Aging and Addiction
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Debra Jay is a counselor, interventionist, trainer and author, with Carol Colleran, of Aging and Addiction, and with her husband, Jay, of Love First: A New Approach to Intervention for Alcoholism and Drug Addiction.
I want to start out by thanking NCCA, the board of directors, the membership, and most importantly my dear friend Bob LaPrad for inviting me here to talk to you about aging and addiction. I want to start out by sharing with you an article that I just ran across. Last week I was reading the New York Times, (June 11, 2002) and this little piece stopped me dead in my tracks. It’s written by David McCoy, and it’s titled “Abundance of Cures Brings Ills.” And he writes, “Recently my mother, 94, lay slowly dying. She was skeletal, feeble, disoriented, delusional and agitated. And she slept fitfully. She took water by medicine dropper and refused all food. Helpful caring hospice and healthcare workers attended her in my brother’s house around the clock. Three days later, although still occasionally confused, she sat at the kitchen table requesting pancakes for breakfast and making sharp-witted remarks. Two weeks later her mental condition and energy level were essentially normal for the first time in years. A month later her weight was normal. “How did this miracle occur? That isn’t the first question to ask. Instead it is ‘How did a bright happy energetic elderly woman get in such bad shape?’ The answer is drugs. Not heroine or anything elicit, but prescription drugs given by reputable doctors with the best of intentions. “Ten years ago after my father died, my mother’s internist prescribed an anti-depressant. A few years later her cardiologist prescribed a potassium supplement and a diuretic. Her ophthalmologist prescribed three types of eye drops for glaucoma. She became increasingly lethargic and in recent years she could not even force herself to write a note or call a friend. She ate and drank less and less. Last spring she essentially stopped eating, became disoriented and could not sleep. Her internist prescribed sleeping pills, to no avail. He added a typical anti-psychotic drug. Her decline was so pronounced that hospice nurses were called in. As a last attempt the doctor prescribed morphine to ease the pain of dying, we supposed. When I went to see her she barely recognized me. “Learning earlier of her rapidly declining health, I began to talk to friends and professionals. A chance observation by a visiting relative that my mother was being given a lot of pills started me thinking. Few liquids, many medications, including a diuretic, inactivity, lower metabolism rate with age, and no appetite, she must be dehydrated and over-medicated. Studies have shown that feelings of thirst decline with age, a result is that many older people frequently drink fewer liquids than needed for optimum health. That causes medications to concentrate in the body and older people generally have lower metabolism, meaning that they also do not eliminate drugs as quickly. When I looked at the possible side effects of the drugs she was taking, including the eye drops, they were almost in every case, disorientation of time and place, agitation, difficulty sleeping, and loss of appetite. “The internist, instead of carefully reviewing her medications for possible side effects, reducing doses, checking contact levels in the blood, or considering the possibility of dehydration, had prescribed more drugs to medicate the increasing side effects, thereby speeding her decline. First we stopped the morphine. Next, after checking with the professionals and reading the literature, we stopped the anti-psychotic, anti-depressant, diuretic and potassium supplement. With the concurrence of the ophthalmologist we eliminated one of the eye drops for glaucoma. We encouraged liquids and gave her a low dose of new generation anti-psychotic drug, recommended to me by a professional in the field. Its main side effects were more appetite and drowsiness. “The results were astounding. She slept through the night. Her agitation stopped. Her thinking cleared markedly. She started eating and drinking hardily, and her mood elevated sharply. We will never know which drug or drugs caused the problem. My mother’s leg muscles atrophied during her extended inactivity. She is now receiving assistance in physical rehabilitation in a nursing home, and she has no recollection of her ordeal.
“What did I learn? That it is dangerous to grow old. Problems that would cause
great concern if exhibited by a younger person may be dismissed or ignored in
the elderly.”
When I read this, anybody notice anything? This is a case of a woman, from everything that I am reading, that does not have an addiction problem. There is not a mention of alcoholism. There is not a mention of a dependency on benzodiazepine or pain pills, and yet this woman was in this state because of prescription medications. When I work with families concerned with an older adult, they’re looking at an older adult who is also probably on multiple prescription medications, plus alcoholic, often consuming huge amounts of alcohol daily, and many times being given prescription drugs by multiple doctors, mood-altering prescription drugs by multiple doctors. One of our greatest assets in our communities, in our churches, and in our families are our older adults. When they are being ignored, are being put into nursing homes, we all lose. We all lose. If you are looking at typical research, when they talk about older adults, they talk about 60 or 65 and up. When you’re looking at treatment centers that specialize in older adults, they’re usually talking about age 55 and up. When I work with families, people in their 60s, 70s, and early 80s are the ones I see most often. When we talk about the later years, there are long periods of later years. It’s kind of broken up to 65 to 75, 75 to 85, and 85 above. Jimmy Carter came out recently with a book called The Virtues of Aging. He writes, “The virtues of aging include both the blessings that come to us as we grow older and what we have to offer that might be beneficial to others.” There’s an awful lot that is beneficial to others. The later years are a time for integrating life experience, knowledge, and spirituality. By doing so, older adults are able to really develop a deeper meaning for life and create a greater integrity in self. In our communities, in our churches, in our families we have the great gift of being around older adults. We can learn so much from them.
When I think about the people that matter the most in my life, probably my
grandparents had the greatest influence on me. I was reading recently about
women and generations of women, and they said, “You know, we really have it
all wrong. Women don’t become their mothers; they become their grandmothers.”
I think if you’re lucky enough to have a close relationship with a grandmother
when you’re young, that’s really true.
Addiction closes the door to the gifts of the later years; and when it does, we all lose. Many people are calling it the hidden epidemic. To give you an idea how big this problem is I want to look at a few statistics, the first being this: 70% of all hospital admissions and visits to the emergency room are for illnesses — now I am talking about people age 60 and over — are for illnesses and accidents related to alcohol use. Anybody find that surprising? This comes from a study done on 1991 by the U.S. House of Representatives Select Committee on Aging. In 1991, believe me they found this shocking. They also found that 50% of older adults in nursing homes have an alcohol problem. 50%. Most older adults, if they don’t die first, are going to end up in a nursing home, not treatment and recovery. The highest rate of alcoholism is happening among 75-year-old widowers. You know it’s interesting to think back in the 1970s, there was research that said that if you weren’t an alcoholic by 45, you probably never would be one. We know that’s not true today. When we start looking at these statistics, it’s really important to think what role alcohol plays in unsuccessful aging, and how important abstinence, or using small amounts of alcohol among non-alcoholic people, is for successful aging. We can differentiate between young-old and old-old. Young-old are people in their retirement years who are still active. They’re involved with family. They’re involved with community. They’re learning new things. Life is great. They have their health. People who are old-old — the No. 1 thing that differentiates them is the loss of health. When we start looking at alcoholism in older adults, that is the No. 1 thing that we see. The loss of health. The loss of cognitive functioning and the loss of the ability to live independently.
Among the alcoholics, and when I say alcoholics I’m talking about addiction to
all drugs — I have seen people in their late 50s that are functioning like
they are a very ill 85 year old. I work all the time with families who are
concerned, for instance, with a mother who might be only 67 years, in the
prime of her life, but because of alcohol or mood-altering medications or both
is unable to function, is unable to live independently. It has a profound
effect.
What is the first thing people are told if they are concerned about somebody who has an alcohol or drug problem: Where do you go? Who should you go to first? Your doctor. I love doctors. However, doctors are at a tremendous disadvantage. No. 1, most doctors simply do not have the education around addiction. There’s what we call the 4-2-1 rule. Four years of medical school, probably they got two hours of education for the No. 1 problem in this country. So they’re uneducated. No. 2, a lot of studies have been done and doctors are suffering from ageism, like a lot of other people in this country. They’re no different. They may think a darling 80 year old couldn’t possibly be an addict, just because she’s a grandmother and she’s 80. Hey, what does it hurt if I write her out this prescription for Zanex? It’ll just make things a little nicer for her. So what happens is the families are assuming the doctors know what they are doing. The doctors have less and less time and the older adult is just falling through the cracks. Sixty billion dollars right now is the annual cost of alcohol-related hospital care for older adults. We have to start doing the math as Baby Boomers start getting on Medicare — what it’s going to cost our society. Older adults lose an average of 10 years of their life span due to alcoholism. They probably lose 15 years to mood-altering prescription drugs. Columbia University did a study a couple of years ago on older women. They presented 400 doctors with a list of symptoms of an older woman who is suffering from all the classic signs of alcoholism. But they didn’t tell them that, just gave them the symptoms and asked them to respond. The No. 1 diagnosis was depression. So now we’re going to medicate her for depression. Only 1% wrote alcoholism. This is a recent study, okay? One percent. I just talked to a family, three daughters down in Florida, concerned about their mother who is an alcoholic, a wonderful Southern woman, just a charming lady. She was drinking bourbon with her morning coffee and she kept drinking until she passed out, then woke up to drink some more. They thought, “We should bring her to the doctor for this problem. Even better yet, we’re going to get a good psychiatrist for her.” Mom walked out with a prescription for Zanex. Luckily those girls had done a little bit of homework. They snatched that out of her hand and made sure she didn’t get to the pharmacy with it. We have to be really careful. There are a lot of doctors that are getting special education. I really encourage you, if you’re concerned about an older adult and you do decide to talk to a doctor, really ask them very specific questions about what they’re training is in addiction. As we age the liver shrinks. We start metabolizing drugs, including alcohol, out of our body more slowly. The liver enzymes that help that along also decline. So when we have drugs and alcohol in our system, the older we get, the longer they stay in our system. The kidneys also slow down, shrink, and the filtering system slows down. Body fat with age goes up, lean mass goes down, so if you’re talking about your sedatives and your tranquilizers, they’re actually absorbed into the fat of the body, and they’ll stay in the body longer. The water content in our body decreases, so when we drink alcohol the blood alcohol content is actually going up. There are other body changes as well, but for older adults having one alcoholic beverage — one beer, one glass of wine, 4½ or 5 ounces of wine, one shot of 86 proof alcohol, all equal the same amount of alcohol, all are one drink — might be equivalent to four or five drinks in their body as compared to a 35 year old or a 45 year old. So less is more. It has a greater impact in the brain and all the organs in the system as it stays in there. Of all the drugs, alcohol is the most damaging to the human body.
Of people over the age of 65, 83% use prescription medications; and of that
83% a full 50% are being prescribed a sedative. 70% of all over-the-counter
drugs are purchased and used by older adults, and 16.9 million prescriptions
for tranquilizers are written to older adults annually. Zanex has become
really popular. I think it is important to know that Valium was developed as a
two-week trauma drug. A two-week trauma drug. I see older adults who’ve been
on benzodiazepines for 20 years or longer. And they’re drinking with this, and
drinking a lot in most cases.
It’s tough with managed care; you might have seven minutes to 15 minutes with a patient. You know you’re going to talk to an older adult about what medications they’re on, what are the side effects, what’s going on with their health, their life. Give me a break. How are you going to do that in that amount of time? When we look at our older adults and the mood-altering drugs they’re being prescribed, there are three really important questions to ask. One: Is the drug blocking the older adult’s personal growth? Are there non-drug methods that I can use to deal with problems, such as relaxation techniques, counseling, grief counseling. A lot of older adults are experiencing tremendous grief, watching their friends die, losing a spouse, empty-nest syndrome, change of body image, change of life roles, many many loses through the years. Oftentimes if the grieving process is not allowed to happen, they’ll actually start to experience physical pain. The grief will come out as physical pain. And instead of asking questions about what is going on in their life, they get a pain medication. The second question is: Is the drug preventing the older adult from finding the source of the problem? Is it preventing them from taking positive action to deal with it? Thirdly, what non-drug recommendations did the doctor present before writing a prescription? We do hear a lot about how alcohol is good for your health these days. I was at a talk by Jane Brody, health editor for the New York Times. Her talk was to people over 65, for seniors, and boy did she ever press that point about all the good research about drinking. It made her really popular with the group. I want to go through some of the problems, but let’s just look at people who shouldn’t drink. This is according to the National Institute of Health. You should not use alcohol in any amount if you have a family history of alcoholism, if you are an alcoholic or are addicted to any other mood-altering drug, if you are on any medication, if you have any health problems, and certainly if you are operating any equipment, boats, cars, things like that.
Dr. Robert Dupont, former drug czar under President Ford, has developed what
he’s called the Red Light, Green Light, Yellow Light, and he’s adapted it for
older adults. If you use alcohol and you don’t fit in any of those other
categories and if you choose to use alcohol, he says, “Over the age of 60, you
should consume no more than one drink per 24 hours, four drinks per seven
days.” We’re getting a lot of messages about how good it is to have two drinks
a day, and you know some people get a really nice pour going on those drinks.
It might be three. It might be four. No one talks about what one drink means.
The aging process and addiction mirror each other: Memory loss, shaking hands, frequent napping, and we talk about nesting, older adults nesting. They have a chair. They have their drink there. They have their eyeglasses. They have their clicker, and they spend the day drinking and watching TV and napping, passing out in the chair. They experience boredom, depression, frequent falls, bruises, and dizziness. More often than not, for older adults it’s just considered part of the natural aging process.
There is a blurry line between heavy drinking and addiction. But the effect on
the heart can be heart failure, coronary artery disease, high cholesterol,
arrhythmia, high blood pressure. The pancreas stops or digestive juices
actually begin to digest the pancreas itself. As for the brain, alcohol
impairs judgment, impairs reasoning, learning, coordination, memory, speech;
it acts upon the central nervous system, has a sedative effect. It’s a
depressant. Then there is osteoporosis, a loss of calcium. It lessens the
ability to fight disease as the body ages. There is anemia, bruising. A lot of
times you can really tell with alcoholic older adults. They’ll come into
treatment with huge black bruises all over their body, cuts, burns, repeated
falls, and less red and white blood cells. You never see this stuff on the
news. The kidneys experience inflammation. There is edema: the legs swell up.
The abdomen may be full of liquid. Drinking causes gastritis, bleeding ulcers,
perforation of the intestines, colitis, swelling and blocks in the intestines,
and reduced absorption of vitamins and minerals.
In the liver of course we have jaundice, we have hepatitis, cirrhosis. There
is low blood clotting, diarrhea, pneumonia, malnutrition. I see that all the
time, it’s unbelievable; coming into homes to do an intervention and the older
adult is just skin and bones. The stomach is bloated out from edema or liver
problems, and then bird-like, the skin just hangs off the bones. There is
unbelievable wasting away of the body. People have insomnia. Muscles are
wasting from the alcoholism. People have stroke, bleeding in the brain, that
type of stroke; lung failure, brain cancer, breast cancer, lung cancer. 75% of
the cancer of the esophagus can be attributed to heavy alcohol use.
Looking at alcoholism with older adults, we’re typically looking at two groups. The early onset group probably had an alcohol problem going back as early as their teens, their 20s, maybe it happened as late as their 40s, but usually its earlier. They have functioned in their jobs to varied degrees, in their families to varied degrees, but in their retirement, they just weren’t accountable like they once were. They didn’t have to get up for the job. The kids have left the house. Life changed. They may have some grief issues and they start drinking more. Late onset alcoholics didn’t have an alcohol problem earlier; they tripped that wire in later years. More men are early onset, more women are late onset. We hear a lot that people become alcoholics because of grief issues, or they become alcoholics because of boredom. I just want to be clear about this. Older adults can drink for any number of issues, grief, this, that; but that’s not the issue that causes the alcoholism. You can have two people going through grief and self-medicating, and one trips the wire for alcoholism and one does not. It certainly is the increased level of drinking and increased tolerance that trips the wire for the alcoholism.
When a family starts seeing problems with an older adult and alcoholism, they
often wait for years and years and years before they take any action. Some of
the myths that will block family action are, first of all, the alcoholic is
too old to change. I hear that a lot. What difference does it make anyway,
they’re old. Somehow life just is not worth living after 65. It’s prevalent.
It gets back to ageism. It’s the lack of understanding how important these
years are to the person living them and to everybody else. Just look at the
statistics for who is volunteering in this country. It’s not somebody with
three kids and a job; it’s mostly people in retirement. People say it’s the
alcoholic’s last pleasure. Since when is alcoholism a pleasure? Another one:
The pills are prescribed by the doctor. The doctor must have his thumb on the
pulse of things here. The family just thinks, hey…
Who do you think is the No. 1 most likely candidate to step forward and help an older adult who has an alcohol or other drug problem? Your adult child. Probably they have known about the alcohol problem for some time. They step forward because the older parent starts losing their ability to live independently. It’s not the drinking. It’s the loss of independence that will motivate them. This is not a big research project that has gone on. I work with families all the time. It’s going to be an adult child who calls me 95% of the time. The No. 1 concern is that mom can no longer live safely alone anymore. She is falling. She is walking around in the middle of the night delusional. She is passing out and leaving food cooking on the stovetop. She is smoking and dropping them in her chair. She has cognitive impairment. She no longer has short-term memory. She’s repeating herself. She’s calling repeatedly telling us the same thing over and over again. The list goes on. That’s what gets them to step up to the plate. Suddenly mom is 65, 67, dad is 70 years old, should be in the prime of his life, and he has moved into the old-old category already. This shouldn’t be happening for another 15 plus years, if ever. He could live independently until the day he dies hopefully. And suddenly this younger-older parent is unable to live alone. You’ve got a Baby Boomer who probably has kids still in school. You have a sandwich generation responsible for three generations. They’re responsible for their own children. They’re responsible for their marriage, their spouse, their work, and they’re suddenly responsible now for an older parent who oftentimes lives in another state. Suddenly they realize, wow, I think this is the alcohol and this is what we need to do. Or they don’t, and they ship mom or dad off to the nursing home.
The consequences for the adult children, and there are many, but one of them
is loss of income. Adult children cut down hours to be a primary care giver,
pass aside promotions, lose personal investments, make less money and invest
less for their future. I’ve worked with families who said, you know, mom’s
lost all our money in her addiction. We are now supporting her. This is money
for our retirement that we’re having to put out to take care of this parent.
One piece of research came up with a staggering number. They said on average
$600,000, now that includes investments, meaning what that money would become.
$600,000. So when you’re looking at alcoholism and a young-old parent moving
into the old-old faster, that’s a huge cost.
These are some maxims that block the help older people may need: Don’t air your dirty laundry. Pick yourself up by your bootstraps. Put your best foot forward. If you don’t have anything good to say, don’t say anything at all. Leave well enough alone. Hold your tongue. Put on a happy face. I grew up with all these things. These are things that my grandparents said to me, and even my parents. When it comes to addiction, these things can be blocks for accepting help and for treatment. The worldview when we were born is really a factor. For people that came to age before 1950, nobody was talking about Freud. No one talked about counseling. Certainly if you got it, you didn’t talk about it. And who talked about self-help groups? That just wasn’t well known, and it hadn’t been around very long anyway. After the 1950s, for people who came to age in the 60s and 70s, that was more normal. The Baby Boomers were really a self-help generation. That really blocks a lot of older adults who still find it very shameful to reach out and accept help and get counseling. Some values of this generation can really help in treatment: The sense of hard work, having to do what you need to do. I tell Baby Boomers that during an intervention, the wrong answer is, “Mom, who cares what people think? Just do what’s good for you.” That’s a Baby Boomer worldview. This is a generation for which your reputation meant everything. You probably were born and grew up and worked with the same people in the same town for most of your life, if not all of your life. You depended on those people for your livelihood, for your friendship, for your entertainment. If you ruined your reputation, it really meant something, it impacted your life. What I always say is, “You know what, Mom, the alcohol is taking away your good reputation. Treatment is going to give it back. People are seeing it.” That makes sense to somebody from that generation.
Self-sacrifice. I think this works in favorable way for adults getting into AA
and doing what they need to do. They say, “Okay, this is what I have to do,
and I’m not going to be watching TV all the time. I’m going to go to these
meetings.” They sign up for that. Also, life isn’t about feeling good, it’s
about doing good. That can really help older adults in recovery.
Older adult treatment programs that are age-specific are really beneficial. When I do interventions and the older adult understands that they are going to a treatment program designed specifically for people in their age group, the resistance drops. If they think they are going to go and sit next to a 25-year-old crack addict, forget it. They just don’t want to do it. But when they hear, “You’re going to be with people your own age,” you can see them begin to relax. Mary Pipher wrote a wonderful book called Another Country: Navigating the Emotional Terrain of Our Elders. She writes about the worldview of older adults and says, “Not only does this age group have no experience with the talking cure, they have training in just the opposite. They learned to whisper words such as cancer and divorce.” I remember that. The big “C.” “They were taught that even to speak about an event made it more real.” Therapy flies in the face of this theory. In group therapy with the younger population, the goal is to get the group to do most of the work. When you do that with people from this generation, nobody says anything. To get them to give feedback to other people, they want to be polite. That’s not polite. Honest feedback is not going to happen either, so the counselor really needs to understand the differences in the worldview in order to make the therapy process work better. Older adults are less likely to be diagnosed and treated for addiction than younger adults. They really slip through the cracks for a number of reasons, and they’re going to take longer to recover. Typically an older adult is going to move more slowly through treatment. Sometimes in treatment if they just get through step one that’s all we can do in four weeks. The good news is that older adults have the highest success rate in treatment of any age group, so it’s very hopeful. They do very well in treatment. In the Big Book, there’s a wonderful story called “Those Golden Years,” and I’d like to share that with you. This was written by a retiree after five years of sobriety. “When I retired I said I’d never be bored. AA has not let me down there. How full it has kept my retirement years, the five I have lived, since the first two were lost in traveling a rocky road to hell before I made a U-turn. Not long ago I was lunching with another retired publicist. He was close to tears in describing his boredom without an activity. He said, “How I envy you for whatever you’ve found.” He did not know it was AA, and it was useless to tell him for he doesn’t have our disease. I tried to encourage a search for some new goal, but I couldn’t help thinking, “You poor guy, I feel so sorry for you. You’re not an alcoholic. You can never know the pure joy of recovering within the fellowship of Alcoholics Anonymous.” With recovery, and I’ve seen it so many times, I have seen people come into treatment who couldn’t walk, couldn’t write their name. The first patient I ever worked with, I’ll call her Audrey, she was 72. She was in a wheelchair. She was emaciated. She could barely speak a coherent sentence to me. She was bruised. She was cut. She was burned. She was found passed out face first in her driveway in the morning by her neighbor. She had been on benzodiazepine, Percaset, for 25 years, plus drank large quantities of alcohol. Her children wouldn’t see her anymore. She was not allowed to see her grandchildren. She went through treatment. I get cards from her 10 years later all the time, snorkeling in the Caribbean with her daughter, trekking in the mountains of Arizona with her son, Christmas cards, her new house she bought, her new dog she got. Recovery is a miracle. No one, no one is a lost cause, and it’s never too late. Thank you.
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