Identification and Treatment of Senior Citizens With Addiction Problems

Donna Pinter, Ph.D.
Psychological Services Clinic
Sunbury, Pennsylvania

This interagency effort addresses the identification and treatment of Seniors with Addictions Problems (SWAP) in rural Northumberland County, Pennsylvania. The objective of this program is to combine the knowledge and services of area agencies. Agencies involved in this joint effort to improve the delivery of substance abuse, mental health, and related public health services to the elderly population of Northumberland County include the Northumberland County Area Agency on Aging (AAA), Northumberland County Single County Authority (SCA), and Psychological Services Clinic This effort is based on the premise that, through interagency networking, a broad range of expertise can be shared to enhance the lives of our elderly population.

Introduction

In Northumberland County, the traditional approach to identifying, evaluating, and treating substance abusers was not effective for senior citizens with addiction problems. We therefore designed an in-home program with a holistic approach in hopes of meeting the unique problems of senior citizens who have alcohol and/or other drug (AOD) problems. Our overall philosophy is consistent with that of the Administration on Aging, which is to help older people live more meaningful, independent, and dignified lives in their own homes and communities for as long as possible.

Purpose

The overall goal of the SWAP program is, in a timely manner, to identify, intervene with, treat, and provide aftercare for substance-abusing senior citizens in Northumberland County, Pennsylvania. We provide these services in the homes of the identified elderly clients. This is accomplished through the cooperation of an interagency network that strives to provide appropriate services to senior citizens who have addiction problems. The goals for the SWAP program are:

• To provide ongoing trainings of AAA staff on addiction issues in order to assist with appropriate identification of senior citizens who have addiction problems
• To set up a referral system that will expedite treatment services for the targeted population
• To maintain an interagency network to best serve clients
• To provide ongoing and accessible information on healthy life skills to the elderly population
• To provide a holistic approach to the treatment of this population through collaborative efforts

Methods

U.S. statistical projections indicate that the number of individuals older than age 65 will increase from 9 percent of the total population recorded in 1960 to 13 percent of the total population in the year 2000. Further projections indicate that 20 percent of the U.S. population will be age 65 and older by the year 2040. According to the 1990 census, there were 2.4 million people aged 60 and over living in Pennsylvania. In Northumberland County in 1990, 25 percent of residents were already 60 or older (24,000 residents of the total 97,000). In the surrounding county of Montour, 21percent are older Americans; Columbia County registered a 21 percent older population; Snyder County had 21 percent older persons; and Union County recorded 17 percent older residents. Overall, this rural area has a significantly larger percentage of older Americans than the country's norm.

Traditionally, this has been a rural farming region with a long history of coal mining, particularly in Northumberland County. The majority of the population was born in these small communities, married locally, and raised their families here. Those individuals who have left the area, for employment or other reasons, often return for their retirement years. There are 459.9 square miles in this mainly rural county, with small towns dispersed throughout the region. Historically, these small communities were basically self-contained entities with their own ethnic backgrounds, religions, and cultures. While modern times are breaking down these barriers, there still exists, particularly in the coal regions, a wariness of "outsiders." This belief system is still very much in evidence among the elderly population. With the heyday of coal as king having passed, many residents, particularly the elderly, live at minimum economic levels below State and national norms.

Statistics indicate that medication misuse among the elderly may be conservatively estimated at approximately one-third of the elderly population. This misuse is generally considered to be unintentional, but still serious. Research indicates that behavioral and physical symptoms that are related to medication misuse and alcohol abuse may be misinterpreted as signs of aging (Shipman 1990, p. 21). Therefore, it is critical that staff who provide services to older adults be knowledgeable about AOD issues. Frequently, staff rely on their own subjective judgment and reports from family members to identify substance abuse problems among the elderly. Case histories frequently do not include substance abuse histories. Studies indicate there is a fairly universal deficiency in drug and alcohol education for staffs who provide services to the elderly population (Schonfeld et al. 1993).

Background of County Services

In 1978, Psychological Services was established as a nonprofit outpatient mental health clinic with approval from the Department of Public Welfare and ODAP (Office of Drug and Alcohol Programs). A broad range of outpatient services (individual, family, group therapies) are rendered at the Sunbury office and at the Montour County satellite office which is in Danville, 22 miles from the Sunbury location. The establishment of the clinic makes evident the difficulties that many rural counties were having in obtaining treatment services for residents. Fifteen years ago, this clinic began a comprehensive range of services on site to Sullivan County (75 miles north). Trainings and consultations are provided on location to companies and agencies throughout the region.

In 1992, the Northumberland County Single County Authority (SCA) Director, Sam Williamson, met with the Clinical Director of Psychological Services to discuss the possibility of establishing a program in Northumberland County that would specifically address drug and alcohol problems among the elderly population of this county. Williamson, who had recently become SCA Director, was attempting to introduce innovative programs into what had previously been a conservative approach to drug and alcohol treatment. While it was hypothesized that addiction problems among the elderly must exist, referrals of elderly persons to the SCA were virtually nonexistent. Likewise, referrals of elderly clients to the mental health component of Psychological Services Clinic were minimal. The clinic had served some elderly clients in crisis situations. Severe depression and suicidal ideation were prevalent presenting problems in these referrals. Even in these crisis cases, the referred elderly clients vocalized their discomfort at coming to a mental health clinic.

Start-up of the Pilot Project

With the support of the Drug and Alcohol Advisory Board, a small sum of money was designated for a pilot project to be used for educational outreach addictions trainings and in-home treatment for the elderly. These services would provide AOD education to the staff of the Northumberland County Area Agency on Aging (AAA). Concurrently, meetings of the Single County Authority and Psychological Services Clinic took place with the executive staff of Northumberland County AAA. Staff of the AAA heartily agreed that such AOD education would be beneficial to them. It was further agreed that such training would be given to all AAA staff including bus drivers, senior citizens' center personnel, and all AAA individuals who had contact with senior citizens.

It was anticipated that, through this AOD education of AAA staff, more elderly clients with addiction problems would be identified and referred to the Northumberland County SCA for referral and appropriate treatment. It was mutually agreed that all services rendered would be done in the homes of the elderly clients. It was also agreed that elderly clients had to be dealt with in a somewhat different manner from the younger AOD clients. A strong mental health component would have to be an integral part of treatment.

Ensuring Comprehensive Treatment

Throughout our interagency meetings, all parties agreed that a strong need existed to provide effective prevention, intervention, treatment, and aftercare programs to the elderly population of Northumberland County. It was also mutually agreed that such a comprehensive program would need to include a strong mental health component.

As part of this proposed program, the need for training all levels of AAA staff was deemed critical for accurate identification of addiction problems. The treatment segment would have to be conducted in the homes of designated clients, and staff training would also need to be brought to the many remote AAA sites. Furthermore, this collaborative network would need to establish a plan for timely communications that would include regular meetings, phone calls, and fax transmissions.

To ensure the most comprehensive treatment and the success of this SWAP program, the following target areas were identified:

1. Potential elderly clients needed to be correctly identified by AAA staff. To accomplish this goal, staff of Psychological Services began the outreach process of going to AAA sites to meet with staff for shared learning and training. For example, Psychological Services staff rode AAA buses to train AAA bus drivers.
2. The concept of shared knowledge would be applied to surrounding communities. On May 5, 1993, a joint interagency conference, "Alcohol and Drug Abuse/Misuse Among the Elderly," was held at Mt. View Manor in Shamokin, Pennsylvania. The Pennsylvania Council of Addictions Certification Board (PCACB) granted C.A.C. credits for attendance. AAA staff from several counties, public health nurses, and mental health workers attended. Participants numbered over 100. Mental health issues of the elderly (suicide, depression), drug and alcohol problems of the elderly, and problems of caregivers were discussed. Among the presenters was a recovering alcoholic who is an active AOD counselor and, also, 70 years young. A physician from a nearby teaching hospital (Geisinger Medical Center) discussed the physiological ramifications of drug and alcohol abuse on the elderly. Participant evaluations of the workshop indicated very positive responses and a need for similar educational training in the future
3. The population of senior citizens who are relatively isolated and stay at home needed to be addressed. They all receive monthly AAA newsletters, and this medium would be utilized for educational purposes. Staff of Psychological Services write articles for the monthly AAA newsletter. With longevity often come issues of significant loss, dramatic changes in lifestyles, diminished capacities, loneliness, boredom, and feelings of helplessness. Some elderly individuals develop drinking problems later in life in an effort to cope with these stressors. The articles address these issues and provide suggestions for healthy ways to cope with the stressors that many senior citizens face.
4. To disseminate as much educational outreach as possible, senior citizens' centers would be targeted for onsite visits. SWAP has found that going to senior citizens' centers to provide AOD training to AAA staff is an effective way to transmit needed education. SWAP staff have also spoken to groups of senior citizens at these centers about stress management, alternative life skills, and grieving. Participants asked for more training, which we take as a positive response.
5. The provision of continuing current information on research and programs for the elderly needed to be an integral component of this project. Staff of Psychological Services agreed to obtain current information accessible through the library of Bucknell University; this information would be shared with all agencies
6. A timely, concise referral system needed to be established to ensure that comprehensive services would be implemented. The referral system for the SWAP program follows these procedures:
   • The Northumberland County Area Agency on Aging notifies the Northumberland County Single County Authority (usually by telephone, but sometimes in person or by fax) about an AAA client in need of possible AOD services.
   • A designated SCA representative makes phone contact with the AAA client referral, and asks if this individual would like to be seen (at home).
   • If the AAA client responds that he or she does wish this, the SCA representative schedules an appointment and meets in the home of the AAA client.
   • At the time of this meeting, the SCA representative does an intake (fiscal, personal information, prior AOD experience, presenting problem, assessment of type of treatment needed). In addition, pertinent releases of information are signed (i.e., to AAA, former treatment facilities if any, Psychological Services Clinic, and doctors).
   • If an AOD problem is evidenced, the SCA representative asks the AAA client if he or she wishes to pursue recommended treatment. If the answer is yes, collected information is processed at the SCA. Authorizations for treatment are generated to Psychological Services. The Clinic Director assigns the AAA client to the appropriate Drug and Alcohol (D&A) staff.
   • The clinic D&A staff calls the AAA client to schedule a D&A psychosocial appointment (at the client's home). If further treatment is then recommended, clinic D&A staff will administer outpatient counseling in the home of the AAA client. If inpatient treatment is deemed appropriate, clinic D&A staff will refer the client back to the Northumberland County SCA.
   • With the AAA client's written consent, significant parties will be contacted (e.g., AAA, doctors) to formulate a consistent treatment for the AAA client. As in all treatment, timeliness is critical and treatment is implemented within 2weeks of the initial referral.

7. A crucial component of the SWAP program was determined to be onsite counselors possessing a comprehensive AOD background and a solid knowledge of mental health and specific issues of the elderly. Psychological Services Clinic would provide these counselors and assume the responsibility for ongoing supervision and training of personnel participating in the SWAP program.

Project Findings

Prior to the inception of the SWAP program, senior citizens in this area who had addiction problems were frequently not being identified and referred for treatment. In the small number of prior referred cases, these clients were in crisis situations, with major depressive episodes and often suicidal ideations being the initial presenting problems. Substance abuse issues were then discovered after the fact.

The difficulties in accessing treatment facilities are significant in a rural community. Northumberland County has no public transportation services available between small towns. Additionally, senior citizens who do drive are reluctant to travel outside their small communities. Another major factor is that senior citizens regard going to treatment or prevention sites as a stigma. They often view having AOD problems and/or mental health issues as shameful. Without exception, their response to in-home services has been extremely positive.

We have also discovered that the type of professional rendering services to the elderly is of utmost importance in treatment success. The traditional hard-line AOD treatment is, at the least, not effective. The treating professional must be knowledgeable in alcohol and other drug abuse, mental health, and the specific issues of the elderly, as well as being compassionate. Trust and security are major components of successful treatment with the geriatric population.

Our project also gained a heightened awareness of the lack of AOD knowledge among the various professionals who work with the geriatric population. The amount of "doctor shopping" and ensuing prescription abuse was notable. Among many physicians, there was a noteworthy lack of awareness about their elderly patients' abusing of medications and frequent abuse of alcohol.

Through frequent interagency communications, SWAP began to formulate comprehensive profiles of elderly clients; these profiles are crucial to successful treatment. With their newly acquired knowledge of AOD signs and symptoms, caregivers could identify AOD issues significantly more frequently, as evidenced by the dramatic increase in referrals to the Single County Authority.

Conclusion

The SWAP project has seen a significant increase in AOD referrals of elderly clients, going from no referrals in the beginning to between three and seven referrals per week. Because of the AAA personnel's heightened awareness and expertise on drug and alcohol issues resulting from their training, more elderly clients are being referred for services.

Responses of the AAA staff continue to be positive, as is their realization of the need for continuing education of AAA personnel. Training of senior citizens on a one-to-one basis and in groups has received positive feedback. This component includes education on AOD issues and on developing positive life skills.

The continuation and extension of collaborative networks is essential to the maintenance and growth of these programs. Shared learning and training benefits all. The importance of a holistic approach to prevention, intervention, treatment, and aftercare programs is vital to the continuing success of SWAP.

Recommendations

The overall recommendation of this project is to provide more education for professionals, policymakers, and the general public on AOD issues among our elderly population. The consensus among the participating agencies in this project is that, at best, there exists a minimal knowledge of these issues. It is anticipated that education will create a heightened awareness of the tremendous costs, direct and indirect, of AOD problems among the elderly. Through the education of families of the elderly and the general public about AOD issues facing our geriatric population, we anticipate that faulty belief systems will change. The addiction problems of our rural elderly population must be viewed as part of the community as a whole, not in isolation. Based on the experience of this project, we recommend the following:

• Extend the network of AOD/elderly information on the county, State, and national levels
• Develop more life-skills trainings and activities for the elderly as alternatives to substance abuse

• Identify those inpatient AOD facilities that contain specific rehabilitation programs for the elderly population with addictions problems, and educate facilities that lack such programs about the significance of specialized programming
• Continue to collect data on the usage and effectiveness of SWAP
• Educate more physicians on the high incidence of prescription abuse among their elderly patients
• Continue to recruit qualified staff who have the expertise to work effectively with the elderly population, and who are willing to travel

References

Schonfeld, L.; Rohrer, G.; Zima, M.; and Spiegel, T. Alcohol abuse and medication misuse in older adults as estimated by service providers. Journal of Gerontological Social Work 21(1/2):113–125, 1993.

Shipman, A. Communities aren't helpless: Outreach to older alcoholics works. Aging 361:18–21, 1990.

Back to Top