Want to know more

SUBSTANCE ABUSE
Nursing Standard of Practice Protocol: Substance Abuse in Older Adults

Madeline Naegle

Evidence-Based Content - Updated March 2008


The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:

 

Goal

Implement best nursing practices to care for older persons with drug, alcohol, tobacco, or other drug abuse or dependencies 

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Overview 

A. Several factors increase the risks associated with alcohol and drug use for an older individual, making any drug use in circumstances that, earlier in life were commonplace, potentially harmful. Constitutional risk factors include changes in body composition like decreased muscle mass, decreased organ efficiency (especially kidney and liver), and increased vulnerability of the central nervous system. 1, 2

B. The consequences of alcohol use in combination with other drugs and excessive use include falls, impaired cognition, malnourishment, and decreased resistance to disease, interpersonal, and legal problems. 2

C. At-risk drinking for older adults increases the likelihood of negative health consequences and is defined as more than one drink per day, seven days a week, or more than three drinks on any one occasion. 3

D. Any amount of smoking places older persons at risk for negative health consequences, and advancing age increases the likelihood of the emergence of respiratory and cardiovascular illnesses. 

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Background/Statement of Problem

A. Definitions

1. Substance Use Disorders: A broad category of disorders that include a continuum of use or misuse of alcohol, tobacco, prescription or illicit drugs, and the abuse or dependence on these drugs. 4 adapted

2. Substance Abuse: A maladaptive pattern of substance use evidenced in recurrent and significant adverse consequences related to the repeated use of substances. It is associated with repeated failure to fulfill role obligations, use in situations where use is physically hazardous, and/or when it results in legal and/or interpersonal problems. 4 adapted

3. Substance Dependence: A pattern of self-administration of a drug that is maladaptive and results in the development of tolerance, withdrawal, and compulsive drug-taking behavior. Dependence is both physiologic and psychological. 4 adapted

4. Drug Misuse: Use of a drug for purposes other than that for which it was intended.

5. Polysubstance-Related Disorder: Misuse, abuse, or dependence on three or more drugs. 4 adapted

6. Tolerance: (1) A need for markedly increased amounts of a substance to achieve intoxication or the desired effects, or (2) a markedly diminished effects with the continued use of the same amount of a substance. 4 adapted

7. Withdrawal: A characteristic group of signs and symptoms that has its onset following the sudden cessation of consumption of a drug (including alcohol and nicotine) that induces physiologic dependence. 4

8. At-Risk Drinking: Defined as more than one drink per day, seven days a week, or more than three drinks on any one occasion. For elders, at-risk drinking increases the likelihood of negative health consequences. 5

B. Etiology and/or Epidemiology

1. In 1998, the prevalence of alcoholism, alcohol abuse, or problem drinking in persons aged 60+ was estimated at 5% to 10% in community studies. Approximately 11% of men and 9% of women 75 years and older report heavy use, placing them "at risk" for a range of problems. 5

2. Excessive drinking among individuals of all ethnic groups 65+ years is approximately 7%, down from 12% in persons ages 55 to 64. 6

3. 500,000 persons ages 55 and older reported monthly use of illicit drugs in the National Household Survey of Drug Use National Institute of Drug Abuse. 7

4. Approximately 11% of women older than 59 misuse psychoactive drugs. 8

C. Risk Factors 9

1. Family history of dependence on alcohol, tobacco, prescription or illicit drugs

2. Co-occurrence of addiction with dependency or abuse of another substance dependence (i.e., alcohol and tobacco)

3. Lifelong pattern of substance use, including heavy drinking

4. Male gender

5. Social isolation

6. Recent and multiple losses

7. Chronic pain

8. Co-occurrence with depression

9. Unmarried and/or living alone

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Parameters Of Assessment

A. Screening for alcohol, tobacco, and other drug use is recommended for all community-dwelling and hospitalized older adults. It is essential that the nurse:

1. state the purpose of questions about substances used and link them to health and safety

2. be empathic and nonjudgmental

3. ask the questions when the patient is alcohol- and drug-free

4. inquire re: patient's understanding of the question. 10

B. Assessment/Screening Tools

1. The Quantity-Frequency Index: 11: Review all classes of drugs: alcohol, nicotine, illicit drugs, prescription drugs, OTC drugs and vitamin supplements, for each drug used. Record the Types of drugs, including types of beverages; Frequency: the number of occasions on which the drug is consumed (daily, weekly, monthly); Amount of drug consumed on each occasion during the last 30 days. The psychological function that the substance serves for the individual is also important to identify. The Quantity-Frequency Index tool should be part of the intake nursing history. The Brown Bag approach is useful. 12 The patient is asked to bring all drugs and supplements listed herein to the interview with the provider

2. Short Michigan Alcohol Screening Test-Geriatric Version (SMAST-G):
Highly valid and reliable, this is a 10-item tool that can be used in all settings. Three minutes for administration. This instrument is derived from the MAST-G with a sensitivity of 93.6% and positive predictive values of 87.2%. 13

3. Alcohol Use Disorders Identification Test (AUDIT):
This 10-item questionnaire has good validity in ethnically mixed groups and scores classify alcohol use as hazardous, harmful, or dependent. Administration: 2 minutes. Sensitivity scores range from 0.74% to 0.84% and specificity around 0.90% in mixed age and ethnic groups. 14 This instrument is highly effective for use with elders as well. 15

4. Fagerstrom Test for Nicotine Dependence: 16
This six-question scale provides an indicator of the severity of nicotine dependence (Scores of 0-2, Very low, to 8-10, Very High). The questions inquire as to first use early in the day, amount and frequency, inability to refrain, and smoking despite illness. This instrument has good internal consistency and reliability in culturally diverse, mixed-gender samples.

C. Atypical Presentation:
Men and women older than 65 may have substance-use and dependence problems even though the signs and symptoms may not correspond to those listed in the DSM-IV TR (APA, 2000).

D. Signs of CNS Intoxication (i.e., slurred speech, drowsiness, unsteady gait, decreased reaction time, impaired judgment, disinhibition, ataxia):

1. Assess in individual or collateral (speaking with family members) data collection, consumption of amount and type of depressant medications including alcohol, sedatives, hypnotics, and opioid or synthetic opioid analgesics. 

2. Assess vital signs and determine respiratory, cardiac, or neurological depression. 

3. Assess for treatable existing medical conditions, including depression. 

4. Arrange for emergency room/hospitalization treatment as necessary. 

5. Obtain urine for toxicology, if possible.

E. At-risk Drinking Consumption of alcohol in excess of one drink per day for seven days a week or more than three drinks on any one occasion. 3

1. Assess for readiness to change behavior using Stages of Change Model. 17

2. Is drinker concerned about amount or consequences of the drinking? Has she/he contemplated cutting down?

3. Does she/he have a plan for cutting down/stopping consumption?

4. Has he/she previously stopped but then resumed risky drinking?

5. Personalized feedback and education and education on at-risk drinking results in a reduction in at-risk drinking among older primary-care patients. 18

F. Signs of Withdrawal of CNS Depressant Drugs (including alcohol such as tremors, disorientation, tachycardia, irritability, anxiety, insomnia, moderate diaphoresis):

1. May develop extreme CNS stimulation and progress to seizures, hallucinosis, withdrawal delirium, extreme hypertension, profuse diarrhea, from 4 to 8 hours and for up to 72 hours following cessation of alcohol intake (Delirium Tremens/DTs). 

2. Assess for risk factors: (a) previous episodes of detoxification, (b) recent heavy drinking, (c) medical co-morbidities including liver disease, pneumonia, anemia, (d) previous history of seizures or delirium. 19 

3. Assess neurological signs using the CIWA-AR. This Clinical Institute Withdrawal Assessment of Alcohol Scale, revised (CIWA-Ar), is a 10-item rating scale that delineates symptoms of gastric distress, perceptual distortions, cognitive impairment, anxiety, agitation, and headache. 20

4. Medicate with a short-acting benzodiazepine (lorazepam or oxazepam) in doses titrated to patient’s score on the CIWA, patient’s age and weight. 20

G. Reported Sleep Disturbance, Anxiety, Depression, Problems with Attention and Concentration (Acute Care):

1. Assess for neuropsychiatric conditions using the Mental Status exam, Geriatric Depression Scale, or Hamilton Anxiety Scale. (See Dementia and Depression topics). 

2. Obtain sleep history because drugs disrupt already altered sleep patterns in older persons. 

3. Assess intake of all drugs, including alcohol, OTC, prescription, herbal and food supplements, and nicotine. Use Brown Bag strategy.
 
4. If positive for alcohol use, assess for last time of use and amount used. 

5. Assess for alcohol or sedative drug withdrawal as indicated.

H. Smoking Cigarettes or Using Smokeless Tobacco:

1. Assess for level of dependence using the Fagerstrom Test (See tool above).

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Nursing Care Strategies

A. At-risk Drinking (consumption of alcohol in excess of one drink per day for seven days a week or more than three drinks on any one occasion.):

1. Hydrate with clear fluid p.o. as indicated. Limit use of intravenous fluid except as necessary. Hospitalize if:

a. Blood alcohol level (BAL) >100mg/dl
b. Severe withdrawal symptoms
c. Suicidal ideation or attempts
d. Co-morbid conditions that compromise treatment
e. Polysubstance dependence

2. Conduct Brief Intervention (FRAMES) 21

a. Feedback information to patients about current health problems or potential problems associated with their level of consumption.
b. Responsible choice about how to respond to the information provided to the patients is their choice.
c. Advice must be clear about drinking their amounts and recommended moderate levels of drinking.
d. Menu of choices is provided by the nurse to the patient/client regarding future drinking behaviors.
e. Empathy is essential to the exchange. Offer information based on scientific evidence, acknowledge the difficulty of change, avoid confrontation.
f. Self-efficacy of the individual is supported and the nurse helps patient explore options for change.

B. Smoking cigarettes or using smokeless tobacco.

1. Apply the AHRQ Five A’s Intervention Cessation 24

a. Ask: Identify and document tobacco use.

b. Advise: Urge the user to quit in a strong personalized manner.

c. Assess: Is the tobacco user willing to make a quit attempt at this time?

d. Assist: If user is willing to attempt, refer for individual or group counseling and pharmacotherapy.

e. Arrange: Referrals to providers, agencies, and self-help groups. Monitor pharmacotherapy once quit date is established. FDA-approved pharmacotherapies for smoking cessation are:

i. Bupropion SR (Zyban) and nicotine replacement products such as nicotine gum, nicotine inhalers, nicotine nasal spray, and nicotine patch. Psychoeducation about these medications is essential.

ii. Zyban, for example, should not be combined with alcohol. Nurses working with in-patients in a case-management model were found to produce outcomes in smoking cessation. 22,23

iii. Communicate Caring and Concern:
• Encourage moderate intensity exercise as a means of reducing cravings for nicotine because 5 minutes of such exercises is associated with short-term reduction in the desire to smoke and tobacco withdrawal symptoms. 23
• Arrange: Schedule follow-up contact in person or by telephone within 1 week after planned quit date. Continue telephone counseling for those using nicotine patches. 25,26

C. Smoking Marijuana: Little research regarding effective intervention for psychological dependence on marijuana is available. Some guidance can be found in smoking cessation and self-help approaches.

1. Refer to Steps for Smoking Cessation.

2. Refer patient to addiction specialist for counseling for psychological dependence and/or cognitive-behavioral therapy.

3. Refer to community-based self-help groups such as Narcotics Anonymous, Alcoholics Anonymous, and Al-Anon.

4. Encourage development or expansion of patient’s social support system.

D. Heroin or Opioid Dependence

1. Older long-term opioid users may relapse and require treatment. Methadone or Buprenorphine are current pharmacological treatment options, effective in conjunction with self-help programs and/or psychosocial interventions. 27

2. Treatment with methadone, a synthetic narcotic agonist, suppresses withdrawal symptoms and drug cravings associated with opioid dependence but requires daily dosing of 60 mg, minimum. It is dispensed only in specially licensed clinics.

3. Buprenorphine (Subutex or Suboxone), recently approved for use in office practice by trained physicians, is an opioid partial agonist-antagonist. Alone and in combination with Naloxone (Suboxone), it can prevent withdrawal when someone ceases use of an opioid drug and can be used for long-term treatment. Naloxone is an opioid antagonist used to reverse depressant symptoms in opiate overdose and at different dosages to treat dependence.

i. Close collaboration with the prescriber is required because these drugs should not be abruptly terminated, used with antidepressants, and interact negatively with many prescription medications.

4. Naltrexone, a long-acting opioid antagonist, blocks opioid effects and is most effective with those who are no longer opioid-dependent but are at high risk for relapse. 28

5. Treatment of an older patient who has become addicted to oxycontin or other opioids should be done in consultation with an addictions specialist nurse or physician.

a. It is recommended that the prescriber avoid opioids and the synthetic opioids Demerol, Dilaudid, and Oxycontin. The opioids have high potential for addiction and Demerol has been associated with delirium in elders. 28, 29

b. Barbiturates should be avoided for use as hypnotics and the use of benzodiazepines for anxiety should be limited to 4 months. 9

E. Relapse Prevention

1. Monitor pharmacologic treatment such as Naltrexone as short-term treatment for alcohol dependence. The benefits of this treatment are dependent on adherence, and psychosocial treatment should accompany its use. 30 Methadone or Buprenorphine should be used for long-term treatment of opioid dependence.

2. Refer to community-based Alcoholics Anonymous, Narcotics Anonymous, Al-Anon groups, and encourage attendance.

3. Educate family and patient regarding signs of risky use or relapse to heavy or alcohol-dependent behavior.

4. Counsel patient to reduce drug use (Harm Reduction) and engage in relationship healing/building, community or intellectually rewarding activities, spiritual growth, which increase valued nondrinking rewards.

5. Counsel in the development of coping skills:

a. Anticipate and avoid temptation.

b. Learn cognitive strategies to avoid negative moods.

c. Make lifestyle changes to reduce stress, improve the quality of life, and increase pleasure.

d. Learn cognitive and behavioral activities to cope with cravings and urges to use.

e. Encourage development or expansion of patient's social support system.

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Evaluation/Expected Outcomes

A. Patient will have:

1) Improved physical health and function.
2) Improved quality of life, sense of well-being and mental health.
3) More satisfying interpersonal relationships.
4) Enhanced productivity and mental alertness.
5) Decreased likelihood of falls and other accidents.

B. Nurses will have:

1) Increased accuracy in detecting patient problems related to use/misuse of substances.
2) Interventions will be more evidence-based resulting in better outcomes.

C. Institution will have:

1) Increased number of referrals to ambulatory substance-abuse/mental-health treatment programs.
2) Improved links with community-based organizations engaged in prevention, education, and treatment of elders with substance-related disorders.

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Follow-up Monitoring

A. Evaluate for increase in substance use/misuse associated with growing numbers of aging adults.

B. Increase outreach to targeted vulnerable populations.

C. Document chronic care needs of elders diagnosed with substance-related disorders.

D. Monitor alcohol use among older adults with chronic pain. 31

E. Communicate findings to all members of the involved caregiver team.

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Guidelines

A. The National Quality Forum is completing review for "Evidence-based practices to treat substance use disorders." These guidelines are inclusive of primary care, the settings in which most elders seek treatment.

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For Definition of Levels of Quantitative Evidence Click Here

Reprinted with permission from Springer Publishing Company. Naegle, M. (2008). Substance abuse in older adults. In E. Capezuti, D. Zwicker, M. Mezey, & T. Fulmer (Eds.) Evidence-based geriatric nursing protocols for best practice. (3rd ed.) (pp. 649-672). New York: Springer Publishing Company, Inc.

 

References

1.  Lang, M. M. (2001). Screening for cognitive impairment in the older adult. Nurse Practitioner, 26(11), 26, 32–34, 36–37, 41–43. Evidence Level VI: Expert Opinion.

2.  Kennedy, G. J. (2000). Geriatric mental health care: A treatment guide for health professionals. New York: The Guilford Press. Evidence Level IV: Nonexperimental Study.

3.  U.S. Department of Health and Human Services, National Institute of Alcohol Abuse and Alcoholism (2005). Helping patients who drink too much: A clinician’s guide. Rockville, MD: USDHHS. Evidence Level VI: Expert Opinion.

4.  American Psychiatric Association (APA) (2000). Diagnostic and statistical manual of mental disorders-IV-TR (4th ed.). Washington, DC: American Psychiatric Association: Author.

5. Fleming, M. F., Manwell, L. B., Barry, K. L., & Johnson, K. (1998). At-risk drinking in an HMO primary care sample. Prevalence and health policy implications. American Journal of Public Health, 88(1), 90–93. Evidence Level III: Quasi-experimental Study.

6.  New York City Department of Health and Mental Hygiene (NYCDHMH) (2005). Alcohol use in New York City. NYC Vital Signs, 4(1), 1–4.

7.  National Institute of Drug Abuse (NIDA) (2001). The economic costs of drug abuse in the United States, 1992–1998. Retrieved August 1, 2005, from http://www.nida.nih.gov. 

8.  Fingeld-Connett, D. (2004). Treatment of substance misuse in older women using a Brief Intervention Model. Journal of Gerontological Nursing, 31–37. Evidence Level IV: Nonexperimental Study.

9.  U.S. Department of Health and Human Services (2004b). Substance abuse among older adults: A guide for physicians (DHHS Publication No. SMA 00-3394). Rockville, MD: USDHHS, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. Evidence Level VI: Expert Opinion.

10. Aalto, M., Pekuri, P., & Seppa, K. (2003). Primary health care professionals' activity in intervening in patients' alcohol drinking during a 3-year brief intervention implementation project. Drug and Alcohol Dependence, 69(1), 9–14. Evidence Level III: Quasi-experimental Study.

11. Khavari, K. A., & Farber, P. D. (1978). A profile instrument for the quantification and assessment of alcohol consumption: The Khavari Alcohol Test. Journal of Studies on Alcohol Abuse, 39, 1525. Evidence Level VI: Expert Opinion.

12. Armor, D. J., Polish, M., & Stambul, H. B. (1978). Alcoholism and treatment. New York: Plenum Press. Evidence Level VI: Expert Opinion.

13. Blow, F. C., Brower, K. J., Schulenberg, J. E., Demo-Danenberg, L. M., Young, J. P., & Beresford, T. P. (1992). Michigan Alcoholism Screening Test-Geriatric Version: A new elderly specific screening instrument. Alcoholism, Clinical and Experimental Research, 16(2), 372. Evidence Level III: Quasi-experimental Study.

14. Allen, J. P., Litten, R. Z., Fertig, J. B., & Babor, T. (1997). A review of research on the Alcohol Use Disorders Identification Test (AUDIT). Alcohol, Clinical and Experimental Research, 21(4), 613–619. Evidence Level III: Quasi-experimental Study.

15. Roberts, A. M., Marshall, E. J., & MacDonald, A. J. (2005). Which screening test for alcohol consumption is best associated with "at risk" drinking in older primary care attenders? Primary Care Mental Health, 3(2), 131–138. Evidence Level III: Quasi-experimental Study.

16. Pomerleau, C. S., Carton, S. M., Lutzke, M. L., Flessland, K. A., & Pomerleau, O. F. (1994). Reliability of the Fagerstrom Tolerance Questionnaire and Fagerstrom Test for Nicotine Dependence. Addictive Behavior, 19(1), 33–39. Evidence Level V: Program Evaluation.

17. Prochaska, J. O., & Di Clemente, C. C. (1992). Stages of change in the modification of problem behaviors. Progress in Behavior Modification, 28, 183–218. Evidence Level II: Individual Experimental Study. 

18. Fink, A., Eliott, M. N., Tsia, M., & Beck, J. C. (2005). An evaluation of an intervention to assist primary care physicians in screening and educating older patients who use alcohol. Journal of the American Geriatrics Society, 53(11), 1937–1943. Evidence Level III: Quasi-experimental Study.

19. Wetterling, T., Weber, B., Depfenhart, M., Schneider, B., & Junghanns, K. (2006). Development of a rating scale to predict the severity of alcohol withdrawal syndrome. Alcohol and Alcoholism, 41(6), 611–615. Evidence Level III: Quasi-experimental Study.

20. Sullivan, J. T., Sykora, K., Schneiderman, J., Naranjo, C. A., & Sellers, E. M. (1989). Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-AR). British Journal of Addictions, 84, 1353–1357. Evidence Level III: Quasi-experimental Study.

21. Dyehouse, J., Howe, S., & Ball, S. (1996). FRAMES model in training manual for nursing using brief intervention for alcohol problems. Retrieved March 22, 2007, from http://pathwayscourses.samhsa.gov/vawp/vawp_supps_pg20.htm. Evidence Level VI: Expert Opinion.

22. Smith, P. M., Reilly, K. R., Houston-Miller, N., DeBusk, R. F., & Taylor, C. B. (2002). Application of a nurse-managed inpatient smoking cessation program. Nicotine and Tobacco Research, 4(2), 211–222. 

23. Daniel, J., Cropley, M., Usher, M., & West, R. (2004). Acute effects of a short bout of moderate versus light intensity exercise versus inactivity on tobacco withdrawal symptoms in sedentary smokers. Psychopharmacology, 174(3), 320–326. Evidence Level II: Individual Experimental Study.

24. AHRQ Clinical Practice Guidelines: Smoking Cessation Guidelines, 2002, are available to download. Retrieved on January 25, 2007 from http://www.guideline.gov/summary/summary.aspx?
ss=15&doc_id=3307&nbr=2533. 

25. Cooper, T. V., DeBon, M. W., Stockton, M., Kleges, R. C., Steenbergh, T. A., & Sherrill-Mittleman, D., et al. (2004). Correlates of adherence to transdermal nicotine. Addictive Behaviors, 29(8), 1565–1578.

26. Boyle, R. G., Solberg, L. I., Asche, S. E., Boucher, J. L., Pronk, N. P., & Jensen, D. J. (2005). Offering telephone counseling to smokers using pharmacotherapy. Nicotine & Tobacco Research, 7(Suppl. 1), S19–S27. Evidence Level III: Quasi-experimental Study.

27. Center for Substance Abuse Treatment. (2004). Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Dependence.Download from http://www.guideline.gov/summary/summary.aspx?
doc_id=5887&nbr=003873&string=opioid+AND+addiction 

28. Srisurapanont, M., & Jarusuraisin, N. (2005). Naltrexone for the treatment of alcoholism: A meta-analysis of randomized controlled trials. The International Journal of Neuropsychopharmacology, 8, 267–280. Evidence Level III: Quasi-experimental Study.

29. Collins, E. D., & Kleber, H. D. (2004). Opioids. In M. Galanter & H. D. Kleber (Eds.), Textbook of substance abuse treatment. Washington, DC: American Psychiatric Association. Level VI: Expert Opinion.

30. World Health Organization (WHO) (2000). A systematic review of opioid antagonists for alcohol dependence. Management of Substance Dependence Review Series. Downloaded  from www.who.int.org. Evidence Level I: Systematic Review.

31. Brennan, P. L., Schutte, K. K., & Moos, R. H. (2005). Pain and use of alcohol to manage pain: Prevalence and 3-year outcomes among older problem and non-problem drinkers. Society for the Study of Addiction, 100, 777–786. Evidence Level III: Quasi-experimental Study.

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Last updated - March 2008