PowerPoint Presentation - Virginia Department of Alcoholic

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					The Use of Brief Interventions for At-Risk Drinking in
                     Older Adults

                      Kristen L. Barry, PhD
                       Research Professor

               University of Michigan Department of Psychiatry
         and Department of Veterans Affairs National Serious Mental
        Illness Treatment Research and Evaluation Center (SMITREC)
Aspects of Effective Brief
 Support Self-efficacy
                    Miller and Rollnick, 1993
Settings for Brief Interventions
•   Primary Care
•   Emergency Department
•   Hospitals
•   Community
•   Workplace
•   Home Health Care
•   Substance Abuse Treatment Programs
Who Can Conduct Brief Alcohol
•   Physicians
•   Nurses/Nurse Practitioners
•   Physician Assistants
•   Social Workers
•   Psychologists
•   Health Educators
•   Home Health Workers
•   Other Allied Health Providers
     Confrontation vs. MI
                                   Motivational Interviewing
Confrontational Approach           Approach
•Accept self as alcoholic          •De-emphasis on labels

•Personal pathology - reduces      •Emphasis on personal choice and
personal choice, judgment, control responsibility

•Present evidence of problems      •Elicit concern/evidence

•Resistance = “denial”             •Resistance influenced/induced by

•Meet resistance with              •Meet Resistance with Reflection
argumentation and correction

•Goals and strategies prescribed   •Goals and Strategies negotiated -
                                   involvement and acceptance of
                                   goals are vital
Steps in Brief Alcohol Intervention
 Identifying future goals
 Summary of health habits
    individualized feedback on health, drinking, med use,
 Standard drinks
 Types of Older Drinkers
 Consequences of At-Risk drinking
 Reasons to quit or cut down
 Drinking agreement and plan
    controlled drinking vs. abstinence goal
 Risky situations/Alternatives
      Brief Intervention Steps
Identifying future goals
 Participants are asked to identify their goals
     Physical and mental health
     Social lives/relationships
     Finances, etc.
 This makes certain issues affected by alcohol
 salient, and may assist in developing a discrepancy
 between current drinking and valued goals during
 the course of the intervention.
        Brief Intervention Steps
 Summary of health habits

• Participants provide information regarding
   – physical and mental health functioning
   – health habits, nutritional issues, tobacco use
   – alcohol consumption

This is an opportunity for the interventionalist to give
 individualized Feedback, and facilitates self-reflection
 regarding health status and alcohol use.
      Brief Intervention Steps
Standard Drinks and Types of Older Drinkers
• Participants are introduced to the concept of
  standard drinks
• Participants are shown how their level of
  alcohol consumption compares to other older

This assists participants in understanding that the
 effects of alcohol are similar across beverage
 groups and puts their drinking in perspective.
         Brief Intervention Steps

   Reasons to Quit or Cut Down

 Participants are asked to identify positive and
  negative aspects of their alcohol use
 Participants are asked to identify “benefits of
  change” and “barriers to change”

This assists participants in weighing the issues, and
 hopefully “tipping the decisional balance” in favor of
 changing drinking habits.
          Brief Intervention Steps
   Drinking Agreement and Plan

 Participants are asked to choose a drinking goal
  (reduction vs. abstinence), their start date for
  addressing their drinking, their rate of reduction,
  and target date
This provides a MENU of options to participants.
 Intervention staff may offer additional Feedback/Advice.
 Goal choice increases a sense of personal
       Brief Intervention Steps
Risky Situations/Alternatives are identified

• Participants are asked about the situations and
  environmental cues that may trigger drinking

Increases insight into consumption, allows
 participants to identify their own strategies for
 cutting down. Staff are trained in Empathic
 techniques and to Support Self-efficacy.
     Practical Summary
 Assessboth consumption and
 Consider possible goals (engage in
   treatment/quit or reduce drinking)
 Use the FRAMES/Motivational
   Enhancement Approach
If a Follow-up Intervention
      Session is Needed
        Follow-up Sessions
• The timing of these sessions are
  – Clients should receive a follow-up
    session at 6 and 12 weeks after the initial
• The purpose is multifaceted
  – Assess progress
  – Show concern and empathy
  – Provide support and advice
 Differences from Initial Session
• There is a greater focus on alcohol use and
  the consequences of the alcohol use

• More time is available to discuss
  consequences of use and strategies for
  changing behavior

• The individual has had a chance to try and
  change their behavior based upon prior
  visit(s) and thus you have the opportunity to
  discuss successes and shortfalls
Special Circumstances/Issues
Medical Issues to Consider
 for Brief Interventions
Alcohol can cause or exacerbate the
    following health problems:
 malnutrition, stomach problems, liver
 disease, stroke, cardiac problems,
 pancreatitis, hypertension, insomnia,
 cognitive problems/dementia, falls,
 depression, cancer, chronic pain,
 adverse medication effects/interactions,
 Lifetime Prevalence (%) of Substance Use
Disorders for Various Psychiatric Disorders

                            % ANY SUBSTANCE
  General population               16.7
  Schizophrenia                    47.0
  Any affective disorder           32.0
    Any bipolar disorder           56.1
    Major depression               27.2
    Dysthymia                      31.4
  Any anxiety disorder             23.7
    OCD                            32.8
    Phobia                         22.9
    Panic                          35.8
                                   Regier et al,
         Factors Associated with Dual
          Diagnosis in Older Adults
• Compared to older adults with psychiatric illness alone,
  those with dual diagnoses:
   –   DD more likely in males, Minority populations
   –   More likely to have dementia
   –   Less likely to have schizophrenia or PTSD
   –   No difference in rate of major depression or bipolar disorder
               • Prigerson, et al., 2001

• Compared to older adults with SA alone:
   – DD more likely in women, Caucasians
               • Brennan, et al., 2002
 Impact of Co-occurring
Disorders in Older Adults

– Higher rates of active suicidal ideation compared
  to persons with depression or alcohol use alone

– Higher health care utilization
   • Psychiatric services
   • Substance abuse services
   Factors Associated with Dual
 Diagnosis in Older Adults (Cont.)

• Prevalence of lifetime alcohol abuse
  and dependence
  – 1.5 times higher among persons with cognitive
           • George, Landeman, Blazer, & Anthony, 1991
• Highest rates of suicide occur in late life
  among men
• Depression causes a 5.8 fold increase in risk
  of suicide compared to death from other
• Heavy drinking (3+ drinks/day) causes a 8.9
  fold increase in risk of suicide compared to
  death from other causes
• Moderate drinking (1-2 drinks/day) causes a
  10.6 fold increase in risk of suicide compared
  to death from other causes
                                    Grabble, et al. 1997
Effects of Treating Both Alcohol
     Abuse and Depression
• Importance of treating both depression and alcohol
• Combination of depression treatment and reduced
  alcohol use was beneficial in significantly reducing
            • Oslin, et al., 2000
Depression Treatment Outcomes in Older
   Adults with Alcohol Use Disorders

 • Inpatients treated for depression
    – Improved Geriatric Depression Scores (GDS)
       • Across light, moderate, and heavy alcohol consumers
    – Among patients drinking at admission
       • 80% reduced drinking by 90%+

 • History of alcohol-related problems
    – Not predictive of discharge outcomes
    – 3 to 4 months post-discharge outcomes
       • Improved social functioning and energy
               • Oslin, et al., 2000
       The Spectrum of Interventions for
                 Older Adults
                 A            B            C           D          E              F
                Not    Light-Moderate    Heavy      Alcohol     Mild       Chronic/Severe
              Drinking    Drinking      Drinking   Problems   Dependence    Dependence


Brief Advice


Formal Specialized Treatments

A brief intervention is one of the effective
tools for working with older adults across a
range of issues related to alcohol misuse and

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