Understand the Developmental Issues of Aging

Older adults are not a homogenous group. As with any group, older adults may hold a diverse range of opinions and attitudes toward alcohol and drug use. For example, within the older adult population, people in various age ranges differ from one another in significant ways that may influence which approaches will most successfully address substance misuse.

Earlier cohorts of older adults (e.g., adults born before or during World War II) are more likely to have moralistic attitudes about drinking and drug use—attitudes that, for some, were shaped by Prohibition and the Temperance Movement.²⁴¹ They may feel deeply ashamed about alcohol misuse or drug use. If they attribute their substance misuse to a moral failing, they may be less likely to seek SUD treatment.²⁴² These cohorts are likelier to benefit from screening and brief intervention with a healthcare provider when questions about drinking and drug use are part of an overall approach to health assessments.

Baby boomers (i.e., adults born between 1946 and 1964) grew up in a time when substance use was more culturally acceptable. They may have more permissive attitudes toward drinking and drug use. They are also more likely to be willing to seek and agree to specialized addiction treatment.²⁴³

Older adults have unique developmental challenges that younger adults may not have. These include possibly losing a spouse or partner, as well as experiencing:

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Increasing numbers of deaths of friends in the same age cohort.

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Role changes in families and work-related activities.

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Reduced opportunities for increasing or maintaining income levels.

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Normal age-related cognitive and physical decline leading to loss of functioning and reduced capacity to carry out ADLs.²⁴⁴

Providing age-sensitive, age-specific treatment approaches helps older adults feel more comfortable discussing personal issues and age-related changes than they would feel doing so in mixed-age treatment programs.²⁴⁵ Whether or not you can offer age-specific treatment options, your program needs to create an environment that responds to older adults' needs (Exhibit 2.2).

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EXHIBIT 2.2 How Administrators Can Create a Treatment Environment Responsive to Older Adults.

The consensus panel recommends that you engage your clients in discussions about their attitudes toward substance misuse, create an age-sensitive treatment environment that is responsive to older adults, and offer age-specific treatment options when possible.

Acknowledge and Address Older Adults' Diversity

The older adult population is as culturally diverse as other age groups. Yet older adults who are members of racial/ethnic and other minority groups are often at greater risk of poor health, disability, social isolation, and poverty than are their younger counterparts. Older adults from diverse racial and ethnic backgrounds are also more likely to be underinsured and receive fewer routine screenings for health concerns.²⁴⁷ Therefore, they face more barriers to accessing health care and experience greater health disparities.²⁴⁸ These disparities increase risk for developing SUDs and increase barriers to treatment.

Lesbian, gay, bisexual, transgender, and questioning (LGBTQ) older adults may experience poor health care and lack of access to services. Given discrimination and prejudice, they may have to hide, or feel the need to hide, their LGBTQ identity to receive care.²⁵⁰

Gender-related disparities can create or compound health disparities in older adults. Older women are at higher risk for co-occurring mental disorders and social isolation than older men.²⁵¹ They are also more likely to be prescribed medications (e.g., benzodiazepines) that negatively interact with alcohol and to be prescribed them for longer periods of time, increasing the risk of SUDs.²⁵²

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Providers and program administrators must learn how older clients' race, ethnicity, sexual orientation, gender identity, and socioeconomic status influence overall health, substance misuse, and availability of healthcare and behavioral health services.²⁵³ They should also recognize that older adults can draw on their cultural heritage in ways that improve health and well-being.²⁵⁴

“As people age, they shape their world in ways that maximize their well-being … within the confines and definitions of their respective cultures.”

—H. H. Fung (2013), p. 375²⁵⁵

The consensus panel recommends that you maintain awareness of older adults' racial, ethnic, gender, and LGBTQ diversity when addressing late-life substance misuse, health disparities, and barriers to access to care. Provide culturally responsive screening, assessment, and treatment for clients across settings.

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RESOURCE ALERT: IMPROVING CULTURAL COMPETENCE.

Recognize the Difference Between Early- and Late-Onset Substance Misuse

Diagnosis and treatment planning differ for older adults who have a history of substance misuse (early onset) and those who develop problems only later in life (late onset). For example, older adults who begin to drink because of late-life stressors (e.g., loss of a significant other) may not have the same chronic, co-occurring medical conditions or mental disorders that older adults who have been drinking since adolescence or early adulthood have. Late-onset substance misuse may respond well to brief interventions. Older adults who exhibit chronic misuse may need more intensive SUD treatment.²⁵⁶

The consensus panel recommends that, as part of regular screening and assessment, you determine whether clients have a history of substance misuse or are using in response to more recent stressors. Use this information to identify appropriate treatment options. Discuss these options with clients.

Emphasize Client Education, Early Identification, Screening, and Brief Treatment

Substance misuse in older adults is often unrecognized by older adults themselves, as well as by their family members, friends, and healthcare and social service providers. To ensure that older adults receive education, screening, assessment, and treatment, all who have regular contact with them—whether in the home, at healthcare visits, at community-based senior services, or in long-term care facilities—must recognize the signs of substance misuse (including prescription drug misuse) in older adults.

Older adults are less likely to get referrals to specialized SUD treatment from healthcare providers than other sources (e.g., self-referral, referrals from legal incidents related to driving and substance misuse).²⁵⁷ Yet healthcare providers are well positioned to identify and screen for substance misuse in older adults.

Older adults are more likely than younger adults to see their healthcare providers to discuss and receive treatment for numerous medical and health-related concerns. Healthcare visits are opportunities to discuss substance use and related health risks and consequences. Healthcare providers can also take these opportunities to talk with older clients about drug-drug interactions with alcohol, prescription medications, and other substances in the context of routine medical care.²⁵⁸

If you are a healthcare or social service provider who has contact with older adults in home-care situations, residential care facilities, community-based programs, or emergency departments, you should be aware of the signs of substance misuse among this population. Within your scope of practice, you should engage in routine screening of older adults for substance misuse in accordance with your program's policies and procedures.

A growing body of research demonstrates that different kinds of brief interventions delivered in a variety of healthcare and social service settings can effectively reduce alcohol consumption and substance misuse and lower health-related risk among older adults.^{259,260,261,262,263} Brief interventions can also facilitate entry into more intensive treatment.²⁶⁴

The consensus panel recommends that providers across settings in which older adults may seek care:

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Promote early identification, education, outreach, and prevention in their programs/communities.

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Promote universal screening for alcohol misuse, drug use, and prescription medication misuse for older adults.

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Develop and expand brief interventions for older adults who misuse substances.

Engage in Health Risk Reduction Practices

Older adults who misuse substances may not want to set abstinence as their goal. Engaging in health risk reduction practices is an important and viable option for older adults and is consistent with age-sensitive treatment practices.²⁶⁵ For example, medical providers can slowly taper older adults to the lowest possible doses of benzodiazepines without withdrawing them completely. Another health risk reduction approach specifically designed for older adults is the BRITE project, an adaptation of screening, brief intervention, and referral to treatment (SBIRT). It has demonstrated lowered alcohol severity and depression in older adults and improvements in medication misuse.²⁶⁶ (See Chapter 3 of this TIP for more information on screening and assessment.)

Risk reduction strategies lower health-related risk for older adults and can boost functioning. Risk reduction can also be a first step toward abstinence. For example, once older adults who misuse alcohol begin to experience the health benefits of less drinking, they may be more willing to stop completely.

The consensus panel recommends engaging in health risk reduction practices to lessen the impact of substance misuse on the physical and mental health of older adults.

Provide Person-Centered Care

Based on a literature review and qualitative research, a consensus panel convened by the American Geriatrics Society determined that a person-centered approach to care for older adults puts older adults' values and preferences at the center of the decision-making process regarding healthcare options and treatment goals.²⁶⁷

“‘Person-centered care’ means that individuals' values and preferences are elicited and, once expressed, guide all aspects of their health care, supporting their realistic health and life goals. Person-centered care is achieved through a dynamic relationship among individuals, others who are important to them, and all relevant providers. This collaboration informs decision-making to the extent that the individual desires.”

—American Geriatrics Society (2015), p. 16²⁶⁸

Consider client needs and preferences when deciding treatment intensity (e.g., inpatient or outpatient), method (i.e., group or individual treatment), and goal choice (i.e., abstinence or reduction in use).

Collaborating with clients to develop treatment goals enhances positive outcomes.²⁶⁹ Offer clients a menu of treatment options that fit their needs and preferences. Options should include the least intensive treatment approaches that are medically appropriate as well as more intensive alternatives.

More treatment leads to better outcomes, regardless of the level of care (e.g., residential versus outpatient treatment) or whether treatment is greater in intensity or greater in length of overall treatment. The more attention older clients receive, the more likely they are to improve.²⁷⁰

Continually reassess older clients' needs, treatment goals, priorities, and intensity of care throughout treatment. Maintaining clients at the center of the conversation is essential to this process.

The consensus panel recommends that you engage older clients in a comprehensive, person-centered, trauma-informed approach to SUD treatment that emphasizes their values, needs, and preferences. Offer a menu of care options, including the least intensive treatment approach.

Build Alliances With Age-Sensitive Engagement and Retention Strategies

Building a strong treatment alliance with each client fosters engagement and retention in treatment. The treatment alliance is a collaborative process based on agreement on treatment goals and tasks and a bond between you and your client.²⁷¹ A large body of research shows the alliance as significant in all kinds of helping relationships across a variety of treatment methods, including SUD treatment.²⁷²

Retention in SUD treatment predicts good outcomes for older adults regardless of treatment approach.²⁷³ Retention refers to a client's length of time in treatment and adherence to treatment.

To engage and retain older adults in treatment, the following practices are helpful:

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Recognize the importance of establishing a collaborative relationship as the primary mechanism for engaging clients in treatment and supporting behavior change.

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Create a culture of respect, which is nonconfrontational, focuses on building older clients' sense of value and worth, acknowledges the wisdom of their own lived experience, and expresses confidence in their ability to participate in treatment and accomplish their treatment and recovery goals. Respect the customary social conventions of older adults' age cohort (e.g., refrain from swearing or using slang) and ask clients how they would like to be addressed and introduced to others.

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Use proven treatment approaches that have demonstrated effectiveness or shown promise with older adults in addressing substance misuse across a variety of settings. Such approaches include brief advice and brief interventions, SBIRT, motivational interviewing, supportive therapy, problem-solving therapy, individual therapy, and cognitive-behavioral therapy.^274,275

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Match treatment to older adults' needs and levels of functioning.

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Outpatient programs should provide services during daytime hours and assist clients with transportation. Offer in-home or telehealth support services to homebound older adults.

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Inpatient and residential treatment programs should create an environment that is easy for older adults to navigate. Facilities should be well lighted and accessible to individuals with disabilities, and should have other accommodations as needed for older clients.

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Programs should modify design and delivery of services to accommodate vision, hearing, and mild cognitive problems that develop or increase in later life.

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A slower program pace, repetition of information and instructions, and allowing time for clients to integrate and respond to information and questions can enhance their learning and participation in program activities.

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Implement age-sensitive group treatment approaches to meet older adults' needs and preferences. Older adults, regardless of gender, tend to be more private and concerned about how much personal information they will share in a mixed-age group setting. They may not relate to or feel comfortable sharing their problems with younger adults.²⁷⁶

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Use age-sensitive adaptions if your program only has mixed-age groups: Emphasize privacy/confidentiality, accommodate physical needs, establish group norms for respect, and ensure older adults' voices are heard by creating opportunities to share without pressure to disclose.

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Work with older clients to explore pros and cons of age-specific and mixed-age groups, and honor their preferences if possible in your program. Age-specific groups for older adults should focus on topics such as grief and loss, trauma, social isolation, social pressure to drink, life-stage and role transitions, and coping skills specific to older adults (e.g., strategies for coping with loneliness). Match older adults to groups based on availability, primary substance use concerns, age-related issues, and client preference. If possible, match older adults who have experienced trauma to gender-specific groups and those with chronic pain to groups that address pain and medication misuse.

The consensus panel recommends incorporating into your program age-sensitive and age-specific treatment practices that engage clients and improve retention in treatment. (See Chapters 4 and 5 for additional information on treatment of older adults for AUD and other SUDs, respectively.)

Help Older Clients Use Social Networks and Community-Based Services

Older adults in long-term recovery from SUDs demonstrate better outcomes when they have social supports that promote abstinence.^277,278 Social networks for older adults in recovery include caregivers, family, friends, faith-based communities, peer recovery support services, and mutual-help groups.

Older adults' social networks frequently narrow because of retirement, loss of spouses or friends, or reduced ability to engage in activities outside the home. This can increase some older adults' isolation and contribute to substance misuse.²⁷⁹

Assess older adults' current social networks. Help them improve and use social supports to reduce isolation and support recovery from substance misuse.

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CASE MANAGEMENT SERVICES.

The consensus panel recommends that SUD treatment programs help older clients connect with social networks that promote recovery. Use a CCM approach to link clients actively to community services.

Encourage Family and Caregiver Involvement

Involving caregivers throughout treatment and ongoing recovery enhances retention and improves treatment outcomes for people with SUDs.²⁸¹ Include caregivers (e.g., family members or guardians) in the entire treatment and recovery process, with the permission of the older client. Caregivers and family members can be essential partners in helping older adults participate fully in treatment and recovery activities. For example, they can assist older adults who have mobility challenges and cognitive impairments that make it difficult to follow treatment and recovery plans without support.

Educate caregivers about how substance misuse can affect older adults' physical and mental health, as well as their relationships. Include them in counseling sessions that focus on recognizing relapse triggers, improving communication, and teaching constructive problem-solving skills. This knowledge will help them more effectively support the recovery of your older clients.

Family members are often both caregivers and case managers for older adults with SUDs. The stress of this responsibility and resulting neglect of their self-care can put them at risk for developing SUDs, worsening chronic medical conditions, or increasing vulnerability to stress-related illnesses.²⁸² Help caregivers reduce their stress levels and maintain their own mental, emotional, and physical health.²⁸³ Encourage family members to take care of their own emotional, mental, and health needs and participate in community-based supports such as caregiver groups.

The consensus panel recommends that, with older clients' consent, providers across service settings involve caregivers in all aspects of older clients' treatment and recovery.

Coordinate Care and Develop Service Linkages

Develop linkages to appropriate services and maintain ongoing relationships with other providers to coordinate care across settings for older adults with SUDs. Doing so will increase successful referral outcomes.²⁸⁴ Coordinated care involves establishing and strengthening referral streams and partnering with community-based resources serving older adults (e.g., local Area Agencies on Aging).

Referring older clients to other services is not a once-and-done event. It requires actively connecting clients to appropriate providers or services (e.g., a “warm handoff” in which you make a referral to another agency in person with the client present) and following up with clients to ensure that referral was successful.

Care coordination and management are especially important for older adults with co-occurring medical or mental disorders. For example, a client with an SUD in a healthcare setting who screens positive for anxiety or depression should receive a referral for further assessment and treatment to a mental health service clinician experienced in working with older adults who have co-occurring disorders. Consider availability, accessibility, and client preferences when making referrals to other providers or community-based services. In addition, stay informed of available services. Treatment options within a given agency may change frequently.

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RESOURCE ALERT: DEVELOPING REFERRAL RESOURCES.

The consensus panel recommends that you establish ongoing relationships with providers across services and community-based programs to ensure active linkage of clients to older adult services, healthcare professionals who specialize in geriatrics, addiction treatment services, mental health services, and recovery resources.

Make Programmatic Changes To Effectively Serve Older Adults With SUDS

Before administrators and clinical supervisors can focus on workforce development, they must establish their organizations' vision and commitment to making programs more accessible to older clients and to creating new or adapting existing programs to accommodate older adults' unique needs. Start with an organizational self-assessment and change plan that includes:

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A rationale for providing age-sensitive and age-specific services.

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An assessment of the organization's strengths and needs for improving services for older adults.

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A review of priorities, goals, and tasks to help develop or augment existing services for older adults.

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A plan for adapting facilities and programs to accommodate the unique needs of older adults throughout the continuum of care. This includes establishing age-sensitive and age-specific policies and practices for outreach, universal screening for substance misuse, and enhancing access and flow of clients through the continuum of care from screening to brief intervention and referral or admission to SUD treatment and continuing care.

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A plan for identifying and developing linkages to community-based resources serving older adults.

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A plan for involving staff, older clients, and members of older adult programs and recovery-focused organizations in the planning and implementation of services.

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Guidelines for implementing organizational change that describe roles, responsibilities, timeframes, and specific activities for each step of the change process.²⁸⁵

In addition, administrators need to be aware of state-level variance in policies and practices, which can dictate the parameters and limitations of a program's features and implementation process.

The consensus panel recommends that you do an organizational self-assessment and have a plan in place before implementing any organization-wide changes to policies and practices.

Invest in Age-Sensitive Workforce Development

To implement older adult-specific SUD treatment programs and services successfully, program administrators must hire and retain highly motivated staff who are committed to serving older adults. To ensure staff are knowledgeable and have the skills to care for older adults with SUDs, engage in ongoing workforce development practices:^286,287

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Develop staff recruitment, retention, and promotion strategies that engage clinical and program staff who are knowledgeable about older adult health, mental health, and substance misuse and are motivated to work with this population.

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Recruit older peer recovery support providers and create a work environment that recognizes lived experience as a valuable source of knowledge.

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Develop pathways for integrating older peer recovery support providers into service teams and provide them with ongoing supervision and professional development opportunities.

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Create training plans and curriculums that address ageism, health disparities, and cultural diversity among older adults; the culture of aging; physical and mental health needs of older adults; and treatment practices and evidence-based approaches that are effective with older adults.

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Provide ongoing clinical and administrative supervision that emphasizes the attitudes, knowledge, and skills required to care for older adults.

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Evaluate staff performance on the attitudes, knowledge, and skills required to care for older adults.

The consensus panel recommends that you implement workforce development strategies for building or improving age-sensitive and age-specific treatment for older adults with SUDs.

Provider Resources

American Psychological Association (APA)— Guidelines for Psychological Practice With Older Adults (www.apa.org/pubs/journals/features/older-adults.pdf): These guidelines provide information on evaluating psychologists' readiness for working with older adults; this information is also applicable to other behavioral health service providers.

APA—Multicultural Competency in Geropsychology (www.apa.org/pi/aging/programs/pipeline/multicultural-competency.pdf): This report describes behavioral health service providers' multicultural competencies for working with older adults.

Council on Social Work Education—Gero-Ed Center (www.cswe.org/Centers-Initiatives/CSWE-Gero-Ed-Center.aspx): The center's website provides resources, educational materials, and a curriculum to enhance social work competencies, which apply to all behavioral health service providers caring for older adults.

Institute of Medicine (IOM)—The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? (www.nap.edu/download/13400; download for free as a guest): The IOM provides this report as an overview of the eldercare workforce and workforce development barriers and needs. (IOM is now the National Academy of Medicine.)

Office of Minority Health—National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (https://thinkculturalhealth.hhs.gov/clas): These standards describe principles of culturally appropriate services applicable to treating culturally diverse older adults in healthcare and behavioral health service settings.

Understanding Issues Facing LGBT Older Adults (www.lgbtmap.org/file/understanding-issues-facing-lgbt-older-adults.pdf): This report from the Movement Advancement Project and SAGE helps providers and others better understand the social isolation and health challenges that affect many LGBT older adults.