 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. While we're waiting, there were a few resources that I found when I was getting ready for today's class that are not part of today's class, but I wanted to make you aware in case you do happen to work with this population. We have from SAMHSA. All these are from SAMHSA. You can order them free. They're shipped free. It's awesome. You just go to SAMHSA.store.gov or you can just do Google SAMHSA store and you'll come up with their store page. But one of the resources is linking older adults with medication, alcohol, and mental health resources. There are a bunch in stock, so you can order those. A guide to promoting emotional health and preventing suicide in senior living communities. That's a 150-page guide, so there's a bunch of information there. Treatment of depression in older adults. This is actually an evidence-based practices kit, and you can get the entire kit from SAMHSA, but this is just one part of it, so you can download the kit and have everything you need to implement this evidence-based practice. Substance abuse relapse prevention for older adults. A group treatment approach. Really helpful if you're working with a specifically older adult population. And alcohol use among older adults. Pocket screening instruments for health care and social service providers. All of these you can order for free. Most of them you can also go to the HTML page and print it out as a PDF if you don't want to wait for it to be shipped. So those are awesome resources that are available for you already. Today's presentation is based off substance abuse among older adults, as well as the course that I did on problem gambling. I kind of merged the two. But that is also a treatment improvement protocol from SAMHSA, which is SAMHSA Tip 26. All that being said, we'll go ahead and get started. I'd like to welcome everybody to today's presentation based on Tip 26, Substance Abuse Treatment in Older Adults. And today we're going to talk about more than substance abuse. We're also going to talk about gambling, because gambling is becoming a significant emerging problem in the older adult population. We'll review data about substance abuse and gambling issues in older adults. And for those of you who haven't had a class with me before, I'm not going to test you on specific percentages. So don't get all caught up in remembering that 20% this, 80% that. I want you to get the big ideas and not down in the weeds. You can come back to the PowerPoint later to look at the weeds if you want to find out that data. We're going to review screening for substance abuse and mental health disorders in the elderly. A little bit of a review from yesterday, but we're going to add on to it, and we're going to add on even more tomorrow when we talk about Alzheimer's and dementias. We'll identify risk factors for substance abuse and mental health issues, and identify placement and treatment issues specific to older adults. Abuse of alcohol and prescription drugs among people age 60 and older is growing quickly. And we talked about this a little bit yesterday. It's not hard for this population to actually access alcohol and prescription drugs. So obviously, you know, path of least resistance, they're probably going to go that way as opposed to heroin and illicit drugs. An estimated 2.5 million older adults have problems related to alcohol and consume more prescribed and over-the-counter medications. So remember, things like pseudofed can be abused. And dextremothorfin, which is the cough-suppressant ingredient in a lot of your DM formulas or the 12-hour cough-suppressant formulas, can be abused. And some of the teenagers are actually taking it rectally to increase their high. But older adults, obviously, if they want some hallucinogenic side effects in addition to whatever, you know, that's an over-the-counter medication that they could get and abuse. A 2006 New Jersey study indicated that 23% of citizens over 55 were disordered gamblers. Now, New Jersey has casinos. So obviously, the percentages are going to be different in places without casinos. Right before class, I Googled Orlando where the villages is, and that's one of the largest retirement communities. And they don't have any casinos, really, of note that are close. There's a day cruise that goes out from Cape Canaveral. So you can go out for four hours and gamble in international waters and come back. And then, otherwise, you have to go all the way down to Tampa, which is quite a haul for somebody. So, you know, the prevalence in the villages is probably going to be different than the prevalence up around Atlantic City. But it's worth noting that 23% of citizens in a community where there are prominent casinos are disordered gamblers. 23% of citizens over 55. Seniors are the fastest growing group of gamblers between 1974 and 1989. Now, this study was done in 1999. The numbers have continued to grow. I haven't found another study that has compared it with other age groups, but it's a big growing group. The study reveals that seniors tend to gamble for extrinsic reasons, including winning money, obvious, gaining independence. If I have enough money, I don't have to live with my children anymore. Or, you know, maybe I can hire somebody to come in and spend time with me instead of having, help me do what I need to have done, instead of having to go to assisted living facility, etc. And supplementing income. So, basically about money and what the independence money can provide. Intrinsic reasons they may gamble include entertainment and excitement. You know, if you gamble, I don't have the stomach for it. I'm far too frugal, we'll say. That's a nice word for it. But I can't take the tension of thinking if I lose. But some people love the tension of it. My father used to go once a year and he would go to Las Vegas and gamble. And, you know, that just made him happy as a clam. Now, he was good about setting limits, but there is a certain group of people who find that it's extremely exciting and entertaining to do. Some people, older people do it to be around others. You know, they're retired, they're not going into work anymore. So they're missing out on a lot of social stimulation that they used to have. Maybe if they don't live in a retirement community that they're the only one home from 8am until 6pm in their neighborhood. And, you know, it gets kind of lonely and they're knocking around their house by themselves. So they may go to be around other people. It can distract from everyday problems such as loneliness and boredom. My grandfather, when he got older and his eyesight went, and especially once his Parkinson's started setting in, couldn't do, he used to make these beautiful, very intricate miniatures. You know, little wooden dollhouse furniture and everything. I mean, it was amazing what he could do. But once his Parkinson's set in and his eyesight went, he couldn't do it anymore. And he couldn't read anymore. And so there were pretty much everything that he liked to do. His body was saying, no, not so much anymore. So he started getting really bored. And after he watched Every Western Known to Man, he didn't even have TV to watch anymore. So working with people, you know, from a prevention and intervention standpoint, we want to look at why are you gambling? You know, and for some it may not be a problem. It's just something that they do like, like for my daddy. But for others, it may be a problem. So then we want to look at what function is that gambling serving and how else can you meet that need. People also gamble to escape from feelings of grief and loss associated with the death of a loved one or close friend, especially if it's, you know, your spouse. You know, you've been living in a house with somebody for 10, 15, 30 years and they pass on. And, you know, it's really quiet and you don't have anybody to talk to anymore. And it's a big change. So they may not want to knock around that house, but they may not be ready to sell the house either. So those are all things to consider. And those are some of the things that were identified by the Arizona compulsive gambling council for reasons people identify older adults identify that they actually gamble. Among adults over 65 years of age, gambling is the most frequently identified social activity. Let that sink in for a second. So we're not just talking about casinos here. You know, we're talking about poker games. We're talking about, you know, you can gamble on a variety of things, but there is some sort of gambling involved going to the track. So paying attention to what things in your area might promote gambling and also socialization because if it's just gambling itself like playing the lottery. That's generally not as detrimental as doing something social, unless it's like online gambling. If they get into online poker or something, that's just a whole nother rabbit hole they can go down. So we want to be aware of what's going on with older adults in communities where there is a casino. A lot of times the casinos will actually send a bus out to the retirement communities to pick people up and bring them there. Because, you know, the retirees, they're around all day long. The people who are working are working. So during the day, there's not much activity at the casino. The retirees go into the casino. They are made to feel like they are super special, important, their friends are there. There's a whole lot of stuff going on and they may get more hooked on it, if you will, than they really anticipated. So some articles I read had a negative twist indicating that maybe the casinos are preying on older adults. But we just kind of need to be cognizant of what's going on with our loved ones and encourage them to be cognizant of what's going on for themselves. Reduced cognitive capacity can make it difficult for older adults to make sound decisions. So if you've got an older adult who also has cognitive decline, and remember it doesn't have to happen, but if they do have cognitive impairment of some sort, it may be more difficult for them to make good choices. And at casinos, there is a lot of inexpensive, most of the time, relatively inexpensive alcohol. Because the casinos want people to be disinhibited, you know, make sense from their point of view. So, you know, you take somebody who's, you know, more susceptible to the effects of alcohol and give them alcohol, they may also have problems making sound decisions. Older adults living on a fixed income with limited savings can't necessarily afford the financial drain of a gambling disorder. And one of the quotes I found that just really stuck with me, this guy named Nour was talking and he said, when you're younger, maybe you gamble, you get $100,000 in debt, but you've got your spouse, you got your kids, you got your job. You still have a reason to get up in the morning. But with older adults, you know, their spouse may have passed on, their children are off leading their own lives now. They're retired, so they may have fewer reasons to get up in the morning. And now they see that they're in debt and they may feel guilty because they're going to leave that debt to their kids. So, it can be a huge trigger for depression and suicidal ideation. Because older adults tend to have less contact with friends and family, gambling problems may go unnoticed. If they're interacting with friends, you know, some of those friends may be going to the same casinos. So it may be sort of a group think sort of situation where nobody really notices a problem. They may gamble at home on the internet, you know, some older adults do get engaged in online gambling. But definitely if they have less contact with family, if they don't see their kids every day or whatever, if they don't live with their kids, then there may be a greater chance for the gambling related problems to be minimized and hidden for a lot longer and go unnoticed. And then all of a sudden there's this crisis point. Gambling should be identified as a problem when it disrupts damages or limits a person's life. Signs of problem gambling are spending more money on gambling than intended, feeling bad sad or guilty about it, not having enough money for food, rent or bills, being unable to account for blocks of time. You know, you go in, you start gambling at 9 in the morning and before you know it, it's 5 p.m. and you're like, well, where did the day go? Experiencing social withdrawal can be withdrawing and gambling on your own. It can be doing slot machines at the casino. There's a lot of different ways that people can show this and experiencing anxiety or depression. Older adults may try to hide or deny a gambling problem. They may feel hopeless or ashamed about the situation. And or maybe unaware that help is even available. They don't really realize it's a problem. I mean, we're just now in the clinical community starting to recognize gambling as sort of a diagnosable issue. And, you know, if we're looking at people who really don't want to admit that there's mental health problems to begin with, especially mental health problems with a stigma like addiction, then they may really be reluctant to come forward. So you've got gambling. And we've talked about that. It's something to be aware of with the older adult population. If they engage in it and it's not having a negative impact on their life, then, you know, Ducky, encouraging them to be aware of, you know, any warning signs is really important. When they get older, when people get older, alcohol affects you differently. There's a normal decrease in body water that comes with age. So because of this dehydration, the same amount of alcohol can now cause intoxication. And there's increased sensitivity to alcohol and a decreased tolerance, which is basically three different ways of saying the same amount of alcohol is going to get you way drunker than it did before. And there's also a decrease in the rate of metabolism. So whereas the younger person will metabolize one ounce of alcohol roughly per hour, it's not the same with the older adult. So we need to pay attention to that. And if they already have reduced hepatic liver functioning, we need to be aware that that will also slow down the metabolism of alcohol and it could cause all kinds of other problems because, you know, alcohol and the liver not friends. Alcohol can also trigger or worsen serious problems like heart problems. We know that the first part of alcohol intoxication is depressant. It slows down breathing, slows down heart rate. As it starts to wear off, that depressant effect goes away faster than your body can put GABA back into the system. So people tend to have an anxiety response and an increase of blood pressure. If they've been drinking for a long time and they quit cold turkey or decide they're not going to drink today, they could also increase their risk of stroke because of high blood pressure. Alcohol detox is a life-threatening detox and it's not something that should be undertaken lightly. It could cause, alcohol can cause cirrhosis of the liver and other liver diseases. It can also worsen other liver diseases like hepatitis. It can cause gastrointestinal bleeding or make it worse. My grandpa had ulcers from, you know, the time I can remember. But he also drank a lot and I have to believe that that didn't help his ulcers any. But he got ulcers from stress and drank to control stress and the alcohol made the ulcers worse. So you see illogical thinking but logical at the same time. So we want to look again, what function is the alcohol serving for you? And depression, anxiety and other mental health problems can be made worse by the use of alcohol because it messes with those neurochemicals. It messes with the balance of the excitatory and inhibitory neurochemicals, the relaxation and the get up and go neurochemicals. So recognizing that people can have rebound anxiety. And we talked yesterday about the fact that anxiety is the most prevalent mental health disorder in the older adult population. So anything we can do to not make it worse, probably a good thing. Prescription drugs. Now, you know, older adults generally, not always, but generally are on a lot of prescriptions, but not because they're drug seeking because they have multiple issues going on. Many medications interact negatively with alcohol. Painkillers are depressants. Your opiates are system depressants. Alcohol is a system depressant. You mix the two of them together, you get one plus one is five. You know, it's not going to have the effect of having, you know, two drinks. If you have the opiate and a drink, it's going to be a whammy. So it's important for people to recognize that it's not safe to mix these medications. High blood pressure medications often need to be adjusted in people who drink alcohol or quit drinking alcohol. There's a lot of a variety of medications, not just your psychotropics and your painkillers that don't do well with alcohol. So encouraging the patient to become informed and talk with their doctor openly about how much they drink. Many, not all, not even most, but many older adults have a dependence on psychoactive medications, psychotropics. Some of them, like we talked about yesterday, may be dependent on benzodiazepines, which also can be a life-threatening withdrawal. People who withdraw too quickly can have seizures. So we don't want people to just say, oh, I'm done with these and quit. We want them to talk with their primary care. But psychoactive medications can also cause other problems because the person misunderstands the directions, how much to take, how often, or they lose track of time. They can't remember, did I take it three hours ago or two hours ago? They may have multiple prescriptions from different doctors and the doctors aren't coordinating. So they've got a pain physician. They've got their general physician that's prescribing blood pressure medication. They've got a psychiatrist and they've got a neurologist. Now, the neurologist may prescribe Gabapentin for pain and the pain management guy may be prescribing opiates for some other kind of pain. And then the psychiatrist may be prescribing benzodiazepines. Well, you have three basic system depressants there that could work together in a bad way and seriously depress the person's respiratory function. And they may have unintentional misuse leading to abuse. And they may just follow doctor's directions and develop a tolerance that ends up getting compounded. So if they're on chronic pain medication, you know, they are going to develop a tolerance and a dependence. Now, are they abusing it or are they taking it as prescribed? Is it causing them negative life consequences or is it helping them have their highest quality of life? Those are all things that we've got to look at when we're looking at prescribed opiates over time. So what do we do? In terms of screening, some of the things that we need to be aware of, and I want to read this to you first. So think about if you encounter somebody who has diminished psychomotor performance, you know, they're kind of clumsy, you know, a little slower, impaired reaction time, loss of coordination, falls, daytime drowsiness, confusion, maybe an irritable aggravated emotional state, some amnesia, forgetfulness, and we'll leave dependence out. Those symptoms when you look at them are what people stereotypically think of an older person. So we need to dispel that myth. You know, older people don't have to lose their coordination. They don't have to be falling. You know, this is not necessarily normal aging. So we don't want to assume that any of these symptoms are just normal aging, especially if they come on suddenly. But if you haven't seen the person in a couple of weeks and this is happening, there's a bunch of things that could be going on besides aging that include substance abuse, Huntington's disease, Parkinson's, Alzheimer's, and alcohol-related dementia that could all cause these symptoms. So what are the risk factors? You know, if we're, we started seeing these symptoms, we're going, ooh, I don't know if I should refer this person. Let's look at what else is going on in their life to see if they're at higher risk. Bereavement and sadness, okay. Losses, like we talked about yesterday. Spouses, friends, family members, loss of social status, loss of their sense of professional identity. Loss of hopes for the future. Sometimes they look forward and they go, I've got 20 years left. I can't change and I didn't do two things on my bucket list and I can't accomplish them now, so I give up. And loss of independence or their ability to function. Social isolation and loneliness. And, you know, this is something that happens after they retire, not necessarily because of a death. Reduce self-risk regard or self-esteem because of a lot of these losses, maybe isolation, family conflict and estrangement, problems in managing their leisure time and boredom, and loss of physical attractiveness. Those are all things that have been identified as risk factors for the development of substance abuse problems. Medical problems, loss of hearing and sight can make a lot of people end up being homebound. So when they are homebound, they can get excessively depressed and may end up self-medicating in order to deal with that. Chronic pain can be debilitating and keep people homebound, but it can also make them seek out pain management and narcotic pain management. Physical disabilities and handicapping conditions, reduced mobility, insomnia and cognitive impairment can all set a person up to be in a place where they're at risk for substances of abuse. Practical problems, impaired self-care, dislocation from housing, reduced coping skills, and loss of income or increased health care costs. So, you know, some really practical issues that can add a lot of stress may lead some people to try to self-medicate or disappear from the problem for a while, whether it's with alcohol, opiates, gambling, over-the-counter medications. And yes, I mean ideally the doctors are using the controlled substance monitoring database, but it doesn't happen, you know, it doesn't happen the way it should. So, I mean, that's an ideal situation, but we know that that's actually not occurring. And I don't know if pharmacists or psychiatrists have access to it, but either way, we know that a lot of the people that can prescribe opiates and benzos are not using it. So, just being aware of that. And we also know from talking to people that have worked with this population, as well as from personal experience, that a lot of physicians that treat older people aren't trained in treating older people, which is why they prescribe benzodiazepines at an inappropriately high rate for an overly long period of time, which can cause lots of problems, and other medications. Benzos are just the ones I'm most familiar with. Other issues, older men are at increased risk of depression and addiction when their wives die. High rates of alcoholism occur in medical settings if somebody's in residential care. Sometimes they feel a little bit more claustrophobic, but one of the things that they may do is get alcohol and use it in the medical setting. If there was a substance use disorder earlier in life, there's a greater chance that it will come back later in life. So, if you have two disorders, a family history of addiction, or prescription drug use of psychoactive medications. So, if you're already using them, you know, if you have a prescription for Xanax, for example, my grandmother had one. And, you know, if you're already using them, it's not too big of a leap to start every once in a while taking an additional one, an additional two, and then all of a sudden you're abusing and you're dependent. So, the controlled substance monitoring database is evidently a state requirement in certain states, but evidently not in others, because I know there's a lot of poor prescribing in certain states. What types of early intervention and prevention activities could be done or are being done in your community and where? So, let's not let people get to the point of being addicted or depressed with suicidal ideation. What can we do? Well, one of the first things is to implement regular screenings. So, who do we screen? Every adult annually at their physical. And older adults are more likely to go in for their annual physicals, especially once they're retired because they're not having to take time off from work, but also because they tend to have more somatic complaints, so they don't avoid the doctor quite as much as some of us do. We should also screen people during major life transitions. It's really important to make sure that, you know, people are coping with these transitions. Okay, and that doesn't have to be like this devastating, you know, your wife died or your husband died or somebody was diagnosed with cancer or something. It could be an older adult getting married. You know, that's a major life transition or an older adult moving to a new house and selling the house that they had lived in with their spouse for 30 years. So, we want to kind of check in with people. And obviously, you know, they may not be seeing their primary care during these times. So, we want to let everybody know, the family, the caregivers, you know, what to kind of look for their friends. So, they see if Sally is starting to, you know, seem like she's a little bit depressed or withdrawal from going out to bingo or whatever it is. You know, somebody's there to go, that may be a problem. You know, let me have somebody check in on Sally. Or if the person has unexpected or unexplained physical symptoms, it's always good to screen for concurrent or causative addictive disorders. Potential signs of development of an addiction include sleep related problems, cognitive difficulties, seizures, malnutrition, muscle wasting, liver function abnormalities, obviously is only going to come back on blood tests, persistent irritability and altered mood, depression and anxiety. Unexplained complaints about chronic pain and incontinence, urinary retention and difficulty urinating. So, looking at these symptoms, each one individually could be caused by 10 other things, not necessarily just substance use. So, we don't want to like start setting off warning bells because somebody's liver enzymes are too high. They may have taken Tylenol the entire week before because they had the flu. Or if they're becoming incontinent, you know, that happens for some people. And so, we want to look at what may be causing it. Is it a prostate thing? You know, what's going on? But it is definitely worth getting checked out. There's probably, if any of these things happen, there's signs of a problem somewhere and we need to take a look at it. Poor hygiene and self-neglect. That could be depression, that could be tiredness, that could be too much pain. My grandmother had an impingement of one of her nerves in her neck and she couldn't raise her arm above her head. So, she couldn't wash her hair on her own and it was hard for her to get a shirt over her head. So, changing clothes, you know, my uncle noticed that he went over there and she hadn't changed clothes in a couple of days and that's very unlike her. And so, we started talking to her and realized that she couldn't dress herself anymore because the pain was too excruciating. So, we want to pay attention. Unusual restlessness or agitation, complaints of blurred vision or dry mouth, unexplained nausea and vomiting, changes in eating habits, slurred speech, tremors, poor motor coordination, shuffling gate, frequent falls, unexplained bruising. These could be side effects of medication. These could be caused by a variety of physiological conditions or substance abuse. And some of them could even be caused by major depression. So, let's differentially diagnose. Delirium and dementia. When there's a presence of a severe cognitive impairment, it impairs screening. If somebody can't answer the questions well and especially if you don't have a family member there to help you, it's going to be hard to get a good idea about what's going on. Withdrawal-induced delirium is a medical emergency. When somebody is withdrawing from alcohol, the blood pressure can spike, their vitamin B levels can go way down. It can actually cause something that is often called alcohol-related dementia or Wernicke-Korsakov syndrome. It's a medical emergency. Now, the cognitive impairment from this can be stopped and reversed if they get immediate medical attention, but if they don't, it could become permanent. So, it's really, really important to pay attention to older adults who are drinking alcohol. Signs of delirium, disorientation, impaired attention, concentration, memory, anxiety and suspicion or agitation, hallucinations or delusions. Obviously, those are going to be some big warning signs. You don't want to assume that it's just because of a random cognitive impairment or Alzheimer's. We'll get you to see a neurologist later. We want to ask right then and there about alcohol use because if it's due to alcohol, we need to get them to the ER. Dementia is chronic, progressive and irreversible cognitive impairment. It complicates monitoring drinking outcomes. If someone who has already got dementia, it's really hard to see what kind of quality of life progression they're having because their dementia is progressing as their recovery is progressing. It complicates getting clients into treatment and them getting benefit from treatment because every day is a different day with them. And very few places are equipped to handle a client that has dementia. Signs of dementia, impaired short and long term memory, impaired abstract thinking and judgment, language problems, personality changes or alterations and mood disturbances. So we do want to be cognizant of all of those. And again, it could be caused by a variety of things, but it's better to rule out anything that could be physiologically going on right now that needs emergency medical attention. Indications for inpatient hospitalization, especially during detox. If the person has a high potential for developing dangerous abstinence symptoms or seizure or delirium because they've had higher prolonged dosage of benzodiazepines, barbiturates or alcohol. Those are the three that are really life threatening or can be life threatening detoxes. If their substances are abruptly discontinued, if they have a positive past history, now some people will say, well, opiates, you can get really dehydrated and it can be life threatening. If you get really dehydrated and the diarrhea is bad and you get super malnourished. Yeah. But 99% of the time if the person is getting enough fluids and everything, it can be managed on an outpatient basis. I worked in a clinic where we did a lot of outpatient detoxification for opiates. Suicidal ideation or threats, indication for inpatient and any other major psychopathology. Now not, you know, persistent depressive disorder. We're talking major depressive episode with suicidal ideation. You know, if they've got something else major going on that may put them at risk, we want to look at inpatient detoxification. If they have unstable or uncontrolled comorbid medical conditions like renal disease, diabetes or high blood pressure, they need to be inpatient or if they need medications to be administered or need 24-hour care. If they have mixed addictions including alcohol, if they lack social supports in the living situation or are living alone, it's really dangerous for somebody to detox all by themselves if they're living alone. Especially for an older adult who can fall and break a hip or get disoriented. So we want to make sure that their recovery environment can sustain outpatient detox if that's what the medical team decides. And or if the person has continued access to the abused drug. So what do we do with them? We screen, we help them get detox, either inpatient or outpatient. And obviously for gambling, you don't need to detox, but you need to provide a recovery environment that keeps them from having access to gambling. If they do online gambling, then you may need to have somebody come in and block IP addresses for the gambling sites and lock it down. But that's a different topic. The frames approach, you want to provide feedback to the person of their personal risk or impairment as derived from the screening. Tell them what you're concerned about. Put the responsibility for change on them. You can't force them to do diddly squat. So, you know, and I tell them that, I'm like, it's up to you what you want to do here. But, you know, I do have some concerns. You can provide advice about ways they can change, different programs they can enter, different things they might try, provide them a menu of options. Obviously, be as empathic as possible, recognizing that this is a really uncomfortable topic for them. And support self-efficacy and ongoing follow-up, even if they're not ready to enter treatment right now. Or they're not ready to start addressing this problem, or they're still in pre-contemplation with their gambling, for example. And don't quite see it as a problem yet. All right, you know, whatever brought you here today. You know, how can I help you address that issue? You know, did your kids say you needed to come? Or, you know, what brought you in for your assessment today? How can I help you deal with that? And then, you know, if you feel like you need to come back, or, you know, if it ever becomes a problem, the door is always open. And encouraging them to be empowered to come back and feel like they can come back without having to have their tail between their legs and go, okay, you're right, I have a problem. No, we want them to come back and go, all right, I guess I do need some help. But we want to let them know that there are services out there that can help them and that lots of people have problems with whatever the addiction is or the mood disorder. With brief interventions, use a non-confrontational, supportive approach, because we want to have them embrace recovery, not feel ashamed. They already probably do have shame issues, so we don't want them to feel like we're lecturing them or wagging a finger. Provide customized feedback about what could help and, you know, ask those strengths-based questions and solution-focused questions. When you didn't have this problem, what was different? When you've tried to control this, what has worked? Even if for half a day. Provide information based on age, health, and medications about their condition and what your concerns are. Explore their reasons for drinking or gambling or using drugs. Explore the consequences of drinking or gambling or using drugs. So we want to look at the benefits or the reasons for this, but we also want to look at the consequences. And if you approach it that way instead of just looking at the consequences and trying to help them see how bad it is, they tend to be a little less defensive and resistant. Discuss key motivators to cut down or quit, including maintaining independence, physical health, financial security, and mental capacity. Mental capacity, not so much with gambling, but the other three definitely if they lose all their money and they can't pay their bills, they're going to have to move in with their kids, and it could be a whole thing. But with substances, they could actually impair their mental capacity if they're using. So it's important to point out potential benefits of cutting down or quitting. Identify sensible ways to cut down or quit. Developing sober social opportunities, getting reacquainted with hobbies and interests, pursuing volunteer activities. And for some people like my grandfather, it's going to be tough to find alternatives. I mean, he had an eighth grade education. He worked like a dog all his life. He always had two jobs, sometimes three, and he was always a hard worker and did great things with his hands. He was a painter. He made the miniatures. But then when the Parkinson's set in and he couldn't see anymore, he was like, well, what do I do? I don't have any other interests and I'm not into intellectual type clubs. That's just not for me. So I don't know what to do. So it's going to be important and you could even get a vocational rehabilitation specialist involved to look back over there, the history of what they've done for work and identify possible transferable skills to identify hobbies and volunteer activities. And you may develop a drinking agreement, prescription or contract. You know, if you're going to drink, how much are you going to drink? And if they're on medications, then we definitely want to get this cosigned by the prescribing physicians. Identify what types of coping methods could be used to deal with social isolation, boredom and negative family interactions. So, you know, what would you suggest for somebody who's, let's say, 70 years old and they're dealing with one of these things? What types of coping skills might you suggest for them or referral sources? Some of the coping skills for social isolation would include support groups, older adult daycare drop-in facilities, as well as looking at... The other word I'm looking for, senior living, not senior living centers, but senior activity centers. And I know we have one in our town and there's one in the next townover. It's like every town has a center where generally has a center where seniors can get together. But if they don't, many churches do. So, and if one doesn't exist, then it's important to look at, you know, how could we get one together? In a really rural community, maybe having a church host a senior gaming day or each month a different church hosts the seniors could be something to do. If they're bored, brainstorm ideas of what they could do. Look at volunteer opportunities. You know, transportation may be an issue, so you're going to have to have solutions for that. If they're bored at home, you know, talking with them about different things that they could do so they don't feel like they're just knocking around in the four walls. With negative family interactions. You know, obviously, you know, communication is going to be important. Not taking things, everything personally, looking at those cognitive distortions because they may feel guilty. They may feel ashamed. They may feel inadequate or, you know, there's a lot of things they could feel if they have to move in with a family member. Or they may think, you know, my family member hates me because I've got to move in with them and I'm just putting a real crimp in their style, which some of that may exist, but they've got to figure out how to work that out. So identifying different ways that people can start adjusting, encouraging caregivers to go to support groups and get support. So they're able to figure out how to deal with things and encouraging the older adult to do this too. Treatment settings can be inpatient, 24-hour primary medical, psychiatric and nursing care, medically managed, monitored and intensive. So this is your hospital. The indicators are typically if the person is brittle, frail, acutely suicidal, medically unstable or for some reason these constant one-to-one monitoring. Insurance companies are really not fond of this level of care unless it's an absolute emergency and neither are most people. So, you know, that's something to consider. Older people dependent on psychoactive prescription drugs need flexible community-oriented programs with case management services. A lot of times they don't need inpatient. It's important to try to figure out how can we get case management to go out there every day? How can we get a nurse to stop in once a day? It's still going to be far less expensive to do that than have somebody in 24-7 care. Age-specific group treatment can be helpful. It's supportive, non-confrontational and often builds or rebuilds patient self-esteem. And it can be art groups. It doesn't necessarily have to be a therapy group. It can be a psychoeducational group or a, you know, meditation group, Tai Chi is a big one. Anything people can do together where they can form some social bonds and start feeling more like their old selves. We can help them with focus, coping with depression, loneliness and loss from death of a spouse or retirement. You know, that's one area that we can focus some of our treatment activities and prevention activities on. You know, what should you do when this happens? If your spouse is terminally ill or after your spouse has a heart attack, maybe they're not even terminally ill. You know, how do you deal with that? There's a lot of anxiety. What resources are out there? Who can you talk to? Spiritual providers, who's, you know, what churches or spiritual leaders are willing to provide some, you know, counseling and encouragement. We can help them rebuild their social support network. Through all this, though, we need to make sure that we pace it so it's appropriate for the older person. Because remember, they're going to have a little bit of a delay in some of the information processing. They're still gaining new skills, but it may take a little bit longer for everything to click through. The staff working with them should be interested and experienced with older adults. Older adults are very perceptive. They recognize if somebody really doesn't want to be working with them. So we want to have people who really like working with this population and they exist. And we want to provide in a treatment setting, now whether it's a community-based treatment or an inpatient, medical services and services for the aging. We want to make sure that we can help them get hooked up with hearing aids and vision and, you know, regular medical checkups. And, you know, if they need to have medication administered, you know, anything like that they might need, if they need to get diabetic equipment. Making sure that there's a resource at the facility that they can go to, especially if they're having a hard time affording their stuff that can help them get linked with the appropriate companies and agencies that can help them there. We should provide institutional settings for referral into and out of treatment. So, you know, sometimes health waxes and wanes. My grandmother, my best friend's husband, went into the hospital and, you know, was in really bad shape, was in 24-7 care, in acute care. Then came out and was in inpatient, basically, all day assisted living, but it wasn't like medically monitored. And then was able to go back out to the community and then how to relapse, had to go back into the intensive level again. So we want to be able to seamlessly transfer people between these levels of care. And that's going to require case management. I mean, it's just a fact of life. It's going to have to happen to make sure it gets paid for, to make sure that the referrals go through, that the warm handoffs happen and there's no glitches, et cetera. Five principles to remember when you're treating older adults. Treat them in age-specific settings when possible. They're going to feel a lot more comfortable. Create a culture of respect for older clients. Especially if you're in a mixed-age treatment program, we want to make sure that the older clients feel like they're respected and not looked on like, you've got one foot in the grave, you don't have anything to offer me, because they have so much to offer. So we want to respect the elders. Take a broad holistic approach to treatment, emphasizing age-specific psychological, social, and health problems, which is why age-specific is useful, because the age-specific depression triggers are a little bit different for somebody who's 70 than for somebody who's 27. A flexible treatment program allows older people to accommodate their needs if they're having somatic complaints or transportation issues. And we want to adapt treatment to the client's gender. Especially older people, like my grandmother's age, in their 80s, people who grew up in the 30s and 40s and 50s, tend to have stronger traditional gender roles in many cases. So they may feel more comfortable in a unigender group or treatment program. Cognitive behavioral motivational approach works really well to help them identify negative consequences of their behavior. Shift perceptions about the impact of what they're doing. Empower them to generate insights and solutions. How could I keep this from, you know, breaking the bank or causing problems with my family or whatever? Express belief in their capacity for change. You know, they are very wise and they have a lot of experience and they know themselves way better than I know them. So how can I help you change? What motivates you to change? You know that better than I do. Help offset the denial, resentment and shame. And CBT motivational approaches focus on rebuilding social support networks. You know, keep hearing that one. Self-management approaches for overcoming depression, grief or loneliness. So they need to have a toolbox. And I encourage them to write it down so they have a page that's their depression toolbox. And general problem-solving skills. So, you know, maybe they only have two or three skills that they use with any regularity, but they know how to access those tools and they know where to go to find other tools. You know, they may need to drop into the day center or call up their case worker or whatever to get some more tools to use. But they know how to find or how to deal with it if the tools they have aren't working. Group-based approaches. Great for establishing social relationships and helping people regain self-esteem. We'll have an educational theoretical approach and a personal practical application. So we want to teach them the skill, but then we want to have them take it to that next step and say, how does this apply to you? How could you use it? Give me an example of how you might have used it last week. So we want to make sure that, as with any adult learners, we help them apply it to their own situation and actually manipulate it and hypothetically use it so they're sure that they actually understand the process all the way through. Group-based approaches should have a stated goal and purpose of the session and ideally provide a content outline. It doesn't have to be a big one. You know, it doesn't have to be a 30-slide PowerPoint. It can be a little bit smaller. But a lot of learners will prefer to have a general idea about what we're covering in group. Go sequentially through the topics like building blocks. So you're building on one thing and you take a break, let them digest it for a second, teach the next thing, take a break, and it doesn't have to be, you know, a bathroom break. It can just be, all right, I want you to take 30 seconds and think about how this applies to you and then we're going to talk about the next thing. Begin with a review of previously presented materials so you're still building and they can see how one thing connects to another. Try to incorporate as many senses as possible when you're talking about things in order to help them learn. So let them see it, let them hear it, and let them talk about it. Know more than about 55 minutes for this population is ideal. Make sure the room is well lit without glare, interruptions, or noise because they have problems filtering and the glare can make it difficult to read. And try to keep superfluous material to a minimum. You know, try not to have it in a room that has posters and stuff everywhere all around. Try to have it in a relatively sedate, calm environment. Individual counseling is also obviously going to be helpful. Medical and psychiatric interventions are often needed. We talked yesterday about SSRIs being the first line approach to treating major depressive disorder in the older adult population. But we also want to rule out medical causes of mood-oriented or cognitive-oriented symptoms because it could be something totally medical. Marital and family involvement and family therapy can be really helpful to ease the transition as the older adult may need help caring for themselves and the children have to kind of step up to that responsibility. And case management and community-linked services and outreach are really essential, even if you're not doing a whole lot of intensive therapy in order to prevent the need for intensive therapy. Staffing should have gerontology training to be aware of what these issues are, be aware of how to communicate with the cognitively impaired, yada yada. Enjoy working with older adults. It's imperative to provide training to all staff who's going to interact with older adults on empirically demonstrated principles. You know, help them understand and actually get training, not just read a paragraph on reminiscence therapy. Help them understand the function of, you know, doing any particular intervention that they're doing. Help them understand what sundowning is. So there's many issues that are unique to treating older adults. Substance abuse treatment in this population is very necessary and worthwhile. You know, just because someone is older, you know, it's not time to say, well, you know, they're almost at the end of the road, let them just have fun. You know, they can really prolong their life and increase the quality of life if they deal with any substance abuse issues. Ease clients by providing treatment in peer settings, by persons sensitive to gerontological issues, and by clinicians of similar ages. So if you can provide treatment in the older adult day center, you know, that's perfect. You know, maybe you have a little room off to the side where you can provide treatment services or maybe the big room, maybe everybody needs to participate in the activity. And it's facilitated by a clinician of a similar age. That's going to help in some cases. It doesn't have to be a clinician of a similar age if it's a clinician who really enjoys working with this population, but it still does help because they feel like that person gets it a little bit more. Withdrawal from psychoactive drugs can induce delirium and is a medical emergency. So not just alcohol, but withdrawing from benzos, from barbiturates. And, you know, if they're on Ambien, well, that falls in the barbiturate category or the sedative hypnotics. But, you know, any medications they're withdrawing from, be aware of side effects. Talk with them about potential side effects, nausea, dizziness, anything that may happen. And this can even be if they're withdrawing from tricyclic antidepressants or SSRIs. So don't assume just because it's a standard psychotropic that withdrawal will be no problem. Make sure that you're aware of what the side effects could be and they're aware and preferably their caregivers are aware so somebody can check in on them. Resources, AARP, the National Center on Addiction and Substance Abuse at Columbia University, join together. And the National Aging Information Center at the U.S. Center on Information... National Aging Information Center at the U.S. Administration on Aging. Those are four good resources. SOMPS is another great resource as I was telling you at the beginning of the class. There are a lot of options that people have these days. Now let me see if I can answer that question that came up earlier. Oh, this is...let's see. I was trying to find some of those day cruises and I thought I found one earlier, the one that goes out of Cape Canaveral. But they're really not that expensive so it can be something seniors really get into doing. So even if there isn't a casino nearby, that might be something that seniors end up doing. While I'm looking this up, if you have any questions, please feel free to type them. Okay, so according to this, there are 37 states that have prescription drug monitoring capabilities. 11 states have enacted legislation to establish one but they're not fully enacted. So that's from the Drug Enforcement Administration's website. So being aware, if you're in one of those states that, especially one that doesn't have prescription drug monitoring or controlled substance monitoring that's required of physicians, then you may need to be one of the potential people that keeps an eye out for problems. If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. You can attend and participate in our live webinars with Dr. Snipes by subscribing at allCEUs.com slash Counselor Toolbox. 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