• Screening for alcohol, tobacco, and other drug use is recommended for all community-dwelling and hospitalized older adults. It is essential that the nurse:
  • State the purpose of questions about substances used and link them to health and safety
  • Be empathic and nonjudgmental
  • Ask the questions when the patient is alcohol- and drug-free
  • Inquire regarding patient's understanding of the question (Aalto, Pekuri, & Seppa, 2003 [Level III]).
• Assessment/Screening Tools
  • The Quantity-Frequency Index (Khavari & Farber, 1978 [Level VI]. Review all classes of drugs: alcohol, nicotine, illicit drugs, prescription drugs, over-the-counter (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 (Armor, Polish, & Stambul, 1978 [Level VI]). The patient is asked to bring all drugs and supplements listed herein to the interview with the provider.
  • 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% (Blow et al, 1992 [Level III]).

  • 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 (Allen et al., 1997 [Level III]).  This instrument is highly effective for use with elders as well.

  • Fagerstrom Test for Nicotine Dependence (Pomerleau et al., 1994 [Level V]).

    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.

• 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 Diagnostic and Statistical manual, Fourth Edition (DSM-IV TR).

• Signs of central nervous system (CNS) Intoxication (i.e., slurred speech, drowsiness, unsteady gait, decreased reaction time, impaired judgment, disinhibition, ataxia):
  • 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.
  • Assess vital signs and determine respiratory, cardiac, or neurological depression.
  • Assess for treatable existing medical conditions, including depression.
  • Arrange for emergency room/hospitalization treatment as necessary.
  • Obtain urine for toxicology, if possible.
• 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 (U.S. Department of Health and Human Services [USDHHS], 2005 [Level VI]).
  • Assess for readiness to change behavior using Stages of Change Model (Prochaska, & Di Clemente, 1992 [Level II]).
  • Is drinker concerned about amount or consequences of the drinking? Has she/he contemplated cutting down?
  • Does she/he have a plan for cutting down/stopping consumption?
  • Has he/she previously stopped but then resumed risky drinking?
  • Personalized feedback and education and education on at-risk drinking results in a reduction in at-risk drinking among older primary-care patients (Fink et al., 2005 [Level III]).
• Signs of Withdrawal of CNS Depressant Drugs Including Alcohol (such as tremors, disorientation, tachycardia, irritability, anxiety, insomnia, moderate diaphoresis):
  • 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).
  • Assess for risk factors: (a) previous episodes of detoxification, (b) recent heavy drinking, (c) medical comorbidities including liver disease, pneumonia, anemia, (d) previous history of seizures or delirium (Wetterling et al., 2006 [Level III]).
  • 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 (Sullivan et al., 1989 [Level III]).
  • Medicate with a short-acting benzodiazepine (lorazepam or oxazepam) in doses titrated to patient's score on the CIWA, patient's age and weight (Sullivan et al., 1989 [Level III]).
• Reported Sleep Disturbance, Anxiety, Depression, Problems with Attention and Concentration (Acute Care):
  • Assess for neuropsychiatric conditions using the Mental Status exam, Geriatric Depression Scale, or Hamilton Anxiety Scale. (See the National Guideline Clearinghouse [NGC] summaries of the Hartford Institute for Geriatric Nursing protocols Dementia and Depression).
  • Obtain sleep history because drugs disrupt already altered sleep patterns in older persons.
  • Assess intake of all drugs, including alcohol, OTC, prescription, herbal and food supplements, and nicotine. Use Brown Bag strategy.
  • If positive for alcohol use, assess for last time of use and amount used.
  • Assess for alcohol or sedative drug withdrawal as indicated.
• Smoking Cigarettes or Using Smokeless Tobacco:
  • Assess for level of dependence using the Fagerstrom Test (See tool above).

Nursing Care Strategies

• 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):
  • Hydrate with clear fluid by mouth (p.o.) as indicated. Limit use of intravenous fluid except as necessary. Hospitalize if:
    • Blood alcohol level (BAL) >100 mg/dL
    • Severe withdrawal symptoms
    • Suicidal ideation or attempts
    • Comorbid conditions that compromise treatment
    • Polysubstance dependence
  • Conduct Brief Intervention (FRAMES) (Dyehouse, Howe, & Ball, 1996 [Level VI]).
    • Feedback information to patients about current health problems or potential problems associated with their level of consumption.
    • Responsible choice about how to respond to the information provided to the patients is their choice.
    • Advice must be clear about drinking their amounts and recommended moderate levels of drinking.
    • Menu of choices is provided by the nurse to the patient/client regarding future drinking behaviors.
    • Empathy is essential to the exchange. Offer information based on scientific evidence, acknowledge the difficulty of change, avoid confrontation.
    • Self-efficacy of the individual is supported and the nurse helps patient explore options for change.
• Smoking cigarettes or using smokeless tobacco.
  • Apply the Five A's Intervention ("Treating tobacco," 2008)
    • Ask: Identify and document tobacco use.
    • Advise: Urge the user to quit in a strong personalized manner.
    • Assess: Is the tobacco user willing to make a quit attempt at this time?
    • Assist: If user is willing to attempt, refer for individual or group counseling and pharmacotherapy.
    • Arrange: Referrals to providers, agencies, and self-help groups. Monitor pharmacotherapy once quit date is established. U.S. Food and Drug Administration (FDA)-approved pharmacotherapies for smoking cessation are:
      • 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.
      • 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 (Smith et al., 2002; Daniel et al., 2004 [Level II]).
      • 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 (Daniel et al., 2004 [Level II]).
        • 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 (Cooper et al, 2004; Boyle et al., 2005 [Level III]).
• 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.
  • Refer to Steps for Smoking Cessation.
  • Refer patient to addiction specialist for counseling for psychological dependence and/or cognitive-behavioral therapy.
  • Refer to community-based self-help groups such as Narcotics Anonymous, Alcoholics Anonymous, and Al-Anon.
  • Encourage development or expansion of patient's social support system.
• Heroin or Opioid Dependence
  • 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. (National Institute for Drug Abuse, 2008 [Level IV]).
  • 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.
  • 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.
    • 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.
  • 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 (Srisurapanont & Jarusuraisin, 2005 [Level III]).
  • 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.
    • 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 (Collins & Kleber, 2004 [Level VI]).
    • Barbiturates should be avoided for use as hypnotics and the use of benzodiazepines for anxiety should be limited to 4 months (USDHHS, 2004 [Level IV]).
• Relapse Prevention
  • 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 (World Health Organization [WHO], 2000 [Level I]). Methadone or Buprenorphine should be used for long-term treatment of opioid dependence.
  • Refer to community-based Alcoholics Anonymous, Narcotics Anonymous, Al-Anon groups, and encourage attendance.
  • Educate family and patient regarding signs of risky use or relapse to heavy drinking or alcohol-dependent behavior.
  • 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.
  • Counsel in the development of coping skills:
    • Anticipate and avoid temptation.
    • Learn cognitive strategies to avoid negative moods.
    • Make lifestyle changes to reduce stress, improve the quality of life, and increase pleasure.
    • Learn cognitive and behavioral activities to cope with cravings and urges to use.
    • Encourage development or expansion of patient's social support system.

Follow-Up Monitoring of Condition

• Evaluate for increase in substance use/misuse associated with growing numbers of aging adults.
• Increase outreach to targeted vulnerable populations.
• Document chronic care needs of elders diagnosed with substance-related disorders.
• Monitor alcohol use among older adults with chronic pain (Brennan, Schutte, & Moos, 2005 [Level III]).
• Communicate findings to all members of the involved caregiver team.

Definitions:

Levels of Evidence

Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews)

Level II: Single experimental study (randomized controlled trials [RCTs])

Level III: Quasi-experimental studies

Level IV: Non-experimental studies

Level V: Care report/program evaluation/narrative literature reviews

Level VI: Opinions of respected authorities/Consensus panels

Reprinted with permission from Springer Publishing Company: Capezuti, E., Zwicker, D., Mezey, M. & Fulmer, T. (Eds). (2008) Evidence Based Geriatric Nursing Protocols for Best Practice, (3^rd ed). New York: Springer Publishing Company.

References open in a new window

Electronic copies: Available from the Hartford Institute for Geriatric Nursing Web site.

Copies of the book Geriatric Nursing Protocols for Best Practice, 3rd edition: Available from Springer Publishing Company, 536 Broadway, New York, NY 10012; Phone: (212) 431-4370; Fax: (212) 941-7842; Web: www.springerpub.com.

• Alcohol use screening and assessment for older adults. Try this: best practices in nursing care to older adults. 2007. Electronic copies: Available from the Hartford Institute for Geriatric Nursing Web site.
• Substance abuse: post-test and evaluation. Continuing education activity. Available from the Hartford Institute for Geriatric Nursing Web site.

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