____________________________________ Substance Use Disorders: Assessment and Treatment, 2nd Edition
altogether. However, if this is too difficult for you, cutting down is a good start. I’d like to see you reduce your drinking to no more than one drink on the days that you do drink. We’ll monitor your progress over the next few weeks and see if this helps with your diabetes. Client : I will try, but I’m not sure I can do that because I’ve been drinking like this for so long. You know, it’s one of the only things I do for enjoyment since my wife died years ago. Practitioner : I understand how difficult it might be to change such a long-standing habit and how much you enjoy relaxing in the evening. However, I think your health will greatly improve if you stop. You know, there are a few resources in the community that might be help- ful for you if you’re interested. Some of my other clients have told me about a meeting that is held near where you live on Monday evenings at 6:00 p.m. The meeting is for people just like you—older people who don’t drink to get drunk, but whose drinking is now causing health problems for them. The community center provides transportation if you’re unable to drive at night. Let me know how I can be of further assistance to you if you want to discuss other resources. Assessment tools can be used to determine the presence and severity of substance abuse problems among older adults. One of the most frequently used tools is the Short Michigan Alcohol Screening Test—Geriatric Version (SMAST-G). The 10-item SMAST-G was developed as the first short-form alco- hol use screening instrument for older adults. The items on the test address the physical signs of excessive drinking, the connection between drinking and emotional states, problems controlling the amount of alcohol consumed, and the reactions of others to the older person’s drinking. The test is available in English or Spanish and can be either practitioner- or self- administered. A score of two or more “Yes” responses suggest an alcohol problem. The tool can be accessed at https:// www.ndbh.com/Docs/PCP/Michigan%20Alcoholism%20 Test%20(SMAST-G).pdf A comprehensive assessment of an older adult’s social circum- stances, nutritional status, and living environment may also be helpful. It is important to note whether an older person lives alone and possibly in a home with stairs, which might suggest a risk of falling should the person abuse alcohol. Like- wise, an older person may be at risk of malnutrition if he or she “drinks” meals or ingests medications that affect appetite. Obviously, assessment of an older adult’s mental status may indicate co-occurring mental disorders, such as depression or cognitive impairment. Alcohol use can exacerbate depression, and depression can exacerbate alcohol use (Royal College of Psychiatrists, 2015), complicating efforts at assessment. Indeed, the identification of comorbid medical and psychi- atric disorders will influence treatment choices and priorities for treatment goals. In cases in which depression is detected, reducing alcohol consumption becomes a priority. Until drinking is eliminated, medications prescribed for depression or a variety of other conditions may be ineffective. It is also important to obtain information about financial resources because insurance coverage might be available for potential treatment options.
Understandably, screening is a delicate issue, and profession- als will benefit from a few general considerations. Some older adults may not be aware of the impact of their drinking because they may have had a drink or two with their dinner for many years. The tone of the interview should be nonjudgmental, and the purpose of the questions should be clearly related to the person’s health status. For example, an older adult may be more receptive to questions about drinking as it relates to the impact on blood sugar. In addition, the older person must be able to participate. Any signs of intoxication should be documented. Before asking the questions, the provider should inform the client about the importance of honest responses and the confidentiality of his or her responses. The following exchange illustrates a screening interview with an older adult that is aimed at establishing the quantity and frequency of alcohol usage while demonstrating several of the considerations noted previously: Practitioner : Hello, Mr. Morrison. I see here in your medical chart that you are having difficulty managing your blood sugar since your last visit. I know we have discussed the diabetic diet in our previous sessions, and you indicated that you are carefully following your caloric allowance. According to our past conversations, you mentioned that you do drink alcohol on occasion. I’m wondering if alcohol may be the reason your diabetes isn’t better managed at this time. On average, how many days a week do you drink? Client : Well, I don’t drink every day. I know some of my kids think I might drink too much, but it’s none of their business; it’s my life. I also don’t see how my drinking could affect my diabetes all of a sudden. Practitioner : Well, we’re not here to judge anyone’s behavior. Our focus is on keeping people healthy, and we are better able to do that when we know exactly how much alcohol is consumed. As I’ve told you, our talk here is confidential, and we just need honest information to help you with your diabetes. On days when you do drink alcohol, how many drinks do you have? Client : Well, on two or three nights a week I might have two or three martinis, but again, I don’t drink every night, so I can’t understand how my diabetes would be affected. Practitioner : Alcohol breaks down into sugar in the body. We’ve talked before about how your body is unable to handle sugar once it enters the bloodstream. You take your insulin shot daily to prepare your body for your sugar intake and drinking alcohol can affect your need for insulin. Please know that this is a medical situation that is very treatable once we know for sure that’s why your sugar is up. So, is there any more information you can give me about your drinking that I should know? Client : Well, truthfully, I think it’s no more than nine or ten drinks weekly. Practitioner : I appreciate your honesty. You know, cutting out drink- ing would probably make you feel a whole lot better. I know you haven’t been able to be very active this month, and I know how important your independence is to you. If you would like to get around better, managing your blood sugar will help you feel less sluggish. So, to feel better—like yourself again—I strongly recommend that you stop drinking
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