Older Adults: “Why Bother… They’re Gonna Die Anyway!”

1. Older Adults: “Why Bother…They’re Gonna Die Anyway!” Carol S. D’Agostino LCSW, MA, BCD, CASAC Robert Wood Johnson Fellow (Developing Leadership in Reducing Substance Abuse)

2. “The difficulty lies, not in the new ideas, But in escaping from the old ones.” John Maynard Keynes

3. Remember… • Nothing about your client’s 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!

4. Donna – Case Study

5. 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?

6. Older Adult Substance Abuse:A National Epidemic • National Perspective >30 million 60+ 17.7% suffer from substance misuse • New York State Perspective >1/2 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

7. 1996 CASA Physician Study…

8. Complex Profile

9. Co-occurring Disorders • Depression 20-30% • Anxiety disorders 10-20% • Cognitive loss 10-40%

10. Dementia/Alcohol Cycle Acceleration Of cycle Loss of Self-esteem Malnutrition Alcohol Use (Alleviate Stress)

11. Medication Mismanagement

12. Community Barriers Advocacy! Advocacy! Advocacy!

13. Complex Client Profile

14. Need For A New Clinical Pathway Aging Network Addiction Treatment CLIENT Mental Health Senior Living Communities Healthcare

15. 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)

16. Medical model Abstinence model Non-compliance=“not 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 Broadening the Clinical Toolkit:Traditional + Risk Reduction

17. 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

18. 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?

19. THINK OUTSIDE OF THE BOX! • Don’t follow “recommended” drink charts • Don’t 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”

20. Transitional Care Management:Direct 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

21. Supportive Care Management:Risk 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

22. Intensive Care Management:Environmental 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 communities—Step Down • Geriatric Neuropsychiatric evaluations • Guardianship

23. What are we learning? • Use has not changed, client profile has! • Average age of clients b/t 75-85 • >40% 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

24. 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%

25. 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 Alzheimer’s Association Senior Living Communities

26. 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

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

28. 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