rehabilitative/treatment environment.
In addition to the information gathered through medical history and family
reports, incorporate standardized screening tools that have been normed
with an older population, such as the Short Michigan Alcoholism Screen-
ing Test Geriatric Version (SMAST-G; Blow, 1991) in initial and ongoing
assessments of SUDs.
Recommendations for community partners.
Continue to integrate screening and assessment for SUDs, memory loss,
and depression to provide a more holistic approach for promoting behav-
ioral health.
Reframe the conceptualization of harmful substance use, beyond the scope
of simply alcohol abuse or dependence. This approach recognizes the
Downloaded by [Christine Jensen] at 08:01 16 April 2012
220 C. J. Jensen et al.
risks associated with older adults exceeding the NIAAA-recommended
consumption rates and is sensitive to inadvertent harmful or hazardous
substance use.
Remain alert to the risk factors associated with late-onset substance use
patterns in older adults and continually screen, whether there is a history
of substance use or not, to capitalize on improved treatment efforts with
this population.
Develop exportable training packages that address the recognition, screen-
ing, and differentiation between SUDs, memory, and mood issues for
presentation to direct care workers and other paraprofessionals.
Partner with graduate counseling and gerontology programs to offer train-
ing on differentiating between SUDs, dementia, and mood disorders during
screening, assessment, diagnosis, and treatment in preparation for interact-
ing with older adults in practicum, internship, and professional practice.
Older adults face a number of well-documented physical and psychological
changes as they age. Because some of these changes are not clearly under-
stood, particularly as they relate to metabolism, many older adults regularly
exceed recommended limits of alcohol consumption, in particular. Not only
does this place these consumers at risk for increased health challenges, but
also the effects of alcohol and other substances may also mask symptoms of
dementia and the presence of mood disorders such as depression or anxiety.
These risks are not limited to the lifetime, chronic users but also negatively
affect those older adults that develop problematic late-onset drinking pat-
Another significant barrier that interferes with the ability to differentiate
between SUDs, cognitive decline, and mood issues is the negative view of
aging and the aged that predominate society. Many cast older people as
being rigid, unhappy, frail, and forgetful, and stereotypes such as these are
internalized by old and young alike. In fact, some family members incorrectly
assume that their older relative is depressed or has developed AD, or that
their relative has the right to use substances, even to excess, as they wish.
Other beliefs include that older adults are unwilling to change if confronted,
that physicians would alert them to any possible physical and mental health
challenges if they existed, and that disturbing or unusual symptoms are
natural consequences of dementia.
Even when screeners are knowledgeable about changes in later adult-
hood, screening efforts are most often inadequate—because they do not fully
differentiate between cognitive, mood, and SUDs and because instruments
have not been normed with older populations. Primary care physicians may
not be familiar with late-onset drinking patterns, and although they may
Downloaded by [Christine Jensen] at 08:01 16 April 2012
Overcoming Barriers to Care for Older Adults 221
be prepared to refer patients to specialty treatment services for patients
with cognitive or mood disorders, they report being less prepared to do so
when a SUD presents. The SAMSHA Get Connected (2003) toolkit includes
two, user-friendly, age-normed instruments to differentiate substance use and
depression issues. The program guide also includes tips for conducting brief
interventions to address these issues, but it does not provide any vehicle for
assessing a change in cognitive status.
A consensus panel for CSAT (2005) noted that older adults are most
concerned by threats to physical health, mobility, bodily functioning, fi-
nance, and independence. As such, programs must be designed to take
these findings into consideration, particularly in light of the huge growth
of older adults driven by the aging of the Baby Boomer generational cohort
and their unique needs. Services aimed at promoting healthy aging, which
in turn prolongs independence and ultimately supports an increased quality
of life, must include efforts to accurately identify and differentiate physical
and psychological challenges. To this end, a broad range of activities should
be examined which include collaboration and community networking, case
consultation, prevention and outreach efforts, and educational programs for
older adults, their families, and their healthcare providers.
American Psychiatric Association. (2002). Diagnostic and statistical manual of men-
tal disorders-IV-TR. Washington, DC: American Psychiatric Association.
Atkinson, R. (1994). Late onset problem drinking in older adults. International
Journal of Geriatric Psychiatry, 9(4), 321–326.
Blow, F. C. (1991). Short Michigan Alcoholism Screening Test–Geriatric Version
(SMAST-G). Ann Arbor, MI: University of Michigan Alcohol Research Center.
Blow, F. C. (2004, September). Substance abuse prevention, screening and identifi-
cation, and assessment for older adults. Paper presented at the meeting of the
National Institute on Drug Abuse, Bethesda, MD. Retrieved from http://www.
Blow, F. C., Bartels, S. J., Brockmann, L. M., & Van Citters, A. D. (2005). Evidence-
based practices for preventing substance abuse and mental health problems in
older adults. Older Americans Substance Abuse and Mental Health Technical
Assistance Center. Rockville, MD: Substance Abuse & Mental Health Services
Administration. Retrieved from
Blow, F. C., Walton, M. A., Chermack, S. T., Mudd, S. A., & Brower, K. J. (2000). Older
adult treatment outcome following elder-specific inpatient alcoholism treatment.
Journal of Substance Abuse Treatment, 19, 67–75.
Center for Substance Abuse Treatment. (2004). Substance abuse among older adults:
A guide for social service providers (Treatment Improvement Protocol (TIP)
Series 24. DHHS Publication number 04-3971). Rockville, MD: Substance Abuse
and Mental Health Services Administration.
Downloaded by [Christine Jensen] at 08:01 16 April 2012
222 C. J. Jensen et al.
Center for Substance Abuse Treatment. (2005). Substance Abuse treatment for per-
sons with co-occurring disorders (Treatment Improvement Protocol (TIP) Series,
Number 42, DHHS Publication number 08-3992). Rockville, MD: Substance
Abuse and Mental Health Services Administration.
Center for Substance Abuse Treatment. (2008). Substance abuse treatment for per-
sons with co-occurring disorders (Treatment Improvement Protocol (TIP) Series.
Number 42. DHHS Publication number 08-3992). Rockville, MD: Substance
Abuse and Mental Health Services Administration.
Crum, R., Puddey, I., Gee, G., & Fried, L. (2002, August). Reproducibility of two
approaches for assessing alcohol consumption among older adults. Addiction
Research & Theory, 10(4), 373–385.
Culberson, J. (2006a). Alcohol use in the elderly: Beyond the CAGE. Geriatrics,
61(10), 23–27.
Culberson, J. (2006b). Alcohol use in the elderly: Beyond the CAGE. Geriatrics,
61(11), 20–26.
Drug and Alcohol Services Information System. (2007). Adults aged 65 or older in
substance abuse treatment: 2005 (SAMHSA Treatment Episode Data Set [TEDS]).
Retrieved from
Egbert, A. (1993). The older alcoholic: Recognizing the subtle clinical clues. Geri-
atrics, 48(7), 63–69.
Fick, D. M., Cooper, J. W., Wade, W. E., Waller, J. L., Maclean, J. R., & Beers, M. H.
(2003). Updating the Beers criteria for potentially inappropriate medication use
in older adults: Results of a US consensus panel of experts. Archives of Internal
Medicine, 163, 2716–2724.
Glicken, M. D. (2009). Evidence-based counseling and psychotherapy for an aging
population. Burlington, MA: Academic Press.
Hazlett, R. W. (2009, July). Overview of the Florida brief intervention and treatment
for elders. Paper presented at the 2009 Center for Excellence in Aging and
Geriatric Health’s BRITE Orientation and Workshop, Williamsburg, VA.
Hulse, G., Lautenschlager, N., Tait, R., & Almeida, O. (2005). Dementia associated
with alcohol and other drug use. International Psychogeriatrics, 17, S109–S127.
Juan, D., Zhou, D. H. D., Li, J., Wang, J. Y. J., Gao, C., & Chen, M. (2004). A 2-year
follow-up study of cigarette smoking and risk of dementia. European Journal
of Neurology, 11, 277–282.
Klap, R., Unroe, K. T., & Unutzer, J. (2003). Caring for mental illness in the United
States: A focus on older adults. American Journal of Geriatric Psychiatry, 11,
Lang, I. A., & Melzer, D. (2009). Moderate alcohol consumption in later life: Time
for a trial? Journal of the American Geriatrics Society, 57, 1110–1112.
Luchsinger, J., Tang, M., Siddiqui, M., Shea, S., & Mayeux, R. (2004). Alcohol intake
and risk of dementia. Journal of the American Geriatrics Society, 52, 540–546.
Maples, M., & Abney, P. (2006). Baby boomers mature and gerontological counseling
comes of age. Journal of Counseling & Development, 84, 3–9.
Myers, J., Dice, C., & Dew, B. (2000). Alcohol abuse in later life: Issues and inter-
ventions for counselors. Adultspan: Theory Research & Practice, 2, 2–14.
National Institute on Alcoholism and Alcohol Abuse. (1998). Alcohol Alert No. 40.
Alcohol and Aging. Retrieved from
Downloaded by [Christine Jensen] at 08:01 16 April 2012
Overcoming Barriers to Care for Older Adults 223
O’Connell, H., Chin, A., Cunningham, C., & Lawlor, B. (2003). Alcohol use disorders
in elderly people: Redefining an age old problem in old age. British Medical
Journal, 327, 664–667.
Oslin, D., & Cary, M. (2003). Alcohol-related dementia: Validation of diagnostic
criteria. American Journal of Geriatric Psychiatry, 11(4), 441–447.
Oslin, D. W., & Holden, R. (2002). Recognition and assessment of alcohol and drug
dependence in the elderly. In A. M. Gurnack, R. Atkinson, & N. J. Osgood
(Eds.), Treating alcohol and drug abuse in the elderly (pp. 11–31). New York:
Oslin, D. W., Katz, I. R., Edell, W. S., & Ten Have, T. R. (2000). Effects of alcohol
consumption on the treatment of depression among elderly patients. American
Journal of Geriatric Psychiatry, 8, 215–220.
Ruitenberg, A., van Swieten, J. C., Witteman, J. C. M., Mehta, K. M., van Duijn,
C., Hofman, A., & Breteler, M. M. B. (2002). Alcohol consumption and risk of
dementia: The Rotterdam Study. Lancet, 359(9303), 281–286.
Sharp, L., & Vacha-Haase, T. (2011). Physician attitudes regarding alcohol use screen-
ing in older adult patients. Journal of Applied Gerontology, 30, 226–240.
Solfrizzi, V., Colacicco, A., Gagliardi, G., Santamato, A., & Panza, F. (2007). Lifestyle-
related factors, alcohol consumption, and mild cognitive impairment. Journal
of the American Geriatrics Society, 55, 1679–1681.
Substance Abuse and Mental Health Services Administration. (2003). Get connected:
Linking older Americans with medication, alcohol, and mental health resources
(DHHS publication number 03-3824). Rockville, MD: Substance Abuse and
Mental Health Services Administration, Center for Substance Abuse Treatment.
Substance Abuse and Mental Health Services Administration. (2005). National survey
on drug use and health. Rockville, MD: U.S. Department of Health and Human
Thomas, V. S., & Rockwood, K. J. (2001). Alcohol abuse, cognitive impairment, and
mortality among older people. Journal of the American Geriatrics Society, 49,
Tyas, S. (2001). Alcohol use and the risk of developing Alzheimer’s disease. Alcohol
Research & Health, 25(4), 299–306.
U.S. Census Bureau. (2005). 65C in the United States: 2005 (U.S. Census Bureau Cur-
rent Population Reports P-23-209). Washington, DC: U.S. Government Printing
Wetterling, T., Veltrup, C., John, U., & Driessen, M. (2003). Late onset alcoholism.
European Psychiatry, 18, 112–118.
Downloaded by [Christine Jensen] at 08:01 16 April 2012
  • [Show abstract] [Hide abstract] ABSTRACT: Alcohol use among older adults (65+) is thought to be one of the fastest growing health problems in the country. Although proper assessment and diagnosis is crucial in addressing problem drinking in this population, research suggests that physicians are not adequately screening their older adult patients for alcohol use. The present study examined the relationship between family physicians’ attitudes and perceptions and their screening prevalence with their new and existing older adult patients collected and analyzed in 2007. Results indicated that physicians in the study reported screening 73% of their new patients on intake and 44% of their existing patients. Family physicians with more positive perceptions of their alcohol-management skills with older adults performed more screening with their new and existing older adult patients. Year of medical school graduation was related to screening but only with new patients.
    Article · Apr 2011
  • [Show abstract] [Hide abstract] ABSTRACT: After the first descriptions of late onset alcoholism in the early 1970s, no systematic attention followed for more than a decade. In the past 10 years, however, that has changed, and this report seeks to summarize recently acquired knowledge about late onset problem drinking, including the author's own work on this phenomenon. The incidence of new alcoholism cases does decline with age but remains appreciable into the late sixties. Samples of ageing alcoholics in treatment show that as many as ¼ to ⅔ of cases had onset after age 60. Risk factors for late onset alcoholism include female gender, higher socioeconomic status and (in some but not all studies) life stressors, but neither psychiatric comorbidity nor positive family history of alcoholism appears to contribute in a majority of cases. Compared to longstanding alcoholics, late onset cases tend to be milder and more circumscribed, and they may also fluctuate more, with an apparently high likelihood of spontaneous remission, at least over the short term. These characteristics have implications for the use of brief and informal interventions to prevent and reduce late onset problem drinking, but also suggest caution in interpreting the response of late onset cases to treatment in uncontrolled studies. Present knowledge of late onset alcoholism is fragmentary; more systematic clinical research on its characteristics and treatment is needed.
    Article · Apr 1994
  • [Show abstract] [Hide abstract] ABSTRACT: This study examined multidimensional 6-month outcomes of elder-specific inpatient alcoholism treatment for 90 participants over the age of 55. At baseline, physical health functioning was similar to that reported by seriously medically ill inpatients in other studies while psychosocial functioning was worse, and nearly one third of the sample had comorbid psychiatric disorders. Based on 6-month outcomes, participants were classified into the following groups: Abstainers, Non-Binge Drinkers, and Binge Drinkers. The groups did not differ on any baseline measures (demographics, drinking history, alcohol symptoms and age of onset, comorbidity, or length of treatment). General health improved between baseline and follow-up for all groups. Psychological distress decreased for Abstainers and Non-Binge Drinkers, but did not change for Binge Drinkers. Results suggest that a large percentage of older adults who receive elder-specific treatment attain positive outcomes across a range of outcome measures.
    Article · Aug 2000
  • [Show abstract] [Hide abstract] ABSTRACT: The acute use of alcohol and several other licit and illicit drugs can affect mental state and cognitive function. The chronic use of certain drugs may also increase the risk of cognitive impairment and perhaps dementia in later life. This paper focuses on the long-term cognitive consequences of using alcohol, benzodiazepines, tobacco and cannabis. Currently available evidence indicates that mild to moderate alcohol consumption is not associated with increased risk of cognitive decline and may in fact have a protective effect against dementia, although heavy, long-term consumption is likely to have a negative impact on cognitive function. The degree that alcohol-related cognitive impairment must reach to be classified as dementia is currently obscure. Longer-term smoking is associated with increased risk of cognitive impairment and possibly dementia. The chronic use of benzodiazepines has been associated with increased risk of cognitive impairment but information relating to dementia remains inconclusive. The chronic use of cannabis may impair intellectual abilities but data on this topic remain sparse and difficult to interpret. In conclusion, there is evidence that some drugs contribute to the causal pathway that leads to the development of cognitive impairment but currently available data do not support the introduction of a separate diagnostic category of drug-induced dementia (such as alcohol-related dementia). Health promotion programs designed to decrease tobacco smoking and "harmful" alcohol use (and possibly other drug use) may decrease the burden of cognitive impairment and perhaps dementia in later life.
    Article · Feb 2005
  • [Show abstract] [Hide abstract] ABSTRACT: Some of the detrimental effects of heavy alcohol use on brain function are similar to those observed with Alzheimer's disease (AD). Although alcohol use may be a risk factor for AD, it is difficult to study this relationship because of similarities between alcoholic dementia and AD and because standard diagnostic criteria for alcoholic dementia have not yet been developed. Similar biological mechanisms may be involved in the effects of AD and alcohol abuse on the brain. Epidemiologic studies have investigated the relationship between alcohol use and AD but have not provided strong evidence to suggest that alcohol use influences the risk of developing AD. Further research is needed before the effect of alcohol use on AD is understood fully.
    Article · Feb 2001
  • [Show abstract] [Hide abstract] ABSTRACT: Medication toxic effects and drug-related problems can have profound medical and safety consequences for older adults and economically affect the health care system. The purpose of this initiative was to revise and update the Beers criteria for potentially inappropriate medication use in adults 65 years and older in the United States. This study used a modified Delphi method, a set of procedures and methods for formulating a group judgment for a subject matter in which precise information is lacking. The criteria reviewed covered 2 types of statements: (1) medications or medication classes that should generally be avoided in persons 65 years or older because they are either ineffective or they pose unnecessarily high risk for older persons and a safer alternative is available and (2) medications that should not be used in older persons known to have specific medical conditions. This study identified 48 individual medications or classes of medications to avoid in older adults and their potential concerns and 20 diseases/conditions and medications to be avoided in older adults with these conditions. Of these potentially inappropriate drugs, 66 were considered by the panel to have adverse outcomes of high severity. This study is an important update of previously established criteria that have been widely used and cited. The application of the Beers criteria and other tools for identifying potentially inappropriate medication use will continue to enable providers to plan interventions for decreasing both drug-related costs and overall costs and thus minimize drug-related problems.
    Full-text · Article · Dec 2003
Show more