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Chapter 1
The Need for Addictions Treatment for the Elderly
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Only in the past decade have the special needs of older persons who have alcohol or drug problems been given much consideration. This lack of attention to substance problems of older persons was partially attributable to the low problem rate estimated for this group on the basis of general population surveys. National surveys in the U.S. and Canada have indicated that older persons report the lowest rate of alcohol problems and the highest rate of abstinence compared to other adult age groups (Clark &; Midanik, 1982; Health and Welfare Canada, 1990). In addition, illicit drug use is exceedingly rare among older adults (Health and Welfare Canada, 1990). Moreover, surveys of treatment programs have found that older persons are underrepresented in treatment populations (Rush & Tyas, 1990).
Nevertheless, substance use and abuse by older people has begun to receive more attention. This has occurred for several reasons. First, problem rates based on community surveys may underestimate the extent of the problem, since surveys usually exclude institutionalized elderly where problem rates seem to be higher (see review by Gomberg, 1982). Second, problem rates may be inaccurate because the framework for defining alcohol problems has tended to be based on the problems experienced by younger people (e.g., family problems, employment problems) rather than those types of problems more likely to be experienced by older alcohol abusers, such as inability to care for self and home, and memory or cognitive problems (Graham, 1986).
Third, it is well recognized that the human body's ability to absorb and eliminate alcohol and drugs deteriorates with aging. Therefore, older persons may be more likely to experience problems from levels of alcohol use that typically would not cause problems for younger persons. Fourth, prescription drug use (including use of psychoactive prescription drugs) is highest among older people (Health and Welfare Canada, 1990). Prescription drugs may directly cause problems for the user (e.g., problem consequences, addiction), or these drugs may interact with alcohol, accentuating any effects of drinking. Finally, as will be described in Chapter 2, clinical primary care workers (e.g., physicians, public health nurses) began to express a need for strategies for dealing with older people experiencing alcohol and drug problems. Thus, despite the low prevalence rates indicated by general population surveys and surveys of treatment programs, greater attention began to be paid to the problem because of cases being encountered by families of older persons and by health and other professionals interacting with older persons.
The overall conclusion of recent literature reviews (Schonfeld & Dupree, 1990) is that alcohol and drug problems among older persons need to be addressed, despite the apparent low prevalence of such problems. As the population ages, even a small rate of problem use is likely to translate into increasingly larger numbers. In addition, there is some speculation that those who will become elderly in the near future are more likely to be drinkers and, therefore, more likely to have drinking problems, although the evidence is mixed as to whether drinking decreases with age (Adams et al., 1990; Busby et al., 1988; Glynn et al., 1984; Temple & Leino, 1989).
ADDICTIONS TREATMENT ISSUES PERTAINING TO OLDER ADULTS
There has been only a small amount of research on the treatment needs of older adults who have substance problems, or on the effectiveness of addictions treatment programs for older people. As the literature on treatment needs of older persons has grown, suggestions regarding treatment have been proposed based on identified characteristics of the target population. These suggestions have included: that treatment of older substance abusers requires knowledge of both alcoholism and aging and that the aged alcoholic is particularly likely to fall between the cracks of the support service network (Rathbone-McCuan et al., 1976); that the older alcoholic is usually hidden, and therefore it may be necessary to involve outreach caseworkers in treatment (Duckworth & Rosenblatt, 1976); and that support services should exist for older alcoholics who cannot or do not want to be ācuredā (Van de Vyvere, Hughes, & Fish, 1976). Other suggestions for treatment have been based on physicians' informal clinical experience with older persons who have alcohol problems. These include suggestions that there is a need for medical and supportive treatment; that treatment directed at social and psychological stresses is particularly useful (Droller, 1964; Rosin & Glatt, 1971; Zimberg, 1978a); and that service delivery needs to involve outreach, case-finding, and home-care (Zimberg, 1978b). Also on the basis of clinical experience (in a geriatric center), Rathbone-McCuan suggested that a comprehensive assessment is an important part of treatment (including case identification), and that community agencies need to work together in designating one resource for inpatient treatment and in providing ongoing case management (Rathbone-McCuan, 1982). RathboneMcCuan also recommended that a suitable typology for helping the older problem drinker could be based on the presence or absence of (1) alcoholism or symptoms of problem drinking, (2) health problems, and (3) difficulties or inadequacies in the social network (Rathbone-McCuan & Bland. 1975).
A distinct issue that has emerged in the literature is whether there is a need for elder-specific treatment. While early views on the subject (based on clinical experience) promoted the need for special programs for older people who have substance problems, Hinrichsen (1984) surveyed staff in 40 alcoholism treatment programs in six states and found that the majority (84 percent) felt that age-segregated treatment was unnecessary. However, recent data suggest that those who receive elder-specific treatment remain in treatment longer and are more likely to complete treatment than those in mixed-age outpatient groups (Kofoed et al., 1987).
In sum, specific considerations for treating older substance abusers have received very little attention until recently. The prevailing views of those who have written on this topic include the following: that outreach is required, that age-specific programs may be desirable, and that non-confrontational individual or group approaches based on providing social and medical support are likely to be most useful. There is also some evidence that older alcoholics do at least as well in treatment as younger alcoholics (Carstensen, Rychtarik, & Prue, 1985; Hanson, 1988; Linn, 1978).
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Chapter 2
The Development of the Community Older Persons Alcohol (COPA) Program
The following is extracted from a recent paper by Graham, Saunders, and Flower (1990) and describes the background that led Dr. Sarah J. Saunders to establish the COPA project:
In the late 1960s when I first started working in the field of addictions, the conclusion of the research literature was essentially that older people did not have alcohol problems. This view was partly based on the fact that very few people age 65+ ever entered an alcoholism treatment program and consequently were not visible to those persons in the alcoholism treatment field.
Then, when I was invited to develop a treatment program for a group of actively drinking men, creating behavioral havoc in a large home for the aged, it seemed like an interesting challenge but a rather low priority. Fortunately, I had the time to respond. I was aware that Alcoholics Anonymous had been involved in the home for 18 months with all contact being totally refused by these residents. What evolved was a quasi-behavioral program that seemed to work after about 9 monthsāwork in the sense that the behavior problems and frequency of intoxication dropped significantly (according to daily records of alcohol use and related behavior). Associated with this drop was a significant improvement in socializing skills and non-alcohol-related use of leisure time. At no time did the residents acknowledge a problem with their use of alcohol. This concept was important in the development of future programs.
Over the next 8 years as this program was enlarged, I began receiving many requests from the community for assistance with elderly alcohol abusers. I noted that most of these requests came from home caregivers. Consequently, I began making home visits with community health nurses to see if indeed there was a population of elderly alcoholics who were not being identifiedāthere was!
Common themes that emerged were:
ā¢ most refused to leave the home for almost any reason
ā¢ many demonstrated problems related to alcohol use in every aspect of their lives
ā¢ most totally resisted any suggestion of formal treatment for alcoholism
ā¢ many identified needs that seemed to be quite different from those of younger alcoholics.
What I learned from this experience was that given the opportunity to resolve some of their more acceptable problems (health, housing), helping them make the link between these problems and their use of alcohol was also often possible. We found that working with people on other problems often seemed to lead to their reducing their alcohol consumption, although total abstinence occurred in only a few people. However, even without total abstinence, the majority of those persons visited seemed to improve significantly in terms of living arrangements, health, non-alcohol-related socializing and leisure activities, as well as reduced alcohol consumption. We also found that because of the multiplicity and variety of life-style problems, many other agencies and services needed to be involved in the therapeutic process.
We seemed to have identified a hitherto unrecognized population of elderly alcohol abusers, and had developed a means whereby treatment was possible and apparently effective. By January 1981 I was receiving requests to develop a formal treatment program for elderly persons living in their own homes. A planning committee was formed that included representatives from all the major gerontological resources in Toronto as well as the Addiction Research Foundation (ARF). The concept for the COPA program was developed in May 1981. When taking into account all the themes identified in the earlier project, the new program bore little resemblance to existing alcohol treatment programs either in the treatment goals, methodology or program content. (pp. 197ā198)
In 1983, the Community Older Persons Alcohol (COPA) Program was established in West Toronto. The program was developed specifically to meet the needs of hard-to-reach older people who have alcohol or drug problems and was structured on three major principles: (1) that outreach should be provided where appropriate to older people who have substance problems, rather than assuming (as with traditional addictions programs) that persons should come to the program; (2) that it was not necessary for clients of the program to acknowledge substance problems in order for meaningful change to take place (again, a principle in direct opposition to traditional addictions treatment approaches); and (3) that one important goal of addictions treatment for older persons is to maintain the independent living of these persons in the community (by linking them with necessary community supports).
For the purpose of this book, Margaret Flower (the first director of COPA) provided the following reminiscences regarding the delivery of the program in its early days:
Travelling uncharted areas, we had no āclinical model.ā We went with hope, learn on the job, do no harm, and improvise.
What I think we did was:
a. Responded immediately to the problem(s) identified by the clientāregardless of its origin (i.e., even if not directly related to substance abuse), building trust, rapport, providing immediate support, and providing case management. This was done with āhigh intensity empathy!ā
b. Kept clear definitions of the client's goals versus āourā goalsāmy feeling is that much of this was done at staff meetings through case consultation. These meetings provided a forum for keeping perspective on clients' strengths and achievements (small goals) and ensuring that our motives were in the clients' best interests. Since the program was innovative and we were not able to measure our work against existing programs, these meetings helped to affirm that we were on the right track.
c. Some of the issues that we had to deal with included: What would happen when we disengagedāwould the client relapse? Did we recognize our limitations? How could we involve other supports (e.g., other agencies, families)? Probably treatment is the wrong word for our approach. What we tried to do was introduce a new element for the clientāchoice.
āAcceptingā the client and being there for them became an actuality, not just a phrase. It started with visiting homes, often in total squalor (reflecting not just the addiction limiting the indivi...
