Older Adults: Why Bother Theyre Gonna Die Anyway

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Older Adults Why BotherTheyre Gonna Die
Anyway!

• Carol S. DAgostino
• LCSW, MA, BCD, CASAC
• Robert Wood Johnson Fellow
• (Developing Leadership in Reducing Substance
  Abuse)

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The difficulty lies, not in the new ideas,

• But in escaping from the old ones.
• John Maynard Keynes

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Remember

• Nothing about your clients drinking may have
  changed
• BUT
• Everything associated with their aging has.
• More individuals 65 are admitted to hospitals
  for ETOH-related problems than for heart attacks!

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Donna Case Study
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Client Solution?

• Borrows 2 cups vodka from a neighbor
• Refusal of all recommendations (higher level of
  care, Guardianship for finances, out-of-county
  detox, MH day program, companion services)
• Where do the ethical/moral responsibilities lie?
• Hospital? Insurer? Senior Living?
• PCP? Family? Adult Protective?
• HHC? Client? County/State?

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Older Adult Substance AbuseA National Epidemic

• National Perspective
• gt30 million 60
• 17.7 suffer from substance misuse
• New York State Perspective
• gt1/2 million NYers 60
• 1996 only 3.8 of 250,000 admits were 55
• Monroe County Perspective
• 16,000 currently suffering 65
• Only one geriatric-specific licensed program
• No licensed medical detox beds

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1996 CASA Physician Study
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Complex Profile
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Co-occurring Disorders

• Depression 20-30
• Anxiety disorders 10-20
• Cognitive loss 10-40

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Dementia/Alcohol Cycle
Acceleration Of cycle
Loss of Self-esteem
Malnutrition
Alcohol Use (Alleviate Stress)
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Medication Mismanagement
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Community Barriers
Advocacy! Advocacy! Advocacy!
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Complex Client Profile
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Need For A New Clinical Pathway
Aging Network
CLIENT
Mental Health
Addiction Treatment
Senior Living Communities
Healthcare
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Geriatric Co-occurring Disorders Model(Lifespan,
Rochester, NY)

• Community outreach model
• not treatment/not licensed
• Utilize a stratified geriatric care management
  approach
• Collaboration between aging, MH/CD and healthcare
  networks
• Clients 55, no court mandates, no homeless
• Minimal fee for service/Funding from local
  foundations
• Data collections on first 120 (Journal of Dual
  Disorders, in print)
• Clinical evaluation (Un. of Michigan/Dr. Frederic
  Blow)

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Broadening the Clinical Toolkit Traditional
Risk Reduction

• Medical model
• Abstinence model
• Non-compliancenot ready, hit bottom
• Client has to reach out first
• Strong cognitive component

• Public health model
• Non-abstinence model
• Health, safety, functioning focus
• Holistic treatment plan
• Linkage/support
• Redefines success
• Slower pace

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Focus on Medical Concerns

• The relationship between alcohol consumption and
  risk (stroke, HTN, cancer, depression, etc.)
• The interaction of alcohol prescription meds
  (HTN, ulcers)
• Concerns regarding health, safety, functioning
• Use at risk or misuse vs. Alcoholic

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Ask Alcohol Relationship QuestionsAdapted from
A. Weil and W. Rosen, 1993From Chocolate to
Morphine Everything You Wanted to Know About
Mind-Active Drugs

• Do you recognize that ETOH is a drug?
• Do you have an awareness of what it does to your
  body?
• Do you experience any useful effects?
• Can you easily separate from your use?
• Are you free from adverse effects on your health,
  functioning, or behavior?

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THINK OUTSIDE OF THE BOX!

• Dont follow recommended drink charts
• Dont condone alcohol for health reasons (heart,
  blood, anxiety, etc.)
• Screen for insomnia (ETOH ?)
• Utilize support at healthcare appointments
• Brown bag assessments
• Aging ETOH Sicker Quicker

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Transitional Care ManagementDirect
Intervention/Linkage

• Assessment
• Motivational enhancement techniques
• 12 Step/AA Grey AA
• Crisis intervention skills mandatory
• Powerful brokerage with CD facilities
• Geriatric care management thru CD treatment

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Supportive Care ManagementRisk Reduction Model

• Clinical evaluation
• Risk reduction strategies/psychotherapy
• Motivational enhancement techniques
• Powerful integration with aging and mental health
  networks
• Linkage to CD treatment when appropriate
• Geriatric care management (can be intensive)
• Crisis intervention skills mandatory

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Intensive Care ManagementEnvironmental
Treatment Model

• Medically/mentally fragile
• Dementia
• Never going to be appropriate for tx sole focus
  on health, safety, functioning
• Intensive geriatric care management
• Crisis intervention skills mandatory
• Use of senior living communitiesStep Down
• Geriatric Neuropsychiatric evaluations
• Guardianship

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What are we learning?

• Use has not changed, client profile has!
• Average age of clients b/t 75-85
• gt40 of referrals from families/caregivers in
  crisis
• Common threads self-neglect, isolation, and
  medication mismanagement
• Only 10 of clients have any previous CD tx
• Over 40 of clients have some form of dementia
• 20 involve some form of elder abuse
• 15 of clients die annually

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What else?

• Inpatient Linkage
• --w/o motivational enhancement, 57
• completion rate
• --w/motivational enhancement, 80
• Outpatient Linkage
• --w/o motivational enhancement, 10
• completion rate
• --w/motivational enhancement, 40

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G.A.P. Program Expansion

• Monroe County Geriatric Substance Abuse Coalition
• Monroe County Dept. of Human/Health Services
• Monroe County Office for the Aging
• Monroe County Office of Mental Health
• Monroe County Medical Society
• United Way
• Excellus/BlueCrossBlueShield
• National Council on Alcohol and Drug Dependence
• Alzheimers Association
• Senior Living Communities

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Monroe County Coalition, cont.

• Direct Service Subcommittee
• 1. Surveying Senior Living Committees
• 2. Surveying Licensed CD Tx Facilities
• 3. Design of a new clinical pathway
• Step Down Model
• 4. Ethnic Outreach

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Monroe County Coalition, cont.

• Public Policy Subcommittee
• 1. Lack of licensed medical detox beds in
• Monroe County hospitals for high-risk,
  frail
• elderly

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Monroe County Coalition, cont.

• Knowledge Management Subcommittee
• 1. Monroe County Senior Action Plan
• Geriatric Mental Health Specialist
• Training Program
• 2. Consultation 5 Counties in NYS
• 3. Contracts Urban Healthcare Clinics