What are the most common substance use problems/disorders?
Nicotine
Alcohol
Psychoactive Prescription Drugs
Other Illegal Drugs (marijuana, cocaine, narcotics)
What generation has much higher rates of illicit drug use?
Baby boomers
What is the ratio of older people on risky drugs?
1 in 4
What are age-related changes that make older adults more vulnerable to adverse alcohol effects?
Higher BAC from a given dose
More impairment at a given BAC
What are implications for older adult drinkers?
Moderate levels of consumption can be more risky
More consequences from maintaining consumption
Increased consumption may quickly result in consequences
What are the recommendations for alcohol consumption by the NIAAA and CSAT for adults 65 and older?
No more than 1 drink per day
Never more than 2 drinks on any drinking day (binge drinking)
How should limits be for older women compared to older men?
Limits for older women should be somewhat lower than those for older men
What is equivalent to one standard drink in the U.S.?
12 ounce bottle of beer
4 ounce glass of wine
1� ounces (a shot) of liquor (e.g., vodka, gin, whiskey)
4 ounces of liqueur.
Abstinence
No alcohol in the previous year
Low-risk use
Alcohol use within guidelines and not associated with problems
At-risk and problem use
Alcohol use that has resulted in adverse medical, psychological or social consequences; or substantially increases the likelihood of such problems
Dependence
Medical disorder characterized by loss of control, preoccupation with alcohol, continued use despite problems, physiological symptoms such as tolerance and withdrawal
What happens to rates of alcoholism with age?
Decline
What can drinking patterns that do not meet traditional abuse definitions lead to?
Can lead to higher BAC, chronic illness, poor nutrition and poly-pharmacy in older patients
Why is the extent of alcohol dependence in older adults difficult to determine?
Because of differences in definitions and lack of age-specific measures
What can make older adults more vulnerable to misuse?
Loss of spouse, occupational and role status, and poor social supports
Use of illicit drugs?
More or Less?
Less
Unintentional misses of drugs? More or less?
More
Why are older women at risk for alcohol problems?
Potential loneliness and depression from outliving spouse, other losses
Physiologically at greater risk as they age
What are potential comorbidities with alcohol use?
Interference with metabolizing medications
Increased side effects from medication
Sleep disorders
Psychiatric conditions (e.g. depression, anxiety)
Increased risk of suicide
Dementia
Depression
What neurotransmissions do drugs alter?
Dopaminergic, serotonergic, and glutamatergic systems
What does serotonin regulate?
Learning, memory, sleep, and mood.
What does glutamate regulate?
Regulates learning and memory, etc.
What does dopamine regulate?
Pleasure, motivation, motor function, and saliency of stimuli or events.
What meds have alcohol interactions?
Anxiolytic (Benzodiazepines)
Sedative/Hypnotic (Benzodiazepines)
Opiate/Opioid (Analgesics)
Other sedatives
What is the Brown Bag Approach?
Every person age 60 and older should be screened for alcohol and prescription drug use/abuse
Screen or re-screen if certain physical symptoms are present or if the older person is undergoing major life changes or transitions
Ask direct questions about con
Screening
Application of a test to members of a population for the purpose of estimating their probability of having a specific disorder
Sensitivity
Measure of instrument's accuracy in detecting individuals who do have an alcohol problem (True positive/ False negative)
Specificity
Measuring of instrument's accuracy in identifying individuals who do not have an alcohol problem (True negative/ False positive)
How do you choose screens?
Number of items
Method of administration
Substances covered
Accuracy by age group, gender, pregnancy status, ethnic group
Describe CAGE
Questions:
Administered by:
Covers:
Screens for:
What kinds of questions?
Sens:
Spec:
4 yes/no questions (1 yes = positive)
Administered by interview
Covers alcohol only
Screens for abuse and dependence
Add quantity and frequency questions to screen for at-risk drinking
Sens: 43% - 94% Spec: 78% - 96%
Describe AUDIT
Questions:
Administered by:
Covers:
Screens for:
Accurate across?
Sens:
Spec:
12 questions - multiple choice
Administered in writing
Covers alcohol only
Screens for at-risk drinking, abuse, and dependence
Accurate across many cultures/nations
Sens: 51% - 97% Spec: 78% - 96%
Describe SMAST-G
Questions:
Administered by:
Covers:
Validated for ages:
Sens:
Spec:
10 yes-no items
Administered by questionnaire
Covers alcohol only
Validated for ages 55 to 81
Sens: 89% Spec: 72%
Describe Two-Item Conjoint Screen
Questions:
Administered by:
Covers:
Screens for:
What kinds of questions?
Sens:
Spec:
Describe CAGE
2 yes/no questions (1 yes = positive)
Administered by interview
Covers alcohol and drugs
Screens for abuse and dependence
Add quantity and frequency questions to screen for at-risk use
Sens: 81% Spec: 81%
What questions does the NIAAA Clinician's Guide recommend?
1)
2)
Recommends
Do you sometimes drink beer, wine, or other alcoholic beverages?
How many times in the post year have you had....
5 or more drinks in a day? (men)
4 or more drinks in a day? (women)
What are screening instruments and assessment tools for Alcohol Consumption?
Quantity, Frequency, Binge Drinking
What are screening instruments and assessment tools for Alcohol Consequences?
AUDIT, MAST, SMAST, CAGE
Elder-Specific: MAST-Geriatric Version, SMAST-G
What are screening instruments and assessment tools for Health Screening Survey?
Includes other health behaviors
nutrition, exercise, smoking, depression
Describe a sample of an adult screening protocol?
Transition: Stresses and ways of coping
"Do you drink alcohol?"
"Have you ever experimented with any drugs?"
Ask CAGE questions
Ask Q/F questions on alcohol
Usually takes less than one minute
What percent of problem drinkers are identified in clinical laboratory testing?
10-30%
What do confirming biomarkers include?
Gamma-glutamyl transferase (GGT)
Mean corpuscular volume (MCV)
Carbohydrate-deficient transferrin (CDT)
What is the action for results of abstinence or low-risk drinker?
Prevention message
What is the action for results of at-risk drinker or drug user with other-wise negative screen?
Brief intervention
What is the action for results of positive screen for use or dependence?
Brief assessment
Definition of brief intervention?
Time-limited (5 minutes to 5 brief sessions) and targets a specific health behavior
Goals of brief intervention?
a) Reduce alcohol consumption
b) Facilitate treatment entry
What are the key components of alcohol brief interventions?
Screening
Feedback
Motivation to change
Strategies for change
Negotiated behavioral contract
Follow-up
Pre contemplation Stage of Behavior Change
Not ready to change
Contemplation
Plans to change
Preparation
Prepares an action plan
Action
Currently making change
Maintenance
Strives to prevent relapse
What does the R stand for in Motivational Interviewing?
Roll with Resistance - introduce change strategies
What does the E stand for in Motivational Interviewing?
Express Empathy - often, accurately with effective reflection
What does the D stand for in Motivational Interviewing?
Develop Discrepancy - between patient's goals and behavior
What does the S stand for in Motivational Interviewing?
Support Self-Efficacy - express confidence in patient's abilities
What does the O stand for in Motivational Interviewing?
Open questions (can't be answered with yes/no)
What does the A stand for in Motivational Interviewing?
Affirming (patient's character/values, things they have done well)
What does the 2nd R stand for in Motivational Interviewing?
Reflecting ("sounds like..." guess at feeling, meaning, affect)
What does the 2nd S stand for in Motivational Interviewing?
Summarize ("what I hear you saying is...and we talked about... and the plan is...