CSAT’s
Knowledge Application Program
KAP Keys for Clinicians
Based on TIP 26
Substance Abuse Among Older Adults
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
www.samhsa.gov
Introduction
Key 1 Physical Symptom Screening Triggers
Key 2 Applying DSM-IV Diagnostic Criteria to Older Adults with Alcohol Problems
Key 3 Clinical Characteristics of Early and Late Onset Problem Drinkers
Key 4 Effect of Aging on Response to Drug Effect
Key 5 Michigan Alcoholism Screening Test-Geriatric Version (MAST-G)
Key 6 The AUDIT Questionnaire
Key 7 The CAGE Questionnaire
Ordering Information
These KAP Keys were developed to accompany the Treatment Improvement Protocol (TIP) Series published by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration. These KAP Keys are based entirely on TIP 26 and are designed to meet the needs of the busy clinician for concise, easily accessed "how-to" information.
For more information on the topics in these KAP Keys, readers are referred to TIP 26.
Other Treatment Improvement Protocols (TIPs) that are relevant to these KAP Keys:
TIP 6, Screening Instruments for Infectious Diseases Among Substance Abusers (1993) BKD131
TIP 9, Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other Drug Abuse (1994) BKD134
TIP 11, Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Diseases (1994) BKD143
TIP 27, Comprehensive Case Management for Substance Abuse Treatment (1998) BKD251
TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment (1999) BKD342
• Sleep complaints; observable changes in sleeping patterns; unusual fatigue, malaise, or daytime drowsiness; apparent sedation (e.g., a formerly punctual older adult begins oversleeping and is not ready when the senior center van arrives or pickup)
• Cognitive impairment, memory or concentration disturbances, disorientation or confusion (e.g., family members have difficulty following an older adult's conversation, the older adult is no longer able to participate in the weekly bridge game or track the plot on daily soap operas)
• Seizures, malnutrition, muscle wasting
• Liver function abnormalities
• Persistent irritability (without obvious cause) and altered mood, depression, or anxiety
• Unexplained complaints about chronic pain or other somatic complaints
• Incontinence, urinary retention, difficulty urinating
• Poor hygiene and self-neglect
• Unusual restlessness and agitation
• Complaints of blurred vision or dry mouth
• Unexplained nausea and vomiting or gastrointestinal distress
• Changes in eating habits
• Slurred speech
• Tremor, motor uncoordination, shuffling gait
• Frequent falls and unexplained bruising
Key 2 Applying DSM-IV Diagnostic Criteria to Older Adults with Alcohol Problems
Diagnostic criteria for alcohol dependence are subsumed within the DSM-IV's general criteria for substance dependence. Dependence is defined as a "maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period" (American Psychiatric Association 1994, p. 181). There are special considerations when applying DSM-IV criteria to older adults with alcohol problems.
Tolerance: May have problems with even low intake due to increased sensitivity to alcohol and higher blood alcohol levels
Withdrawal: Many late onset alcoholics do not develop physiological dependence
Taking larger amounts or over a longer period than was intended: Increased cognitive impairment can interfere with self-monitoring; drinking can exacerbate cognitive impairment and monitoring
Unsuccessful efforts to cut down or control use: Same issues across life span
Spending much time to obtain and use alcohol and to recover from effects: Negative effects can occur with relatively low use
Giving up activities due to use: May have fewer activities, making detection of problems more difficult
Continuing use despite physical or psychological problem caused by use: May not know or understand that problems are related to use, even after medical advice
Key 3 Clinical Characteristics of Early and Late Onset Problem Drinkers
Age at Onset
Early Onset: Various, e.g., < 25, 40, 45
Late Onset: Various, e.g., > 55, 60, 65
Gender
Early Onset: Higher proportion of men than women
Late Onset: Higher proportion of women than men
Socioeconomic Status
Early Onset: Tends to be lower
Late Onset: Tends to be higher
Drinking in Response to Stressors
Early Onset: Common
Late Onset: Common
Family History of Alcoholism
Early Onset: More prevalent
Late Onset: Less prevalent
Extent and Severity of Alcohol Problems
Early Onset: More psychosocial, legal problems, greater severity
Late Onset: Fewer psychosocial, legal problems, lesser severity
Alcohol-Related Chronic Illness (e.g., cirrhosis, pancreatitis, cancers)
Early Onset: More common
Late Onset: Less common
Psychiatric Comorbidities
Early Onset: Cognitive loss more severe, less reversible
Late Onset: Cognitive loss less severe, more reversible
Age-Associated Medical Problems Aggravated by Alcohol (e.g., hypertension, diabetes mellitus, drug–alcohol interactions)
Early Onset: Common
Late Onset: Common
Treatment Compliance and Outcome
Early Onset: Possibly less compliant; Relapse rates do not vary by age of onset
Late Onset: Possibly more compliant; Relapse rates do not vary by age of onset
Source: Atkinson et al. 1990; Blow et al. 1997; Schonfeld and Dupree 1991.
Key 4 Effect of Aging on Response to Drug Effect
Analgesics
Aspirin
Action: Acute gastroduodenal mucosal damage
Effects of Aging: No change
Morphine
Action: Acute analgesic effect
Effects of Aging: Increased
Pentazocine
Action: Analgesic effect
Effects of Aging: Increased
Anticoagulants
Heparin
Action: Activated partial thromboplastin time
Effects of Aging: No change
Warfarin
Action: Prothrombin time
Effects of Aging: Increased
Bronchodilators
Albuterol
Action: Bronchodilation
Effects of Aging: No change
Ipratropium
Action: Bronchodilation
Effects of Aging: No change
Cardiovascular Drugs
Adenosine
Action: Minute ventilation and heart rate
Effects of Aging: No change
Diltiazem
Action: Acute antihypertensive effect
Effects of Aging: Increased
Enalepril
Action: Acute antihypertensive effect
Effects of Aging: Increased
Isoproterenol
Action: Chronotropic effect
Effects of Aging: Decreased
Phenylephrine
Action: Acute vasoconstriction; Acute antihypertensive effect
Effects of Aging: No change
Prazocin
Action: Chronotropic effect
Effects of Aging: Decreased
Timolol
Action: Chronotropic effect
Effects of Aging: No change
Verapamil
Action: Acute antihypertensive effect
Effects of Aging: Increased
Diuretics
Furosemide
Action: Latency and size of peak diuretic response
Effects of Aging: Decreased
Psychotropics
Diazepam
Action: Acute sedation
Effects of Aging: Increased
Diphenhydramine
Action: Psychomotor function
Effects of Aging: No change
Haloperidol
Action: Acute sedation
Effects of Aging: Decreased
Midazolam
Action: Electroencephalographic activity
Effects of Aging: Increased
Temazepam
Action: Postural sway, psychomotor effect, and sedation
Effects of Aging: Increased
Triazolam
Action: Psychomotor activity
Effects of Aging: Increased
Others
Levodopa
Action: Dose elimination due to side effects
Effects of Aging: Increased
Tolbutamide
Action: Acute hypoglycemic effect
Effects of Aging: Decreased
Source: Adapted from Cusack and Vestal 1986.
Key 5 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 chest?
YES NO
2. When talking with others, do you ever underestimate how much you actually drink?
YES NO
3. Does alcohol make you sleepy so that you often fall asleep in your chair?
YES NO
4. After a few drinks, have you sometimes not eaten or been able to skip a meal because you didn't feel hungry?
YES NO
5. Does having a few drinks help decrease your shakiness or tremors?
YES NO
6. Does alcohol sometimes make it hard for you to remember parts of the day or night?
YES NO
7. Do you have rules for yourself that you won't drink before a certain time of the day?
YES NO
8. Have you lost interest in hobbies or activities you used to enjoy?
YES NO
9. When you wake up in the morning, do you ever have trouble remembering part of the night before?
YES NO
10. Does having a drink help you sleep?
YES NO
11. Do you hide your alcohol bottles from family members?
YES NO
12. After a social gathering, have you ever felt embarrassed because you drank too much?
YES NO
13. Have you ever been concerned that drinking might be harmful to your health?
YES NO
14. Do you like to end an evening with a nightcap?
YES NO
15. Did you find your drinking increased after someone close to you died?
YES NO
16. In general, would you prefer to have a few drinks at home rather than go out to social events?
YES NO
17. Are you drinking more now than in the past?
YES NO
18. Do you usually take a drink to relax or calm your nerves?
YES NO
19. Do you drink to take your mind off your problems?
YES NO
20. Have you ever increased your drinking after experiencing a loss in your life?
YES NO
21. Do you sometimes drive when you have had too much to drink?
YES NO
22. Has a doctor or nurse ever said they were worried or concerned about your drinking?
YES NO
23. Have you ever made rules to manage your drinking?
YES NO
24. When you feel lonely, does having a drink help?
YES NO
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.
©The Regents of the University of Michigan, 1991.
Circle the number that comes closest to the patient's answer.
1. How often do you have a drink containing alcohol?
(0) Never (1) Monthly or less (2) Two to four times a month (3) Two to three times a week (4) Four or more times a week
2. How many drinks containing alcohol do you have on a typical day when you are drinking? [Code number of standard drinks.1]
(0) 1 or 2 (1) 3 or 4 (2) 5 or 6 (3) 7 to 9 (4) 10 or more
3. How often do you have six or more drinks on one occasion?
(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily
4. How often during the last year have you found that you were not able to stop drinking once you had started?
(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily
5. How often during the last year have you failed to do what was normally expected from you because of drinking?
(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily
6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily
7. How often during the last year have you had a feeling of guilt or remorse after drinking?
(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily
8. How often during the last year have you been unable to remember what happened the night before because you had been drinking?
(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily
9. Have you or someone else been injured as a result of your drinking?
(0) No (2) Yes, but not in the last year (4) Yes, during the last year
10. Has a relative or friend or a doctor or other health worker been concerned about your drinking or suggested you cut down?
(0) No (2) Yes, but not in the last year (4) Yes, during the last year
1. In determining the response categories it has been assumed that one drink contains 10 g alcohol. In countries where the alcohol content of a standard drink differs by more than 25 percent from 10 g, the response category should be modified accordingly.
Scoring
Question 1: Never, 0; Monthly or less, 1; 2 to 4 times per month, 2; 2 to 3 times per week, 3; 4 or more times per week, 4
Question 2: 1 or 2, 0; 3 or 4, 1; 5 or 6, 2; 7 or 9, 3; 10 or more, 4
Question 3-8: Never, 0; Monthly or less, 1; Monthly, 2; Weekly, 3; Daily or almost Daily, 4
Question 9-10; No, 0; Yes but not in the last year, 2; Yes during the last year, 4
The minimum score (for nondrinkers) is 0 and the maximum possible score is 40. A score of 8 or more indicates a strong likelihood of hazardous or harmful alcohol consumption.
In some patients, the AUDIT questions may not be answered accurately because they refer specifically to alcohol use and problems. Some patients may be reluctant to confront their alcohol use or to admit that it is causing them harm. Individuals who feel threatened by revealing this information to a health worker, who are intoxicated at the time of the interview, or who have certain kinds of mental impairment may give inaccurate responses. Patients tend to answer most accurately when:
• The interviewer is friendly and nonthreatening
• The purpose of the questions is clearly related to a diagnosis of their health status
• The patient is alcohol- and drug-free at the time of the screening
• The information is considered confidential
• The questions are easy to understand
Source: Saunders, J.B., Aasland, O.G., Baabor, T.F., de la Fuente, J.R., and Grant, M. WHO collaborative project on early detection of persons with harmful alcohol consumption. II. Development of the screening instrument "AUDIT." British Journal of Addictions, in press.
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.
Note: 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.
Source: Ewing 1984.
TIP 26
Substance Abuse Among Older Adults
Easy Ways to Obtain Free Copies of All TIP Products
1. Call SAMHSA’s National Clearinghouse for Alcohol and Drug Information (NCADI) at 800-729-6686, TDD (hearing impaired) 800-487-4889.
2. Visit CSAT’s Web site at www.csat.samhsa.gov
Do not reproduce or distribute this publication for a fee without specific, written authorization from the Office of Communications, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services.
DHHS Publication No. (SMA) 01-3586
Printed 2001