Aging and Long Term Care by Aspira Continuing Education

AGING AND LONG TERM CARE (10 Hours/units) ÂŠ 2010 by Aspira Continuing Education. All rights reserved. No part of this material may be transmitted or reproduced in any form, or by any means, mechanical or electronic without written permission of Aspira Continuing Education.

Course Objectives: This course is designed to help you: 1. Define aging and long term care 2. Become familiar with relevant demographic information. 3. Obtain information that includes but is not limited to, the biological, social, and psychological aspects of aging. 4. Learn the psychological impact of aging. 5. Describe the relationship between aging and culture. 6. Distinguish between long term and alternative types of care. 7. Become familiar with Elder and Dependent Abuse and Reporting. 8. Become familiar with principles and techniques used in counseling the elderly. 9. Identify sexual issues and concerns related to the elderly. 10. Identify relevant issues and clinical implications in coping with aging. 11. Become familiar with the clinical implications and issues surrounding the elderly and substance abuse. 12. Identify and access relevant resources.

Table of Contents: 1. Definitions 2. Demographic Information 3. Biological Aging 4. Aging and Culture 5. Long Term Care 6. Psychological Considerations 7. Elder and Dependent Adult Abuse Reporting 8. Counseling and the Elderly 9. Sexuality 10. The Aging American Workforce 11. Nursing Homes 12. Coping with Aging 13. Older Adults, Substance Abuse, and Mental Health 14. Resources 15. References

1. Definitions Aging is defined as â&#x20AC;&#x2022;the accumulation of changes in an organism over time.â&#x20AC;&#x2013; Aging is also a multidimensional process of physical, psychological, and social change (Masoro E.J. & Austad S.N..eds: Handbook of the Biology of Aging, Sixth Edition. Academic Press. San Diego, CA, USA, 2006). Some

dimensions of aging grow and expand over time, while others decline. For example, although reaction time may decrease with age, knowledge of world events and wisdom may increase. Research shows that even late in life potential exists for physical, mental, and social growth and development (Strawbridge, W.J., Wallhagen, M.I. & Cohen, R.D., 2002. Successful aging and well-being: Self-rated compared with Rowe and Kahn. The Gerontologist). Aging is an important part of all human societies which not only reflects the biological changes that occur, but also the cultural and societal conventions (Masoro E.J. & Austad S.N.. eds: Handbook of the Biology of Aging, Sixth Edition. Academic Press. San Diego, CA, USA, 2006).

2. Demographic Information The number of Americans age 55 and older will almost double between now and the year 2030. This number will grow from 60 million today (21 percent of the total US population) to 107.6 million (31 percent of the population) as the Baby Boomers reach retirement age. During that same period of time, the number of Americans over 65 will more than double, from 34.8 million in 2000 (12 percent of the population) to 70.3 million in 2030 (20 percent of the total population). The next generation of retirees will be the healthiest, longest lived, best educated, and most affluent in history. Americans reaching age 65 today have an average life expectancy of an additional 17.9 years (19.2 years for females and 16.3 years for males). The likelihood that an American who reaches the age of 65 will survive to the age of 90 has nearly doubled over the past 40 years from just 14 percent of 65-year-olds in 1960 to 25 percent at present. By 2050, 40 percent of 65-year-olds are likely to reach age 90 (Fentleman, D.L., Smith, J. & Peterson, J., 1990. Successful aging in a postretirement society. In P.B. Baltes and M.M. Baltes, Eds. Successful aging: Perspectives from the Behavioural Sciences). Highest level of education achieved is increasing in the older population. Although less than one-third of todayâ&#x20AC;&#x2DC;s adults aged 70-74 have at least some college education that percentage will increase to more than 50 percent by the year 2015. Currently, older Americans possess more financial resources compared to previous generations. Households headed by persons age 65 and older reported a median income in 2000 of $32,854 ($33,467 for Caucasians, $27,952 for African-Americans, and $24,330 for Hispanics).

While one of every eight (12.1 percent) households headed by someone age 65 or older had incomes less than $15,000, nearly half (49.2 percent) had annual incomes of $35,000 or more, and nearly three in ten households (29.8 percent) had incomes greater than $50,000 per year (Fentleman, D.L., Smith, J. & Peterson, J., 1990. Successful aging in a postretirement society. In P.B. Baltes and M.M. Baltes Eds. Successful aging: Perspectives from the Behavioural Sciences). Approximately fifty percent of Americans age 55 and over volunteered at least once in 2002. Even among those aged 75 and older, 43 percent had volunteered at some point in the previous year.

Older Adults as Volunteers Age 55 to 64 % of age group who 50.3 % volunteer total number of volunteers 11.9 million Avg weekly hours/volunteer 3.3 hours Total time volunteered 4.8 billion annually hours

Age 65 to 74

Age 75+

46.6 %

43.0 %

8.5 million 3.6 hours 1.6 billion hours

7.1 million 3.1 hours 1.1 billion hours

Older volunteers devoted the most time to community activities amounting to almost double the national median for all ages. Compared with the U.S. median commitment of 52 volunteer hours annually, those 65 and over contributed 96 hours per year. (U.S. Department of Labor's Bureau of Labor Statistics, Volunteering in the United States, December 2002). It is estimated that the number of older volunteers would increase significantly if more were asked to volunteer or were offered an incentive. Older Americans now view retirement as an increasingly active, engaged phase of life that includes work and public service. Factors in the Decision to Work in Retirement (%)*

Desire to stay mentally active Desire to stay physically active Desire to remain productive or useful

Pre-retirees who Working plan to work in retirees Total retirement 87 68 83 85 61 80 77 73 76

Desire to do something fun or enjoyable Need health benefits Desire to help other people Desire to be around people Need the money Desire to learn new things Desire to pursue a dream (Source: AARP, Staying Ahead of the Curve 2003)

71 66 59 58 54 50 32

49 20 44 47 51 37 20

66 56 56 55 53 48 29

According to a 2002 survey conducted for Civic Ventures, 59 percent of older Americans view retirement as ―a time to be active and involved, to start new activities, and to set new goals.‖ Just 24 percent see retirement as ―a time to enjoy leisure activities and take a much deserved rest.‖ Retirees who intend to work during their retirement identify the desire to stay active and productive, rather than economic necessity, as the primary reason. More than half of the respondents (56 percent) say civic engagement will be at least a fairly important part of retirement (Peter D. Hart Research Associates, “The New Face of Retirement: An Ongoing Survey of American Attitudes on Aging,” San Francisco: Civic Ventures, 2002). A 2003 survey conducted for AARP found that many Americans between the ages of 50 and 70 plan to work far into what has traditionally been viewed as their "retirement years": 

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Nearly half of all pre-retirees (45 percent) expect to continue working into their 70s or later. Of this group, 27 percent said they would work until they were in their 70s, and 18 percent said ―80 or older,‖ ―never stop working,‖ or ―as long as they are able to work.‖ The most common reasons given by pre-retirees for wanting to continue working in retirement were the desire to stay ―mentally active‖ (87 percent) or ―physically active‖ (85 percent), and the desire ―to remain productive or useful‖ (77 percent). Slightly more than half of the pre-retirees (54 percent) indicated that their motivation was based on "a need for money.‖ (S. Kathi Brown, “Staying Ahead of the Curve 2003: The AARP Working in Retirement Study,” Washington, DC: AARP, 2003). The result of these demographic trends is the emergence of a new lifestage between adulthood and true old age – which has been called the ―third age‖ or ―midcourse‖ or ―my time.‖

(Source: AARP, Staying Ahead of the Curve 2003) ―The third age is no longer a brief intermezzo between midlife and drastic decline… Instead, it has the potential to become the best stage of all, an age of liberation when individuals combine newfound freedoms with prolonged health and the chance to make some of their most important contributions to life.‖ Mark Freedman, founder of Civic Ventures, author of PrimeTime: How Baby Boomers Will Revolutionize Retirement and Transform America. ―Midcourse connotes the period in which individuals begin to think about, plan for, and actually disengage from their primary career occupations and the raising of children; launch second or third careers; develop new identities and new ways to be productively engaged; establish new patterns of relating to spouses, children, siblings, parents, friends; leave some existing relationships and begin new ones…. The fact that most retirees say that they retired ‗to do other things‘ suggests that midcoursers are retiring to move to something else, not simply from boring or demanding jobs.‖ Phyllis Moen, McKnight Presidential Chair, Sociology, University of Minnesota. ―Midcourse: Navigating Retirement and a New Life Stage.‖ Jeylan Mortimer and Michael J. Shanahan, eds., Handbook of the Life Course. New York: Kluwer Publishers, 2003. ―Something huge is happening here… The emergence of an older, more vigorous population is the most significant story of our times.‖, Abigail Trafford, Washington Post health columnist and author, My Time: Making the Most of the Rest of Your Life.

3. Biological Aging In biology, senescence is the state or process of aging. Cellular senescence is ―a phenomenon where isolated cells demonstrate a limited ability to divide in culture‖. Organismal senescence is the aging of organisms. After a period of near perfect renewal in humans, between 20 and 35 years of age, organismal senescence is characterized by the declining ability to respond to stress, increasing homeostatic imbalance and increased risk of disease. This irreversible series of changes inevitably ends in death. Some researchers (specifically biogerontologists) are treating aging as a disease. As genes that have an effect on aging are discovered, aging is increasingly being regarded in a similar fashion to other genetic conditions, potentially treatable (Masoro

E.J. & Austad S.N.. eds: Handbook of the Biology of Aging, Sixth Edition. Academic Press. San Diego, CA, USA, 2006).

Human life and development often occurs in stages. Historically, the lifespan of people are divided into seven stages. Because biological changes may vary among people, developmental stages and milestones are identified to mark periods of human life. In some cultures, the divisions given below are varied. In the USA, adulthood legally begins at the age of eighteen, while old age begins at the age of legal retirement (approximately 65).           

Pre-conception: ovum, spermatozoon Conception: fertilization Pre-birth: conception to birth (pregnancy) Infancy: Birth to 1 Childhood: 1 to 12 Adolescence: 13 to 19 Early adulthood: 20 to 39 Middle adulthood: 40 to 64 Late adulthood: 65+ Death Post-Death: Decomposition

(Masoro E.J. & Austad S: Handbook of the Biology of Aging, Sixth Edition. Academic Press. San Diego, CA, USA, 2006). Cognitive Impact Deterioration and/or decline occur in many cognitive processes throughout the lifespan. A great deal of research has focused on memory and aging, and has found decline in many types of memory with aging, but not in semantic memory or general knowledge such as vocabulary definitions, which typically increases or remains steady. Early studies on changes in cognition with age generally found declines in intelligence in the elderly, but studies were cross-sectional rather than longitudinal and thus results may be an artifact of cohort rather than a true example of decline. Intelligence may decline with age, though the rate may vary depending on the type, and may in fact remain steady throughout most of the lifespan, dropping suddenly only as people near the end of their lives. Individual variations in rate of cognitive decline may therefore be explained in terms of people having different lengths of life (Mather, M., & Carstensen, L. L., 2005. Aging and motivated cognition: The positivity effect in attention and memory. Trends in Cognitive Sciences).

4. Aging and Culture Among the cultures of the world, there are different ways to express age. Some cultures measure age by counting years with or without including current year. For example, it could be said about the same person that he is twenty years old or that he is in the twenty-first year of his life. In Russian the former expression is generally used, the latter one has restricted usage: it is used for age of a deceased person in obituaries and for the age of a child when it is desired to show him/her older than he/she is. Psychologically, a boy in his 4th year seems older than one who is 3 years old. Many cultures have less of a problem with age, and it is seen as an important status to reach stages in life, rather than defined numerical ages. Advanced age is given more respect and status. East Asian age reckoning is different from that found in Western culture. Traditional Chinese culture uses a different aging method, called Xusui with respect to common aging which is called Zhousui. In the Xusui method, people are born at age 1, not age 0. The financial impact of aging is also significant. Although minors often have little money of their own, most of it is used for buying consumer goods.

They also have considerable impact on how their parents spend money. Young adults are an even more valuable cohort. They often have jobs with few responsibilities such as a mortgage or children. They do not yet have set buying habits and are more open to new products. The young are thus the central target of marketers. Television is programmed to attract the range of 15 to 35 year olds. Mainstream movies are also built around appealing to the young.

5. Long Term Care Most civilized societies such as The United States, Western Europe and Japan, have aging populations. While the effects on society are complex, there is concern about the impact on health care demand. Numerous suggestions found in literature for specific interventions to cope with the expected increase in demand for long-term care in aging societies can be organized under four headings: improve system performance; redesign service delivery; support informal caregivers; and shift demographic parameters. However, the annual growth in national health spending is not mainly due to increasing demand from aging populations, but rather has been driven by rising incomes, costly new medical technology, a shortage of health care workers and informational differences between providers and patients (AARP, Staying Ahead of the Curve 2003). Estimates indicate that population aging only explains 0.2 percentage points of the annual growth rate in medical spending of 4.3 percent since 1970. In addition, certain reforms to Medicare decreased elderly spending on home health care by 12.5 percent per year between 1996 and 2000. This would suggest that the impact of aging populations on health care costs is not inevitable. Long-term care is a variety of services which help meet both the medical and non-medical need of people with a chronic illness or disability who cannot care for themselves for long periods of time (AARP, Staying Ahead of the Curve 2003). Among its many functions, long-term care is designed to provide custodial and non-skilled care, such as assisting with normal daily tasks like dressing, bathing, and using the bathroom. Increasingly, long term care involves providing a level of medical care that requires the expertise of skilled practitioners to address the often multiple chronic conditions associated with older populations. Long-term care is designed to be flexible and can be provided at home, in the community, in assisted living or in nursing homes.

Long-term care may be needed by people of any age, even though it is a common need for senior citizens (AARP, Staying Ahead of the Curve 2003). The Centers for Medicare and Medicaid Services (CMS) estimates that about 9 million men and women over the age of 65 in the US will need long-term care in 2006. By 2020, approximately 12 million older Americans will require long-term care. It is anticipated that most will be cared for at home; family and friends are the sole caregivers for 70 percent of the elderly. A study by The U.S. Department of Health and Human Services says that people who reach age 65 will likely have a 40 percent chance of entering a nursing home. About 10 percent of the people who enter a nursing home will stay there five years or more (AARP, Staying Ahead of the Curve 2003). A 2006 study conducted by AARP found that most Americans are unaware of the costs associated with long-term care and overestimate the amount that government programs such as Medicare will pay. Medicaid Medicaid is a government program that will pay for certain health services and nursing home care for older people. In most states, Medicaid also pays for some long-term care services at home and in the community. Eligibility and covered services vary from state to state. Most often, eligibility is based on income and personal resources (AARP, Staying Ahead of the Curve 2003). Medicare Generally, Medicare does not pay for long-term care. Medicare pays only for medically necessary skilled nursing facility or home care. However, certain conditions must be met for Medicare to pay for even those types of care. Medicare specifically will not pay for custodial and non-skilled care (AARP, Staying Ahead of the Curve 2003). Long-term care funding Many national governments have addressed the growing long-term care needs at varying levels. Most Western European countries have implemented structures to fund formal care and, in a number of Northern and Continental European countries, arrangements exist to at least partially fund informal care as well. Some countries have had publicly organized

funding arrangements in place for many years: the Netherlands adopted the Exceptional Medical Expenses Act (ABWZ) in 1967, and in 1988 Norway established a framework for municipal payments to informal caregivers (in certain instances making them municipal employees). Other countries have only recently put in place comprehensive national programs: in 2004, for example, France set up a specific insurance fund for dependent older people (Saltman, R.B.; Dubois, H.F.W.; Chawla, M., 2006. "The Impact Of Aging On Long-term Care In Europe And Some Potential Policy Responses). Some countries (Spain and Italy in Southern Europe, Poland and Hungary in Central Europe) have not yet established comprehensive national programs, relying on informal caregivers combined with a fragmented mix of formal services that varies in quality and by location. (Saltman et al. 2006). Home care / Informal care Home care is designed to be flexible and can be provided by informal (nonprofessional, usually volunteer) or formal (professional) providers and can incorporate a wide range of clinical (nursing, drug therapy, physical therapy), social (food preparation, cleaning, shopping), and even physical construction (installing hydraulic lifts, renovating bathrooms and kitchens) activities (Saltman et al. 2006). Informal care plays an important part in many countries across the world. In many countries, the largest percentages of older persons using services are those who rely on informal home care. Estimates of these figures often are in the 80 to 90 percent range; for example, in Austria, 80 percent of all older citizens (OECD 2005). The similar figure for dependent elders in Spain is 82.2 percent (Costa-Font and Patxot 2005). In the 1980s, some Nordic countries began making payments to informal caregivers, with Norway and Denmark allowing relatives and neighbors who were providing regular home care to become municipal employees, complete with regular pension benefits. In Finland, informal caregivers received a fixed fee from municipalities as well as pension payments. In the 1990s, a number of countries with social health insurance (Austria in 1994, Germany in 1996, Luxembourg in 1999) began providing a cash payment to service recipients, who could then use those funds to pay informal caregivers. In Germany, the long-term care fund may also make pension contributions if an informal caregiver works more than 14 hours per week (Saltman et al. 2006)

For many people "long-term" care may translate into assistance from family and friends or regular visits by a home health aide. For others who are frail

or suffering from dementia, long-term care may involve moving to a place where professional care is available 24 hours a day. More choices exist in long-term care today than ever before. Services include home health care, adult day care, and transportation services for frail seniors as well as foster care, assisted living and retirement communities, and traditional nursing homes. 

If the client is experiencing difficulty with activities of daily living such as bathing, managing finances, or driving, they may want to talk with their doctor and other health care professionals about needed assistance. A social worker/geriatric case manager can provide assistance by developing a long-term care plan and identifying necessary services.

 Learn about the types of services and care in your community. The Area Agency on Aging and local and state offices of aging or social services can provide directories of adult day care centers, meal programs, companion programs, and transportation services.  The Federal Medicare program and private "Medigap" insurance only offer short-term home health and nursing home benefits. Contact your state-run Medicaid program about long-term nursing home coverage for people with limited means. Also, your state's insurance commission can provide additional information concerning private long-term care policies and offer helpful tips.  The client‘s needs may change over time. What worked 6 months ago may no longer apply. Insurance coverage is often very limited and families may have problems paying for services. In addition, rules about programs and benefits change, and it's hard to know from one year to the next what may be available.

For some clients, support received from family, friends, or local meal or transportation programs is not adequate. There are two basic types of residential care:

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Assisted living arrangements are available in large apartment or hotellike buildings or can be set up as "board and care" homes for a small number of people. They offer different levels of care, but often include meals, recreation, security, and help with bathing, dressing, medication, and housekeeping.

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Skilled nursing facilities otherwise known as nursing homes provide 24-hour services and supervision. They provide medical care and rehabilitation for residents, who are mostly very frail or suffer from the later stages of dementia.

Be aware that health care providers may offer different levels of care. These continuing care communities may identify an assisted living facility in close proximity to a nursing home so that people can move from one type of care to another if necessary. Several offer programs for couples, trying to meet needs when one spouse is doing well but the other has become disabled. There are many different ways to assist your client or client‘s family in locating the most suitable residential program. You may provide them with psychoeducation including encouraging them to: 

Find out about specific facilities in their area. Doctors, friends and relatives, local hospital discharge planners and social workers, and religious organizations can help. Your state's Office of the Long-Term Care Ombudsman has information about specific nursing homes and can let you know whether there have been problems at a particular home. Other types of residential arrangements, like "board and care" homes, do not follow the same Federal, state, or local licensing requirements or regulations as nursing homes. Talk to people in your community or local social service agencies to find out which facilities seem to be well run.

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Contact the places that interest them. They can ask questions about vacancies, number of residents, costs and method of payment, and participation in Medicare/Medicaid. Encourage your client to consider what's important to them, such as transportation, meals, special units for Alzheimer's disease, or medication policies.

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Visit any places/facilities that appear to be a good match. Talk to the staff, residents, and, if possible, family members of residents. Set up

an appointment, but also go unannounced and at different times of the day. See if the staff treats residents with respect and tries to meet the needs of each person. Check if the building is clean and safe. Are residents restrained in any way? Are social activities and exercise programs offered--and enjoyed? Do residents have personal privacy? Is the facility secure for people and their belongings? Understand that once a choice has been made, be sure you understand the facility's contract and financial agreement. It's a good idea to have a lawyer look them over prior to signing. Transitioning into a long-term care facility or nursing home can be challenging while impacting family members. Some facilities staff social workers who may provide assistance through the transition. Consistent visits by family and friends are helpful as they can provide reassurance and comfort.

6. Psychological Considerations Coping and well-being Many variables impact coping and well being in the elderly. Social support, religion and spirituality, active engagement with life and having an internal locus of control have been proposed as being beneficial in helping elderly people to cope with stressful life events. Social support and personal control are possibly the two most important factors that predict well-being, morbidity and mortality in adults. Other factors that may link to well-being and quality of life in the elderly include social relationships (possibly relationships with pets as well as humans), and health (Fentleman, D.L., Smith, J. & Peterson, J., 1990. Successful aging in a postretirement society. In P.B. Baltes and M.M. Baltes Eds. Successful aging: Perspectives from the Behavioural Sciences). Individuals in different wings in the same retirement home have demonstrated a lower risk of mortality and higher alertness and self-rated health in the wing where residents had greater control over their environment, though personal control may have less impact on specific measures of health. Social control, perceptions of how much influence one has over one's social relationships, shows support as a moderator variable for the relationship between social support and perceived health in the elderly, and may positively influence coping in the elderly (Fentleman, D.L., Smith,

J. & Peterson, J., 1990. Successful aging in a postretirement society. In P.B. Baltes and M.M. Baltes Eds. Successful aging: Perspectives from the Behavioural Sciences). Religion Religion has been an important factor used by the elderly in coping with the demands of later life, and appears more often than other forms of coping later in life. Religious commitment may also be associated with reduced mortality, though religiosity is a multidimensional variable; while participation in religious activities in the sense of participation in formal and organized rituals may decline, it may become a more informal, but still important aspect of life such as through personal or private prayer (Fentleman, D.L., Smith, J. & Peterson, J., 1990. Successful aging in a postretirement society. In P.B. Baltes and M.M. Baltes Eds. Successful aging: Perspectives from the Behavioural Sciences). Self-rated health Self-ratings of health, the beliefs in one's own health as excellent, fair or poor, has been correlated with well-being and mortality in the elderly; positive ratings are linked to high well-being and reduced mortality. Various reasons have been proposed for this association; people who are objectively healthy may naturally rate their health better than that of their ill counterparts, though this link has been observed even in studies which have controlled for socioeconomic status, psychological functioning and health status. This finding is generally stronger for men than women, though the pattern between genders is not universal across all studies, and some results suggest sex-based differences only appear in certain age groups, for certain causes of mortality and within a specific sub-set of self-ratings of health (Fentleman, D.L., Smith, J. & Peterson, J., 1990. Successful aging in a postretirement society. In P.B. Baltes and M.M. Baltes Eds. Successful aging: Perspectives from the Behavioral Sciences) Emotional improvement Given the physical and cognitive declines seen in aging, a surprising finding is that emotional experience improves with age. Older adults are better at regulating their emotions and experience negative affect less frequently than younger adults and show a positivity effect in their attention and memory. The emotional improvements show up in longitudinal studies as well as in

cross-sectional studies and so cannot be entirely due to only the happier individuals surviving (Mather, M., & Carstensen, L. L., 2005. Aging and motivated cognition: The positivity effect in attention and memory. Trends in Cognitive Sciences). The concept of successful aging can be traced back to the 1950s, and popularized in the 1980s. Previous research into aging exaggerated the extent to which health disabilities, such as diabetes or osteoporosis, could be attributed exclusively to age, and research in gerontology exaggerated the homogeneity of samples of elderly people. Successful aging consists of three components: 1. Low probability of disease or disability; 2. High cognitive and physical function capacity; 3. Active engagement with life. (Mather, M., & Carstensen, L. L., 2005. Aging and motivated cognition: The positivity effect in attention and memory. Trends in Cognitive Sciences ) A greater number of people self-report successful aging than those that strictly meet these criteria. Successful aging may be viewed an interdisciplinary concept, spanning both psychology and sociology, where it is seen as the transaction between society and individuals across the life span with specific focus on the later years of life. The terms "healthy aging" "optimal aging" have been proposed as alternatives to successful aging (Mather, M., & Carstensen, L. L., 2005. Aging and motivated cognition: The positivity effect in attention and memory. Trends in Cognitive Sciences) Six suggested dimensions of successful aging include: 1. No physical disability over the age of 75 as rated by a physician; 2. Good subjective health assessment (i.e. good self-ratings of one's health); 3. Length of undisabled life; 4. Good mental health; 5. Objective social support; 6. Self-rated life satisfaction in eight domains, namely marriage, incomerelated work, children, friendship and social contacts, hobbies, community service activities, religion and recreation/sports

Depression Later in life, the reasons for becoming depressed appear to be obvious and common. The things which we expect to make us feel depressed do become more common as we grow older such as retirement, less income, and perhaps the start of physical problems. There are also the emotional losses such as the death of a partner, family member, friends, or a pet. Surprisingly, less than one elderly person in six feels so depressed that they or others notice. Fewer than one in thirty are so depressed that doctors would diagnose an illness or diagnose a depressive disorder (Strawbridge, W.J., Wallhagen, M.I. & Cohen, R.D., 2002. Successful aging and well-being: Self-rated compared with Rowe and Kahn. The Gerontologist). Symptoms of physical illnesses may be similar to those of Depression. For example, loss of appetite or disturbed sleep may also be caused by physical illnesses, like thyroid problems, heart disease or arthritis.

7. Elder and Dependent Adult Abuse Reporting Throughout the past three decades, significant progress has been made in increasing awareness of abusive relationships. Nonetheless, child abuse and domestic violence continue to receive more recognition than elder abuse and more attention in both public and medical settings. Due to medical advances and other factors, people are living longer then ever before. Older Americans constitute the most rapid growing segment of the United States population. According to the US Census Bureau, people 65 years of age and older accounted for 12.5% of the US population in 2000. By the year 2020, this group will increase by 5.5%, and by 2050, older Americans are projected to account for 25% of the population. Due to the growing number of older Americans, the number of elder abuse cases will increase. The impact of elder abuse as a public health issue will likely grow in the future. Abuse victims have twice as many physician visits compared with the general US population. This of course allows opportunities for detection. Since many elders are isolated, an unexpected visit to the emergency department may be the only opportunity for detection. Emergency physicians are in a unique position to affect diagnosis and management of this vulnerable population.

Elder abuse encompasses a range of behaviors, events, and circumstances. Elder abuse usually consists of repetitive incidences including any act of commission or omission that result in harm or threatened harm to the health and welfare of an older adult. The US National Academy of Sciences defines elder abuse as follows: 

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“Intentional actions that cause harm or create a serious risk of harm (whether or not harm is intended), to a vulnerable elder by a caregiver or other person who stands in a trusted relationship to the elder Failure by a caregiver to satisfy the elder's basic needs or to protect the elder from harm”.

However, terms may vary among professionals and researchers, and usage is not consistent in the laws of different states. For example, the age at which a person is considered elderly, usually 60 or 65 years, varies. Seven categories of elder abuse have been described by the National Center on Elder Abuse (NCEA) including: 

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―Physical abuse - Any act of violence that causes pain, injury, impairment, or disease, including striking, pushing, force-feeding, and improper use of physical restraints or medication Emotional or psychological abuse - Conduct that causes mental anguish including threats, verbal or nonverbal insults, isolation, and humiliation. Some legal definitions require identification of at least 10 episodes of this type of behavior within a single year to constitute abuse. Financial or material exploitation - Misuse of an elderly person's money or assets for personal gain. Acts such as stealing (money, social security checks, possessions) or coercion (changing a will, assuming power of attorney) constitute financial abuse. Neglect - Failure of a caretaker to provide for the patient's basic needs. As in the previous examples of abuse, neglect can be physical, emotional, or financial. Physical neglect is failure to provide eyeglasses or dentures, preventive health care, safety precautions, or hygiene. Emotional neglect includes failure to provide social stimulation (leaving an older person alone for extended periods). Financial neglect involves failure to use the resources available to restore or maintain the well-being of the aging adult.

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Sexual abuse - Nonconsensual intimate contact or exposure or any similar activity when the patient is incapable of giving consent. Family members, friends, institutional employees, and fellow patients can commit sexual abuse. Self-neglect - Behavior in which seniors compromise their own health and safety, as when an aging adult refuses needed help with various daily activities. When the patient is deemed competent, many ethical questions arise regarding the patient's right of autonomy and the physician's oath of beneficence. Abandonment - The desertion of an elderly person by an individual who has assumed responsibility for providing care for an elder, or by a person with physical custody of an elder.‖

Source: National Center on Elder Abuse (NCEA)

Occurrence A 2003 report from the National Research Council suggests that 1-2 million Americans age 65 years or older have been injured, exploited, or otherwise mistreated. Other studies suggest that 3-10% of elders are abused or neglected. Several variables contribute to the underestimation of abused elders including fear, shame, guilt, and/or lack of information. A variety of professionals underreport elder abuse due to lack of recognition and awareness of reporting requirements. A significant amount of research excludes specific demographics such as persons unable to respond to a survey, speakers of languages other than English, and persons with mental illness. Studies have shown that only 1 in 6 victims are likely to self-report mistreatment to the appropriate legal authorities. Elder physical abuse victims, caregiver neglect, or self-neglect have triple the mortality of those never abused. Proactive detection and intervention by professionals could potentially lead to decreased mortality. Healthcare provider proactivity is essential. Race Elder abuse exists throughout all racial, socioeconomic, and religious backgrounds. The NCEA found the following racial and ethnic distribution among older persons who had been abused:  

White, non-Hispanic – 66.4% Black – 18.7%

20  

Hispanic – 10% Other – 4.9%

Gender Women are believed to be the most common victims of abuse, perhaps because they report abuse at higher rates or because the severity of injury in women typically is greater than in men. Numerous studies, however, have found no differences based on sex. Age By definition, elder abuse occurs in the elderly, although there is no universally accepted definition of when old age begins. Typically, 60 or 65 years is considered the threshold of old age. The American Medical Association has recommended that health care professionals regularly ask elderly patients about abuse, even when there are no visible signs/symptoms. There is not yet a consensus on what constitutes an appropriate screen or assessment instrument for detecting elder abuse. Risk factors of elder abuse include:    

Shared living situation with abuser, likely due to an increased opportunity for contact Dementia Social isolation Pathologic characteristics of perpetrators such as mental illness and alcohol misuse

It would be helpful for providers to consider these "red flags" while providing services for the elderly. The presence of red flags is an indicator that a more in-depth history and/or assessment are necessary. While evaluating a client for possible elder abuse, the provider may want to consider simple and direct questions which are posed in a nonjudgmental or nonthreatening manner. It is also helpful to interview the patient and caregiver both together and separately to detect disparities offering clues to the diagnosis of abuse. Accurate and objective documentation of the interview is important partially because findings may be entered as evidence in criminal trials or in guardianship hearings. Documentation must be complete, thorough, and legible. It is helpful to quote direct statements made by the client.

Physical In a systematic summary of the published work on forensic markers of elder abuse with respect to physical findings, there is a paucity of primary data. Most research on clinical findings purported to be common in elder abuse derives from anecdotes, case reports, or small case series. As a result, consider abuse in the differential diagnosis of every elderly person entering the ED. Thoroughly disrobe the patient to evaluate for unexpected injuries. Roll the patient to evaluate for back injuries and/or decubitus ulcers. Although not guided strongly by evidence, a number of clinical findings and observations make elder abuse a strong possibility, including the following:          

Several injuries in various stages of evolution Unexplained injuries Delay in seeking treatment Injuries inconsistent with history Contradictory explanations given by the patient and caregiver Laboratory findings indicating under dosage or over dosage of medications Bruises, welts, lacerations, rope marks, burns Venereal disease or genital infections Dehydration, malnutrition, decubitus ulcers, poor hygiene Signs of withdrawal, depression, agitation, or infantile behavior

During the physical examination, note the size, shape, and location of all injuries. Incorporate the use of body maps/charts in cases of extensive injuries. Photographing the injuries is helpful for forensic documentation. Causes Many theories have been developed to explain abusive behavior toward elderly people. Clearly, no single answer exists to explain behavior in an abusive relationship. A number of psychosocial and cultural factors are involved. Theories of the origin of mistreatment of elders have been divided into 4 major categories, as follows: physical and mental impairment of the patient, caregiver stress, transgenerational violence, and psychopathology in the abuser.

22 

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Physical and mental impairment of the patient o Recent studies have failed to show direct correlation between patient frailty and abuse, even though it had been assumed that frailty itself was a risk factor for abuse. o Physical and mental impairment nevertheless appear to play an indirect role in elder abuse, decreasing seniors' ability to defend themselves or to escape, thus increasing vulnerability. Caregiver stress o This theory suggests that elder abuse is caused by the stress associated with caring for an elderly patient, compounded by stresses from the outside world. o The effect of stress factors (e.g., alcohol or drug abuse, potential for injury from falls, incontinence, elderly persons' violent verbal behavior, employment problems, low income on the part of the abuser) may all culminate in caregivers' expressions of anger or antagonism toward the elderly person, resulting in violence. o This theory, however, does not explain how individuals in identically stressful situations manage without abusing seniors in their care. Stress should be seen more as a trigger for abuse than as a cause. Transgenerational violence: This theory asserts that family violence is a learned behavior that is passed down from generation to generation. Thus, the child who was once abused by the parent continues the cycle of violence when both are older. Psychopathology in the abuser: This theory focuses on a psychological deficiency in the development of the abuser. Drug and alcohol addiction, personality disorders, mental retardation, dementia, and other conditions can increase the likelihood of elder abuse. In fact, family members with such conditions are most likely to be primary caretakers for elderly relatives because they are the individuals typically at home due to lack of employment. Other risk factors in abuse are (1) shared living arrangements between the elder person and the abuser, (2) dependence of the abuser on the victim, and (3) social isolation of the elder person.

A mandated reporter must report a known or suspected instance of elder or dependent adult abuse when, in his or her professional capacity, or within the scope of his or her employment, he or she (1) has observed or has knowledge of an incident that reasonably appears to be physical abuse, neglect, financial abuse, abandonment, abduction, or isolation; (2) is told by an elder or dependent adult that he or she has experienced behavior constituting physical abuse, neglect, financial abuse, abandonment, abduction, or isolation; or (3) reasonably suspects abuse. Optional Reports: Mandated reporters may report a known or suspected instance of elder or dependent adult abuse when they have knowledge of or reasonably suspect that a form of elder or dependent adult abuse for which a report is not mandated has been inflicted upon an elder or dependent adult or that the elder or dependent adult's emotional well-being is threatened in any other way. Definition of Elder: An â&#x20AC;&#x2022;elderâ&#x20AC;&#x2013; is a person who is age 65 years or older. Definition of Dependent Adult: a dependent adult is a person, between the ages of 18 years and 64 years, who has physical or mental limitations that restrict his or her ability to carry out normal activities or to protect his or her rights. Mandated reporters, including therapists, are now required to report the following: Known and reasonably suspected physical abuse of an elder or dependent adult. Instances of known and reasonably suspected neglect, financial abuse, abandonment, abduction, and/or isolation of an elder or dependent adult, and any other treatment that results in physical harm, pain, or mental suffering. As a mandated reporter, a psychotherapist is required to make a report of known or suspected elder or dependent adult abuse when, in his or her professional capacity, or within the scope of his or her employment, he or she has observed or has knowledge of an incident that reasonably appears to be abuse, is told by an elder or dependent adult that he or she has experienced behavior constituting abuse; and/or reasonably suspects abuse.

Abuse of an elder or dependent adult includes the following categories: Physical abuse, neglect, financial abuse, abandonment, abduction, isolation, and any other form of treatment that results in physical harm, pain, or mental suffering. Mental suffering may consist of fear, confusion, severe depression, agitation, or other serious emotional distress caused by threats, harassment, or other forms of intimidating behavior. Physical Abuse includes assault, assault with a deadly weapon or with force likely to cause great bodily injury; battery; sexual assault, unreasonable physical restraint; prolonged or continual deprivation of water or food; and the use of physical or chemical restraint for punishment, for a period of time beyond that for which the medication was ordered through instructions from a licensed physician or surgeon caring for the elder or dependent adult, and/or for any purpose not authorized by the elder or dependent adult's physician or surgeon. Neglect refers to the negligent failure of any person having the care or custody of an elder or dependent adult to exercise that degree of care that a reasonable person in a similar position would provide. Neglect also includes self-neglect, the negligent failure of an elder or dependent adult to provide a reasonable degree of care to himself or herself. Specific examples of neglect include the failure to assist in personal hygiene or in the provision of food, clothing, or shelter,; the failure to provide medical care for physical or mental health needs and the failure to prevent malnutrition or dehydration. Financial Abuse means concealing, taking, or appropriating an elder or dependent adult's property or money to any wrongful use or with the intent to defraud. Abandonment, desertion or willful abandonment by a person having the care or custody of the elder or dependent adult person under circumstances in which a reasonable person would continue to provide care and custody. Isolation, deliberately preventing an elder or dependent adult from receiving his or her mail or phone calls. False imprisonment; and/or the physical restraint of an elder or dependent adult for the purpose of preventing him or her from meeting with his or her visitors.

Reports of known or reasonably suspected elder or dependent adult abuse must be filed by telephone immediately or as soon as practically possible. A written report must then be sent within two working days. Reporters should generally make reports to their county's adult protective agency or a local law enforcement agency. There are two exceptions to this, however: First, if the abuse occurred in a state mental health hospital or state developmental center, the report should be made to designated investigators of the State Department of Mental Health or the State Department of Developmental Services or to the local law enforcement agency. Second, if the abuse occurred in a long-term care facility (other than a state mental hospital or a state developmental center), reports should be made to the local ombudsman or to the local law enforcement agency. Any person legally required to report elder or dependent adult abuse who knowingly fails to report can be found guilty of a misdemeanor that is punishable by not more than six months in the county jail or a fine not to exceed $1,000 or both imprisonment and a fine. A therapist who fails to make a timely mandated elder or dependent adult abuse report may also face disciplinary action by their governing board and civil action for damages. The law provides that no person required making a report of elder or dependent adult abuse shall be criminally or civilly liable for such a report, as long as it cannot be proven that the report was made falsely.

8. Counseling and the Elderly Today, life expectancy in the United States is over 75 years – a fact that has created a substantial and growing population of the ―elderly‖ who will require a significant amount of medical, psychiatric, and other types of care over time. Butler, Lewis, and Sunderland (1998) noted that a ―demographic revolution‖ is underway in the United States in which members of the socalled ―baby boomer‖ generation entering the period after age 65 will eventually comprise about 20 percent of the national population. Older individuals, male and female, wealthy and poor, urban and rural, will consume a disproportionate level of care resources in the coming decades. This ―demographic revolution‖ demands that counselors and therapists develop effective intervention strategies for assisting older clients in coping with the myriad issues that confront the elderly. This brief essay will address some of the key issues related to this process, including ageism

itself, counter transference and transference issues in counseling, psychiatric problems including dementia, assessment techniques, and ―best practice‖ interventions. Ageism is a general term that encapsulates the prejudices and stereotypes that are applied to older people purely on the basis of their age (Butler, et al, 1998). Ageism is a construct that functions to ―pigeonhole‖ people in much the same manner as sexism and racism; in essence, ageism is a way of thinking about the elderly that marginalizes them, demeans them, and isolates them. Ageism begins in childhood, according to Butler, et al (1998), and represents in part an attempt by younger people to shield themselves from the recognition that they, too, will eventually age and confront the inevitability of death and physical decline. The effects of ageism are numerous and potentially debilitating. Ageism can constitute the societal sacrifice of older people for the sake of younger people. In the workplace and in the family unit, older individuals (i.e., those over age 65, which is an admittedly arbitrary cutoff for defining the ―elderly‖) are often dismissed as unable to make adequate contributions to the group. Ageism also encompasses the assumption, common even among counselors and other caregivers, that older individuals have lost much of the capacity for self-management and self-care that characterizes younger individuals. Ageism also incorrectly assumes that the process of aging is invariably associated with a decline in mental and physical competencies. It can and does provide a rationalized excuse for forcing older workers to retire. In the United States, federal legislation has been enacted to prevent age discrimination in the workplace, but many older workers still find that they are devalued and passed over for promotions or other benefits simply because of negative assumptions regarding their age and its putative impact upon performance (Butler, et al, 1998). In the context of counseling and therapy, ageism can negatively impact upon the capacity of professional caregivers to work effectively with clients. Attributions of individual traits, behaviors, needs, or other issues addressed in the context of counseling can distort the process itself. For mental health caregivers, serving the older client necessitates coming to terms with one‘s own fears and anxieties regarding the aging process (Butler, et al, 1998). Countertransference and Transference

In providing services to the older client, a counselor must be aware of the issues associated with both transference and countertransference. Countertransference is described by Butler, et al (1998) as follows: Countertransference in the classic sense occurs when mental Health personnel find themselves perceiving and reacting to older persons in ways that are inappropriate and reminiscent of previous patterns of relating to parents, siblings, and other key childhood figures. Love and protectiveness may vie with hate and revenge. Ageism takes this a step further. Mental health personnel not only have to deal with leftover feelings from their perceptions of older persons, but they must also be aware of negative cultural attitudes toward older persons (p. 208).

Central to the therapeutic relationship, regardless of the age, gender, or ethnicity of the client and therapist, are the processes of both transference and countertransference. In transference, as the class lectures and discussions demonstrated, clients often come to regard their counselor or therapist as an authority figure or another or loved or hated figure from the past. Often, clients will transfer their previous attitudes toward significant others in their lives to the therapist. The older client may display an overwhelming desire to please the analyst, or may also display resentment and hatred even though the analyst has done nothing to provoke such emotions. Transference allows the therapist to identify a pattern of the unconscious problems that the client is experiencing and can therefore be valuable in facilitating the therapeutic process. Countertransference may be more difficult in the context of dealing with older clients. Butler, et al (1998) pointed out that some aged clients may stimulate therapistsâ&#x20AC;&#x2DC; fears about his or her own old age, arouse the therapistâ&#x20AC;&#x2DC;s conflicts about relationships with parental figures, or suggest to the therapist that intervention is wasted effort because the older client may be nearing death. When therapists working with elderly clients allow negative attitudes to intervene, therapy cannot be successful. In other words, therapists must avoid negative countertransference based on ageism as well as an unconscious over identification with older people. Certainly, the therapist working with older patients must recognize that simply being elderly does not mean that an individualâ&#x20AC;&#x2DC;s capacity for enjoying life, making a meaningful contribution to family and society, or participating competently in problem resolution cannot occur.

Psychiatric Problems, Dementia Older individuals may present for treatment with any one of a number of psychiatric problems. Anxiety of an acute or chronic nature, substance abuse engendered by over-medication, depression, difficulties with activities of daily life (ADLs), and social isolation are among these problems. Older adults may experience all of the neuroses and psychoses that are found in younger patients, including schizophrenia and paranoid disorders manifested by delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, or negative symptoms (Butler, et al, 1998). Mood disorders, including major depressive disorder, bipolar disorder, and dysthymic disorder are also observed in older individuals, as are the various somatoform and personality disorders. Butler, et al (1998) reported that the American Psychiatric Association estimates that between 15 and 25 percent of all individuals over the arbitrary age of 65 suffer from symptoms of mental illness. Of those older people with mental disorders, depression appears to be the most common primary diagnosis. Dementia is one of the most frequently observed forms of mental illness in older patients. While it is certainly true that there are often organic explanations for psychoses suffered by older individuals, it is also true that the vast majority of older individuals suffering from psychiatric syndromes do not have mental problems as a result of physiological conditions. It is all too often assumed that any psychiatric syndromes that arise in later life are secondary to the problems of aging itself. Because this is the case, older patients, including those in residential or institutional facilities who are known to have psychiatric syndromes tend to be undertreated. It is fallacious to assume that the physical health problems that emerge as individuals age invariably give rise to psychiatric disorders (Butler, et al, 1998). It is far more likely that older individuals experience psychiatric problems as a consequence of legitimate fear of being alone, a sense of social isolation, a feeling of worthlessness, and any number of other anxietyproducing sociocultural or familial situations. Mood disturbances such as depression are of particular significance because the depressed individual also experiences sleep disturbance, appetite and weight changes, decreased concentration, feelings of fatigue or loss of energy, psychomotor disturbances, and recurrent thoughts of death (Butler, et al, 1998).

For the older individual it may very well be that this type of mental illness (i.e., depression) exacerbates physiological anomalies or health problems. Dementia and the various psychoses, according to discussions in class and lectures, represent a break in the ability to manage the activities of daily living and a lack of reality testing. This may occur in the older person as a consequence of multiple losses within a close time period or as a reaction to certain extreme stresses. In other words, the therapist or counselor working with the older individual must recognize that these individuals will manifest many of the same presenting problems exhibited by younger clients. Dismissing these problems as an artifact of the aging process or declining health status is inappropriate. The older individual is as worthy of intervention as any other client. Assessments Older clients should be as thoroughly assessed or evaluated as any other particular population. Geriatric assessment is a multidisciplinary evaluation in which the multiple problems of older persons are identified, described, and explained. The resources and strengths of the individual are identified, service needs assessed, and a coordinated care plan developed in order to focus interventions (Butler, et al, 1998). It is important to recognize that the older individual needs a multidisciplinary assessment in which a number of professionals pool their knowledge and expertise to construct as complete profile of the psychiatric, physical, social, financial, and other problems of the older client as is possible. Such assessments fulfill preventive and screening functions as well as diagnostic functions. For therapists working with geriatric patients, assessment and evaluation procedures and tools are important elements in the avoidance of countertransference. A thorough assessment as described above can help a therapist to overcome any preconceptions or stereotypes that he or she may possess regarding the aged. Medical as well as psychiatric assessment and the taking of a complete case history combine to assist the therapist in developing an effective intervention plan.

Interventions Interventions designed to meet the needs of older clients can range from pharmaceutical treatment to psychotherapy and environmental therapy, other somatic therapies, cognitive and behavioral therapies, reality-orientation, remotivation, and rehabilitation programs, to assistance with ADLs. What is essential in designing any intervention for the older client, as was discussed in class, is pinpointing what is threatening the client and what they are reacting to.

The counselor should be careful not to argue with the client or attempt to impose his or her version of what is or is not the truth about the problem as the client sees it. Doing so can increase the fear of the older adult and jeopardize the development of the kind of rapport needed in the therapeutic relationship. The goal of intervention, whatever form it might take, is to contain any paranoid, anxious, or other self-damaging reaction that the older client has to his or her problems. A related goal is addressing the underlying problem and ensuring that interventions designed to ameliorate or eliminate that problem are forthcoming. Process becomes more important than content in this therapist/client relationship. Process may be defined as dealing with or addressing the underlying verbal or nonverbal feelings expressed by the client. Warmth and empathy without condescension are essential aspects of the therapistâ&#x20AC;&#x2DC;s behavior and attitudes. Realistic treatment goals should be set via consultation with the client and other caregivers. Assisting the older person who has lost a loved one, for example, may involve addressing issues of guilt and atonement as well as the clientâ&#x20AC;&#x2DC;s personal fears regarding illness or death. In any event, interventions that are successful with older clients are those that are framed to meet specific needs and result in positive improvements in mood, affect, outlook, and functioning. The field of geriatric counseling is an increasingly important practice focus because of the aging of the American population. It is likely that members of the care giving professions will devote even more time to research on the best practices for treating this population effectively. What emerges from this discussion is the recognition that the older individual is entitled to caring, supportive, and non-prejudicial service from a counselor. Moving from a thorough assessment of the clientâ&#x20AC;&#x2DC;s need to a

multidisciplinary set of interventions offered in an empathetic and caring manner is essential. Avoiding countertransference is necessary and can be helpful to the therapist in confronting his or her own concerns regarding the aging process.

9. Sexuality The topic of Love, Intimacy and Sexuality in the area of healthy aging should be addressed for several reasons. "A happy sex life is part of the enjoyment of good health. Enjoyable sex refreshes both the mind and body" (Gillie & Mercer, 1979, p. 158). The elderly population is increasing annually at the same time that a youth-culture mentality is flourishing. A commonly held societal view is that older people ought not, or do not want to engage in sexual activity. Studies and research data, however, indicate that there is no automatic cut-off age for sexual activity. The loss of desire and need for love and intimacy are not dependent on the calendar. While there are significant changes in the physical and psychological aspects of sex with age, in the absence of illness or psychological factors, such changes do not lessen the capacity to engage in and enjoy sex in older adults. As early as 1979 data indicated that "many old people continue to enjoy sex in their eighties and there is often no reason why sex life should not continue at this age. The exercise is good for the heart and lungs, quite apart from the pleasure which sex itself brings" (Gillie & Mercer, p. 186). More recent data on sex and aging confirms the earlier findings. The Sexual Health InfoCenter (2001) reports that "most older people experience some interest in sexual intimacy. Many people are sexually intimate well into their 80s and beyond. We do not all of a sudden become asexual beings; our capacity for sexual intimacy will be with us our entire lives." In 1998 there was vast media coverage of the results of a survey commissioned by the National Council on Aging; the survey reported "that nearly one-half of Americans 60 and older engaged in sexual activities at least once a month. More than 7 out of 10 sexually active men and women said they were as satisfied, or even more satisfied, with their sex lives as they were in their 40s; 43 percent said that their sex is just as good as or better than in their youth" (Social Gerontology: Sex and the Elderly). A 1999 survey conducted by the American Association of Retired People

(AARP) on sex and aging revealed that despite popular myths to the contrary, "most elderly people are able to lead an active, satisfying sex life" (PR Newswire, 1999). As the studies indicate, older adults can enjoy and participate in intimacy and sexual relations. There are, however, several mitigating factors preventing intimacy and sex. In the case of women especially, the lack of available partners can decrease sexual activity. Demeter (1998) contends that women are more often the victims of ageism than men are in American society. There is a widely held myth that physical attractiveness and sex belong solely to the young, a belief also held by some elderly people. For example, many people believe that when a woman goes through menopause and can no longer bear children, she should accept the fact that her sex life is at an end. While older men are not expected to give up their sex lives so readily, the myth of the "dirty old man" still exists. Deacon, Minichiello, Plimmer, 1995 believe that "cultural attitudes that revere reproductiveness and youthful good looks may contribute to the expectation that older people, are, or ought to be asexual." Another factor for decreased sexual relations is that many older adults are not familiar with the physical changes that are a normal part of aging, and may come to believe that they are sexually inadequate; this, in turn, can lower their self-esteem, raise their anxiety level, and ultimately prevent them from attempting to engage in intimate relationships. This may hold true for couples in a marital relationship as well as for single, divorced or widowed older adults. Demeter (1998), and health educators, hold that "couples need to be open with each other and bring love and acceptance to a sexual problem so as to enhance their relationship." Sex education, which is usually reserved for the very young, would be helpful for older people. Unfortunately, sex is not usually discussed in senior centers or retirement homes. "There is ample evidence to suggest that sex education for older people leads to the development of more positive attitudes....the current cohort of older people continues to have few opportunities than their younger counterparts to access education..." (Deacon, Minichiello, Plummer, 1995). Attitudes toward love, intimacy and sex do not generally alter in old age, but reflect a lifelong pattern of sexual behavior. White (1982) holds that people who are sexually active when they are young "tend to continue this pattern in their later years." On the other hand, negative attitudes toward love, intimacy and sex that were formed in youth continue to hold true in later

years. Older adults could greatly benefit from interventions that would help alter negative attitudes and patterns, and professionals in the field of gerontology, health education and psychology could greatly profit the aging population with interventions that could change lifelong negative patterns and thus lead to more healthy aging. Such educational interventions to change negative attitudes of children and caregivers of the elderly, as well as society as a whole, would also be of great use to help young and old alike realize the positive results on healthy aging that intimate relationships have for older adults. Health educators can make an invaluable contribution to healthy aging by helping to eliminate myths and misconceptions regarding sex and the elderly. As people age, they are usually faced with the elimination of two very satisfying and nurturing parts of life; these are careers and co-workers, and in many cases grown children who are on their own and do not live nearby. In addition, as people age, many relatives, partners, mates and close friends have passed on. The loss of these intimate relationships and work can leave a vacuum in the day to day lives of many older people. For healthy aging to occur, new personal relationships must be formed. The need for intimacy does not diminish with age. In fact, as the Sexual Health InfoCenter points out, personal relationships become even more important. Although many older people may still have spouses or life partners, the loss of children and career intensifies the need for love, intimacy and sex "as a way of solidifying our relationship with our partner and taking refuge from the sometimes harsh reality of the world. Sex is a way to affirm the love of life....It expresses the closeness of our deepest relationships and is an important measure of the quality of life." Healthy aging is, of course, inevitably tied to the quality of life. The quality of life can be maintained in old age if one is lucky enough to be relatively healthy, to have a network of friends, to have hobbies or some kind of work in which creativity can be expressed -- whether it is volunteering at a free health clinic, or a local school, gardening, painting, sports or any other activity that fills time in a meaningful way. In addition, the role of love, intimacy and sex in healthy aging cannot be underestimated.

10. The Aging American Workforce The baby boomers are perhaps the most studied generation in the history of the United States. This first post-World War II generation, larger than any generation before it, has shaped America's attitudes toward clothing, war, race relations, music and family with greater influence than any other group. Some of its members fought the Viet Nam War at the same time that others protested the same war. This is the generation that gave rise to the terms "hippie," "yuppie," and "dink." This generation has also benefited from a panoply of programs, government-sponsored and private, including Head Start for its children, Medicare for its parents, and 401(k) funds offered through employers. It is a generation generally considered better off than its parents, and as it has moved through life's stages, it has changed the nation at each. Today, the baby boomers are approaching retirement age, and there are significant ramifications for the economy as a whole, individual companies, and for the baby boomers themselves. This research considers the aging American workforce and its consequences for society as well as its consequences for African-Americans. Although older individuals are sometimes thought of as frail and feeble, unable to focus on tasks for long periods of time, there are examples of older workers who have been successful through the centuries. Michelangelo was appointed chief architect of St. Peter's when he was 71. Adolph Zukor ran Paramount Studios until he was 91. Grandma Moses began her painting career when she was well advanced in years, and there are other numerous achievements by older individuals that are often cited as proof that older workers can be contributing members of society (Caudron, 1997, p. 42). The baby boomers are sometimes referred to as the "pig in the python," meaning that the largest generation in American history is slowly making its way toward advanced age. Through each of its life stages, the baby boom generation has influenced American society, including popularizing rock and roll music and making casual dress in the office a commonplace event. It should therefore not be surprising that the baby boomers are now about to remake the face of the workforce as they continue to age and continue both to work longer, and retire earlier, than previous generations (Caudron, 1997, p. 43). As the baby boomers age, they continue to make up the largest single age group of the workforce. While there is some reluctance to hire older workers, particularly among companies with young managers who may fear that older workers are either seeking their own jobs or will require excessive

training to get the job done, some companies have recognized that there can be significant benefits to hiring older workers (Albrecht, 2001, p. 57). According to one recent study, employees under 35 years of age rank perquisites and salary as the top two job requirements sought from employers. Older employees (those aged 55 and older) seek a positive work environment and useful information, meaning that they are likely to remain more loyal to an organization rather than change jobs merely for more money (Albrecht, 2001, p. 57). Older workers are ideal, for example, at working in situations that require an on-call mode rather than a day-to-day job. In a tight job market, one firm in Oregon processes mail by hand for top clients. By hiring older workers specifically to address this need, the company found that it could have a steady pool of on-call employees who were available over long periods of time because the job fit their lifestyle as well as their economic needs (Albrecht, 2001, p. 58). At the same time that the baby boomers are getting older and leaving the workforce, there are fewer younger workers available to replace them. Thus, the baby boomers are both the single largest pool of workers available, and the group that is aging and retiring in today's market. The number of employees aged 50 and older increased 21 percent from 1990 to 1997; this was at a time when the overall number of employees in the workforce increased by only nine percent (Mazurkiewicz, 1998, p. 10). As employers face the challenge of finding qualified workers, they may find that the same workers who are leaving the workforceâ&#x20AC;&#x201D;the baby boomersâ&#x20AC;&#x201D; are also looking for different employment, either part-time work, or work in a different field than they have spent the rest of their careers. In addition, since many of today's older workers are healthier than workers of the same age in the past, many employers are recognizing the advantage of keeping experienced older workers on the job in order to provide companies with the experience and personal contacts that can be invaluable. This is particularly true among those workers termed "optimal agers," which are workers aged 55 to 72 who score as well or better than workers in the 40s on cognitive ability tests (Mazurkiewicz, 1998, p. 10). In a survey conducted by the University of Michigan in the late 1990s, threequarters of those workers in their 50s indicated that they would like to continue to work on a reduced basis. Early retirement continues to offer strong allure, however, since the number of those over age 55 who have retired has increased in recent years. In 1970, 83 percent of those between the ages of 55 and 64 worked full-time. By 2000, this figure was expected to drop to only 68 percent. In this way, employers must find ways to attract

and retain older workers if they are to continue to fill their vacancies and maintain their competitive position (Mazurkiewicz, 1998, p. 10). Because older workers may already have pension or retirement programs from other employers, they may be interested in part-time or seasonal employment rather than full-time work. This can be of particular benefit to companies in the retail and service industries that often have high turnover rates in these positions. In addition, older workers are often willing to participate in job sharing programs where younger workers might be reluctant to do so due to an expectation that such programs do not lead to promotions. In addition, older workers are ideally suited to project-oriented environments and independent contract situations where benefits are not as critical as they might be to younger workers with young children (Mazurkiewicz, 1998, p. 10). Tenure increases as the average age of the workforce increases; older workers remain at their jobs longer than younger workers. In a study conducted during 1995 through 1997 by Watson Wyatt Worldwide, the average job tenure increased to 13.4 years from 12.6 years earlier in the 1990s. The number of employees remaining with an organization for at least a decade increased from 54.5 percent to 58.6 percent, and the number of employees remaining with the same employer for 20 years or more increased to 26.2 percent, up from 25.6 percent earlier in the 1990s (Szalai, 1998, p. 2). There are benefits to having this employee loyalty within an organization. Older workers can train new employees not only in the job functions, but in the culture of the organization, as well. Formal and informal communication channels are communicated from older workers to younger workers, and the organization's memory is perpetuated through older workers. While problems can arise with disgruntled older workers, employers generally acknowledge that older workers can serve as mentors to younger employees and maintain continuity from generation of workers to the next. American companies are not the only ones facing the challenge of an older workforce. Today's global economy means that the aging workforce is a worldwide phenomenon, and one that is affecting European and Japanese companies at the same time as American companies. Where the global workforce might once have been considered a solution to the problem since workers from one country could migrate to other countries where there are jobs, the shrinking pool of younger talent means that employers around the world are taking steps to retain their workers. This changes the benefit and compensation programs for older workers around the world, as well, since

there is now increased information available about different benefits in different countries and companies (Maitland, 2001, p. 15). European governments and companies have long engaged in practices that encourage early retirement, but the result is a drain on the nation's labor pool at a time when jobs are left unfilled due to a lack of qualified candidates. As a result, trade unions in Europe are working with companies to pay older workers to stop working shifts in order to avoid job burnout. By contributing to a savings account for shift workers over the course of their careers, companies are making it possible for older workers to change to day shifts without losing the pay differential that makes shift work attractive. As a result, there is less strain on older workers who work shifts since they are able to transition to day jobs that are less stressful (Maitland, 2001, p. 15). Such a plan does have financial costs to the organizations, and may not be practicable in all corporate environments, but it does offer an alternative to the drain of older workers. Challenges for Employers One of the most obvious challenges to employers is balancing the experience and knowledge that older workers bring to the job with the cost associated with having older workers on the payroll. Older workers often command higher salaries and wages than their younger counterparts, particularly when they have been with the same organization for an extended period of time. At the same time, older workers use more health care benefits than younger workers, contribute more money to 401(k) and other retirement plans that might be subject to employer matches, and are able to contribute moreâ&#x20AC;&#x201D;and withdraw moreâ&#x20AC;&#x201D;from pension plans (Szalai, 1998, p. 2). Employers must therefore find ways to balance the benefits of older workers, including a strong work ethic, with the cost of having an older workforce. As today's workforce ages, employers must confront the challenge of having large numbers of experienced employees retiring at the same time. For example, it is estimated that approximately 20 percent, or 281,000 federal employees, will retire between 2001 and 2005 (Tobias, 2001, p. 27). Any organization which loses not only 20 percent of its workforce, but the most experienced 20 percent of its workers, over a five-year period is in danger of losing its competitive edge and its ability to perform effectively. In order to meet this challenge successfully, Tobias recommends that organizations put a workforce plan into place. Such a plan is important for all organizations at any time, but becomes especially important when there are critical factors at work affecting the employment pool. A workforce plan identifies the jobs that will need to be filled over a given period of time, the

skills needed for those jobs, and whether those skills are available from within the organization or whether they will have to be brought in from the outside (Tobias, 2001, p. 27). With the workforce plan providing guidance, companies can then make decisions about recruiting new employees and transferring knowledge from employees who will be leaving the workforce to the newer employees so that organizational memory is maintained. But there are other challenges facing companies as the workforce ages. Older workers, defined as those aged 55 and older, are likely to have higher workers' compensation claims than younger workers when individual claims are considered. However, older workers have a lower frequency of claim than younger workers, so the lower overall number offsets the higher cost (Hays, 2001, p. 16). While the cost of workers' compensation claims may average over the longrun between older workers and younger workers, there are risks associated with older workers that simply do not exist, or are less profound, with younger workers. When an older work is injured, regardless of whether the injury occurs on the job or not, the recovery time is generally greater than with younger workers. Employers are thus advised to maintain safe work areas in order not only to prevent workers' compensation claims, but also to ensure that older workers do not miss time from work due to injury (Hays, 2001, p. 16). In addition, older workers have "diminished vision, hearing and bladder capacity" that employers should take into account. This may mean that safety labels are produced with large print and that telephones are equipped with volume controls. The work structure itself may have to change in order to accommodate more breaks, and some employers may want to build more washrooms to accommodate older workers (Hays, 2001, p. 16). Health care costs increase for older workers, as well. As employees continue to work past the ages at which their parents retired, and as detection methods improve, there will be increased detection of cancer in workers. This, in turn, will require treatment, but as cancer treatment methods improve, it is more likely that these workers will be able to return to their jobs after some time, or that they will be able to continue working while going to treatment. Changes in the workplace structure to accommodate these employees may also be necessary. It is also likely that as employees remain in the workplace longer, there will be a greater incidence of illness resulting from exposure to hazardous

materials in the workplace. Asbestos exposure is already a well-known risk, but there are likely to be illnesses resulting from exposure to other materials that are only now being identified (Hays, 2001, p. 17). These factors will change the insurance benefits offered by companies as employers seek to control costs and still offer insurance benefits to their employees, and the ramifications will affect all workers, not just older employees, since benefits are offered to employees as a whole. In this way, the aging workforce will be changing the benefits that all employees receive through the workplace. As employers seek to attract the best workers and become employers of choice, they seek to put together benefit packages which are both attractive to job seekers and cost-effective to the organization. For many years, vision care insurance plans were either not available to employees, or they were available through employee-only contributionsâ&#x20AC;&#x201D;meaning that although companies made such plans available to employees, they did not fund the plans at all. As the workforce aged, however, the number of workers requiring prescription eyewear also increased with the result that employees are increasingly attracted to those companies that offer vision plans as part of their benefits package (Woodward, 2000, p. 119). Discrimination Against Older Workers Despite the benefits of hiring and retaining older workersâ&#x20AC;&#x201D;experience in the field, strong work ethic, and loyalty to employersâ&#x20AC;&#x201D;age discrimination is a problem for many individuals over 40 who are seeking employment. Age discrimination cases declined during the 1990s, according to the Equal Opportunity Employment commission, but began increasing again in 2000. More than 16,000 reports of age discrimination were filed with the commission in 2000; this is a substantial increase from the 14,000 reports filed in 1999. According to the American Association of Retired Persons (AARP), more than 17 million workers in the employment market in 2000 were over the age of 55, and as that number increases, some expect the amount of age discrimination cases to increase, as well (Ormsbee, 2001, p. 40). Discrimination based on age was made illegal by the Age Discrimination in Employment Act (ADEA) of 1967 and the Older Workers Benefit Protection Act (OWBA) of 1990. Specifically, decisions regarding hiring, firing, promotion, layoffs, compensation, job assignments and training cannot be made based on age according to ADEA. Job notices and announcements cannot be based on age, either, although an exception is made for companies

that can demonstrate a legitimate reason for specifying a particular age for a particular job. At the same time, the EEOC also monitors company requests for ages prior to employment in order to ensure that the information is not used to discriminate against job candidates. In addition, most states have specific laws forbidding discrimination based on age. However, proving that age discrimination is the reason that a prospective employee is not hired, or not promoted, or not interviewed, can be difficult, and evidence is largely anecdotal (Ormsbee, 2001, p. 41). Even when individuals are convinced that they have been subject to age discrimination, there is a general reluctance to bring the matter to the attention of the EEOC or other authorities. In the case of discrimination that occurs at a current job, employees may fear recrimination, and may not have the financial resources for a protracted legal conflict. When the age discrimination occurs at potential employers, it can be more difficult to demonstrate that the essential factor was age discrimination and not some other factor. Statements such as "we cannot afford you" and "you are overqualified" may be other ways of indicating age discrimination, however (Ormsbee, 2001, p. 42). The African-American Older Worker African-American workers face the same problems as other employees as they age. However, the issue of discrimination in the workplace can be more problematic for these workers since it can be difficult to distinguish when age discrimination occurs when race discrimination is also a possibility. In a pending case, two employees of Reynolds and Reynolds Company, which supplies information management services to automobile dealers, filed racial discrimination suits against the company. The older of the two, who is 46, also alleges age discrimination. At issue are management positions that the men allege they were promised before they were hired, but that never materialized. Reynolds and Reynolds have put a formal diversity program into place, and have even appointed a vicepresident in charge of diversity, but the suits were filed after this announcement (Sawyers, 2001, p. 6). Other cases of age discrimination that have garnered national attention have been difficult to prove. In 1997, for example, the Michigan Court of Appeals upheld a lower court's decision to dismiss a lawsuit against General Motors. That suit, brought by William S. Johnson (an African-American), alleged that GM engaged in racial harassment, race discrimination, age

discrimination and retaliation. In this case, the various courts involved did not directly address the issue of age discrimination, but instead focused on the racial overtones of the case. This is often the situation when allegations charge more than one type of discrimination since age discrimination can be difficult to document (Freedman, 1997, p. 24). Beyond discrimination, there are other issues confronting AfricanAmericans that separate them from other older American workers. As the American population ages, there is a growing tendency to move away from traditional migration patterns of African-Americans to the central cities and so-called "white flight" to the suburbs, a demographic shift that characterized the period following World War II. Instead, traditional notions of city-suburb, black-white profiles do not recognize the role of immigration, and of migration patterns within the United States itself (Frey, 2000, p. 20). The immigrant minorities are generally recognized as having different migration patterns than baby boomers, regardless of whether the baby boomers are white or African-American. It is expected by some that suburbs of major metropolitan areas and regions of the country that do not have a large influx of immigrants will be the geographic locations where baby boomers will retire. Within metropolitan areas, older populations who are less well off than their peers will settle closer to the center of the region while those older persons who have more financial resources will be located on the periphery of these areas (Frey, 2000, p. 24). Los Angeles County offers an example of this type of migration pattern. Years of outmigration by white residents have been coupled with years of in-migration by new ethnic populations. The elderly population of the county is still predominately white, but the working age population is only approximately one-third white. The population of children is predominantly Hispanic with a multitude of other racial and ethnic groups represented. The younger population with school-aged children will be concerned with a county that provides good schools and affordable housing, while older white residents of the county are likely to be interested in health and social services appropriate to the needs of those their age (Frey, 2000, p. 25). Directions for Future Research Although the literature offers a significant amount of information about the benefit of hiring and retaining older workers, and also details the costs associated with older workers, there is considerable lack of information

regarding the specific issues that confront African-American older workers. Additional research should be conducted to determine the effect of the geographic placement of older African-Americans on their ability to find and keep jobs as well as on discrimination issues that might be unique to African-Americans. At the same time, additional research should be conducted to determine whether there is disparity in the incomes of older African-American workers, and whether there are differences between the living situations of African-American older workers and other older Americans (for instance, whether one group is more likely than another to live with family members, on their own, or in a group environment). The baby boom generation is getting older, and it is changing the way that American companies view their workforce. There is a potential employee drain that companies must face as baby boomers begin retiring in record numbers, and some employers are recognizing that older workers can be brought back as part-time or contract workers who have a strong work ethic and high sense of loyalty. There can be significant costs associated with older workers, including accommodations for physical limitations and higher insurance premiums. It is also unclear whether African-Americans face different challenges than other older American workers since age discrimination is often coupled with racial discrimination. Additional research needs to be conducted to address the issues that are unique to African-American older workers.

11. Nursing Homes The number of elderly who are living longer is on the rise because of new methods of treatments, new medications and use of medical technology to improve their life span. On any given day, nursing homes, or as many are now called, â&#x20AC;&#x2022;long-term care facilitiesâ&#x20AC;&#x2013;, are caring for about one in twenty Americans over the age of 65. Almost half of all Americans turning 65 this year will be admitted into a nursing home at least once. It is projected that in 2020, 40 percent of Americans will die in nursing homes. As the numbers increase in utilization of nursing homes, there is increasing concern about cost, quality and access- concerns that need to get attention. The purpose of this research paper is to discuss what has been done in recent years and what can be done in the future to make long term care better for the elderly who are no longer able to care for themselves. We will also look at the impact of cost, quality and access of Medicare, Medicaid and new technology in nursing homes. We need to establish what nursing homes are, and how they

operate. Nursing homes can vary by type of ownership, type of certification, the number of beds, and the region of the country. When and if a decision must be made about placing an elderly person in a nursing home, no matter what its title, care must be taken that it is a ―skilled nursing facility- a government category for a Medicare-certified, state-licensed organization that must provide room and board as well as all the care that is needed by the resident. (Acute hospitals and specialized medical care are excepted)‖ (Davis 10). Expense Long term-care is very expensive and it often becomes a financial catastrophe for the elderly person and their family. The average cost of staying in nursing homes, depending on the level of care received, can run anywhere from $350 to $2000 a month. A study indicates that 46% of 75-year-olds are bankrupt after 13 weeks of nursing home care‖(Forrest 209). But, while costs vary even within a community- ―Rates around the country vary from under $100 to over $200 a day…And you should realize that higher prices may not always mean better service (Davis 43). Why do costs vary so much? As Davis (43) points out: One reason is location, even the age and condition of the building, staffing, actual day-today costs, and whether the facility is supported by an organization such as a Church, foundation, or government sponsorship. The future does not hold much financial relief. It is quite possible within a few years, as the baby boomers become senior citizens, the demand and the cost for nursing homes will climb even higher Private insurance is unlikely to cover the full cost of long-term care. So that brings us to two programs that are funded by the federal and state government that help to cover part of the cost for nursing homes, Medicare and Medicaid. Most of the elderly become eligible for Medicaid, which has become the main funding source for nursing homes. ―More then 50 percent of nursing homes revenue comes from Medicaid‖ (Pieper 86). (In California, there is also a supplementary program called MediCal.) In order for elderly persons to qualify for nursing home care under Medicaid, The potential recipient must be able to demonstrate that he/she has income below the minimum set by the state and that the kind of care he/she needs

can best be provided in either a skilled or an intermediate care nursing home (Pieper pg. 88). (See table below) Medicare is a federal health care program that has been the center of attention. Medicare has two parts: Part A and Part B. Part A of Medicare is covered by the taxes that are collected from employees and employers. It covers hospital insurance, home health care, and nursing home care. ―Medicare does not cover nursing home stays beyond 100 days annually and requires $95 per day co-payment after 21 days‖ (Kovner, pg.230) (see the table below). According to the‖ Medicare and You 2001‖ booklet, the copayment after 21 days has been changed to $99, which shows that as demand for health care rises, so has the cost. One of the problems with federal and state programs, such as Medicare and Medicaid, is the fact that the cost of the services provided has a way of increasing at a much greater pace than the government‘s ability to do anything about it. In order to cover some of the extra costs of nursing homes some people purchase supplementary insurance, like Medigap or other kinds of insurance, which will protect their assets from any kind of risk. To sum up- long term facility costs are high and bound to go higher, as government funding cannot keep pace with rising rates, and many seniors and their families are unable to pay for Medigap and other private insurance to bridge the gap. Quality The health care system in this country has been under scrutiny for many years. More recently, managed health care programs and nursing homes have been highly criticized for their lack of quality services. Nursing homes present an even more complex problem because it is the vulnerable elderly who cannot speak, walk or talk that most often need professional care and help. Where quality care is vital for the patients is in helping solve the fear that the very term ―nursing home‖ brings to many elderly. They tend to see it as a last stop before the mortuary, and their attitude and stress levels are high. So, at least at the outset, those fears and stress need to be calmed and alleviated. No part-time low-wage workers can do that. It requires specialists in gerontological care. And those nurses and assistants do not come cheap! The best way to describe quality is when ―right care is provided at the right time, care is provided in the right manner, and care can be obtained when is needed‖ (Kovner, 1999, pg.374). Some of the problems with nursing homes are lack of technology and lack of training that affects the quality. All these problems can affect the elderly physically and emotionally.

There have been many rules and regulations that have been passed to provide high quality nursing homes. Some of the regulations that have been designed by the government to ensure the quality at the long-term care facility are by state licensure regulations, federal regulations and Joint Commission on Accreditation of Health Care Organizations (JCAHO). State licensure is mandatory, Federal regulation is only necessary if the facility participates with Medicare and Medicaid, and JCAHO standards are voluntary. Still, with so many regulations and laws, two main aspects that makes a nursing home a home-like atmosphere has not been given enough attention. These aspects are lack of trained staff, and the lack of technology at the facilities. Because of wage scales and the hours of shifts, and the st6ress on employees, there is usually a very high turnover rate. This means hiring new people, training them, getting them to work as a team,. And getting them familiarized with the patients. The patients themselves often have come to depend on a special nurse or orderly, and when they leave and someone else comes in fresh, the rapport must be reestablished. Sometimes this causes a setback for some of the most fragile parents. However, if the facility is determined to keep good, productive employees, it means raising their pay, which then has to be reflected in increased rates for patients and their families. The most important aspect of trained employees who stay at the facility is that patients have little contact except with one another and the staff. While patients love to share memories and experiences with others in the facility, they depend on the staff to take care of them and give them a sense of hope. As vital as avoiding huge turnover is the training given to the facilities‘ staff. There have been many reports in the news about people being abandoned in their rooms, leaving them sometimes for a day or more lying in their own feces or urine. There have been reports of over- or under-medication, accidents, and even physical abuse. By the time a facility‘s administration becomes aware of such problems, it may already be too late for some residents. Accidents can be minor or can be severe, they can be anything from a fractured hip caused by under-trained staff ―trying to transfer a very heavy male resident from bed in to a wheelchair, but they forgot to lock the wheels of the chair‖(Ridge, Pg. 77). At times it is difficult to work with an elderly person and a lot of patience is needed. At times many of the staff are tired. Some have worked long hours on many different clients because of the absence of other staff during that day. The nurses and staff may be over-

worked and tired so that result in to anger and abuse of the elderly who lack the will to cooperate with treatments. So the result is inadequate treatment and low quality of care. In the Sacramento Business Journal, Kathy Robertson points out, We deliver care like we did in the 1960s and its time we move in to the next millennium. It‘s a crime. We invent all these wonderful medical technologies and when it comes to implementing them, they are so cost-prohibitive that there‘s limited use (Robertson, 1999). Many years ago patients with infectious problems were taken cared of by traditional kinds of treatments that used Band-Aids and Maalox. Today there are many different technologies that can cure a wound better in less time. The problem of having this kind of technology, which helps the quality of life, is the cost. Medicare and Medicaid don‘t cover many of these technologies, because they cost a lot. For example a VAC ―promotes wound closure by applying localized negative pressure to draw the edges of the wound to the center. A sponge-like device is placed in the wound cavity or over flap or graft. The machine then sucks out bacteria and excess fluid‖(business and company Journal). It can run anywhere between $117 and $130 a day to operate, in addition to the cost of the nurse that have to change the dressing more then 3 times a day. The cost is putting a damper over the use of technology at the nursing homes. Access The major question about access is Do we have enough long term, skilled care facilities to meet the demand. The answer is undoubtedly NO. And, as was mentioned earlier, the fact that the Baby Boomer generation is aging and will increase the demand for space in long-term care facilities makes it vital that new facilities be built that will include the latest technological and medical advances. While it is true that people now live longer, it is also a fact that a longer life will incur more and different ailments and medical conditions that home care may not be able to solve. Most families care for their relatives as long as possible, until the physical, emotional or social demands become too great for the family to continue without assistance (Richards 11).

This situation will only worsen in the next decade, and there are no available statistics about plans for constructing new, modern long-term care facilities. There are a number of public corporations, such as Columbia/HCA that operate more than 200 for=-profit health care facilities coast to coast. But these are mainly hospitals and not nursing homes. And, besides, Columbia is now under investigation by the federal government for Medicare and Medicaid fraud- over-billing in many cases, listing more complicated procedures when actually, simple ones were performed. The key to proper access, as rooms become less available, is to have a family member or members do a very careful search and examination of available facilities- checking everything from climate control to diet, medical facilities as well as social opportunities, and preferably a location close to home which would allow for more frequent visits. As the future will bring us more and more elderly who may need long term care, the obligation of the medical and care industries are to find the fundseither through public offerings of stock or affiliation with a foundation or church, to build as soon as possible in order to be ready for the flood-tide of new arrivals. One can easily ascribe the present need for more long-term care facilities to the Titanic. At its construction, it seemed impregnable. The same thing is true with the long-term care facility industry. At one time, it was able to solve the needs for elderly patients whose families could no longer maintain them. But now, the ice-berg, in the form of the Baby Boomer generation is upon the industry. Access delayed is access denied. Someone in the federal government needs to step forward and make it not only possible, but financially meaningful for new facilities to be built nownot years from now. Alternative choice The question whether there is an alternative to long-term care in a facility cannot be totally answered, because some elderly and others who need longterm care have conditions that could be handled at home, while others require round-the-clock care with medication and technology not available to be placed in the home. But there are some alternatives to nursing home care, For example, there is home health care. Home health care is a better alternative in some cases

because it helps the elderly who are afraid of nursing home to stay with in their home. According to Growing Old in America (1996), "Home health care is one of the fastest growing segments of the health care industry" (p 114). Alternatives for home care can often meet both the medical and nonmedical needs of a patient. These services are provided to patients and their families in their home or place of residence. Home care is a method of delivering nursing care and other therapies as required by the patient's needs for example new technology. Numerous alternatives are available for persons seeking health care at home. With transportable technologies such as durable medical equipment, oxygen supply and intravenous fluids there are countless possibilities for treatment within the home setting. It is the home setting and the surroundings that the patient is used to that help his emotional well-being and relieve stress and anxiety of being in a strange place, where all the others are either the same age, and mostly infirm. One needs to satisfy the difference between what it would cost for home care, compared with stay in a long-term facility. Chances are, if round-the-clock professional help is needed (assuming family members are not trained enough) the expenses may be more than it would cost per day in a facility. There is also a question of how much Medicare or Medicaid or Medigap insurance would cover. The decision for a facility or home care is often a difficult one for family members, because it is not merely a medical and financial burden, but an emotional situation as well. A nursing home is a place to live if a person must have human help in several of these activities: Getting food to the mouth (or otherwise into the body), moving the body from place to place, breathing, knowing where the patient is, being continent of bladder and bowels, or coping with incontinence, being in need of special nursing treatments for rehabilitation (Davis 10). For most patients, especially the elderly, nursing homes may well be the best solution. But, not the only solution. Nevertheless, as more and more people age, grow ill or feeble, and require moirĂŠ than home care can provide, a long term facility may well be the only answer. Cost, quality, and access are the major areas in which to confront that choice. While costs may be within a familyâ&#x20AC;&#x2DC;s budget, and quality may be the answer to careful selection, it is still access that presents the major problem. Until there are enough facilities, modern, clean, up-to-date medical and social facilities, at reasonable cost and with caring professionals in charge, there is still a cloud that hangs over the future of an entire generation.

12. Coping with Aging Throughout history, humans have been dealing with the aging process. Aging has been viewed differently historically by different societies. In Asia and South America, family members of advanced age are respected for their vast experience and included into the immediate family group. In the United States, which emphasizes youth and energy over age and wisdom, family members of advancing years are placed in nursing homes where they can live comfortably out of sight. However, as the baby-boomer generation rapidly advances in age, Americans will have to rethink their attitudes towards aging. In a rapidly aging society, the bias towards youth will have to be replaced by an added level of respect for the elderly and the values that are important to the aging demographic. Growing older is an experience we all share and many of us worry about. As we age, we face many changes and many sources of stress -we are not as strong as we used to be, illness is more of a problem, children move away from home, people we love die, we may become lonely, and eventually we must give up our jobs and retire. Coping with all these changes is difficult, but it can be done. The keys to coping include your long-term lifestyle, your ability to expect and plan for change, the strength of your relationships with surviving family and friends, and your willingness to stay interested in and involved with life. It is, therefore, very important to think carefully about what will happen to you as you age and how you are going to deal with the changes that will happen. Dealing with physical changes As you grow older, your body will naturally change. You may tire more easily than you used to. You may become ill more often. You may not see or hear as well as you did when you were younger. Here are some things you can do to cope with these physical changes:

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Accept reality. Denying these changes will only make life less enjoyable for you and the people around you. Get the things that will help you - eyeglasses or hearing aids for example. Keep a positive attitude. Remember that slowing down does not mean you have to come to a complete stop. Chances are you will still be able to do almost all the things you used to; you may just need to take a little more time and learn to pace yourself. See your family doctor regularly. He/she can, then, deal with any changes or symptoms that require medical attention. Be careful about your medications. As you get older, they may begin to interact differently with other drugs and to affect you differently than before. Make sure your doctor knows about all your medications, even those prescribed by another doctor. Take responsibility for your own health. Do not hesitate to ask your doctor questions; some do not offer explanations unless asked. Change your eating habits. Adopt a balanced diet with fewer fatty foods, and try not to over-eat. Drink less alcohol. Your body will have more difficulty coping with it as you grow older.

Dealing with bereavement As you get older, you will likely experience the loss of loved ones more often. It is important to remember the following ways of coping with your grief: 

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Do not deny your feelings. Losing someone to death is like being wounded, and you need to heal. If you do not allow yourself to go through the grieving process, you are only storing up problems for a delayed reaction later on. Accept the range of emotions you will feel. Tears, anger and guilt are all normal reactions. Remember and talk about the deceased person. He/she was an important part of your life. Although your grief will pass, your memories will always stay with you. Look to your family and friends for support. They can help you through the grieving period and help you establish a new life afterwards.

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Be supportive of those you know who have suffered a loss. They need the warmth and caring that friendship can bring, just as you will when it happens to you.

Dealing with loneliness Everyone needs some time alone, but being alone against your will is very painful. You risk losing your sense of purpose and self-worth, and becoming depressed. As family members and friends die and children become more involved in their own lives, it is important for you to find ways to cope with loneliness. You may want to consider some of the following suggestions: 



Stay active, and look for new social contacts. Most communities have a number of programs which can help replace the support that used to be provided by family and life-long friends. These programs provide older people with the chance to try new activities and make new friends. Very young children can brighten up your life. Try to make friends with people of different ages. You may be pleasantly surprised to find how much you have in common with someone 15 or 20 years younger than you. Spend time with grandchildren and great-nieces and nephews. Volunteer to help part-time in a local school or day-care centre. Very young children can brighten up your life with their enthusiasm and energy. Learn to recognize and deal with the signs of depression. Loss of appetite and weight, inability to sleep, loss of energy and motivation, and thoughts of suicide are all signs of depression. Your family doctor can refer you to a mental health professional for treatment.

Dealing with retirement Your retirement can be a major source of stress because your job is usually a very important part of your life. This stress may be even greater if you have been forced to retire because of your employer's retirement policies. You may lose your sense of identity and feel less worthwhile. You will probably miss the daily contact with friends from work. However, retirement can be one of the best times of your life, and there are things you can do to meet the challenges facing you, such as:

52 



 

Make a list of your abilities and skills. The skills and experience you have gamed from a lifetime of work may help you succeed in a small business or do valuable volunteer work for a favorite charity. Enrich your life by renewing contacts with neglected family members and old friends. All too often, our work gets in the way of our relationships and those we care about. Renew your interest in the hobbies and activities you enjoy. You now have time to play - enjoy! If you can afford it, travel. There are probably places you have wanted to see all your life. The early years of your retirement can be the ideal time to become a nomad for a while.

Do you need more information? If you or someone you know is concerned about growing older, check your local library or bookstores for some helpful books that can give you more information. There are also professional counselors who specialize in the problems of aging. If you need more information about resources in your area, contact a community organization, such as the Canadian Mental Health Association, which can help you find additional support. The majority of older Americans successfully cope with the physical and cognitive changes associated with aging as well as various losses, such as the loss of family and friends that frequently are associated with late life. However, a substantial proportion of the population aged 55 years and older—almost 20 percent of this age group—experience specific mental disorders that are not part of ―normal‖ aging including depression, anxiety disorders, and dementia including Alzheimer‘s disease which can be debilitating and severely affect an older adult‘s quality of life.6 Depression – between 8 to 20 percent of older adults in the community and up to 37 percent in primary care settings suffer from depressive symptoms.1 These symptoms can range from depressive illness (major depressive disorder, dysthymic disorder, or bipolar disorder) to depressive symptoms that fall short of meeting full diagnostic criteria for a disorder and is associated with an increased risk of developing major depression (subsyndromal depression).7-8 In any of these forms, however, depressive symptoms are not a normal part of aging. In contrast to the normal emotional experiences of sadness, grief, loss, or passing mood states, they tend to be persistent and to interfere significantly with an individual's ability to

function. Depression often co-occurs with other serious illnesses such as heart disease, diabetes, or cancer.9 Because of these co-occurring conditions health care professionals may mistakenly conclude that depression is a normal consequence of these problems—an attitude often shared by patients themselves.10 These factors together contribute to the underdiagnosis and undertreatment of depressive disorders in older people. Depression can and should be treated when it occurs and many effective therapies are available. If left untreated, depression impairs one‘s enjoyment of life and may increase disability. It can also delay recovery from or worsen the outcome of other co-occurring chronic illnesses. Cognitive health – or brain health, is an important part of healthy aging. Cognitive health refers to maintaining and improving mental skills such as learning, memory, decision-making, and planning. Many older adults mistakenly believe becoming ―senile‖ or forgetting is a normal part of aging. Although one in four older adults experiences these events (known collectively as cognitive decline), they are not a normal part of healthy aging.11 There are certain changes in cognitive health that occur as you age. Normal changes usually mean a slower pace of learning and the need for new information to be repeated. While the majority of older adults will experience these normal changes in cognition, some older adults will experience cognitive decline. Older adults with cognitive decline have a higher risk of developing dementia later in life. Among Americans 65 years and older, approximately 6–10% have dementia, and two-thirds of people with dementia have Alzheimer‘s disease.12 Although research has not found a way to prevent dementia or Alzheimer‘s disease, cognitive decline may be preventable. Recent research suggests that being physically active, controlling your hypertension, and engaging in social activities may help you maintain and improve your cognitive health. Source: CDC Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System.

13. Older Adults, Substance Abuse, and Mental Health Substance Abuse Among Older Adults: Treatment Improvement Protocol (TIP) Treatment Improvement Protocols (TIPs) are best practice guidelines for the treatment of substance abuse, provided as a service of the Substance Abuse

and Mental Health Service Administration's Center for Substance Abuse Treatment (CSAT). This TIP brings together the literature on substance abuse and gerontology to recommend best practices for identifying, screening, assessing, and treating alcohol and prescription drug abuse among people age 60 and older. Alcohol Abuse Physiological changes, as well as changes in the kinds of responsibilities and activities pursued by older adults, make established criteria for classifying alcohol problems often inadequate for this population. Abuse of Prescription Drugs People 65 and older consume more prescribed and over-the-counter medications than any other age group in the United States. Prescription drug misuse and abuse is prevalent among older adults not only because more drugs are prescribed to them but also because, as with alcohol, aging makes the body more vulnerable to drugs' effects. Figure 3-6: Drug-Alcohol Interactions and Adverse Effects

Figure 3-6 Drug-Alcohol Interactions and Adverse Effects Drug

Acetaminophen

Anticoagulants, oral

Antidepressants, tricyclic

Adverse Effect With Alcohol Severe hepatoxicity with therapeutic doses of acetaminophen in chronic alcoholics Decreased anticoagulant effect with chronic alcohol abuse Combined central nervous system depression decreases psychomotor performance, especially in the first week of treatment

Figure 3-6 Drug-Alcohol Interactions and Adverse Effects Aspirin and other nonsteroidal antiinflammatory drugs

Barbiturates

Benzodiazepines

Beta-adrenergic blockers

Bromocriptine

Increased the possibility of gastritis and gastrointestinal hemorrhage

Increased central nervous system depression (additive effects) Increased central nervous system depression (additive effects)

Masked signs of delirium tremens

Combined use increases gastrointestinal side effects

Caffeine

Possible further decreased reaction time

Cephalosporins and

Disulfiram-like reaction with some

Chloramphenicol

cephalosporins and chloramphenicol

Chloral hydrate

Cimetidine

Cycloserine

Prolonged hypnotic effect and adverse cardiovascular effects Increased central nervous system depressant effect of alcohol Increased alcohol effect or convulsions

Figure 3-6 Drug-Alcohol Interactions and Adverse Effects Digoxin

Decreased digitalis effect Abdominal cramps, flushing, vomiting,

Disulfiram

hypotension, confusion, blurred vision, and psychosis

Guanadrel

Glutethimide

Heparin

Increased sedative effect and orthostatic hypotension Additive central nervous system depressant effect Increased bleeding Acutely ingested, alcohol canincrease the

Hypoglycemics,

hypoglycemic effect of sulfonylurea drugs;

sulfonylurea

chronically ingested, it candecrease hypoglycemic effect of these drugs

Tolbutamide, chlorpropamide Isoniazid Ketoconazole, griseofulvin Lithium

Disulfiram-like reaction

Increased liver toxicity

Disulfiram-like reaction

Increased lithium toxicity

Figure 3-6 Drug-Alcohol Interactions and Adverse Effects

Meprobamate

Methotrexate

Synergistic central nervous system depression Increased hepatic damage in chronic alcoholics

Metronidazole

Disulfiram-like reaction

Nitroglycerin

Possible hypotension

Phenformin

Lactic acidosis (synergism)

Phenothiazines

Additive central nervous system depressant activity Acutely ingested, alcohol can increase the

Phenytoin

toxicity of phenytoin; chronically ingested, it can decrease the anticonvulsant effect of phenytoin

Quinacrine

Disulfiram-like reaction

Tetracyclines

Decreased effect of doxycycline

Source: Korrapati and Vestal, 1995.

Any use of drugs in combination with alcohol carries risk; abuse of these substances raises that risk, and multiple drug abuse raises it even further. For example, chronic alcoholics who use even therapeutic doses of acetaminophen may experience severe hepatoxicity. Alcohol can increase

lithium toxicity and enhance central nervous system depression in persons taking tricyclic antidepressants. High doses of benzodiazepines used in conjunction with alcohol or barbiturates can be lethal. The many possible unfavorable reactions between prescription drugs and alcohol are summarized in Figure 3-6. Benzodiazepines Benzodiazepine use for longer than 4 months is not recommended for geriatric patients. (2) Furthermore, among the different benzodiazepines, longer acting drugs such as flurazepam (Dalmane) have very long half-lives and are more likely to accumulate than the shorter acting ones. They are also more likely to produce residual sedation and such other adverse effects as decreased attention, memory, cognitive function, and motor coordination, and increased falls or motor vehicle crashes. By contrast, some shorter acting benzodiazepines such as oxazepam (Serax) and lorazepam (Ativan) have very simple metabolic pathways and are not as likely to produce toxic or dependence-inducing effects with chronic dosing. Because of these side effects, the Panel recommends caution in selecting the most appropriate benzodiazepines for elderly patients.

Sedative/Hypnotics Aging changes sleep architecture, decreasing the amount of time spent in the deeper levels of sleep (stages three and four) and increasing the number and duration of awakenings during the night. However, these new sleep patterns do not appear to bother most medically healthy older adults who recognize and accept that their sleep will not be as sound or as regular as when they were young. Although benzodiazepines and other sedative/hypnotics can be useful for short-term amelioration of temporary sleep problems, no studies demonstrate their long-term effectiveness beyond 30 continuous nights, and tolerance and dependence develop rapidly. The Panel recommends that symptomatic treatment of insomnia with medications be limited to 7 to 10 days with frequent monitoring and reevaluation if the prescribed drug will be used for more than 2 to 3 weeks. Intermittent dosing at the smallest possible dose is preferred, and no more than a 30-day supply of hypnotics should be prescribed. (1) The Panel further recommends that clinicians teach older patients to practice good sleep hygiene rather than prescribe drugs in response to insomnia. (1) The former includes regularizing

bedtime, restricting daytime naps, using the bedroom only for sleep and sexual activity, avoiding alcohol and caffeine, reducing evening fluid intake and heavy meals, taking some medications in the morning, limiting exercise immediately before retiring, and substituting behavioral relaxation techniques. Antihistamines Older persons appear to be more susceptible to adverse anticholinergic effects from antihistamines and are at increased risk for orthostatic hypotension and central nervous system depression or confusion. In addition, antihistamines and alcohol potentiate one another, further exacerbating the above conditions as well as any problems with balance. Because tolerance also develops within days or weeks, the Panel recommends that older persons who live alone do not take antihistamines. Identification, Screening, and Assessment The Consensus Panel recommends that every 60-year-old should be screened for alcohol and prescription drug abuse as part of his or her regular physical examination. (2) However, problems can develop after the screening has been conducted, and concurrent illnesses and other chronic conditions may mask abuse. Although no hard-and-fast rules govern the timing of screening, the Panel recommends screening or rescreening if certain physical symptoms are present or if the older person is undergoing major life changes or transitions. Do not use stigmatizing terms like alcoholic or drug abuser during these encounters. Although it is important to respect the older person's autonomy, in situations where a coherent response is unlikely, collateral participation from family members or friends may be necessary. In this case, the screener should first ask for the older adult's permission to question others on his or her behalf. Instruments The Panel recommends use of the CAGE Questionnaire and the Michigan Alcohol Screening Test-Geriatric Version (MAST-G) to screen for alcohol use among older adults. (1) The Alcohol Use Disorders Identification Test (AUDIT) is recommended for identifying alcohol problems among older members of ethnic minority groups.

Assessment Substance abuse The Panel recommends a sequential approach that looks at various dimensions of an older adult's suspected problem in stages, so that unnecessary tests are not conducted. (1) The Panelists recommend the use of two structured assessments with older adults: the substance abuse sections of the Structured Clinical Interview for DSM-III-R (SCID) and the Diagnostic Interview Schedule (DIS) for DSM-IV. (2) Functioning To identify functional impairments, the Panel recommends measuring the activities of daily living (ADLs) and the instrumental activities of daily living (IADLs) with the instruments in Appendix B. (1) Another useful instrument is the SF-36, a 36-item self-report questionnaire that measures health-related quality of life, including both ADLs and IADLs. (1) Cognitive dysfunction Patients who have been medically detoxified should not be screened for cognitive dysfunction until several weeks after detoxification is completed, because a patient not fully recovered from detoxification may exhibit some reversible cognitive impairment. (2) The Panel recommends use of the Orientation/Memory/Concentration Test (1), which is simple and can be completed in the office. The Folstein Mini-Mental Status Exam (MMSE) is an acceptable alternative (1), although it can be insensitive to subtle cognitive impairments among older problem drinkers who have recently attained sobriety (past 30-60 days). The MMSE is weak on visual-spatial testing, which is likely to show some abnormality in many recent heavy drinkers. The draw-a-clock task is a good additional task to complement the MMSE. (1) The Neurobehavioral Cognitive Status Examination, which includes screening tests of abstract thinking and visual memory (not measured on the MMSE), is also recommended for assessing mental status in this population. (1) The Confusion Assessment Method (CAM) is widely used as a brief, sensitive, and reliable screening measure for detecting delirium. (1) The Panel recommends that a positive delirium screen be followed by careful clinical diagnostics based on DSM-IV criteria and that any associated cognitive impairment be followed clinically using the MMSE.

Sleep disorders The Panel recommends that sleep history be recorded in a systematic way in order to both document the changes in sleep problems over time and to heighten the awareness of sleep hygiene. Depression The Geriatric Depression Scale (GDS) and the Center for Epidemiological Studies Depression Scale (CES-D), reproduced in Appendix B, have been validated in older age groups although not specifically in older adults with addiction problems. The Panel recommends the CES-D for use in general outpatient settings as a screen for depression among older patients. (1) Treatment The Consensus Panel recommends that the least intensive treatment options be explored first with older substance abusers. (1) These initial approaches, which can function either as pretreatment strategy or treatment itself, are brief intervention, intervention, and motivational counseling. They may be sufficient to address the problem; if not, they can help move a patient toward specialized treatment. The Consensus Panel recommends that every reasonable effort be made to ensure that older substance abusers, including problem drinkers, enter treatment. Brief intervention is the recommended first step, supplemented or followed by intervention and motivational interviewing. (1) Because many older problem drinkers are ashamed about their drinking, intervention strategies need to be nonconfrontational and supportive. Conducting Brief Interventions A brief intervention is one or more counseling sessions, which may include motivation for change strategies, patient education, assessment and direct feedback, contracting and goal setting, behavioral modification techniques, and the use of written materials such as self-help manuals. An older adultspecific brief intervention should include the following steps (2): 1. Customized feedback on screening questions relating to drinking patterns and other health habits such as smoking and nutrition. 2. Discussion of types of drinkers in the United States and where the patient's drinking patterns fit into the population norms for his or her age group. 3. Reasons for drinking. This is particularly important because the practitioner needs to understand the role of alcohol in the

context of the older patient's life, including coping with loss and loneliness. Consequences of heavier drinking. Some older patients may experience problems in physical, psychological, or social functioning even though they are drinking below cutoff levels. Reasons to cut down or quit drinking. Maintaining independence, physical health, financial security, and mental capacity can be key motivators in this age group. Sensible drinking limits and strategies for cutting down or quitting. Strategies that are useful in this age group include developing social opportunities that do not involve alcohol, getting reacquainted with hobbies and interests from earlier in life, and pursuing volunteer activities, if possible. Drinking agreement in the form of a prescription. Agreedupon drinking limits that are signed by the patient and the practitioner are particularly effective in changing drinking patterns. Coping with risky situations. Social isolation, boredom, and negative family interactions can present special problems in this age group. Summary of the session.

If the older problem drinker does not respond to the brief intervention, two other approaches - intervention and motivational interviewing - should be considered.

Intervention The Panel recommends the following modifications to interventions for older patients. No more than one or two relatives or close associates should be involved along with the health care provider; having too many people present may be emotionally overwhelming or confusing for the older person. Inclusion of grandchildren is discouraged, because many older alcoholics resent their problems being aired in the presence of much younger relatives. Treatment Approaches The Panel recommends incorporating the following six features into treatment of the older alcohol abuser (1):

63  Age-specific

group treatment that is supportive and nonconfrontational and aims to build or rebuild the patient's self-esteem  A focus on coping with depression, loneliness, and loss (e.g., death of a spouse, retirement)  A focus on rebuilding the client's social support network  A pace and content of treatment appropriate for the older person  Staff members who are interested and experienced in working with older adults  Linkages with medical services, services for the aging, and institutional settings for referral into and out of treatment, as well as case management. Building from these six features, the Consensus Panel recommends that treatment programs adhere to the following principles (2):  Treat older people in age-specific settings where feasible  Create a culture of respect for older clients  Take a broad, holistic approach to treatment that emphasizes age-specific psychological, social, and health problems  Keep the treatment program flexible  Adapt treatment as needed in response to clients' gender. To help ensure optimal benefits for older adults, the Consensus Panel recommends that treatment plans weave age-related factors into the contextual framework of the American Society of Addiction Medicine (ASAM) criteria. (2) The Consensus Panel recommends the following general approaches for effective treatment of older adult substance abusers (2):  Cognitive-behavioral approaches  Group-based approaches  Individual counseling  Medical/psychiatric approaches  Marital and family involvement/family therapy  Case management/community-linked services and outreach. The Panel recommends that cognitive-behavioral treatment focus on teaching skills necessary for rebuilding the social support network; selfmanagement approaches for overcoming depression, grief, or loneliness; and general problem solving.

Barriers To Identifying And Treating Older Adults With Substance Abuse Problems The sheer number and the interconnectedness of older adults' physical and mental health problems make diagnosis and treatment of their substance abuse more complex than for other populations. That complexity contributes - directly or indirectly - to the following barriers to effective treatment:  Ageism  Lack of awareness  Clinician behavior  Comorbidity.

Identification, Screening, and Assessment Although the vast majority of older adults (87 percent) see physicians regularly, their service providers estimate that 40 percent of those who are at risk do not self-identify or seek services for substance abuse problems on their own (Raschko). Moreover, they are unlikely to be identified by their physicians despite the frequency of contact. Because most older adults live in the community and fewer than 5 percent older than 65 live in nursing or personal care homes, training supervisors in such residences does not offer a reasonable strategy for increasing problem identification. To ensure that older adults receive needed screening, assessment, and intervention services, stepped-up identification efforts by health care providers and multitiered, nontraditional case-finding methods within the community are essential (DeHart and Hoffmann). Most older adults see a medical practitioner several times per year, often for conditions that lend themselves to collateral discussion of the patients' drinking habits. Thus the primary care setting provides an opportunity for screening that is currently underutilized, as is the hospital. Home health care providers have unparalleled opportunities to observe isolated, homebound seniors for possible problems and, if substance abuse is suspected, administer a nonthreatening screen. Screening for Alcohol and Prescription Drug Abuse Barriers to Screening False assumptions, failure to recognize symptoms, and lack of knowledge about screening are among the barriers that inhibit family members, service providers, and others concerned about older adults from raising the issue of alcohol and prescription drug abuse. Although these are the two primary substances of abuse now, providers are likely to see more marijuana and

other drug use among adults over 60 in the coming years. Health care providers sometimes share the ageist attitudes discussed in Chapter 1. They may not be trained to recognize signs of substance abuse and furthermore may be unwilling to listen attentively to older patients. The latter type of provider often dismisses older patients' observations about their own symptoms and attempts at self-diagnosis and attributes all complaints or changes in health status to the aging process. Family members also can impede problem recognition. Biases persist against perceiving older adults as alcoholics or recognizing that drinking or prescription drugs, rather than age or disease, may be a cause or chief contributor to sleep problems, mood changes, or memory deficits (Finlayson, 1995b). Another assumption inhibiting identification is the belief that older adults do not respond to treatment, a misperception flatly contradicted by studies showing that older adults are more likely to complete treatment (Linn, 1978; Cartensen et al., 1985) and have outcomes that are as good as or better than those of younger patients when treated as outpatients (Atkinson, 1995; in press). Who and When To Screen It is preferable to use standardized screening questionnaires, but friendly visitors, Meals-On-Wheels volunteers, caretakers, and health care providers also can interject screening questions into their normal conversations with older, homebound adults. Comfort with this line of questioning will depend on the person's relationship with the older person and the responses given; however, anyone who is concerned about an older adult's drinking practices can try asking direct questions, such as  "Do you ever drink alcohol?"  "How much do you drink when you do drink?"  "Do you ever drink more than four drinks on one occasion?"  "Do you ever drink and drive?"  "Do you ever drink when you're lonely or upset?"  "Does drinking help you feel better [or get to sleep more easily, etc.]? How do you feel the day after you have stopped drinking?"  "Have you ever wondered whether your drinking interferes with your health or any other aspects of your life in any way?"  "Where and with whom do you typically drink?" (Drinking at home alone signals at-risk or potentially abusive drinking.)

66  "How

do you typically feel just before your first drink on a drinking day?"  "Typically, what is it that you expect when you think about having a drink?" (Note: Positive expectations or consequences of alcohol use in the presence of negative affect and inadequate coping skills have been associated with problem drinking.) If less direct questioning seems appropriate, other useful questions for identifying problematic alcohol or prescription drug use include  "Are you having any medical or health problems? What symptoms do you have? What do you think these mean? Have you felt this way before?"  "Do you see a doctor or other health care provider regularly? When was the last time? Do you see more than one? Why? Have you switched doctors recently? Why?"  "Have you experienced any negative or unwanted events that altered the way you lived (in the last 5 years)? Any since we last met? How much of an impact did the event have on the way you lived or felt? What feelings or beliefs did it cause or change? Do you believe that you are coping with the changes in a healthy fashion? How (specifically) do you manage (control) the circumstances (consequences) of the problem(s) or event(s)?"  "What prescription drugs are you taking? Are you having any problems with them? May I see them?" (This question will need to be followed by an examination of the actual containers to ascertain the drug name, prescribed dose, expiration date, prescribing physician, and pharmacy that filled each prescription. Note whether there are any psychoactive medications. Ask the patient to bring the drugs in their original containers.)  "Where do you get prescriptions filled? Do you go to more than one pharmacy? Do you receive and follow instructions from your doctor or pharmacist for taking the prescriptions? May I see them? Do you know whether any of these medicines can interact with alcohol or your other prescriptions to cause problems?"  "Do you use any over-the-counter drugs (nonprescription medications)? If so, what, why, how much, how often, and how long have you been taking them?"

Figure 4-3: The CAGE Questionnaire

Figure 4-3 The CAGE Questionnaire 1. Have you ever felt you should cut down on your drinking? 2. Have people annoyed you by criticizing your drinking? 3. Have you ever felt bad or guilty about your drinking? 4. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye opener)? Scoring: Item responses on the CAGE are scored 0 for "no" and 1 for "yes" answers, with a higher score an indication of alcohol problems. A total score of 2 or greater is considered clinically significant. Source: Ewing, 1984.

Nonmedical caretakers, volunteers, and aides may opt to ask only the four CAGE questions, reproduced in Figure 4-3 and discussed in the Screening Instruments section. If the older adult answers yes to any of the four, refer to a clinician for evaluation. If the questioner suspects that prescription drug abuse may be occurring and the older adult is defensive about his or her use, confused about various prescription drugs, seeing more than one doctor, or using more than one pharmacy, a clinician should probably be notified to probe further. Other warning signs that may emerge in conversation and should prompt a more in-depth screen or an assessment include  Excessively worrying about whether prescription psychoactive drugs are "really working" to alleviate numerous physical complaints; complaints that the drug prescribed has lost its effectiveness over time (evidence of tolerance)  Displaying detailed knowledge about a specific psychoactive drug and attaching great significance to its efficacy and personal impact  Worrying about having enough pills or whether it is time to take them to the extent that other activities revolve around the dosage schedule  Continuing to use and to request refills when the physical or psychological condition for which the drug was originally

prescribed has or should have improved (e.g., prescription of sleeping pills after the death of a loved one); resisting cessation or decreasing doses of a prescribed psychoactive drug  Complaining about doctors who refuse to write prescriptions for preferred drugs, who taper dosages, or who don't take symptoms seriously  Self-medicating by increasing doses of prescribed psychoactive drugs that aren't "helping anymore" or supplementing prescribed drugs with over-the-counter medications of a similar type  Rating social events by the amount of alcohol dispensed  Eating only at restaurants that serve alcoholic beverages (and wanting to know whether they do in advance)  Withdrawing from family, friends, and neighbors  Withdrawing from normal and life-long social practices  Cigarette smoking  Involvement in minor traffic accidents (police do not typically suspect older adults of alcohol abuse and may not subject them to Breathalyzer_ and other tests for sobriety)  Sleeping during the day  Bruises, burns, fractures, or other trauma, particularly if the individual does not remember how and when they were acquired  Drinking before going to a social event to "get started"; gulping drinks, guarding the supply of alcoholic beverages, or insisting on mixing own drinks  Changes in personal grooming and hygiene  Expulsion from housing  Empty liquor, wine, or beer bottles or cans in the garbage or concealed under the bed, in the closet, or in other locations. Asking Screening Questions Screening questions should be asked in a confidential setting and in a nonthreatening, nonjudgmental manner. Many older adults are acutely sensitive to the stigma associated with alcohol and drug abuse and are far more willing to accept a "medical" as opposed to a "psychological" or "mental health" diagnosis as an explanation for their problems. Prefacing questions with a link to a medical condition can make them more palatable. For example, "I'm wondering if alcohol may be the reason why your

diabetes isn't responding as it should," or, "Sometimes one prescription drug can affect how well another medication is working. Let's go over the drugs you're taking and see if we can figure this problem out." It is vitally important to avoid using stigmatizing terms like alcoholic or drug abuser during these encounters. Another technique that may help when talking with older adults is active listening (Egan, 1994). The four components of active listening are (1) observing and reading the person's nonverbal behavior - posture, facial expressions, movement, and tone of voice; (2) listening to and understanding the person's verbal communication; (3) listening in context, that is, to the whole person in the context of the social settings of his or her life; and (4) listening to sour notes, that is, things the person says that may have to be challenged. Motivational interviewing techniques also can be applied when screening older adults. Essentially this approach, which is described in more detail in Chapter 5, assumes that the patient is both capable of and responsible for initiating needed changes. Motivational interviewing is nonconfrontational, egalitarian, and supportive. When screening anyone, especially older adults, empathy is crucial. However, in attempting to be nonconfrontational and circumspect, it is also important to avoid using euphemisms that minimize the problem. Older adults with alcohol and prescription drug problems are just as likely to engage in denial and rationalization as younger adults; those who are inadvertently misusing a prescription drug or who are unaware that their customary drink before dinner may now be causing problems are unlikely to be defensive about acknowledging the need to change. Screening Instruments The CAGE Questionnaire (Ewing, 1984) and the Michigan Alcoholism Screening Test - Geriatric Version (MAST-G) (Blow et al., 1992a) are two well-known alcohol screening instruments that have been validated for use with older adults. One of the most widely used alcohol screens, the CAGE consists of four questions, can be self-administered even by those with low literacy reading skills (see Figure 4-3), and can be modified to screen for use of other drugs. Positive responses on the CAGE are for lifetime problems, not current ones. Before administering the CAGE, the MAST-G, or any other screen, ascertain that the person does currently drink alcohol and that

the questions that are endorsed are for problems that they have experienced recently, usually within the last year. Although two or more positive responses are considered indicative of an alcohol problem, a positive response to any one of these questions should prompt further exploration among older adults. The CAGE is most effective in identifying more serious problem drinkers, including those with abuse and dependence, and less effective for women problem drinkers than their male counterparts. Figure 4-4: Michigan Alcoholism Screening Test - Geriatric Version (MAST-G)

Figure 4-4 Michigan Alcoholism Screening Test - Geriatric Version (MAST-G) 1. After drinking have you ever noticed an increase in your heart rate or beating in your

YES NO

chest? 2

When talking with others, do you ever

YES NO

underestimate how much you actually drink? 3

Does alcohol make you sleepy so that you

YES NO

often fall asleep in your chair? 4

After a few drinks, have you sometimes not eaten or been able to skip a meal because you

YES NO

didn't feel hungry? 5

Does having a few drinks help decrease your

YES NO

shakiness or tremors? 6

Does alcohol sometimes make it hard for you

YES NO

Figure 4-4 Michigan Alcoholism Screening Test - Geriatric Version (MAST-G) to remember parts of the day or night? 7

Do you have rules for yourself that you won't

YES NO

drink before a certain time of the day? 8

Have you lost interest in hobbies or activities

YES NO

you used to enjoy? 9

When you wake up in the morning, do you ever have trouble remembering part of the

YES NO

night before?  10

Does having a drink help you sleep?

YES NO

 11

Do you hide your alcohol bottles from family

YES NO

members?  12

After a social gathering, have you ever felt

YES NO

embarrassed because you drank too much?  13

Have you ever been concerned that drinking

YES NO

might be harmful to your health?  14

Do you like to end an evening with a

YES NO

nightcap?  15

YES NO

Figure 4-4 Michigan Alcoholism Screening Test - Geriatric Version (MAST-G) Did you find your drinking increased after someone close to you died?  16

In general, would you prefer to have a few drinks at home rather than go out to social

YES NO

events?  17

Are you drinking more now than in the past?

YES NO

 18

Do you usually take a drink to relax or calm

YES NO

your nerves?  19

Do you drink to take your mind off your

YES NO

problems?  20

Have you ever increased your drinking after

YES NO

experiencing a loss in your life?  21

Do you sometimes drive when you have had

YES NO

too much to drink?  22

Has a doctor or nurse ever said they were

YES NO

worried or concerned about your drinking?  23

Have you ever made rules to manage your drinking?

YES NO

Figure 4-4 Michigan Alcoholism Screening Test - Geriatric Version (MAST-G) ď&#x201A;ˇ 24

When you feel lonely, does having a drink

YES NO

help? Scoring: Five or more "yes" responses are indicative of an alcohol problem. For further information, contact Frederic C. Blow, Ph.D., at University of Michigan Alcohol Research Center, 400 E. Eisenhower Parkway, Suite A, Ann Arbor, MI 48108; (734) 998-7952. Source: Blow, F.C.; Brower, K.J.; Schulenberg, J.E.; Demo-Dananberg, L.M.; The MAST-G was developed specifically for older adults (see Figure 4-4) and has high sensitivity and specificity among older adults recruited from a wide range of settings, including primary care clinics, nursing homes, and older adult congregate housing locations.

Although the Alcohol Use Disorders Identification Test (AUDIT) (Babor et al., 1992) has not been evaluated for use with older adults, it has been validated cross-culturally. Because there are few culturally sensitive screening instruments, the AUDIT (in the opinion of the Consensus Panel) may prove useful for identifying alcohol problems among older members of ethnic minority groups (see Appendix B). Before discussing results with an older adult, clinicians must be prepared with information about community resources available to assist in coping with this problem (e.g., meeting dates, times, and locations of Alcoholics Anonymous and other self-help recovery groups whose membership is largely 55 and older; contact and eligibility information for treatment programs that respond to the special needs of older adults); the older adult's available supports (e.g., Is transportation available? Is the recommended program affordable or covered by insurance?); and the older adult's special needs (e.g., Is the program bilingual or wheelchair accessible?). In addition, a strategy for responding to denial or refusal to follow through with a plan of action should be in place. With the agreement of an older adult involved in a self-help group or treatment program, clinicians can broker an introduction to a peer "who's been there." Frequently, these "veterans" will accompany

prospective members to meetings and mentor them through the treatment process. For some older adults coming to grips with an alcohol or prescription drug problem, repeated contacts will be necessary before they are willing to cooperate with a referral. Clinicians have observed that this process is akin to planting and nurturing a seed. Bringing the seed to fruition, however, ultimately depends on the older adult. Scoring: Five or more "yes" responses are indicative of an alcohol problem. Source: Blow, F.C.; Brower, K.J.; Schulenberg, J.E.; Demo-Dananberg, L.M.; Young, J.P.; and Beresford, T.P. The Michigan Alcoholism Screening Test - Geriatric Version (MAST-G): A new elderly-specific screening instrument. Alcoholism: Clinical and Experimental Research 16:372, 1992. Communicating Negative Screening Results The process of conveying negative screening results provides an important opportunity to reinforce healthy practices and educate older adults about the impact that alcohol and prescription drugs have on aging systems. However, even older adults who have had negative screening results may need screening repeated in the future. As discussed previously, life events render older adults vulnerable to developing problems; as the changes occur, screening questions should be asked again and the benefits of maintaining healthy habits reemphasized. Assessment For older adults with positive screens, an assessment is needed to confirm the problem, to characterize the dimensions of the problem, and to develop an individualized treatment plan. For purposes of insurance or other funding resources, the assessment should follow criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association, 1994) or other relevant criteria, bearing in mind that these criteria may not apply directly to planning older adults' treatment. The unqualified application of such criteria is problematic in older adult populations because the symptoms of other medical diseases and psychiatric disorders overlap to a considerable extent with substance-related disorders. In addition, as discussed in Chapter 2, the altered social roles and circumstances of older adults may further reduce the applicability of the criteria. For example, interference with occupational activities or work obligations may no longer be relevant as a manifestation of maladaptive

functioning, although the emphasis for a retired person can still be placed on maintaining a dwelling, managing finances, or participating in social or recreational activities. "Recurrent substance use in situations in which it is physically hazardous," a substance abuse criteria in the DSM-IV (American Psychiatric Association, 1994, p. 183), need not mean driving drunk: Climbing a ladder, crossing a street, or taking a bath while impaired by alcohol is dangerous for a frail, older person. With respect to tolerance - one of the DSM-IV criteria for a diagnosis of substance dependence - the aging process itself, as well as other concurrent medical diseases commonly found in older patients, lowers the threshold for onset of physiological dependence on prescription drugs. The presence of tolerance among older adults is not necessarily characteristic of substancerelated psychological dependence. Conversely, the absence of tolerance to alcohol does not necessarily mean that an older adult does not have a drinking problem. To be useful in assessing older adults, the DSM-IV criteria must be interpreted age-appropriately. (See Figure 2-3, which presents the DSM-IV criteria for substance dependence as they apply to older adults with alcohol problems.) Because the assessment process can be time-consuming and expensive, the Institute of Medicine (IOM) recommends (and the Panel supports) a sequential approach that looks at various dimensions of an older adult's suspected problem in stages so that unnecessary tests are not conducted (Institute of Medicine, 1990). Substance Abuse Assessment Instruments Although informed clinical judgment is essential for a sound assessment, validated substance abuse assessment instruments can provide a useful structured approach for many clinicians as well as a convenient checklist of items that should be consistently evaluated during the assessment. In general, specialized assessment is conducted by treatment program personnel or specially trained health care providers. As described by the IOM, structured assessment interviews "possess (at least potentially) the desired qualities of quantifiability, reliability, validity, standardization, and recordability" (Institute of Medicine, 1990, pp. 267-268). Based on their experience, the Consensus Panelists recommend the use of two structured assessments with older adults: the Structured Clinical Interview for DSM-III-R (SCID) (Spitzer and Williams, 1985) and the Diagnostic Interview Schedule (DIS) for DSM-IV (Robins et al., 1981). The SCID is a multimodule assessment that covers

76  Substance

use disorders  Psychotic disorders  Mood disorders  Anxiety disorders  Somatoform disorders  Eating disorders  Adjustment disorders  Personality disorders. It takes a trained clinician approximately 30 minutes to administer the 35 SCID questions that probe for alcohol abuse or dependence. The DIS is a highly structured interview that does not require clinical judgment and can be used by nonclinicians. The DIS assesses both current and past symptoms and is available in a computerized version. It has been translated into a number of languages including Spanish and Chinese. Special Assessments For some older adults, it may be impossible to understand the true impact of their alcohol and drug use or to recommend appropriate treatment services without a full assessment of their physical, mental, and functional health. Assessing Functional Abilities Functional health refers to a person's capacity to perform two types of everyday tasks: activities of daily living (ADLs), which include ambulating, bathing, dressing, feeding, and using the toilet, and instrumental activities of daily living (IADLs), which include managing finances, preparing meals, shopping, taking medications, and using the phone. Limitations in these domains, sometimes referred to as disabilities, can result in an inadequate diet, mismanagement of medications or finances, or other serious problems. These disabilities are major risk factors for institutionalization and are more likely than physical illness or mental health problems to prompt older adults to seek treatment. Impairments in functional abilities are common in older adults with medical and psychiatric disorders. For instance, 90 percent of adults over the age of 65 require the use of glasses and 50 percent of adults over 65 have some degree of hearing loss (Hull, 1989; Plomp, 1978). Sensory impairments affect older adults in subtle ways that are not always immediately obvious to health practitioners but need to be anticipated, identified, and incorporated into treatment practices. Clinicians should ensure that older patients, for example, can read their prescriptions or hear what is said in a group therapy

session. When not considered and compensated for, functional impairments can obstruct treatment. For example, it would be futile to enroll an older patient who is obese and has limited mobility in a program housed in a facility with steep flights of stairs and no elevator. Likewise, it makes little sense to recommend an evening program to older adults who cannot drive at night and do not have someone else to drive them. Alcohol use can diminish IADLs and ADLs. Although alcohol-related functional impairments are potentially reversible, they should be considered when planning a treatment regimen. There are known complications of and differences between alcohol use in men and women related to compromised functional abilities and ADLs. In a recent study of older adults with a former history of alcohol abuse, impairment in ADLs was twice as common in women as in men (Ensrud et al., 1994). In addition, alcohol use was more strongly correlated with functional impairment than were smoking, age, use of anxiolytics, stroke, or diminished grip strength. To identify functional impairments, the Panel recommends measuring the ADLs and the IADLs with the instruments in Appendix B. Another useful instrument is the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36), a self-report questionnaire that measures health-related quality of life, including both ADLs and IADLs (McHorney et al., 1994). Although this instrument is more comprehensive, it is also more difficult to use because of complex scoring of the various subscales. The SF-36 does provide, however, a comprehensive assessment of health and not just functional abilities. These instruments can be used by health care providers in a range of settings. Assessing Comorbid Disorders The relationship between alcohol use and a coexisting physical or mental disorder can take many different forms. At one extreme, medical and psychiatric problems can coexist with alcohol use with no specific relationship to drinking. Alternatively, those problems may be precipitating or maintenance factors for drinking. The use of alcohol to anesthetize pain is an example of a maintenance factor; alcohol use can then become its own problem or cause drug interaction problems with prescribed pain medications. Medical or psychiatric problems such as alcoholic cirrhosis or cognitive deficits are other possible consequences of drinking. Even when the link is not so direct, alcohol use can worsen other conditions such as hypertension or congestive heart failure.

The existence of comorbid medical and psychiatric disorders will influence treatment choice and priorities and will affect treatment outcome. Frail or medically compromised alcohol abusers, for example, may require more intensive monitoring during the detoxification period of treatment than their more robust peers. When disorders such as uncontrolled hypertension or depression are detected, reducing alcohol consumption becomes a priority; until drinking is curbed, medication prescribed for those conditions will not work effectively. In contrast, for older adults suffering from chronic pain, the priority would be to identify an effective painkiller, then taper the amount of alcohol consumed. Psychiatric comorbidities Data from the Epidemiologic Catchment Area (ECA) study have strengthened support for a possible link between alcohol use and abuse and the development of other psychiatric illnesses (Regier et al., 1990). Adults with a lifetime diagnosis of alcohol abuse or dependence had nearly three times the risk of being diagnosed with another mental disorder. Comorbid disorders associated with alcohol use include anxiety disorders, affective illness, cognitive impairment, schizophrenia, and antisocial personality disorder (Finlayson et al., 1988; Blow et al., 1992b; Blazer and Williams, 1980; Saunders et al., 1991; Oslin and Liberto, 1995; Wagman et al., 1977). According to one study, older alcohol abusers are more likely to have triple diagnoses - alcohol, depression, and personality disorders - whereas younger substance abusers are more likely to have diagnoses of schizophrenia (Speer and Bates, 1992). Cognitive impairments Figure 4-5: Comparison of Dementia and Delirium: Characteristics and Causes

Figure 4-5 Comparison of Dementia and Delirium: Characteristics and Causes Dementia

Delirium ď&#x201A;ˇ Impairments

ď&#x201A;ˇ Inability

Characterist

short- and

appreciate and

ics

long-term

respond

Figure 4-5 Comparison of Dementia and Delirium: Characteristics and Causes memory,

normally to

abstract

the

thinking, and

environment,

judgment

often with

 Aphasia

altered

(language

awareness,

disorder)

disorientation,

 Apraxia

inability to

(inability to

process visual

carry out

and auditory

motor

stimuli, and

activities

other signs of

despite intact

cognitive

comprehensi

dysfunction

on and motor function)  Agnosia

(inability to recognize or identify items despite intact sensory function)

 Potentially

life-

threatening  Acute

onset

 Clouding

consciousness  Reduced

wakefulness  Disorientation

time and space  Increased

motor

 Constructional

activity (e.g.,

difficulty

restlessness,

Figure 4-5 Comparison of Dementia and Delirium: Characteristics and Causes (inability to

plucking,

copy three-

picking)

dimensional

 Impaired

figures,

attention and

assemble

concentration

blocks, or

 Impaired

arrange

memory

sticks in

 Anxiety,

specific

suspicion, and

designs)

agitation

 Personality

 Variability

change or

symptoms

alteration

over time

and

 Misinterpretation

accentuation

, illusions, or

of premorbid

hallucinations

traits

 Disrupted

 Mood

thinking,

disturbances  Loss

delusions,

of self-

speech

care abilities Most Common Causes  Alzheimer's

Causes

disease  Vascular

dementia

abnormalities Common Intracranial Causes  Infections

(e.g.,

meningitis, encephalitis)

Figure 4-5 Comparison of Dementia and Delirium: Characteristics and Causes  Alcohol-related

 Seizures

dementia

 Stroke

Common

 Subdural

Metabolic/Toxic Causes  Chronic

hematomas

drug-

 Tumors

alcohol-

Common Extracranial

nutritional

Causes

abuse (e.g.,

 Anesthesia

Wernicke-

 Drug-drug

Korsakoff

alcohol-drug

syndrome)

interactions

 Organ

system

failure

 Intoxication

and/or

 Anoxia

withdrawal

 Folic

from alcohol or

acid

deficiency  Hypothyroidis

m  Bromide

intoxication  Hypoglycemia

drugs (particularly psychoactive drugs)  Toxic

effects of

prescribed or

Common Infectious

over-the-

Causes

counter drugs  Neurosyphilis

 Giant

cell

paresis (a

arteritis (a

syphilitic

chronic

Figure 4-5 Comparison of Dementia and Delirium: Characteristics and Causes infection

inflammatory

manifested

process

as dementia,

involving the

seizures, and

extracranial

problems

arteries)

walking and

 Hip

standing)

 Hydrocephalus

 AIDS/HIV-

fracture

(increased

fluid in the

disorders

brain)

 Meningitis  Encephalitis

Other Common Causes  Huntington's

Chorea  Parkinson's

disease  Jakob-

Creutzfeldt disease  Lewy

body's

dementia

 Hypercapnia

(reduced ventilation often associated with chronic obstructive pulmonary disease)  Infections  Dehydration  Malnutrition  Metabolic

disturbances (e.g., liver or kidney failure,

Figure 4-5 Comparison of Dementia and Delirium: Characteristics and Causes electrolyte disturbances, hyper- or hypoglycemia, diabetes, thyroid disorders) ď&#x201A;ˇ Myocardial

infarction (heart attack) ď&#x201A;ˇ Sudden

environmental changes ď&#x201A;ˇ Depression

The presence of cognitive impairment or dementia significantly alters treatment decisions. It is particularly important to distinguish between dementia and delirium, which are often mistaken for each other by clinicians diagnosing older patients (see Figure 4-5). Affective disorders Affective disorders, common in older patients, also influence treatment choices. For example, a patient with an affective disorder who takes psychotropic drugs requires a treatment program with a staff familiar with these medications. Suicidal patients require intensive inpatient programs and an immediate intervention. Significant depressive symptoms, which are a common reaction after detoxification, can be worse in older adults than in younger patients and may require prescribed medicines to alleviate the depression before the abuse or addiction therapy is resumed. As noted below, research in the area of mental health comorbidities supports these findings.

Comorbid depressive symptoms are not only common in late life, but are also an important factor in the course and prognosis of psychiatric disorders. Depressed alcoholics have been shown to have a more complicated clinical course of depression with an increased risk of suicide and more social dysfunction than nondepressed alcoholics (Conwell, 1991; Cook et al., 1991). Moreover, they were shown to seek more treatment. However, relapse rates for alcoholics did not appear to be influenced by the presence of depression. Alcohol use prior to late life has also been shown to influence treatment of late-life depression. Cook and colleagues found that a prior history of alcohol abuse predicted a more severe and chronic course for depression (Cook et al., 1991). Screening instruments for depression can be extremely useful as methods of detecting significant affective illness and for monitoring changes in affective states. The Geriatric Depression Scale (GDS) Short Form (Sheikh and Yesavage, 1986) and the Center for Epidemiological Studies - Depression Scale (CES-D) (Radloff, 1977), reproduced in Appendix B, have been validated in older age groups although not specifically in older adults with addiction problems. The Panel recommends the CES-D for use in general outpatient settings as a screen for depression among older patients. Other psychiatric disorders There are other psychiatric disorders (e.g., schizophrenia, obsessive and compulsive behaviors) that complicate the treatment of abuse and addiction. In these instances, treatment options must be evaluated on a case-by-case basis, although all programs considered for referral should include medical and mental health personnel skilled in responding to those disorders. Although suicide is not a specific psychiatric disorder, the Panel believes that there is a significant relationship among aging, alcohol use, and suicide. People older than 65 account for 25 percent of the national suicide rate (Conwell, 1991). Patients who attempt suicide require immediate and intensive inpatient therapy for as long as the illness persists. Providers must be alert to the possibility of major depression, which is common in older adults, evolving into suicidal tendencies. It helps if family and significant others, clergy, social workers, and home health care providers are knowledgeable about the warning signs for suicide, because these symptoms are more frequently manifested in nonclinical settings. Moving the Older Adult Into Treatment After determining that an older adult may benefit from a reduction in or complete abstention from alcohol use, the clinician must next assess the

patient's understanding of this benefit. Many older adults may not know that their alcohol use is affecting their health. Because patient understanding and cooperation are essential both in eliciting accurate information and following through on the treatment plan prescribed, clinicians should use the assessment process as an opportunity to educate the older adult and to motivate him or her to accept treatment. Interacting With Older Adults Many health care professionals rarely interact with older adults. To facilitate the assessment process with this population, the Consensus Panel recommends that clinicians adhere to the following guiding principles:  Areas of concern most likely to motivate older substance abusers are their physical health, the loss of independence and function, financial security, and maintenance of independence.  Assessment and treatment decisions must include the patient in order to be successful. This is particularly relevant for older adults, who may be very uncomfortable in formalized addiction treatment programs that do not include many of their peers or address their specific developmental and health needs.  Depending on an individual's particular situation, it may be important to include family members in treatment or intervention discussions (understanding that children may vacillate between a desire to help and denial and that patient confidentiality must always be respected).  Addiction is a chronic illness that ebbs and flows. Thus, patients' needs will change over time and will require different types and intensities of treatment.  Because many older adults have several health care providers (e.g., visiting nurses, social workers, adult day care staff, religious personnel), it is important to include this network as a resource in assessment and in providing treatment.  Given the complex health needs of older adults, health care providers may need assistance from experienced nonmedical personnel to adequately assess the totality of treatment issues and choices. Providers should be aware of their limitations both in providing addiction treatment and in assessing and treating mental or physical health needs.

86 ď&#x201A;ˇ All

treatment strategies must be culturally competent and, to the extent possible, incorporate appropriate ethnic considerations (e.g., rituals). ď&#x201A;ˇ Overarching continuity of care issues and considerations should be identified and addressed, especially in rural and minority communities where emergency room staff function as primary care providers. The next chapter builds on these guiding principles in describing referral and treatment options for older adults with substance abuse problems. Referral and Treatment Approaches Once screening and assessment have identified a problem, the clinician and patient must choose the most appropriate treatment. The Consensus Panel recommends that the least intensive treatment options be explored first: brief intervention, intervention, and motivational counseling. Although these three approaches can be sufficient to address the problem for some older patients, for others they will function as pretreatment strategies. These less intensive options will not resolve the latter type of patients' alcohol or other drug problems but can move them into specialized treatment by helping them overcome resistance to and ambivalence about changing their drinking behavior. Like treatment itself, pretreatment activities in some cases may be conducted best in the client's home and can be coupled with other personal or social services (Fredriksen, 1992; Graham et al., 1995b) or with home-based detoxification services (Cooper, 1995). This approach is ideal for the large number of at-risk older individuals who are homebound; it can be conducted by visiting nurses, housing authorities, and social workers. Community health services often have staff designated to make visits to older adults in their homes, and some in-home treatment programs have a visiting nurse who identifies and treats substance abuse in the home. Least Intensive Options Brief Intervention for At-Risk Drinkers Research has shown that 10 to 30 percent of nondependent problem drinkers reduce their drinking to moderate levels following a brief intervention by a physician or other clinician. A brief intervention is one or more counseling sessions, which may include motivation-for-change strategies, patient education, assessment and direct feedback, contracting and goal setting, behavioral modification techniques, and the use of written materials such as

self-help manuals (Fleming et al., 1997b). Brief intervention techniques have been used to reduce alcohol use in adolescents, in adults under age 65 who are nondependent problem drinkers, and most recently, in older adults (Blow, in press; Fleming et al., 1997a). All of these activities can be conducted by trained clinicians, home health care workers, psychologists, social workers, and professional counselors (e.g., physicians, nurses, physicians' assistants). Brief intervention strategies range from relatively unstructured counseling and feedback to more formal structured therapy and rely heavily on concepts and techniques from the motivational psychology and behavioral self-control training literature (Miller and Taylor, 1980; Miller and Hester, 1986; Miller and Munoz, 1976; Miller and Rollnick, 1991). The goal is to motivate the problem drinker to change his behavior, not to assign blame. Drinking goals accordingly should be flexible, allowing the individual to choose drinking in moderation or abstinence. Conducting brief interventions with older adults Older adults present unique challenges to those applying brief intervention strategies for reducing alcohol consumption. Because many older at-risk and problem drinkers are ashamed about their drinking, intervention strategies need to be especially nonconfrontational and supportive. In addition, as discussed in Chapter 2, the consumption level that constitutes at-risk drinking is lower than that for younger individuals (Chermack et al., 1996), so even low levels can be dangerous. Chronic medical conditions may make it more difficult for clinicians to recognize the role of alcohol in decreases in functioning and quality of life. These issues must be kept in mind during brief interventions with this vulnerable population. Following identification of at-risk or problem drinkers through screening techniques (see Chapter 4), a semistructured brief intervention can be conducted. An older adult-specific brief intervention should include the following steps: 1. Customized feedback on patient's responses to screening questions about drinking patterns and other health habits such as smoking and nutrition. 2. Discussion of types of drinkers in the United States and where the patient's drinking patterns fit into the population norms for his or her age group. 3. Reasons for drinking. This is particularly important because the practitioner needs to understand the role of

alcohol in the context of the older patient's life, including coping with loss and loneliness. 4. Consequences of heavier drinking. Some older patients may experience problems in physical, psychological, or social functioning even though they are drinking below cutoff levels. 5. Reasons to cut down or quit drinking. Maintaining independence, physical health, financial security, and mental capacity can be key motivators in this age group. 6. Sensible drinking limits and strategies for cutting down or quitting. Strategies that are useful in this age group include developing social opportunities that do not involve alcohol, getting reacquainted with hobbies and interests from earlier in life, and pursuing volunteer activities, if possible. 7. Drinking agreement in the form of a prescription. Agreed-upon drinking limits that are signed by the patient and the practitioner are particularly effective in changing drinking patterns. 8. Coping with risky situations. Social isolation, boredom, and negative family interactions can present special problems in this age group. 9. Summary of the session. One approach devised to facilitate brief interventions is known by the acronym FRAMES. This approach emphasizes  Feedback of personal risk or impairment as derived from the assessment  Personal responsibility for change  Clear advice to change  A menu of change options to increase the likelihood that an individual will find a responsive treatment (although multiple attempts may be necessary)  An empathic counseling style  Enhanced client self-efficacy and ongoing follow-up (Miller and Sanchez, 1994). Panel members agree that when older adults are motivated to take action on their own behalf, the prognosis for positive change is extremely favorable. Key to inspiring motivation is the clinician's caring style, willingness to view the older adult as a full partner in his or her recovery, and capacity to

provide hope and encouragement as the older adult progresses through the referral, treatment, and recovery process. Intervention and Motivational Counseling If the older problem drinker does not respond to the brief intervention, two other approaches - intervention and motivational counseling - should be considered. Intervention In an intervention, which occurs under the guidance of a skilled counselor, several significant people in a substance abuser's life confront the individual with their firsthand experiences of his or her drinking or drug use (Johnson, 1973; Twerski, 1983). The formalized process begins before the intervention and includes a progressive interaction between the counselor and the family or friends for at least 2 days before meeting with the patient. During this time, the counselor not only helps plan the intervention but also educates the family about substance abuse and its prevention (Johnson, 1973). Participants are coached about offering information in an emotionally neutral, factual manner while maintaining a supportive, nonaccusatory tone, thus presenting incontrovertible evidence to the loved one that a problem exists. When using this approach with older adults, Panel members recommend some modifications. No more than one or two relatives or close associates should be involved along with the counselor; having too many people present may be emotionally overwhelming or confusing for the older person. The most influential person to include in interventions or any other pretreatment activity may be a spouse, cohabitant, caregiving son or daughter, clergy member, or visiting nurse or caseworker, depending on the particular social network of the client. Inclusion of grandchildren is discouraged: Panel members report that many older alcoholics describe long-lasting resentment and shame about the airing of their problems in the presence of much younger relatives. Because denial is as much a part of psychoactive prescription drug dependence as it is of alcoholism and addiction to illicit drugs, an intervention may help move psychoactive drug abusers toward detoxification or other formal treatment, although extra caution is advisable. Both the diagnosis of abuse or dependence and the need for treatment are particularly difficult for older patients to accept because their initial use of psychoactive prescription drugs was, in almost all cases, originally sanctioned by a health care provider and prescribed as a remedy for a legitimate medical problem or complaint. As a group, older adults tend to

have even greater disdain for "drug addicts" than the general population: Any implied linkage with the criminalized population of illicit drug users is unnecessarily stigmatizing and appropriately resented. Such labels as addict, alcoholic, and drunkard should be avoided. Figure 5-1: ASAM-PPC-2 Assessment Dimensions

Figure 5-1 ASAM-PPC-2 Assessment Dimensions Dimension 1 - Acute Intoxication and/or Withdrawal Potential What risk is associated with the patient's current level of acute intoxication? Is there significant risk of severe withdrawal symptoms or seizures, based on the patient's previous withdrawal history, amount, frequency, and recency of discontinuation or significant reduction of alcohol or other drug use? Are there current signs of withdrawal? Does the patient have supports to assist in ambulatory detoxification, if medically safe? Dimension 2 - Biomedical Conditions and Complications Are there current physical illnesses, other than withdrawal, that need to be addressed or that may complicate treatment? Are there chronic conditions that affect treatment? Dimension 3 - Emotional/Behavioral Conditions and Complications Are there current psychiatric illnesses or psychological, behavioral, or emotional problems that need to be addressed or which complicate treatment? Are there chronic conditions that affect treatment? Do any emotional/behavioral problems appear to be an expected part of

Figure 5-1 ASAM-PPC-2 Assessment Dimensions addiction illness, or do they appear to be autonomous? Even if connected to the addiction, are they severe enough to warrant specific mental health treatment? Dimension 4 - Treatment Acceptance/Resistance Is the patient actively objecting to treatment? Does the patient feel coerced into treatment? How ready is the patient to change? If willing to accept treatment, how strongly does the patient disagree with others' perceptions that he or she has an addiction problem? Does the patient appear to be compliant only to avoid a negative consequence, or does he or she appear to be internally distressed in a self-motivated way about his or her alcohol/other drug use problems? Dimension 5 - Relapse/Continued Use Potential Is the patient in immediate danger of continued severe distress and drinking/drug-taking behavior? Does the patient have any recognition of, understanding of, or skills with which to cope with his or her addiction problems in order to prevent relapse or continued use? What severity of problems and further distress will potentially continue or reappear if the patient is not successfully engaged in treatment at this time? How aware is the patient of relapse triggers, ways to cope with cravings to use, and skills to control impulses to use? Dimension 6 - Recovery Environment Are there any dangerous family members, significant others, living situations, or school/working situations that pose a threat to treatment

Figure 5-1 ASAM-PPC-2 Assessment Dimensions engagement and success? Does the patient have supportive friendships, financial resources, or education/vocational resources that can increase the likelihood of successful treatment? Are there legal, vocational, social service agency, or criminal justice mandates that may enhance the patient's motivation for engagement in treatment? Source: American Society of Addiction Medicine, 1996.

Figure 5-1 shows the six problems or assessment dimensions that ASAMPPC-2 uses to make patient placement decisions both among and within levels of service. The answers to these questions should help the health care provider assess the severity of the problem and the intensity of the services required. For older adults, the triage process is often greatly influenced by factors other than the severity of a drinking or prescription drug problem. For example, physical accessibility of facilities will influence treatment choices for wheelchair-bound patients; hearing-impaired patients will need programs with individual therapy and/or modified small group therapy. Language barriers, illiteracy, and different cultural views of and customs surrounding substance abuse add to the complex of factors required to assess functional abilities in older adult patients. To help ensure optimal benefits for older adults, the Consensus Panel recommends that treatment plans weave age-related factors into the contextual framework of the ASAM criteria. Levels of Treatment Services The following section provides an overview of treatment services from the most to the least intensive, with examples demonstrating how various circumstances may affect the level of care at which a service is offered. Inpatient/Outpatient Detoxification Treatment One of the first issues to consider for an older patient with a substance dependence diagnosis is whether detoxification management is necessary and, if so, whether it should be undertaken in an inpatient hospital-based setting or managed on an outpatient basis. No studies or reports specifically assess the potential risks or benefits of outpatient detoxification among older

adults, but detoxification is generally seen as medically riskier for an older person. Until more research is available, best clinical judgment must guide such decisions. For more information on detoxification, see TIP 19, Detoxification From Alcohol and Other Drugs (CSAT, 1995a). Medical safety and potential access to the abused drugs are primary considerations when deciding whether an older patient's withdrawal from prescription drugs requires supervision in a hospital. Factors indicating the need for inpatient detoxification include  A high potential for developing dangerous abstinence symptoms such as a seizure or delirium because (1) the dosage of alcohol or drug has been particularly high or prolonged and has been discontinued abruptly or (2) the patient has experienced these serious symptoms at any time previously  Suicidal ideation or threats  The presence of other major psychopathology  Unstable or uncontrolled comorbid medical conditions requiring 24-hour care or parenterally administered medications (e.g., renal disease, diabetes)  Mixed addictions, (e.g., alcohol, sedative/hypnotic drugs)  A lack of social supports at home or living alone with continued access to the abused substance(s)  A failure to respond to outpatient treatment. Treatment Approaches The Consensus Panel recommends the following general approaches for effective treatment of older adult substance abusers:  Cognitive-behavioral approaches  Group-based approaches  Individual counseling  Medical/psychiatric approaches  Marital and family involvement/family therapy  Case management/community-linked services and outreach. Not every approach will be necessary for every client. Instead, the program leaders can individualize treatment by choosing from this menu to meet the needs of the particular client. Planning information comes from interviews; mental status examinations; physical examinations; laboratory, radiological, and psychometric tests; and social network assessments, among others.

Figure 5-3: Treatment Objectives and Approaches

Figure 5-3 Treatment Objectives and Approaches General Objectives/ Examples

General Approaches/Examples

Cognitive-behavioral (group or individual)  Alcohol

(drug) effects

 Relapse

Eliminate or reduce substance abuse

 Stress

prevention

management

Group approaches  Alcohol

(drug) effects

education Medical  Naltrexone,

acamprosate

(alcohol) Medical  Remove

Safely manage intoxication

patient from

activities and observe

episodes during treatment

 Link

and refer to

detoxification program Cognitive-behavioral (group or individual)  Social

Enhance relationships

skills and network

building Group approaches  Social

support

 Socialization

skill education

Figure 5-3 Treatment Objectives and Approaches  Gender-specific

issues

Marital and family approaches  Spouse

counseling

 Marital

therapy

 Family

therapy

Case management  Linkage

to community

social programs  Home

visitation

Individual counseling  Focus

on psychodynamic

issues in relationships Medical  Provide

Promote health

care

 Improve

sleep

habits

Cognitive-behavioral (group or individual)

 Improve

nutrition

 Increase

exercise

 Reduce

tobacco

 Self-management

skills

training Group approaches

use  Reduce

primary medical

 Health

stress

education

 Education

on nutrition, diet,

cooking, shopping  Sleep

Stabilize and resolve comorbidities  Medical

hygiene

Medical  Consultation

and special

assessments, including

Figure 5-3 Treatment Objectives and Approaches  Psychiatric

(e.g.,

medication assessment

depression,

 Primary

anxiety)  Sensory

and specialized

medical care

deficits

 Psychiatric

care for chronic

mental disorders (by geriatric psychiatrist, if possible)  Pain

management for

chronic pain disorders  Antidepressants,

antianxiety medication Cognitive-behavioral (group or individual)  Relaxation

training

 Depression

Figure 5-3 lists the major treatment objectives that the Panel recommends for older substance abusers and the approaches that can best accomplish them. Cognitive-Behavioral Approaches There are three broad categories of cognitive-behavioral approaches: behavior modification/therapy, self-management techniques, and cognitivebehavioral therapies. Behavior modification applies learning and conditioning principles to modifying overt behaviors - those behaviors obvious to everyone around the client (Powers and Osborne, 1976; Spiegler and Guevremont, 1993). Self-management refers to teaching the client to modify his or her overt behaviors as well as internal or covert patterns. Cognitive-behavior modification involves altering covert patterns or behaviors that only the client can observe. Cognitive-behavioral techniques teach clients to identify and modify self-defeating thoughts and beliefs (Dobson, 1988; Scott et al., 1989). The cognitive-behavioral model offers an especially powerful method for targeting problems or treatment objectives

that affect drinking behavior. Together, provider and client analyze the behavior itself, constructing a "drinking behavior chain." The chain is composed of the antecedent situations, thoughts, feelings, drinking cues, and urges that precede and initiate alcohol or drug use; the drinking or substance-abusing behavior (e.g., pattern, style); and the positive and negative consequences of use for a given individual. When exploring the latter, it is particularly important to note the positive consequences of use: those that maintain abusive behavior. Researchers have developed an instrument that can elicit by interview the individual's drinking or drug use behavior chain (Dupree and Schonfeld, 1986). Immediate antecedents to drinking include feelings such as anger, frustration, tension, anxiety, loneliness, boredom, sadness, and depression. Circumstances and high-risk situations triggering these feelings might include marital or family conflict, physical distress, or unsafe housing arrangements, among others. Many older adults drink excessively in response to perceived losses and changes associated with aging and their affective and behavioral response to those losses. Alcohol use is often a form of "self-medication," a means to soften the impact of unwanted change and feelings. For the patient, new knowledge of his or her drinking chain often clarifies for the first time the relationship between thoughts and feelings and drinking behavior, a discovery one Panel member calls "taking the mystery out of drunkenness." This method provides insight into individual problems, demonstrates the links between psychosocial and health problems and drinking, and provides the data for a rational treatment plan and an explicit individualized prevention strategy. Breaking drinking behavior into the links of a drinking chain serves treatment in other ways, too. It suggests elements of the community service network that may be helpful in establishing an integrated case management plan to resolve antecedent conditions (e.g., housing, financial, medical problems) that necessitate involvement from the community beyond the treatment program (see Case Management section). Behavioral treatment can be used with older adults individually or in groups, with the group process particularly suited to older adults (see Group-Based Approaches section below). Equipped with the knowledge of the individual's drinking or drug abuse behavior chain, the group leader begins to teach the client the skills necessary to cope with high-risk thoughts or feelings. The leader teaches the older person to initiate alternative behaviors to drinking, then reinforces such attempts. The leader may demonstrate through role-

playing alternative ways to manage high-risk situations, permitting the client to select coping behaviors that he or she feels willing and able to acquire. The leader may also ask for feedback from the group and use that feedback to work gradually toward a workable behavioral response specific to the individual. The behaviors are rehearsed within the treatment program until a level of skill is acquired. The patient is then asked to try out the behaviors in the real world as "homework." For example, a client who has been practicing ways to overcome loneliness or social isolation may receive a community-based assignment in which to carry out the suggested behaviors. The individual reports back to the group, then the therapist and group members provide feedback and reinforce the individual's attempt at selfmanagement (whether the outcome was a success or not). This process continues until the individual develops coping skills and brings the antecedents for abuse under self-control or self-management. Typically, as patients learn to manage the conditions (thoughts, feelings, situations, cues, urges) that prompt alcohol abuse, abstinence can be maintained. Defining drinking behavior antecedents is also useful for determining when a client is ready for discharge. When the individual has acquired and can successfully use coping behaviors specific to his or her antecedents for drinking, the treatment team might begin to assist the person in gradually phasing out of the program. Discharge that takes place before the client has acquired specific coping behaviors is almost certain to result in relapse - probably very soon after discharge. One older adult-specific treatment program that has used these cognitivebehavioral and self-management approaches is the Gerontology Alcohol Project (GAP) (Dupree et al., 1984). The program assessed antecedents on a typical day of drinking for each person entering treatment. Group treatment involved skill acquisition in order to cope with problems such as anger and frustration, depression and grief, tension and anxiety, lack of social support, passivity, and an unstructured life. GAP staff were encouraged to teach skills at a slower pace than might be used with younger adults and to limit the amount of information taught per session by following written curriculum manuals. These teaching guides provided age-specific examples and maintained consistency in teaching. Confrontation was not permitted. This facilitated more open discussion between staff and clients, encouraging clients to report instances when they slipped. This information was used in the group to help both the person who slipped and other clients. Each slip was diagrammed in terms of that person's drinking behavior chain, with the antecedent conditions and consequences, in order to teach group members

how to avoid or manage their own high-risk situations. The group engaged in exercises or rehearsals of the necessary actions and cognitions to prevent one drink (a slip) from becoming a full relapse. A 1-year follow-up of clients completing GAP indicated a high rate of success. Seventy-five percent of clients maintained their drinking reduction goals and increased the size of their social support networks (Dupree et al., 1984). Later studies comparing early and late-onset older problem drinkers showed great similarity between these two groups' antecedents to drinking and treatment outcomes (Schonfeld and Dupree, 1991). Another study described a behavioral regimen that included psychoeducation, self-management skills training, and marital therapy. A follow-up study of 16 male inpatients, ages 65 to 70, undertaken 2 to 4 years after discharge, indicated that half were abstaining, two had reduced their drinking, and the remaining patients' drinking was destructive (Carstensen et al., 1985). These studies recommend (and the Panel concurs) that treatment focus on teaching skills necessary for rebuilding the social support network; self-management approaches for overcoming depression, grief, or loneliness; and general problem solving (Schonfeld and Dupree, 1990, 1991). Group-Based Approaches Group experiences are particularly beneficial to older adults in treatment. They provide the arena for giving and sharing information; practicing skills, both new and long-unused; and testing the clients' perceptions against reality. Perhaps the most beneficial aspect of groups for older adults is the opportunity to learn self-acceptance through accepting others and in return being accepted. Guilt and forgiveness are often best dealt with in groups, where people realize that others have gone through the same struggles. Special groups may also deal with the particular problems of aging; the group format can help patients learn skills for coping with any of the life changes identified in Figure 5-2. Self-paced learning is best for older adults. To allow clients to set their own pace in a group setting, the leader can give individualized or take-home assignments. Clients who have not reached the needed level of expertise on a topic can receive an individualized "booster session" while remaining in the group. Older clients also should get more than one opportunity to integrate and act on new information. For example, information on bereavement can be presented in an educational session, then reinforced in therapy. To help participants integrate and understand material, it may even be helpful to expose them to all units of information twice. Groups help create a sense of

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camaraderie and high morale. Research on group work with older adults suggests that older adults bond into groups at a faster pace than younger adults do (Finkel, 1990). One successful treatment program made use of this phenomenon by assigning each person to another client who served as a "buddy," explaining and facilitating the day's events. Some of the most effective types of groups are socialization, therapy, educational, and self-help or support groups. Socialization groups Groups may focus on socialization skills: teaching clients skills for meeting new people, interacting better with peers, and giving them opportunities to practice. These skills are honed whenever clients gather together, whether in recreation, on coffee breaks, or at lunch. This type of activity is particularly valuable for those who live with loneliness or who have become socially isolated. Panel members report that many older adults keep in touch with friends they made during treatment, especially if the treatment program sponsored social activities. Some treatment programs sponsor an evening a week where clients can socialize, which helps them rebuild or expand their social contacts in the community. Therapy groups Some therapy groups engage in behavioral interaction, as discussed above, others in more psychodynamic therapy. Both types of groups allow clients to test the accuracy of their interpretations of social interactions, measure the appropriateness of their responses to others, and learn and practice more appropriate responses. Groups provide each client with feedback, suggestions for alternative responses, and support as the individual tries out and practices different actions and responses. Some people may need help in entering the group, particularly if they are accustomed to isolation. This help could include individual counseling sessions in which the counselor explains how a group works and answers the client's questions regarding confidentiality. The client's entry into the group may be eased by joining in stages, at first observing, then over time moving into the circle. The counselor may formally introduce the new person to the members of the group so that upon entering the group, he or she is at least somewhat familiar with them. Older adults grew up before psychological terms had been integrated into the everyday language. Therefore, therapy groups for older adults should avoid the use of jargon, acronyms, and "psychspeak." If leaders do use such terms,

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they should begin by teaching the group their meanings. If a participant uses an unfamiliar term, the leader should explain it. It may be helpful to develop a vocabulary list on a chart and for any individual notebooks. Similarly, because many older individuals were raised not to "air their dirty laundry," they should never be pressured to reveal personal information in a group setting before they are ready. Nor should older patients be pressured into "role-playing" before they are ready. Educational groups Educational groups are an integral part of addiction treatment. Patients need information about addiction, the substances, their use, and their impact. Older adults also benefit from shared information about the developmental tasks of the later stages of life, support systems, medical aspects of aging and addiction, the concepts and processes of cognitive-behavioral techniques, and experiences they are likely to be facing, such as retirement, loss, partner's illness, and family concerns. Educational units can be designed to teach practical skills for coping with any aspect of daily life, such as nutrition, household management, or exercise. Some basic principles for designing educational groups follow: ď&#x201A;ˇ Older adults can receive, integrate, and recall information better if they are given a clear statement of the goal and purpose of the session and an outline of the content to be covered. The leader can post this outline and refer to it as she moves through the session. The outline may also be distributed for use in personal note-taking and as an aid in review and recall. Courses and individual sessions should be conceived as building blocks that are added to the base of the older adult's life experience and needs. Each session should begin with a review of previously presented materials. ď&#x201A;ˇ Members of the group may range in educational level from being functionally illiterate to possessing advanced degrees. Many older adults are adept at hiding a lack of literacy skills. These individuals need to be helped in a way that maintains their self-respect. Group leaders should choose vocabulary carefully to comply with clients' communication skills. ď&#x201A;ˇ Groups should accommodate clients' sensory decline and deficits by maximizing the use of as many of the clients' senses as possible. Simultaneous visual and audible

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presentation of material, enlarged print, voice enhancers, and blackboards or flip charts can be helpful. An overhead projector allows the leader to display written material on a screen while facing and speaking to the group. Group members may also take home supplemental audiotapes and videotapes for review. It is important to recognize clients' physical limitations. Group sessions should last no longer than about 55 minutes. The area should be well lighted without glare, and interruptions, noise, and superfluous material should be kept to a minimum. Distractions generally interfere more with learning for older patients than for younger ones (Myers and Schwiebert, 1996). Alcoholics Anonymous and other self-help groups Many treatment programs refer patients to Alcoholics Anonymous (AA) and other self-help groups as part of aftercare. Providers should warn older patients that these groups might seem confrontational and alienating. The referring program should tell patients exactly what to expect - that the group discussions may well include profanity and younger members' accounts of their antisocial behavior. To orient clients to these groups, the treatment program may ask that local AA groups provide an institutional meeting as a regular part of the treatment program. Other options are to help clients develop their own self-help groups or even to facilitate the development of independent AA groups for older adults in the area. Individual Counseling or Short-Term Psychotherapy Individual counseling is especially helpful to the older substance abuser in treatment's beginning stages, but the counselor often must overcome clients' worries about privacy. Subjects that many older adults are loath to discuss include their relationships to their spouses, family matters and interactions, sexual function, and economic worries. It is essential to assure the client that the sessions are confidential and to conduct the sessions in a comfortable, self-contained room where the client can be certain the conversation will not be overheard. Older clients often respond best to counselors who behave in a nonthreatening, supportive manner and whose demeanor indicates that they will honor the confidentiality of the sessions. Clients frequently describe the successful relationship in familial terms: "It is like talking to my son," or, "It is as though she were my sister." Older clients value spontaneity in relationships with the counselor and other staff members; a counselor's

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appropriate self-disclosure often enhances or facilitates a beneficial relationship with the patient. Because receiving counseling may be a new experience for the client, the provider should explain the basics of counseling and clearly present the responsibilities of the counselor and the client. Summarizing at the beginning of each session helps to keep the session moving in the appropriate direction. Summarizing at the end of a session and providing tasks to be thought about or completed before the next session help reinforce any knowledge or insights gained and contribute to the older client's feeling that she is making progress. In individual sessions, counselors can help clients prepare to participate in a therapy group, building their understanding of how the group works and what they are expected to do. Private sessions can also be used to clarify issues when the individual is confused or is too embarrassed to raise a question in the group. As the client becomes more comfortable in the group setting, the counselor may decide to taper the number of individual counseling sessions. Likewise, the client may prepare for discharge by reducing the frequency or length of sessions, secure in the knowledge that more time is available if needed. Family and marital therapy The dynamics of a marriage can change drastically as couples grow older. These changes stem from retirement, the deaths of friends, and health issues that affect marital relationships, such as changes in sexual function or the need for caregiving. Any of the issues typically experienced by older adults, such as financial concerns or fear of the death of a spouse, can affect the stability of the marital relationship and place additional stress on the client in treatment. The best setting for providing counseling to substance-abusing older patients with marital problems may be individual couple counseling or in a group setting with other couples of similar age. Counseling the couple separately from the group is advisable for addressing very personal concerns such as sexual problems or other highly sensitive issues that could be damaging to the couple's marriage. Case Management, Community-Linked Services, and Outreach

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Case management is the coordination and monitoring of the varied social, health, and welfare services needed to support an older adult's treatment and recovery. Case management starts at the beginning of treatment planning and continues through aftercare. One person, preferably a social worker or nurse, should link all staff who play a role in the client's treatment as well as key family members and other important individuals in the client's social network. The multiple causes of older adults' problems require multiple linkages to community services and agencies. The treatment program that seeks to be the sole source of all services for its older clients is likely to fail. Even in very isolated areas, programs can strengthen their services for older adults through linkages to local resources such as the faith community. The case manager will likely refer the client to a combination of several community resources in response to the issues associated with the substance abuse problem. Case managers must have strong linkages through both formal and informal arrangements with community agencies and services such as  Medical practitioners, particularly mental health providers, geriatricians, and geriatric counselors  Medical facilities for detoxification and other services  Home health agencies.  Housing services for specialized housing (i.e., wheelchair-accessible housing, congregate living)  Public and private social services providing in-home support for housekeeping, meals, etc.  Faith community (e.g., churches, synagogues, mosques, temples)  Transportation services  Senior citizen centers and other social activities  Vocational training and senior employment programs  Community organizations that place clients in volunteer work  Legal and financial services  The Area Agency on Aging (funded under Title 20). If a program includes outreach services, case management may offer the best means of providing them (Graham et al., 1995b; Fredriksen, 1992). Case managers may, for example, initiate outreach services for homebound clients, although it is important to maintain continuity and assign only one case manager to an older client. If clients in a treatment program become seriously ill or dysfunctional and temporarily require services at home, a

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case manager may be the ideal staff person to broker services on their behalf. (Comprehensive case management for substance abuse treatment will be described in detail in a forthcoming TIP to be published in 1998.) Legal and Ethical Issues by Margaret K. Brooks, Esq Used with permission U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, Rockwall II, 5600 Fishers Lane, Rockville, MD 20857

Screening any population for substance abuse raises key legal and ethical concerns: how one can inquire about an individual's alcohol and drug use while continuing to respect that person's autonomy and privacy. Screening of older adults for substance abuse brings these concerns into particularly sharp focus - whether the person screening is a clinician, a staff member at a senior center, a member of the clergy, an adult protective service worker, a Meals-On-Wheels volunteer, a pharmacist, a community health worker, an adult day care worker, or staff member at a long-term care facility. This appendix examines how the issues of autonomy and privacy (or confidentiality) affect the way providers working with older adults may screen for substance use problems. The first section discusses the relationship between patient or client autonomy and the provider's obligation to inform and counsel the older individual about the health risks of alcohol or other drug use. The second section concerns privacy of information about substance use problems: How can a provider keep accurate records and communicate with others concerned about the older individual's welfare without disclosing information that may subject the individual to scorn or create problems with family or third-party payers? Autonomy and the Provider's Mission: A Dilemma Americans attach extraordinary importance to being left alone. We pride ourselves on having perfected a social and political system that limits how far the government - and others - can control what we do. The principle of autonomy is enshrined in our Constitution, and our courts have repeatedly confirmed our right to make our own decisions for ourselves. Most of us cherish our autonomy and fear its loss, particularly as we age. Although providers who screen or assess for substance abuse do so because they are genuinely concerned about an individual's health or functioning, screening means seeking very personal information - an unavoidable intrusion on a person's autonomy and privacy. Alert to suggestions that their judgment or abilities are impaired, older adults may not always see a

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provider's effort to "help" as benign. Performed insensitively, screening or assessment may intensify denial. A person of any age who is "in denial" may not realize, or want to realize, that he has to cut back on or give up his intake of alcohol or prescription medications; an older person may view the provider's questions and suggestions as intrusive, threatening, and offensive. Suggestions that an older individual's complaint has an emotional basis may tap an underlying reluctance to acknowledge an emotional component to any problem and reinforce the individual's resistance. Because the substance abuse label carries a powerful stigma, an older individual may become alarmed if a provider intimates that alcohol or drug abuse may be involved. It will be tempting for the older individual to point to the "normal" infirmities of old age as the source of his difficulty rather than acknowledge a problem with alcohol or other drugs. How can the provider raise the question of alcohol and drug use constructively, without eliciting a defensive response? Should she raise the issue and then drop it at the slightest hint of resistance on the part of the older individual? Or should she intervene more forcefully - with argument or by involving the family? To fulfill her ethical responsibility, the provider should do more than simply raise the issue. As the Consensus Panel suggests, most older adults are unaware that their metabolism of alcohol and prescription drugs changes as they age and that lower amounts of alcohol and medicines may incapacitate them. Respect for a person's autonomy means informing him of all relevant medical facts and engaging him in a discussion about his alternatives. If there is a substance abuse problem, the provider can supply the information and encouragement, but only the person with the problem has the power to change what he is doing. Respecting the patient's autonomy - his right to make choices - is central to encouraging that change. Privacy and Confidentiality Aside from perceived threats to autonomy, an older person may also be concerned about the practical consequences of admitting a substance use problem. Such patients may find it difficult or impossible to obtain coverage for hospitalization costs if an insurer or health maintenance organization (HMO) learns that their traumatic injuries were related to alcoholism. Relationships with a spouse, children, grandchildren, or friends may suffer. Adverse consequences such as these may discourage patients with substance use problems from seeking treatment. Concern about privacy and confidentiality is fueled by the widespread perception that people with substance use disorders are weak and/or morally impaired. For an older person, this concern may well be compounded by an

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apprehension that others may view acknowledgment of a substance use disorder as a sign of inability to continue living independently. If the individual is having family problems - with a spouse or with children information about substance use could have an adverse impact on resolution of those problems. Or the individual may experience difficulties with health insurance. Federal Law The concern about the adverse effects that social stigma and discrimination have on patients in recovery (and how those adverse effects might deter people from entering treatment) led the Congress to pass legislation and the U.S. Department of Health and Human Services to issue a set of regulations to protect information about individuals' substance abuse. The law is codified at 42 U.S.C.ยง 290dd-2. The implementing Federal regulations, "Confidentiality of Alcohol and Drug Abuse Patient Records," are contained in 42 CFR Part 2 (Vol. 42 of the Code of Federal Regulations, Part 2). The Federal law and regulations severely restrict communications about identifiable individuals by "programs" providing substance use diagnosis, treatment, or referral for treatment (42 CFRยง 2.11). The purpose of the law and regulations is to decrease the risk that information about individuals in recovery will be disseminated and that they will be subjected to discrimination and to encourage people to seek treatment for substance use disorders. In most settings where older adults receive care or services, Federal confidentiality laws and regulations do not apply.1b Providers should be aware, however, that if a health care practice or social service organization includes someone whose primary function is to provide substance abuse assessment or treatment and if the practice or organization benefits from "Federal assistance,"2 that practice or organization must comply with the Federal law and regulations and implement special rules for handling information about patients who may have substance abuse problems.3 Moreover, the fact that most providers for older adults are not subject to the Federal rules does not mean that they can handle information about their clients' substance use problems in a cavalier manner. Because of the potential for damage, providers should always handle such information with great care. State Laws Although Federal rules do not restrict how most providers gather and handle information about an older individual's substance abuse, there are other rules

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that may limit how such information may be handled. State laws offer some protection to medical and mental health information about patients and clients. Most doctors, social service workers, and clients think of these laws as the "doctor-patient privilege" or "social worker-client privilege" or "psychotherapist-patient privilege." Strictly speaking, these privileges are rules of evidence that govern whether a professional provider can be asked or compelled to testify in a court case about a patient or client. In many States, however, laws offer wider protection. Some States have special confidentiality laws that explicitly prohibit physicians, social workers, psychologists, and others from divulging information about patients or clients without consent. States often include such prohibitions in professional licensing laws; such laws generally prohibit licensed professionals from divulging information about patients or clients, and they make unauthorized disclosures grounds for disciplinary action, including license revocation. Each State has its own set of rules, which means that the scope of protection offered by State law varies widely. Whether a communication is "privileged" or "protected" may depend on a number of factors: 1. The type of professional provider holding the information and whether he or she is licensed or certified by the State 2. The context in which the information was communicated 3. The context in which the information will be or was disclosed 4. Exceptions to any general rule protecting information, and 5. How the protection is enforced. Professionals covered by the "doctor-patient" or "therapist-client" privilege Which professions and which practitioners within each profession are covered depends on the State where the professional practices. California, which grants its citizens "an inalienable right to privacy" in its Constitution, has what may be the most extensive protections for medical (including mental health) information. California law protects communications with a wide variety of professionals, including licensed physicians, nurses, and psychotherapists (which includes clinical social workers, psychologists, marriage and family counselors), as well as many communications with trainees practicing under the supervision of a number of these professionals. A California court has held that information given to an unlicensed professional by an uneducated patient may be privileged if the patient reasonably believes the professional is authorized to practice medicine.4

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Other States' laws cover fewer kinds of professionals. In Missouri, for example, protection is limited to communications with State-licensed psychologists, clinical social workers, professional counselors, and physicians. Depending on their professional training (and licensing), primary care physicians, physician assistants, nurse-practitioners, nurses, psychologists, social workers, and others may be covered by State prohibitions on divulging information about patients or clients. Note that even within a single State, the kind of protection afforded information may vary from profession to profession. Professional providers should learn whether any confidentiality law in the State where they practice applies to their profession. The context in which the information was communicated State laws vary tremendously in this area, too. Some States protect only the information that a patient or client communicates to a professional in private, in the course of the medical or mental health consultation. Information disclosed to a clinician in the presence of a third party (like a spouse) is not protected. Other States, such as California, protect all information the patient or client tells the professional or the professional gains during examination.5 California also protects other information acquired by the professional about the patient's mental or physical condition, as well as the advice the professional gives the patient.6 When California courts are called upon to decide whether a particular communication of information is privileged, State law requires them to presume that it is. California affords great protection to communications between patients and psychotherapists, a term that covers a wide range of professions. Not only are communications by and to the patient protected, information communicated by a patient's intimate family members to therapists and psychiatric personnel is also protected. California also protects information the patient discloses in the presence of a third party or in a group setting. Understanding what medical information is protected requires professional providers to know whether State law recognizes the confidentiality of information in the many contexts in which the professional acquires it. Circumstances in which "confidential" information is protected from disclosure Some States protect medical or mental health information only when that information is sought in a court proceeding. If a professional divulges information about a patient or client in any other setting, the law in those States will not recognize that there has been a violation of the individual's

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right to privacy. Other States protect information in many different contexts and may discipline professionals who violate their patients' privacy, allow patients to sue them for damages, or criminalize behavior that violates patients' privacy. The diversity of State rules in this area compounds the difficulty professionals face in becoming knowledgeable about what rules apply to them. Exceptions to State laws protecting medical and mental health information Consent All States permit health, mental health, and social service professionals to disclose information if the patient or client consents. However, each State has different requirements regarding consent. In some States, consent can be oral; in others, it must be written. States that require written consent sometimes require that certain elements be included in the consent form or that everyone use a State-mandated form. Some States have different consent forms with different requirements for particular diseases.

Other exceptions Consent is not the only exception. All States also require the reporting of certain infectious diseases to public health authorities and some require the reporting of elder abuse to protective service agencies, although definitions of "infectious disease" and "elder abuse" vary. And most States require health care professionals and mental health counselors to report to the authorities threats patients make to inflict harm on others. There are States that permit or require health care professionals to share information about patients with other health care professionals without the patients' consent, but some limit the range of disclosure for certain diseases, like HIV. Most States make some provision for communicating information to health insurance or managed care companies. Many of the situations that physicians and social service workers face daily - processing health claims or public benefit applications, for example - are covered by one of these exceptions. To fully understand the "rules" regarding privacy of medical and mental health information, professionals must also know about the exceptions to those rules. Those exceptions are generally in the statute books - in either the sections on evidence or the professional licensing sections, or both. The state licensing authority as well as professional associations can usually help answer questions about State rules and the exceptions to those rules.

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Enforcing confidentiality protections The role of the courts To determine the "law" - that is, the rule one must follow - in any particular area, an attorney will search for statutes, regulations, administrative rulings, and court decisions. There is no question that in this country, the courts play a large role in "making" law - particularly in an area like privacy, which involves human behavior, shades of meaning, and intent. No legislator drafting a statute (or bureaucrat drafting a regulation) can foresee all the circumstances under which it may be applied. When one party sues another, a court is forced to decide whether a provider's disclosure of medical information was appropriate or whether such information should be disclosed during the lawsuit itself. For example, after a car crash, the drivers may sue each other and ask the court to order the disclosure of medical records. Or the victim of an assault by an adolescent may sue the parents and seek disclosure of medical records to prove they knew their child was dangerous. How a court decides whether to order disclosure in such cases will depend on a variety of factors, including State law and regulation, court rules, and the relevance of the information sought to the dispute at hand. Similarly, when a patient or client sues a professional for releasing information to someone without her consent, the court will be called upon to weigh a variety of factors to decide whether the disclosure violated what the State recognizes as the patient's privacy. Over time, court decisions like these add flesh to the bare statutory and regulatory rules and suggest how those rules will be applied the next time. When a difficult case arises that does not fit neatly within the rule of law as understood, it may be helpful to consult with an attorney familiar with the rules and how the State's courts are likely to interpret them. Penalties for violations States differ in the ways they discipline professionals for violations of patients' or clients' privacy. In some States, violation of confidentiality is a misdemeanor, punishable by a fine or short jail term. In many States, the professional licensing agency has the power to bring disciplinary charges against a professional who violates a client's privacy. Such charges may result in censure or license suspension or revocation. Finally, the State may permit the aggrieved patient or client to sue the professional for damages caused by the violation of his right to confidentiality. The reality is, these enforcement mechanisms are rarely used. States rarely prosecute privacy violation offenses and professional disciplinary

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committees in most States are more concerned with other kinds of professional infractions. That is not to say that violation of a patient's privacy is cost-free. A patient or client who thinks he has been hurt by a professional's indiscretion is free to sue; while such cases are difficult for clients to win, they can cause the professional and the organization employing her a good deal of grief - financial, emotional, and professional. Even short of litigation, no professional wants to acquire the reputation of being thoughtless or indiscreet. Strategies for Dealing With Common Situations Charting substance use information One way for a professional to safeguard clients' privacy and avoid breaking the rules is to develop a charting, or record-keeping, system that is accurate but still protects clients' rights to privacy and confidentiality. It is important to remember how many people could see a client's medical, mental health, or social service record. A medical chart, for example, will be seen by the medical office staff, the insurance company (or HMO or managed care organization [MCO]), and in the event of a referral, another set of clinicians, nurses, clerical workers, and insurers. If the patient is involved in litigation and his medical or mental health is in issue, the court will most likely order disclosure of his chart or file in response to a subpoena. When a provider documents the results of substance abuse screening or assessment or flags an issue to be raised the next time he sees the client, he should use neutral notations or reminders that do not identify the problem as being substance-use-related. Following are three record-keeping systems that comply with the stringent Federal confidentiality regulations, protect clients' autonomy and privacy, and can be used in a wide variety of settings (TIP 16, Alcohol- and Other-Drug Screening of Hospitalized Trauma Patients, CSAT, 1995): ď&#x201A;ˇ The "minimalist" approach, which relies on the provider to enter only that information in the chart that is required for accuracy and to use neutral terms wherever possible. ď&#x201A;ˇ The "rubber band" approach, which segregates substance abuse information in a separate "confidential" section in the chart. Information in this section would be shared with other providers only on a need-to-know basis, without being open to the view of every staff person who picked up the chart. ď&#x201A;ˇ The "separate location" approach, which keeps sensitive information separate from the rest of the client's chart. The

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other place might be a locked cabinet or other similarly secure area. A "gatekeeper" familiar with the provider's record-keeping system and the reasons for the extra security would be responsible for deciding when others - within or outside the office - will have access to this information. This approach provides, in effect, a stronger "rubber band" than that described in the second approach.8 The push toward computerization of medical records will complicate the problem of keeping sensitive information in medical records private. Currently, there is protection afforded by the cumbersome and inefficient way many, if not most, medical, mental health, and social service records make their way from one provider to another. When records are stored in computers, retrieval can be far more efficient. Computerized records may allow anyone with a disc and access to the computer in which the information is stored to instantly copy and carry away vast amounts of information without anyone's knowledge. Modems that allow communication about patients among different components of a managed care network extend the possibility of unauthorized access to anyone with a modem, the password(s), and the necessary software. The ease with which computerized information can be accessed can lead to "casual gossip" about a client, particularly one of importance in a community, making privacy difficult to preserve. Communicating with others One of the trickiest issues is whether and how providers of older adults health care should communicate with others about their clients' substance use problems. Communications with others concerned about the client may confirm the provider's judgment that the client has a substance use problem or may be useful in persuading a reluctant client that treatment is necessary. Before a provider attempts to gather information from other sources or enlist help for a patient or client struggling with recovery, he should ask the older client's permission to do so. Speaking with relatives (including children), doctors, or other health and mental health professionals not only intrudes on the client's autonomy, it also poses a risk to her right to privacy. Gathering information (or responding to questions about a client's problems) from a spouse, child, or other provider can involve an explicit or implicit disclosure that the provider believes the client or patient has a substance use problem. And the provider making such a disclosure may be inadvertently stepping on a land mine.

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Making inquiries or answering questions behind the client's back may seriously jeopardize the trust that has developed between the provider and the client and undermine his attempt to offer help. The professional who talks to the client's son and then confronts her with their joint conclusions runs the risk that he will damage his relationship with the client. Feeling she can no longer trust the provider and angry that he has shown little respect for her autonomy or privacy, the client may refuse to participate in any further discussions about her problems. Dealing with questions of incapacity Most older clients or patients are fully capable of comprehending the information and weighing the alternatives offered by a provider and making and articulating decisions. A small percentage of older patients or clients are clearly incapable of participating in a decision-making process. In such cases, the older person may have signed a health care proxy or may have a court-appointed guardian to make decisions in his stead. The real difficulty arises when a provider is screening or assessing an older person whose mental capacity lies between those two extremes. The client or patient may have fluctuating capacity, with "good days" and "bad days" or periods of greater or lesser alertness depending upon the time of day. His condition may be transient or deteriorating. His diminished capacity may affect some parts of his ability to comprehend information but not others. How can the provider determine whether the patient or client understands the information she is presenting, appreciates the implication of each alternative, and is able to make a "rational" decision, based on his own best interests? There is no easy answer to this question. One can, however, suggest several approaches. Maximizing autonomy. The provider can help the patient or client who appears to have diminished capacity through a gradual informationgathering and decision-making process. Information the client needs should be presented in a way that allows the patient or client to absorb it gradually. The provider should clarify and restate information as necessary and may find it helpful to summarize the issues already covered at regular intervals. Each alternative and its possible consequences should be laid out and examined separately. Finally, the provider can help the client identify his values and link those values to the alternatives presented. By helping the patient or client narrow his focus and proceed step-by-step, the provider may be able to assure herself that the client, despite his diminished capacity, has understood the decision to be made and acted in his own best interest.

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Enlisting the help of a health or mental health professional. If working with the patient or client in a process of gradual information-gathering and decision-making is not making headway, the provider can suggest that together they consult a health or mental health professional. Perhaps there is someone who has known the patient or client for a number of years who has a grasp of the client's history and better understanding of the obstacles to decision-making. Or, the provider may suggest a specialist who can help determine why the patient is having difficulty and whether he has the capacity to make this kind of decision. Enlisting the help of family or close friends. Another approach is for the provider to suggest to the patient or client that they call in a family member or close friend who can help them organize the information and sort through the alternatives. Asking the client who he thinks would be helpful may win his endorsement of this approach. When the client cannot grasp the information or come to a decision. If the provider's efforts to inform the patient or client and help him reach a decision are unsuccessful, she might seek his permission to consult a family member or close friend to discuss the problem. If the client consents, the provider should lay out her concerns for the family member or friend. It may be that the client has already planned for the possibility of his incapacity and has signed a durable power of attorney or a health care proxy. Guardianship. A guardian9 is a person appointed by a court to manage some or all aspects of another person's life. Anyone seeking appointment of a guardian must show the court (1) that an individual is disabled in some way by disease, illness, or senility, and (2) that the disability prevents him from performing the tasks necessary to manage an area or areas of his life. Each state handles guardianship proceedings differently, but some principles apply across the board: Guardianship is not an all-or-nothing state. Courts generally require that the person seeking appointment of a guardian prove the individual's incapacity in a variety of tasks or areas. Courts may apply different standards to different life tasks - managing money, managing a household, making health care decisions, entering contracts. A person may be found incompetent to make contracts and manage money but not to make his own health care decisions (or vice versa), and the guardianship will be limited accordingly. Guardianship diminishes the older adult's autonomy and is an expensive process. It should, therefore, be considered only as a last resort. Making referrals to substance abuse treatment programs

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The provider has persuaded the patient or client to try outpatient treatment and knows the director of an excellent program in the immediate area. Rather than simply picking up the phone and letting the director know she has referred the patient, she should consult the patient about the specific treatment facility. Though it may seem that consent to treatment is the same as consent to referral to a particular facility, it takes very little time to get the patient's consent, demonstrates respect for the client or patient, and protects the provider if, say, the treatment program's director is a relative or has some other connection to the client. Communications with insurers, HMOs, and other third-party payers The structure of health, mental health, and ancillary social service care for older adults is changing rapidly. Of course, older adults are covered by Medicare, but many have supplementary insurance or have joined HMOs or are entitled to government-sponsored social services because of particular medical, physical, or mental disabilities. How should the professional provider communicate with these different types of entities? Traditional health insurance programs offering reimbursement to patients for health care expenditures typically require patients to sign claim forms containing language consenting to the release of information about their care. The patient's signature authorizes the practitioner to release such information. Although HMOs do not require patients to submit claim forms, both practitioners and patients understand that the HMO or MCO can review clinical records at any time and may well review records if it has questions about the patient's or client's care. Should the provider rely on the patient's signed consent on the health insurance form or the HMO contract and release what she has in her chart (or a neutral version of that information)? Or should she consult the patient? The better practice is for the provider to frankly discuss with the patient what information she intends to disclose, the alternatives open to the client (disclosure and refusal to disclose), and the likely consequences of those alternatives. Will the information the provider sends explicitly or implicitly reveal the nature of the patient's problem? Does the client's chart contain a substance abuse diagnosis? Once again, the provider confronts the question of how such information should be recorded. Has she balanced the need for accuracy with discretion and a respect for patients' privacy? Finally, even if the chart or file contains explicit information about the client's substance use problem, can the provider characterize the information and her diagnosis in more neutral terms when releasing information to the third-party payer?

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Once the client understands what kind and amount of information the provider intends to send a third-party payer, he can decide whether to agree to the disclosure. The provider should explain that if she refuses to comply with the third-party payer's request for information, it is likely that at least some related services will not be covered. If the client expresses concern, she should not mislead him, but confirm that once a third-party payer learns he has had a substance use problem, he could and may lose either some of his insurance coverage or parts of other entitlements and be unable to obtain other coverage. The final decision should be the client's. He may well decide to pay out of pocket. Or he may agree to the limited disclosure and ask the provider to inform him if more information is requested. As managed care becomes more prevalent throughout the country, medical and mental health providers are finding that third-party payers demand more and more information about patients and about the treatment provided to those patients in order to monitor care and contain costs. Providers need to be sensitive about the amount and kind of information they disclose because there is a risk that this information may be used to deny future benefits to the client. Chart notes may also contain detailed and very personal information about family life that may be unnecessary for a third-party payer to review in order to determine whether and what kind of treatment should be covered. As in so many other areas involving patients' privacy, it is best to follow two simple rules: First, keep notations and documentation as neutral as possible while maintaining professionally acceptable standards of accuracy. Second, consult the client and let the client decide whether to agree to the disclosure. Communicating with the legal system If a doctor, psychologist, social worker, or other provider gets a call from a lawyer asking about a patient or client, or a visit from a law enforcement officer asking to see records, or a subpoena to testify or produce medical records, what should he or she do? As in other matters of privacy and confidentiality, (1) consult the patient, (2) use common sense, and (3) as a last resort, consult State law (or a lawyer familiar with State law). Responding to lawyers' inquiries. Say a lawyer calls and asks about Emma Bailey's medical, mental health, or social service history or treatment. As a first approach to the question, the provider could tell the lawyer, "I don't know that I have a client with that name. I'd have to check my records" 11 or tell the caller that he must consult with his client before having a conversation about her: "I'm sure you understand that I am professionally obligated to speak with Emma Bailey before I speak with you." It will be

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hard for any lawyer to disagree with this statement. The provider should then ask the client if she knows what information the caller is seeking and whether the client wants him to disclose that or any other information. He should leave the conversation with a clear understanding of the client's instructions - whether he should disclose the information, and if so, how much and what kind. It may be that the lawyer is representing the client in a case and the client wants the provider to share all the information he has. On the other hand, the lawyer may represent someone with whom the client has a dispute. There is nothing wrong with refusing to answer a lawyer's questions. If the lawyer represents the client and the client asks the provider to share all information, the provider can speak freely with the lawyer. However, if the provider is answering the questions of a lawyer who does not represent the client (but the client has consented to the disclosure of some information), the provider should listen carefully to each question, choose his words with care, limit each answer to the question asked, and take care not to volunteer information not called for. Visits by law enforcement. A police officer, detective, or probation officer who asks a provider to disclose medical, mental health, or social service information about a client or a client's case records can usually be handled in a similar manner:13 The provider can safely tell the officer, as he might a lawyer, "I'm sure you understand that I am professionally obligated to speak with my patient before I speak to you." The provider should then speak with the client to find out whether she knows the subject of the officer's inquiry, whether she wants the provider to disclose information and if so, how much and what kind. The caretaker might end the conversation by asking whether there are any particular areas the client would prefer he not discuss with the officer. When a law enforcement officer comes armed with a search warrant, the answer is different. In this case, the provider has no choice but to hand over the records listed in the warrant. Responding to subpoenas. Subpoenas come in two varieties. One is an order requiring a person to testify, either at a deposition out of court or at a trial. The other - known as a subpoena duces tecum - requires a person to appear with the records listed in the subpoena. Depending on the State, a subpoena can be signed by a lawyer or a judge. Unfortunately, it cannot be ignored. In this instance, the provider's first step should be to call Emma Bailey - the client about whom he is asked to testify or whose records are sought - and

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ask what the subpoena is about. It may be that the subpoena has been issued by or on behalf of Emma's lawyer, with Emma's consent. However, it is equally possible that the subpoena has been issued by or on behalf of the lawyer for an adverse party. If that is the case, the provider's best option is to consult with Emma's lawyer to find out whether the lawyer will object - ask the court to "quash" the subpoena - or whether the provider should simply get the client's consent to testify or turn over her records.15 An objection can be based on a number of grounds and can be raised by any party as well as by the person whose medical information is sought. If the provider is covered by a State statutory privilege, he may be able to assert the client's privilege for her. It is essential for those who work with older adults to respect their clients' autonomy and rights to privacy and confidentiality if they are to be effective in screening and assessing clients for substance use disorders and persuading them to cut down their use or enter treatment. In most situations, providers can follow these simple rules: (1) consult the client, (2) let the client decide, and (3) be sensitive to how information is recorded or disclosed. It is only as a last resort that the provider will have to consult State law or a lawyer. Footnotes 1a Margaret K. Brooks is an independent consultant in Montclair, New Jersey. 1b For many years, there was confusion about whether general medical care settings such as primary care clinics or hospital emergency rooms were subject to the Federal law and regulations because they provided substance abuse diagnosis, referral, and treatment as part of their services. In 1995, DHHS revised the definition of the kinds of "programs" subject to the regulations that made it clear that the regulations do not generally apply to a general medical care facility unless that facility (or person) holds itself out as providing, and provides, alcohol or drug abuse diagnosis, treatment, or referral for treatment . . . (42 CFR§ 2.11).The full text of § 2.11 now reads:Program means:(a) An individual or entity (other than a general medical care facility) who holds itself out as providing, and provides, alcohol or drug abuse diagnosis, treatment, or referral for treatment; or(b) An identified unit within a general medical facility which holds itself out as providing and provides, alcohol or drug abuse diagnosis, treatment, or referral for treatment; or(c) Medical personnel or other staff in a general medical care facility whose primary function is the provision of alcohol or drug abuse diagnosis, treatment, or referral for treatment and who are identified as such providers. (See § 2.12(e)(1) for examples.)60 Federal Register 22,297 (May 5, 1995). 2 The regulations provide that "federally assisted" programs include:  Programs run directly by or under contract for the Federal government;  Programs carried out under a Federal license, certification, registration, or other authorization, including certification under the Medicare Program, authorization to conduct a methadone maintenance treatment program, or registration to dispense a drug that is regulated by the Controlled Substances Act to treat alcohol or drug abuse;  Programs supported by any federal department or agency of the United States, even when the federal support does not directly pay for the alcohol or drug abuse diagnosis, treatment, or referral activities;  Programs conducted by State or local government units that are supported by Federal funding that could be (but is not necessarily) spent for the substance abuse treatment program;  Tax-exempt programs. 42 C.F.R.§ 2.12(b). 3 For a full explanation of the Federal law and regulations, see TIP 8, Intensive Outpatient Treatment for Alcohol and Other Drug Abuse (CSAT, 1994) and TAP 13, Confidentiality of Patient Records for Alcohol and Other Drug Treatment (CSAT, 1994).

120 4 Luhndorff v. The Superior Court of Tulare County, 166 CA 3d 485, 212 Cal. Rptr. 516 (5th District, 1985). Interestingly, Luhndorff was a criminal case in which the prosecution sought the records of an unlicensed social worker who interviewed the defendant, diagnosed his problem, determined the appropriate treatment, and treated him for 3 months. The social worker was working under a licensed individual's supervision. The defendant thought the social worker was a psychiatrist. 5 Section 451 of the California Evidence Code codifies the doctor-patient privilege. See Grosslight v. Superior Court of Los Angeles, 42 CA 3d 502, 140 Cal. Rptr. 278 (1977), in which the court held that information communicated by the parents of a minor psychiatric patient to her doctor and his secretary was privileged, even though the parents were being sued by someone the child injured on the theory that the parents knew their child was a danger to others. 6 Note that the breadth of the protection may vary according to the clinician's profession. 7 Grosslight v. Superior Court of Los Angeles, 72 Cal. App. 3d 502, 140 Cal. Rptr. 278 (1977), interpreting Section 451 of the California Evidence Code (see footnote 5). 8 The Consensus Panel for TIP 16 noted: "Physical separation of clinical information is not unusual. Patient charts from past years are generally kept in a separate location. Physicians routinely request charts to be sent to them from this location so that they can review historical clinical information about the patient. In addition, nurses are quite accustomed to keeping some medications locked up and accessible only to designated personnel." (TIP 16, CSAT, 1995, p. 76) 9 In some States, a guardian is referred to as a fiduciary, conservator, or committee. The person who has a guardian is generally called a "ward" or an "incapacitated person." 10 Some States prohibit insurance companies from discriminating against individuals who have received substance abuse treatment; however, these kinds of discriminatory practices continue. Insurance companies routinely share information about applicants for life and disability insurance through the Medical Information Bureau - a data bank maintained by a private organization and supported by the industry. 11 In fact, in some States, depending on the provider's profession, the identity of patients or clients as well as their records are protected. Therefore, professionals should find out whether disclosing a patient's name or acknowledging that the individual about whom the lawyer is inquiring is a client would be considered a violation of the client's right to confidentiality. 12 A firm, but polite, tone is best. If confronted by what could be characterized as "stonewalling," a lawyer may be tempted to subpoena the information he is asking for, and more. The clinician will not want to provoke the lawyer into taking action that will harm the patient. 13 The only exception to this advice would be if the provider knew the patient was a fugitive being sought by law enforcement. In that case, in some States, a refusal to assist or give officers information might be a criminal offense. 14 As noted above, in those States where the identity of clients or patients as well as their medical or mental health records are protected, the professional should give a noncommittal response, such as "I'll have to check my records to see whether I have such a patient." In most instances, the provider is not legally required to notify the client or get his consent to release records that have been subpoenaed. However, notifying the client shows respect for his autonomy and privacy and gives him an opportunity to object to the subpoena

14. Resources Generations United www.gu.org Generations United (GU) focuses solely on promoting intergenerational strategies, programs, and policies. GU serves as a resource for educating policymakers and the public about the economic, social, and personal imperatives of intergenerational cooperation. National Council on Aging (NCOA) www.ncoa.org Founded in 1950, NCOA is the nation's first association of organizations and

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professionals dedicated to promoting the dignity, self-determination, well being, and contributions of older persons. Senior Corps www.seniorcorps.org Senior Corps is a network of programs that tap the experience, skills, and talents of older citizens to meet community challenges with Foster Grandparents, Senior Companions, and RSVP (Retired and Senior Volunteer Program). Senior Corps, part of the USA Freedom Corps, is administered by the Corporation for National and Community Service, the federal agency that also oversees AmeriCorps and Learn and Serve America. AARP www.aarp.org AARP conducts and publishes a wide range of studies on aging. Most of it is available at their Online Research Center at http://research.aarp.org/. Administration on Aging www.aoa.gov This government agency, which is part of the Department of Health and Human Services, provides a great deal of information about the economic and health status of older Americans. U.S. Census Bureau www.census.gov Provides a wide range of statistics on demographics as well as economics of Americans of all ages. Centers for Medicare and Medicaid Services http://cms.hhs.gov/researchers/ A good source for data on the health status of older Americans. Federal Interagency Forum on Aging-Related Statistics http://www.agingstats.gov/chartbook2000/ This site provides access to a comprehensive report, Older Americans 2000: Key Indicators of Well-Being. Civic Ventures www.civicventures.org This non-profit organization, which is the parent of Experience Corps, conducts research and publishes studies on topics such as attitudes toward retirement and volunteering and civic engagement among older Americans. Most of this research is available online. Independent Sector www.independentsector.org

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An excellent source of information about the involvement of Americans as volunteers. Independent Sector has just published a new report, Experience at Work: Volunteering and Giving Among Americans 50 and Over. International Longevity Center www.ilcusa.org An independent research organization that conducts and publishes research on many subjects related to the extension of the life span and its social and economic impacts. The Eldercare Locator (1-800-677-1116) can direct you to your Area Agency on Aging. They will give you information on local long-term care resources and programs. Visit their website at http://www.aoa.dhhs.gov. The Nursing Home Information Service at the National Council of Senior Citizens, 8403 Colesville Road, Suite 1200, Silver Spring, MD 20910 (301578-8938) has information on community services and offers a free guide on how to select a nursing home. Visit their website at http://www.ncscinc.org. The Health Care Financing Administration publishes the "Guide to Choosing a Nursing Home" and the annual "Guide to Health Insurance for People with Medicare." The nursing home guide includes a detailed checklist. Call 1-800-638-6833. Visit their website at http://www.hcfa.gov. Each state Office of the Long-Term Care Ombudsman visits nursing homes on a regular basis and handles complaints. Find your ombudsman by calling the National Association of State Units on Aging at 202-898-2578. The association has publications about long-term care and can provide a list of facilities. Other sources of information include: The American Association of Homes and Services for the Aging 901 E Street, N.W., Suite 500 Washington, D.C. 20004-2011 202-783-2242 http://www.aahsa.org The Assisted Living Federation of America Suite 400, 10300 Eaton Place Fairfax, VA 22030 703-691-8100

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http://www.alfa.org The American Health Care Association 1201 L Street, N.W. Washington D.C. 20005 202-842-4444 The National Citizens' Coalition for Nursing Home Reform's publications list is available from Suite 202, 1424 16th Street, N.W., Washington, D.C. 20036-2211; call 202-332-2275. For more information about health and aging, contact: National Institute on Aging Information Center P.O. Box 8057 Gaithersburg, MD 20898-8057 1-800-222-2225 1-800-222-4225 (TTY) http://www.nih.gov/nia Alzheimer's Disease Education and Referral (ADEAR) Center P.O. Box 8250 Silver Spring, MD 20907-8250 1-800-438-4380 http://www.alzheimers.org

15. References AARP, Staying Ahead of the Curve 2003 Bath, P.A. (2003). Differences between older men and woman in the SelfRated Health/ Mortality Relationship. The Gerontologist, 43 387-94 Charles, S.T., Reynolds, C.A., & Gatz, M. (2001). Age-related differences and change in positive and negative affect over 23 years. Journal of Personality and Social Psychology, 80, 136-151.

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Mather, M., & Carstensen, L. L. (2005). Aging and motivated cognition: The positivity effect in attention and memory. Trends in Cognitive Sciences Masoro E.J. & Austad S.N.. (eds.): Handbook of the Biology of Aging, Sixth Edition. Academic Press. San Diego, CA, USA, 2006. ISBN 0-12088387-2 Saltman, R.B.; Dubois, H.F.W.; Chawla, M. (2006). "The Impact Of Aging On Long-term Care In Europe And Some Potential Policy Responses Strawbridge, W.J., Wallhagen, M.I. & Cohen, R.D. (2002). Successful aging and well-being: Self-rated compared with Rowe and Kahn. The Gerontologist. Zacks, R.T., Hasher, L., & Li, K.Z.H. (2000). Human memory. In F.I.M. Craik & T.A. Salthouse (Eds.), The Handbook of Aging and Cognition (pp. 293-357). Mahwah, NJ: Erlbaum. Frey, W. H. (2000, Summer). The New urban demographics. Brookings Review (18), pp. 20-25. Hays, D. (2001, April 30). Risk managers cope with aging workforce. National Underwriter Property & Casualtyâ&#x20AC;&#x201D;Risk & Benefits Management (105), pp. 16-18. Maitland, A. (2001, June 26). An Alternative to early retirement. The Financial Times, p. 15. Ormsbee, J. T. (2001, August 13). An age-old story. InfoWorld, pp. 40-44. Sawyers, A. (2001, February 26). Reynolds workers allege race discrimination. Automotive News (75), p. 6. Tobias, R. M. (2001, September). An Aging workforce: A Time of opportunity or a time of calamity? The Public Manager (30), pp. 27-32. Woodward, H. (2000, September). I can see clearly now. HRMagazine (45), pp. 119-121.