Aging Clin Exp Res (2017) 29:1149–1155 DOI 10.1007/s40520-016-0718-z
ORIGINAL AREffect of alcohol and other substance use on quality of life in older adultsTICLE
Alcohol and other drug use in older adults: results from a community needs assessment
Emily Loscalzo1 · Robert C. Sterling1 · Stephen P. Weinstein1 · Brooke Salzman2
Received: 18 September 2016 / Accepted: 22 December 2016 / Published online: 8 February 2017 © Springer International Publishing Switzerland 2017
Discussion A substantial percentage of the sample reported alcohol and substance misuse. Alcohol use was predictive of depression, global psychological distress, and decreased quality of life. Conclusions This needs assessment reinforces findings from previous studies and addresses the added dimen- sion of examining this in an urban, lower socioeconomic population.
Keywords Needs assessment · Older adult · Drug and alcohol use · Quality of life
The misuse of licit, as well as illicit substances is a devel- oping problem in the “Baby Boomer” generation with alco- hol and prescription painkillers being frequently cited as abused substances [1–5]. As a result, the substance abuse treatment community finds itself lagging behind in address- ing the unique needs of this burgeoning population [6, 7]. For example, survey results indicate that only 18% of treat- ment providers have designated services specific to the needs of this group .
Moderate versus heavy alcohol use in older adults
Guidelines for alcohol consumption for individuals aged 65 and over are more restrictive, especially in cases of indi- viduals who are taking prescription medications known to interact with alcohol . Alcohol, when used in modera- tion, has been shown to be beneficial with respect to certain health outcomes. For example, light to moderate alcohol use has been associated with a lower incidence of non- insulin dependent diabetes in older adults  while other
Abstract Background With the “Baby Boomer” generation reach- ing older adulthood, substance abuse treatment providers find themselves needing to address the unique needs of this population. Heavy drinking in adults ages 65 and over is strongly correlated with depression, anxiety, decreased social support, and poor health. However, while alcohol misuse has been shown to be predictive of a lower quality of life in older adults, the generalizability of these findings to urban dwelling, lower socioeconomic status individuals remains unclear. Aims To identify potential treatment needs of this popula- tion, a city-funded needs assessment was conducted. Methods Subjects were 249 individuals (44% male) who voluntarily completed measures of quality of life (QOL), depression, and substance abuse. Measures used included the Psychological General Well-Being Schedule, the Geri- atric Depression Scale-15, and the Alcohol Use Disorders Identification Test (AUDIT). Results Alcohol or substance abuse was reported by over 20% of respondents, with 3.4% of respondents engaged in maladaptive alcohol use. Scores on the AUDIT were pre- dictive of increased depression (r = − .209, p = .01), anxiety (r = − .201, p = .002), lower general well-being (r = − .154, p = .019), and decreased self-control (r = − .157, p = .017).
1 Department of Psychiatry and Human Behavior, Thomas Jefferson University, 1021 S. 21st Street, Philadelphia, PA 19146, USA
2 Department of Family and Community Medicine, Thomas Jefferson University, 834 Walnut Street, Suite 110, Philadelphia, PA 19107, USA
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dietary benefits such as improved appetite and digestion, as well as psychosocial advantages, have also been identified .
However, the intemperate use of alcohol in this popula- tion may lead to a variety of physical health problems, such as deficiencies in essential vitamins and fatty liver disease , mental health problems (i.e., poor short-term memory as well as mood disorders), and diminished quality of life . Of those who abuse alcohol in older adulthood, approx- imately one third are believed to have developed alcohol use disorders later in life (i.e., post age 70). The remainder are believed to have suffered with an untreated alcohol use disorder for some unspecified period of time .
Depression and alcohol use in older adults
Research examining the relationship between alcohol use and depression has been of growing interest to behavio- ral health workers who focus on this age group. Kirchner et al.  found a strong correlation between heavy drink- ing in adults aged 65 and older and mood disorders (i.e., depression and anxiety), as well as decreased social support and the subjective experience of poor health. Rodriguez et al.  also noted higher risk for alcohol abuse in older adults reporting depressive symptoms, particularly those on the younger end of the older adult age bracket. Interest- ingly, Merrick et al.  observed a lower prevalence of unhealthy drinking in depressed older adults. Reasons for these discrepancies in findings are unclear and point to the need for continued research on the relationship between mood, alcohol misuse and aging, and could help to inform treatment options for this age group.
Effect of alcohol and other substance use on quality of life in older adults
Laudet and others have postulated that the quality of life (QOL) of substance abusers is frequently poorer than that of non-substance abusers . Whether this find- ing is robust across all age groups is unknown. Quality of life is a complex construct; one that in older, as well as in younger adults, may be influenced by myriad factors, such as activities, relationships, health, wealth, and surroundings [17, 18]. Farquhar  has demonstrated that not only the absence of negative factors such as depression and anxi- ety, but also the presence of positive factors, such as good physical health as well as social contacts and support, are important determinants of elder QOL. Tuchman , in reviewing the literature on addiction in women, noted the challenges associated with delivering care to middle aged, female substance abusers.
The generalizability of these reported findings to an urban dwelling, potentially lower socioeconomic status
older adult population remains unknown however. In an attempt to understand the distinctive treatment challenges confronting this population, the present study was con- ducted to examine the prevalence of substance abuse in a sample of urban older adults attending an inner city senior center facility. Pre-survey discussions with senior center administrative personnel pointed to the relevance of acute alcohol intoxication as the most frequent determinant of behavioral difficulties in this population. It was anticipated that via this needs assessment, basic information about the need for and willingness to utilize behavioral health ser- vices would be documented. As such, it was expected that the result of this study could help to inform decision-mak- ing at the city Department of Behavioral Health level.
Inasmuch as the present study was exploratory in nature, we had very few a priori hypotheses. However, given the prevalence of substance misuse in many low-income, urban settings, it was anticipated that this population, consisting primarily of lower SES, older adults, would report a mean- ingful level of alcohol and/or substance misuse. Based on the findings of Laudet et al. , it was expected that older adults reporting alcohol and/or substance misuse would report a lower quality of life. It was further expected that higher levels of alcohol use would be associated with higher levels of self-reported depressive affect.
Respondents to this city-funded needs assessment were 249 individuals (56% female) participating in a major Northeast city Senior Center (SC) sponsored activities. In an attempt to ensure anonymity, participants were asked to identify their age according to five broad categories. Two-hundred eighteen respondents provided this information. Results indicate that the five age groupings were satisfactorily rep- resented—60–65 (22.9%), 66–70 (23.4%), 70–75 (20.2%), 76–80 (13.8%), and 81 and over (19.7%).
SC participant screening process
To establish the prevalence and scope of depression in SC participants, as well as overall psychological distress and potential alcohol/substance abuse disorders, the abbreviated Geriatric Depression Scale (GDS) , the Psychological General Well-Being Index (PGWBI) , and the Alco- hol Use Disorders Identification Test (AUDIT)  were administered anonymously to sub-samples of SC enrollees. A series of investigator designed questions further queried
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respondents about use/misuse of licit and illicit substances as well as their perceived need for help with this drug use. Approval from the city and the organization’s Institutional Review Boards was secured prior to onset of data col- lection. In an effort to avoid sampling biases and to most accurately estimate the need for services, these sub-groups included individuals attending the Family Medicine spon- sored medical clinic on-site, a large number of the consum- ers who participated in SC activities and/or participated in programs, as well as a sample of individuals residing in SC sponsored housing. All measures were self-administered unless the respondent requested investigator assistance.
The abbreviated GDS, a brief (15 item) psychometrically sound self-rated scale has been reported to successfully distinguish depressed from non-depressed individuals . Sensitivity and specificity rates of 92.7 and 65.2%, and pos- itive and negative predictive values of 82.6 and 83.3%, have also been noted . The psychometric properties of the GDS have also been established with a sample of cogni- tively intact older adults with functional impairments living in the community .
The PGWBI is a 22 item self-administered measure that in addition to a total score that provides scores in across six dimensions—anxiety, depressed affect, positive well-being, self-control, general health, and vitality . In a non- clinical population, the PGWBI’s psychometric properties were found to be quite acceptable with measures of internal consistency (Cronbach’s alpha) and test–retest reliabilities being quite good (0.94 and 0.66, respectively) . Valid- ity estimates were also acceptable.
The AUDIT is a well-documented, relatively brief (10 item) screening tool for alcohol use disorders. The AUDIT demonstrates strong psychometric properties, including test–retest reliability (r = .80) , internal consistency (Cronbach’s alpha = 80) , and construct validity (sen- sitivity 100%, specificity 76% for identifying alcohol use disorders) .
In addition, respondents were asked (1) how troubled they were about their alcohol/drug use (scaled as Very, Somewhat, or Not At All), and across a series of investiga- tor-designed dichotomized items (i.e., Yes/No), (2) whether their alcohol/drug use caused problems such as craving and/or withdrawal, (3) whether they would use specialized behavioral health services if they were provided at the Sen- ior Center (for example, a depression-oriented treatment group), and (4) whether there were barriers that prevented them from accessing behavioral health services.
To avoid a “priming” effect, presentation of the screen- ing and needs assessment items were counterbalanced. In 50% of the survey packages, the needs assessment preceded
the screening instruments (i.e., GDS, AUDIT, PGWBI.) The entire battery and brief narrative question set in most instances took no more than 20 min to complete.
SC program attendees
While we initially had planned to randomly survey a pre- selected sample of individuals participating in daily ser- vices, this plan ultimately proved to be unfeasible due to unreliable attendance.
Discussion with SC senior administrative staff suggested that convenience sampling of SC program attendees might be the most likely means of securing an adequate sized and representative sample, and we ultimately were able to col- lect completed data from 128 individuals.
Sponsored housing elders
While estimates based on published data  suggest that a 2% random sample would be satisfactory to achieve 87.5% certainty that homebound elders scores would fall within the range of 3.3 and 5.3 on the GDS, a 10% random sam- ple of the approximately 1200 older adults residing in the 13 SC sponsored remote housing sites was proposed. Indi- viduals at these sites were informed by mail that they were invited to participate in an anonymous survey of the behav- ioral health needs of older adults. Screening instruments were delivered to the residences by project personnel who followed-up within one week to both collect completed instruments and provide assistance to those individuals who were otherwise unable to complete the measures on their own. Surveys were returned by 101 of the 186 resi- dents to which they were offered (54.3%).
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