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Roger Nicholas
Ann Roche
Nicole Lee
Stephen Bright
Katherine Walsh
PREVENTING AND REDUCING
ALCOHOL- AND OTHER DRUG-RELATED
HARM AMONG OLDER PEOPLE
A practical guide for
health and welfare professionals
ii
iii
Ageing is not lost youth
but a new stage of
opportunity and strength
Bey Friedan
iv
v
PREVENTING AND REDUCING
ALCOHOL- AND OTHER DRUG-RELATED
HARM AMONG OLDER PEOPLE
A practical guide for
health and welfare professionals
Roger Nicholas
Ann Roche
Nicole Lee
Stephen Bright
Katherine Walsh
vi
Citaon
Nicholas, R., Roche, A., Lee, N., Bright, S., & Walsh, K. (2015). Prevenng and reducing alcohol- and other drug-
related harm among older people: A praccal guide for health and welfare professionals. Naonal Centre for
Educaon and Training on Addicon (NCETA), Flinders University: Adelaide, South Australia.
ISBN: 978-1-876897-60-4
Acknowledgements
A resource like this cannot be produced without the extensive knowledge and hard work of many individuals. We
would like to gratefully acknowledge Mr Simon Ruth, for his vision and creave persistence in the establishment of
the Older Wiser Lifestyles (OWL) Program at Peninsula Health following his Travelling Fellowship which idened a
signicant service gap in Australia. We would also like to acknowledge the valuable contribuons of the Building
Up Dual Diagnosis Holisc Aged Services (BUDDHAS) working alliance, in parcular Dr Kathleen Ryan and Dr
Kar-Seong Loki. Dellie McKenzie RN and Adam Searby PhD(c) RN dedicated a wealth of experse in their reviews
of this project. A special menon is well deserved for the OWL Program clinicians, past and present, for their
dedicaon and commitment to both the program development and the consumers.
Last but not least, we greatly appreciate and acknowledge the following funding sources that have made the OWL
Program and this resource possible:
• Peninsula Health
• Victorian Department of Health and Human Services
• Australian Government Department of Health
• St. John of God Health Care.
The Older Wiser Lifestyles (OWL) Program, Peninsula Health, Victoria
Older Wiser Lifestyles (OWL) is Australia’s rst older adult age-specic alcohol and other drug (AOD) service. It
was established by Peninsula Health in 2009 following the idencaon of a service gap. OWL aims to elevate the
issues in regard to AOD use among older adults and provide leadership in the development and delivery of
evidence-based models of care.
Peninsula Health commissioned the Naonal Centre for Educaon and Training on Addicon (NCETA) to develop
this resource.
NCETA
The Naonal Centre for Educaon and Training on Addicon (NCETA) is an internaonally recognised research
centre that works as a catalyst for change in the alcohol and other drugs eld. Our mission is to advance the
capacity of organisaons and workers to respond to alcohol- and drug-related problems. Our core business is the
promoon of workforce development (WFD) principles, research and evaluaon of eecve pracces;
invesgang the prevalence and eects of alcohol and other drug use in society; and the development and
evaluaon of prevenon and intervenon programs, policy and resources for workplaces and organisaons.
NCETA is based at Flinders University and is a collaboraon between the University and the Australian
Government Department of Health.
This project formed part of NCETA’s program of work funded by the Australian Government Department of Health.
Tania Steenson, from NCETA, is thanked for the desktopping and preparaon of this report.
For further informaon about NCETA’s work on alcohol and other drugs and older people visit our website
www.nceta.inders.edu.au.
vii
Part 1: Introducon 1
1.1 Epidemiology 2
1.2 Reasons for alcohol and other drug use 7
1.3 AOD-related preventave measures 8
1.4 Reasons why older people experience alcohol and other drug harm 9
1.5 Physiological changes 9
1.6 ‘Safe’ limits for use of alcohol 10
1.7 Harms 11
1.8 The spectrum of use and harms 13
1.9 Early versus late onset problems 15
1.10 Mulple morbidies 15
1.11 Interacons with other medicines 20
1.12 Falls and other injuries 22
1.13 The experience of sgma 23
1.14 Vulnerability to exploitaon 23
1.15 Groups at parcular risk 24
Part 2: Prevenon and treatment 27
2.1 The importance of harm reducon and primary, secondary and terary prevenon eorts 28
2.2 Does treatment work? 32
2.3 Features of successful intervenons 32
2.4 Challenges to accessing help / treatment and responses 36
2.5 Enhancing communicaon with older clients 39
2.6 Primary health care and community services 40
2.7 Assessing readiness to change 44
2.8 Movaonal interviewing 48
2.9 Relapse prevenon and management 50
2.10 The role of AOD specialist services 50
Part 3: The Older Wiser Lifestyles (OWL) Program
Australia’s rst older person-specic AOD program 53
3.1 What is the OWL program? 54
3.2 OWL Early Intervenon (OWL-EI) 56
3.3 OWL Treatment (OWL-TR) 58
3.4 Promoonal and networking acvies and resources 61
3.5 OWL resources 61
3.6 Community awareness 62
3.7 Service sector awareness 62
3.8 Referral pathways 63
References 65
Contents
viii
ix
FOREWORD
This guide was developed to assist specialist and generalist clinicians to assess and respond to the needs of older
people experiencing, or at risk of experiencing, alcohol- and other drug-(AOD) related harm. Longer life expectancy,
more people living longer, and dierent expectaons of current and future generaons of older people will
increase service delivery demands.
This resource is a praccal guide for:
• Health workers
• Service providers
• Policy makers.
Alcohol and other drug use paerns and problems among older Australians have been under-researched and are
not well understood. It is an emerging area of concern that requires:
• Greater resources
• Improved understanding
• Changes in health service provision and delivery.
The term ‘older people’ can be dened in various ways. Here, we generally refer to people aged 55 years and
above. For Aboriginal and Torres Strait Islanders, services may also need to target people younger than 55 years.
The term ‘older people’ should not be interpreted to mean a single undierenated group. Sensive responses are
required to address the needs of the diverse populaon groups that fall under the broad umbrella heading of ‘older
people’.
The unique requirements of dierent age groups need to be addressed. Those aged 55-65, 66-80 and 80+ may
have had diverse life experiences and be at very dierent places in their life’s journey. Similarly, those from
dierent cultural backgrounds may have specic needs, as will Aboriginal and Torres Strait Islanders.
The substances addressed in this guide fall into four broad categories:
1. Alcohol
2. Illicit drugs (including cannabis, heroin, amphetamines)
3. Medicines used in opioid substuon therapy (OST)
4. Prescripon and over the counter (OTC) drugs.
Each drug group is addressed separately, followed by generic principles applicable across all AOD issues. Finally,
this resource contains details of the Older Wiser Lifestyles (OWL) Program as an example of an intervenon and
response approach.
x
1
PART 1: INTRODUCTION
Summary
Alcohol- and other drug-(AOD) related harms among older Australians are
increasing.
Australia’s populaon is ageing and the current cohort of ‘younger older’
Australians (i.e., the ‘baby boomers’ born between 1946 and 1964) use alcohol and
other drugs at higher rates than their predecessors. Consequently, a larger number
of older people will require treatment for substance use problems in the future.
Problemac use of alcohol and illicit drugs is increasing among older Australians, as
is the use of prescribed psychoacve drugs. In addion, opioid substuon clients
are ageing.
Older harmful substance users can be categorised as:
• Maintainers (those whose previously unproblemac use has become
harmful)
• Reactors (late onset users)
• Survivors (early onset users).
Older Australians are highly heterogeneous and require a range of prevenon and
treatment programs that reect this diversity.
Older people use alcohol and other drugs for similar reasons to the rest of the
populaon, but have physiological, psychological and social characteriscs that
make them more vulnerable to problemac use.
Many older people with substance use problems have physical and mental health
comorbidies and are vulnerable to interacons between prescribed and non-
prescribed substances.
Older Australians parcularly at risk of AOD-related harm include:
• Aboriginal and Torres Strait Islanders
• Culturally and linguiscally diverse people
• Lesbian, gay, bisexual, transgender, queer, and intersex people
• Women
• Injecng drug users.
2
1.1 Epidemiology
1.1.1 Demographics
Australia’s populaon is ageing, primarily as a result of sustained low ferlity and increasing life
expectancy. The proporon of the populaon aged ≥65 years is projected to increase from 14% in
2014 to 18-20% in 2032 (see Figure 1).
Current projecons suggest that there will be 40,000 people aged over 100 years by 2054-55. This is:
• Almost nine mes the number in 2014-15
• Well over 300 mes the number in 1974-75 (The Treasury, 2015).
In the next 40 years, there will also be substanal reducons in the number of people aged 15 to 64
relave to the number of people aged 65 and over (see Figure 2). By 2054-55, more than 22% of the
Australian populaon will be aged ≥65 years, compared to 15% today (The Treasury, 2015).
Current demographic trends have major implicaons for the future provision of services to older
people with alcohol and other drug problems.
Baby boomers use alcohol and drugs at higher rates than previous generaons, and greater numbers
of older people will experience harm as a result (Han, Gfroerer, & Colliver, 2009; Hunter, Lubman,
& Barra, 2011). Even if the proporon of older adults with AOD problems remained constant, the
increased size of this populaon will produce a dramac growth in the absolute number of older
people with AOD problems (Dowling, Weiss, & Condon, 2008).
Year
0–14
15–24
25–44
45–64
65+ 85+
30
25
20
15
10
5
Millions Projection
Figure 1: Historical and projected Australian populaon, 1922–2032
Source: Australian Instute of Health and Welfare, 2013.
3
In the future
greater proporons of
Australia’s populaon will be
aged over 65 years.
There will also
be fewer younger people
available to care for
older adults.
Figure 2: Number of people aged 15 to 64 relave to the number of
people aged 65 and over
Source: The Treasury, 2015.
1.1.2 Patterns of use
1.1.2.1 Alcohol
Alcohol is the most commonly used drug and causes most AOD-related problems and harms among
older people. Between 2001 and 2013, among 60-69 year olds:
• Short-term risky drinkers1 increased by 31% (12.4% vs 16.3%)
• Lifeme risky drinkers2 increased by 20% (15.5% vs 18.6%) (see Figure 3).
12.4%
15.5%
16.3%
18.6%
Short-Term Risky Drinkers Lifetime Risky Drinkers
2001 2013
Figure 3: Percentage of Australians aged 60-69 who were short-term and lifeme risky drinkers 2001 and
2013 – Naonal Drug Strategy Household Survey data
Source: Australian Instute of Health and Welfare, 2014a.
1 Short-term risky drinking is dened by NHMRC as the consumpon of more than 4 standard drinks on a single occasion at
least once per month.
2 Lifeme risky drinking is dened by NHMRC as the consumpon of more than 2 standard drinks per day on average.
4
The data in Figure 3 may be conservave due to under-reporng. Older people also pour alcohol-
ic drinks that are 16-32% larger than a standard drink (10 grams of alcohol). Older men have been
shown to over-pour spirits by 58% (Wilkinson, Allsop, & Chikritzhs, 2011).
Older people also comprise the largest proporon of the populaon who drink on a daily basis (see
Figure 4).
27%
16% 16% 20%
32%
40%
37% 30% 26%
24%
30%
36%
35% 27%
20%
3%
7%
11%
13% 10%
1%
4%
9% 14% 15%
14-24 25-39 40-59 60-69 70+
Age Group
Abstainers 1-3 days p/mth 1-4 days p/wk 5-6 days p/wk Everyday
Figure 4: Frequency of Australian alcohol consumpon by age group 2013
Source: Naonal Centre for Educaon and Training on Addicon (2015a). Secondary analysis of Naonal Drug
Strategy Household Survey data (Australian Instute of Health and Welfare, 2014a).
In sucient quanes, daily drinking can:
• Impair funconality and hand-eye coordinaon
• Cause sleeping dicules
• Elevate cancer risk (especially bowel and breast cancer)
• Contribute to economic hardship and weight gain.
Older Australians (especially women) living in rerement villages appear to drink more frequently
than those living in private homes, but do not necessarily consume larger quanes of alcohol. This
may stem from:
• Greater levels of social engagement in rerement villages, facilitang opportunies to
drink alcohol
• No need to drive home aer social acvies
• Posive normave drinking pracces within rerement village communies (Wilkinson,
Dare, Waters, Allsop, & McHale, 2012).
The type of alcohol people drink also changes over the life span. Older people consume
proporonally more cask, boled and fored wine, and low strength beer (Naonal Centre for
Educaon and Training on Addicon, 2015a).
5
1.1.2.2 Other drugs (illicits)
In previous generaons, it was rare for an older person to use illicit drugs. Today, a substanal
proporon of older people have previously used some form of illicit drug and some have connued
to do so as they have aged (Beynon, 2009; Han et al., 2009; Wu & Blazer, 2011). Recent illicit drug
use (i.e., last 12 months) among older Australians has also increased over the past decade, in
contrast to other age groups where drug use has declined (see Figure 5).
0
5
10
15
20
25
30
35
40
14–19 20-29 30-39 40–49 50–59 60+
Per cent
Age Group (Years)
2001 2004 2007 2010 2013
Figure 5: Recent illicit use of any drug, people aged 14 or older, by age, 2001 to 2013
Source: Naonal Centre for Educaon and Training on Addicon (2015a). Secondary analysis of Naonal Drug
Strategy Household Survey data (Australian Instute of Health and Welfare, 2014a).
Cannabis is the illicit drug most frequently used by older Australians, with 7.3% of 50-59 year olds
and 1.2% of 60+ year olds having used it in the last 12 months (Australian Instute of Health and
Welfare, 2014a).
1.1.2.3 Opioid substitution therapy (OST)
Australians receiving OST are ageing. From 2006 to 2013 the proporon of OST clients aged <30
years more than halved (from 28% to 11%), while those aged ≥50 more than doubled (from 8% to
19%) (see Figure 6). Contributory factors include:
• Some clients remaining in treatment for several decades
• Pharmacotherapy treatment reducing the risk of premature death
• More clients seeking treatment for the rst me at an older age
(Australian Instute of Health and Welfare, 2014b).
6
7.9%
10.6% 11.1%
13.3% 14.1%
16.0%
17.7%
19.4%
0%
5%
10%
15%
20%
25%
2006 2007 2008 2009 2010 2011 2012 2013
Figure 6: Proporon of clients aged ≥50 years receiving opioid pharmacotherapy in Australia on a snapshot
day 2006-2013
Source: Australian Pharmacotherapy Data (Australian Instute of Health and Welfare, 2014b).
1.1.2.4 Prescription and over the counter (OTC) drugs
The use of sleeping and sedave medicaon is highest among Australians aged ≥65 years, and peaks
among those aged 85–89. Those aged 85–89 use these medicaons at a rate ve mes that of
people aged 45–49. Use among women is 1.5 mes greater than among men. Use of
benzodiazepines, especially temazepam, nitrazepam and oxazepam is parcularly high among older
people (Hollingworth & Siskind, 2010).
Use of prescripon opioids also peaks among older Australians. Between 2002-03 and 2007-08
oxycodone prescribing increased substanally, parcularly among those aged 80+ years (see Figure
7). Between 2002 and 2012, fentanyl prescripons also increased dramacally among this age group
(Roxburgh et al., 2013).
Use of strong opioids may increase endocrine and sexual dysfuncon, osteoporosis and hyperalgesia
(Baldini, Von Kor, & Lin, 2012). Long-term, high-level use of OTC opioid-containing medicines can
lead to gastro-intesnal perforaon, clong disorders and liver and kidney problems (related to the
paracetamol and ibuprofen they contain) and codeine dependence (Dobbin, 2008).
A recent study (Veal, Bereznicki, Thompson, & Peterson, 2015) raised concerns regarding the use of
opioids by vulnerable older Australians. The study involved a sample of 20,000 older people who
were either living in the community and deemed at risk for adverse medicaon outcomes or living
full me in an aged care facility.
Issues highlighted in the study included:
• The high prevalence of opioid use (32%), with 22% receiving regular dosages
• Nearly 12% of regular opioid users exceeded maximum recommended dosages
• Over-reliance on opioid analgesics at the expense of non-opioid analgesics
7
• Concurrent use of sedaves and opioids was commonplace
• Sedave use was most common among those receiving high dose opioids, increasing the
risk of falls and fractures
• Insucient use of laxaves to prevent opioid-related conspaon.
The study concluded that there is a signicant evidence-to-pracce gap regarding the use of opioids
among older Australians (Veal, Bereznicki, Thompson, & Peterson, 2015).
Figure 7: Prescripons for oxycodone dispensed on the Australian Pharmaceucal Benets Scheme from 2002
to 2008, per thousand populaon, by 10-year age groups
Source: Roxburgh, Bruno, Larance, & Burns (2011).
1.2 Reasons for alcohol and other drug use
Older people use alcohol and other drugs for much the same reasons as the rest of the populaon,
namely:
• For pleasurable eects and social funcon
• To block out physical pain
• To block out emoonal pain.
Changes in alcohol and drug use as people age can occur for a number of reasons, including:
• Increased free me
• Boredom
• Loss of identy
• Loss and grief
• Loneliness.
8
Increases in disposable income and buying power of many older people may also facilitate greater
alcohol and drug consumpon and associated problems (Anderson, Scafato, & Galluzzo, 2012).
Evidence regarding the role of rerement on alcohol problems among older adults is variable. There
are many studies which suggest that rerement:
• Increases drinking
• Decreases drinking
• Has no impact on drinking
(Bamberger, 2014).
It is not rerement itself which exclusively impacts paerns of drinking. Rather, drinking is
inuenced by a range of individual, social, and environmental characteriscs that include:
• Whether rerement was voluntary or involuntary
• The person’s gender and health status (e.g., pain or sleep problems)
• A history of problem drinking
• Extent of stressors in rerement (e.g., nancial, marital)
• Whether harmful drinking was part of the former workplace culture or post-work social
networks
• Whether rerement is perceived by the reree as a ‘loss’ or a ‘relief’
• The extent of non-work-related support networks
(Bamberger, 2014; Kuerbis & Sacco, 2012).
There are also more medicaons available now to treat more condions than ever before. Increased
awareness of these medicaons may drive increased use of psychoacve substances as the use of
these substances becomes more normalised. Further, some members of the baby boomer
generaon may hold expectaons of a ‘quick-x’ which may contribute to greater use of medicaons
(Dowling et al., 2008).
Larger numbers of older people are using alcohol and other drugs in conjuncon with prescribed
and OTC medicaons. Some combinaons are contra-indicated and can result in adverse outcomes
(see Table 3, p21). Many such medicaons may not provide informaon about their potenal for
adverse interacons with alcohol.
1.3 AOD-related preventative measures
Australians are living longer and more healthily. A range of measures (such as health screening,
u shots, diabetes control measures, and prevenve medicaons) have averted many premature
deaths. AOD-related preventave measures include:
• Widespread introducon of opioid substuon programs
• Needle and syringe programs
• Enhanced treatments for blood borne and other AOD-related diseases.
However, improved health status and advances in health care can reduce incenves to modify
problemac AOD use (Dowling et al., 2008).
9
1.4 Reasons why older people experience alcohol and other drug
harm
AOD-related dicules among older Australians may result from:
• Social factors, including:
Rerement (and associated boredom and loss of idenfy)
Increased aordability of AOD
Bereavement (and associated grief, loss and loneliness)
Social isolaon
Poverty
Homelessness
• Psychological factors, including:
Depression
Anxiety
Insomnia
Stress
Loneliness
• Physical factors, including:
Chronic painful illness resulng in long-term use of analgesics, alcohol and illicits
Physiological changes leading to dierences in drug eects
Comorbid medical / psychological condions
(DrugScope, 2014).
1.5 Physiological changes
As people age, their ability to metabolise drugs decreases. There is also an ageing-related decrease
in the body’s water to fat rao. A reducon in body water can:
• Increase drug concentraons
• Reduce liver blood ow
• Decrease liver enzyme eciency.
The eects of alcohol or other drugs can therefore be more pronounced and longer-lasng at lower
thresholds. This can increase suscepbility to AOD problems among older people.
Alcohol, for example, may produce a more rapid depressant eect and increased impairment of
motor coordinaon and memory funcon in older people (Royal College of Psychiatrists, 2011). For
a given quanty of alcohol, older people will generally have a higher blood alcohol concentraon
compared to younger people.
10
Individual dierences in metabolism can be dicult to predict (Kinirons & O'Mahony, 2004) for:
• Alcohol
• Illicit drugs
• OST
• Prescribed and OTC medicines.
Underlying and / or compounding problems may include:
• Anxiety
• Depression
• Post-traumac stress disorder
• Drug-induced psychosis
• Schizophrenia
• Delirium3
• Demena (Royal College of Psychiatrists, 2011).
As people age, the toxic eects of alcohol or drug use and associated diseases (e.g., blood borne
viruses) can compromise the body’s ability to recover from related illnesses.
Older drinkers are more vulnerable to alcohol-related harm than their younger counterparts, even
when drinking at relavely low levels. Older heavy drinkers with health problems are parcularly
vulnerable (Royal College of Psychiatrists, 2011). Older problem drinkers also have more physical
health problems related to their drinking than younger people, even if they drink less and are less
alcohol dependent (Gossop et al., 2007).
Excessive drinking among older people is complicated by a reduced capacity to break down alcohol
and can cause or aggravate medical problems associated with ageing. Because older heavy drinkers
with health problems are at elevated risk, they should be targeted for intervenon (Gossop, 2008).
1.6 ‘Safe’ limits for use of alcohol
There has been lile research on safe, or low risk, limits for older people’s use of alcohol. General
populaon consumpon guidelines may not be suitable, as they were developed from research
conducted with younger populaons. Their applicability to older populaons has not been
conrmed.
Current guidelines (Naonal Health and Medical Health Research Council, 2009) do not indicate a
low risk consumpon level for older people, but state that the lifeme risk of harm from alcohol-
related disease or injury is minimised for healthy men and women when they drink:
no more than two standard drinks
4
on any one day.
3 Delirium, for example, may be associated with withdrawal from alcohol or benzodiazepines, but can also be the result of
demena, head injury or serious infecon (Royal College of Psychiatrists, 2011).
4 A standard drink in Australia contains 10 grams of alcohol.
11
The guidelines highlight that drinking alcohol increases the risk of falls and injuries and some chronic
condions, and suggest that older people should drink less than the general recommended
guidelines and that they should consult their health professionals about an appropriate level of
drinking.
Clinicians should be conservave when advising older paents about low risk use of alcohol, illicit
drug use, opioid substuon therapy medicines, and prescribed and OTC drugs (see Secon 1.11
(p19)).
It is important that advice is tailored to each individual’s
circumstances and risk factors such as:
• Concurrent medicaon use
• Physical health
• Psycho-social context.
1.7 Harms
Changing paerns of alcohol and drug use among older people, as highlighted above, have resulted
in increased harms.
Victorian ambulance data have found an increase in aendances for intoxicaon related to alcohol,
benzodiazepines and pain medicaons for people aged over 65. Alcohol intoxicaon-related
aendances nearly trebled from 3.3 individuals per 10,000 in 2004 to 8.2 per 10,000 in 2008 (Hunter
et al., 2011).
The number and proporon of older people who received publicly funded treatment for alcohol
and other drug problems in Australia also increased over the past decade. Among those aged 60-69
there was a 79% increase in treatment episodes. In 2012/13, there were 4,343 treatment episodes
for 60-69 year olds (2.7% of all episodes) up from 2,419 episodes (1.8% of all episodes) in 2003/04
(see Figure 8).
12
Figure 8: Total number of publicly funded alcohol and other drug treatment episodes for older Australians
2003/04 to 2012/13
Source: Naonal Centre for Educaon and Training on Addicon (2015b). Secondary analysis of Alcohol and
Other Drug Treatment Services Naonal Minimum Data Set (Australian Instute of Health and Welfare, 2014).
Publicly funded AOD treatment episodes for those aged ≥50 years rose from 9.6% in 2003/04 to
12.1% in 2012/13, an increase of 26% (Naonal Centre for Educaon and Training on Addicon,
2015b).
16%
18%
25%
23%
13%
5%
0-29 30-39 40-49 50-59 60-69 70+
Age Group
Figure 9: Alcohol-caused hospitalisaons by age group, Australia 2009-2010
Source: Naonal Centre for Educaon and Training on Addicon (2013b). Secondary analysis of Naonal
Hospital Morbidity Database 2009/10 (Australian Instute of Health and Welfare, 2011).
Hospitalisaons caused by alcohol also increase with age and peak among those aged 40-49
(Naonal Centre for Educaon and Training on Addicon, 2013c) (see Figure 9). Falls,
supraventricular cardiac dysrhythmias and alcohol dependence were the major causes of alcohol-
related hospitalisaon among Australians aged 65-74 between 1994-2003 (Chikritzhs & Pascal, 2005)
(see Table 1).
13
Deaths due to alcohol-aributable diseases peak among 50-69 year olds (see Figure 10). Older
Australians aged 65-74 years living in non-metropolitan areas are more likely to die from alcohol-
aributable condions than city dwellers. Alcoholic liver cirrhosis and haemorrhagic stroke are the
major causes of death among this age group (Chikritzhs & Pascal, 2005) (see Table 1).
Table 1: Causes of alcohol-related deaths and hospitalisaons
Most common causes of alcohol-related death and hospitalisaon
among Australians aged 65-74 between 1994-2003 (Chikritzhs & Pascal, 2005)
Causes of death Causes of hospitalisaons
• Alcoholic liver cirrhosis
• Haemorrhagic stroke
• Falls
• Supraventricular cardiac
dysrhythmias
• Alcohol dependence
7%
19%
30%
26%
19%
14-39 40-49 50-59 60-69 70+
Age Group
Figure 10: Australian deaths due to alcohol-caused diseases, 2010
Source: Naonal Centre for Educaon and Training on Addicon (2013b). Secondary analysis of 2010 Australian
mortality data (Australian Bureau of Stascs, 2010).
1.8 The spectrum of use and harms
Alcohol and other drug use among older people occurs along a spectrum. At one end of the
spectrum are individuals who do not use any alcohol or drugs. Among those who do use alcohol or
drugs, some people experience unproblemac use while others may develop a range of problems.
Individuals can move backwards and forwards along the spectrum of use (see Figure 11).
14
Figure 11: The spectrum of alcohol and other drug use and problems
Dierent approaches are needed to prevent and reduce harm at various points on the spectrum.
Educave measures may be appropriate for non-users or non-problemac users to help maintain the
status quo or idenfy emergent problems. Problems related to intoxicaon or regular hazardous use
(see Figure 12) may respond to brief intervenon. Clients who are dependent may require
counselling and withdrawal services.
Issues related to problemac AOD use fall into three groups:
• Intoxicaon
• Regular hazardous use
• Dependence (see Figure 12).
These paerns of problems:
• May be disnct or overlap in the same individual
• Can stem from dierent contributory factors
• Require dierent responses and intervenons.
Intoxication problems
Accidents, Falls,
Medication interactions,
Misadventure,
Poisoning, Hangovers,
Risky behaviour
Regular hazardous
use problems
Health harms,
Impaired
relationships,
Financial problems
Dependence
problems
Impaired control,
AOD-centred
behaviour,
Withdrawal
Figure 12: Dierent types of alcohol and drug problems
15
1.9 Early versus late onset problems
Older harmful substance users can be categorised as:
• Maintainers
• Reactors (late onset users) (Schonfeld & Dupree, 1991)
• Survivors (early onset users) (Schonfeld & Dupree, 1991).
The maintainer / survivor/ reactor typology parcularly applies to alcohol and prescripon drugs.
The extent to which it also applies to illicit drugs is unclear, as studies to-date have largely
overlooked illicit drug use among older populaons (Wu & Blazer, 2011).
Three factors could potenally facilitate the uptake of illicit drug use among older people:
• The medicalisaon of cannabis for the treatment of pain and other condions (Leung,
2011) may enhance uptake among older people for non-medical purposes
• As a greater proporon of baby boomers used illicit drugs when they were younger
compared with previous cohorts (Han et al., 2009; Wu & Blazer, 2011) they may be more
likely to recommence illicit drug use later in life
• The high level of prescripon opioid (and OTC) use among older people may act as a
pathway to heroin use as has been seen overseas (Dertadian & Maher, 2014; Kolodny
et al., 2015; Lankenau et al., 2012; Mars, Bourgois, Karandinos, Montero, & Ciccarone,
2014).
1.10 Multiple morbidities5
Mulple morbidies are common among older people experiencing AOD problems. Health care
advances have averted many substance-related deaths, and more people are surviving into older age
with comorbidies as a result. Ageing is associated with a range of social, psychological and health
problems which can be risk factors for, and / or exacerbated by, substance use. These may also lead
to the development or connuaon of substance use problems to cope with physical or psychologi-
cal pain / distress (Gossop, 2008).
Mulple morbidies can interfere with physical funconing and emoonal, cognive and social
behaviour and result in poorer outcomes. Comorbidies also make assessment and treatment more
dicult (Royal College of Psychiatrists, 2011).
1.10.1 Mental health comorbidities
Mental health / alcohol and other drug comorbidies are common across the Australian community
(see Figure 13). These comorbidies are also common among older people but widely under-
diagnosed (Royal College of Psychiatrists, 2011; Searby, Maude, & McGrath, 2015).
5 At the me of wring, work was currently underway on the development of a manual for clinicians whose clients are aged
55 years and older and have a mental illness and / or use substances. The resource is being developed by Building Up Dual
Diagnosis Holisc Aged Services (BUDDHAS) under the auspices of the Victorian Dual Diagnosis Iniave.
16
Table 2: A typology of older users
Group Characteriscs Case Illustraon
Maintainers
This group has connued previously
unproblemac use into old age.
Ageing-related changes and comorbidies
aect the body’s ability to absorb,
distribute and excrete alcohol and other
drugs.
Levels of use that may be relavely
unproblemac in younger years can
become harmful in older age.
Age-related changes in metabolism may
result in AOD harms later in life.
Mrs H is a 66-year-old woman living alone
in a rerement village aer the death of her
husband 6 years ago. On most evenings over
the past forty years she has enjoyed 2 large
glasses of white wine. She exceeded this
amount only on special occasions. Recently
she has had a series of falls aer returning
home from social funcons at the rerement
village at which alcohol was served. Her GP
informs her that her liver enzyme results and
blood pressure are both elevated. It appears
that Mrs H is not able to metabolise alcohol
as well as in the past.
Reactors
Usually begin problemac drinking in their
50s or 60s.
Can have problems related to intoxicaon,
regular hazardous use or dependence.
Tend to have a stronger associaon with
stressful / adverse life events such as
bereavement, rerement, marital
breakdown and social isolaon.
Tend to have a beer prognosis than
survivors.
Are less likely to know where to seek help
and be too embarrassed to speak with
their GP
(Royal College of Psychiatrists, 2011).
Mr W, a 73-year-old rered pharmacist, lives
alone in his own house since his wife’s death
3 years ago. He has been experiencing
progressive memory loss over the last 2
years along with deteriorang self-care,
weight loss and several falls. His daughter
is concerned that he is becoming muddled,
parcularly when driving. His daughter said
that Mr W’s drinking has gradually increased
since his wife’s death and he was now
drinking at least half a bole of scotch per
day.
Survivors
Have a long history of substance use which
persists into older age.
Oen have mulple morbidies.
Make up two thirds of older problem
drinkers in the US (Rigler, 2000).
Are more likely to experience loneliness
and depression as a result of their AOD-
related problems, having alienated
signicant others over a long period of
me (Schonfeld & Dupree, 1994).
May have less self-ecacy than reactors as
a result of mulple aempts at treatment
(Wadd, Lapworth, Sullivan, Forrester, &
Galvani, 2011).
Oen have beer knowledge of the AOD
services that are available.
Mr B is a 74-year-old man living in rented
accommodaon with his wife. He has
mulple chronic alcohol-related physical
problems, which have resulted in many
hospital admissions. He has been drinking
at least two boles of wine per day for
almost 40 years. He lost his job in his late
50s because of his drinking. His wife can no
longer cope with him as a result of his poor
hygiene, threatening behaviour, drink
driving and poor medicaon adherence.
17
23%
3% 3%
15% 13%
44%
Anxiety disorder
only
Affective
disorder only
Other drug use
disorder only
Anxiety and
affective
disorder
Anxiety or
affective
disorder plus
other drug use
disorder
No other mental
disorder
Type of Disorder
Figure 13: Mental health comorbidies amongst Australians with an alcohol disorder
Source: Naonal Centre for Educaon and Training on Addicon (2013). Secondary analysis of 2007 Naonal
Survey of Mental Health and Wellbeing (Australian Bureau of Stascs, 2009).
Many older people with major alcohol-related problems have a history of depression (Caputo et al.,
2012). Alcohol problems can be 3 to 4 mes more common among depressed compared to non-
depressed older people (Devanand, 2002). The relaonship between alcohol and late life depression
is complex, but depressed older people who stop drinking improve more than those who connue
to drink (Caputo et al., 2012).
One Australian study of males in Geelong reported a U-shaped relaonship between alcohol
consumpon and depression among older people. Depression was most prevalent among non-
drinkers and those drinking ≥3 drinks per day, and lowest among moderate drinkers (Coulson et al.,
2014).
Substance use problems can:
• Worsen or precipitate mental health problems, including demena
• Trigger the onset of mental health problems in suscepble individuals
• Be an aempt to self-treat or relieve mental health symptoms
• Lead to general life dicules which can precipitate or worsen mental health problems
(Substance Abuse and Mental Health Services Administraon, 1998).
Comorbid AOD and mental health problems among older people are oen associated with:
• Frequent relapse
• Poor treatment engagement
• Unsasfactory treatment outcomes overall
(Searby et al., 2015).
18
Other mental health comorbidies among older people with AOD problems include:
• Anxiety
• Confusional states
• Sleep problems
• Post-traumac stress disorder
• Drug-induced psychosis
• Schizophrenia
• Self-harm
• Delirium
(Royal College of Psychiatrists, 2011).
Heavy, prolonged alcohol use may also increase risk of vascular demena and Alzheimer’s disease. In
addion, it can have indirect eects on brain funcon through decreased absorpon of thiamine,
resulng in problems such as Wernicke–Korsako syndrome. Alcohol may also have a direct
neurotoxic eect, producing ‘alcoholic demena’. The management of alcohol misuse in paents
with cognive impairment / demena presents a signicant clinical challenge (Royal College of
Psychiatrists, 2011).
Case study 1: Mental health comorbidies
Eric is a 64-year old ler who had been treated for depression by his GP for six years. His GP
prescribed an andepressant, which he had been taking in increasing doses, but his
depression was worsening. An assessment by a locum GP revealed he was drinking a carton
of full strength beer per day (360 grams or 36 standard drinks) and was alcohol dependent.
Following admission to a detoxicaon facility Eric stopped drinking for ve months and his
mood improved. However he relapsed and began drinking at former levels. He was again
admied to a detoxicaon facility and then engaged with a counsellor as an outpaent.
One year later Eric was sll not drinking, was no longer depressed and was reducing his
andepressant use.
1.10.2 Physical comorbidities
Mulple physical morbidies are largely the norm among older people experiencing severe AOD
problems. The physical complicaons of alcohol use are numerous and manifest in almost all organs
of the body (Crome & Bloor, 2005). Problem alcohol and other drug use can cause and exacerbate
some medical problems.
Interacons between these morbidies can not only interfere with physical funconing and
emoonal, cognive and social behaviour, but can result in poorer treatment adherence and short-
and longer-term outcomes (Royal College of Psychiatrists, 2011).
19
Common physical comorbidies include:
• Injuries related to falls and trauma
• Cardiovascular problems (e.g., hypertension, heart enlargement, heart rhythm and blood
clong abnormalies, hyperlipidaemia, stroke)
• Liver diseases (e.g., fay liver, brosis, infecve and non-infecve hepas and cirrhosis)
• Blood borne diseases
• Irritable bowel syndrome and inconnence
• Dietary deciencies, diabetes, malnutrion and pancreas
• Overweight and obesity
• Seizures and neuropathy
• Sexual dysfuncon
• Cancers (parcularly mouth, oesophagus, throat, liver and breast)
• Immune system impairments
(Devanand, 2002; Hunter & Lubman, 2010; Royal College of Psychiatrists, 2011; Substance
Abuse and Mental Health Services Administraon, 1998).
Case study 2: Physical and mental health comorbidies
Frank is a 72 year old single man who had been a long-term heavy drinker (>200 grams of
alcohol / day, >20 standard drinks per day) living in unstable accommodaon at a boarding
house. On presentaon to an orthopaedic ward following a fall which badly fractured his arm,
he was found to have very high blood pressure and liver cirrhosis. He was very distrusng of
hospital sta. A subsequent psychiatric review found that he had a severe generalised anxiety
disorder with evidence of signicant cognive decline. A case management meeng was
iniated involving orthopaedic, psychiatric, alcohol and other drug, and social work team
members as well as his GP.
Frank made a full recovery from his fracture and he found accommodaon in an aged care
facility. His ongoing care was coordinated by his GP with assistance from psychiatric and
alcohol and other drug outreach service sta.
20
1.11 Interactions with other medicines
Many older Australians are regular users of prescripon and OTC medicines. As a result, there is a
risk of adverse interacons with other AOD use.
1.11.1 Interactions with alcohol
Alcohol can interact in harmful and unpredictable ways with many prescribed and OTC medicaons
and some herbal preparaons (see Table 3, p21). Such interacons may:
• Change the eect of the alcohol and / or the medicaon
• Occur at low levels of drinking (as low as one standard drink)
• Vary depending on the medicaons and individual dierences.
Alcohol dampens acvity in the brain (by depressing the central nervous system). When used with
medicaons or other drugs that have similar eects, these aects can be amplied and increase po-
tenal for harm especially if operang machinery or when engaged in other risky acvies.
Older people taking medicaons or other health preparaons:
• Should carefully read the labels and pamphlets with their medicaons (including herbal
preparaons), to check for harmful interacons with alcohol
• Seek advice from a health professional about potenal interacons as some products do
not state this on the label or in the informaon pamphlet. Health care professions should
be encouraged to check MIMS or consult with a pharmacist to ensure full and accurate
advice is provided
• May need to reduce or cease alcohol consumpon
• Need to be very cauous if drinking alcohol while using:
benzodiazepines
methadone (or other forms of opiate substuon)
analgesic patches
other central nervous system depressants
• Are at greater risk of harmful interacons if taking a number of medicaons
(Australian Government Department of Veterans’ Aairs, n.d.).
Health care providers should:
• Be aware of the possibility of medicaon interacons with alcohol
• Advise the client of possible interacons and eects
• Be parcularly mindful of potenal interacons when prescribing medicaons for mental
health problems, pain and blood pressure.
1.11.2 Interactions with illicit drugs
Illicit drugs can interact with medicines in a range of ways (see Table 4, p22.)
21
Table 3: Potenal eects of medicines used in combinaon with alcohol (Source: Drug Educaon Network, 2014)
Type of substance Potenal eects in combinaon with alcohol
Andepressants and anpsychocs
Impaired mental skills
Worsening of psychiatric symptoms
Sedaon and impaired breathing
Drop in blood pressure
Liver damage
Anhistamines Drowsiness, sedaon, dizziness
Sedave hypnocs
Drowsiness
Decreased motor skills and breathing
Fatal overdose
Anbiocs
Nausea, voming, headache
Convulsions
Liver damage
Sedaon
Medicaon to control diabetes
Headache
Nausea
Reduced diabetes control
Medicines that contain alcohol Increased alcohol intake
Increased intoxicaon eects
Heart and circulatory system medicaon
Dizziness
Fainng
Reduced medicaon eecveness
Ancoagulants Increased risk of bleeding
Decreased medicaon eecveness
Arthris medicaons
Stomach upset including gastrointesnal bleeding
Stomach inammaon
Increased risk of liver damage
Opioid-based pain medicaons
Increased sedaon
Decreased motor skills
Overdose
An-seizure medicaon Decreased medicaon eecveness
Increased medicine side eects
22
Table 4: Potenal interacons between illicit drugs and medicines (Dean, 2006; Lindsey, Stewart, & Childress, 2012)
Illicit drug Medicine Potenal resultant interacon
Cannabis
Andepressants Mania, fast heartbeat, delirium
Erecle dysfuncon drugs Heart aack
An-alcohol misuse medicine Hypomania
Anpsychocs Reduced treatment eecveness
Sedave hypnocs, pain medicines Sedaon, central nervous system depression
Anviral drugs Reduced anviral eecveness
Amphetamine
type
smulants
(ATS)
Andepressants Severely elevated blood pressure
An-seizure medicaon Increased likelihood of seizures
Blood pressure medicines Reduced treatment eecveness
Anpsychocs Reduced treatment eecveness
Urinary alkalinisers Increased eect and duraon of ATS
Heroin Sedave hypnocs, pain medicines Sedaon, reduced breathing, low blood
pressure, fatal overdose
1.12 Falls and other injuries
Alcohol and other drug use is a major risk factor for falls and injuries. Risk is further exacerbated
when medicines are used concurrently with alcohol or other drugs and in the presence of comorbid
condions, parcularly demena (Mallet, Spinewine, & Huang, 2007; Royal College of Psychiatrists,
2011).
It is especially important to consider alcohol and other substance use-related problems among
clients who present with unexplained falls (Royal College of Psychiatrists, 2011).
Alcohol misuse is an important risk factor for falls and fractures as it can cause:
• Confusion
• Low blood pressure on standing up
• Nerve damage
• Reduced coordinaon
• Reduced bone mineral density, parcularly in combinaon with smoking
(Caputo et al., 2012).
23
1.13 The experience of stigma
The sgma associated with having an alcohol or other drug problem remains one of the strongest
barriers to seeking treatment (Conner & Rosen, 2008). Many older people with alcohol and other
drug problems experience the dual sgmas associated with these problems as well as ageing
(Doukas, 2011; Royal College of Psychiatrists, 2011; Wadd et al., 2011).
Sgma is parcularly felt by older women (Wadd et al., 2011) and people with illicit drug problems,
especially those on pharmacotherapy programs (Doukas, 2011; Kelsall, Parkes, Watson, Madden,
& Byrne, 2011). Older people may also feel sgmased by having to aend tradional alcohol and
other drug services developed for younger people (Wadd et al., 2011).
Reducing the sgma experienced by older people with alcohol and other drug problems will require
improved community and praconer atudes towards this group and greater eorts to reduce the
sense of therapeuc hopelessness and social exclusion they oen experience (Royal College of
Psychiatrists, 2011).
In addion, it will be important to enhance program privacy and accessibility by introducing a
broader range of service opons including home vising (Wadd et al., 2011).
1.14 Vulnerability to exploitation
Older people with alcohol and other drug problems can be at risk of exploitaon as a result of:
• Substance-related disabilies resulng in reliance on others for assistance or care
• The need to rely on strangers for care (somemes as a result of poor family relaonships
or estrangement stemming from long-term substance use problems)
• Substance-related cognive loss reducing their ability to resist or detect coercion and
fraud
• Being encouraged or forced to take drugs, or drink excessively, to facilitate exploitaon by
carers
• Being substance dependent and unable to purchase the substances themselves
• Being regularly intoxicated
(Wadd et al., 2011; World Health Organizaon, 2006).
It is important for services providing support for older people with AOD problems to be aware of the
potenal for exploitaon and to promote mul-agency partnerships to prevent this (World Health
Organizaon, 2006).
24
1.15 Groups at particular risk
Groups of older people who are at parcular risk of experiencing alcohol and other drug harm
include:
1. Aboriginal and Torres Strait Islander peoples
2. People from culturally and linguiscally diverse backgrounds
3. Lesbian, gay, bisexual, transgender queer and intersex people
4. Women
5. Injecng drug users.
1.15.1 Aboriginal and Torres Strait Islanders
Substance use among Aboriginal and Torres Strait Islander peoples can:
• Contribute to physical and psychosocial health problems and disadvantage
• Widen the gap between Indigenous and non-Indigenous Australians’ life expectancy
(Australian Instute of Health and Welfare, 2011b)
• Be understood in the context of a history of dispossession, denial of culture and conict
(Gleadle et al., 2010).
Compared with non-Indigenous Australians, Aboriginal and Torres Strait Islander Australians:
• Have higher rates of tobacco and other drug use
• Are less likely to drink alcohol but are more likely to consume at risky or high risk levels
(Australian Instute of Health and Welfare, 2011a, 2011b).
1.15.2 Culturally and linguistically diverse groups
The needs of older people from culturally and linguiscally diverse (CALD) backgrounds are not well
understood. Prevalence of AOD use in CALD communies is generally lower than the broader
populaon but they are under-represented in treatment services. Reasons for this include:
• Lack of awareness of services
• Language barriers
• Lack of understanding and trust
• Treatment retenon problems stemming from:
unrealisc expectaons of treatment
inappropriate referrals to mulcultural or ethno-specic welfare services that lack
necessary AOD knowledge
(Drug and Alcohol Mulcultural Educaon Centre, 2010).
1.15.3 Lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI) people
The prevalence of alcohol and other drug problems among older LGBTQI people has not been well
25
researched. However, most research concerning lesbian, gay, bisexual and transgender people has
found higher rates of alcohol use disorders, illicit drug use and illicit drug use disorders among these
populaons compared to heterosexual populaons. Factors that may account for higher rates of
alcohol and other drug problems include: sgma; abuse and vicmisaon; strained relaonships
with family and friends; and stresses associated with ‘coming out’. Many of these factors are likely
to be inter-related; for example the process of ‘coming out’ may have implicaons for relaonships
with family and friends (Rier, Mahew-Simmons, & Carragher, 2012). This trend may connue in
older age.
1.15.4 Women
Older women have some unique AOD risk factors. Older women are more likely to:
• Live longer than men
• Live alone
• Lack nancial independence / security
• Have physical risk factors that make them suscepble to the negave eects of AOD (such
as having proporonately more body fat) (Blow & Lawton Barry, 2003)
• Experience anxiety and sleep disorders and be prescribed anxiolyc and hypnoc
medicines (Hollingworth & Siskind, 2010)
• Experience chronic pain (Pain Australia, 2011)
• Not have their AOD problems detected, resulng in lost intervenon opportunies and
accumulaon of harm over me (Blow & Lawton Barry, 2003).
1.15.5 People who inject drugs
People who inject drugs in Australia are ageing. Many did not ancipate or prepare for old age and
rerement (Kelsall et al., 2011). People who inject drugs disproporonately report lower socio-
economic status, limited formal educaon and inadequate housing. These factors contribute to poor
physical and mental health (Kelsall et al., 2011).
Dicules experienced by this group include:
• Health problems
injecon-related vascular problems
endocardis
blood borne diseases
pain
masking of serious health problems as a result of opioid use
• Sgma and discriminaon (older people who inject drugs are oen vilied and considered
beyond help due to their advanced years and may be judged even more harshly than their
younger counterparts)
26
• Pharmacotherapy problems
cost
transport dicules
lack of exibility
longer term pharmacotherapy eects
• Involvement in criminality to purchase illicit drugs
• Employment issues (parcularly when juggling pharmacotherapy commitments)
• Social isolaon and family problems (Kelsall et al., 2011).
Ageing and injecng drug use can combine to create a set of unique issues (Kelsall et al., 2011). The
needs of this group will require parcular focus by specialist AOD and generalist services alike.
27
PART 2: PREVENTION AND TREATMENT
Summary
Older people in treatment for alcohol or other drug problems do not achieve worse
outcomes than younger people and may do slightly beer.
Treatment programs for older people are broadly similar to services provided to
other sectors of the populaon, but may need subtle adaptaons and must take
account of older people’s heterogeneity.
The nature and level of intensity of intervenons needs to be tailored to the
characteriscs of the problems being experienced.
The high prevalence of comorbidies among older people with alcohol or drug
problems requires a range of specic approaches.
As a result of the high prevalence of comorbidies among older people with
alcohol or drug problems, it is important to have sound referral protocols in place.
Challenges to older people accessing help / treatment may stem from:
• The knowledge, skills and atudes of health professionals
• Client characteriscs or beliefs
• Praccal problems of accessibility.
There is a range of strategies which can be implemented to enhance
communicaon with older adults.
Reliable screening tools are available to detect alcohol problems among older
people (AUDIT-C and A-ARPS). No similar tools are available for drugs other than
alcohol.
Screening programs for older people have not been widely implemented in primary
health care and community sengs.
Brief intervenons have great potenal to prevent and reduce alcohol- and other
drug-related harm among older people, but their uptake, parcularly in primary
care sengs, has been poor.
Intervenons need to be based on the person’s readiness to change.
Movaonal interviewing can play an important role in enhancing movaon to
change risky substance-related behaviours.
Alcohol and drug specialist services play important policy, funding, workforce
development and service provision roles in relaon to older people and substance
use.
28
2.1 The importance of harm reduction and primary, secondary and
tertiary prevention efforts
2.1.1 Harm reduction strategies6
Harm reducon involves strategies that can help an older person avoid harms associated with their
alcohol or other drug use, without necessarily resulng in a reducon in use. The goal is to work
towards less problemac AOD use and involves non-confrontaonal and non-judgmental
approaches which help the person make beer decisions and choices.
Helping clients with the problems that are most salient to them (e.g., insecure housing, poor health)
can be helpful, even if the client feels unable to stop or reduce their AOD use. This approach can
also create opportunies for service providers to establish and maintain relaonships with the older
adult.
Harm reducon strategies can be used with a range of problems. There are 6 key steps involved in
harm reducon intervenons.
1. Providing feedback to clients, including:
• A summary of the harms being experienced as a result of their AOD use
• Idenfying the connecon between the presenng problem and AOD use
• Idenfying the manner in which the client’s behaviour is contribung to the harms
they are experiencing
2. Adopt a collaborave approach to idenfy harm reducon strategies by:
• Idenfying previously successful strategies
• Exploring barriers to harm reducon intervenons
• Using movaonal techniques
• Focussing on the behaviours the client wants to change
• Brainstorming together
3. Helping the client to idenfy their harm reducon goals. Goals should be SMART.
• Specic
• Measurable
• Aainable
• Realisc
• Time-limited (short-term)
4. Monitoring the client to see how they are faring in relaon to their harm reducon goals
and reinforcing progress made
5. Reviewing the goals to see if they connue to be appropriate
6. Re-establishing goals if necessary.
6 Secon 2.1.1 draws on Seeking Soluons (2004).
29
2.1.1.1 Health problems
Compared to younger people, older adults are at greater risk of having their health and
independence jeopardised by their AOD use, and may feel that they are facing an inevitable decline.
Older adults may have also lost contact with former health care providers. Relevant harm reducon
strategies include:
• Helping the older adult connect with health praconers and keep appointments
• Ensuring that the client’s care is coordinated among all the agencies involved
• Assisng with transportaon
• Helping the older adult recognise and understand the connecon between paerns of
AOD use and health problems being experienced
• Ensuring pain management needs are addressed.
2.1.1.2 Safety concerns
Intoxicaon-related safety concerns include falls and re risk (e.g., leaving the stove on, falling
asleep while smoking), drink / drugged driving or blood borne diseases. Harm reducon strategies
include:
• Making arrangements through family, friends, volunteers, or neighbours to check on the
older adult or assist with transport
• Providing a telephone reassurance service for frail older adults through community or
police services
• Ensuring that older people who inject drugs have access to sterile injecon consumables.
2.1.1.3 Medication harms
Harm reducon strategies for medicaon harms centre on educang the older adult about potenal
interacons between alcohol and other drugs and their specic medicaons (including OTC drugs,
and herbal medicines). Other useful strategies include:
• With the permission of the client, ensuring that the prescriber has an accurate picture of
the client’s level of alcohol and other drug use
• Working with the prescriber to ensure that the least harmful medicaons are prescribed.
2.1.1.4 Nutritional problems
Older adults misusing alcohol and other drugs are at a greater risk of malnutrion and consequent
illness. Older adults who eat well, compared to those who do not, experience fewer adverse eects
from their AOD use, even at moderately high levels of AOD consumpon.
Heavy alcohol use can aect an older adult’s appete and nutrient absorpon. Money spent on
alcohol or drugs may also result in having insucient money le for food. Strategies to deal with
harms associated with poor nutrion may include:
• Encouraging the client to eat when drinking
30
• Arranging for the client to buy groceries before purchasing alcohol
• Providing help with accessing meal programs (e.g., Meals on Wheels)
• Helping with praccal maers that can aect access to proper food (e.g., a broken
refrigerator)
• Encouraging aendance at cooking classes for people who live and eat alone to enhance
socialisaon and learning opportunies
• Encouraging vitamin and mineral supplementaon (parcularly Vitamin B1 - thiamine).
2.1.1.5 Isolation
Older adults with alcohol and other drug problems may have very few connecons to their
community, health services, or other social services. Eecve harm reducon strategies for reducing
older adults’ isolaon may include:
• Providing outreach services (i.e., going to the person’s home)
• Facilitang access to support groups and social support networks.
2.1.1.6 Vulnerability to exploitation
Older people with alcohol and drug use problems can be vulnerable to assault, abuse, and
exploitaon by family or others. Strategies to reduce this include:
• Helping the client plan how to avoid risky situaons (e.g., withdrawing less money when
drinking, taking precauons so that others do not see the money)
• Pung safeguards in place (e.g., direct deposit, automac rent payment)
• Informing the client’s bank of the potenal for exploitaon
• Informing relevant authories of instances of exploitaon.
2.1.1.7 Risky sex
For some older adults, alcohol and other drug use can leave them at risk of sexually transmied
diseases, including HIV / AIDS which are increasing among older Australians (Carman, Grierson, Hur-
ley, Pis, & Power, 2009). Harm reducon strategies can include:
• Acknowledging that older adults connue to have sexual feelings and can be sexually
acve
• Providing age-appropriate and non-judgmental informaon specically geared to older
adults about risky sexual behaviour and methods of sexual protecon
• Making condoms easily available in washrooms of health centres, seniors’ centres, and
bars or other places that older adults may visit.
2.1.1.8 Family problems
In some instances, an older adult may be unable or unwilling to change their substance use
behaviour despite the eect it may be having on them or others. In the laer case, the harm
reducon goal may be to reduce harms to family members. Relevant harm reducon strategies can
31
include:
• Educang family members about alcohol and ageing, especially its eects on memory and
behaviour
• Helping family members establish appropriate personal boundaries to ensure their safety
• Helping family members develop posive coping strategies and avoid developing AOD
problems in their own lives.
2.1.2 Primary, secondary, and tertiary prevention
Reducing alcohol and other drug harm among older people requires aenon to the three levels of
prevenon.
2.1.2.1 Primary prevention
The goal of primary prevenon is to protect older people from experiencing AOD-related harm. This
includes:
• Educaon about low risk levels of consumpon and the risk of adverse interacons with
medicaons
• Regular screening for risk factors for AOD problems
• Regular screening for the emergence of symptoms of AOD problems
• Informaon to help recognise and respond to the emergence of AOD problems.
2.1.2.2 Secondary prevention
The goal of secondary prevenon is to respond to emerging AOD problems, or risk factors, to pre-
vent the situaon from worsening. Appropriate strategies include:
• Brief intervenons
• Harm reducon measures
• Enhancing access to social and other acvies that do not involve alcohol consumpon.
2.1.2.3 Tertiary prevention
The goal of terary prevenon is to treat and reduce the harm experienced by people with
established alcohol and other drug problems. This includes:
• Detoxicaon programs
• Pharmacotherapy (such as OST and benzodiazepine stabilisaon and reducon programs)
• Long-term counselling.
32
2.2 Does treatment work?
Older people in treatment for AOD problems do not achieve worse outcomes than younger people
and may do slightly beer (Moy, Crome, Crome, & Fisher, 2011). Reactors tend to do beer than
survivors in treatment (see Table 2, p16). Factors associated with older age which may enhance a
posive prognosis, especially for alcohol problems, include:
• Staying in treatment longer, which older people tend to do
• Having a supporve family / friends
• Being less likely to have family and friends who condone AOD use
(Satre, Mertens, Arean, & Weisner, 2004).
Treatment outcomes for older clients could be improved by:
• More specically designated services for older people
• Intervenons tailored to older individuals’ needs
• Meeng transport and healthcare costs
• Minimising discriminaon and sgma
(Crome, Sidhu, & Crome, 2009).
2.3 Features of successful interventions
2.3.1 Alcohol and other drug problems
Evidence-based AOD prevenon and treatment services for older people:
• Are broadly similar to services provided to other sectors of the populaon
• May need subtle adaptaons of widely used approaches
• Need to take account of older people’s heterogeneity.
Successful intervenons for older clients with AOD problems rely on:
• A client-centred, empathec, non-judgmental and trusng relaonship between client
and praconer
• The client seeing the intervenon as a mutual exercise where the client makes acve
decisions
• Clients being supported to develop a sense of responsibility for their AOD use and the
self-condence to believe they can change
• Thorough assessment with a view to:
building rapport
gathering informaon to guide treatment planning
33
providing clients with feedback to help develop alternave responses
personalising the health eects of their AOD use
monitoring progress
• Tailoring intervenon intensity and duraon to the client’s degree of dependence or AOD
harm (see Table 5 and Figure 14).
Table 5: Tailoring the intervenon to paerns of AOD harm experienced by older people
(Babor & Higgins-Biddle, 2001; Heather, 2003).
Type of behaviour / problem Intervenon / response
No use / unproblemac use Prevenon acvies, informaon about parcular AOD-related
risks and strategies to adopt if use becomes problemac
Risky or hazardous use Brief intervenons, discussion of harm reducon measures,
medical assessment
Harmful use / dependence Intensive treatment, counselling, detoxicaon, maintenance
therapy, relapse prevenon
As alcohol and other drug problems become more severe, more intensive intervenons are
required. These range from low intensity prevenon intervenons for those who are not using AOD
problemacally, through to high intensity intervenons for harmful users or those who are
dependent (see Figure 14).
Intensity of Intervention
No Use Unproblematic
Use
Risky Use Harmful Use
Figure 14: The intensity and level of intervenon necessary for dierent paerns of use
34
2.3.2 Responses to comorbidity
Outcomes for older adults with comorbid substance use and physical / mental health problems are
improved when their problems are approached in a holisc and coordinated way.
In relaon to mental health comorbidies, there are a number of factors that may act as barriers to
alcohol and other drug and mental health agencies rounely screening, assessing and treang these
co-occurring disorders. Potenal barriers to roune screening, assessment, and treatment of
comorbid condions, and possible strategies to address them are idened in Table 6 (Croton,
2007).
Table 6: Barriers and strategies to address roune screening, assessment, and treatment of comorbid condions
(Source: Croton, 2007)
Barriers Strategies
Lack of awareness of:
• prevalence and harms associated with
co-occurring disorders
• likely interacons between disorders
• treatment implicaons.
Provide this informaon in mulple formats, for example:
• training sessions
• sta orientaon procedures and manuals
• client and carer educaon packages.
Enhance the capacity of agencies to record the results of
their clients’ dual diagnoses screening.
Percepon of added work, especially when
clinicians may feel overwhelmed by mulple
demands, stresses and paperwork, or are
change-weary and change-wary.
Promote the view that the goal is more eecve, rather than
added, work – that recognising and addressing co-occurring
disorders is likely to lead to more successful treatment of
target disorders.
When introducing a new screening or assessment form, take
the opportunity to review and simplify exisng assessment
forms and processes and remove some of the exisng
paperwork burden.
Lack of familiarity with using screening tools
and diculty integrang their use into
roune pracce. Clinician concerns that
client engagement may be compromised by
formal screening for a disorder that the client
hasn’t presented for help with.
Provide informaon about the raonale for screening and
assessment.
Provide training, modelling and clinical supervision around
seamlessly integrang screening into roune pracce.
Include careful explanaon to clients of the raonale for and
condenality of screening.
Clinicians may lack skills, knowledge and
condence in their ability to provide
appropriate treatment for a co-occurring
disorder and be reluctant to ask quesons of
the client that would lead to the
idencaon of that disorder.
Provide educaon, training and realisc evidence for
opmism about eecveness of treatment.
Address clinician ‘self-ecacy’ about providing eecve
treatment.
Lack of clarity about scope of pracce
(e.g., some AOD workers may have anxiety
about whether it is within their scope of
pracce to conduct a detailed risk
assessment).
Clarify explicit scope of pracce guidelines and treatment
manuals.
Promote tools which contain an integrated risk assessment
(e.g., PsyCheck).
Table 6 cont. on next page
35
Barriers Strategies
Implicaon of current ‘wrong pracce’.
Reframe the development of integrated screening,
assessment and treatment as an evoluonary step towards
more eecve treatment approaches.
Need for changes to pracce, language,
beliefs, values, and client exclusion criteria.
Use policy to reinforce that addressing co-occurring
disorders is core business for both mental health and AOD
treatment agencies.
Sgma of client group – two relapsing, highly
sgmased disorders in the one individual.
The clinician’s own cognive dissonance
(e.g., to address my client’s substance use or
mental health issue, it is necessary (at some
level) to examine my own substance use or
mental health issues).
History of own substance-related or mental
health-related trauma.
Encourage treatment providers to idenfy their own
atudes and feelings evoked by dealing with the disorder.
Provide integrated treatment-oriented clinical supervision.
Lack of knowledge of the ‘opposite’
treatment system, its strengths, dierences
and constraints on service.
Provide opportunies to understand and maximise formal
and informal contacts through:
• Rotaons and placements with collaborave services
• Joint training
• Roune provision of service from other agencies
• Worker-developed protocols
• Co-locaon
• Scheduled, regular interagency managerial and
clinician meengs.
Other comorbidity response opons include:
• Adopng a ‘no wrong door approach’ in which older people can get help for a range of
problems regardless of the service inially contacted
• Ensuring the health and welfare workforce has essenal knowledge and skills about AOD
problems, ageing and mulple morbidies
• Enhancing inter-professional pracce
• Improving primary care, ageing and specialist drug service coordinaon
• Using specialist drug workers in consultaon, liaison and educaon roles with other
services
• Ensuring funding arrangements support services for older people with mulple and
complex needs
• Developing maps of local service referral pathways
• Encouraging consistent approaches to screening, assessment, clinical notes, referral, care
coordinaon, case management, client informaon, data sharing and training between
agencies
(Nicholas & Roche, 2014).
Table 6 cont.
36
Table 7 cont. on next page
Table 7: Challenges and strategies for accessing help / treatment and responses
Challenges Aects
Service Responses
Awareness and Atudes
Health
Professionals
Clients
Aribute problems to ageing, or
concurrent illnesses, rather than
AOD-related causes
Recognise older people with substance misuse
problems are not a homogenous group
Provide services and treatment which are relevant
and responsive to individual needs
Educaon for healthcare professionals
Lack awareness that AOD
problems aect older people
Develop policies and pracces which raise awareness
of AOD problems in older populaons and challenge
tradional percepons / atudes towards old
people and AOD use
Believe it is too late to change
Believe it is wrong to ‘deprive’
older people of their ‘last
pleasure in life’
Be reluctant to ask quesons due
to embarrassment Ensure there are sta members who are interested,
experienced and competent in working with older
adults
Universal screening
Lack condence to intervene
2.4 Challenges to accessing help / treatment and responses
There is an ongoing need for workforce development approaches to ensure that praconers fully
understand the parcular needs of older people with AOD problems, and are supported to meet
them (DrugScope, 2014). Some of these challenges and potenal are outlined in Table 7.
37
Table 7 cont.
Challenges Aects
Service Responses
Awareness and Atudes
(cont.)
Health
Professionals
Clients
Be reluctant to ask for help or
disclose problems because they
feel:
• they shouldn’t need
support
• embarrassed about
having these problems at
an older age
• reluctant to re-engage
with services if they think
that they have ‘failed’
Develop a culture of respect for older clients
Oer opons of one-to-one counselling and group
work
Maintain privacy and condenality
Diagnosc Tools
Lack the ability to idenfy signs
and symptoms of AOD problems
in older people
Take a broad, holisc approach that emphasises
age-specic psychological, social and health
problems
Rely on self-diagnosis and / or
inadequate diagnosc tools
Ensure that services have age-specic diagnosc
tools that are appropriate for clients who may have
cognive impairment
Have cognive problems, such as
substance-induced amnesia or
underlying demena
Access, Equity, and Quality
Transport or mobility problems
(parcularly in communies
lacking public transport)
Ensure equity of access (i.e., services for older
people are given the same priority as other groups
and are physically accessible to older people)
Create outreach services
Involve interpreters and other communicaon aids
where possible
Explain issues in understandable terms
Hearing or language dicules
Table 7 cont. on next page
38
Challenges Aects
Service Responses
Access, Equity, and Quality
(cont.)
Health
Professionals
Clients
Limited me availability
(e.g., having to care for a spouse,
relave, friend or grandchild; key
performance indicators,
workload)
Plan and develop exible and adaptable services in
consultaon with consumers
Priorise the treatment of alcohol and other drug
problems as part of a broad, holisc treatment
approach
Mixed aged services (some older
people may nd younger clients
hecc, chaoc or inmidang)
Oer age-specic, supporve, non-confrontaonal
programs that:
• aim to build or rebuild the client’s self-esteem
• focus on coping with depression, loneliness
and loss (e.g., death of a spouse, rerement)
and rebuilding the client’s social support
network
Support
Not knowing where to refer / turn
for help
Create linkages with medical services, aged services
and other sengs for referral into and out of treat-
ment, case management, and community support
Colluding family members
Reversal of the parent-child
dynamic7
Want to connue using
Sources: DrugScope (2014); Fry (2007); Schonfeld & Dupree (1995); Substance Abuse and Mental Health Services
Administraon (1998); Dowling et al. (2008); Wadd et al. (2011); Royal College of Psychiatrists (2011).
Table 7 cont.
7 This occurs when the adult child sacrices his or her own needs in order to accommodate and care for the logiscal or
emoonal needs of the aged parent when taking on caring roles. They may forego a range of experiences and may develop
a range of emoonal problems.
39
2.5 Enhancing communication with older clients
Enhancing communicaon with older clients with alcohol and other drug problems draws on skills
which clinicians regularly apply when interacng with older people. These include:
1. Recognising risks of stereotyping older clients which can lead to inappropriate and
demeaning interacons
2. Avoiding overly simple or patronising language (e.g., terms such as “honey” or
“darling”)
3. Asking the client how he or she would like to be addressed and introduced to others
4. Using surnames and formal terms of address unl given permission to do otherwise
5. Maintaining eye contact, rather than focusing on other things (e.g., client notes or a
computer screen)
6. Avoiding looking or sounding impaent
7. Ensuring the environment is quiet and uncluered
8. Facing older adults when speaking with them, with your face at the same level as theirs
9. Paying close aenon to sentence structure when conveying crical informaon
10. Pung individual pieces of informaon into separate sentences and using direct,
concrete, aconable language
11. Using visual aids to clarify and reinforce key points
12. Asking open-ended quesons (e.g., “Tell me about how….”)
13. When others are present, including the older client in the conversaon and avoiding
referring to the client in the third person
14. Sharing decision making and providing complete and imparal informaon about the
pros and cons of each intervenon opon
15. Outlining the issues that need to be discussed with the client and presenng them one
at a me
16. Checking that the client understands what is being said
17. Cauously using humour and direct communicaon styles with older clients from
culturally and linguiscally diverse backgrounds, as this may be seen as condescending
and disrespecul
18. Respecng the client’s privacy and personal space and ensuring the security of the
client’s possessions
19. Using shorter, informal sessions rather than longer sessions
20. Respecng the client’s spiritual concerns and desire to discuss meaning and purpose in
life.
Sources: Substance Abuse and Mental Health Services Administraon (1998); The Gerontological
Society of America (2012).
40
2.6 Primary health care and community services
Many primary health care and welfare agencies are well placed to provide support and intervenon
for older people, including screening, prevenon, harm minimisaon and early intervenon
(Naonal Centre for Educaon and Training on Addicon Consorum, 2004). The general pracce
seng is parcularly important in this regard.
2.6.1 Screening
Screening programs for older people have not been widely implemented in primary health care and
welfare sengs. This is largely a result of a lack of tools to cater for the unique and oen complex
needs of older people (Bright, Fink, Beck, Gabriel, & Singh, 2013).
Aer the age of 60 every adult should be screened for AOD problems as part of their regular physical
examinaon. Screening, or rescreening, should also occur if the symptoms listed in Table 8 are
present or if the older person is undergoing major life changes or transions.
Table 8: Triggers for screening older people for alcohol and drug problems
Source: Substance Abuse and Mental Health Services Administraon (1998).
Triggers to Screen for AOD Problems
Sleep complaints; observable changes in sleeping paerns; unusual fague, malaise, or dayme drowsiness
Apparent sedaon
Cognive impairment, memory or concentraon disturbances, disorientaon or confusion
Seizures, malnutrion, muscle wasng
Liver funcon abnormalies
Persistent irritability (without obvious cause) and altered mood, depression, or anxiety
Unexplained complaints about chronic pain or other somac complaints
Inconnence, diculty urinang
Poor hygiene and self-neglect
Unusual restlessness and agitaon
Complaints of blurred vision or dry mouth
Unexplained nausea and voming or gastrointesnal distress
Changes in eang habits
Slurred speech
Tremor, motor incoordinaon, shuing gait
Frequent falls and unexplained bruising
41
AUDIT-C is a 3 item alcohol screening tool that can help idenfy persons who are hazardous drinkers
or have acve alcohol problems. It is a modied version of the 10 queson AUDIT instrument and
can accurately detect alcohol problems among older people if cut o points are tailored to this age
group (Aalto, Alho, Halme, & Seppä, 2011).
While AUDIT-C is an accurate tool to detect alcohol problems it does not detect:
• Other drug problems
• Use of other medicines
• Other comorbidies.
The Australian Alcohol-Related Problems Survey (A-ARPS) is an age-specic 10 minute pencil and
paper or online screening and educaon tool that reliably idenes hazardous and harmful paerns
of alcohol use among older people (Bright, 2011). It takes into account the client’s:
• Quanty and frequency of alcohol consumpon
• Age and gender
• Medical history
• Medicaon use
• Symptoms
• Funconal status
• Binge drinking and drink-driving risks
• Risk of mixing alcohol with medicaon (Bright et al., 2013).
A-ARPS helps clinicians idenfy if a client’s medicaons or health condions could be aected by the
amount of alcohol they drink (Bright et al., 2013). A-ARPS is discussed more fully in Part 3.
Laboratory tesng can also be helpful in detecng alcohol problems among older people. In
parcular, mean corpuscular volume (MCV) and liver funcon tests such as gamma-glutamyl-
transpepdase (GGT) are sensive markers to detect alcohol misuse among older populaons
(Caputo et al., 2012).
To-date no equivalent screening process has been developed for older people’s use of drugs other
than alcohol. Screening tools such as the Alcohol, Smoking and Substance Involvement Screening
Test (ASSIST) may be of assistance but have not been validated in older populaons. There are a
number of characteriscs of the ASSIST tool which may render it insuciently sensive to detect
alcohol and other drug problems among older people.
For example, in assessing the impact of AOD use on fullling usual roles, the scoring of ASSIST may
not take into consideraon role changes that are associated with ageing. Equally, assessing the
extent to which others have expressed concern about the older person’s AOD use may not take into
consideraon social isolaon which may limit the ability of others to express this concern.
Nevertheless, research is underway to determine if ASSIST can be adapted to be more sensive to
detecng AOD problems among older people.
42
2.6.2 Brief interventions
Brief intervenons involve screening, assessment and feedback to prevent and reduce risky AOD
consumpon (Haber, Lintzeris, Proude, & Lopatko, 2009). They range from ve minutes of advice
in the primary care seng (‘minimal intervenon’) to 5-6 sessions of counselling, more suitable for
AOD specialist sengs (‘brief therapy’).
Brief intervenons in primary care:
• Are cost-eecve
• Can be delivered in a me-limited way
• Involve one or more sessions of between 5 and 30 minutes
• Usually involve movaonal interviewing counselling techniques (see below)
• Can be oered to people who have not sought treatment or assistance but have been
idened through roune screening as risky users
• Inform people that they may be at risk of harm and encourage strategies to reduce risk
(Anderson, Chisholm, & Fuhr, 2009; Haber et al., 2009; O'Donnell et al., 2014).
Six common elements of brief intervenons delivered in primary care sengs have been idened
with the acronym FRAMES (Miller & Sanchez, 1994).
Feedback
Provide feedback about the risks associated with AOD use
Responsibility
Emphasise the client’s personal responsibility and choice to
reduce AOD use
Advice
Provide explicit verbal or wrien advice to the client about
changing hazardous AOD behaviour
Menu
Provide the client with a Menu of alternave strategies and
self-help opons to help nd an approach that is appropriate
for them
Empathy
An empathic, warm and reecve approach adopted by the
clinician
Self-efficacy
Reinforce and enhance the client’s belief in their ability to
complete tasks and reach goals
Despite its potenal, the uptake of AOD brief intervenons in primary care sengs has been poor
(Roche & Freeman, 2004; Swan, Sciacchitano, & Berends, 2008).
43
2.6.3 Referral
While successful intervenons can occur in primary health and welfare sengs, somemes referral
is necessary. A low threshold for referral for comprehensive medical assessment for older people
experiencing AOD harm is needed, due to:
• Ageing-related physiological changes which make them vulnerable to medical condions
• Increased likelihood of health problems as a result of longer exposure to AOD
• The risk of withdrawal syndromes if use is ceased or abruptly reduced (parcularly
alcohol, prescripon drugs such as benzodiazepines or opioids).
Clients may need referral to specialist agencies if they require:
• Management of intoxicaon, detoxicaon or withdrawal
• Pain management
• Pharmacotherapy treatments
• In-depth counselling
• Treatment of complex psychiatric or other comorbidies
• Follow up or review
(Naonal Centre for Educaon and Training on Addicon Consorum, 2004).
Once medical / specialist assessment has occurred, the client’s AOD issues may be able to be
addressed in non-medical sengs. On-going inter-agency case management may be needed.
In many parts of Australia there are few opons available to refer clients to services such as
detoxicaon and rehabilitaon which are established specically to cater for the needs of older
people. Consequently, older clients may be required to use services which include younger people,
whom older people may regard as ‘hecc’, or ‘chaoc’, or inmidang (Wadd et al., 2011). The
idencaon of referral services should be undertaken in consultaon with the client and formalised
in a referral leer (Carmichael, 2001).
Referral leers should contain:
• Client detail: name, age and date of birth, address and contact details, and signed consent
• Current issues: reasons for presenng at the service being referred from
• Service requested from agency
• Requests for any feedback or follow-up and how this should be arranged
• Details of ongoing services that will be provided by referring worker or their agency.
Referral guidelines can be extremely useful if developed collaboravely among agencies involved in
client referrals. Guidelines should:
• Be developed by those who have to implement them
• Cover all types of appropriate referral, the process of informaon exchange and feedback
• Serve as the basis for client-centred shared care and cover the roles and responsibilies of
services
(Carmichael, 2001).
44
2.7 Assessing readiness to change
Many contemporary approaches to helping older clients with AOD problems are underpinned by the
Trans-Theorecal Model (TTM) of behaviour change (Prochaska, 1991; Prochaska, DiClemente, &
Norcross, 1992). This approach suggests that people using AOD in risky or harmful ways are in one of
ve stages of change (SOC). Intervenons are geared to their SOC.
A descripon of the ve stages of change (adapted from Jarvis, Tebbu, & Mack, 1998) appears
below.
Stage 1: Pre-contemplaon
Those in the pre-contemplaon SOC lack recognion of the risky or harmful nature of their AOD use
and have no intenon of changing their behaviour.
Case study 3: Pre-contemplaon
Daryl is a 67-year-old truck driver who presented to his GP aer his wife Sarah “told him to
go and get his dope problem sorted out”. Daryl’s heavy, almost daily, use of cannabis dates
back to his early 20s. He has recently tested posive for cannabis on two occasions at
random drug tesng staons (RDTS) while driving a car and is at risk of losing his truck licence
and livelihood. He is also spending $150 per week on cannabis, which is pung a strain
on household nances. He believes that he was just unlucky to get caught at the RDTS and
doesn’t want to reduce his cannabis use. He said:
“Everyone does it, it’s never done me any harm, I enjoy it. Sarah needs to lighten
up”.
His GP explored some of the posive and not so posive eects of his cannabis use (see
movaonal interviewing below). She also advised him to avoid breath-holding or deep
inhalaon to reduce the harm from smoking and gave him some resources to use if he
wanted to stop or reduce his cannabis use in the future.
Stage 2: Contemplaon
In the contemplaon stage individuals begin to recognise the negave consequences of their AOD
use, but do not change it. People in this stage are ambivalent about change and may feel trapped
but don’t act.
45
Case study 4: Contemplaon
Carol, a 58-year-old rered physiotherapist, began drinking heavily two years ago aer the
sudden death of her husband. She aended a hospital emergency department with
abdominal pain which was diagnosed as alcoholic gastris. She was drinking a bole and a
half of red wine per day. She said:
“I know it’s not good for me and I should stop, but I enjoy it. I like a wine in front
of the telly in the evening”.
Carol was referred to the hospital drug and alcohol worker. He explored Carol’s ambivalent
feelings and beliefs about her drinking. He also informed her that tests showed that her liver
was being damaged and that her blood test results were more elevated than 95% of the
populaon.
Stage 3: Preparaon
Clients in the third SOC, the preparaon stage, are commied to changing their behaviour and may
have already made a previous aempt to do so. At this point clients believe that the negave conse-
quences of AOD use outweigh the benets.
Case study 4 (cont.): Preparaon
The diagnosis of alcoholic gastris had come as a shock to Carol and had pped the balance
about how she saw the pros and cons of her drinking. When she got home from the hospital
she made an appointment with her GP for 10 days later to discuss the issue. Four days aer
returning home she started drinking again, although not quite at the same level as before.
She had felt much beer when she was not drinking and was concerned that her gastris
would return. She said:
“I’d like some help with cung back on the booze”.
Her GP helped Carol to work out what her goals were. They used the SMART acronym to help
with the development of her goals. The goals were:
ÂSpecic
ÂMeasurable
ÂAainable
ÂRealisc
ÂTime-limited (short-term).
Carol decided that she wanted to have no more than 2 small glasses of wine per day with one
alcohol-free day per week for the next 3 months.
46
Stage 4: Acon
During the Acon stage the client implements measures to reduce or stop AOD use.
Case study 4 (cont.): Acon
Carol’s GP gave her some wrien materials with hints about keeping track of, and reducing, her alcohol
intake. Her GP gave her a chart to monitor her drinking in standard drinks. She decided to do a number
of things:
ÂKeep track of how much she was drinking at night
ÂAlternate alcoholic drinks with non-alcoholic ones
ÂCatch up with her friends in the evening, rather than staying home alone
drinking
ÂDilute her wine with sparkling mineral water
ÂOer to be the designated driver whenever she went out with her friends
ÂDevelop strategies to get herself back on track if she started drinking heavily again
ÂTake 100mg of Vitamin B1 (thiamine).
Stage 5: Maintenance
At this stage the client has changed their AOD use and is sustaining that change. During this stage a
large number of clients will relapse and return to an earlier stage of change.
Case study 4 (cont.): Maintenance
Carol connued to see her GP fortnightly. Aer three months, Carol and her GP did a ‘stocktake’ of
how things were going. Overall, Carol had kept to her plan for most weeks. Christmas and New Year
occurred during this period and she didn’t sck strictly to her plan over that me. On the other hand,
on some weeks Carol had two or three alcohol free days per week. She felt like she had more energy,
her sleep had improved and she had no symptoms of gastris. Her GP informed her that her blood
tests had almost returned to normal.
Carol and her GP developed some more strategies to prevent and manage relapse. These included:
ÂMonthly follow-up visits with the GP
ÂAvoiding being at home alone each night of the week
ÂSpending the money she had previously spent on alcohol on treats for herself.
47
Clients may progress sequenally through these stages, however this is the excepon rather than
the rule. They may relapse and return to an earlier stage several mes before they achieve their
goals. Nevertheless each me this happens, they gain new knowledge about their behaviour and will
be able to apply that in the next aempt (Jarvis et al., 1998).
The stages of change cycle is demonstrated diagrammacally in Figure 15.
Maintenance
Relapse
Exit
Lapse
Contemplation
Preparation/
Decision
Action
Precontemplation
Figure 15: The stages of change cycle
48
The contemplaon ladder (or ladder of change) can be a useful tool to idenfy which stage of
change an older person is currently in (Biener & Abrams, 1991; Rusn & Tate, 1993). The client
places a mark at the posion of the ladder that best describes their current intenons. This makes
it easier to work out where the client is at and to record their changes in the stages of change (see
Figure 16).
I have reduced the amount that I drink over 6 months ago
I have recently reduced the amount that I drink (in the last 6
months)
I am planning on reducing the amount that I drink in the next
30 days
I am thinking about reducing the amount that I drink
I am not planning on reducing the amount that I drink any
time soon
The Ladder of Change
Please mark a cross on the rung of the ladder that best describes you.
Figure 16: The Ladder of change
2.8 Motivational interviewing
Movaon interviewing (MI) involves enhancing a client’s movaon to change risky AOD
behaviours. Movaon can be inuenced and it uctuates in response to clinician style.
Authoritave or paternalisc approaches increase clients’ resistance to change.
Collaborave relaonships which respect client autonomy and use the client’s own abilies to
change are most likely to be successful (Hall, Gibbie, & Lubman, 2012). Movaonal interviewing
can be linked to the Stages of Change model discussed above.
There are four key principles for the use of MI (Miller, Rollnick & Butler, 2008 as cited in Hall et al.,
2012). These are represented by the acronym RULE (see p49).
49
Resisting the righting
reflex
8
The righng reex oen inadvertently reinforces movaon to
maintain the status quo. Most people resist persuasion when they
are ambivalent about change and will respond by strengthening
their resolve not to change.
Understanding client
motivations
It is the client’s own reasons for change, rather than the clinician’s,
that will ulmately lead to behaviour change. Openly exploring the
client’s movaons for change helps the clinician beer
understand their movators and barriers.
Listening with empathy
Eecve listening skills are essenal to understand what will
movate the client as well as the pros and cons of their situaon.
Empowering the client
Client outcomes improve when they draw on their knowledge
about what has succeeded in the past. A truly collaborave
therapeuc relaonship is a powerful movator. Client benets are
maximised when the clinician is condent that change is possible.
If a clinician has more me, the following four addional principles can be applied within a longer
therapeuc intervenon (Hall et al., 2012).
Express empathy
Empathic communicaon involves reecve listening skills and
seeking to understand the client’s perspecves, thoughts and
feelings without judging, cricising or blaming. Without condoning
the problemac behaviour, the clinician creates an open and
respecul exchange with the client.
Develop discrepancy
Assisng clients to idenfy discrepancies between their current
behaviour and future goals or values about themselves as a person,
partner, parent, or worker is a powerful movator that helps ‘p the
balance’ toward change. Exploring the pros and cons of change can
help a client develop discrepancy.
Roll with resistance
When clinicians aempt to move a client towards change too quickly,
parcularly if using a coercive or authoritave approach, they oen
encounter resistance. Rolling with this resistance involves reecng
the resistance back to the client, emphasising their choice to change
or not (‘it’s up to you’).
Support self-efficacy
Many older people with AOD problems have made their own
aempts to change and been unsuccessful.
Highlighng the client’s strengths and reecng on mes in their
life when they have successfully changed can be very valuable. The
praconer’s belief in a client’s ability to change is a powerful way to
promote self-ecacy, and in doing so can help the individual develop
the condence that they are capable of change.
8 The righng reex describes the tendency of clinicians to advise paents about the right path for good health.
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2.9 Relapse prevention and management
Lapses and relapses occur frequently among older people who are trying to change problemac
AOD behaviour. A lapse occurs when a person inially achieves their AOD-related goals and has a
lapse before geng back on track. If a person has a lapse, but instead of geng back on track with
their goals returns to a pre-intervenon level of use, this is a relapse. Principles that guide relapse
prevenon include encouraging the client to :
• Undertake more posive acvies
• Develop coping skills to manage high risk situaons
• Make lifestyle changes to decrease AOD use
• Be ready to interrupt lapses so that they do not lead to relapses and potenal harms are
minimised (Alcohol and Other Drug Educaon and Training Unit, 2013).
Relapse / lapse management strategies can include:
• Contracng with the client to limit the extent of use
• Contacng the therapist as soon as possible aer the lapse
• Evaluang the situaon and idenfying the triggers that preceded the lapse
• Reframing a relapse as a hiccup, a learning opportunity, or a temporary setback
• Using previously learnt problem solving strategies
• Using posive self-talk to prevent a lapse becoming a relapse
• Ulising a previously negoated support network (e.g. friends, family, doctor, or 24-Hour
Alcohol and Drug Informaon Service)
• Providing simple wrien instrucons (for example a lapse coping card) to refer to in the
event of a lapse (Alcohol and Other Drug Educaon and Training Unit, 2013).
2.10 The role of AOD specialist services
There are important roles for AOD specialist services to play in relaon to older people and alcohol
and drug problems. Some of these roles are complementary to the roles and support that can be
provided by more generic health care services and primary care. Others are specic to the specialist
AOD sector.
For specialist AOD services to beer cater to the needs of older people, a range of responses and
acons are required. These include the following:
1. Policy
It is important that all AOD specialist services have in place appropriate policies that recognise the
growing and dierent needs of older members of the community. Each service should have clear and
explicit policies that address the ways in which their service and their operaons are sensive to the
needs of older people. This includes the physical layout and structure of services, appropriate and
51
sensive assessment protocols, the recording of appropriate details regarding older people’s needs,
close collaboraon with other sectors, and the delivery and oversight of services designed and
tailored to the needs of older people.
2. Funding
Funding arrangements should reect the growing impost on AOD specialist services of older people
with AOD problems, with funds specically allocated for the needs of this segment of the
populaon. This entails recognion that older adults may require longer episodes of care, and
services will need to be funded accordingly. Reports and deliverables should also incorporate details
of older clients and the extent to which current services cater for the needs of this group.
3. Workforce development (WFD)
AOD services should ensure that appropriate WFD responses are provided to upskill workers. This
includes incorporang relevant clinical supervision components and other forms of support for
workers who will be increasingly dealing with clients from older age groups.
4. Service provision
Many services will need to undergo a degree of service redesign to ensure that older client popula-
ons are appropriately supported and cared for. This will be essenal to ensure high quality,
appropriate and sensive services are provided to this group.
The next secon of this guide provides examples of ways in which services may be beer tailored to
meet the needs of older clients.
Some of these examples may be readily adopted and modied in a range of dierent services. In
other instances, a service may need to address their local and specic needs in a manner that best
reects their parcular circumstances. In either instance, it is crucially important that all agencies
provide close and careful consideraon to the ways in which services can be improved to cater for
the growing needs of this important segment of the community.
52
53
PART 3:
THE OLDER WISER LIFESTYLES (OWL) PROGRAM
AUSTRALIA’S FIRST OLDER PERSON-SPECIFIC AOD PROGRAM
Summary
The Older Wiser Lifestyles (OWL) Program was developed by Peninsula Health,
Victoria as an age-specic best pracce service model to address alcohol- and
other drug-related harm among older adults.
The program has two disnct arms: early intervenon (OWL-EI) and treatment
(OWL-TR) which are underpinned by ve core elements:
• Comprehensive screening and / or assessment
• Engagement
• Harm reducon strategies
• Oce-based and outreach support
• Evidence-driven best pracce.
The main referral sources for the OWL program are:
• Self-referrals
• Health organisaons
• Allied health programs.
Based on the Florida BRITE project, OWL-EI idenes older adults at risk of
experiencing AOD-related harm and provides age-specic early intervenons. It
oers a stepped care intervenon tailored to the client’s readiness to change and
can be used with older adults within a range of specialist and non-specialist
community health sengs.
OWL-TR idenes older individuals who are currently drinking or using drugs at
harmful levels or experiencing related problems. It involves a holisc assessment
and intensive client-centred counselling, and can be used in a range of specialist
alcohol and other drug sengs.
Promoonal acvies among service providers and the broader community are
crical to the success of OWL as they raise awareness and encourage access to the
program.
The OWL program has developed a number of resources including:
• An informaon pamphlet for disseminaon throughout the community
• The A-ARPS screening tool
• An OWL DVD.
54
3.1 What is the OWL program?
3.1.1 How was OWL developed?
The Older Wiser Lifestyles (OWL) Program was developed by Peninsula Health as a unique age-
specic best pracce service model to address alcohol- and other drug-related harm among older
adults.
In 2007, Peninsula Health idened a gap in services for older adult-specic AOD treatment. Older
people are under-represented in AOD treatment. Physiological changes and increased isolaon put
older people at increased risk of developing substance use issues. They are parcularly vulnerable to
the deleterious eects of substance use. Academic literature recommends developing older
person-specic treatment opons.
In 2008, Peninsula Health appointed the rst older adult age-specic AOD clinician to develop an
older person program. In 2009, funding was received from the Victorian Department of Health to
appoint a specialised older adults psychologist, and develop OWL-Early Intervenon (OWL-EI) with
the aim of reducing risky drinking.
In 2010, Peninsula Health received a grant from St John of God to fund a nursing posion to add to
the team.
Currently the OWL program is comprised of a muldisciplinary team that has overcome barriers
and built strong linkages with key stakeholders such as Aged Persons Mental Health and Aged Care
services and local GPs.
3.1.2 Principles
The OWL program is underpinned by health promoon and harm minimisaon principles and is
designed to respond to the needs of a diverse client group. The program has two disnct arms: early
intervenon and treatment.
Both arms are underpinned by ve core elements:
• Comprehensive screening and / or assessment
• Engagement
• Harm reducon strategies
• Oce-based and outreach support
• Evidence-driven best pracce.
3.1.3 Consumer consultation
Consistent with Peninsula Health’s strong commitment to community parcipaon, during the
development of the OWL program consultaon was undertaken with both the Older Persons’
Community Advisory Group and the Alcohol and Drug Community Advisory Group. Both groups have
been supporve of the OWL program and its direcon.
55
3.1.4 Community consultation
Establishing and maintaining eecve and meaningful partnerships with services and organisaons
in the broader community is a key priority for the OWL program. In the developmental stage of the
OWL program a partnership was established with the Peninsula General Pracce Network in order to
disseminate informaon relang to the program and AOD issues faced by older adults.
Posters and brochures were designed using markeng images appropriate to older adults and
disseminated by targeng locaons that older adults are likely to aend. More recently the OWL
program has partnered with the Frankston and Mornington Peninsula Medicare Local to distribute
the Older and Wiser DVD.
3.1.5 Effective leadership
Prior to the establishment of OWL, few eorts had been made to increase older Australians’
awareness of the risk of alcohol- and other drug-related harm. Through advocacy, research,
evaluaon, educaon and eecve leadership, OWL has increased awareness and understanding of
these harms to older adults, including the provision of asserve engagement and educaon to
idened ‘at-risk communies’.
In developing and disseminang Australia’s rst older adult-specic early intervenon for alcohol-
and drug-related harm, OWL has led and achieved much at a local, regional, statewide, federal and
internaonal level, including:
• Establishment of a peer-led screening program within Frankston Hospital
• Using iPads to access the screening
• Raising alcohol use among older adults as a priority area for response
• Facilitang training for health care workers, including GPs and HACC workers
• Improving referral and healthcare pathways based upon evidence gleaned from OWL.
In 2012, the OWL program was recognised naonally as a nalist in the Australian Alcohol and other
Drug Awards. The Program has been a leading voice regarding AOD and older adults with a number
of peer-reviewed and professional papers published both naonally and internaonally (e.g., Bright,
2011; Bright et al., 2013). It has received naonal and internaonal media coverage. At one point,
more than 150 Australians accessed the OWL screening tool in a 24 hour period. OWL sta present
at naonal and internaonal conferences and collaborate with internaonal experts, including the
University of Southern Florida and the University of California, Los Angeles.
In November 2012, OWL developed and facilitated a naonal training program for GPs and other
healthcare providers and connues to provide training programs as well as secondary consultaons.
56
3.1.6 How effective is the program?
An independent evaluaon of OWL was undertaken in 2013 and showed it to be a well-received and
eecve program:
• On the whole there was support for the eecveness of the service model
• The program provided a broad range of intervenons in response to the various needs of
older adults
• Clients beneted from their experience with OWL and reported high sasfacon with the
service
• Posive changes in drinking behaviour were observed among parcipants
• There were noceable improvements in parcipants’ physical and mental health
• Clients aributed changes in their drinking behaviour and health status to the informaon
and educaon they received from the program
• The outreach mode of service delivery and aercare were idened as key strengths of
the program.
3.2 OWL Early Intervention (OWL-EI)
3.2.1 What is OWL-EI?
OWL Early Intervenon (OWL-EI) is designed to idenfy older adults who are at risk of experiencing
AOD-related harm and to provide an age-specic early intervenon. OWL-EI draws from, and
extends, the Florida BRITE project, adapted for the Australian context.
The Florida Brief Intervenon Treatment for Elders (BRITE) Project oered brief intervenon of one
to ve sessions to address substance use among older adults. A signicant reducon in parcipants’
SMAST-G scores was observed from baseline to discharge, and maintained at a 30 day follow up
(Schonfeld et al., 2010).
OWL-EI oers a stepped care intervenon tailored to the client’s readiness to change. It is framed as
a modulated program with intervenons ranging from informaon, educaon and brief movaonal
intervenon. Clients are inially expected to aend one to two sessions, however further contacts
are scheduled as needed.
Readiness to change is measured using the Transtheorecal Model (TTM) of behaviour change
(Prochaska, 1991; Prochaska, DiClemente, & Norcross, 1992; Prochaska & Velicer, 1997). The
transtheorecal model outlines ve stages of readiness to change (see Fig. 15, p47). Movement
through each stage of change is not necessarily linear and typically progresses as follows:
1. Pre-contemplaon: not thinking about change
2. Contemplaon: beginning to recognise possibility of change but ambivalent about change
3. Preparaon: commied to change, but not yet taking acon
57
4. Acon: making concrete changes
5. Maintenance: successfully changed her or his behaviour for a substanal period of me.
The content of the OWL-EI program is matched to the client’s readiness to change based on the
transtheorecal model.
3.2.2 Why brief intervention?
To eecvely reduce alcohol- and other drug-related harm, it is essenal to develop intervenons
that target the large populaon of individuals drinking at high levels, and not only those individuals
who are dependent or problemac drinkers. There is extensive evidence that brief intervenons are
eecve in reducing risky alcohol and other drug consumpon and related harms (Kaner et al., 2007;
Miller & Hester, 2003). Eecve brief intervenons range from ve minutes of advice suitable for the
primary care seng (‘minimal intervenon’) to six sessions of counselling that can be
delivered within alcohol and other drug sengs (‘brief therapy’).
3.2.3 Who is OWL-EI for?
OWL-EI is designed to be used with older adults within a range of specialist and non-specialist
community health sengs that respond to people who use alcohol or other drugs, inclusive of
misuse of prescripon medicaons and OTC medicaons.
OWL-EI Case Study
Bob is a 74 year old rered, married male with a 12 year diagnosis of depression which he
started to experience aer he rered. He was referred to OWL by his GP who expressed
concerns to him about a fay liver. His wife also wanted him to enjoy more acvies. Bob
met with the OWL nurse and undertook the A-ARPS (Australian Alcohol-Related Problem Sur-
vey). Bob’s AOD use was assessed as “harmful” due to the combinaon of his andepressant
medicaon and alcohol use, which he reported had increased from “a couple of stubbies” to
about 4 stubbies of full strength beer daily.
Bob was movated to change as he wanted to enjoy his rerement, be healthy and improve
his relaonship with his wife. He engaged in 6 sessions with the OWL nurse. Sessions
covered psycho-educaon regarding the impacts of alcohol on depression, medicaon
interacons and standard drinks, as well as counselling to manage his moods. Bob was
supported to signicantly reduce his alcohol use, develop meaningful acvies and set
achievable goals to improve the quality of his life.
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3.3 OWL Treatment (OWL-TR)
3.3.1 What is OWL-TR?
OWL Treatment is aimed at idenfying individuals aged 60 years and over in the community who are
currently drinking or using drugs at harmful levels or experiencing problems with their alcohol or
other drug use. The treatment arm of OWL oers holisc assessment and intensive client-centred
counselling.
3.3.2 Why OWL-TR?
As discussed in Part 2, the terms ‘early onset’ (survivors), ‘late onset’ (reactors) and ‘maintainers’ are
oen used to describe the drinking behaviour of older adults. These terms reect the age at which a
person starts to experience alcohol-related problems. Typically, early onset drinkers have had a long
history of harmful drinking, spanning early to late adulthood, whereas late onset drinkers started
experiencing alcohol-related problems later in life.
In general, late onset drinkers appear ‘psychologically and physically healthier’, and tend to be more
amenable to treatment compared with early onset drinkers (Atkinson & Misra, 2002). It is esmated
that one-third of older adults experiencing alcohol problems may be late onset drinkers (Liberto,
Oslin, & Ruskin, 1992; Sorocco & Ferrell, 2006).
A number of risk factors have been idened for AOD problems among older people, which have
implicaons for treatment, including:
• Gender: older men are much more likely than older women to have alcohol-related
problems (Myers et al., 1984)
• Loss of spouse: Hazardous drinking is more common among divorced or separated
older adults and widowed men (Bucholz et al., 1995 cited in Substance Abuse and Mental
Health Services Administraon, 1998)
• Other losses: As people age, major life transions are associated with signicant loss for
many older adults, including diminished income, self-esteem, purpose, social support
networks, mobility and sense of independence, capacity to use or access public transport,
and physical health (Substance Abuse and Mental Health Services Administraon, 1998)
• Comorbid psychiatric disorders: Mood disorders may be either precipitang or
maintenance factors associated with late onset drinking. Depression, for example,
appears to precipitate drinking, parcularly among women (Dupree, Broskowski, & Schon-
feld, 1984)
• Family history of alcohol problems: There may be a greater genec aeology of problem
drinking in early onset than in late onset male alcohol abusers (Atkinson, Tolson, & Turner,
1990)
• Concomitant substance use: Older adults who misuse alcohol tend to also use nicone
and misuse prescripon drugs more than those who do not misuse alcohol (Goldberg,
Burchel, Reed, Wergowske, & Chiu, 1994).
Given the range of risk factors, signicant life transions, and oen minimal contact with services by
older adults, it is crical to develop services that are responsive to the needs of older people.
59
3.3.3 Who is OWL-TR for?
OWL-TR is designed to be used with older adults in a range of specialist alcohol and other drug
sengs. Older adults are at increased risk of alcohol- and other drug-related harm because of the
biological changes that occur as part of the ageing process, the interacon of AOD with medicaons,
and the role these substances can play in the aeology, exacerbaon, and perpetuaon of medical
condions.
OWL-TR Case Study
Mary presented as a 63 year old female, referred by Complex Care, with a 40-year history of
alcohol and cannabis problems and mental illness due to childhood trauma and abuse. She
currently lives alone with her dog and reports to be consuming 2-3 litres of white wine and
smoking 1-2 grams of cannabis daily. Mary immigrated to Australia from Switzerland 13 years
ago. She states she was sober for 12 years prior to her immigraon but resumed drinking and
using upon arrival due to loneliness and separaon from family. Mary also advised she suers
from agoraphobia, major depressive disorder, anxiety and borderline personality disorder.
She also has several health concerns aer experiencing a bad fall previously this year. Mary
reports she is prescribed several medicaons for pain and sleep and is compliant.
The OWL clinician conducted sessions in Mary’s home where she was assessed and entered
into the OWL program. A treatment plan was developed to include: alcohol and cannabis
use reducon with a goal of absnence; educaon regarding medicaon and AOD; individual
counselling; coping skills development; exposure therapy; and support. The Mental Illness
Fellowship, her general praconer and a physiotherapist provided Mary with addional
support.
Mary had insight into underlying issues yet she struggled with lack of movaon to reduce
her alcohol and cannabis use. Aer four months of weekly counselling sessions she agreed to
enter residenal rehabilitaon. Mary was supported by the OWL clinician through her
admission and remained in the clinic for 40 days. Upon discharge from rehabilitaon, Mary
was slowly geng out of the house, walking her dog, aending the neighborhood
community centre and starng to build a network of friends. She is remaining absnent and
reports she is feeling beer emoonally and physically. Mary has remained engaged with
OWL for relapse prevenon strategies.
60
3.3.4 Treatment Tips from the OWL Clinicians
Respect
Understand that the person with whom you are speaking has lived many
years and their life experience, strengths and personal history are valuable.
Acknowledging this will assist parcularly if the individual is losing or has lost
hope.
Paence
Anecdotal evidence demonstrates that the old adage “you can’t teach an old
dog new tricks” is a myth. Older adults can indeed change their habits, but
may take longer in doing so. Some older adults may repeat themselves or
have poor short-term memory, and session content may have to be
reiterated a few mes before it is absorbed.
Rapport
It is important to build rapport to foster and enhance trust. Find an age-
relevant topic to discuss (e.g., interests, hobbies, grandchildren, gardening,
book clubs, etc.). You do not need to be older to work with older adults; you
just need empathy and an ability to relate.
Approach
Choose your words carefully when approaching the subjects of alcohol and
other drug use. You will get a more honest and accurate answer if you are
non-judgemental and casual. For example, ask: “Do you enjoy a drink?” as
opposed to “Are you concerned about your drinking?” or “Do you think you
have a problem?”
Flexibility
Older adults are not all the same and will require a wide variety of
intervenons depending on their individual presentaons and goals. Be
willing to adjust goals as they may tend to change depending on the client’s
current movaon and abilies.
Boundaries
Somemes you are the only contact in a person’s life. Depending on your
client’s situaon they may be experiencing loneliness and isolaon. This
could potenally create signicant dependency on you, so it is always best to
be clear about what your role is and the client’s expectaons of your
involvement.
Thoroughness
Be as thorough as possible when assessing an older adult, ensuring you
gather informaon regarding their mental and physical health as well as so-
cial and familial inuences.
Awareness
Have a good understanding of the variety of issues that are unique to this
stage of life. This may include: rerement, identy and role changes,
bereavement, loneliness, isolaon and sgma just to name a few. Also be
aware of your own beliefs and values regarding the ageing process and
reect on how these beliefs could impact on your percepon of the client
and your subsequent interacons.
61
3.4 Promotional and networking activities and resources
Promoonal acvies are crical to the success of OWL. Older risky drinkers and drug users can be
a hidden populaon and proacve strategies are essenal for engagement. Promoonal acvies
serve three key purposes:
• Raising awareness of the program among older adults and the broader community
• Educang older adults about AOD-related health risks
• Facilitang access to the program.
Promoonal acvies include:
• Community-based talks (e.g., in nursing homes, rerement villages, ProBUS clubs, Rotary
clubs, community groups)
• Media releases, arcles and events
• Stands at public events (e.g., Annual Ageing Well Expos)
• In-service training and site visits (e.g., GP clinics, sta training sessions within Peninsula
Health).
3.5 OWL resources
As part of the development of the OWL program the following resources have been developed:
OWL informaon pamphlet: for disseminaon throughout the community.
A-ARPS screening tool: A partnership was established with the developers of the Alcohol-
Related Problems Survey (ARPS) at The University of California, Los Angeles. The ARPS is a
computerised screening tool that assesses clients’ risk of experiencing alcohol-related harm
using 176 algorithms. These algorithms consider medical history, prescripon and OTC
medicaon use and acvies of daily living. As there is a 40% dierence in what constutes a
standard drink in Australia compared with the USA, the ARPS was rst recalibrated to ensure
that it would be valid to use in Australia. There is no other equivalent tool in Australia. The
Australian ARPS (A-ARPS) is now freely available for use and is valid across all Australian
jurisdicons (see www.wisedrinking.org).
OWL DVD: Through a partnership with Casuarina Media and a steering commiee of older
consumers, the OWL team developed an educaonal DVD resource targeng older adults and
health professionals. It aims to raise awareness of the risks associated with alcohol use and
provide skill development opportunies for health professionals. The Older and Wiser DVD is a
20 minute lm told through three entwining stories and interspersed with professional
commentary. The DVD includes: Older and Wiser, Older and Wiser with professional
commentary, 10 minute commentary for health praconers, 10 minute meditaon exercise
and a 20 minute Radio Naonal interview on the Older Wiser Lifestyles program.
62
3.6 Community awareness
Awareness generates concern and curiosity and that leads to self-referrals
Many older adults are unaware of the impact that ageing can have on their risk of experiencing
alcohol-related harm. Prior to the establishment of the OWL team there had been lile eort within
Australia to increase older adults’ awareness of these issues. The OWL team has enhanced
awareness in the local community through the delivery of community educaon in a variety of
contexts, including: aged care facilies, ageing well expos, demena awareness days, Probus clubs,
rehabilitaon programs, rerement villages and seniors’ clubs.
Community presentaons and media acvies are an eecve way of raising awareness of AOD-
related health issues and generang referrals. During the evaluaon of the OWL Program, one key
referrer associated a peak in referrals with ‘workers being out and about in the community
spreading the word’.
Acvies such as presentaons can provide ‘teachable moments’ for older adults who may not
otherwise receive informaon about alcohol-related health issues such as the interacon between
alcohol and medicaons.
Promoonal material focusing on older adult specic heath concerns, such as demena, tend to
yield more interest than messages about alcohol-related health issues. This illustrates the
importance of tailoring health messages to the target audience and being aware of the sgma oen
associated with alcohol and other drug use.
It was easy to discuss things with [the OWL worker] and she listened to
what I had to say. It was good to speak to someone who knew about
medications and dierent health problems.
I was embarrassed to admit I had a drinking problem but [the OWL worker]
was very knowledgeable and non-judgmental.
3.7 Service sector awareness
The broader health service sector may be a more dicult audience to engage than the older people
themselves. Delivering presentaons to sta and conducng in-service training sessions within
health services can raise awareness of the program. Age-specic services, such as aged care and
rerement homes, are recepve services for OWL. Relaonships and referral networks need to be
maintained through regular and ongoing communicaon with the service sector, including GPs and
other primary and community health providers.
63
Key referrers to the OWL program have described OWL community presentaons and media
acvies as eecve in raising awareness of alcohol-related health issues and generang referrals.
OWL Promoonal acvies study
Alice is a 67 year old rered female who aended a Cardiac Rehab group. She listened to an
informave session that educated her regarding the physiological changes that happen as
we age, interacons between alcohol and medicaons, and gave a demonstraon of what a
standard drink is.
Alice stated that she was never aware of this and will now measure and limit her drinks as she
does enjoy a glass of wine most evenings. She will also discuss what is considered safe for her
with her GP.
3.8 Referral pathways
3.8.1 What are the main referral pathways?
The main referral sources for the OWL program are likely to be:
• Self-referrals (e.g., older people registering interest in the program directly)
• Health organisaons’ centralised intake services
• Allied health programs (e.g., occupaonal therapist, physiotherapist, diecian).
The inial informaon point oen diers for EI and treatment clients. For example, EI clients
typically self-refer in response to aending a health awareness raising presentaon delivered by
OWL sta, whereas treatment clients may learn about OWL via speaking with a health praconer
(e.g., nurse) about their AOD use.
3.8.2 How are referrals facilitated?
Risky or dependent AOD use by older adults is typically idened via standard screens or through
conversaons with paents about other health or lifestyle issues such as poor sleep paerns,
medicaons or grief. This suggests that potenal referrers need to be provided with training and
ongoing informaon about the program in order to facilitate referrals.
Factors facilitang the referral process are:
• A clear understanding of the program by referrers through in-service training and ongoing
contact with OWL
• Access to informaon about OWL (i.e., pamphlets)
• Timely response to referrals
• Direct contact with OWL sta either via the telephone or in person.
64
65
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