VARIETY
OF PROBLEMS
Forum
Aging And Alcoholism: A Treatment Model For Any Community
By Roland Atkinson and Frederic C. Blow
A million older adults in the U.S.--and perhaps more--suffer from alcohol dependence. They experience serious adverse health and social consequences because they regularly drink to excess and cannot control their drinking without help. The increasing size of the aging population means that the ranks of aging alcoholics in the U.S. will likely swell to 23 million over the next 25 years. Social, health and substance-abuse treatment services in most communities are currently ill-prepared to address this growing problem.
The needs of older abusers of alcohol are distinctive. Cookie-cutter approaches to treatment based on work with younger alcoholics may not be effective. We propose a model that can provide a framework for developing such services in communities that differ in size, demographics and resources.
VARIETY
OF PROBLEMS
Alcohol problems afflict the aging population in three ways. Some relatively healthy older adults simply drink too much. Safe drinking limits for older adults are about 7 to 14 standard drinks a week, and no more than 3 or 4 on a given occasion. (See accompanying graphic of standard drinks). Heavier drinkers regularly exceed these safe consumption limits. Although their drinking may currently cause few if any problems, continued heavy consumption could result in more serious health problems in the years ahead. The World Health Organization calls these people risky drinkers.
Other older adults encounter trouble because alcohol interferes with or complicates their responses to prescribed medications. Risky drinkers and those combining alcohol and medications together add up to several million older Americans. For them, straightforward, inexpensive strategies for intervention exist. These brief-advice or brief-intervention strategies employ several highly efficient methods that can be practiced in any primary care or counseling setting. With the goal of reducing alcohol consumption to safe limits, an approach commonly called harm reduction, these interventions include screening, education, motivational counseling, goal-setting for reduced drinking, monitoring progress toward goal attainment, and periodic reassessment.
For the smaller number of older adults suffering from the third kind of problem--alcohol dependence--consumption and difficulties are typically more pervasive, entrenched and longstanding. Even in many cases that develop late in life, an earlier pattern of risky drinking is usually found to presage the development of dependence on alcohol. Levels of consumption can be quite high: It is not uncommon for a 70-year-old male alcoholic to drink up to a fifth (25 ounces) of hard liquor a day. That translates to over 120 standard drinks a week. Abstinence from alcohol, rather than reducing consumption, is usually necessary for these people.
Effective approaches for identifying, assessing and treating older alcoholic individuals have evolved over the last 20 years. Best practice guidelines were documented in a federally sponsored treatment improvement protocol published by the Center for Substance Abuse Treatment of the U.S. Department of Health and Human Services. This protocol, Substance Abuse Among Older Adults; Treatment Improvement Protocol 26, DHHS Publication No. (SMA) 98-3179, is available free from the National Clearinghouse for Alcohol and Drug Information at (800) 729-6686. Although the practices described in this guidebook provide important information, the publication was based on efforts by a handful of large programs specializing in the treatment of older alcoholics. Such programs are usually funded well enough to support a large multidisciplinary staff. They also treat large clienteles, and their programs favor client peer-group activities and other endeavors that can take advantage of economies of scale.
GRASSROOTS MODEL
The question that concerns us is this: How can the knowledge and skills learned in these large demonstration programs be widely adapted to assure provision of essential services in a variety of communities where professional resources may be thinner and scattered among agencies, where the costs of care must be supported by the usual funding mechanisms for health and social services, and where client referrals may be sporadic, so that only one or a few older clients are engaged in treatment at any given time?
Essential services include screening, information and referral; assessment and selection of the most appropriate treatment setting; care management; healthcare and psychosocial interventions; practical assistance; management of other drug dependencies and misuse; and involvement of family and caregivers.
We propose a grassroots model of treatment in which the realities of local resources and commitment determine the best strategy for delivering essential services to aging alcoholics in that particular community. Alcohol problems are sufficiently common in older adults so that all providers in aging services, healthcare and substance abuse programs should be able to screen routinely for such problems. Furthermore, when screening suggests that a person has an active drinking problem, more careful assessment is needed. This requires the services of a professional who has the requisite background in substance abuse, mental health and gerontology. Whether these professionals work for an agency on aging, a healthcare provider or a substance-abuse treatment program, they need to be well trained and visible as a resource in the community.
In addition, when a program confirms a case of active alcohol dependence, the client should be linked to a professional who can serve as a care manager, perhaps the same person who conducted the assessment. The care manager also needs training and should have an interest in treating those with alcohol problems. We are not advocating centralized assessment or care management--although that might be the best approach for some communities--because in a very small community there might be only one individual to take on this challenge.
THE CARE MANAGER
In the model we propose, the care manager needs to form a close working relationship with the client and, whenever appropriate, with the client's caregivers. This professional must generate a comprehensive treatment plan that addresses not only drinking behavior, but also associated health, mental health and social problems. The care manager should then arrange and coordinate services to meet the client's needs, monitor progress and help the older person to sustain sobriety and attain an improved quality of life. The care manager in this model becomes the best substitute for the sort of integrated programs in which the best practice guidelines were originally developed.
Care managers may provide only a few of the essential services, depending on their training and job description, and may call on other assistance as needed. Besides services in aging, healthcare or substance abuse, care managers should be able to reach out to senior community services, such as senior centers or meals-on-wheels; self-help groups such as Alcoholics Anonymous and Alanon; volunteer groups; or clergy and religious and social organizations. Some of these resources may be strong in one community, weak or missing in others. We have designed the proposed model to be flexible in working with the mix of resources available in a given community to help a given alcoholic client.
We have seen communities take action to face this neglected problem; we know that such efforts begin when the people who care the most start to speak up and invite others to join them. It is critical that those who are concerned not wait for someone else to take the lead. Taking action may very well depend on you.
Roland Atkinson is professor of psychiatry at Oregon Health and Science University in Portland. Frederic C. Blow, a senior research scientist at the University of Michigan Department of Psychiatry, directs the Serious Mental Illness Treatment Research and Evaluation Center in Ann Arbor.
American Society on Aging
833 Market St., Suite 511
San Francisco, CA 94103
www.asaging.org
info@asaging.org