Substance Abuse in the Elderly

Substance / Alcohol Abuse among the Elderly

Substance/alcohol abuse among the elderly 60 years and older

Alcohol and substance abuse among the elderly is a significant social problem, not only because people in this age group tend to have very permissive attitudes towards social drug and alcohol usage but also because the stressors that accompany aging may result in increases in drug or alcohol usage to problematic levels. While people may begin experiencing age-related problems in their 40s and 50s, it is not generally until their 60s that most people begin to experience significant physical or emotional challenges related to age. These challenges are often accompanied by major life changes, such as retirement, the death of a spouse or friends, relocation, and diminished physical and intellectual capabilities. These changes may mean a lack of access to the coping mechanisms that have traditionally served the individual, leading to a rise in other coping behaviors, including alcohol usage.

There are a number of models that have proven successful in the treatment of alcohol and drug addiction, though no one model is successful in treating all addicts. One approach that may have greater efficacy than other treatments is a type of cognitive therapy known as Mindfulness-Oriented Recovery Enhancement (MORE). MORE involves the use of mindfulness meditation to direct attention to the sensory features of a pleasant experience, image, or object (Garland et al., 2014). This mindful meditation allows them to focus more on positive images than on neutral images, which can be verified with examinations of brain activity (Garland et al., 2014). Given that people with substance addictions demonstrate decreased brain reactivity to naturally occurring rewards, the use of MORE to increase brain response to positive images could have the potential of redirecting addicts from the pursuit of substances to the pursuit of other naturally-occurring positive stimuli.

MORE has been used in a number of different contexts. For example, Garland and Howard examined its efficacy in chronic pain management where patients may be hypervigilant for pain-related stimuli (2013). By increasing the patient's attentiveness to positive stimuli, MORE was able to reduce their ability to focus on the pain-related stimuli (Garland & Howard, 2013). The belief is that it would work similarly in an addiction context. Addicts pick up on cues in their surroundings that prompt them to use; focusing on positive stimuli would prevent them from picking up on these cues to use.

Examining the MORE model and its impact on opioid dependence in patients with chronic pain, Garland et al., discovered that MORE actually serves two functions: first, MORE teaches patients skills that allow them to focus attention elsewhere, lowering their perceptions of pain; second, it appears to lower their desire for opioids, resulting in less drug use (2014). However, these results were short-term and not sustained over longer periods of time, suggesting that follow-up care and intervention is critical to long-term sobriety goals.

Specifically in the context of alcohol dependence, MORE's efficacy seems to be linked to its utility as a coping mechanism that can be substituted for drinking behaviors, rather than simply the fact that it replaces cueing behavior. In a study that used MORE with alcoholics seeking treatment in a residential treatment facility, the participants discussed their feelings about the MORE process. "The themes of awareness, acceptance, and nonreactivity permeated the narratives of participants, many of whom appeared to believe that mindfulness was a useful means of coping with addiction and stress. On the whole, it appeared that as individuals engaged in mindful breathing practice over time, they discovered it to be an increasingly potent means of decentering or "stepping back" from the stressors and hassles of their everyday lives" (Garland et al., 2012). Given that addicts typically use drugs to step back from their everyday lives, having a coping skill that permits them do the same thing, without the negative impact of the drug usage, creates an ideal substitute behavior.

Furthermore, elderly people in the 60 plus demographic grew up in a time period when meditation was being introduced to the United States in a widespread manner, and, therefore, may be more receptive to the use of mindfulness and meditation as a treatment modality. Another benefit of MORE treatment is that it does not contraindicate other treatments and would not interfere with other therapies; therefore, it could be used as a stand-alone therapy or as an adjuvant therapy along with other treatments. This would make it a great approach for people who seem amenable to treatment and for patients who present as treatment resistant.

The use of Mindfulness-Oriented Recovery Enhancement (MORE) by the alcohol-abusing elder in this study, will be effective in reducing her undesirable alcohol consumption.

Problem

By 2020, almost one-fifth of the population will be 65 or older, which means that health issues impacting the elderly are going to impact all of society (Matthews & Oslin, 2009). Substance abuse disorders are one of those health issues, though society has been reluctant to talk about addiction and substance abuse and misuse among the elderly. The cultural attitude has, instead, been one of acceptance of addiction in the elderly or a denial that a problem exists. The reality, however, is that substance abuse among the elderly is a significant problem impacting up to 17% of the population (Center for Substance Abuse Treatment, 2012).

Substance abuse in the elderly is often misdiagnosed. "Alcohol and substance use disorders in the elderly are underrecognized and may be misattributed to aging. Family members and mental health practitioners should look for signs of falls, relationship conflicts, and memory impairment in their diagnosis of substance use disorders" (Klimstra & Mahgoub, 2010). This is due, in part, to the fact that traditional definitions of substance abuse, such as those found in the various iterations of the DSM may not be inclusive enough to cover the type of drinking that would be indicative of a problem in an older population. This is because, while younger adults may be heavy drinkers without being problem drinkers, the thought is that older adults who are heavy drinkers are likely to experience problems, and therefore should be categorized as either at-risk or problem drinkers, instead of receiving a three-part classification scheme, which younger drinkers would receive (Center for Substance Abuse Treatment, 2012). In addition, there are cultural considerations that hamper diagnosis and treatment; family members are less likely to intervene when an elderly family member is addicted because they may not perceive the addiction as having a negative impact on quality of life, and instead may assume that some of the negative consequences of addiction are actually linked to the aging process.

Part of the reason that heavy drinking is considered so problematic in the elderly is that the aging body becomes increasingly susceptible to the impact of alcohol. This susceptibility is increased by the medications and other drugs that elderly people are likely to use. "People 65 and older consume more prescribed and over-the-counter medications than any other age group in the United States. Prescription drug misuse and abuse is prevalent among older adults not only because more drugs are prescribed to them but also because, as with alcohol, aging makes the body more vulnerable to drugs' effects" (Center for Substance Abuse Treatment, 2012). This is true even when the other drugs being used are not ones considered psychoactive, because they may still impact the central nervous system, and, therefore, mediate the impact of alcohol or other drugs on the patient (Folkman et al., 1987). Therefore, the impact of alcohol or drug use can be far more severe in an elderly patient.

Denial can have severe negative health consequences for the elderly. One problem that medical professionals see frequently is withdrawal from drugs or alcohol in hospitalized elderly patients. Depending on the severity of the addiction, withdrawal symptoms can be severe and can complicate the medical treatment for the underlying reason for hospitalization. Furthermore, the withdrawal process tends to be longer in the elderly, especially those who also suffer from dementia (Ondus et al., 1999). Furthermore, ongoing addictions can significantly alter treatment plans because drug or alcohol usage may contraindicate some therapies or medications.

Another way that alcohol or drug addiction can have a significant impact on the elderly is by increasing the risk of falls. Falls are a serious health risk for the elderly; they are the leading cause of non-fatal injury and can lead to a loss of independence and even to death (Finkelstein et al., 2007). Elderly patients with substance abuse issues are not only more likely to experience falls, but also more likely to experience injuries from those falls. Furthermore, the strategies used to minimize the risk of falls in the regular population, such as Tai Chi and other strengthening exercises, may actually exacerbate risk in the substance-abusing population (Finkelstein et al., 2007). .

Introduction of Client

The client, Pat, is a 62-year-old female with an alcohol-abuse problem. While she acknowledges that she is a daily drinker and the amount of alcohol that she consumes, which is four or more alcoholic beverages each evening, she does not acknowledge that her drinking is a problem. However, she has been hospitalized with liver-related health conditions and has been advised by her doctors that she needs to stop drinking, but insists that her doctors are being alarmists. She is in stage one/pre-contemplation/denial that she has a problem, but has not been dishonest about her doctor's concerns, suggesting that she may have some of her own concerns about the alcohol-related health conditions and be ready to begin contemplating an alcohol intervention program, so that she might be about to transition into stage two/contemplation/ambivalent. The difficulty with assessing Mary's stage is that she has been active in therapy and has made positive life changes, working her way through all of the stages of change; however, she simply refuses to acknowledge that her drinking is a contributing factor to the other problems she is experiencing in her life. She is willing to follow her doctor's medical advice. The most significant foreseeable problem with the fact that she does not see her drinking as an addictive behavior is that she does not seem prepared to deal with the psychological consequences that will come with her stopping drinking.

Mary's life experience is not atypical for a woman of her age, though it could be characterized as being on the extreme ends of the normal distribution. In her youth, she spent time as a singer in a number of rock and roll bands, and spent time touring with those bands. Though none of them became famous, she saw a moderate amount of success on the club circuit. She used drugs and alcohol recreationally and frequently, and developed a cocaine addiction in the early 1980s, which she handled successfully through recovery, and she has not used any illegal substances since completing her recovery, but never stopped drinking. She has never been married, but did have a long-term, live-in relationship, which ended when she was in her late 40s. She has three brothers. Both of her parents are alive. They are divorced. Her father lives with his second wife. Mary moved in with her mother after the death of her mother's second husband because her mother could not pay for her home without help. Mary works as an executive assistant. She receives good compensation and has a good benefits package, but her finances are stretched by having to help support her mother. She receives no financial assistance for her mother from her brothers, who are angry that she will receive her mother's home when her mother dies, despite the fact that she refinanced the home, which was in foreclosure at the time, and has been paying the mortgage for more than a decade. She has some age-related health problems, which are exacerbated by obesity, including high blood pressure, a stomach ulcer, and a bad knee. These limit her mobility. While she has always struggled with weight, a lifelong struggle with an extra 50 pounds has morphed into a struggle with an extra 120 pounds over the last decade as she has become less able to exercise.

Mary is very receptive to the therapeutic process. She has been seeing a counselor for some personal and family issues for several years and does take steps to follow that counselor's advice. She reports a lack of family support for recovery. Specifically in regard to the drinking, she reports that one brother is a recovering alcoholic and that other family members refused to stop drinking, even briefly, at family functions, when he was initially going through sobriety. The one positive is that the substance abuse issues appear to be linked to her father's side of the family; her mother has an occasional glass of wine with dinner, but is willing to forego having any alcohol in the home in order to support Mary's efforts to drink less or stop drinking.

At the initial stage in the process, Mary is willing to stop drinking because her medical doctor has told her that she needs to do so because of her liver condition. She is convinced that she can stop drinking temporarily and that it will correct her liver condition, which is not supported by anything that her doctor has told her. She has not come to counseling seeking help with ending the drinking behavior, but has actually mentioned that she intends to stop drinking during a routine counseling session in which she discussed her last hospitalization period. At this period in time, she is actually technically sober, because she has only recently been released from the hospital. She did detox during her hospital stay and has not had any alcohol since being released from the hospital. She denies experiencing any withdrawal symptoms while in the hospital, but describes physical symptoms that she attributes to her liver condition that align with the physical symptoms that occur with alcohol withdrawal.

Because of Mary's denial, forming a treatment plan is somewhat difficult. She is very scared about her most recent hospitalization and has been worried about her declining health, in general. However, she has expressed similar concerns about her increasing weight and has not been able to make a commitment to the lifestyle changes that would have prevented weight gain and helped encourage weight loss, making the clinician skeptical that she will commit to the lifestyle changes necessary to support long-term drinking cessation. She is adamant about refusing to consider any type of residential recovery program, because she differentiates her drinking behavior, which she considers normal, from her earlier cocaine addiction. This attitude has impacted the development of her treatment plan, so that the one suggested is not the optimal one that would be suggested if she acknowledged a drinking problem and was seeking help specifically for that problem.

The first component of the treatment plan focuses on Mary's living situation. She lives with her mother, which is a stressful situation. Her mother is an 87-year-old woman who is largely dependent upon Pat. They have a good relationship, but her mother has hearing loss, which makes communication difficult and frustrating except under ideal conditions. However, her mother is also supportive of the efforts to stop drinking. Mary reported being upset when she returned home and found that her mother had removed all alcohol from the home after finding out that the doctor had instructed Mary to stop drinking. She will provide transportation for Mary until Mary is cleared to drive, and will attend family counseling sessions, if necessary. The brother who is an alcoholic in recovery has previously talked to Mary about getting sober and would probably offer support, but she is not ready for that intervention. The rest of Mary's extended family are, from her descriptions, all active alcoholics, and would probably be detrimental to her recovery at this point in time.

One of Mary's largest psycho-social barriers is that she does not view herself as a 62-year-old woman. In her mind, she is still a very young, vibrant woman, and she views her body's changes as betrayals. Almost all of her friends are much younger than she is, which has left her without a group of supportive peers. One of the recommended features of a treatment plan for older adults is to rebuild the client's social support network; building a social support network of peers in the same life stage may be important for Pat. This does not have to be done in the context of alcohol treatment. Instead, the clinician will suggest that she attend support groups for adult caregivers of elderly parents. There, she will be likely to meet people her age dealing with many of the same stressors she experiences with her mother, as well as the same types of family tensions she experiences with her brothers as a result of her living with her mother and being the one likely to inherit the bulk of her mother's estate. This is way to build a support group that does not focus on her substance use.

In addition, Mary will be taught the MORE approach outlined in Garland's treatment manual. Mary readily admits to using alcohol, specifically wine, to cope with stressors. She also admits to being frazzled by the idea of not being able to unwind with some wine and is receptive to learning other coping skills. This will involve the use of mindfulness meditation exercises and the intentional use of those exercises in response to stressors, including cravings for alcohol. At this point, Mary's therapy will not involve education on addiction or substance abuse, or any interventions more specifically aimed at dealing with addiction because those actually seem as if they would be counter-productive in producing the short-term goal of keeping her alcohol-free, and the longer she remains sober, the more likely she is to want to address the underlying addiction issues.

Implications for Counselors

The hypothetical patient described in this paper was loosely inspired by one of the author's good friends and presents a challenge for a counselor: a patient who is seeking to stop a problem behavior but is not addressing the underlying issues that make the behavior problematic. In this hypothetical, Mary has been instructed by her doctor that she must stop drinking because she is experiencing liver problems that are exacerbated by alcohol. She detoxed while in the hospital and has been sober since her release from the hospital and is willing to follow the doctor's instructions, for a short time period. However, the patient is still very much in denial about having an alcohol problem. She believes that she will be able to return to her heavy drinking behavior after her liver problem is resolved and that her drinking behavior, which is very excessive, is actually well within the range of normal behavior. She becomes very defensive about suggestions that it is not.

The implication from this client is that counselors have to treat the client that they have, not the idealized version of a client. In an ideal world, Mary would recognize that she was a problem drinker and want to seek sobriety, not only to help her liver condition, but to improve her overall life circumstances. However, many patients do not see drinking as a source of negative consequences, but, instead, as one of their primary sources of stress relief. As a result, they are very reluctant to cease drinking behavior. Refusing to help those patients stop drinking for whatever reason brings them to the counselor would be counter-productive. The longer that they are sober and able to clearly examine their lives without alcohol usage, the more likely it is that these patients will conclude that alcohol use had a negative impact on their lives. Moreover, as in Mary's condition, many of these patients may face significant consequences if they do not stop drinking. Some patients will present with medical issues, others may present with legal issues, but the reality remains that there will be many patients with a need to get sober who are not motivated by the fact that they are addicts or by the fact that substance abuse is having a negative impact on their life. Instead, they will solely be motivated by a desire to avoid the negative impact that substance abuse is having on their lives. These patients need help, just like other substance abusing patients need help. Therefore, counselors should be willing to modify their approach for patients and meet patients where they are at the beginning of counseling programs aimed at ending substance abuse.