The dilemma of alcohol use among the elderly: Then what?

Dave Gustafson, Director
Center for Health Enhancement Systems Studies and NIATx
University of Wisconsin-Madison

April marks NCADD’s 28th Annual Alcohol Awareness Month with a focus on preventing underage drinking and its harmful consequences. Alcohol use and misuse among young people is extremely dangerous, no doubt about it. But at the other end of the lifespan, alcohol use among the elderly presents another dilemma.

Let me tell you more about my view of this.

If you’ve visited a nursing home you’ve probably seen a resident in a wheelchair who just seems to be out of it. The likelihood is that the person is daydreaming about the past: maybe refereeing a flag football game in the old neighborhood or teaching a high school English class, or having a picnic beside a lake surrounded by family on a nice summer day.

It used to be common in nursing homes (and maybe it still is) to use a practice called “reality orientation.” With this process, for some reason, we thought it was important to take a person out of their reverie. So, a staff person would come up to that resident and say something like: “Dave, it’s important for you to understand that you are here at a nursing home in Madison, Wisconsin, and it is Friday, April 3, 2015.” 

In other words, “You are alone in a wheelchair in a nursing home staring at the wall across from you.”

It never made sense to me that we should retrieve people from pleasant memories or daydreams to take them back to a hard reality.

And that’s not too different from how I see the issue of alcohol use among the elderly. For some older adults, alcohol is a source of comfort. Some consider it one of life’s few remaining pleasures. Should they be deprived of that?

Don’t get me wrong—I’m not advocating to leave alcohol abuse untreated among people of any age group. Alcohol use has risks for the elderly, even if it’s not abuse. For the elderly, alcohol use is linked to hospital readmissions, poor decision-making, and falls that can lead to nursing home stays. So many elderly end their days in a nursing home after breaking a hip. And we know that alcohol use contributes to a myriad of other health problems.

(See related blog post: A Hidden Epidemic: Older Adults and Substance Abuse)

The results of a recent study reported in the article, “Winding Down and Boozing Up: The Complex Link Between Retirement and Alcohol Misuse” found that older adults are often unprepared for the changes that come with retirement and other later life events. These changes can contribute to depression, financial worry, and troubling questions about the meaning and purpose of their lives. For some elderly people, a daily drink or two or three is the only way out of a lonely, isolating situation. While a few drinks a day might not qualify as dependence, older adults have a harder time handling alcohol. They get drunk quicker on less alcohol.

So tackling the dilemma of alcohol use with the elderly means we have to be prepared to answer the question “Then what?” What do we do when removing alcohol makes an older person even more lonely or more depressed? If we’re going to confront alcohol use among the elderly, we have to look at issues like of the meaning of life, loneliness, and isolation.

A solution that we’ve been working on at the Center for Health Enhancement Systems Studies is called Elder Tree. It's part of our Active Aging Research Center,  funded under a Center of Excellence grant from the Agency for Healthcare Research and Quality.

(Click this link to watch a 4-minute video about Elder Tree.)

With Elder Tree, we’ve designed a computer system specifically to address the loneliness and isolation that many elders face. Elder Tree is a website just for older adults aged 65 and older, living in Wisconsin, who have access to a computer and the Internet. It makes it easy for older adults to stay in touch with family and friends, learn about local events and resources in their communities, and track their health and personal to-dos. The health tracker focuses on falls prevention, safe driving, medication management, care giving, and health and wellness. The site also has discussion forums that allow participants to support and encourage each other.

What we’re doing with Elder Tree is not specifically intended as a treatment or recovery intervention. Through tools that make it easy for two people to connect, communicate, and build relationships,  we’re looking at Elder Tree as offering an alternative to the isolation that so often leads to and accompanies alcohol use among older adults.

And that’s all good, but Elder Tree and other tools still don’t do enough to help elders find meaning in their lives. That's the next “Then what?” that needs to be answered.

David H. Gustafson, Ph.D., is Research Professor of Industrial and Systems Engineering at the University of Wisconsin-Madison and director of the Center for Health Enhancement Systems Studies, which includes NIATx. His interests in decision, change, and information theory come together in the design of systems and tools to help individuals and organizations make effective changes. Dr. Gustafson leads a research team that has developed A-CHESS, a smartphone-based health system for recovery support and relapse prevention.

Teen brains and marijuana: Marijuana Lit Video Series

Maureen Fitzgerald
ATTC Network Coommunications Coordinator
Senior Editor, NIATx

There’s a lot that’s new on the ATTC website!

Have you seen the new HCV Current site? We’ve also released Integrating Substance Use Disorder and Health Care Services in an Era of Health Reform, the first white paper for our project on Advancing Integration.

But another new item that we don’t want you to miss is the latest video in the ATTC Network’s Marijuana Lit series. Just released:  “Effects of Marijuana Use on Developing Adolescents.”

You don't have a gambling problem, do you?

Maureen Fitzgerald
Communications Coordinator, ATTC Network
Senior Editor, NIATx

Have you filled out your bracket?  March Madness officially began on March 15, Selection Sunday,  with 64 college basketball teams embarking on a four-week odyssey to the Final Four and the ultimate championship game. Across the country people are rooting for their teams, practicing their bracketology skills, and placing bets.

(By the way, how about those Badgers?) 

It’s no coincidence that March is also the National Council on Problem Gambling’s Problem Gambling Awareness Month, and in some states (Iowa, for example) March 15-21 is National Problem Gambling Awareness Week.

For many people betting on sports teams is just plain fun, and gambling is considered a harmless pastime. As Christine Reilly, Senior Research Director of the National Center for Responsible Gaming states in this month’s ATTC Messenger, “an estimated 80 percent of adults in the U.S. gambled in the past year,” in activities ranging from buying lottery tickets to making illegal bets with bookies. Of this group, about 1 percent of the U.S. population meets the diagnostic criteria for a gambling disorder.

That seems like a pretty low number. But is it really an accurate estimate of the number of people who may be experiencing serious difficulties because of their  gambling?
Dr. Lori Rugle, Program Director of the Maryland Center of Excellence on Problem Gambling at the University of Maryland School of Medicine, has more than 30 years of experience in problem gambling prevention and treatment. Her presentation “Screening, Brief Intervention, and Referral to Treatment,” is the second webinar in the ATTC Network’s Problem Gambling Webinar Series.
Dr. Rugle believes that better and wider screening will lead to a more accurate representation of the true extent of gambling disorders, which often accompany substance use and mental health disorders.
View Dr. Rugle’s presentation slides and watch her recorded webinar here.

I caught up with Dr. Rugle last week to ask a few questions about gambling disorder screening tools. As she points out in her recorded webinar, some screening tools that work well in research settings are less effective in real-world clinical practice.  (Sound familiar?)

 “After finding this in state after state, we realized that we need to see how we can help counselors use the screening tools more effectively in actual clinical practice,” says Dr. Rugle.
It may be that addiction treatment counselors are just as uncomfortable asking their patients about their gambling behavior as, say, some primary care physicians are when asking people about their alcohol and other drug use.

 “What happens so often in clinical practice is that a counselor will ask a Yes/No question such as ‘You don't have a gambling problem, do you?’” says Dr. Rugle.  “Counselors and doctors are wary of asking questions about an area they’re unsure about,” she says. “With training on the right techniques and how to ask the right questions, clinicians can overcome their lack of confidence about exploring their patients’ gambling behaviors.”
One solution might be to include a question about problem gambling in existing SBIRT activities.
“Asking the question ‘What role does gambling play in your life, and is it helping or hurting?’ could start a longer conversation that might lead to treatment,” says Dr. Rugle.

That question is part of the conversations in Maryland, which has provided funding to agencies to integrate gambling into screening activities.

“I’m asking people to include gambling in every section of the intake, so patients can start making the connection between gambling and other parts of their lives,” she explains.

It's also important to define what is meant by gambling.

"Often, people don't automatically think about playing the lottery or bingo as gambling, just as some may discount beer when asked whether or not they drink alcohol," comments Dr. Rugle. 
Maryland is also introducing a program for a high-risk group for problem gambling: young adults. The Above All Odds campaign aims to help young adults recognize how to keep gambling fun and affordable, and how to get help if it gets out of hand.

Gambling disorder awareness has increased significantly since Dr. Rugle began her career.

“The DSM-5 reclassification of gambling disorder with substance use has also brought more attention to gambling disorder, and it has also encouraged state systems to look at it differently,” says Dr. Rugle. “In Maryland, it helped us to include problem gambling in the state’s recent integration of substance use and mental health disorders,” she says. “Without that new definition, it would have been much more difficult.”
With the increase of legalized gambling (and no end to that in sight) more treatment for problem gambling is available than in the past.
“Right now, 39 states offer funding of varying amounts to address problem gambling, but in most cases it is just a fraction of what’s available for other disorders,” comments Dr. Rugle. She’d like to see a public source of funding for research in this area and to be included along with funding for other addictive disorders, especially as gambling continues to proliferate.

For more information, see the 2013 National Survey of Problem Gambling Services.

One potential funding source is the tax revenue that the federal government receives from gambling winnings. “This could provide more funding for problem gambling prevention and treatment,” notes Dr. Rugle.

In conclusion, Dr. Rugle encourages treatment professionals to think about ways they can “have the conversation” about gambling behaviors with their clients. “People are really surprised to learn how pervasive it is and the issues it’s creating in families, at work, and as a relapse risk factor," says Dr. Rugle. “Not addressing gambling issues decreases treatment effectiveness and adds to treatment costs,” says Dr. Rugle.

For more information, visit:
Maryland Center of Excellence on Problem Gambling
National Council on Problem Gambling
ATTC Network Problem Gambling Webinar Series

Urgent care for the uninsured: a walk-through with an international visitor

Kim Johnson, PhD
Deputy Director, NIATx
Co-Director, ATTC Network Coordinating Office

Last week I was able to experience the American health care system through the eyes of a person without health insurance. This unexpected walk-through was a Kafkaesque experience that made me wish deeply for Madison to have a “Doc in a Box” or a Walmart or CVS walk-in clinic.

I have great appreciation for that business model now.

Tools for Treating Teens: the Center for Adolescent Substance Abuse Research

This year, the Center for Substance Abuse Research (CASAR) at the University of Minnesota Medical School celebrates 25 years of developing research-based tools and resources for adolescent drug abuse assessment and treatment.  Dr Ken C. Winters, director of CASAR, shares some insights on adolescent treatment in the interview that follows.

A Hidden Epidemic: Older Adults and Substance Abuse

North Carolina filmmaker Linda Warden left a career in information technology to make movies, focusing on topics that help children and families. Having lost a child to addiction, she is especially interested in increasing awareness of substance use disorders and their impact on families and communities.

 “Addiction affects people of all ages,” she comments. “To my knowledge, nothing has really been done on older adults and addiction in the mass media.”
That explains, in part, her interest in producing a documentary on older adults and substance use disorder, A Hidden Epidemic. “Although addiction is a part of this program, the focus is on prevention and recovery,” says Ms. Warden.

Lost in the weeds about marijuana?

Maureen Fitzgerald
Communications Coordinator, ATTC Network Coordinating Office
Editor, NIATx

If you've been to the ATTC website in the past few days, we hope you've stopped by the webpage for our new resource,  Marijuana Lit: Fact Based Information to Assist You in Providing SUD Services.
As you'll notice, we've made it easy to find!