the probability that the screening test will be positive among those who have problematic drinking.
In contrast, specificity reflects the probability that the screening test will be negative among those who do not have problematic drinking.
One study comparing the CAGE questionnaire with the Michigan Alcohol Screening Test (MAST) concluded that while both have low sensitivities in older adults, the CAGE questionnaire is more effective overall (Jones, Lindsey, Yount, Soltys, & Farani-Enayat, 1993). Some disadvantages of the CAGE questionnaire include the fact that it was not specifically developed for older adults, it Table 2. Short Michigan Alcoholism Screening Test — Geriatric
Scoring: Two or more “yes” responses indicates an alcohol problem 1. When talking with others, do you ever underestimate how much you drink?
2. After a few drinks, have you sometimes not eaten or been able to skip a meal because you didn’t feel hungry? 3. Does having a few drinks help decrease your shakiness or tremors?
4. Does alcohol sometimes make it hard for you to remember parts of the day or night? 5. Do you usually take a drink to relax or calm your nerves?
6. Do you drink to take your mind off your problems?
7. Have you ever increased your drinking after experiencing a loss in your life?
8. Has a doctor or nurse ever said they were worried or concerned about your drinking? 9. Have you ever made rules to manage your drinking?
10. When you feel lonely, does having a drink help?
problematic or risky substance use through eight questions covering tobacco, alcohol, cannabis, cocaine, amphetamine- type stimulants, inhalants, sedatives, hallucinogens, opiates and other drug use (Humeniuk et al., 2008). This tool is user-friendly and quick to administer, with the advantage of screening for multiple substances at the same time. Significant correlations with other measures of alcohol use disorders were found using the ASSIST in French geriatric outpatients (Khan et al., 2012).
The PDUQp was recently tested in patients aged 50 or older who went to an emergency department due to prescription opioid misuse and opioid use disorder (Beaudoin, Merchant, & Clark, 2016). The study’s authors concluded that it could be a viable instrument, but likely requires some modifications to increase its predictive value in the older adult population. The PDUQp also takes about 20 minutes to complete, which might limit its use in many clinical settings.
The DAST-10 is a brief general screening tool for “drug abuse,” excluding alcohol and tobacco, and can be completed in under eight minutes (Skinner, 1982).
A recent Australian study used both the AUDIT-C and the ASSIST to screen for alcohol and substance use among older adults in both a geriatric hospital and community health setting (Draper et al., 2015). The results showed that 19.5% of participants screened positively for alcohol and substance use, with 17.1% positive for alcohol use, 3.3% for non-medical benzodiazepine use and 1% for non-medical opioid use. Using the ASSIST, 12.4% were rated as medium-high risk. A score of five or higher on the AUDIT-C was used to determine risky alcohol use. The study’s authors concluded that, while many patients in geriatric health services have risky alcohol or substance use, there are few clinical features that distinguish them from other patients. As a result, they recommended routine screening of alcohol and substance use in these settings. Screening for inappropriate use of prescription drugs requires questions that focus on adherence, prescriptions from multiple physicians, where prescriptions are filled, and the use of over-the-counter and alternative medications. Simoni-Wastila and Yang (2006) listed a number of additional warning signs that could indicate inappropriate use of prescription drugs, including:
• Excessive worry about whether psychoactive medications are working or about the supply and timing of medications;
The AUDIT-C is a shortened version of the AUDIT that uses only three questions:
• How often did you have a drink containing alcohol in the past year?
• How many drinks did you have on a typical day when you were drinking this year?
• How often did you have six or more drinks on one occasion in the past year?
Each question is scored on a scale from 0 to 4, with a higher score assigned to heavier or more frequent alcohol use. For older adults, a total AUDIT-C score of 4 or higher (out of 12) could indicate problematic drinking (Aalto, Alho, Halme, & Seppa, 2011). The AUDIT-C has been shown to have nearly identical sensitivity as the full instrument in a general primary care population (Bradley et al., 2007). Another tool, the Senior Alcohol Misuse Indicator (SAMI), is popular in some areas of Canada. The SAMI tool was designed to be sensitive to the feelings of older adults by asking questions in a nonjudgmental way, initially focusing on physical or emotional symptoms. It is also designed to provide for a collaborative discussion between clinician and patient with opportunities for education about the harmful effects of alcohol (Lum, 2005).
In their overview of the available alcohol screening tools, Taylor and colleagues (2014) concluded there is a need for better detection tools for specific use in older adults. They suggest no one screening tool is adequate on its own and that no tool or questionnaire can be an adequate substitute for taking a full patient history of alcohol use. They also note the need for clinicians to consider the possibility of alcohol use disorders across a variety of different settings. For example, the Substance Abuse and Mental Health Services Administration (2012) recommends using the CAGE questionnaire and the MAST-G for screening for alcohol use among older adults, and the AUDIT for identifying alcohol problems among older adults in minority ethnic groups. Screening for Other Substances
Screening tools for substances other than alcohol include the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), the Prescription Drug Use Questionnaire Patient Version (PDUQp) and the Drug Abuse Screening Test (DAST-10).
The ASSIST, which was developed by the World Health Organization and validated in older adults, screens for
• Where appropriate, a physical examination or blood and urine tests (or both); and • Neuroimaging for individuals with recent
head injuries or when there is evidence of cognitive impairment.
6.4.1 Diagnosing a Substance Use Disorder
A diagnosis of a substance use disorder can be made using the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013). However, unlike in DSM-IV, DSM-5 does not separate the diagnoses of substance abuse and dependence. Instead, criteria are provided for substance use disorder accompanied by criteria for intoxication, withdrawal, substance/medication-induced disorder and unspecified substance-induced disorder.
For the most part, the criteria for substance use disorder are identical to the combined DSM-IV diagnoses of substance abuse and dependence, but with two exceptions:
• First, the criterion of “legal problems” was deleted from DSM-5 and a new criterion of “craving or a strong desire or urge to use a substance” was added.
• Second, the number of criteria required for a diagnosis of a substance use disorder is now set at two or more. The severity of the disorder is based on the number of criteria endorsed, with two or three criteria indicating a mild substance use disorder, four or five criteria indicating a moderate substance use disorder, and six or more criteria indicating a severe substance use disorder. Early remission is defined as at least three but less than 12 months without meeting any criteria, while sustained remission is defined as at least 12 months without any criteria, except craving.
Many of the DSM-5 criteria are more relevant to younger people, particularly those that focus on functional level (Farkas, 2014). In addition, these diagnostic items might not be especially relevant or useful for many older adults, especially those who are socially isolated and do not drive, work or volunteer. Observations of physical symptoms and changes in health are more appropriate when assessing this population, with poor sleeping and eating habits being common and often related to substance use in older adults. • Detailed knowledge about or attachment
to a particular drug;
• Complaints about other physicians who refuse to write prescriptions;
• Excessive daytime sleepiness;
• Changes in personal grooming and hygiene; and • Social withdrawal.
When considering which screening tool to use with older adults, it is important to keep in mind that each tool varies in terms of ease of use, sensitivity, specificity and applicability to different subsets of this population. Therefore, it might be useful to employ more than one tool to improve screening effectiveness (Moore et al., 2002; Koh et al., 2016). Some laboratory tests, such as mean cell volume and liver function tests, can be used as a form of screening. These tests can show damage relating to alcohol use in older adults at lower levels of consumption, making it a more sensitive test in this population.
6.4 Assessment
There is always a need for comprehensive assessment when evaluating older adults. A guide from the United Kingdom’s Royal College of Psychiatrists (2015) provides useful considerations about history-taking and systematic assessment in older adults. It emphasizes the need for a non-judgmental, non-ageist approach that takes into account the values and experiences of the patient. It is also points out that it is important to adjust the tempo of the assessment according to the needs of the patient. In the case of a possible diagnosis of a substance use disorder, considerable information must be gathered from the patient and often from providers of collateral information such as family members and caregivers. An essential biopsychosocial approach includes the following items:
• A full history of the patient’s medical and psychiatric illnesses;
• The patient’s use of medications and other substances;
• The patient’s personal and family history; • A mental status examination, including
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at least three times more likely than non-depressed older adults to have an alcohol use disorder (Caputo et al., 2012; Devanand, 2002). Older adults with generalized anxiety disorder are more than twice as likely as those without an anxiety disorder to have a substance use disorder (Mackenzie, Reynolds, Chou, Pagura, & Sareen, 2011). There is also a particularly high suicide rate among the older adult population, especially in men, with alcohol abuse and dependence being the second most common category of psychiatric disorder associated with completed suicide in this population (Blow, Brockmann, & Barry, 2004).
Some older adults can have an early onset disorder that has been present throughout much of their adult life (Farkas, 2014). These individuals may have a history of multiple treatment attempts as well as multiple medical and psychiatric problems associated with their substance use. There is often a history of marital and family dysfunction and estrangement, and there might be associated homelessness in some cases. The prognosis for early onset clients is often worse because of their lack of social support, chronic physical problems (such as liver and cardiovascular illness) and cognitive impairment.
In comparison, people with a late onset disorder are characterized by a history of more significant alcohol or drug use after mid-life. Some of these individuals may have been social drinkers. There is often a strong association between late onset of substance use and many of the mental and physical deficits associated with aging. Physicians might also unwittingly worsen the situation by prescribing additional medications that either interact with alcohol or lead to an additional substance use disorder. However, the prognosis for late onset substance use disorder is often good. When compared to those with early onset disorders, these individuals will typically have developed coping skills that do not involve the use of alcohol or other substances, and they often have stronger social support systems along with better physical and mental health (Farkas, 2014).
6.4.3 Atypical Presentations in Older Adults
Detection and diagnosis in older adults can be difficult as the signs of problematic substance use and addiction can be confused with symptoms of aging and a variety of other health problems associated with older age such as dementia, depression, Parkinson’s disease, falls, sedation or insomnia. Changes in level of functioning can be attributed to other conditions or the aging process itself.
6.4.2 Diagnostic Challenges
of Co-occurring Disorders
The multiple overlapping medical problems often seen in older adults can create a complex diagnostic challenge for clinicians. In many cases, older adults will attribute health symptoms to their underlying medical conditions rather than substance use. The relationship between alcohol use and cognition in older adults is also complicated, as chronic alcohol use can lead to a variety of cognitive disorders such as alcohol-related dementia and Wernicke-Korsakoff syndrome. To complicate matters further, patients could present with evidence of mixed dementia, including features of vascular dementia and Alzheimer’s disease, in addition to a history of excessive alcohol use.
Specific criteria for alcohol-related dementia have been proposed and validated in at least one study (Oslin & Cary, 2003). It is important that clinicians use an appropriate standardized cognitive screening test during assessment, such as the Mini-Mental State Examination or the Montreal Cognitive Assessment (Folstein, Folstein, & McHugh, 1975; Nasreddine et al., 2005). In addition to cognitive screening, clinicians should evaluate the person’s ability to function, including basic functions (“activities of daily living”) and more complex tasks (“instrumental activities of daily living”; Lawton & Brody, 1969). It is also important to evaluate the presence of chronic pain, which is commonly associated with alcohol and other substance use.