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

Treatment Interventions

a) Presentation by Margaret Flower

The senior is the expert and this is an important principle that must guide work with them. Service providers must learn to draw strength from what clients know about their own situation and needs.

Being 'client centred'

One of the main principles common to treatment programs for seniors is that they are client centred. This means listening to what the client wants and seeing if there is a way to help them get what they want. There are varying interpretations of what client centred means and agencies should be very clear about what the term means to them.

Working with seniors - getting started

Agencies may not be able to have staff time dedicated solely to work with seniors with separate programs but they can start by finding someone within the organization who is really interested in working with seniors and dedicate a modest percentage of the person's time to this work.

Agencies have to change their programs in order to serve seniors. This will involve changing the pace, goals and direction of treatment. The pace of treatment will need to be slower because as individuals get older there is a tendency to work and learn at a slower pace. Attention should be given to whether clients can hear and/or understand what is being said and asked of them. Language barriers and cultural differences also need to be considered. Seniors may need help in defining realistic goals that mean something to them.

Harm reduction

Services providers need to be familiar with the philosophy of their agencies regarding harm reduction and whether the community is comfortable with this approach, as without the agency and community's support work around harm reduction approach can be very difficult. Agencies may need to adapt and accept this approach in working with seniors. However, harm reduction approach may not be for all seniors, as some want to work on abstinence. There may also be a need to educate the community about harm reduction.

The signs of aging or an alcohol/drug problem

It is important to note that some of the signs of substance misuse can be wrongly attributed to other health conditions or aging. These signs can include confusion, depression, disorientation, unsteady gait/falls, recent memory loss, loss of interest in activities, social isolation, tremors, irregular heart rate, poor appetite, and stomach complaints.

Older adults and special needs

Service providers should be aware of the unique needs of seniors. Are anxiety, pain or fear complicating factors for adults in admitting they have a problem? Many seniors may be afraid to admit to an addiction for fear of losing independence or ending up in a nursing home. Service providers need to really listen to their clients and treat them with respect, for example, by not addressing questions to family members. Service providers also need to be aware of what can limit effective communication, for example, hearing difficulties or the use of jargon.

Service providers need to identify if the presenting problem is masking substance abuse or is the abuse masking other problems? Identifying the problems that lie behind the abuse will help make treatment more effective. A key step in identifying underlying problems is to establish rapport with clients. This is often more easily accomplished by meeting the person in their home where they feel more comfortable, and engaging them through discussions about lifestyle and what they enjoy doing. Such an engagement process helps point towards first steps in the treatment plan.

The assessment

Assessments should consider mental health issues, such as mood, affect, etc. For example, in the case of hallucinations, the root of the problem may not be substance abuse but dementia. In some cases dementia can be reversed, for example when it is the result of a low-grade urinary tract infection. When depression is present, service providers need to determine whether it is clinical or related to the substance use. The Folstein Mini Mental State Exam can be a useful assessment tool. Service providers should include in their assessment the use of prescription medications, over-the counter medications and holistic preparations. The patterns of use, including history, quantity and frequency of alcohol use also need to be identified. Be aware that mainstream tools for assessing alcohol are often not adapted for use with seniors.

Typology of the older client

Most of the people seen in agencies are early onset drinkers whose problem started in their youth or middle age. These people tend to be familiar with the system, with addictions and are willing to work on the problem. Late onset drinkers are more difficult to identify and tend to connect with services because family or other health care providers are concerned. In the case of late onset, misuse often begins as a response to the losses and other challenges that accompany aging. A third group are clients with concurrent disorders who have mental health issues. For most seniors maintaining their independence is a huge motivator. They can be encouraged by recognizing that in seeking help they have taken an enormous first step.

Stages of change

There are five stages of change ranging from not thinking about change to maintaining change. The first step is to move people from not thinking about change to thinking about change. In order to do this service providers need to gain trust and access to the person through what they are interested in. Then, work to increase their awareness of the problem, the costs and benefits of their behaviour and hope that this will plant a seed to get them thinking about change.

Treatment must respond to what the client tells you about their situation and needs.

b) Group Discussion - Best Practices and Challenges Identified by the Participants

Getting clients engaged

Make use of 'the power of physicians' to get clients engaged in addressing their problems. This will involve outreach to physicians.

Assessment process

The assessment process has to be comprehensive and client centred. Work to build rapport with the client. An assessment of where the client is located in the 'stages of change' continuum can be useful. Experience has shown that sometimes families are too involved in the assessment process and that poses certain challenges, as the focus must be on the client and listening to the client.

Key elements in successful treatment

• Collaborate with other helpers such as family and caregivers. Consult with them on addiction issues and support them whenever possible.
• Helping seniors develop their social network should be a key element of treatment.
• Adjust the pace as required.
• Show respect for the senior's life experience. Having them tell their story sometimes helps them to see their lives in a different light, as the story is validated.
• Listen to clients.

Harm reduction and abstinence approaches

Harm reduction strategies used in one location with a certain population may not be transferrable to other population groups. Flexibility and open-mindedness are important to the harm reduction approach; for example, client choice may mean that the client is supported in addressing the drinking problems while not tackling their use of marijuana.

Variety in programming

Older adults are not always receptive to participating in group therapy. A one-on-one approach in the home can be more suitable for some. Agencies should attempt to offer various options.

Adapting existing programs to accommodate seniors

• Existing group therapy programs can be made 'senior friendly' and include seniors with other age groups. Programs need to address questions like lighting, seating, mobility, and hearing levels in order to ensure successful participation.
• Introduce flexibility to in-patients programs to allow people to attend fewer days and for shorter periods of time.

Unique programming ideas

• Photographs can be very powerful tools to spark discussion and sharing.
• Linking seniors to youth can be very therapeutic.

Challenges - Reaching rural residents

Serving rural residents presents particular challenges. Issues of confidentiality arise, as do transportation and sufficient referral numbers.

Challenges - Pace of change

The pace of individual change may be slower than for younger people. Seniors will achieve greatest success when they work at a comfortable pace. Professionals need to be patient and avoid being stressed about the pace of change. This pacing can sometimes lead to conflict with the organization that is looking for evidence of results.

Challenges - Advantages of nurturing partnerships

Outreach and collaboration with other agencies, services, professionals and seniors' groups in the community can help overcome many of the challenges in this work. Partnerships between addiction services and other seniors' services can lead to finding treatment that makes most sense for the client. Referral sources can be nurtured and strengthened, and information exchange can help educate other sectors about seniors' and addiction issues.

Challenges - Cognitive impairment

New challenges arise when clients are unable to conceptualize cause and effect or fully understand the consequences of their actions.

Challenges - Competing interests

There are competing interests in the treatment process. Agencies need to clearly identify who the client is. Is the client the senior, the substitute decision-maker, the family, the nursing home, the legal system? Clarifying this will help in finding a balance between interests and maintaining flexibility.