Workshop Summary Report - Best Practices - Treatment and Rehabilitation for Seniors with Substance Use Problems, March 6 and 7, 2003

Age Specific Programming

a) Presentation by Betty MacGregor

Lifestyle Enrichment for Senior Adults (LESA) has been in existence for 22 years as part of the Centretown Community Health Centre in Ottawa. The program provides support for adults aged 55 and older who are concerned about their alcohol or drug use, or problem gambling. The program is mainly an urban community-based service, but also services rural areas to some extent.

Alternative treatment options are often indicated for seniors because of their unique issues and needs. Seniors with substance use problems may have difficulty reaching out for help or utilizing treatment services. There can be many reasons for these barriers. For example, treatment programs that are very structured may be too intense or tiring; other health issues may affect their ability to participate; treatment location may not be accessible; and there can be feelings of stigma and shame around needing services.

Most clients of the LESA program are at the 'precontemplation stage', in the 'stages of change' model. They do not feel the need nor the desire to change. Many are in contact with services because family members have expressed concerns. The implication for the counsellor is that they need to focus on engaging the client in what he/she is interested in doing or achieving, and help him/her examine the family's concerns. The 'cause of concern' can be a forum to move the client to the 'contemplation' stage.

An age specific approach should:

• be senior-specific;
• be flexible;
• offer a holistic lifestyle treatment model that does not necessarily require abstinence;
• aim to reduce harm and increase quality of life;
• support choices made by the client;
• be non-confrontational;
• respect each individual's preferred pace for making changes and acknowledge small steps toward goals;
• provide support based on individual strengths and needs;
• use a multi-disciplinary approach involving input from nurses, doctors and social workers; and
• provide senior-specific information and education on addiction issues.

LESA's harm reduction approach is designed to reflect the client's particular needs and treatment pace. Recognizing that seniors, especially women, may feel there is a social stigma against using alcohol, the program takes a non-judgmental view of both substance use and people who use. The program permits flexibility to accommodate individual needs in terms of reduced use versus abstinence. Priority is given to strategies that can achieve an immediate reduction of harm, such as preventing a home eviction or improving client nutrition. Throughout the process, clients are regarded as active participants and are given as many choices as possible.

Services provided by LESA:

• Home visits by experienced counsellors;
• One-to-one support and counselling (to caregivers as well as to seniors);
• Group counselling;
• Social outings and recreational activities;
• Support to care-givers and other professionals;
• Intensive case management;
• A telephone help line; and
• Health promotion and community education.

Fifty to sixty percent of LESA's clients are seen in their homes. Experience has shown that the social programming is very important to clients and for that reason LESA offers frequent social outings.

Collaboration and co-operation with other service providers are necessary and support effective referrals and case management.

Guidelines for staff:

• Be comfortable with the pace of change when working with seniors.
• Be adaptable to working with someone in their home.
• Understand the boundaries involved in being in someone's home.
• Obtain training in substance abuse and geriatrics.
• Be knowledgeable about other community resources.
• Be prepared to act as an advocate for clients who are in treatment mainly because of family members' concerns.
• Be creative, persistent and open-minded in approach.

Case Studies

Two case studies were presented to illustrate the struggle seniors can face when dealing with substance use problems.

• The first case study was a woman with a 40-year addiction to Librium. Success was achieved by lowering the dosage from 50mg per day to 15mg per day, rather than by eliminating the drug completely. Attempts were made to lower the dosage further but were abandoned due to episodic anxiety and panic. The psychiatrist agreed that the client needed to be on a maintenance dose and this course of action was followed.
  
  
• In the second case study, an elderly client tried on numerous occasions to reduce her drinking. Due to severe depression she had been unable to do so. It was not until she broke her hip and was hospitalized for a period of time and detoxicated that she was able to abstain. In this case the process from first contact with LESA to abstinence took three years.

b) Group Discussion - Age Specific Programming

Age Specific Programming Challenges and Solutions Identified by the Participants
Challenges	Solutions
Agencies do not recognize the need for senior-specific programs.	Devote resources to a dedicated position to do advocacy for seniors' programming. Create educational opportunities on seniors' issues for the agency. Increase awareness by offering training in college programs.
Insufficient resources or competition for resources, both human and financial, for senior-specific programs.	Pool resources from different agencies and disciplines. Integrate community-based services into acute care programs. Increase knowledge of the nature/extent of seniors' problems with better history-taking and screening tools for doctors. For example, a laminated card to guide the collection of senior-specific information. Where budgets are non-existent develop support groups using volunteers and one paid staff.
Staff, agencies, and the community are uncomfortable with harm reduction approach.	Provide educational forums on harm reduction to allow people to voice their concerns and to hear stories of clients who have been helped under this approach. Information about Canada's leading role in harm reduction and useful websites should be distributed.
Agency policies that pose barriers to outreach and home visits and a lack of staff training to do outreach.	Consult with agencies that have outreach programs, to learn from their experience and to share staff training tools. Target staff who have outreach or extensive experience and who are committed to working with seniors.
Agencies that help seniors with various issues (e.g., addictions, violence) often work at cross purposes.	Coordination and regular dialogue between agencies is essential. Joint educational sessions and exchange of information among staff can also help.
Meeting the needs of a diverse group with an age range from 55-100 years.	Maintain a client centred approach; allow seniors to identify their needs; understand age-specific issues. Establish a creative treatment setting with a variety of designs and programs. Top of Page
Some therapies are not appropriate for seniors (e.g., cognitive therapy is not indicated for seniors with cognitive difficulties).	Devote resources to the design of age-specific programs. Improve coordination within and between organizations mandated to work with seniors.
Conflict between organizational goals and the needs of the client.	Educate management. Try to reduce workload of staff so they can spend more time with seniors.
Services for seniors are often dispersed geographically. It is hard for families to access/coordinate services.	Integrate intake services and case management to develop a team.
Barriers to services for seniors.	Make it possible for people to access services without a referral from a doctor (general practitioner). Ensure transportation is provided. Eliminate physical barriers to buildings. Do some needs assessment to identify other potential barriers. Adopt a multicultural programming model.
Assessment practices can be lengthy and tiring or disrespectful to seniors.	Develop senior-friendly and senior-specific assessment tools, in collaboration with addictions, mental health and family violence agencies.
Some physicians may have a tendency to under-estimate drug/alcohol interactions.	Develop activities to increase awareness of addiction issues among seniors. Organize education days for physicians in geriatrics and psychiatry. Address potential alternatives to medication.
Physicians are not always aware of supports offered to seniors by other health professionals.	Promote resources that are currently available. Identify ways to have open dialogue with physicians.
The pace of change with seniors can be slow and professionals/volunteers can become discouraged.	Promote knowledge and understanding of the pace of change.
Seniors who supply other seniors with alcohol.	Educate seniors about addictions and the consequences of enabling behaviours. Offer information about constructive peer support. Train nurses and staff to recognize when this is occurring.
Clients who do not want to change.	Work to raise awareness rather than push to action. Develop programs that encourage client self-determination.