The Use of Brief Interventions for At-Risk Drinking in Older Adults

1. The Use of Brief Interventions for At-Risk Drinking in Older Adults Kristen L. Barry, PhD Research Professor University of Michigan Department of Psychiatry and Department of Veterans Affairs National Serious Mental Illness Treatment Research and Evaluation Center (SMITREC)

2. Aspects of Effective Brief Interventions • Feedback • Responsibility • Advice • Menu • Empathy • Support Self-efficacy Miller and Rollnick, 1993

3. Settings for Brief Interventions • Primary Care • Emergency Department • Hospitals • Community • Workplace • Home Health Care • Substance Abuse Treatment Programs

4. Who Can Conduct Brief Alcohol Interventions? • Physicians • Nurses/Nurse Practitioners • Physician Assistants • Social Workers • Psychologists • Health Educators • Home Health Workers • Other Allied Health Providers

5. Confrontation vs. MI

6. Steps in Brief Alcohol Intervention • Identifying future goals • Summary of health habits individualized feedback on health, drinking, med use, consequences • Standard drinks • Types of Older Drinkers • Consequences of At-Risk drinking • Reasons to quit or cut down • Drinking agreement and plan controlled drinking vs. abstinence goal • Risky situations/Alternatives

7. Brief Intervention Steps Identifying future goals • Participants are asked to identify their goals Physical and mental health Social lives/relationships Finances, etc. • This makes certain issues affected by alcohol salient, and may assist in developing a discrepancy between current drinking and valued goals during the course of the intervention.

8. Brief Intervention Steps Summary of health habits • Participants provide information regarding • physical and mental health functioning • health habits, nutritional issues, tobacco use • alcohol consumption • This is an opportunity for the interventionalist to give individualized Feedback, and facilitates self-reflection regarding health status and alcohol use.

9. Brief Intervention Steps Standard Drinks and Types of Older Drinkers • Participants are introduced to the concept of standard drinks • Participants are shown how their level of alcohol consumption compares to other older adults • This assists participants in understanding that the effects of alcohol are similar across beverage groups and puts their drinking in perspective.

10. Brief Intervention Steps Reasons to Quit or Cut Down • Participants are asked to identify positive and negative aspects of their alcohol use • Participants are asked to identify “benefits of change” and “barriers to change” • This assists participants in weighing the issues, and hopefully “tipping the decisional balance” in favor of changing drinking habits.

11. Brief Intervention Steps Drinking Agreement and Plan • Participants are asked to choose a drinking goal (reduction vs. abstinence), their start date for addressing their drinking, their rate of reduction, and target date • This provides a MENU of options to participants. Intervention staff may offer additional Feedback/Advice. Goal choice increases a sense of personal Responsibility.

12. Brief Intervention Steps Risky Situations/Alternatives are identified • Participants are asked about the situations and environmental cues that may trigger drinking • Increases insight into consumption, allows participants to identify their own strategies for cutting down. Staff are trained in Empathic techniques and to Support Self-efficacy.

13. Practical Summary • Assess both consumption and consequences • Consider possible goals (engage in treatment/quit or reduce drinking) • Use the FRAMES/Motivational Enhancement Approach

14. If a Follow-up Intervention Session is Needed

15. Follow-up Sessions • The timing of these sessions are flexible • Clients should receive a follow-up session at 6 and 12 weeks after the initial session • The purpose is multifaceted • Assess progress • Show concern and empathy • Provide support and advice

16. Differences from Initial Session • There is a greater focus on alcohol use and the consequences of the alcohol use • More time is available to discuss consequences of use and strategies for changing behavior • The individual has had a chance to try and change their behavior based upon prior visit(s) and thus you have the opportunity to discuss successes and shortfalls

17. Special Circumstances/Issues

18. Medical Issues to Consider for Brief Interventions Alcohol can cause or exacerbate the following health problems: malnutrition, stomach problems, liver disease, stroke, cardiac problems, pancreatitis, hypertension, insomnia, cognitive problems/dementia, falls, depression, cancer, chronic pain, adverse medication effects/interactions, etc.

19. Lifetime Prevalence (%) of Substance Use Disorders for Various Psychiatric Disorders General population 16.7 Schizophrenia 47.0 Any affective disorder 32.0 Any bipolar disorder 56.1 Major depression 27.2 Dysthymia 31.4 Any anxiety disorder 23.7 OCD 32.8 Phobia 22.9 Panic 35.8 % ANY SUBSTANCE PSYCHIATRIC DISORDER ABUSE/DEPENDENCE Regier et al, 1990

20. Factors Associated with Dual Diagnosis in Older Adults • Compared to older adults with psychiatric illness alone, those with dual diagnoses: • DD more likely in males, Minority populations • More likely to have dementia • Less likely to have schizophrenia or PTSD • No difference in rate of major depression or bipolar disorder • Prigerson, et al., 2001 • Compared to older adults with SA alone: • DD more likely in women, Caucasians • Brennan, et al., 2002

21. Impact of Co-occurring Disorders in Older Adults • Higher rates of active suicidal ideation compared to persons with depression or alcohol use alone • Higher health care utilization • Psychiatric services • Substance abuse services

22. Factors Associated with Dual Diagnosis in Older Adults (Cont.) • Prevalence of lifetime alcohol abuse and dependence • 1.5 times higher among persons with cognitive impairment • George, Landeman, Blazer, & Anthony, 1991

23. Suicide • Highest rates of suicide occur in late life among men • Depression causes a 5.8 fold increase in risk of suicide compared to death from other causes • Heavy drinking (3+ drinks/day) causes a 8.9 fold increase in risk of suicide compared to death from other causes • Moderate drinking (1-2 drinks/day) causes a 10.6 fold increase in risk of suicide compared to death from other causes Grabble, et al. 1997

24. Effects of Treating Both Alcohol Abuse and Depression • Importance of treating both depression and alcohol abuse • Combination of depression treatment and reduced alcohol use was beneficial in significantly reducing depression • Oslin, et al., 2000

25. Depression Treatment Outcomes in Older Adults with Alcohol Use Disorders • Inpatients treated for depression • Improved Geriatric Depression Scores (GDS) • Across light, moderate, and heavy alcohol consumers • Among patients drinking at admission • 80% reduced drinking by 90%+ • History of alcohol-related problems • Not predictive of discharge outcomes • 3 to 4 months post-discharge outcomes • Improved social functioning and energy • Oslin, et al., 2000

26. A Not Drinking B Light-Moderate Drinking C Heavy Drinking D Alcohol Problems E Mild Dependence F Chronic/Severe Dependence The Spectrum of Interventions for Older Adults Prevention/ Education Brief Advice Brief Interventions Pre-Treatment Intervention Formal Specialized Treatments

27. Conclusion A brief intervention is one of the effective tools for working with older adults across a range of issues related to alcohol misuse and abuse.