Best Practices - Treatment and Rehabilitation for Seniors with Substance Use Problems

3. Interviews With Key Experts (continued)

3.2.3 Areas to be Addressed in Treating Seniors with Substance Use Problems

Many key experts identified the need for better co-ordination of services wherein agencies are linked to a comprehensive and well-resourced continuum of care. The use of multi-disciplinary teams was recommended.

Respondents cited the importance of increasing awareness and education efforts among members of the public, physicians and seniors themselves. Public information related to substance use problems must be specific to seniors rather than generic to all adults.

Many key experts identified the importance of establishing programs that are non-confrontational, flexible and based on harm reduction approaches. Services must go beyond the immediate issue of substance use and address the socio-economic and other needs of the client. Treatment approaches must include resolving the client's day-to-day health, social and living needs.

Outreach was also identified as a key priority. Seniors are often unwilling or unable to leave their home, so treatment services must be prepared to go to them. Some seniors may at times experience distrust of services organized and managed by government or bureaucratic organizations. Approaching these clients in their own environment may reduce anxieties, help to build rapport, convey respect and trust and an understanding of the client's way of life. A comprehensive continuum of services would include home detoxification and/or supportive housing services. Key experts highlighted the importance of making transportation services available.

3.2.4 Outreach, Contact & Engagement

a) How Seniors Generally Access Treatment Services

Key experts reported that the most frequent sources of referrals for seniors with substance use problems are:

• health care professionals;
• family members;
• social service agencies;
• self-referrals; and
• legal system.

Many respondents also noted that in some Canadian regions, there are very few services for seniors to access.

b) Challenges Encountered by Seniors in Accessing Services

Feelings of embarrassment and shame were identified as the key challenges faced by seniors when accessing services. Seniors often fear the stigma associated with substance use problems and consequently find it very difficult to request help. These challenges are often exacerbated by a reluctance to participate in programs that put them with younger adults. Seniors may feel frightened or anxious when their younger counterparts are being treated for issues related to illicit drugs. Younger adults may also use colloquialisms that are unfamiliar to seniors, heightening any sense of inadequacy or anxiety.

Key experts also reported that some regions lack appropriate services or that seniors may be unaware of their availability. Other obstacles to accessing services include client's unwillingness to leave their home or community, transportation issues, the lack of financial resources, and the inability of services and programs to accommodate impairments related to physical mobility, sensory deficits or cognitive difficulties.

c) Approaches for Linking Seniors with Appropriate Treatment Services

Key experts reported that the most effective method to link seniors with treatment services is through outreach services that are based on a harm reduction model. Outreach ensures that services are offered to seniors in their own home or environment. In turn, the harm reduction model recognizes the importance of addressing matters related to health or other identified client needs without being exclusively focussed on abstinence issues. A non-confrontational, non-threatening and unhurried approach is the most useful to help build rapport and lead to the identification of other needs related to substance use problems among seniors.

The use of multidisciplinary teams was also noted as a significant advantage as it ensures representation from multiple service providers. In certain communities, many government agencies and service providers could benefit from enhanced coordination through closer cooperation and collaboration. In many instances, service providers could benefit from maintaining service linkages with each other. Coordinated and comprehensive case management services should be provided to seniors when required.

A focus on training and education for professionals working with seniors was also recommended by many of the key experts. Personnel such as nurses working with seniors in areas unrelated to substance abuse could be offered training in basic addiction assessment skills to help them recognize needs for services. Others who will come into contact with seniors, such as building managers, must also be educated to recognize substance use problems among seniors. Within substance abuse treatment programs, key experts recognized that greater importance must be placed on ensuring personnel are appropriately trained with concepts in gerontology, as well as substance use issues.

3.2.5 Assessment Components

a) Aspects of Functioning that Should be Screened or Assessed

Key experts reported that the main aspects of functioning assessed among seniors seeking treatment services should include:

• physical and psychological health;
• social activities;
• interpersonal relationships;
• the physical environment; and
• competency with activities of daily living.

Assessments of physical health focus on mobility, sensory limitations, nutrition, and whether the client is in pain. Supplements of vitamins C and B-complex including thiamine are often recommended for seniors using alcohol in order to prevent neurological deficits and/or ameliorate their progression. A medication review should be undertaken, with questions for example, directed to understanding medication side effects. Some experts also include specific assessments to evaluate patterns and the extent of substance use.

Mental health screening should also be done to test such areas as:

• memory and cognitive impairments;
• dementia;
• depression and anxiety; and
• coping mechanisms.

Some programs explore social aspects of the senior's functioning, including:

• interpersonal and family relationships;
• the degree of social isolation;
• the dependence on family and caregiver stress;
• susceptibility to elder abuse; and
• identification of protective supports.

Importance is also placed on assessing the various aspects of their environment, especially home and neighbourhood safety. Other areas assessed that were mentioned by the key experts include financial status, and their spiritual and cultural context.

b) Instruments and Formal Assessment Processes

Key experts described a range of instruments they used as part of the initial assessment process. Some of these instruments included screening measures for alcohol or drug use, whereas other instruments assessed additional areas of functioning such as depression and cognitive status. Examples included:

• MAST-G: Michigan Alcohol Screening Test - Geriatric Version;
• MAST/CAGE;
• AUDIT: Alcohol Use Disorders Identification Test;
• MDDS: Manitoba Drug Dependency Screen;
• SUDDS: Substance Use Disorder Diagnostic Schedule;
• SASSI: Substance Abuse Subtle Screening Inventory;
• ASI: Addiction Severity Index;
• L'indice de la gravité de la toxicomanie;
• Mini Mental Status Exams;
• GDS: Geriatric Depression Scale;
• BDI: Beck Depression Inventory;
• DATIS: Drug and Alcohol Treatment Information System;
• FIMS: Functional Instrument Measurement Scale; and
• ADL: Activities of Daily Living.

Alcohol and drug screening tools were generally recognized as useful in providing quick and simple overviews of substance use problems. These screening tools, however, are limited in that they do not provide a global picture of the client's functioning. More in-depth assessment tools incorporate both formal and informal data gathering procedures. Although these approaches were viewed as quite beneficial, they tended to require a greater commitment of time and effort on the part of the client and agency. Language, modest education, and cognitive impairments were noted as potential barriers to using various assessment tools.

One area of potential difficulty is that tools designed to investigate potential substance use problems do not take into account possible comorbid features or other conditions which may present similar symptomology. It is important, therefore, to make a comprehensive assessment, taking into account both social and medical history.

c) Individuals Who Should be Involved in the Assessment

Key experts were asked to identify the preferred sources of information for the assessment process. They suggested engaging individuals who are involved in the physical care of the senior during treatment and recovery such as:

• physicians;
• nurses;
• home care providers;
• family members; and
• other multidisciplinary team members.

Physicians should be made aware of the referral so they can provide crucial information on medications. Some key experts suggested that physicians are often too busy to assume a major role in the treatment team processes, but should maintain involvement by co-ordinating medical services.

Family members, friends or significant others are often involved in the assessment process. They may be able to provide further or corroborating information on issues of substance use, especially in cases where the client denies or minimizes use. They can also provide insight into the day-to-day management of the senior and provide ideas on how to support the client through treatment and recovery. By involving family members and friends, clinicians can offer support and suggestions on how to cope with the client when caregiver stress is a concern. Key experts did caution however, that in cases of elder abuse, family involvement must be carefully assessed.

Some respondents reported that the decision to include other individuals in the assessment must lie with the client, as they are ultimately responsible for setting their treatment goals. Others felt that only the client should be involved in the assessment, as involvement from others may adversely impact the therapeutic alliance.

d) Steps to Enhance Present Assessment Practices

Key experts reported that present assessment practices could be significantly improved through the development of better tools. Assessments must be senior specific, standardized, and explore the consequences of substance use. They should also account for denial as many current assessment and screening tools depend on self-reported data.

An unhurried approach is recommended for assessing older adults. The assessment is viewed as a crucial vehicle to build rapport with the client. A longer assessment period may therefore be warranted. Some key experts recommended a move away from the standard structured question-and-answer type format, preferring to allow the information to be gathered once the relationship is properly established.

Key experts cited the importance of placing the assessment's focus on the whole person, not just on the substance use. They also noted that assessments would benefit from increased co-ordination among service providers, especially hospitals and community services. A standardized assessment tool accessible to the range of service providers would reduce the need to provide the same information to different people.