Compared to approximately 7% to 10 of the general population



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B
I. Rationale:
SAS is committed to promoting excellent, effective treatment across the life span, supporting treatment approaches that respond to changes in the capacities and needs of individuals, and their families. This Practice Guidance pays particular attention to the treatment needs of older adults. By 2020 the proportion of adults over age 50 in the general population will increase by approximately 40% over the proportion in 2002.i While this increase alone will boost the number of older adults needing treatment, the need is likely to be greater still given characteristics of this cohort. The ‘baby boomer’ generation has a higher rate of substance use, especially polysubstance use, and started using at an earlier age than previous groups of older adults. Current reports estimate that approximately 17% of older adults abuse alcohol or other drugs,1 compared to approximately 7% to 10 % of the general population.2 Approximately 20% are dependent upon nicotine. These reports are reflected in the increase in treatment admissions: since the 1990’s treatment admissions of adults over 50 have doubled.3

Substance use disorders (SUDs) in older adults are different. Older adults metabolize alcohol and drugs differently due to age-related physical changes. Those with early onset SUD experience more physical and mental health complications as a result of these changes and the co-morbidity resulting from long-term substance use. Older adults are more likely to be prescribed more medications, some with adverse effects that are not identified.4 Primary care providers may misdiagnose, or fail to screen for or to rule out, effects of long-term alcohol and drug use. Cognitive changes due to prolonged polysubstance use may be misinterpreted as symptoms of cognitive losses or dementia.

With a lower threshold of risk, older adults are more vulnerable to late-onset substance use disorders. These may be related to or compounded by increases in medications, and by multiple losses experienced as individuals age: partners, friends, jobs, physical well-being, and economic security. Internalized stigma related to financial and material losses can be exacerbated by substance use. All of these factors can synergistically increase isolation and depression, which can be misconstrued as lack of motivation for treatment. The risks are high for this age group: the second highest suicide rates

of any age group occur among persons 65 and older5, with overdose as the second most common method of suicide.

Assessment, diagnosis and treatment can be complicated when symptoms are masked by co-occurring disorders, cognitive impairments, effects of prescription medications, and changes in physical health, among other factors. In order to provide equitable and effective treatment for older adults, treatment providers will not only need to anticipate the increased need for services. They will also need to respond to the physical, cognitive and social restrictions elders face while recognizing individuals’ continued desire for purposeful lives. Outreach to and coordination with primary care settings, nursing homes and other senior service providers can reach older adults where they already have established productive relationships. Outreach may be key, as clinicians accommodate6 a slower pace of engagement and treatment progress, and modify treatment methods, for example with more individual, and fewer group sessions.


II. GUIDANCE:



A. Organization:

Policy

  • Policies state that engagement and treatment are responsive to physical, cognitive, social and spiritual needs of older adults.

  • Policies state commitment to ensuring coordinated care for older adults and to inclusion of older adults’ families and other significant relationships in treatment, where consented to by the individual served.

Operations

  • Outreach efforts are directed toward senior centers, nursing homes, senior housing and senior/elder service providers.

  • Agencies establish QSOA’s and active working relationships with primary and elder care providers, including specifying methods of referral and providing cross-training.

  • Agencies investigate innovative approaches aimed at reducing the impact of mobility limitations, e.g. consider home-based services or services at senior centers.

  • Agency materials, including orientation information and forms requiring client signatures are available in large print.

Supervision, Training & Staff Development

  • Agency case management staff is knowledgeable about senior services, such as transportation, meals, housing, and is able to effectively make and follow-up on referrals for services.

  • Case management staff is skilled in communicating with primary care providers, family members and others involved in service provision.

  • All staff, including reception, clerical and clinical staff, recognize and respond to the need for information to be presented at a slower pace due to changed capacities in hearing or comprehension.

  • Staff is trained to use tools and therapeutic approaches that are proven effective with older adults.

  • Staff is knowledgeable about the different physical effects of alcohol and drugs on older adults, and about the different risks faced by older adults (e.g. risks related to treatment of pain).

  • Staff is knowledgeable about opioid use among older adults and about opioid overdose prevention, recognition and response.

  • Staff is knowledgeable about related risks of harm such as:

    • Increased rate and lethality of suicide in older adults;

    • Increased gambling activity;

    • Increased risks of falls and injury.

  • Staff is able to provide information to individuals served about the effects of alcohol and drugs on older adults.

  • Staff is knowledgeable about interactions among alcohol, illicit drugs, prescription drugs and over-the-counter medications or, if not knowledgeable, can direct individuals to reliable sources of information.

  • Supervision and training explicitly explore staff perceptions and responses based on age differences between staff and individuals in treatment.


B. Service Delivery and Treatment:

Assessment: Assessments:

  • Recognize that terms and measures applicable for younger adults apply differently to older adults, for example: age of onset, low- vs. high-risk drinking, giving up activities due to use, and type and severity of substance use-related problems.

  • Use tools established as reliable with older adults (such as MAST-G or AUDIT).

  • Gather and record information about:

    • Current physical and mental health care providers;

    • Family, social and economic status and losses;

    • Mental health status and history of suicidal ideation or suicide attempts;

    • Changes in physical or mental capacities and accommodations needed.

  • Include review of prescription and over-the-counter medications, their side effects and potential interactions.

  • Include information about family and friends, particularly those who may be acting as caregivers.

Planning

  • Treatment plans identify individuals’ medical and health care providers, and include information about medications and potential side effects/interactions, as well as about transportation and mobility needs.

  • Treatment plans specify accommodations needed and plan to ensure accommodations are made.

Service Provision

  • Staff is knowledgeable about differences in tolerance and withdrawal risks for older vs. younger adults.

  • Staff is able to discuss losses experienced or likely to be experienced by older individuals.

  • Staff is able to discuss harm reduction strategies, such as:

    • Prevention of injuries related to falls and operating motor vehicles or machinery;

    • Opioid use and prevention, recognition and response to opioid overdose;

    • Monitoring increases in gambling activities.

  • Staff is able to assess mental status, with particular attention to depression and suicidality, and intervene as needed.

  • Staff engages individual served in establishing care coordination with medical and other service providers.

  • When treatment is provided in group sessions, group process accommodates and responds to of older adults.

Education of Individuals

  • Individuals are provided information about risks related to substance use that are specific to older adults, and about benefits treatment can provide for older adults.


III. MEASURES:

Programs can assess their effectiveness by formulating questions specific to their goals in applying standards. Some examples of questions related to serving older adults include:



  • Comparison of demographic characteristics of the community vs. admission data,

  • QSOAs and active referrals with agencies serving older adults,

  • Training topics such as: use of assessment measures applicable to older adults, death and dying, and stages of change as they relate to older adults.

  • Agency data on engagement and retention in treatment, and intensity of services (e.g. number of counseling sessions; number of groups for older adults).


IV. RESOURCES:

NOTE: All linked resources accessed February 2015.
BSAS:

See BSAS Principles of Care and Practice Guidance available at: http://www.mass.gov/eohhs/gov/departments/dph/programs/substance-abuse/providers/program-licensing/principles-of-care-and-practice-guidance.html. These include guidance on: Access for Persons with Disabilities, Effective Treatment for Persons with Co-Occurring Disorders, Engaging Veterans and others.

For providers: The following can be found on the Massachusetts Clearing House: http://www.maclearinghouse.com/category/BSASELD.html:

Healthy aging: Medications and Alcohol

Treatment Provider Update: Substance Use Problems Among Older Adults

Provider Update: Alcohol and medication issues for older adults

Provider Update: Problem Gambling Among Older Adults

For older adults: Also on the Massachusetts Health Promotion Clearinghouse:



Getting Older & Wiser: Safer Drinking As You Age

Other Massachusetts Department of Public Health programs:



Injury Prevention and Control Program: provides comprehensive information about risks of injury for older adults, including risks of suicide. The website also contains materials and links related to reducing risks.

Massachusetts Association of Councils on Aging: provides a comprehensive listing of resources and information: http://www.mcoaonline.com



Massachusetts Executive Office of Elder Affairs: website containing information and links to resources for elders, including Area Agencies on Aging, Councils of Elders, social service organizations servicing older adults including housing, healthcare, home care, nutrition, caregiver support, etc.

SAMHSA:

TIP 26 Substance Abuse Among Older Adults, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, US Department of Health and Human Services. Available at: http://store.samhsa.gov/product/TIP-26-Substance-Abuse-Among-Older-Adults/SMA12-3918
Substance Abuse Among Older Adults: KAP Keys for Clinicians, SAMHSA quick reference guide based on TIP 26. Available at: http://store.samhsa.gov/list/series?name=TIP-Series-Knowledge-Application-Program-KAP-Keys
OTHER:

Depression and Suicide: A range of resources, including journal articles are available at: http://www.apa.org/pi/aging/resources/guides/depression.aspx National Institute on Mental Health lists additional resources, including brochures for consumers and their families. These are available at: http://www.nimh.nih.gov/health/publications/older-adults-and-depression/older-adults-and-depression_141998.pdf

Best Practices: Treatment and Rehabilitation for Seniors with Substance Use Problems: A publication of Canada’s Ministry of Health. This publication is archived at http://www.hc-sc.gc.ca/hc-ps/pubs/adp-apd/treat_senior-trait_ainee/index-eng.php.

National Institutes of Health Senior Health: a website designed for older adults.

National Institute on Aging: contains links to research and publications about aging in general, as well as about substance use.

LGBT Aging Project: an advocacy organization for lesbian, gay, bisexual and transgendered older adults. The website lists resources and links.


V. Forms



An array of screening tools are available in Alcohol Use Among Older Adults: Pocket Screening Instruments for Health Care and Social Service Providers, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, available at: https://store.samhsa.gov/shin/content/SMA02-3621/SMA02-3621.pdf
MAST-G: Alcohol Screening for Older Adults: Available at: http://www.ssc.wisc.edu/wlsresearch/pilot/P01-R01_info/aging_mind/Aging_AppB5_MAST-G.pdf
For guidelines on creating written material for individuals suffering vision and/or hearing loss, see Tips and Strategies to Promote Accessible Communication, a publication of the North Carolina Office on Disability and Health (NCODH), containing information on TTYs, web page design, audiovisual presentations, and print materials. This document includes a detailed section on producing materials in large print. It is available at: http://ucp.org/wp-content/uploads/2013/02/tips-and-strategies-to-promote-accessible-communication.pdf
BSAS welcomes comments and suggestions. Contact: BSAS.Feedback@state.ma.us.


1 SAMHSA Tip 26 and NYS http://www.oasas.ny.gov/AdMed/FYI/FYIInDepth-Elderly.cfm. Accessed February 2015.

2 National Survey of Drug Use and Health, Behavioral Health Barometer 2014, available at: http://www.samhsa.gov/data/population-data-nsduh/reports?tab=32. Accessed February 2015

3 SAMHSA http://www.samhsa.gov/newsroom/press-announcements/201009091100. Accessed February 2015. Note that links in this announcement are no longer active as of February 2015.

4 National Institute on Drug Abuse: Prescription Drug Abuse, available at: http://www.drugabuse.gov/publications/research-reports/prescription-drugs/trends-in-prescription-drug-abuse/older-adults. Accessed February 2015

5 Centers for Disease Control Trends Report: http://www.cdc.gov/ViolencePrevention/suicide/statistics/trends02.html. Accessed February 2015

6 See BSAS Practice Guidance on Access for Persons with Disabilities, which contains information and resources to support a organizations and clinicians in making needed accommodations. This is available at: http://www.mass.gov/eohhs/gov/departments/dph/programs/substance-abuse/providers/program-licensing/principles-of-care-and-practice-guidance.html.

i Han, B., et al. Substance use disorder among older adults in the United States in 2020. Addiction, 104, 88-96 (2009). This article contains a comprehensive review of available data, and its significance and limitations.

Practice Guidance: Treatment Services for Older Adults/ UPDATED February 2015


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