Substance Abuse Prevention,

Screening and Identification, and

Assessment for Older Adults

Frederic C. Blow, Ph.D.

Associate Professor and Research Associate Professor
University of Michigan, Department of Psychiatry
Director, Serious Mental Illness
Treatment Research & Evaluation Center
Department of Veterans Affairs
Presentation Overview
 Prevention Issues
 Diagnostic Criteria
 Barriers to Identification
 Signs and Symptoms
 Psychosocial Manifestations
 Screening Instruments
 Special Assessments
 Future Research Directions
Prevention Issues
 Lifetime Patterns of Substance Use
and Abuse: Focus for Prevention
Strategies
Higher

Older
Prevention of Substance Abuse Among
Older Adults: Conceptual Issues
 Age group definitions
 Life course variations in consumption
 Sensible/appropriate use of alcohol and
prescription drugs
 Diagnostic criteria for abuse/dependence
 Risk profiles for specific subpopulations
 Prevention goals
 Prevention Strategies Effective with
Youth: Relevance to Older Adults
 Individual-Focused: education, skills development,
alternate behaviors, health behaviors
 Families/Social Support: spousal interventions,
family supports, caregivers
 Peer Norms: network of friends, perceptions
 Organizations: health care organizations, AARP,
other policy changes
 Social Environment: social norms and policies,
availability and sanctions
Prevention of Substance Abuse Among
Older Adults: Additional Issues
 Access to target populations
 Optimal modality for materials
 Appropriateness and acceptability of
content
 Delivery systems
 Program-driven vs. research-initiated
interventions
 Policy interventions
 Role of drinking, prescription drugs in late
life
Risk and Protective Factors
Prevention of Substance Abuse Among
Older Adults: Risk Factors
 Male
 Racial/Ethnic Minority Status
 Psychiatric Comorbidity
 Higher SES
 Lower Social Supports
 Previous History of Problems
 History of Using Substances as Coping Strategy
Prevention of Substance Abuse Among
Older Adults: Protective Factors
 Female
 Higher Religiosity
 Fewer Mental/Physical Health Problems
 Lower SES
 Positive Coping Styles
 More Social Supports
Diagnosis Issues
 Problems with Definitions

 Substance Misuse
 At-risk or Hazardous Use
 Problem Use
 Substance Abuse
 Substance Dependence
 Diagnostic Criteria
for Substance Dependence
in Older Adults
The Treatment Improvement Protocol
(TIP #26) Consensus Panel determined:
DSM-IV criteria for substance abuse
and dependence may not be
adequate to diagnose older adults
with substance use problems
 DSM-IV Dependence Criteria
 Tolerance
 Withdrawal
 Use in larger amounts or for longer than intended
 Desire to cut down or control use
 Great deal of time spent in obtaining substance
or getting over effects
 Social, occupational, or recreation activities
given up or reduced
 Use despite knowledge of physical or
psychological problem
 Applying DSM-IV Criteria
to Older Adults
Tolerance Even low intake may cause
problems due to body changes
Withdrawal May not develop physiological
dependence
Use in larger amounts or for longer Cognitive impairment interferes
than intended with self-monitoring
Desire to cut down or control use Same across life span

Time in obtaining substance or Negative effects with relatively

getting over effects low use
Activities given up or reduced May have fewer activities

Use despite knowledge of problems May not know problems are

related to use
Screening
 Practitioner Barriers
to Identification
Ageist assumptions
Failure to recognize symptoms
Lack of knowledge about screening
Physician discomfort with substance abuse
topic
- 46.6% of primary care physicians found it
difficult to discuss prescription drug abuse with
their patients
(CASA, 2000)
 Individual Barriers
to Identification
Attempts at self-diagnosis
Description of symptoms attributed to aging
process or disease
Many do not self-refer or seek treatment
- Although most older adults (87 percent) see
physicians regularly, an estimated 40 percent of
those who are at risk do not self-identify or seek
services for substance abuse
(Raschko, 1990)
Signs and Symptoms of Substance
Use Problems in Older Adults
 Anxiety  Increased tolerance
 Blackouts, dizziness  Legal difficulties
 Depression  Memory loss
 Disorientation  New problems in decision
making
 Mood swings  Poor hygiene
 Falls, bruises, burns  Seizures, idiopathic
 Family problems  Sleep problems
 Financial problems  Social isolation
 Headaches  Unusual response to
 Incontinence medications
 Symptom Identification
 Applying quantity and frequency levels
appropriate for younger adults to elders may cause
failure to identify substance use problems
 Warning signs can be confused with or masked by
concurrent illnesses and chronic conditions, or
attributed to aging
– Sleep problems associated with chronic conditions,
particularly cardiovascular disease and pain
– Falls attributed to poor lower body strength, poor
balance, or vision limitations
– Anxiety attributed to psychosocial concerns
– Confusion/memory problems associated with
Alzheimer’s disease or other dementias
Psychosocial Manifestations of
Mild/Moderate Drug Disorders
 Psychological/Behavioral
– Agitation, irritability, dysphoria, difficulty in coping,
mood swings, hostility, violence, psychosomatic
symptoms, hyperventilation, generalized anxiety, panic
attacks, depression, psychosis
 Family
– Chronic stable family dysfunction, marital problems,
anxiety and depression in family members, divorce,
abuse and violence
(Brown, 1992)
Psychosocial Manifestations of
Mild/Moderate Drug Disorders
 Social
– Alienation and loss of old friends, gravitation toward
others with similar lifestyle
 Legal
– Arrests for disturbing the peace or driving while
intoxicated, stealing, drug dealing
 Financial
– Borrowing or owing money, selling personal or family
possessions

(Brown, 1992)
 Screening Instruments
 Modified CAGE for drug abuse
– Examined for older populations (50 and over)
– Excellent sensitivity, poor specificity
(Hinkin et al., 2001)
 Conjoint two-item screen
– "In the past year, have you ever drunk or used drugs
more than you meant to?"
– "Have you felt you wanted or needed to cut down on
your drinking or drug use in the past year?"
» Ages 50-59: Sensitivity 73.9, Specificity 84.8
(Brown et al., 2001)

 Drug Abuse Screening Test (DAST-10, 20, 28)

 Drug Abuse Screening Test
(DAST-20)
1. Have you used drugs other than those required for medical reasons?
2. Have you abused prescription drugs?
3. Do you abuse more than one drug at a time?
4. Can you get through the week without using drugs (other than those
required for medical reasons)?
5. Are you always able to stop using drugs when you want to?
6. Have you had "blackouts" or "flashbacks" as a result of drug use?
7. Do you ever feel bad or guilty about your drug use?
8. Does your spouse (or parents) ever complain about your involvement
with drugs?
9. Has drug abuse created problems between you and your spouse or your
parents?
10. Have you lost friends because of your use of drugs?
 Drug Abuse Screening Test
(DAST-20)
11. Have you neglected your family because of your use of drugs?
12. Have you been in trouble at work because of drug abuse?
13. Have you lost a job because of drug abuse?
14. Have you gotten into fights when under the influence of drugs?
15. Have you engaged in illegal activities in order to obtain drugs?
16. Have you been arrested for possession of illegal drugs?
17. Have you ever experienced withdrawal symptoms (felt sick) when
you stopped taking drugs?
18. Have you had medical problems as a result of your drug use (e.g.,
memory loss, hepatitis, convulsions, bleeding, etc.)?
19. Have you gone to anyone for help for a drug problem?
20. Have you been involved in a treatment program specifically related
to drug use?
Assessment
 Special Assessments
 Functional Abilities
– Activities of Daily Living (ADLs)
– Instrumental Activities of Daily Living (IADLs)
– SF-36
 Comorbidities
– Physical
– Psychiatric
» Affective disorders
» Suicide risk
 Sleep Disorders
 Special Assessments
 Cognitive Impairments
– Dementia
» Orientation/Memory/Concentration Test
» Folstein Mini-Mental Status Exam (MMSE)
– Delirium
» Confusion Assessment Method (CAM)
– Other cognitive impairments
» Trauma from falls, MVA, accidents
» Wernicke-Korsakoff syndrome
 Screening and Assessment
Recommendations for Older Adults
 Every person over 60 should be screened
for alcohol and drug abuse as part of regular
physical examination
 “Brown Bag Approach”
 Screen or re-screen if certain physical
symptoms are present or if the older person
is undergoing major life transitions
 Screening and Assessment
Recommendations for Older Adults
 Ask direct questions about concerns
 Preface question with link to medical
conditions of health concerns
 Do not use stigmatizing terms (i.e. drug addict)
 Future Directions
 Risk and Protective Factors/Prevention/Early
Identification
 Drug of Choice
• Illicit, Prescription, Alcohol
 Patterns of use
• Drug use trajectories
• Re-emergence of addiction in late life
• Late-life onset of substance use disorder
 Screening, Assessment and Diagnosis
 Identification and treatment of psychiatric
comorbidities
 Contact Information
Frederic C. Blow, Ph.D.
Director
Serious Mental Illness
Treatment Research & Evaluation Center
Department of Veterans Affairs
Associate Professor/Research Associate Professor
University of Michigan Department of Psychiatry
400 E. Eisenhower Parkway, Suite 2A
Ann Arbor, MI 48108
Phone: 734/761-2210 Fax: 734/761-2617
email: fredblow@umich.edu