Final Paper, Substance Abuse in the Elderly (1)

Running head: EFFECTS OF SUBSTANCE ABUSE IN THE ELDERLY 1

The Effects of Substance Abuse in the Elderly:

A Cross-Cultural Comparison

Alexis Curran, Nikki Evans, Evan Flanders

Missouri State University

Anne-Mari Sampakoski

Satakunta University of Applied Sciences

EFFECTS OF SUBSTANCE ABUSE IN THE ELDERLY 2

Introduction

The word "health" carries a simplistic definition within a dictionary or a textbook.

However, the concept of health is highly abstract, variable, and changes over time as society

evolves. Historically, health was defined as the absence of illness or the ability to fulfill one’s

life roles and obligations. In modern times professional organizations such as "The World Health

Organization" (WHO) define health as, "A complete state of physical, mental and social well-

being, and not merely the absence of disease or infirmity." In addition to this, it is important to

stress that an individual’s own definition of health will determine whether or not they will

choose to describe themselves as healthy. For example, if a person has an overall feeling of

contentment with their life and bodily well-being, they will most likely describe themselves as

healthy. In contrast, individuals who feel physical or emotional discomfort or feel they cannot

adequately achieve their duties and goals in life will be less likely to describe themselves as

healthy.

Because the elderly population is somewhat isolated and oftentimes unable to advocate

for themselves, it is difficult to determine what their definition of health would be. It is even

harder to determine these values in certain subcultures, such as those with substance abuse

issues. For example, unlike their younger counterparts, elderly persons with substance abuse

issues may drive less, and therefore have less opportunity for DUI's or other substance-related

arrests (Benshoff & Harrawood, 2003, p. 44). In addition, since they are more likely to be retired,

they may not struggle to balance work responsibilities with their substance abuse. With these

considerations in mind, it is possible that an elderly person with a substance abuse issue may

consider themselves perfectly healthy because they have not suffered any shortcomings in their

day-to-day living activities. However, the medical community would consider their substance


abuse to be an indicator of ill health. Finally, the persons who do experience enough physical or

emotional discomforts to consider their health affected may attribute those symptoms to their old

age rather than to their substance abuse (Benshoff & Harrawood, 2003, p. 44).

The population of older adults have a variety of unique needs and health considerations.

For one thing, the term "older adult" can be used to describe everyone from a healthy able-

bodied 65 year old of sound mind to a terminally ill disabled 95 year old person with advanced

Alzheimer’s. Both of these people would technically be older adults, but their health and health

needs are strikingly different. For this reason, it is important not to oversimplify any assumptions

made about this portion of the population. However, some generalizations can be made in order

to identify and mitigate risk factors to health and safety.

For example, older adults have to find new purpose in life now that their children are

grown and they've retired from their work. For some, this is a welcome period of time spent on

leisurely or altruistic activities that bring joy. However, others, especially the poor, disabled, or

chronically ill, have additional barriers to finding enjoyable activities, which could lead to a loss

of purpose. Finances are a common concern for this population because many of them have

retired and are living on fixed incomes. Compounding this is an overall increase in cost of living

due to increases in illness, which causes a rise in healthcare costs. Many will discover, to their

dismay, that Medicare does not cover all expenses. Even worse, some dishonest individuals

target older adults for financial scams. Those older adults who may be mildly confused or do not

understand technological advancements such as online banking may be at increased risk for

scams.

If a person has decreased mobility and must rely on others for transportation or assistance

with activities of daily living such as cooking, cleaning, laundry, bathing, and dressing, they may


suffer from feelings of shame and depression from having lost so much of their autonomy.

Abusive, neglectful, or otherwise inadequate caretakers and low-quality care can exacerbate this

emotional stress. In addition, this particular season of life may include more incidences of loss

and isolation than previous ones. The person may have had to adjust to the loss of parents and

older relatives in the past; now, they must face the death of spouses, siblings, and peers, as well.

If the person is not able to grieve affectively and make new friends to replace lost relationships,

they may find themselves feeling lonely and depressed.

Statistics indicate that approximately 3 to 25% of older adults suffer from heavy alcohol

use and 2.2 to 9.6% suffer from alcohol abuse (SAMHSA, 2012, p. 4). Researchers estimate that,

"as many as 17 percent of older adults" suffer from alcohol or prescription drug abuse,

(SAMHSA, 2012, p. xv). Reasons for behaviors that lead to substance abuse in older adults are

multitudinous and may include attempts at self-medicating, depression, loneliness, or chronic

pain. A person might choose to self-medicate rather than seeking medical treatment because of

cost, embarrassment, or shame in reporting their needs to a healthcare provider. Historically,

mental illness, particularly addiction, has carried a lot of negative stigma. Older adults in

particular may feel the most shame in admitting to this problem because they see it as a

weakness or moral shortcoming rather than an illness. In depth screening of older adults is of

utmost importance because it can help identify patients who would not otherwise admit to having

substance abuse issues.

Health Promotion and Prevention

Heavy use of alcohol and other substances poses significant risks to a person's health and

welfare. For this reason, health promotion and disease prevention for older adults must include

methods to identify and treat substance abuse before it affects health negatively and to prevent


complications when it has already caused health problems. Therefore, it is unfortunate that the

majority of substance abuse prevention programs focus on youth, adults, and driving. These

programs include education and outreach in schools and workplaces. They also include laws

such as age limits on the purchase and consumption of alcohol, and laws against driving while

under the influence of alcohol. A table demonstrating the availability of alcohol control programs

worldwide is available on WHO's website. It is very difficult, however, to find any programs

targeted to older adults who may no longer work or drive, and are not disadvantaged in their

purchase of substances by age restrictions.

Likewise, most prevention programs for special populations do not include older

adults. In Finland, health promotion programs that seek to prevent substance abuse among the

elderly are provided by the Finish Association for Substance Abuse Prevention (EHYT). This is

a national-level NGO that promotes healthy lifestyles and aims to prevent substance abuse. This

organization focuses on preventing social exclusion among older adults, campaigning to

influence both local and national public policy to promote health, and coordinating with other

NGOs to achieve their goals. They also target addictions other than drugs and alcohol, such as

gambling and video game addiction.

The Substance Abuse and Mental Health Services Administration, a branch of the US

Department of Health and Human Services, publishes a "Treatment Improvement Protocol"

(TIP) Series, to assist healthcare providers. These publications provide guidelines for providers

to improve the quality of their care. These guidelines are agreed upon by "a panel of non-federal

clinical researchers, clinicians, program administrators, and patient advocated," to be the best

and most effective form of practice based on all available research (SAMHSA, 2012, p. xiii).

This organization has a TIP published specifically for the older population.


The Consensus panel in charge of the TIP recommends that healthcare providers screen

all patients age 60 and older for alcohol and drug abuse as part of their regular assessments

(SAMHSA, 2012, p. xvii). However, without a standardized assessment tool, screening may not

be consistent. There is a list of diagnostic criteria available for diagnosing substance dependence

within the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental

Disorders, Fourth Edition (DSM-IV). Nevertheless, some of the criteria within this manual does

not apply to older adults and may lead not readily identify an older person with a problem

(SAMHSA, 2012, pp. xv-xvi).

For this reason, it is recommended that healthcare providers us the, CAGE Questionnaire,

or the Michigan Alcohol Screening Test–Geriatric Version (MAST-G), or The Alcohol Use

Disorders Identification Test (AUDIT), (SAMHSA, 2012, p. xviii). Likewise, other community

outreach programs such as "Meals on Wheels" or home health services should also train their

employees on how to screen clients who may not have regular access to healthcare. Additionally,

because one of the main causes of substance abuse is depression, it is advisable to screen all

clients for depression, as well. A client who is not yet abusing substances could be at risk of

developing the habit if they have an untreated condition, such as depression or complicated grief.

Because mental health is a relatively modern science, some older adults may not feel

comfortable broaching the topic on their own.

If a person shows that they are suffering from substance abuse or are in danger of

becoming a substance abuser, then treatment is the next step. SAMHSA recommends that

treatment should begin with the least intensive options first. These include: "brief intervention,

intervention, and motivational counseling" (SAMHSA, 2012, p. xix). Outpatient programs are

preferred. Inpatient programs are considered a last resort for this type of care.


Treatment and Rehabilitation

Treatment interventions may involve motivational interviewing, education, counseling,

goal setting, contract development, behavioral modification techniques, referral to rehabilitative

services, and the provision of self-help materials (SAMHSA, 2012, p. xix). It is particularly

important that the healthcare provider ascertain what the reasons are for the patient's substance

use, such as coping with stress, grief, loneliness, or depression, so that the person's treatment

plan can be tailored to their needs. Interventions should be age-specific and focus on rebuilding

the person's social support system (SAMHSA, 2012, p. xxi). For this reason, group therapy is

quite effective. However, some treatment programs such as Alcoholics Anonymous (AA) or

Narcotics Anonymous (NA) may seem confrontational to older adults because they include much

younger members, profanity, and stories of wild behavior (SAMHSA, 2012, p. 83). If possible,

older adults should be referred to a group specifically tailored to people their age, instead.

Because social support and sound emotional health are so integral in preventing the

development of substance abuse and aiding in the recovery from substance abuse, it is important

to encourage older adults to experience social activities outside of the home often. Religious

organizations, hobby clubs, senior citizen centers, and volunteer organizations all provide ample

opportunity for the older adult to make new friends, receive emotional support, and construct

more meaningful purpose in their life. For those who are not able to leave the home due to

limited mobility, it is important to arrange for in-home services such as home health,

housekeeping, meals on wheels, or volunteer visitors. The person may also be encouraged to

consider moving to a congregate living facility where they could receive more personal

interaction.


In Finland, the provision of healthcare is based on the Social Welfare Act and the General

Law of Healthcare. Citizens have equal access to healthcare throughout their lives, which

includes preventive services and screenings. The Abusers Act regulates the process of treatment

and rehabilitation for those with substance abuse problems, including the abuse of narcotics,

alcohol, illegal drugs, and some recreational solvents. This act aims to prevent and reduce drug

abuse and related psychosocial and physical health concerns and to promote functioning and

safety for abusers and their families. This act also seeks to help substance abusers and their

families find proper treatment programs. A multidisciplinary approach to substance abuse

treatment is generally utilized. Healthcare providers and social services collaborate to treat those

with substance abuse problems, and volunteer organizations also play a key role in providing

treatment. (Ks.ToimintaSuomi, 5).

In Finland, somatic diseases associated with drug problems are usually treated within a

health center or hospital. Primary care providers may assist in prevention and detection of

substance abuse issues. Health centers provide detoxification and rehabilitation services, and

many hospitals have specialized substance abuse psychiatry units. A-Clinics, detoxification

units, youth centers, rehabilitation centers, and Jarvenpaa Social Hospital offer detoxification and

rehabilitation treatments, as well as different types of psychosocial services. Assistance for

acquiring housing and assistance with physical and psychosocial needs, as well referrals for

institutional commitment are provided by social services. Social services workers may also have

to report families to child services in certain situations, as is required by the Child Healthcare

Act.

The cost of treatment for substance abuse is comparable to other chronic diseases and

may be paid for with health insurance, pension and rehabilitation benefits. The amount and


quality of substance abuse services vary in different municipalities. Treatment should occur in

the least restrictive environment and should involve efficient, professional collaboration of

healthcare and social services workers throughout the entirety of the treatment process. When

caring for the patient with substance abuse issues, healthcare providers should maintain

organization and promote the patient’s dignity. (Alcohol dependence, Kaija Seppa, H. Alho, &.

Kiianmaa Duodecim, 2013)

Older adults with substance abuse problems may seek assistance with treatment and

meeting ADLs from a variety of volunteer organizations. Rehabilitation may be assisted by

liaison officers who regularly visit the patient. Older adults may need assistance with tasks like

cooking, cleaning, and shopping, which liaison officers may also assist with. Those with severe

self-care deficits related to substance abuse may also benefit from being placed in a foster care

program for older adults.

NGO’s and Government Resources

Four general healthcare models, with multiple variations on these models, are generally

utilized in caring for vulnerable groups. When developing resources for vulnerable populations,

like substance abusing older adults, it is important to keep the country of intervention’s

healthcare system in mind. The United States is unique in that is uses the “Out-of-Pocket” model

of healthcare, which is not used in any other country. The quality of the healthcare system in the

U.S. is quite variable because the care provided is based on multiple factors. For example, being

a veteran, having access to Medicaid or Medicare funds, and lacking insurance may affect the

care received, if any is available at all. The biggest challenge in this healthcare system is costly

care. Often, insurance won’t cover the majority of healthcare costs, and full-coverage is quite


expensive. This creates a predicament that is hard to overcome and creates a plight that separates

vulnerable populations in the US to the vulnerability group in Finland.

Finland uses the National Health Insurance model, in which everyone is offered universal

healthcare. Healthcare is paid for by taxes, although it is not completely free. There are

maximum out-of-pocket fees for primary healthcare, which are quite reasonable. Cost varies at

each health care center (Expat-Finland). When considering healthcare of the vulnerability group

in this region, it is important to assess out-of-pocket costs and the financial status of the

individual. One disadvantage to this system is the lack of ability to choose one’s physician.

Physicians assigned to patients based on availability and area of expertise (Yglesias,2010).

Along with the traditional healthcare system in the U.S., there are many governmental

and non-governmental organizations (NGOs) that provide services to the elderly who struggle

with substance abuse. Most of these organizations provide services to all substance abusers, not

just the elderly. A good starting point for people with addictions is HelpGuide. This organization

provides a useful tool for addicts to look for treatment or treat themselves. There are many

guides and links to resources and rehab center locators for a variety of substance addictions.

Although based in the U.S., the website also helps people in the U.K., Australia, and Canada find

resources in their region. A governmental organization in the U.S. that helps substance abuse is

Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA is an

agency within the U.S. Department of Health and Human Services and is a useful tool for addicts

seeking treatment. The agency’s website layout is simple and easy to use, and they have a 24/7

hotline in which addicts seeking help can call any day of the year (SAMHSA). These services

are similar in nature to services offered in Finland.


There are two main services of interest for elderly substance abusers in Finland. These

are the government’s health centers and the NGO A-Clinic Foundation. The health centers are

part of the government’s universal healthcare package for its citizens. Older adults with

substance abuse problems may receive diagnostic services, treatment, and referrals to other

agencies from these groups. These organizations are typically the first stop for seeking treatment,

and some health centers have a specialized addiction nurse (Paihdelinkk, 2014). The A-Clinic

Foundation is an organization that offers rehabilitation services, substance abuse prevention

services, and expert help to reduce substance abuse and other mental problems (A-klinikka). A

useful feature of this NGO is that the outpatient treatment is free of charge for residents of

Finland, and a referral is not needed from a doctor to use it (Paihdelinkki, 2014).

In comparison, the vulnerability group in Finland has easier and more equal opportunities

to seek and receive care compared to the United States. Healthcare in Finland is cheap or free for

its residents, whereas U.S. citizens may run into financial difficulties when trying to afford

treatment. This is one of the reasons HelpGuide offers self-help guides to addicts, as some

addicts want to get better but cannot afford treatment. When comparing the services overall, it is

easy to conclude that Finland substance abuse services are easier and cheaper to access for

everyone, while the U.S. services face challenges of expensive care and unequal opportunity.

Nursing Theory

When caring for any population, the use of evidence-based, research proven methods is

of utmost importance. It is always important to consider the client’s learning capabilities,

emotional state, and physical barriers to improvement when designing a plan of care. When

caring for older adult clients, nurses may need to modify teaching to match learning styles and

functional capabilities of older adults and manipulate certain aspects of care to accommodate for


changes is ability related to the aging process. Depending on the substance of abuse, the amount

and frequency of substance abuse, level of addiction, and possible presence of disease processes,

nurses may need to adapt care and modify teaching to accommodate the learning abilities of the

client who is abusing substances.

Planning care and preparing teaching for the older substance-abusing older adult client

can present unique challenges to even the most experienced nurse. For example, these clients

may be more susceptible to barriers to learning and decision-making, like excessive stress,

impaired emotional state, and feelings of helplessness or hopelessness (Eliopoulos, 2014, p. 74).

These clients may also be abusing substances to cope with barriers to learning, which further

exacerbates their ability and willingness to learn, get help, and make major life changes.

One way nurses can improve treatment outcomes in the population of older adults who

abuse substances is by incorporating nursing theories for assisting these populations into their

practice. One example of a theory that directly relates to all substance-abusing populations is

Barker’s Tidal Model. This model, originally implemented in mental health facilities in the UK,

is now being adopted by mental health care teams in other countries, including those in the

United States and Finland. (Barker, 2000)

The Tidal Model uses the client’s experiences, emotions, and desires as an initiation point

in the care of the mental health client. It states that the following should be taken into account

when assessing the patient and addressing the mental health concern at hand (in this case,

substance abuse): the origin of the problem, how the problem has affected the patient, past and

present feelings about the substance abuse, how it has affected relationships, what the client

thinks about their substance abuse, what the client thinks should happen treatment-wise, and

what lifestyle changes related to substance abuse look like to the client. Incorporating more


holistic and client-opinion centered questions into the assessment may improve healthcare

provider understanding of the client’s wishes, which in turn may lead to a more client-centered

care plan and improved treatment outcomes later on.

The Tidal Model also has ten commandments, which serve as a guide for better relating

the traditional nursing process to the mental health client. The commandments are: value the

voice, respect the language, develop genuine curiosity, become the apprentice, reveal personal

wisdom, be transparent, use the available toolkit, craft the step beyond, give the gift of time, and

know that change is constant. Value the voice explains that healthcare providers should actively

listen to and value the client’s experiences and input, and that the treatment plan should be based

on these principles. Respect the language is similar, but states that healthcare providers should

not underestimate the importance of body language and context cues like tone of voice when

listening to the client. Developing genuine curiosity involves showing clients that the healthcare

provider does care about the client’s input and well-being, and becoming the apprentice involves

recognizing that the client is an expert on their own life and should be treated as such. The

healthcare provider facilitates the revealing of the client’s personal wisdom, Tidal Model

commandment number five, in order to utilize the client’s knowledge about personal experiences

related to substance abuse, treatment, and even life itself, when providing care. In order for

mutual trust to be established, the healthcare provider needs to be transparent by explaining

exactly what they are doing and why. They also need to give their undivided time and attention

to the client, aka Giving the Gift of Time, keep in mind what has led to success or failure in the

client’s past treatment attempts, aka Using the Available Toolkit, realize that change in the client

and the care plan can and will occur, or Know that Change is Constant, and work with the client


to create a step-by-step, systematic approach to treatment, which demonstrates the

commandment, Craft the Step Beyond (Brookes, 2008).

The Tidal Model relates well to the provision of mental health services for older adults.

For many older adults, reflecting on the life story is a positive experience. It allows older adults

to think about how they have overcome prior obstacles and to remember their past

accomplishments, which can lead to an increased sense of self and feelings of improved self-

esteem. It can also lead to reflection on past mistakes. By remembering the triumph over past

obstacles, older adults who abuse substances may feel an increased sense that they can overcome

their addiction and may have more incentive to change related to a desire to make better

decisions in the present. It may also lead to insight about why the person began the substance

abuse in the first place and lead to improved client understanding about their condition

(Eliopoulos, 2014, p. 44-47). Since the Tidal Model places importance of the person’s life story

in developing the treatment plan, it can be very effective when instituting care for the older adult

client with a mental health concern. Older adults with sensory deficits may also become

frightened, agitated or suspicious when confronted by healthcare providers and treatment

options. Ensuring that the client has prescribed sensory aides, limiting distractions, actively

listening, and implementing principles from the Tidal Model may make the client feel more

comfortable with the healthcare provider and recovery process as a whole.

Clients who abuse substances may be ambivalent about seeking treatment. However,

allowing the client to express concerns and desires related to treatment, actively listening to the

client, and modeling the treatment plan around the client’s wishes can facilitate positive

outcomes when providing care for these clients. The Tidal Model encourages these behaviors

with the intention of actively involving mental health clients in the recovery process.


Conclusion

Elderly clients who abuse alcohol, illicit drugs and other substances may view health

differently than other people. This population’s views on health must be taken into consideration

when providing treatment, as well. A variety of treatment and rehabilitation programs exist in the

U.S. and Finland to assist this population, and although they operate similarly in terms of

coordination of care, there are many differences in the costs and accessibility of these programs.

Many governmental organizations and NGOs also operate to combat this issue in both countries,

but differing healthcare structures create variation in how these organizations operate. The

incorporation of nursing theories that apply to care for the target population may benefit

healthcare providers and clients in Finland and the US.


References

A-Clinic Foundation. (n.d.). Retrieved October 4, 2015, from http://www.a-klinikka.fi/in-english

Barker, P. (2000). The tidal model: Humility in mental health care.

Benshoff, J., Harrawood, L. (2003). Substance abuse and the elderly: Unique issues and

concerns. Journal of rehabilitation. Vol 69, 2. National Rehabilitation Association.

Retrieved September 30, 2015 from

http://www.kvccdocs.com/KVCC/2015-Fall/MHT216/content/L-19/SubstanceElderly.pd

f

Brookes, N. Murata, L. & Tansey, M. (2008). Tidal waves: Implementing a new model of mental

health recovery and reclamation. Canadian Nurse, 104(8), 22-27.

European Alcohol Policy Alliance. (2015). Finish association for substance abuse prevention

(EHYT). European Alcohol Policy Alliance. Helsinki, Finland. Retrieved on September

30, 2015 from http://www.eurocare.org/about_us/membership/finnish_association

for_substance_abuse_prevention

Eliopoulos, C. (2014). Gerontological nursing (8th ed.). Philadelphia, PA: Lippincott, Williams,

and Wilkins. ISBN: 978-1-4963-1268-6.

Public Healthcare & Services in Finland. (n.d.). Retrieved October 4, 2015, from

http://www.expat-finland.com/living_in_finland/public_healthcare.html

Substance Abuse and Mental Health Services Administration (SAMHSA). (Updated 2012,

Originally published 1998). Substance abuse among older adults: an invisible Epidemic.

Treatment Improvement Protocol (TIP) Series. No. 26, chap. 1. Substance Abuse and

Mental Health Services Administration. Rockville, MD. Retrieved September 30, 2015

from http://www.ncbi.nlm.nih.gov/books/NBK64419/pdf/Bookshelf_NBK64419.pdf


SAMHSA's National Helpline. (2014, September 11). Retrieved October 4, 2015, from

http://www.samhsa.gov/find-help/national-helpline

What should I do if I have problems with substance abuse? (2014, July 25). Retrieved October 4,

2015, from http://www.paihdelinkki.fi/en/where-find-help/substance-abuse-treatment-

services/what-should-i-do-if-i-have-problems-substance

Yglesias, M. (2010, October 26). Cheap Finnish Health Care Is Built on the Back of Low-Paid

Doctors. Retrieved October 4, 2015, from

http://thinkprogress.org/yglesias/2010/10/26/198898/cheap-finnish-health-care-is-built-

on-the-back-of-low-paid-doctors/

Documents

Final Paper, Substance Abuse in the Elderly (1)