Lifespan’s Geriatric Addictions Program (G.A.P.) in Rochester, N.Y., is tackling a national epidemic that most likely is not being adequately addressed in your community: how to successfully confront and treat the issue of substance abuse/misuse among older adults — especially those isolated and/or homebound. G.A.P. was launched in April 2001 with the goals of: formally addressing the issue of substance abuse among older adults — identifying barriers to intervention, assessment and linkage; and using a community collaborative approach to provide alternative, viable chemical dependency intervention options. This article discusses the aspects of this successful model.

For 30 years, Lifespan has served as Monroe County’s only comprehensive not-for-profit agency dedicated to providing information, guidance, and service to help older adults take on both the challenges and opportunities presented during the latter part of their lives. Lifespan’s long-established community network/referral system for older adult issues has resulted in several cutting-edge programs that focus on addressing the growing needs of the aging community. In the years prior to G.A.P. being launched, geriatric care managers at Lifespan were seeing a growing number of older adults with substance abuse problems being referred to their caseload. They found it difficult to access appropriate levels of service to accommodate their client’s complex, geriatric needs as well as their chemical dependency needs. G.A.P. was designed and piloted as a community collaborative program to focus on providing in-home geriatric intervention, assessment, and linkage services for older adults. The premise of the program was to focus on merging the fields of addiction and senior services in an attempt to meet the growing needs of these clients.

Lifespan’s extensive literature search on the topic of older adult substance abuse revealed some surprising information. Substance abuse — particularly alcohol and prescription drugs — among adults aged 60 and older is one of the fastest growing health problems facing our country. The following are excerpts taken from the U.S. Department of Health and Human Services Treatment Improvement Protocol (TIP) Series #26, “Substance Abuse Among Older Adults” (Blow, 1998):
• Substance abuse among older adults remains underestimated, under-identified, under-diagnosed, and under-treated.
• Health care providers tend to overlook substance abuse and misuse among older people, mistaking the symptoms for those of dementia, depression, or other problems common to adults.
• Adults aged 65 plus consume more prescribed and over-the-counter medications than any other age group in the United States.
• 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.

The demographic changes that currently are being brought about as the result of increased life expectancy and the aging “baby boom” generation will impact this health problem significantly. It is anticipated that by the year 2030 there will be about 70 million older adults in the United States — more than twice their number in 1990 (Blow, 1998).
Lifespan also investigated the growing needs of New York State, which were later more clearly defined in the October 2002 White Paper, “Project 2015: State Agencies Prepare for an Aging New York:”
• Demographic projections indicate that the number of older adults in need of substance abuse services will grow to approximately 630,000 by the year 2015.
• New York’s Office of Alcohol and Substance Abuse Services considers it vital to establish linkages with service providers in the community and other government and private agencies to engage in a comprehensive approach toward education, prevention, and treatment strategies for seniors.
• “Case management” should be a component of senior care across multiple systems to assure identification, assessment, referral and treatment planning.
• There is a need for well-trained, experienced staff who are capable of adapting existing resources to meet projected demands of seniors.

G.A.P. — a new philosophy
The G.A.P. program’s mission was to promote proactive, community-collaborative interventions that include 12-step facilitation, motivational interviewing, substance abuse counseling, and geriatric care coordination. These interventions target older adults age 55 plus, based on a continuum of need from substance misuse (primarily focusing on mismanagement of prescription medications combined with alcohol use); and substance abuse (prevention and early identification) through substance dependence (intervention, assessment, linkage to treatment). The program includes comprehensive geriatric care management with a strong emphasis on risk and protective factors as it applies to geriatric-specific substance abuse issues.

A major component of this mission/philosophy was to introduce to the community a public health model of harm reduction. Harm reduction for the G.A.P. model focuses on reducing the negative consequences associated with substance abuse for older adults, the community, and society. While initially working on reducing the adverse consequences of substance abuse with older adults who were unable or unwilling to cease their behavior in the short term, G.A.P.’s goal continues to be total abstinence in the long term. It was therefore necessary for G.A.P. to redefine “success.” The 12-step thinking that currently dominates many licensed treatment facilities requires the client to agree on total sobriety in order to gain admittance into treatment. Anything else would mean the client was “not ready” to embrace the tenets of the program until a bottom is reached. With G.A.P.’s definition of success, the thinking was a more fluid, continuum focus whereby each client was looked at holistically and tracked on their progress or “baby-steps” occurring in the arenas of health, safety, and functioning. Social, medical and/or mental health influences impacting this population might be at such a multi-dimensional, high-risk level that waiting for a client to “bottom out” and accept total abstinence could equate to their death.

Therefore, an approach that incorporates a philosophy of incremental change in the areas of client health, safety and functioning was structured — the premise being that any reduction in substance-related harm is a step in the right direction. Clients received sensitive treatment and were allowed a menu of geriatric services based on a full geriatric needs assessment without the rigid requirements of the traditional 12-step treatment model. As a result, several professionals who were dealing with their own recovery issues, felt the need to remove themselves from the G.A.P. project in its early stages because the philosophy conflicted with their own staunch beliefs in the 12-Step model. G.A.P. was moving toward a new frontier with its different views on treatment and recovery for seniors with addictions. It was further determined that all intervention and assessment should be provided within the safety and security of the client’s home to address issues of shame, stigma, and isolation — issues that could deter this target population from ever walking through the doors of a clinic or traditional treatment.

It is important to note that this approach was chosen specifically for older adults who were suffering from comorbid issues — both mental health disorders (i.e., dementia, depression) and substance abuse. In the past, the treatment facilities in this community in Rochester, N.Y., had been unsuccessful in their efforts to intervene and engage this population for treatment because of the multiple barriers of access to treatment for this particular group. These barriers will be discussed in further detail, later in this article.

Through its own analysis, Lifespan determined that despite an extensive community campaign directed at medical professionals, mental health professionals, and substance abuse professionals announcing the opening of G.A.P., the majority of referrals were from family members/caregivers who had heard of G.A.P. through word-of-mouth. The majority of these referrals were primarily crisis cases at intake as family members/caregivers hadn’t been able to find that earlier community point-of-entry to treatment for their loved one and the issue had billowed into either a medical and/or mental health crisis. The second highest level of referrals was from community-based organizations such as home health care agencies, Adult Protective Services, and older adult social/medical day programs. Hospital unit discharges and community health care providers ranked third and fourth in providing referrals to G.A.P. Based on these findings, it is clear that an even more intensive, ongoing educational campaign is required to continue raising the community level of consciousness not only on this issue but, also, regarding the availability of G.A.P. to collaborate with medical/mental health care providers.

Lifespan’s analysis of G.A.P. revealed that the average age of its clientele was about 10 to 15 years older than what was anticipated. Lifespan assumed that the average age of clients would be mid-to-late 60s. Also, clients were much sicker and frailer than expected. This was an important discovery, in that it created difficulties in linking our clients with traditional treatment, which could not adequately address our average client’s physical or cognitive needs. G.A.P. had to become extremely creative in working with these clients in order to meet their complex needs in collaborative approaches, by utilizing services from the aging services network, the mental health network, and the chemical dependency network. This is discussed in more depth later in this article.

Gender and income were pretty much as anticipated, but with female referrals slightly higher than anticipated. G.A.P. served a diverse income spread but encountered the same barriers to treatment, regardless of income. In addition to its formal data collection, G.A.P. was able to learn firsthand, the multiple community issues and barriers that were not fully understood or anticipated from the start of program implementation. These issues and barriers have made it clearer to G.A.P. staff why older adult substance abuse remains at a national epidemic level — these clients continue to be discounted and disposable in their communities, as well as in the medical/mental health arena. And despite the fact that the older adult population is rapidly growing, placing enormous financial burdens on their communities, older adult health issues remain on the backburner as far as State/Federal prioritization in the areas of public policy/advocacy for receiving adequate treatment.

Resolving issues and barriers
The first barrier in treating older adult clients was the lack of geriatric-
specific substance abuse services within the community. This barrier was and remains a formidable one. Clients who were interested in receiving traditional treatment found themselves in programs with much younger clients. G.A.P. clients had much difficulty relating to these clients who were presenting with illegal drug issues, court mandates, drug dealing, prostitution, foul language, and loose morals. Very few counselors in the programs had any level of geriatric-specific training and were not able to identify clients with geriatric clinical depression and/or mild dementia. G.A.P. encountered high dropout rates immediately due to this mismatch of populations. Many clients were labeled as non-compliant. Fortunately, many clients who dropped out of treatment programs remained connected with G.A.P., which continued to provide services in the client’s home. The services, which were shifted from traditional treatment to a harm reduction approach, have been met with great success.

Another reason that traditional treatment failed for many of G.A.P.’s clients, is because they were too sick medically or mentally to adhere to the rigors of traditional treatment. The outpatient programs started too early, were too intense, required a high level of cognitive processing, and demanded additional mandatory Alcoholic Anonymous meetings. The inpatient programs were too demanding physically and mentally; no geriatric care management was available for these clients. Therefore, clients presenting with multiple issues had to seek additional resources to assist with their other pressing issues, such as mental health treatment. The majority of G.A.P. clients found themselves overwhelmed by the multitasking, which led to feelings of frustration, hopelessness, and a sense of failure and, ultimately, dropping out of the program and relapsing. Without another option for more viable chemical dependency services suited to their needs, G.A.P. clients had no other community option.

Meanwhile, G.A.P. referrals were increasing from adult children who were unable to find an appropriate entry door to treatment for their aging loved one suffering from substance abuse issues and comorbid medical and/or mental health issues. G.A.P. began working more creatively to address the glaring issue — a lack of appropriate treatment services that lean more toward harm-reduction techniques and motivational interviewing.

Another barrier encountered in the community was the inability of our clients to access a medical bed for alcohol detox. The majority of G.A.P.’s clients requesting or requiring detox were too frail medically to be considered appropriate for either outpatient medical detox or community detox units. These clients required admittance into a hospital for medical management for complications resulting from hypertension, prior histories of heart attacks, strokes, and/or seizures. Not one of our area hospitals in Monroe County has New York State-licensed detox scatter beds or units. Therefore, any older adult client seeking services had two choices: 1) leave the county to receive services; or 2) stop drinking and wait until they exhibited moderate to severe withdrawal symptoms in order to be considered for admission into the hospital.

Many clients who presented to emergency departments in mild withdrawal were discharged back home with prescriptions for Ativan or Valium to self-medicate their own withdrawal until they could get in to see their primary care physician. These clients rarely saw their primary care physicians, had no transportation, and were in withdrawal while receiving these instructions in the hospital. Several clients had histories of alcohol seizures during previous withdrawals. Facing these barriers, the majority of G.A.P. clients simply started drinking again and received the message from the community that they weren’t worth the trouble of receiving appropriate medical attention. In addition, several G.A.P. clients became so medically ill while trying to seek appropriate detox treatment that they required complex, multi-week medical stays with severe complications.

One barrier became apparent from clients referred to G.A.P. once they had been hospitalized due to complications from their alcohol use (i.e. fractured hips, upper GI bleeds, strokes). Some clients being discharged back to their homes had no visible supports, no transportation available to them for outpatient follow-up appointments, issues of elder abuse still prevalent within the home environment, and a lack of resources to follow through with hospital recommendations for additional chemical dependency services. Many G.A.P. clients required transfer to nursing home rehabilitation units to address physical therapy for broken bones. The majority of nursing homes would refuse these clients as soon as they learned there was an alcohol history. In addition, many G.A.P. clients required a higher level of care, such as assisted or enriched living. The majority of these facilities would refuse G.A.P. clients for the same reason. G.A.P. staff spent long hours advocating for services with hospital medical professionals that should have been these older adult’s right to receive without discrimination or stigma.

These barriers to effective intervention and assistance — encountered by clients when they came into direct contact with healthcare professionals — was of great concern to G.A.P. The lack of professional geriatric expertise in areas of mental health and substance abuse compounded with ageist myths regarding older adults and substance abuse issues, placed clients at even higher risk within the systems that were supposed to be helping alleviate their problems. G.A.P. staff experienced firsthand the inability of professionals to put together the constellation of symptoms presenting to them; focus seemed to be solely in diagnosing the acute presentation which allowed the underlying disease of addiction to progress even further. The Columbia University study (June 1998), Under the Rug Substance Abuse and The Mature Woman, speaks strongly to the need for further training of healthcare professionals who are caring for older adult women. While there are certainly profound gender specific issues when working with this population, G.A.P. experienced several of the same issues with male clients.

Compounded with this inability to diagnose appropriately, G.A.P. realized that several of its older adults who had undiagnosed dementia were being corralled through the medical systems. G.A.P. received referrals on clients who had been in area hospital system emergency departments more than 15 times within six months of entering its program. Each time, the client had been labeled as a non-compliant alcoholic and discharged back to his or her home with only bare services provided. Often the client would be back to the hospital within 24 to 36 hours with the same medical complaint. Sometimes, the client would be so medically ill by the second presentation that they required immediate admission to the critical care units.

Upon further in-depth assessment by G.A.P. staff and community geriatric specialists, it was discovered that a majority of these clients actually were suffering from some form of undiagnosed dementia. The dementia was key to determining why these clients were unable to follow through with recommendations or to show improvements in any area of their daily living activities — they were simply incapable of performing the cognitive processing required to manage complex tasks. Only after this information was provided to the medical community, would G.A.P. clients begin to receive the appropriate level of treatment and care upon presentation to either their primary care physician and/or a hospital system. Conversations with primary care physicians prior to the dementia diagnosis regarding these clients revealed statements such as, “They’ve been like this for twenty years; they’re never going to change!” or, “What do you want me to do? She’s crazy!” Conversations with emergency room physicians revealed statements such as, “Get this gutter snipe out of my ED!” or “I have an emergency department to run!” Clearly, healthcare professionals need to be held accountable for the populations they serve and the emerging trends of this new frontier of aging baby boomers.

G.A.P. is beginning its fourth year in providing services to its community. The program is proud of the work that’s been done and the education, advocacy, and creativity that continues to be brought to this issue. G.A.P.’s success rate is high with a model focusing on the holistic geriatric care management approach and its unique continuum of collaborative services. The program continues to sift through the issues that contribute to the ongoing barriers and will continue to educate, advocate, and intervene on the behalf of its older adult older adult clients. A primary concern is that we’re already behind the proverbial “eight-ball” with this cohort group — how will the nation’s communities ever be prepared for the aging population if we don’t put a brighter light on this issue now?

Carol S. D’AgostinoLMSW, CASAC, is the Director of the Geriatric Addictions Program at Lifespan in Rochester, N.Y., and a Robert Wood Johnson Fellow for Developing Leadership in Reducing Substance Abuse.

References
Blow, F. C. (1998). Substance abuse among older adults [Treatment Improvement Protocol (TIP) Series 26.]. Rockville, MD: Substance Abuse and Mental Health Services Administration.
The National Center on Addiction and Substance Abuse at Columbia University (June 1998). Under the rug: Substance abuse and the mature woman.
The New York State Office for the Aging and The State Society on Aging of New York (October 2002). Project 2015: The future of aging in New York State. Articles and briefs for discussion.

This article is published in Counselor,The Magazine for Addiction Professionals, August 2005, v.6, n.4, pp.51-55.

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