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> Evidence-Based Practices\
> for Preventing Substance Abuse and Mental Health Problems in Older
> Adults

table of contents

Chapter Page

Executive Summary 1

Introduction 4

Substance Abuse and Mental Health Problems: The Growing Need\
for Prevention and Early Intervention Among Older Adults 4

Science to Service: Evidence-Based Practices 5

Methods 7

The Institute of Medicine's Prevention Framework 7

Search Strategy Overview 9

Evaluation Process and Criteria 10

Prevention of Substance Misuse Problems 11

Alcohol Misuse 12

Universal Prevention 13

Indicated and Selective Prevention Strategies (Early Intervention) 16

Ongoing Selective Prevention Programs Under Evaluation 18

Conclusions 19

Medication Misuse 25

Universal Prevention 26

Indicated and Selective Prevention Strategies (Early Intervention) 27

Ongoing Prevention Programs Undergoing Evaluation and\
Research Directions 31

Conclusions 32

Prevention of Mental Health Problems 39

Depression and Anxiety 39

Universal Prevention Programs 40

Indicated and Selective Prevention Strategies (Early Intervention) 42

Ongoing Selective Prevention Programs Under Evaluation 46

Conclusions 47

table of contents

Chapter Page

Suicide Prevention 55

Universal Prevention Strategies 56

Selective and Indicated Prevention Strategies 58

Conclusions 60

Prevention of Co-occurring Substance Abuse and Mental\
Health Problems 64

Indicated and Selective Prevention Strategies (Early Intervention) 65

Ongoing Prevention Programs Undergoing Evaluation 66

Conclusions 67

Summary 70

The Current State of the Evidence 70

Dissemination -- Translation, Implementation, and Diffusion 72

Research Needs and Future Directions 75

table of contents (continued)

List of Tables

Table Page

1 Prevention Framework for Substance Misuse, Mental Illness, and Suicide
8

2 Prevention and Screening of Late-Life Alcohol Misuse 21

3 Alcohol Misuse Early Interventions 23

4 Prevention and Assessment of Late-Life Medication Misuse 33

5 Early Intervention with Late-Life Medication Misuse 35

6 Universal Prevention of Late-Life Depression Or Anxiety 49

7 Early Intervention of Late-Life Depression Or Anxiety 52

8 Universal prevention of Late-Life Suicide 62

9 Selective and Indicated Prevention of Late-Life Suicide 63

10 Early Intervention of Co-Occurring Substance Abuse and Mental\
Health Problems 68

Executive Summary

The prevention of substance abuse and mental health problems within the
aging population has been recognized as a national priority. The
Substance Abuse and Mental Health Services Administration's *Older
Americans Substance Abuse and Mental Health Technical Assistance Center*
(TAC) is committed to serving as a leading resource for the prevention
and early intervention of late-life substance use and mental health
problems. Despite the substantial prevalence and adverse consequences of
substance use and mental health problems in older persons and the
considerable knowledge related to preventing these problems,
evidence-based prevention and early intervention services are not widely
available nor promoted for this at-risk population. Given financial
restrictions facing many health care systems, guidance is needed to
direct limited available resources toward the provision of programs that
have proven effectiveness. To support this effort, the TAC has reviewed
the best available evidence supporting programs that target the
prevention and early intervention of substance abuse and mental health
problems in older adults.

The purpose of this review is to highlight prevention and early
intervention programs that have proven effectiveness. This report
identifies the demographic imperative for addressing late-life substance
use and mental health problems, describes the current terminology of
prevention programs and practices, provides a comprehensive review of
the published evidence base for the prevention and early intervention of
geriatric substance abuse and mental health problems based on the
empirical evidence, and describes dissemination and implementation
issues that align with state needs and priorities.

Five specific areas are addressed. These include the prevention and
early intervention of alcohol misuse, medication misuse, depression and
anxiety, suicide, and co-occurring substance abuse and mental health
problems among older adults. This review provides a comprehensive
examination of prevention programs in these areas that have been
published through September 2005.

#### Alcohol Misuse

-   Brief interventions can reduce alcohol misuse and hazardous drinking
    among older adults. Specifically, structured brief interventions and
    brief advice in health care settings have shown to be effective at
    reducing alcohol consumption in this population.

-   Little evidence is available regarding universal prevention programs
    targeted at the prevention or reduction of alcohol misuse among
    older adults. Some health education programs have demonstrated
    increased knowledge among older adults about hazardous alcohol use.

-   Recently developed screening and assessment instruments show promise
    as useful tools to improve identification of older at-risk drinkers
    and enhance clinician interactions to prevent or reduce alcohol
    misuse.

#### Medication Misuse

-   Computer-based health education tools designed for older adults have
    shown gains in knowledge and self-efficacy regarding potential drug
    interactions, as well as improvements in self-medication behaviors.

-   Clinical trials on early interventions with older adults who are at
    increased risk for medication misuse have had mixed results.
    Nonetheless, interventions with patients prior to hospital
    discharge, interventions targeted at changing provider prescription
    patterns, and home-based medication reviews show some promise to
    prevent medication misuse.

#### Depression and Anxiety

-   A moderate amount of evidence supports the effectiveness of problem
    solving therapy (PST) and exercise in preventing the onset or
    worsening of depression. In addition, targeted outreach is effective
    in engaging isolated and vulnerable older adults in mental health
    care.

-   More research is needed to determine whether other potentially
    effective strategies are effective in preventing depression,
    including: life review, reminiscence therapy, educational classes
    for older adults and providers, and mind-body wellness.

-   Minimal evidence supports prevention programs focused on late-life
    anxiety.

#### Suicide

-   Supportive interventions that include screening for depression,
    psychoeducation, and group-based activities have been associated
    with reduced rates of completed suicide among older adults.

-   Telephone-based supportive interventions have also been associated
    with a reduction in the rate of completed suicide.

-   Protocol-driven treatment of depression delivered by a care manager
    has been associated with reduced suicidal ideation.

#### Co-occurring Disorders

-   Concurrent treatment of substance abuse and depression may be
    effective in reducing alcohol use and improving depressive symptoms.

-   The evaluation and treatment of co-occurring substance use and
    mental health problems among older adults is an under-studied area.

This report highlights the evidence base for the prevention and early
intervention of substance use disorders and mental illness in older
adults. Of note, the field of prevention is far less developed than our
understanding of the diagnosis and treatment of substance abuse and
mental disorders in late-life. In particular, comparatively few
scientific efforts have focused on preventive measures, the early
identification of and intervention with high-risk individuals, and the
promotion of optimal health regarding substance abuse and mental health
concerns in late adulthood. However, this summary of the current
evidence base provides direction for both providers and consumers
regarding substance abuse and mental health prevention and early
intervention services. This information can be useful in planning and
implementing effective programs and practices, while also underscoring
future directions for research and evaluation.

Introduction

# Substance Abuse and Mental Health Problems: The Growing Need for Prevention and Early Intervention Among Older Adults

Substance abuse and mental health problems are serious and increasing
threats to the health and well-being of many older adults. Community
surveys indicate hazardous and harmful alcohol consumption patterns are
prevalent among older adults;^1-3^ rates of alcohol misuse and abuse are
even higher among clinical populations because problem drinkers are more
likely to present in health care settings.^4-6^ Combined alcohol and
medication misuse is estimated to affect up to 19 percent of older
Americans.^7-10^ In addition, one in four older adults has a significant
mental disorder.^11^ Among the most common mental health problems in
older persons are depression, anxiety disorders, and dementia.^12^
Finally, older adults have the highest suicide rate of any age group,
with greater risk associated with men,^13^ and with the presence of
alcohol use and depressive symptoms.^14,\ 15^

Demographic projections indicate that the aging of the "baby boom"
generation will increase the proportion of persons over age 65 from 13
percent currently, to 20 percent by the year 2030.^16^ By the year 2030,
the number of older adults with substance abuse or mental illness is
expected to more than double to an estimated 15 million
individuals.^11,16^ As the "baby boom" cohort ages, the extent of
alcohol and medication misuse is predicted to significantly increase due
to the combined effect of the growing population of older adults and
cohort-related differences in lifestyle and attitudes.^16,17^ Based on
these projections, the associated need for treatment services of
substance use disorders in older persons is estimated to increase by 70
percent.^18^ Increases in the need and the demand for mental health
services are expected as well. The demand for mental health services is
likely to increase as the baby boom cohort has tended to utilize mental
health services more frequently than the current older adult cohort and
has tended to be less stigmatized by seeking mental health
care.^11,19,20^ Population growth and cohort-specific characteristics
indicate a future of increasing pressure on all health care resources
and treatment systems but particularly for substance abuse and mental
health services.^21^

Substance abuse and mental health problems among older adults are
associated with poor health outcomes including increased disability and
impairment, compromised quality of life, reduced independence and
community-based functioning, increased caregiver stress, increased
mortality, and higher risk of suicide.^21^ Alcohol and medication misuse
in older persons has negative effects on health and is associated with
increased morbidity, disability, and mortality from disease-specific
disorders, as well as increasing risks for diseases and trauma.^22,23^
Psychiatric disorders such as depression are associated with worse
health outcomes, more compromised health status, and risk of
suicide.^24-27^ Mental health and substance abuse problems are also
associated with significant health care expenditures. Combined, these
costs accounted for 7.6 percent of all U.S. health care expenditures in
2001, including \$85 billion for mental health care and \$18 billion for
substance abuse services.^28^ Prevention and early intervention
represent some of the most promising and appropriate ways to maximize
health outcomes and minimize health care costs among older
adults.^29,30^ Research has identified a number of factors that place
older adults at risk for developing substance abuse and mental health
problems. Prevention programs that address these risk factors, promote
resiliency, and strengthen protective factors can help older adults
weather the unique circumstances that contribute to the development
and/or deterioration of substance abuse and mental health problems.

Limited information is available to providers and consumers on the most
efficacious approaches to adequately prevent and/or intervene with
late-life substance abuse and mental health problems. Many strategies
are neither age-specific nor sensitive to what is most clinically
effective in accommodating the unique biological and social conditions
of older persons. Important differences exist between age cohorts (e.g.,
baby boomers compared to Depression-era older adults), residence status
(e.g., living independently in home or apartment compared to nursing
home or other institutional setting), health and disability status, and
socio-economic status, among other factors. Furthermore, there is
considerable variation and diversity within the older adult population
that magnifies the critical importance of cultural sensitivity and
competence for this group of Americans. The population of older adults
is also expected to become more ethnically and racially diverse in the
coming decades. Minority older adults are among the fastest growing
segment of the population and present new challenges and opportunities
for designing effective prevention services. This increasing diversity
in the U.S. aging population has implications for access and barriers to
mental health and substance abuse services, cultural competency of
providers and consumer-practitioner dynamics, and the need for
research-based knowledge regarding differences in the perception and
experience of mental illness and substance use among older adults. The
current challenges and increasing pressure of demographic trends make
the dissemination and implementation of science-based prevention
knowledge of critical importance.

[]{.mark}

# Science to Service: Evidence-Based Practices 

Evidence-based medicine (EBM) is the provision of health care that
systematically integrates the best available research evidence with
clinical expertise and the patient's unique values, preferences, and
circumstances.^31^ EBM has been defined as "the conscientious and
judicious use of current best evidence from clinical care research in
the management of individual patients."^32^ Identifying evidence-based
practices relies on a systematic approach to identifying and critically
appraising the *best available evidence.*

There is a growing and substantial evidence base supporting the
effectiveness of a variety of treatments for late-life substance abuse
and other mental disorders.^21,33,34^ However, considerably less
research has focused on prevention of and early intervention for
late-life substance abuse and mental health problems. In this respect,
identifying the best available evidence is particularly relevant, where
both the quality and quantity of evidence varies widely. A systematic
evaluation of the literature is critical when the research literature is
not well described or when there are only a small number of studies to
inform clinical decisionmaking. The research evidence is conceptualized
along a hierarchy of evidence from the highest to lowest levels.
Further, the identification of the evidence base is a dynamic process
that must take into account priority areas that lack extensive
research.^35^ In these instances, the best available evidence may be
limited to extrapolation from related populations or early findings that
are promising, but do not meet the standards of a large randomized
controlled trial. For instance, despite a paucity of rigorously
controlled studies that evaluate the effectiveness of interventions for
the prevention of suicide in older adults, current practice should use
principles from the best available evidence from a limited geriatric
literature, while adapting findings from younger populations and
continuously evolving to incorporate new findings.

Lack of awareness, lack of expertise, and organizational barriers often
lead to continued use of unproven strategies rather than implementation
of effective practices based on state-of-the-art prevention research. In
general, scientific knowledge is typically far advanced beyond common
practice, with the time lag between empirically identifying
evidence-based approaches and implementing them into practice often
taking many years. Utilizing evidence-based practices requires an
integration of clinical skills, knowledge of the unique circumstances of
the specific person with the identified problem, and an application of
the best research evidence. Clinical skills and past experience are
crucial to identifying the specific health status, risks, benefits, and
unique circumstances for each individual person's health care need. This
is especially important in the field of geriatrics where the risk and
potential benefits of an evidence-based approach may vary substantially
when the intervention is provided to a young adult with few medical
problems, compared to a frail older person with multiple medical
problems, concurrent treatments, and functional challenges.

The Substance Abuse and Mental Health Services Administration (SAMHSA)
is committed to promoting the practical implementation of evidence-based
practices to address substance abuse and mental health problems among
older adults. The National Registry of Evidence-based Programs and
Practices (NREPP) is an example of a developing resource supported by
SAMHSA that serves as a clearinghouse for pre-screened information on
effective and practical interventions to prevent and/or treat mental and
addictive disorders. As part of that effort, NREPP is currently
expanding its database in the still-nascent field of prevention among
geriatric populations. For example, the Gatekeeper program is listed in
NREPP as a promising practice that trains public service providers and
employees of local businesses (e.g., letter carriers, police officers,
bank tellers, landlords) to identify and refer older adults who are
at-risk for serious substance abuse and mental health problems.^36-38^
In addition, the Suicide Prevention Resource Center's registry of
evidence-based suicide prevention programs identifies the Prevention of
Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) model of
depression care management as an "effective" selective and indicated
prevention program.^39^ In an effort to advance knowledge of
evidence-based practices for older adults, the Older Americans Substance
Abuse and Mental Health TAC developed this review to provide
practitioners, organizations, policy makers, and concerned others with
the current best available evidence regarding the prevention and early
intervention of late-life substance abuse and mental health problems.

Methods

The expected growth in the number of older adults with substance abuse
and mental health disorders, the significant impact of these disorders
on the health and functioning of older people, their families, and their
communities, and the associated increases in health care use and costs
demonstrate a critical need for the identification, organization,
dissemination, and implementation of evidence-based prevention and
intervention programs. Prevention of both the onset of these conditions
and the potential relapse, disability, comorbidity, and continued health
and functional burden among persons with substance abuse and mental
health problems is a necessary focus of attention.^40-43^ This report
attempts to address these issues.

# The Institute of Medicine's Prevention Framework 

Prevention is different from intervention and treatment in that it is
aimed at general population groups with various levels of risk for
problems associated with substance abuse and mental illness. The
Institute of Medicine's (IOM) prevention framework offers a useful model
for understanding the differing objectives of various interventions. The
framework can be used to match interventions to the needs of a targeted
population. The goal of prevention programs is to reduce risk factors
and to enhance protective factors. Table 1 provides an overview of the
IOM's framework 44, as it applies to the prevention of substance abuse,
mental illness, and suicide among older adults.

Table 1. Prevention framework for substance misuse, mental illness, and
suicide

+----------+--------+--------------------------+-----------------------+
| Inte     | Ap     | Target                   | Objectives            |
| rvention | proach |                          |                       |
| Ter      |        |                          |                       |
| minology |        |                          |                       |
+----------+--------+--------------------------+-----------------------+
| U        | Popu   | Entire population, not   | Implement broadly     |
| niversal | lation | identified based on      | directed initiatives  |
| Pr       |        | individual risk.         | to prevent substance  |
| evention |        |                          | misuse, mental        |
|          |        |                          | illness and           |
|          |        |                          | suicide-related       |
|          |        |                          | morbidity and         |
|          |        |                          | mortality through     |
|          |        |                          | reducing risk and     |
|          |        |                          | enhancing protective  |
|          |        |                          | factors.              |
+----------+--------+--------------------------+-----------------------+
| S        | Popul  | Asymptomatic or          | Prevent morbidity and |
| elective | ation; | pre-symptomatic          | mortality through     |
| Pr       |        | individuals or subgroups | addressing specific   |
| evention | High   | with risk factors for    | characteristics that  |
|          | Risk   | substance misuse, mental | place older adults at |
|          |        | illness, or suicide; or  | risk.                 |
|          |        | individuals who have a   |                       |
|          |        | higher-than-average risk |                       |
|          |        | of developing substance  |                       |
|          |        | use or mental disorders. |                       |
+----------+--------+--------------------------+-----------------------+
| I        | High   | Individuals with         | Treat/intervene with  |
| ndicated | Risk   | detectable symptoms      | older individuals     |
| Pr       |        | and/or other primary     | with precursor signs  |
| evention |        | risk factors for         | and symptoms to       |
|          |        | substance abuse, mental  | prevent development   |
|          |        | illness, or suicide.     | of disorders or the   |
|          |        |                          | expression of         |
|          |        |                          | suicidal behavior.    |
+----------+--------+--------------------------+-----------------------+

Universal prevention programs target the general population of older
adults with or without specific risk factors for developing substance
misuse or mental health problems. For instance, a universal prevention
program may provide community-wide support or education to older adults.
Universal prevention may include the implementation of broad, directed
initiatives to prevent substance misuse, mental illness, and
suicide-related morbidity and mortality by reducing risk factors and
enhancing protective factors. Examples of universal prevention programs
that will be described in this report include health education around
issues of substance use and engagement in exercise programming.

Selective prevention programs target older persons who are at high risk
for developing problems with substance use or mental well-being.
Targeted individuals are identified on the basis of the nature and
number of risk factors to which they may be exposed. Selective
prevention programs focus on persons who do not yet display signs of
substance abuse or mental illness. However, they may have a higher than
average risk for developing these problems. For instance, selective
prevention programs may target older adults who have recently lost a
spouse, retired, or experienced other significant lifestyle changes that
may be associated with medical problems such as a stroke, vision loss,
or cognitive impairment. Although these individuals may not currently
have mental health or substance use problems, these conditions may
predispose them to developing these issues in the future. Selective
prevention programs are often designed to prevent the development of
problems by specifically addressing the issues or characteristics that
place older persons at increased risk. Selective prevention programs
described in this report include brief alcohol interventions and
psychoeducation around the management of medical health conditions.

Indicated prevention programs target older persons who have a high risk
for developing substance use disorders or mental illness. Indicated
prevention programs typically focus on persons with detectable symptoms
and/or other proximal risk factors for substance abuse, mental illness,
or suicide in an effort to prevent chronic and severe problems. For
instance, an indicated prevention program may target older adults with
depression and/or substance abuse, in an effort to prevent the
development of greater impairment or the expression of suicidal
behavior. Finally, indicated prevention programs include depression care
management and guideline-based depression treatment as an approach to
reducing suicidal ideation among older adults.

# Search Strategy Overview

Several strategies have been developed to aid health care providers,
administrators, and policy makers in identifying the level of evidence
supporting specific prevention programs and practices.^45^ For the
purposes of this review, multiple strategies were used to identify
programs that target the prevention and early intervention of substance
abuse and mental heath problems among older adults.

Our primary approach to identifying prevention programs involved
systematic reviews of multiple literature databases. These databases
included: Medline, PsychInfo, Ageline, Social Work Abstracts, Social
Services Abstracts, CINAHL (Cumulative Index to Nursing and Allied
Health Literature), and ERIC (Educational Resources Information Center).
General search terms are described below. Each asterisk (\*) represents
a wild card. For instance, *elder\** would include search terms as
*elder, elderly,* and *elders*.

-   Elder\* or Geri\* or Late-life or Senil\* or Gero\*, or "older" in
    the title

-   Substance abuse or Alcohol or Medication Misuse

-   Mental or depress\* or psych\*

-   Suicid\* or suicidal ideation or death ideation

-   Prevent\*

To supplement this strategy, we reviewed several other search engines.
First, the Web-of-Science search engine was used to identify articles
that were related to those identified in our initial search strategy.
This process was supplemented by reviewing the references at the end of
each relevant article. Finally, other online resources were used to
identify unpublished prevention programs. Federal agencies and
foundations supporting research in substance abuse and mental health
were evaluated in each area. The www.clinicaltrials.gov database was
particularly useful in identifying ongoing research efforts. More
details of the search strategy are provided in the review of each of the
five prevention areas: alcohol misuse, medication misuse, depression and
anxiety, co-occurring substance abuse and mental health problems, and
suicide.

# Evaluation Process and Criteria

The following review evaluates the scientific evidence that supports
programs that target the prevention and early intervention of substance
abuse and mental health problems in older adults. The aim of our review
was to (a) identify studies that are published in the scientific
literature or that are currently being evaluated, and to (b) critically
evaluate the effectiveness of these programs. This review includes
programs with established effectiveness, as well as those programs that,
while promising, do not have sufficient evidence indicating their
effectiveness. This comprehensive evaluation strategy provides the
reader with a synopsis of "what works" and "what may not work" and is
designed to serve as a guide to understanding the state of the science
in prevention services for older adults.

This review contains five modules that address the prevention and early
intervention of substance abuse and mental health problems (alcohol
misuse, medication misuse, depression and anxiety, late-life suicide,
and co-occurring substance abuse and mental health problems). Each
module identifies programs that reflect universal prevention, as well as
programs that reflect the selective and indicated prevention. For each
of these areas, we describe the unique search methodology, a description
of universal prevention programs, a description of indicated and
selective intervention strategies (early intervention), and future
research directions. Detailed descriptions of each program are provided
in tables at the end of each module. Please note that a few prevention
programs could have been appropriately located in more than one module,
as they address related issues (e.g., education programs that address
hazardous alcohol use in combination with medications or targeted
outreach programs to identify older adults at risk for both substance
abuse and mental health problems).

The tables provide (a) a description of the scientific design of the
study, (b) the model or conditions that were evaluated, (c) the age of
the study sample, (d) other general characteristics of the study sample,
(e) the duration of the study and the percent of the sample who remained
in the program during the followup period, (f) the effectiveness of the
program, and (g) limitations or other comments that should be considered
in evaluating the program. Each of these areas represents important
criteria for evaluating a program. For example, these criteria allow the
reader to evaluate the rigor of the study (e.g., scientific design),
generalizability (e.g., sample size, age, and demographics), feasibility
(e.g., study drop-outs), and the likelihood of success in preventing the
development of substance use disorders or mental illness or the success
in preventing downstream health impairment (e.g., effectiveness).

Prevention of Substance Misuse Problems

The following two sections highlight the current best evidence
supporting prevention and early intervention programs targeting the
reduction and elimination of two primary areas of substance use
disorders among older adults: alcohol misuse and medication misuse. The
misuse of alcohol, prescription drugs, and other substances among older
adults is a sizeable and growing concern. Problem drinking among older
adults in the community is estimated to range from 1-15 percent.^1-3^
At-risk or problem drinking, as well as alcohol abuse or dependence, is
notably higher among older adults seen in health care settings and
residents of nursing homes.^4-6,\ 46-49^ An estimated one in five older
Americans (19%) may be affected by combined difficulties with alcohol
and medication misuse.^7-10^ Problems related to alcohol use are
currently the largest class of substance use problems seen in older
adults. The substances most commonly abused by older adults besides
alcohol are nicotine and psychoactive prescription drugs. Co-occurring
problems are frequent, as both nicotine and prescription drug abuse are
much more prevalent among older adults who misuse alcohol than among the
general older population.^50-53^

Older adults are uniquely vulnerable to substance use disorders due to a
variety of biological, psychological, and social changes associated with
aging. Older adults have an increased risk for misuse and abuse of
medications, as they use a higher number of prescription and
over-the-counter medications compared to younger adults. In contrast to
younger persons with substance abuse problems who most often abuse
illicit drugs, substance abuse problems among older individuals more
typically occur from misuse of over-the-counter and prescription drugs.
The rates of illegal drug abuse in the current older adult cohort are
very low.^29,54^ The interactions between alcohol and medications are of
notable concern for older populations. Negative interactions between
alcohol and psychoactive medications, such as benzodiazepines,
barbiturates, and antidepressants, are of particular importance. Alcohol
use can interfere with the metabolism of many medications and is a
leading risk factor for the development of adverse drug
reactions.^55-57^ Despite the risks, physical and mental health care
practitioners fail to identify most older adults who consume alcohol at
risky levels, including any consumption in hazardous combinations with
medications, as at-risk or problem drinkers.^4^

The use of nicotine is a significant health problem for older adults.
Although tobacco use declines with age, nearly 4 million older adults
continue to smoke regularly.^58^ In 1999, nearly 23 percent of adults
ages 50 to 64 reported past month use of cigarettes. Among those age 65
and older, this figure was about 11 percent.^58^ Consistent with younger
populations, older women have lower smoking rates than older men.^59^
Nicotine addiction often co-occurs with other substance use disorders,
and can be a marker for other substance abuse. For example, smoking in
older problem drinkers is more prevalent than in the general older adult
population. Some studies indicate that the prevalence of smoking among
alcohol dependent individuals generally is above 80 percent;^60^ an
estimated 60 percent to 70 percent of older male alcohol users smoke a
pack or more of cigarettes each day.^61^ Smoking is a major risk factor
for many of the leading causes of death among individuals age 60 and
older,^62,63^ and is associated with increased risk of losing mobility
^64^ and premature death.^65^ Smoking also affects the performance of
some prescription drugs. For example, smokers tend to require higher
doses of benzodiazepines to achieve efficacy than nonsmokers.^66^

As with other substance misuse among older adults, evidence of effective
prevention strategies for smoking cessation with older populations is
more limited than with younger populations. Many clinicians fail to
counsel older patients about the health effects of smoking even though
older adults are more likely to quit than younger smokers.^67^ Selected
strategies that have shown effectiveness in older adult populations
include brief interventions. One study found a tailored brief
intervention more than doubled 1-year "quit rates" for older adults.^68^
A study of older smokers using transdermal nicotine patches found that
29 percent of the subjects quit smoking for 6 months.^69^ In addition,
there is little evidence that adults in recovery from alcohol problems
relapse when they stop smoking. In summary, efforts to prevent substance
abuse among older adults should include tobacco consumption as a key
health behavior that often co-occurs with substance abuse and with other
mental health problems.^70^

# Alcohol Misuse

Alcohol misuse, such as drinking above age-recommended limits, binge
drinking, or combining alcohol with some medications, is a problem that
can be reduced or eliminated among many older adults through prevention
and early intervention strategies. Health care settings and
organizations providing social or supportive services for older adults,
such as the aging services network, represent essential venues for the
prevention of and early intervention with alcohol misuse among older
adults. Education, resource development, and technical assistance for
health and human services organizations, providers, and policymakers
around this issue are promising directions for broad-based prevention
efforts. Universal prevention strategies such as broad education
programs have been able to increase knowledge among seniors about risky
drinking practices and ways to limit hazardous alcohol use. A number of
screening and assessment tools have been developed and shown to be
reliable and feasible for use with this population. Early intervention
or targeted prevention strategies such as brief advice by primary care
physicians and other brief interventions in health care settings have
reduced alcohol consumption among older adults.

Several search engines were used to identify programs addressing the
prevention of and early intervention with alcohol misuse among older
adults. A number of EBM databases were searched, including the Cochrane
Central Register of Controlled Trials (CCTR), Cochrane Database of
Systematic Reviews, ACP Journal club, and Database of Abstracts of
Review of Effects (DARE). PubMed, PsychInfo, CINAHL, Ageline, Social
Services Abstracts, Social Work Abstracts, and ERIC databases were used
to identify published literature and other resources using a combination
of age-related terms (older, geriatric, elder, late-life, etc.) with the
following search terms: alcohol, prevention, early, intervention, brief
intervention, screening. Search techniques were also employed to follow
promising search directions, such as the "Related Articles" feature in
PubMed. Additional searches were performed using the Google search
engine and federal agency and grant databases, such as the federal CRISP
(Computer Retrieval of Information on Scientific Projects) and National
Institutes of Health (NIH) Clinical Trials database.

## Universal Prevention

The evidence-base supporting effective universal prevention programs for
alcohol misuse among older adults is very limited. To summarize, few
population-based prevention programs targeted at the prevention or
reduction of hazardous or harmful drinking among older adults have been
evaluated rigorously. The best available studies are reviewed below.
Please see Table 2 for further details regarding each study.

#### *Health Education*

Two recent studies have demonstrated improvements in knowledge of
alcohol misuse among older adults using a pretest/posttest evaluation of
health education interventions to prevent alcohol misuse. Fink and
colleagues describe the development and evaluation of health promotion
materials specifically designed to educate older adults about
non-hazardous, hazardous, and harmful alcohol use.^71^ This project
brought together patient focus groups, physicians, educators, and
alcohol researchers in developing materials and measures. Participants
were patients of UCLA physicians who were community-dwelling adults age
60 or older (n=101). The materials consisted of a written booklet and
pamphlet. Knowledge and self-efficacy scores increased among
participants from a pretest assessment to an immediate posttest. Process
evaluation results also indicated high levels of feasibility and patient
satisfaction. The authors concluded that older adults were motivated and
able to learn about age-appropriate and recommended alcohol use. In a
different pilot study among women aged 54-90 (n=32), Eliason and
Skinstad ^72^ found that older women, particularly moderate to heavy
drinkers, demonstrated improved knowledge regarding alcohol and
medication misuse and other health behaviors immediately after a
60-minute educational presentation. These programs did not assess
longer-term knowledge retention, so it is unclear whether the immediate
knowledge and self-efficacy gains are sustainable over time.

#### *Preventive Physician Visits*

There has been very limited research regarding the effectiveness of
general preventive health counseling among older adults. In a randomized
trial, Medicare beneficiaries (age 65 and older) were assigned either to
an intervention group (n=1573) that offered yearly preventive visits for
2 years and optional counseling visits to their primary care provider or
to a control group (n=1524) that received usual care.^73^ Information
was collected at baseline and at 2 years. The intervention visit
included history and physical exam, screening and immunization, and
review of lifestyle health behaviors. Differences were observed between
the intervention and control groups in the extent to which changes
occurred in smoking and problem alcohol use, but none of the differences
were statistically significant. There was virtually no difference
between the groups in changes to sedentary lifestyle. Problem alcohol
use was defined as any positive response to the Cut down, Annoyed,
Guilty, Eye-opener (CAGE) Questionnaire; the CAGE was repeated at 2-year
followup. The authors concluded that the study demonstrated the
difficulty of bringing about health behavior change in older patients
during the course of a yearly preventive visit for 2 years with their
primary care physician when the visit encompasses screening and
immunizations, as well as physician-directed health behavior counseling.
The study implied that more targeted preventive measures are needed than
a general preventive visit to effect changes in specific health
behaviors.

A series of health promotion demonstration programs (the Rural Health
Promotion Program) offered health screening and disease risk factor
interventions, including alcohol counseling, at no cost to rural
Medicare beneficiaries (aged 65 and older).^74,75^ The evaluation
indicated that older rural Americans modestly increased their use of a
range of prevention/health promotion services if covered by Medicare.
However, the study did not analyze the participation in the alcohol
counseling because few people were eligible to receive those services
after assessment (\~2%). Inclusion into the program was determined by a
Health Risk Appraisal (HRA) interview, but the authors did not report
the specific criteria used to determine eligibility for preventive
alcohol counseling among these Medicare beneficiaries.

#### *Screening and Assessment*

Accurate identification of alcohol misuse and risky drinking behaviors
is important in the prevention and early intervention of geriatric
alcohol misuse.^76^ In particular, despite the common occurrence of
alcohol problems, health care personnel often fail to recognize problem
drinking among older patients.^4,77^ A number of screening tools are
often used with older adults, but only a few have been developed and
evaluated specifically for use with this population. The Michigan
Alcoholism Screening Instrument-Geriatric Version (MAST-G) and its
shorter version (SMAST-G) were developed as screening instruments to
detect alcohol abuse and dependence among older adults.^78-80^ Quantity
and frequency measures have also been identified as essential screening
tools among older adults, as recommended alcohol consumption levels for
older adults are lower than those for adults under age 65.^4,81,82^

Several recent studies have evaluated the Alcohol-Related Problems
Survey (ARPS) and a shorter version (Short ARPS or shARPS). The ARPS was
developed and has tested reliably as a screening measure designed for
older adults, intended to identify risks of alcohol consumption due to
age-related physiological changes, declining health and functional
status, and medication use.^83^ It classifies drinking as non-hazardous,
hazardous, or harmful. Non-hazardous drinking is defined as consumption
with no known risks for adverse physical or psychological health events,
hazardous drinking is consumption with such risks, and harmful drinking
results in adverse events. Fink and colleagues ^84^ compared the ARPS to
three validated alcohol screens: the Cut down, Annoyed, Guilty,
Eye-opener (CAGE), Short-Michigan Alcohol Screening Test (SMAST), and
Alcohol-Use Identification Test (AUDIT). Current drinkers 65 years and
older (n=574) completed the ARPS and AUDIT in primary care clinics;
after random assignment, half of the group completed the CAGE and half
completed the SMAST. The ARPS identified nearly all drinkers detected by
the CAGE, SMAST, and AUDIT and detected hazardous and harmful drinkers
not identified by these measures. These drinkers used medications or had
medical conditions that placed them at risk for adverse health events.
Moore and colleagues evaluated the validity and reliability of the ARPS
and the shorter shARPS.^85^ The two measures were compared against a
"LEAD" standard ("longitudinal evaluation done by experts employing all
available data": a medical record review, a clinical interview, and a
telephone interview with a collateral informant) among a sample of 166
drinkers aged 60 years and older in 10 internal medicine clinics. The
ARPS and shARPS proved to be sensitive in identifying older drinkers
with a spectrum of alcohol use disorders. They were also more sensitive
than the AUDIT and the SMAST-G in identifying older persons who may be
at risk or experiencing harm due to alcohol use. The authors suggest
that these instruments provide information on specific risks associated
with alcohol use not obtained by other screening measures and may
therefore better facilitate clinician-provided interventions.

#### *Combined Screening and Health Education*

Nguyen, Fink, and colleagues evaluated the feasibility of a combined
alcohol-screening and health education system for older patients: the
Computerized Alcohol-Related Problems Survey (CARPS) system.^86^ The
CARPS system is a screening and health education device that processes
and produces individual drinking risk reports based on an individual's
survey responses. The study was conducted among primary care patients
age 60 and older (n=106), examining completion rates, participant
drinking characteristics, and patient attitudes. Nearly all participants
were able to complete the program while waiting for a scheduled
physician appointment (median time 15 minutes). Sixty-seven percent of
participants reported learning new information, 78 percent had never
discussed alcohol with a physician, and 31 percent intended to do so.
The authors concluded that combined screening and health education were
feasible in health care settings such as primary care practices. Please
note in the Indicated and Selective Prevention Strategies section below
that a randomized trial is underway to evaluate the effectiveness of the
CARPS system.

## Indicated and Selective Prevention Strategies (Early Intervention)

Clinical trials for brief intervention with at-risk older drinkers have
shown effectiveness with this population. There is a substantial
evidence base indicating that brief interventions in a variety of
clinical settings are effective at reducing alcohol consumption among
adults of younger ages.^1,87-90^ To date, three randomized clinical
trials have examined brief interventions to reduce hazardous drinking
among older adults in primary care settings. Please see Table 3 for more
information regarding each study.

#### *Brief Interventions in Primary Care Settings*

A controlled clinical trial, Project GOAL (Guiding Older Adult
Lifestyles), examined the efficacy of brief physician advice in reducing
the alcohol use and use of health care services of older adult problem
drinkers.^2^ The study involved 43 family physicians and internists in
24 community-based primary care practices in Wisconsin. Subjects age 65
or older were randomized into a control group (n = 71) or an
intervention group (n = 87). Intervention group patients received two
10- to 15-minute physician-delivered counseling sessions scheduled 1
month apart. Sessions included advice, education, and contracting using
a scripted workbook, as well as a followup telephone call by a nurse 2
weeks after each session. Control group patients received a general
health booklet. At total of 146 patients (92.4%) participated in the
12-month followup procedure. No significant differences were found
between the control and intervention groups at baseline in alcohol use,
age, socioeconomic status, depression, onset of alcohol use, smoking
status, activity level, or use of mood-altering drugs. Intervention
group patients demonstrated a significant reduction in 7-day alcohol
use, episodes of binge drinking, and frequency of excessive drinking (p
\<.005) compared with the control group at 3, 6, and 12 months after the
intervention. Specifically, among the older adults who received the
physician-delivered brief intervention, there was a 34 percent reduction
in 7-day alcohol use, 74 percent reduction in mean number of
binge-drinking episodes, and 62 percent reduction in the percentage of
older adults drinking more than 21 drinks per week compared with the
control group. Due to the small number of events, patterns of health
care utilization were not extensively analyzed. This study provided the
first direct evidence that brief physician advice can decrease alcohol
use by older adults in community-based primary care practices. The
methods were replicable and reasonably transferable to comparable health
care settings.

Gordon and colleagues ^91^ compared the effects of three types of early
interventions in a randomized clinical trial among older patients (age
65 and older) with hazardous drinking and examined whether older
patients responded similarly to younger populations. Forty-five older
enrollees met criteria for hazardous drinking and were randomized to
receive Motivational Enhancement (ME, n = 18), Brief Advice (BA, n =
12), and Standard Care (SC, n = 12). At baseline, older adults drank
more alcohol and abstained fewer days than the younger cohort (p \<
0.05). During the 1-year study, older adults in all three conditions
increased the number of days abstained, decreased the number of drinks
per day, and reduced the number of total days per month drinking. There
were trends toward decreases in the alcohol consumption measures in the
ME and BA treatment arms compared to SC. The older groups' response to
all interventions was similar to that of the younger cohort in the
larger study. Despite extremely low sample sizes, the authors suggest
that brief interventions reduce alcohol consumption in older adults
similarly to younger populations.

The Health Profiles Project was a randomized clinical trial that
examined the effectiveness of an age-specific brief alcohol intervention
for older adults in primary care settings who report drinking above
recommended limits.^92^ Health screening, including specific questions
regarding alcohol use and misuse, was conducted with more than 14,000
older patients (age 55 and over) seeking health care in 46 primary care
clinics located in southeast Michigan and northwest Ohio. A total of 446
older patients who screened positive for hazardous drinking were
randomized either to a brief (20-25 minute) alcohol intervention or
control condition. Intervention group patients received an intervention
appointment during which the clinician and patient would review together
a Brief Alcohol Intervention booklet that included the patient's
self-reported drinking data and develop a contract to reduce at-risk
drinking. Control group patients received an intervention appointment
and were given a general health advice booklet (addressing a range of
health behaviors including alcohol use as well as nutrition, exercise,
smoking, etc.). Participants were re-assessed at 3, 6, 12, and 18 months
post-intervention. Preliminary results show significantly more reduction
in frequency and quantity of alcohol consumption for the brief
intervention compared to the control condition. These results suggest
that an easy-to-administer, elder-specific brief alcohol intervention is
effective in reducing at-risk drinking among older adults and shows
promise in improving long-term alcohol-related health outcomes for this
population.

A substudy of the Health Profile Project examined male veterans in the
sample and estimated the effects of the brief intervention on health
care use in that population.^93^ Male veterans exposed to the
intervention (n=100) used more outpatient medical services in the short
term compared to the control group. Long-term effects on
inpatient/outpatient use were not observed. These findings suggest that
brief interventions aimed at reducing drinking may be associated with
increased efforts to seek health care. The authors concluded that early
detection and management of alcohol-related or other illnesses might be
expected to accrue savings in later years due to positive health
behavior changes.

## Ongoing Selective Prevention Programs Under Evaluation

A search of current federally funded research identified three ongoing
projects that are specifically designed to prevent alcohol misuse among
older adults. All three focus on the identification of and brief
intervention with at-risk older drinkers in health care settings. The
CARPS system, described above, is the focus of a current research
project funded by the National Institute on Alcohol Abuse and Alcoholism
(NIAAA).^94^ The project is a randomized trial of the effectiveness and
cost-effectiveness of an integrated patient provider intervention to
prevent harmful, hazardous alcohol use (risks for problems) in older
adults. The patient intervention uses the CARPS, which results in
printed Patient and Physician Reports with classification of the patient
as a harmful, hazardous or non-hazardous drinker and reasons for the
classification. The Patient Report references a companion educational
booklet developed for older adults. The provider component is based on a
physician intervention with proven effectiveness. The proposed research
design involves randomization of 28 primary care physicians in four
clinics and their eligible patients age 65+ to the intervention vs.
"usual care." Outcomes include the comparative effectiveness of a
patient and physician educational intervention to prevent geriatric
alcohol hazardous and harmful use, the comparative costs of the
intervention, and the post-effectiveness of the intervention, all
relative to usual care. Effectiveness measures include alcohol
consumption behaviors, health-related quality of life; proximal outcomes
examined include knowledge and self-efficacy.

A NIAAA-funded study is underway identifying at-risk drinkers using the
shARPS. ^95^ The investigators proposed a 12-month, randomized,
controlled trial involving 880 individuals attending primary care
clinics at two non-academic sites. The intervention consists of advice
given to both at-risk drinkers and their physicians personalized to
address the particular reasons an individual is identified as an at-risk
drinker. At-risk drinkers will be randomized to receive either brief
advice about at-risk drinking (intervention) or a booklet on healthy
behaviors (control). Assessments are planned at baseline, 3 months and
12 months. Planned analyses will assess the effect of the intervention
on the prevalence of at-risk drinking, the amount of drinking, and the
numbers of risks identifying those subjects still considered at-risk
drinkers. This study will be the first to assess a preventive
intervention to reduce risks of alcohol use, alone or in conjunction
with comorbidity and medication use among older adults in primary care.

Funded by NIAAA, the stated aim of Project SHARE (Senior Health and
Alcohol Risk Education) is to examine whether patient and provider
education can decrease risky alcohol use and reduce health care costs in
persons 65 years of age and older.^96^ The proposed research design
involves randomization of 28 primary care physicians in four clinics and
their eligible patients age 65+ to an intervention or "usual care"
condition. The intervention will include a "tested computerized
screening and education system that was developed especially for older
adults and their providers, supplemented by a well-established
intervention for physicians." Expected total study enrollment is 1,229;
the study timeline is May 2005-August 2010. Outcome measures include
hazardous and harmful drinking, health-related quality of life,
utilization and costs, as well as alcohol knowledge, alcohol-related
self-efficacy, and functional status.

In addition to ongoing clinical trials, a recent collaborative
publication from the National Council on the Aging and SAMHSA, entitled
"Promoting Older Adult Health," describes several promising programs and
partnerships that have been developed to address alcohol misuse, as well
as medication and mental health problems in older persons.

## Conclusions

Alcohol problems among older adults are associated with increased health
care utilization and significant health care expenditures. Studies have
indicated that targeted prevention and early intervention with this
population can impact subsequent health care utilization. Prevention and
early intervention programs, including those focused on risk and
protective factors associated with this age group, are some of the most
promising approaches to maximizing health outcomes and minimize health
care costs among older adults. These programs represent the future of
age-appropriate care for the growing number of older Americans. A range
of prevention/intervention strategies available to older adults
including prevention and education for persons who are at risk but
nondependent drinkers, accurate identification and screening tools,
brief advice during medical visits by primary care providers, and
structured brief intervention protocols. These approaches offer
providers and consumers options that meet different needs and
preferences of older adults across the spectrum of drinking patterns.
While progress has been made in understanding the effectiveness of
preventive alcohol screening and brief interventions with older adults,
there are challenges to matching these models to different service
settings and different subgroups of older adults.

The scarcity of prevention programs addressing geriatric alcohol misuse
in the published literature is notable. This review of the existing
evidence base indicated that a number of the evaluated prevention
programs that have included alcohol may have failed to identify alcohol
misuse among older adults accurately (i.e., see Wallace and
colleagues^97^ discussion in the Depression & Anxiety section). For
example, using the CAGE as the only measurement instrument will likely
identify only those with alcohol abuse or dependence issues.^1,86,98^
Further, CAGE scores are a lifetime measure ("Have you
[ever]{.underline} felt the need to Cut-down?"), so are less sensitive
to measuring change. As the CAGE does not have high validity with older
adults,^1^ if used, it should ideally be part of a larger questionnaire
or interview that includes quantity/frequency questions, and questions
about consequences. Other health promotion programs directed at older
adults, such as the one examined by Huang and colleagues,^99^ did not
address alcohol misuse. Although study authors identified the importance
of mental health promotion among older adults, the study did not
indicate specific information provided on alcohol misuse or measure
changes in knowledge in this area.

Table 2. Prevention and screening of late-life alcohol misuse

+----+------+--------+----+---------+-------+--------------+---------+
| R  | S    | Mode   | A  | Sample  | Fol   | Outcome      | Limita  |
| ef | tudy | l/Cond | ge |         | lowup | Measures and | tions/C |
| er | De   | itions |    |         |       | Results      | omments |
| en | sign |        |    |         |       |              |         |
| ce |      |        |    |         |       |              |         |
+====+======+========+====+=========+=======+==============+=========+
| Fi | Pret | Pa     | 6  | 101     | Imme  | Increased    | No      |
| nk | est/ | tients | 0+ | male    | diate | knowledge    | measure |
| et | Post | were   |    | and     | pos   | and          | of      |
| al | test | con    | Ra | female  | ttest | s            | be      |
| ., | Eva  | tacted | ng | p       |       | elf-efficacy | havior. |
| 20 | luat | by     | e: | atients |       | after        | F       |
| 01 | ion; | tel    |    | with    |       | i            | easible |
| ^7 | Fea  | ephone | 6  | variety |       | ntervention. | to      |
| 1^ | sibi | and    | 0- | of MDs  |       | High levels  | re      |
|    | lity | asked  | 89 |         |       | of           | plicate |
|    | Ev   | to     |    |         |       | satisfaction | easily. |
|    | alua | come   | M  |         |       | and interest |         |
|    | tion | earl   | ea |         |       | with         |         |
|    |      | y/stay | n: |         |       | materials.   |         |
|    |      | late   | 72 |         |       |              |         |
|    |      | next   |    |         |       |              |         |
|    |      | dr.    |    |         |       |              |         |
|    |      | appt:  |    |         |       |              |         |
|    |      | 40 min |    |         |       |              |         |
|    |      | for    |    |         |       |              |         |
|    |      | pre-   |    |         |       |              |         |
|    |      | and    |    |         |       |              |         |
|    |      | post   |    |         |       |              |         |
|    |      | test   |    |         |       |              |         |
|    |      | plus   |    |         |       |              |         |
|    |      | read   |    |         |       |              |         |
|    |      | health |    |         |       |              |         |
|    |      | educ   |    |         |       |              |         |
|    |      | b      |    |         |       |              |         |
|    |      | ooklet |    |         |       |              |         |
|    |      | and    |    |         |       |              |         |
|    |      | pa     |    |         |       |              |         |
|    |      | mphlet |    |         |       |              |         |
+----+------+--------+----+---------+-------+--------------+---------+
| Bu | RCT  | I      | 6  | M       | Fol   | No           | Use of  |
| rt |      | nterv: | 5+ | edicare | lowup | statistical  | 1 or    |
| on | J    | Yearly |    | benefi  | 2     | differences  | more +  |
| et | ohns | prev   | I  | ciaries | y     | between      | CAGE    |
| al | Hop  | entive | nt | (male   | ears: | interv and   | score   |
| ., | kins | visits | er | and     | 3097  | controls in  | as only |
| 19 | Medi | for 2  | v: | f       | of    | changes in   | measure |
| 95 | care | y      |    | emale). | 4195  | problem      | for     |
| ^7 | Pr   | ears + | A  | Problem | (7    | alcohol use. | problem |
| 3^ | even | op     | ge | alcohol | 3.8%) |              | alcohol |
|    | tive | tional | 65 | use     |       |              | use in  |
|    | Serv | coun   | -7 | ide     |       |              | this    |
|    | ices | seling | 4: | ntified |       |              | pop     |
|    | Demo | visits |    | with    |       |              | ulation |
|    |      | w/PCP  | 6  | any +   |       |              | is a    |
|    |      |        | 0. | CAGE    |       |              | limi    |
|    |      | Co     | 9% | score.  |       |              | tation. |
|    |      | ntrol: |    |         |       |              | S       |
|    |      | Usual  | A  | Interv: |       |              | upports |
|    |      | care   | ge | n=2105  |       |              | idea    |
|    |      |        | 75 |         |       |              | that    |
|    |      |        | -8 | C       |       |              | t       |
|    |      |        | 4: | ontrol: |       |              | argeted |
|    |      |        | 3  | n=2090  |       |              | pre     |
|    |      |        | 3. |         |       |              | ventive |
|    |      |        | 4% |         |       |              | str     |
|    |      |        |    |         |       |              | ategies |
|    |      |        | Co |         |       |              | are     |
|    |      |        | nt |         |       |              | needed. |
|    |      |        | ro |         |       |              |         |
|    |      |        | l: |         |       |              |         |
|    |      |        |    |         |       |              |         |
|    |      |        | A  |         |       |              |         |
|    |      |        | ge |         |       |              |         |
|    |      |        | 65 |         |       |              |         |
|    |      |        | -7 |         |       |              |         |
|    |      |        | 4: |         |       |              |         |
|    |      |        |    |         |       |              |         |
|    |      |        | 6  |         |       |              |         |
|    |      |        | 2. |         |       |              |         |
|    |      |        | 0% |         |       |              |         |
|    |      |        |    |         |       |              |         |
|    |      |        | A  |         |       |              |         |
|    |      |        | ge |         |       |              |         |
|    |      |        | 75 |         |       |              |         |
|    |      |        | -8 |         |       |              |         |
|    |      |        | 4: |         |       |              |         |
|    |      |        | 3  |         |       |              |         |
|    |      |        | 2. |         |       |              |         |
|    |      |        | 5% |         |       |              |         |
+----+------+--------+----+---------+-------+--------------+---------+
| La | RCT  | Three  | 6  | M       | On    | 2 % eligible | Sc      |
| ve |      | arm    | 5+ | edicare | going | for alcohol  | reening |
| et | R    | study  |    | benefi  | tra   | counseling;  | c       |
| al | ural |        | Ra | ciaries | cking | authors did  | riteria |
| ., | He   | Interv | ng | (male   | of    | not model    | u       |
| 1  | alth | 1:     | e: | and     | use   | p            | nknown. |
| 99 | P    | free   | 6  | f       | of    | articipation | Likely  |
| 5; | romo | ho     | 5- | emale). | h     | due to low   | ina     |
| 19 | tion | spital | 79 | Parti   | ealth | #'s. General | ccurate |
| 96 | Pro  | -based |    | cipants | prom  | outcomes     | measure |
| ^  | gram | health | A  | offered | otion | included     | of      |
| 74 |      | pro    | ge | "       | ser   | p            | those   |
| ,\ |      | motion | 65 | alcohol | vices | articipants' | older   |
|  7 |      | se     | -6 | coun    |       | use of free  | adults  |
| 5^ |      | rvices | 9: | seling" |       | health       | appr    |
|    |      |        | 4  | health  |       | promotio     | opriate |
|    |      | Interv | 1. | pr      |       | n/prevention | for     |
|    |      | 2:     | 4% | omotion |       | services.    | alcohol |
|    |      | free   |    | s       |       |              | misuse  |
|    |      | phy    | A  | ervices |       |              | pre     |
|    |      | sician | ge | after   |       |              | vention |
|    |      | -based | 70 | Health  |       |              | se      |
|    |      | health | -7 | Risk    |       |              | rvices. |
|    |      | prom   | 4: | Ap      |       |              |         |
|    |      | se     | 3  | praisal |       |              |         |
|    |      | rvices | 8. | in      |       |              |         |
|    |      |        | 1% | terview |       |              |         |
|    |      | Co     |    | but no  |       |              |         |
|    |      | ntrol: | A  | info    |       |              |         |
|    |      | O      | ge | re: HRA |       |              |         |
|    |      | ffered | 75 | cr      |       |              |         |
|    |      | no     | -7 | iteria. |       |              |         |
|    |      | health | 9: |         |       |              |         |
|    |      | prom   | 2  | Interv  |       |              |         |
|    |      | se     | 0. | 1:      |       |              |         |
|    |      | rvices | 4% | n=1312  |       |              |         |
|    |      |        |    |         |       |              |         |
|    |      |        |    | Interv  |       |              |         |
|    |      |        |    | 2:      |       |              |         |
|    |      |        |    | n=1347  |       |              |         |
|    |      |        |    |         |       |              |         |
|    |      |        |    | C       |       |              |         |
|    |      |        |    | ontrol: |       |              |         |
|    |      |        |    | n=1225  |       |              |         |
+----+------+--------+----+---------+-------+--------------+---------+

Table 2. Prevention and screening of late-life alcohol misuse
(continued)

+----+------+--------+----+---------+--------+-------------+---+----------+
| R  | S    | Mode   | A  | Sample  | Fo     | Outcome     |   | Limi     |
| ef | tudy | l/Cond | ge |         | llowup | Measures    |   | tations/ |
| er | De   | itions |    |         |        | and Results |   | Comments |
| en | sign |        |    |         |        |             |   |          |
| ce |      |        |    |         |        |             |   |          |
+====+======+========+====+=========+========+=============+===+==========+
| E  | Pret | Two 60 | Ra | 32      | 26 of  | 16-item     | S |          |
| li | est/ | min    | ng | female  | 32     | knowledge   | m |          |
| as | Post | educa  | e: | parti   | partic | test plus   | a |          |
| on | test | tional |    | cipants | ipants | d           | l |          |
| &  | Ev   | pr     | 5  |         | com    | emographics | l |          |
| S  | alua | ograms | 4- |         | pleted | and alc/med | s |          |
| ki | tion | pre    | 90 |         | imm    | consumption | a |          |
| ns |      | sented |    |         | ediate | info.       | m |          |
| ta | (P   | at     | M  |         | po     | Pa          | p |          |
| d, | ilot | local  | ea |         | sttest | rticipants, | l |          |
| 20 | t    | senior | n: |         | (81%   | p           | e |          |
| 01 | est) | center | 75 |         | re     | articularly | s |          |
| ^7 |      |        |    |         | sponse | moderate to | i |          |
| 2^ |      |        |    |         | rate). | heavy       | z |          |
|    |      |        |    |         |        | drinkers,   | e |          |
|    |      |        |    |         |        | improved    | . |          |
|    |      |        |    |         |        | knowledge   | N |          |
|    |      |        |    |         |        | sig         | o |          |
|    |      |        |    |         |        | nificantly. | m |          |
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|    |      |        |    |         |        |             | h |          |
|    |      |        |    |         |        |             | a |          |
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|    |      |        |    |         |        |             | i |          |
|    |      |        |    |         |        |             | o |          |
|    |      |        |    |         |        |             | r |          |
|    |      |        |    |         |        |             | a |          |
|    |      |        |    |         |        |             | l |          |
|    |      |        |    |         |        |             | i |          |
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|    |      |        |    |         |        |             | e |          |
|    |      |        |    |         |        |             | n |          |
|    |      |        |    |         |        |             | t |          |
|    |      |        |    |         |        |             | i |          |
|    |      |        |    |         |        |             | o |          |
|    |      |        |    |         |        |             | n |          |
|    |      |        |    |         |        |             | s |          |
|    |      |        |    |         |        |             | t |          |
|    |      |        |    |         |        |             | o |          |
|    |      |        |    |         |        |             | r |          |
|    |      |        |    |         |        |             | e |          |
|    |      |        |    |         |        |             | d |          |
|    |      |        |    |         |        |             | u |          |
|    |      |        |    |         |        |             | c |          |
|    |      |        |    |         |        |             | e |          |
|    |      |        |    |         |        |             | a |          |
|    |      |        |    |         |        |             | l |          |
|    |      |        |    |         |        |             | c |          |
|    |      |        |    |         |        |             | o |          |
|    |      |        |    |         |        |             | h |          |
|    |      |        |    |         |        |             | o |          |
|    |      |        |    |         |        |             | l |          |
|    |      |        |    |         |        |             | . |          |
+----+------+--------+----+---------+--------+-------------+---+----------+
| Ng | Fea  | Pa     | 6  | Male    | On     | Nearly all  |   | Rep      |
| uy | sibi | tients | 0+ | and     | e-time | pts were    |   | licable. |
| en | lity | com    |    | female  | evalu  | able to     |   | No       |
| et | Ev   | pleted | A  | p       | ation, | complete    |   | measure  |
| al | alua | comput | ge | atients | no     | while       |   | of       |
| ., | tion | erized | 60 | in      | fo     | waiting for |   | b        |
| 20 |      | (      | -7 | co      | llowup | a scheduled |   | ehavior. |
| 01 | C    | CARPS) | 4: | mmunity |        | appt        |   | Presence |
| ^8 | ARPS | s      |    | group   |        | (median     |   | of CARPS |
| 6^ |      | urvey, | 6  | p       |        | time 15     |   | data     |
|    |      | re     | 0% | ractice |        | min). 67%   |   | en       |
|    |      | ceived |    | and     |        | p           |   | couraged |
|    |      | p      | A  | co      |        | articipants |   | alcohol  |
|    |      | rinted | ge | mmunity |        | reported    |   | use      |
|    |      | report | 75 | health  |        | learning    |   | dis      |
|    |      | of     | +: | center; |        | new         |   | cussions |
|    |      | h      |    | current |        | i           |   | between  |
|    |      | is/her | 4  | d       |        | nformation; |   | MD and   |
|    |      | data   | 0% | rinkers |        | 78% had     |   | patient. |
|    |      | and    |    | (       |        | never       |   |          |
|    |      | r      |    | defined |        | discussed   |   |          |
|    |      | elated |    | as 1    |        | alcohol     |   |          |
|    |      | edu    |    | drink   |        | with MD,    |   |          |
|    |      | cation |    | in 12   |        | 31%         |   |          |
|    |      | to     |    | mos)    |        | intended to |   |          |
|    |      | reduce |    |         |        | do so. MDs  |   |          |
|    |      | risks. |    | Partic  |        | in clinics  |   |          |
|    |      | Pa     |    | ipants: |        | found       |   |          |
|    |      | tients |    | n=106   |        | useful.     |   |          |
|    |      | also   |    |         |        |             |   |          |
|    |      | com    |    |         |        |             |   |          |
|    |      | pleted |    |         |        |             |   |          |
|    |      | survey |    |         |        |             |   |          |
|    |      | re:    |    |         |        |             |   |          |
|    |      | usef   |    |         |        |             |   |          |
|    |      | ulness |    |         |        |             |   |          |
|    |      | and    |    |         |        |             |   |          |
|    |      | feasi  |    |         |        |             |   |          |
|    |      | bility |    |         |        |             |   |          |
|    |      | of     |    |         |        |             |   |          |
|    |      | CARPS  |    |         |        |             |   |          |
+----+------+--------+----+---------+--------+-------------+---+----------+
| Fi | In   | All    | 6  | Male    | On     | ARPS        |   | ARPS is  |
| nk | stru | pa     | 5+ | and     | e-time | identified  |   | s        |
| et | ment | tients |    | female  | evalu  | nearly all  |   | ensitive |
| al | Co   | com    | Ra | p       | ation, | drinkers    |   | and      |
| ., | mpar | pleted | ng | atients | no     | detected by |   | id       |
| 20 | ison | ARPS   | e: | in two  | fo     | the CAGE,   |   | entifies |
| 02 |      | and    |    | primary | llowup | SMAST, and  |   | unique   |
| ^8 | ARPS | AUDIT; | 65 | care    |        | AUDIT;      |   | subset   |
| 4^ |      | one    | -1 | c       |        | detected    |   | of       |
|    |      | half   | 00 | linics; |        | hazardous   |   | at-risk  |
|    |      | of     |    | current |        | and harmful |   | drinking |
|    |      | total  | M  | d       |        | drinkers    |   | older    |
|    |      | group  | ea | rinkers |        | not         |   | adults   |
|    |      | also   | n: | (       |        | identified  |   | often    |
|    |      | com    | 75 | defined |        | by these    |   | missed   |
|    |      | pleted |    | as 1    |        | measures.   |   | in other |
|    |      | CAGE,  |    | drink   |        | These       |   | commonly |
|    |      | other  |    | in 12   |        | drinkers    |   | used     |
|    |      | half   |    | mos)    |        | used        |   | screens. |
|    |      | com    |    |         |        | medications |   | Reliance |
|    |      | pleted |    | ARPS:   |        | or had      |   | on       |
|    |      | SMAST  |    | n=574   |        | medical     |   | computer |
|    |      |        |    |         |        | conditions  |   | sco      |
|    |      |        |    | AUDIT:  |        | that placed |   | ring/com |
|    |      |        |    | n=553   |        | them at     |   | plicated |
|    |      |        |    |         |        | risk for    |   | al       |
|    |      |        |    | CAGE:   |        | adverse     |   | gorithms |
|    |      |        |    | n=277   |        | health      |   | to       |
|    |      |        |    |         |        | events.     |   | d        |
|    |      |        |    | SMAST:  |        |             |   | etermine |
|    |      |        |    | n=273   |        |             |   | drinking |
|    |      |        |    |         |        |             |   | category |
|    |      |        |    |         |        |             |   | is       |
|    |      |        |    |         |        |             |   | limits   |
|    |      |        |    |         |        |             |   | replic   |
|    |      |        |    |         |        |             |   | ability. |
+----+------+--------+----+---------+--------+-------------+---+----------+
| M  | In   | Co     | 6  | Male    | On     | Compared to |   | See      |
| oo | stru | mpared | 0+ | and     | e-time | LEAD:       |   | above.   |
| re | ment | ARPS,  |    | female  | evalu  |             |   | May be   |
| et | Ev   | s      | Me | d       | ation, | Sensitivity |   | more     |
| al | alua | hARPS, | an | rinking | no     | ARPS: 93%   |   | s        |
| ., | tion | AUDIT, | Ag | p       | fo     |             |   | ensitive |
| 20 |      | and    | e: | atients | llowup | Specificity |   | than     |
| 02 | ARPS | S      | 74 | in 10   |        | ARPS: 63%   |   | AUDIT    |
| ^8 | and  | MAST-G | .3 | i       |        |             |   | and      |
| 5^ | sh   | a      |    | nternal |        | Sensitivity |   | SMAST-G  |
|    | ARPS | gainst | Ra | m       |        | shARPS: 92% |   | due to   |
|    |      | "LEAD" | ng | edicine |        |             |   | ability  |
|    |      | sta    | e: | clinics |        | Specificity |   | to       |
|    |      | ndard: |    |         |        | shARPS: 51% |   | assess   |
|    |      | m      | 6  | Partic  |        |             |   | comorb   |
|    |      | edical | 0- | ipants: |        | Sensitivity |   | idities. |
|    |      | record | 93 | n=166   |        | AUDIT: 28%  |   |          |
|    |      | r      |    |         |        |             |   |          |
|    |      | eview, |    |         |        | Specificity |   |          |
|    |      | cl     |    |         |        | AUDIT: 100% |   |          |
|    |      | inical |    |         |        |             |   |          |
|    |      | inte   |    |         |        | Sensitivity |   |          |
|    |      | rview, |    |         |        | SMAST-G:    |   |          |
|    |      | int    |    |         |        | 52%         |   |          |
|    |      | erview |    |         |        |             |   |          |
|    |      | with   |    |         |        | Specificity |   |          |
|    |      | coll   |    |         |        | SMAST-G:    |   |          |
|    |      | ateral |    |         |        | 96%         |   |          |
|    |      | inf    |    |         |        |             |   |          |
|    |      | ormant |    |         |        |             |   |          |
+----+------+--------+----+---------+--------+-------------+---+----------+

Table 3. Alcohol misuse early interventions

+----+------+--------+----+--------+--------+-------------+---------+
| R  | S    | Model/ | A  | Sample | Fo     | Outcome     | Limit   |
| ef | tudy | Cond   | ge |        | llowup | measures    | ations/ |
| er | De   | itions |    |        |        | and Results | C       |
| en | sign |        |    |        |        |             | omments |
| ce |      |        |    |        |        |             |         |
+====+======+========+====+========+========+=============+=========+
| F  | RCT  | I      | 6  | Male   | Fo     | Interv      | Strong  |
| le |      | nterv: | 5+ | and    | llowup | group       | e       |
| mi | Pro  | B      |    | female | 3,6,   | compared to | vidence |
| ng | ject | ooklet | Ra | pa     | and 12 | control:    | of      |
| et | GOAL | and 2  | ng | tients | mos    | 34%         | ef      |
| al |      | 10-15  | e: | with   |        | reduction   | ficacy; |
| ., |      | minute |    | p      | 92.4%  | in 7-day    | con     |
| 19 |      | MD-del | 6  | roblem | pa     | alcohol     | sistent |
| 99 |      | ivered | 5- | dr     | tients | use; 74%    | with    |
| ^  |      | coun   | 85 | inking | com    | reduction   | lit     |
| 2^ |      | seling |    | in 24  | pleted | mean \# of  | erature |
|    |      | se     |    | p      | 12     | bin         | for     |
|    |      | ssions |    | rimary | -month | ge-drinking | younger |
|    |      | 1      |    | care   | fo     | episodes;   | adults. |
|    |      | month  |    | cl     | llowup | 62%         | Costs   |
|    |      | apart, |    | inics. |        | reduction   | i       |
|    |      | plus 1 |    |        |        | in % of     | nvolved |
|    |      | nurse  |    | P      |        | older       | in      |
|    |      | call 2 |    | roblem |        | adults      | ph      |
|    |      | weeks  |    | dr     |        | consuming   | ysician |
|    |      | after  |    | inking |        | greater     | time    |
|    |      | each   |    | d      |        | than 21     | /visits |
|    |      | visit  |    | efined |        | drinks/wk   | plus    |
|    |      |        |    | as     |        |             | nurse   |
|    |      | Co     |    | \>11   |        | No          | f       |
|    |      | ntrol: |    | d      |        | significant | ollowup |
|    |      | G      |    | rks/wk |        | changes in  | call.   |
|    |      | eneral |    | for    |        | health      | B.I.    |
|    |      | Health |    | men,   |        | status.     | w       |
|    |      | B      |    | \>8    |        | Health care | orkbook |
|    |      | ooklet |    | for    |        | util not    | and     |
|    |      |        |    | women; |        | analyzed    | pro     |
|    |      |        |    | 2 or   |        | due to      | cedures |
|    |      |        |    | more + |        | small \# of | f       |
|    |      |        |    | CAGE;  |        | events.     | easible |
|    |      |        |    | or 4   |        |             | to      |
|    |      |        |    | or     |        |             | rep     |
|    |      |        |    | more   |        |             | licate. |
|    |      |        |    | dr     |        |             |         |
|    |      |        |    | ks/occ |        |             |         |
|    |      |        |    | for    |        |             |         |
|    |      |        |    | men, 3 |        |             |         |
|    |      |        |    | for    |        |             |         |
|    |      |        |    | women  |        |             |         |
|    |      |        |    | in     |        |             |         |
|    |      |        |    | past 3 |        |             |         |
|    |      |        |    | mos    |        |             |         |
|    |      |        |    |        |        |             |         |
|    |      |        |    | I      |        |             |         |
|    |      |        |    | nterv: |        |             |         |
|    |      |        |    | n=87   |        |             |         |
|    |      |        |    |        |        |             |         |
|    |      |        |    | Co     |        |             |         |
|    |      |        |    | ntrol: |        |             |         |
|    |      |        |    | n=71   |        |             |         |
+----+------+--------+----+--------+--------+-------------+---------+
| Go | RCT  | Three  | 6  | Male   | Fo     | Over the    | Interv  |
| rd |      | arm    | 5+ | and    | llowup | year, all   | entions |
| on | Pos  | study  |    | female | 1, 3,  | three       | co      |
| et | thoc |        |    | pa     | 6, 9,  | groups      | nducted |
| al | anal | ME:    |    | tients | and 12 | increased   | by      |
| ., | ysis | Motiva |    | with   | mos    | days        | r       |
| 20 | by   | tional |    | haz    | (1, 3, | abstained,  | esearch |
| 03 | age  | enhan  |    | ardous | 9 by   | decreased   | int     |
| ^9 | of   | cement |    | dr     | tele   | \# of       | erventi |
| 1^ | ELM  | 45-60  |    | inking | phone; | drks/day    | onists, |
|    | s    | min    |    | in 12  | 6 and  | and \# of   | not     |
|    | tudy | se     |    | p      | 12 in  | total       | pa      |
|    |      | ssions |    | rimary | pe     | drinking    | tient's |
|    |      | with   |    | care   | rson). | days in     | phy     |
|    |      | re     |    | cl     |        | month.      | sician. |
|    |      | search |    | inics. |        | Trend       |         |
|    |      | interv |    |        |        | toward      | Sample  |
|    |      | ention |    | Haz    |        | decreases   | size is |
|    |      | ist, + |    | dr     |        | in alc      | small.  |
|    |      | 2      |    | inking |        | consumption | May     |
|    |      | 10-15  |    | d      |        | for ME and  | provide |
|    |      | min    |    | efined |        | BA compared | e       |
|    |      | b      |    | as 8   |        | to SC, but  | vidence |
|    |      | ooster |    | or \>  |        | not stat    | of      |
|    |      | se     |    | AUDIT  |        | s           | effects |
|    |      | ssions |    | score  |        | ignificant. | of      |
|    |      | 2 & 6  |    | or 16  |        | Similar     | scr     |
|    |      | wks    |    | or     |        | response to | eening: |
|    |      | after  |    | more   |        | younger     | 5       |
|    |      | i      |    | d      |        | cohort.     | fo      |
|    |      | nitial |    | rks/wk |        |             | llowups |
|    |      |        |    | for    |        |             | plus    |
|    |      | BA:    |    | men,   |        |             | b       |
|    |      | Brief  |    | 12 or  |        |             | aseline |
|    |      | Advice |    | more   |        |             | in 1    |
|    |      | 1      |    | for    |        |             | year.   |
|    |      | 10-15  |    | women. |        |             |         |
|    |      | min    |    |        |        |             |         |
|    |      | s      |    | ME: n  |        |             |         |
|    |      | ession |    | = 18   |        |             |         |
|    |      |        |    |        |        |             |         |
|    |      | SC:    |    | BA: n  |        |             |         |
|    |      | St     |    | = 12   |        |             |         |
|    |      | andard |    |        |        |             |         |
|    |      | Care   |    | SC: n  |        |             |         |
|    |      |        |    | = 12   |        |             |         |
+----+------+--------+----+--------+--------+-------------+---------+
| Bl | RCT  | I      | 5  | 452    | Fo     | Preliminary | Study   |
| ow |      | nterv: | 5+ | su     | llowup | results     | a       |
| et | He   | 1      |    | bjects | 3, 6,  | show        | nalysis |
| al | alth | 20-25  | M  | (26 %  | 12, 18 | si          | still   |
| ., | Prof | min    | ea | Afric  | mos.   | gnificantly | being   |
| in | iles | interv | n: | an-Ame |        | more        | com     |
| pr | Pro  | appt   |    | rican) | 92%    | reduction   | pleted. |
| og | ject | with   | 66 |        | pa     | in          | I       |
| re |      | cli    | [+ | Male   | tients | frequency   | ncludes |
| ss |      | nician | ]{ | and    | com    | and         | broader |
| ^9 |      | to     | .u | female | pleted | quantity    | age     |
| 2^ |      | review | nd | pa     | 12     |             | group   |
|    |      | pt     | er | tients | -month |             | and     |
|    |      | dr     | li | with   | fo     |             | diverse |
|    |      | inking | ne | a      | llowup |             | sample. |
|    |      | data   | }6 | t-risk |        |             | Adds to |
|    |      | and    | .4 | dr     |        |             | e       |
|    |      | make   |    | inking |        |             | vidence |
|    |      | co     |    | in     |        |             | base    |
|    |      | ntract |    | p      |        |             | for     |
|    |      | to     |    | rimary |        |             | B.I.    |
|    |      | reduce |    | care   |        |             | among   |
|    |      | dr     |    | cl     |        |             | older   |
|    |      | inking |    | inics. |        |             | adults. |
|    |      |        |    |        |        |             |         |
|    |      | Co     |    | A      |        |             |         |
|    |      | ntrol: |    | t-risk |        |             |         |
|    |      | 1      |    | dr     |        |             |         |
|    |      | interv |    | inking |        |             |         |
|    |      | appt + |    | d      |        |             |         |
|    |      | g      |    | efined |        |             |         |
|    |      | eneral |    | as     |        |             |         |
|    |      | health |    | \>12   |        |             |         |
|    |      | advice |    | d      |        |             |         |
|    |      | b      |    | rks/wk |        |             |         |
|    |      | ooklet |    | for    |        |             |         |
|    |      |        |    | men,   |        |             |         |
|    |      |        |    | \>9    |        |             |         |
|    |      |        |    | for    |        |             |         |
|    |      |        |    | women; |        |             |         |
|    |      |        |    | or 4   |        |             |         |
|    |      |        |    | or     |        |             |         |
|    |      |        |    | more   |        |             |         |
|    |      |        |    | dr     |        |             |         |
|    |      |        |    | ks/occ |        |             |         |
|    |      |        |    | for    |        |             |         |
|    |      |        |    | men, 3 |        |             |         |
|    |      |        |    | for    |        |             |         |
|    |      |        |    | women  |        |             |         |
|    |      |        |    | 2x or  |        |             |         |
|    |      |        |    | more   |        |             |         |
|    |      |        |    | in     |        |             |         |
|    |      |        |    | past 3 |        |             |         |
|    |      |        |    | mos    |        |             |         |
+----+------+--------+----+--------+--------+-------------+---------+

Table 3. Alcohol misuse early interventions (continued)

+----+------+--------+----+----------+------+-------------+---------+
| R  | S    | Mode   | A  | Sample   | Foll | Outcome     | Limita  |
| ef | tudy | l/Cond | ge |          | owup | Measures    | tions/C |
| er | De   | itions |    |          |      | and Results | omments |
| en | sign |        |    |          |      |             |         |
| ce |      |        |    |          |      |             |         |
+====+======+========+====+==========+======+=============+=========+
| Co | RCT  | Same   | 5  | Male     | Same | Interv      | Cost-ef |
| pe |      | as     | 5+ | veterans | as   | patients    | fective |
| la | Subs | above  |    | in VA    | a    | used more   | B.I.    |
| nd | tudy |        | Ra | primary  | bove | outpatient  | may     |
| et | He   |        | ng | care     |      | medical     | i       |
| al | alth |        | e: | settings |      | services in | ncrease |
| ., | Pro  |        |    | with     |      | short term  | health  |
| 20 | file |        | 5  | at-risk  |      | (9 mos      | care-   |
| 03 | Pro  |        | 5- | drinking |      | po          | seeking |
| ^9 | ject |        | 81 | (defined |      | st-interv). | and     |
| 3^ |      |        |    | above)   |      | Effects on  | appr    |
|    |      |        | I  |          |      | long-term   | opriate |
|    |      |        | nt | Interv:  |      | util of     | tr      |
|    |      |        | er | n=100    |      | inpat/outpt | eatment |
|    |      |        | v: |          |      | services    | early.  |
|    |      |        | 65 | Control: |      | not         |         |
|    |      |        | .7 | n=105    |      | observed    |         |
|    |      |        | [+ |          |      | (19 mos     |         |
|    |      |        | ]{ |          |      | po          |         |
|    |      |        | .u |          |      | st-interv). |         |
|    |      |        | nd |          |      |             |         |
|    |      |        | er |          |      |             |         |
|    |      |        | li |          |      |             |         |
|    |      |        | ne |          |      |             |         |
|    |      |        | }6 |          |      |             |         |
|    |      |        | .3 |          |      |             |         |
|    |      |        |    |          |      |             |         |
|    |      |        | Co |          |      |             |         |
|    |      |        | nt |          |      |             |         |
|    |      |        | ro |          |      |             |         |
|    |      |        | l: |          |      |             |         |
|    |      |        |    |          |      |             |         |
|    |      |        | 66 |          |      |             |         |
|    |      |        | .1 |          |      |             |         |
|    |      |        | [+ |          |      |             |         |
|    |      |        | ]{ |          |      |             |         |
|    |      |        | .u |          |      |             |         |
|    |      |        | nd |          |      |             |         |
|    |      |        | er |          |      |             |         |
|    |      |        | li |          |      |             |         |
|    |      |        | ne |          |      |             |         |
|    |      |        | }6 |          |      |             |         |
|    |      |        | .5 |          |      |             |         |
+----+------+--------+----+----------+------+-------------+---------+

# Medication Misuse

Medication misuse is an important arena for prevention and early
intervention among older adults. In contrast to drug abuse in young
adults who often abuse illicit or illegally obtained prescription drugs,
drug abuse problems among older adults more typically occur from misuse
or abuse of prescription and/or over-the-counter medications, as well as
herbal remedies. Relative to younger individuals, older adults use a
high number of prescription and over-the-counter medications, which
increases their risk for inappropriate use of medications. Studies
report that older persons regularly consume on average between two and
six prescription medications and between one to three over-the-counter
medications.^100^ Late-life medication misuse includes the overuse,
underuse, and irregular use of both prescribed and over-the-counter
(OTC) medications.

Medication misuse that involves particular types of medications or
patterns of use may develop into drug abuse.^101,102^ For example, a
subset of older adults is at risk of developing problems with physical
dependence when prescribed narcotics, barbiturates, or benzodiazepines
over long periods of time. Of particular concern is the combined use of
specific prescription medications or OTC medications with alcohol that
are known to result in serious health problems. For example, concurrent
use of alcohol with benzodiazepines or barbiturates can result in
sedation, confusion, falls, delirium, and withdrawal seizures.
Typically, abuse of psychoactive substances among older adults does not
involve the use of these substances specifically to "get high" nor are
they usually obtained illegally.^81^ Instead, unsafe combinations or
amounts of medications may be obtained by seeking prescriptions from
multiple physicians ("doctor shopping"), by obtaining medications from
family members or peers, or by stockpiling medications over time. Thus,
medication abuse among individuals in late life is qualitatively and
quantitatively different than it is for younger adults.

Several search engines were used to identify programs addressing the
prevention of and early intervention with medication misuse among older
adults. A number of EBM databases were searched, including the Cochrane
Central Register of Controlled Trials (CCTR), Cochrane Database of
Systematic Reviews, ACP Journal club, and Database of Abstracts of
Review of Effects (DARE). PubMed, PsychInfo, CINAHL, Ageline, Social
Services Abstracts, Social Work Abstracts, and ERIC databases were used
to identify published literature and other resources using a combination
of age-related terms (older, geriatric, elder, late-life, etc.) with the
following search terms: medication, prescription, benzodiazepine,
misuse, abuse, prevention, screening, assessment. Search techniques were
also employed to follow promising search directions, such as the
"Related Articles" feature in PubMed. Additional searches were performed
using the Google search engine and federal agency and grant databases,
such as the federal Computer Retrieval of Information on Scientific
Projects (CRISP) and the NIH Clinical Trials database.

## Universal Prevention

The evidence base for prevention of medication misuse/abuse among older
adults indicates some promising advances. For example, prevention
programs for late-life medication misuse have developed and tested
computer-based health education tools as well as more traditional
group-based health education programs with an individualized component.
However, the development of assessment and screening tools for this
problem area is limited. Please see Table 4 for further details
regarding each study.

#### *Health Education*

Several programs have addressed medication misuse through the use of
computer technology. Neafsey and colleagues have conducted two studies
evaluating the use of touch-screen notebook computers that employ an
interactive multimedia software program designed for the learning styles
and psychomotor skills of older adults called the Personal Education
Program (PEP). A randomized clinical trial found that older adults (age
60 and older) using the PEP software increased knowledge and improved
self-efficacy regarding the potential drug interactions that can result
from self-medication with OTC medications and alcohol, compared to
controls and those receiving a conventional information booklet.^103^
PEP users also reported fewer adverse self-medication behaviors over
time. Another study involving PEP consisted of a randomized pilot study
with more limited content (drug interactions with OTC antacids, calcium
supplements, and acid reducers).^104^ The group using PEP in this study
also demonstrated increased gains in knowledge and self-efficacy
compared to controls. These programs did not assess long-term knowledge
retention, so it is unclear whether the immediate knowledge and
self-efficacy gains were sustained over time. Alemagno and colleagues
^105^ conducted a pretest/posttest pilot evaluation of an interactive
computer intervention to reduce risk of medication misuse, showing some
promising results at the 2-month followup among older adults recruited
from senior centers (mean age 76): 55 percent of participants used the
computer-generated medication reminder checklist, 32 percent used the
checklist to discuss problems with a physician, and 24 percent reported
"real change" in the way they took medications.

Group health education in church settings combined with individual
sessions with a pharmacist has been evaluated as an alternative approach
to preventing medication misuse. Although this evaluation was not
targeted specifically at geriatric populations, the mean age of the
volunteer participants was 69.7. In this pretest/posttest evaluation
study, Schommer and colleagues.^106^found that participants reported
taking fewer medications on a daily basis and had fewer
medication-related problems 6 months after the intervention.

#### *Assessment*

The evidence base regarding comprehensive screening and assessment for
geriatric medication misuse is narrow. DeBrew and colleagues ^107^
tested a standardized instrument to assess medical knowledge and
practices among a small group (n=20) of older adults age 65 and older
newly admitted to a home health care agency. This instrument showed
promise as a useful tool for health care practitioners in home health
care settings, but data were limited.

#### *Medication Non-adherence*

One aspect of medication misuse that has received extensive attention in
the literature is medication non-adherence. Schlenk and colleagues ^108^
provide a review from a nursing perspective of factors associated with
medication non-adherence among older adults (defined as age 50 and
older), as well as a number of strategies and interventions that have
potential for the prevention of medication misuse. In addition to the
studies reviewed elsewhere in this section, other strategies include
effective instruction formats for older adults (i.e., drug-taking
instructions organized in lists rather than paragraphs, use of pictorial
icons, etc.) ^109-112^ and use of calendar blister packs compared to
standard bottles or packets among older patients.^113^ Schlenk and
colleagues ^108^ also review a variety of methods for assessment of
medication non-adherence among older adults, including self-reports,
pill counts, pharmacy records, biochemical measures, clinical judgment,
therapeutic response, and electronic monitoring.

## Indicated and Selective Prevention Strategies (Early Intervention)

Clinical trials for early intervention with older adults at risk for
medication misuse have shown mixed results. To date, a number of
randomized clinical trials have examined several types of early
interventions, including interventions with older patients prior to
hospital discharge, interventions targeted at provider prescription
patterns, home-based medication review, and patient education. Please
see Table 5 for more information regarding each study.

There is a growing evidence base regarding early interventions focused
on pharmacy services to prevent or minimize drug-related problems in
geriatric populations. Hanlon and colleagues ^114^ recently reviewed the
evidence from randomized controlled studies to determine whether
drug-related problems and associated health outcomes can be modified by
providing clinical pharmacy services for older adults in community-based
settings. They found 14 randomized controlled studies assessing
drug-related problems and health outcomes in individuals age 65 and
older after pharmacist interventions in various settings, including home
health settings (five studies), hospitals prior to discharge with
home-based followup (three studies), clinics (three studies), a
community pharmacy (one study), and long-term care facilities (two
studies). The authors concluded that there was considerable evidence
that clinical pharmacy interventions reduced the occurrence of
drug-related problems but showed limited evidence that the interventions
reduced morbidity, mortality, or health care costs. The study by
Al-Rashed and colleagues ^115^ described below is an example of a
pharmacist intervention study.

#### *Hospital Discharge-based Programs*

Several studies have explored strategies to improve medication
compliance and reduce medication misuse among older adults upon hospital
discharge. Al-Rashed and colleagues ^115^ found that patient knowledge
and compliance to medication regimen was significantly better among
patients (age 65 and older) receiving a 30-minute consultation with a
pharmacist prior to hospital discharge compared to those receiving
standard discharge procedures. Those patients receiving the pharmacist
consultation also had significantly fewer unplanned trips to the doctor,
hospital admissions, and personally altered their medications less than
controls. Pereles and colleagues ^116^ evaluated the Self-Medication
Program (SMP), a three-stage program in which geriatric patients (mean
age 80) were given increasing responsibility for administering their own
medications while still in the hospital. Compared to controls, the SMP
patients had fewer medication errors, showed significant improvement in
compliance, and had fewer serious medication errors at approximately 1
month after hospital discharge. A study by Lowe and colleagues ^117^
found comparable results in a study in which older patients (age range
57-96) who completed a three-stage self-medication program before
discharge had significantly higher compliance scores and greater
knowledge of purpose of medications 10 days after discharge compared to
a control group receiving standard care. Rich and colleagues ^118^ found
that patients (age 70 and older) who received a multidisciplinary
intervention prior to discharge had significantly higher medication
adherence compared to controls receiving standard care. The intervention
included comprehensive patient education, dietary and social service
consultations, medication review with a cardiologist, and intensive
post-discharge followup. Esposito ^119^ evaluated the effects of four
different types of medication education prior to discharge for patients
aged 65 and older. Although those results should be interpreted
cautiously due to small sample size, the groups with medication dosage
schedules had decreased incidence of medication errors compared to
groups without schedules.

#### *Prescribing Guidelines for Providers*

Decision support systems for prescribing have been proposed as one
promising avenue to decrease inappropriate or excessive medication use
and to prevent related adverse drug events among geriatric populations.
In a quasi-experimental study, Peterson and colleagues ^120^ evaluated a
computer-based system of guided dosing of psychotropic medications and
selection guidelines for clinicians treating older inpatients (aged 65
and older). The intervention targeted three medication classes:
benzodiazepines, opiates, and neuroleptics. The intervention increased
the prescription of the recommended daily dose, reduced the incidence of
10-fold dosing, and reduced the prescription of nonrecommended drugs.
Patients in the intervention cohort had lower fall rates (in the
hospital). No effects on length of stay or days of altered mental status
were found.

A study among 41 general practitioners (GPs) in Queensland, Australia,
found that "therapeutic flags" may improve appropriate prescribing
behaviors.^121^ The practitioners used a series of statements
(therapeutic flags) applied to the medication lists of 727 older
patients. These targeted instructional statements on quality prescribing
resulted in changes in 14.5 percent of prescribed medications and the
discontinuation of 6 percent of the medications. The process led to
increased monitoring as well.

#### *Medication Review: Home and Nursing Home Settings*

A number of studies have examined the effectiveness of home-based
medication review as an early intervention strategy to prevent
medication misuse among older adults. The HOMER program was a large
British clinical trial (n=872) in which a pharmacist reviewed
medications, provided education, and addressed barriers to compliance
(such as inability to open pill bottle tops) with adults age 80 and
older in their homes 2 and 8 weeks after hospital discharge.^122^
Surprisingly, the intervention group had significantly more emergency
hospital readmissions and physician home visits than controls. The
authors referenced three additional recent studies in the United Kingdom
of community-based medication review among older adults in which two
showed non-significant decreases in admissions ^123,124^ and one showed
a non-significant increase in admissions.^125^ Finally, they conclude
that the evidence remains mixed regarding community-based medication
review, particularly in regards to outcomes such as hospital admissions.

In a randomized clinical trial involving a series of three home visits
by pharmacists for all study participants, Lowe and colleagues ^126^
demonstrated increased compliance and understanding of purpose of
medications among the group (aged 65 and older) that received additional
pharmacist services during the first two home visits (an assessment of
ability to use medications and appropriateness of prescribed medications
during visit one; discussion and reminder chart during visit two). In a
different three-arm clinical trial, a group (aged 60 and older) that
received a home visit that included a 20-minute teaching session,
provision of pill cassettes, and a followup telephone call 1-2 weeks
after the home visit indicated significantly greater improvement in
medication-taking behaviors than the group without the followup
telephone call.^127^ Both groups receiving the home visit teaching
sessions had significantly higher medication-taking behavior scores
compared to controls. In a study of older adults aged 65 and older
receiving community nursing visits, Griffiths and colleagues ^128^
demonstrated knowledge increases after a home-based medication review
and individualized consultation by a nurse among a group identified with
deficits in medication knowledge and/or self-management ability.

In a small study in an inner-city setting, two general practitioners
made one comprehensive visit each to four randomly selected nursing
homes to review the prescribing record of each patient and alter
prescriptions if needed.^129^ Among the 107 patients (aged 57-99, mean
age 82.1) with "repeat" prescriptions reviewed, 65 percent had their
prescriptions altered. Fifty-one percent had at least one item stopped,
26 percent had at least one item changed, and 7 percent had a new
medication prescribed. One person had the medication dose increased.
Benzodiazepines, antipsychotic drugs, antidepressant drugs, non-opioid
analgesics, and laxatives were the medications most often stopped after
review. Although the study is not generalizable, the authors concluded a
single visit to a nursing home and a comprehensive review of
prescriptions can greatly reduce the consumption of inappropriate
medications.

#### *Patient Education*

A number of studies of variable quality have evaluated nursing-based
education interventions. These studies have indicated mixed results in
increasing knowledge and/or medication compliance among adults age 65
and older, particularly over time (studies are summarized here, but not
included in Table 5). Fielo and Warren ^130^ found that a group with a
teaching session and medication instruction sheet made fewer medication
errors after 1 week compared to controls, but no differences between
groups were sustained after 4 weeks. Harper ^131^ found that a group
receiving oral instruction during four home visits demonstrated
increased knowledge and compliance after 4 days compared to a control
group receiving four home visits but no oral instruction, but again no
differences were sustained after 4 weeks. Kim and Grier ^132^ found that
among groups given taped medication instructions, the group receiving
taped instructions at a slow pace demonstrated improved knowledge after
1 day compared to the groups receiving either no instruction or taped
instructions at a normal pace. Taira ^133^ found that clients
demonstrated improved knowledge regarding medications 1 week after a
teaching session (no control group). Finally, Wolfe and Schirm ^134^
found that a group receiving medication counseling and a fact sheet
demonstrated increased knowledge compared to controls after 3 weeks, but
these differences were not sustained at 6 weeks. No differences in
medication compliance were found between the two groups at 3 or 6 weeks.

## Ongoing Prevention Programs Undergoing Evaluation and Research Directions

A search of the federal web sites did not identify any studies currently
underway that address prevention of or early intervention with
medication misuse among older adults. It is of note that many of the
studies regarding medication misuse have originated internationally. A
current NIAAA-funded study (described above in the Alcohol Misuse:
Ongoing Prevention Program section) assessing a prevention intervention
to reduce risks of alcohol use does include medication use among the
risk factors addressed in the intervention.^95^ However, a variety of
guidelines and recommendations have been developed to assist providers
and consumers in taking steps to minimize risks associated with
medication misuse. An example of a set of basic recommendations aimed at
prevention of medication misuse is provided by an interdisciplinary
panel assembled by the nonprofit Alliance for Aging Research. This group
issued recommendations for researchers, health care organizations, and
public policymakers to address the issue of geriatric medication misuse
in its 1998 publication, "When Medicine Hurts Instead of Helps:
Preventing Medication Problems in Older Persons."^135^ The
recommendations were as follows:

-   Recommendation #1: Compile and disseminate a list of medications
    considered potentially inappropriate for use in older persons and
    mandate that the list be used as a screening tool.

-   Recommendation #2: Provide geriatrics-relevant labeling information
    for over-the-counter medications.

-   Recommendation #3: Fund and encourage research on medication-related
    problems in older persons to determine which medications are most
    troublesome and which patients are most at risk.

-   Recommendation #4: Provide incentives to pharmaceutical
    manufacturers to better study medication effects in the frail
    elderly and oldest old in pre- and post-marketing clinical trials.

-   Recommendation #5: Establish mechanisms for data collection,
    monitoring, and analysis of medication-related problems by age
    group.

-   Recommendation #6: Encourage health care professionals' competency
    in geriatric pharmacotherapy.

-   Recommendation #7: Direct Medicare Graduate Medical Education
    dollars to training in geriatric pharmacotherapy.

-   Recommendation #8: Fund and provide education and resources for
    caregivers providing medication assistance to older people.

## Conclusions

Medication misuse is a serious and growing problem among older adults.
Older adults can be particularly vulnerable to dangerous medication
interactions and other problems related to medication misuse given
age-related physical changes, cognitive changes, health problems with
related numerous medications, and social isolation. Older adults with
limited English language skills or low literacy skills can be at
particular risk for not comprehending complex medication regimes and
failure to recognize risky medication-taking behaviors. There is a
growing body of research indicating that most medication-related
problems are predictable and thus potentially preventable.^135^ The
evidence base for prevention programs to address medication misuse among
older adults is limited and in its early stages. The studies described
above have a variety of methodological limitations, such as selection of
primary outcome measures (e.g., actual medication-taking behavior and
health outcomes are not measured), lack of control groups, short
followup time periods, and poor followup rates. As mentioned above in
the section on Alcohol Misuse, the scarcity of research regarding
prevention programs addressing late-life medication misuse is notable.

The evidence base for early interventions to address this problem is
more substantial, but many questions remain unanswered. The exact
mechanisms at work are unclear in the complex issue of medication misuse
among older adults. For example, findings such as increased hospital
admissions among older persons receiving home-based medication reviews
point to the need for further research to illuminate the most effective
types of interventions. In particular, new technologies are needed that
are matched to the needs of specific groups of consumers in specific
settings. Finally, risk and protective factors need to be identified
that correspond to older adults with a range of health conditions,
cognitive skills, assistance in the home, and complex medical regimens.

Table 4. Prevention and assessment of late-life medication misuse

+-----+----+---------+----+---------+-------+-------------+---------+
| Ref | S  | Mo      | A  | Sample  | Fol   | Outcome     | Limita  |
| ere | tu | del/Con | ge |         | lowup | Measures    | tions/C |
| nce | dy | ditions |    |         |       | and Results | omments |
|     | De |         |    |         |       |             |         |
|     | si |         |    |         |       |             |         |
|     | gn |         |    |         |       |             |         |
+=====+====+=========+====+=========+=======+=============+=========+
| DeB | In | Conv    | 6  | 20      | Same  | Interpreter | Small   |
| rew | st | enience | 5+ | older   | tool  | reliability | sample  |
| et  | ru | sample  | M  | adults  | ad    | 82%         | size.   |
| a   | me | of      | ea | newly   | minis |             | Stand   |
| l., | nt | older   | n: | a       | tered | Test-retest | ardized |
| 1   | E  | adults  | 72 | dmitted | 1     | reliability | ins     |
| 998 | va | admin   |    | to a    | week  | 92%         | trument |
| ^1  | lu | istered |    | home    | later |             | to      |
| 07^ | at | ins     |    | health  | (70%  |             | assess  |
|     | io | trument |    | agency  | fol   |             | med     |
|     | n. | to      |    |         | lowup |             | kn      |
|     | Ho | assess  |    |         | rate) |             | owledge |
|     | me | med     |    |         |       |             | and     |
|     | He | ication |    |         |       |             | pr      |
|     | al | kn      |    |         |       |             | actices |
|     | th | owledge |    |         |       |             | shows   |
|     | Me | and     |    |         |       |             | promise |
|     | di | pr      |    |         |       |             | for     |
|     | ca | actices |    |         |       |             | d       |
|     | ti |         |    |         |       |             | irected |
|     | on |         |    |         |       |             | ed      |
|     | As |         |    |         |       |             | ucation |
|     | se |         |    |         |       |             | with    |
|     | ss |         |    |         |       |             | older   |
|     | me |         |    |         |       |             | adults. |
|     | nt |         |    |         |       |             |         |
+-----+----+---------+----+---------+-------+-------------+---------+
| N   | Ra | Parti   | 6  | 60      | Exp   | PEP users   | Pilot   |
| eaf | nd | cipants | 0+ | re      | group | had         | test    |
| sey | om | re      |    | cruited | t     | si          | shows   |
| et  | iz | cruited | Me | co      | ested | gnificantly | promise |
| a   | ed | from    | an | mmunity | for   | greater     | of      |
| l., | Po | local   | Ex | -living | know  | knowledge   | com     |
| 2   | st | senior  | p: | senior  | ledge | of          | puter-a |
| 001 | te | centers | 68 | center  | and   | potential   | ssisted |
| ^1  | st | and     | .8 | parti   | sel   | drug and    | ed      |
| 04^ | on | divided | [  | cipants | f-eff | alcohol/med | ucation |
|     | ly | ra      | +] | cu      | icacy | i           | p       |
|     | P  | ndomly: | {. | rrently | i     | nteractions | rograms |
|     | il |         | un | taking  | mmedi | and         | to      |
|     | ot | Experi  | de | OTC     | ately | si          | i       |
|     | T  | mental: | rl | calcium | pos   | gnificantly | ncrease |
|     | es | use     | in | suppl   | t-PEP | greater     | kn      |
|     | t. | pilot   | e} | ements, | use;  | se          | owledge |
|     |    | PEP     | 11 | an      | con   | lf-efficacy | and     |
|     | Pe | (see    | .9 | tacids, | trols | for         | self-ef |
|     | rs | below)  |    | or acid | t     | avoiding    | ficacy; |
|     | on |         | Me | re      | ested | in          | no      |
|     | al | C       | an | ducers. | b     | teractions, | beh     |
|     | E  | ontrol: | C  |         | efore | compared to | avioral |
|     | du | wa      | on | Exp: 30 | PEP   | controls.   | me      |
|     | ca | it-list | tr |         | use   | No          | asures. |
|     | ti |         | ol | Co      |       | differences | This    |
|     | on |         | s: | ntrols: |       | between     | version |
|     | P  |         | 73 | 30      |       | groups in   | of PEP  |
|     | ro |         | [  |         |       | mean        | limited |
|     | gr |         | +] |         |       | s           | to      |
|     | am |         | {. |         |       | atisfaction | s       |
|     | (  |         | un |         |       | scores and  | pecific |
|     | PE |         | de |         |       | stated      | content |
|     | P) |         | rl |         |       | behavioral  | of      |
|     |    |         | in |         |       | intentions. | an      |
|     |    |         | e} |         |       |             | tacids, |
|     |    |         | 7  |         |       |             | calcium |
|     |    |         |    |         |       |             | suppl   |
|     |    |         |    |         |       |             | ements, |
|     |    |         |    |         |       |             | and     |
|     |    |         |    |         |       |             | acid    |
|     |    |         |    |         |       |             | re      |
|     |    |         |    |         |       |             | ducers. |
+-----+----+---------+----+---------+-------+-------------+---------+
| N   | RC | Three   | 6  | 85      | Three | PEP users   | No      |
| eaf | T. | arm     | 0+ | re      | time  | had         | p       |
| sey |    | study   |    | cruited | per   | si          | retest. |
| et  | Pe |         | M  | co      | iods: | gnificantly | Fairly  |
| a   | rs | Interv  | ea | mmunity | i     | greater     | small   |
| l., | on | 1: PEP  | n: | -living | mmedi | knowledge   | sample  |
| 2   | al | info    |    | senior  | ately | and         | size.   |
| 002 | E  | book    | 73 | center  | pos   | se          | Course  |
| ^1  | du |         | .8 | parti   | t-int | lf-efficacy | content |
| 03^ | ca | Interv  | [  | cipants | erven | scores than | ad      |
|     | ti | 2: Info | +] | cu      | tion, | info book   | dresses |
|     | on | book    | {. | rrently | 2 and | only group  | OTC and |
|     | P  | only    | un | taking  | 4     | and         | alcohol |
|     | ro |         | de | presc   | weeks | controls.   | c       |
|     | gr | Co      | rl | ription | post- | Decrease in | ombined |
|     | am | ntrols: | in | an      | into. | adverse     | with    |
|     | (  | No      | e} | tihyper | Fol   | self        | meds,   |
|     | PE | inter   | 6  | tensive | lowup | -medication | but     |
|     | P) | vention | .5 | or      | rate  | behaviors   | in      |
|     |    |         |    | anticoa | 100%, | for PEP     | clusion |
|     |    | Parti   |    | gulants | but   | group;      | c       |
|     |    | cipants |    | in      | study | self        | riteria |
|     |    | re      |    | conj    | om    | -medication | only    |
|     |    | cruited |    | unction | itted | behaviors   | i       |
|     |    | from    |    | with    | sub   | did not     | ncludes |
|     |    | local   |    | OTC     | jects | change over | those   |
|     |    | senior  |    | calcium | who   | time for    | taking  |
|     |    | centers |    | suppl   | dr    | other two   | OTC     |
|     |    | to use  |    | ements, | opped | groups.     | (not    |
|     |    | inte    |    | an      | out   |             | those   |
|     |    | ractive |    | tacids, | from  | S           | a       |
|     |    | c       |    | acid    | rep   | atisfaction | ctively |
|     |    | omputer |    | r       | orted | with        | co      |
|     |    | program |    | educers | sa    | program     | nsuming |
|     |    | d       |    | or pain | mple. | rated high  | al      |
|     |    | esigned |    | rel     |       | by most     | cohol). |
|     |    | to      |    | ievers. |       | pa          | F       |
|     |    | teach   |    |         |       | rticipants. | ollowup |
|     |    | older   |    | Interv  |       |             | period  |
|     |    | adults  |    | 1: 30   |       |             | very    |
|     |    | about   |    |         |       |             | short.  |
|     |    | po      |    | Interv  |       |             |         |
|     |    | tential |    | 2: 30   |       |             |         |
|     |    | drug    |    |         |       |             |         |
|     |    | inter   |    | Co      |       |             |         |
|     |    | actions |    | ntrols: |       |             |         |
|     |    | from    |    | 25      |       |             |         |
|     |    | OTC     |    |         |       |             |         |
|     |    | meds    |    |         |       |             |         |
|     |    | and     |    |         |       |             |         |
|     |    | a       |    |         |       |             |         |
|     |    | lcohol. |    |         |       |             |         |
+-----+----+---------+----+---------+-------+-------------+---------+

Table 4. Prevention and assessment of late-life medication misuse
(continued)

+-----+----+---------+----+---------+-------+-------------+---------+
| Ref | S  | Mo      | A  | Sample  | Fol   | Outcome     | Limita  |
| ere | tu | del/Con | ge |         | lowup | Measures    | tions/C |
| nce | dy | ditions |    |         |       | and Results | omments |
|     | De |         |    |         |       |             |         |
|     | si |         |    |         |       |             |         |
|     | gn |         |    |         |       |             |         |
+=====+====+=========+====+=========+=======+=============+=========+
| Sc  | Pr | Parti   | A  | 200     | Fol   | P           | No      |
| hom | et | cipants | ll | male    | lowup | articipants | co      |
| mer | es | re      | ag | and     | s     | reported    | ntrols. |
| et  | t/ | cruited | es | female  | urvey | taking      | Parti   |
| a   | Po | by      |    | vo      | at 6  | fewer meds  | cipants |
| l., | st | parish  | Me | lunteer | mo    | on daily    | self-se |
| 2   | te | nurses; | an | paris   | nths, | basis (4.8  | lected. |
| 002 | st | a       | 69 | hioners | tele  | vs. 5.5)    | Individ |
| ^1  | E  | ttended | .7 |         | phone | and had     | ualized |
| 06^ | va | group   |    |         | or    | fewer       | p       |
|     | lu | ed      | R  |         | in-p  | med-related | rogram, |
|     | at | ucation | an |         | erson | problems    | a       |
|     | io | prese   | ge |         | (94%  | (39 vs 98); | lthough |
|     | n. | ntation | 2  |         | fol   | showed      | not     |
|     | F  | and Q & | 6- |         | lowup | knowledge   | d       |
|     | ea | A, then | 94 |         | rate) | increases.  | irected |
|     | si | 1-on-1  |    |         |       |             | speci   |
|     | bi | session |    |         |       | No sig      | fically |
|     | li | with    |    |         |       | differences | at      |
|     | ty | pha     |    |         |       | in % of     | ge      |
|     | Ev | rmacist |    |         |       | p           | riatric |
|     | al | or      |    |         |       | articipants | popu    |
|     | ua | pharm   |    |         |       | who always  | lation. |
|     | ti | intern, |    |         |       | took drugs  |         |
|     | on | exit    |    |         |       | as directed |         |
|     |    | in      |    |         |       | or          |         |
|     |    | terview |    |         |       | sometimes   |         |
|     |    |         |    |         |       | forgot to   |         |
|     |    |         |    |         |       | take.       |         |
|     |    |         |    |         |       |             |         |
|     |    |         |    |         |       | S           |         |
|     |    |         |    |         |       | atisfaction |         |
|     |    |         |    |         |       | with        |         |
|     |    |         |    |         |       | program     |         |
|     |    |         |    |         |       | rated high  |         |
|     |    |         |    |         |       | by most     |         |
|     |    |         |    |         |       | pa          |         |
|     |    |         |    |         |       | rticipants. |         |
+-----+----+---------+----+---------+-------+-------------+---------+
| Al  | Pr | Parti   | "  | 412     | 2-    | 55% of      | No      |
| ema | et | cipants | Se | co      | month | p           | co      |
| gno | es | tested  | ni | mmunity | fol   | articipants | ntrols. |
| et  | t/ | "t      | or | living  | lowup | reported    | F       |
| a   | Po | alking" | s" | seniors | (63%  | using med   | ollowup |
| l., | st | inte    |    | re      | fol   | reminder    | rate    |
| 2   | te | ractive | M  | cruited | lowup | checklist.  | fair.   |
| 004 | st | c       | ea | from 9  | rate) |             | Further |
| ^1  | P  | omputer | n: | senior  |       | 32% took    | r       |
| 05^ | il | inter   | 76 | centers |       | med         | esearch |
|     | ot | vention |    |         |       | checklist   | re:     |
|     | E  | to      | Ra |         |       | to doctor   | effect  |
|     | va | reduce  | ng |         |       | to discuss  | iveness |
|     | lu | risk of | e: |         |       | problem     | of use  |
|     | at | med     |    |         |       | issues. 24% | of med  |
|     | io | misuse: | 5  |         |       | indicated   | r       |
|     | n. | 30 min  | 9- |         |       | "real       | eminder |
|     |    | inte    | 97 |         |       | change" in  | ch      |
|     | Co | raction |    |         |       | the way     | ecklist |
|     | mp | w/      |    |         |       | they took   | to      |
|     | ut | c       |    |         |       | meds based  | reduce  |
|     | er | omputer |    |         |       | on          | misuse  |
|     | In | v       |    |         |       | in          | would   |
|     | te | ideos + |    |         |       | tervention. | be      |
|     | rv | ch      |    |         |       | P           | h       |
|     | en | ecklist |    |         |       | articipants | elpful. |
|     | ti | and     |    |         |       | responded   | F       |
|     | on | pill    |    |         |       | positively  | easible |
|     |    | box to  |    |         |       | to computer | to      |
|     | F  | take    |    |         |       | in          | rep     |
|     | ea | home    |    |         |       | tervention. | licate; |
|     | si |         |    |         |       |             | may be  |
|     | bi |         |    |         |       |             | c       |
|     | li |         |    |         |       |             | ost-eff |
|     | ty |         |    |         |       |             | ective. |
|     | Ev |         |    |         |       |             |         |
|     | al |         |    |         |       |             |         |
|     | ua |         |    |         |       |             |         |
|     | ti |         |    |         |       |             |         |
|     | on |         |    |         |       |             |         |
+-----+----+---------+----+---------+-------+-------------+---------+

Table 5. Early intervention with late-life medication misuse

+-----+----+---------+----+---------+-------+--------------+--------+
| Ref | S  | Mo      | A  | Sample  | Fol   | Outcome      | Li     |
| ere | tu | del/Con | ge |         | lowup | Measures and | mitati |
| nce | dy | ditions |    |         |       | Results      | ons/Co |
|     | De |         |    |         |       |              | mments |
|     | si |         |    |         |       |              |        |
|     | gn |         |    |         |       |              |        |
+=====+====+=========+====+=========+=======+==============+========+
| Ca  | R  | Three   | 6  | 70      | 4-6   | S            | Study  |
| rgi | CT | arm     | 0+ | p       | weeks | ignificantly | d      |
| ll, |    | study   |    | atients | after | greater      | etails |
| 1   | Ho |         | M  | in a VA | first | improvement  | sparse |
| 992 | me | Group   | ea | general | home  | in           | in     |
| ^1  | -b | 1: No   | n: | m       | visit | medic        | some   |
| 27^ | as | inter   | 72 | edicine | (no   | ation-taking | areas: |
|     | ed | vention |    | clinic  | fol   | behavior in  | dif    |
|     | as | (home   | R  |         | lowup | group 3      | ficult |
|     | se | visit   | an |         | rate  | (teaching +  | to     |
|     | ss | to      | ge |         | repor | telephone    | assess |
|     | me | assess  |    |         | ted). | call)        | q      |
|     | nt | meds/be | 6  |         |       | compared to  | uality |
|     | of | havior) | 2- |         |       | group 2      | of     |
|     | m  |         | 97 |         |       | (teaching    | data.  |
|     | ed | 2: Home |    |         |       | only).       |        |
|     | ic | visit   |    |         |       | Significant  |        |
|     | at | with    |    |         |       | difference   |        |
|     | io | 20-min  |    |         |       | between      |        |
|     | n- | t       |    |         |       | control and  |        |
|     | ta | eaching |    |         |       | int. groups  |        |
|     | ki | se      |    |         |       | in           |        |
|     | ng | ssions; |    |         |       | medic        |        |
|     | r  | pill    |    |         |       | ation-taking |        |
|     | ou | c       |    |         |       | behavior     |        |
|     | ti | assette |    |         |       | scores.      |        |
|     | ne | given   |    |         |       |              |        |
|     |    |         |    |         |       |              |        |
|     |    | 3: Same |    |         |       |              |        |
|     |    | as      |    |         |       |              |        |
|     |    | group   |    |         |       |              |        |
|     |    | 2, plus |    |         |       |              |        |
|     |    | f       |    |         |       |              |        |
|     |    | ollowup |    |         |       |              |        |
|     |    | te      |    |         |       |              |        |
|     |    | lephone |    |         |       |              |        |
|     |    | call    |    |         |       |              |        |
|     |    | 1-2     |    |         |       |              |        |
|     |    | weeks   |    |         |       |              |        |
|     |    | after   |    |         |       |              |        |
|     |    | home    |    |         |       |              |        |
|     |    | visit   |    |         |       |              |        |
+-----+----+---------+----+---------+-------+--------------+--------+
| L   | RC | Int:    | "  | 88      | Home  | Compliance   | Very   |
| owe | T. | P       | El | cons    | visit | with and     | short  |
| et  |    | atients | de | ecutive | 10    | knowledge of | fo     |
| a   | Se | given   | rl | p       | days  | the purpose  | llowup |
| l., | lf | ed      | y" | atients | after | of their     | p      |
| 1   | Me | ucation |    | a       | disc  | medicines,   | eriod; |
| 995 | di | and     | In | dmitted | harge | including    | longer |
| ^1  | ca | inc     | t: | to 4    | (90%  | pill counts. | term   |
| 17^ | ti | reasing |    | ge      | fol   | Int group    | gains  |
|     | on | respons | Me | riatric | lowup | had          | of     |
|     | P  | ibility | an | in      | rate) | s            | interv |
|     | ro | for     | 77 | patient |       | ignificantly | ention |
|     | gr | admini  | (  | units   |       | higher       | un     |
|     | am | stering | 57 | who     |       | compliance   | known. |
|     |    | own     | -9 | would   |       | scores (95%) |        |
|     |    | meds in | 6) | be      |       | compared     |        |
|     |    | h       |    | resp    |       | with         |        |
|     |    | ospital | C  | onsible |       | controls     |        |
|     |    |         | on | for     |       | (83%). A     |        |
|     |    | Co      | tr | s       |       | s            |        |
|     |    | ntrols: | ol | elf-med |       | ignificantly |        |
|     |    | S       | s: | ication |       | higher       |        |
|     |    | tandard | Me | upon    |       | proportion   |        |
|     |    | care    | an | di      |       | of Int.      |        |
|     |    |         | 79 | scharge |       | group        |        |
|     |    |         | (  |         |       | patients     |        |
|     |    |         | 59 | Interv: |       | (90%) knew   |        |
|     |    |         | -9 | 45      |       | the purpose  |        |
|     |    |         | 3) |         |       | of their     |        |
|     |    |         |    | Co      |       | meds         |        |
|     |    |         |    | ntrols: |       | compared to  |        |
|     |    |         |    | 43      |       | controls     |        |
|     |    |         |    |         |       | (46%).       |        |
+-----+----+---------+----+---------+-------+--------------+--------+
| Esp | RC | Four    | 6  | 42      | Fol   | Groups with  | Small  |
| osi | T. | arm     | 5+ | p       | lowup | medication   | sample |
| to, |    | study.  |    | atients | home  | schedule (3  | size,  |
| 1   | D  |         | (  | hospi   | v     | & 4) had     | partic |
| 995 | is | P       | Me | talized | isits | decreased    | ularly |
| ^1  | ch | atients | an | at      | made  | incidence of | for    |
| 19^ | ar | r       | a  | least   | 2     | medication   | b      |
|     | ge | eceived | ge | 24      | w     | error        | etween |
|     | me | upon    | by | hours   | eeks, | compared to  | group  |
|     | di | h       | g  |         | 1     | groups       | compa  |
|     | ca | ospital | ro | Group   | m     | without a    | rison. |
|     | ti | dis     | up | 1: n    | onth, | schedule.    |        |
|     | on | charge: | ne | =11     | and 2 |              |        |
|     | e  |         | xt | (mean   | m     |              |        |
|     | du | Group   | c  | age 74) | onths |              |        |
|     | ca | 1: Med  | ol |         | post  |              |        |
|     | ti | fact    | um | 2: n=8  | -int. |              |        |
|     | on | sheet   | n) | (mean   |       |              |        |
|     |    |         |    | age 79) |       |              |        |
|     |    | 2: Med  |    |         |       |              |        |
|     |    | fact +  |    | 3: n=10 |       |              |        |
|     |    | 30 min  |    | (mean   |       |              |        |
|     |    | verbal  |    | age 75) |       |              |        |
|     |    | inst    |    |         |       |              |        |
|     |    | ruction |    | 4: n=14 |       |              |        |
|     |    |         |    | (mean   |       |              |        |
|     |    | 3: Med  |    | age 76) |       |              |        |
|     |    | and     |    |         |       |              |        |
|     |    | dosage  |    |         |       |              |        |
|     |    | sc      |    |         |       |              |        |
|     |    | hedule, |    |         |       |              |        |
|     |    | list of |    |         |       |              |        |
|     |    | side    |    |         |       |              |        |
|     |    | effects |    |         |       |              |        |
|     |    |         |    |         |       |              |        |
|     |    | 4: Med  |    |         |       |              |        |
|     |    | sch     |    |         |       |              |        |
|     |    | edule + |    |         |       |              |        |
|     |    | 30 min  |    |         |       |              |        |
|     |    | verbal  |    |         |       |              |        |
|     |    | inst    |    |         |       |              |        |
|     |    | ruction |    |         |       |              |        |
+-----+----+---------+----+---------+-------+--------------+--------+

Table 5. Early intervention with late-life medication misuse (continued)

+-----+----+---------+----+---------+-------+--------------+--------+
| Ref | S  | Mo      | A  | Sample  | Fol   | Outcome      | Li     |
| ere | tu | del/Con | ge |         | lowup | Measures and | mitati |
| nce | dy | ditions |    |         |       | Results      | ons/Co |
|     | De |         |    |         |       |              | mments |
|     | si |         |    |         |       |              |        |
|     | gn |         |    |         |       |              |        |
+=====+====+=========+====+=========+=======+==============+========+
| P   | RC | Int:    | "  | 107     | Med   | SMP group    | Ri     |
| ere | T. | SMP (3  | Ge | cons    | know  | had fewer    | gorous |
| les |    | stage   | ri | ecutive | ledge | med errors,  | study. |
| et  | Ev | program | at | p       | and   | significant  | Short  |
| a   | al | w/pt    | ri | atients | m     | improvement  | fo     |
| l., | ua | given   | c" | a       | orale | in           | llowup |
| 1   | ti | inc     | pa | dmitted | (Ph   | compliance,  | p      |
| 996 | on | reasing | ti | to 2    | ilade | and fewer    | eriod; |
| ^1  | of | respons | en | in      | lphia | serious med  | longer |
| 16^ | S  | ibility | ts | patient | M     | errors,      | term   |
|     | el | for     |    | ge      | orale | compared to  | gains  |
|     | f- | admini  | M  | riatric | S     | controls. No | of     |
|     | Me | stering | ea | units   | cale) | significant  | interv |
|     | di | own     | n: | who     | ass   | differences  | ention |
|     | ca | meds in |    | would   | essed | between      | un     |
|     | ti | h       | 80 | be      | at    | groups in    | known. |
|     | on | ospital | [  | resp    | adm,  | ability to   |        |
|     | P  | while   | +] | onsible | disc  | s            |        |
|     | ro | com     | {. | for     | harge | elf-medicate |        |
|     | gr | pliance | un | s       | and   | upon         |        |
|     | am | is      | de | elf-med | in    | discharge,   |        |
|     | (  | mon     | rl | ication | home  | morale, or   |        |
|     | SM | itored; | in | upon    | visit | medication   |        |
|     | P) | 20-min  | e} | di      | 40    | knowledge,   |        |
|     |    | cou     | 7  | scharge | days  | although     |        |
|     |    | nseling |    |         | post  | both groups  |        |
|     |    | by      |    | Interv: | -disc | made         |        |
|     |    | pha     |    | 51      | harge | significant  |        |
|     |    | rmacist |    |         | (69%  | gains in     |        |
|     |    | 72      |    | Co      | foll  | knowledge    |        |
|     |    | hours   |    | ntrols: | owup; | from adm to  |        |
|     |    | before  |    | 56      | most  | followup.    |        |
|     |    | dis     |    |         | of    |              |        |
|     |    | charge. |    |         | those |              |        |
|     |    |         |    |         | lost  |              |        |
|     |    | Co      |    |         | to    |              |        |
|     |    | ntrols: |    |         | fol   |              |        |
|     |    | S       |    |         | lowup |              |        |
|     |    | tandard |    |         | disch |              |        |
|     |    | care    |    |         | arged |              |        |
|     |    | (meds   |    |         | to    |              |        |
|     |    | admin   |    |         | long  |              |        |
|     |    | istered |    |         | -term |              |        |
|     |    | in      |    |         | c     |              |        |
|     |    | h       |    |         | are). |              |        |
|     |    | ospital |    |         | Pill  |              |        |
|     |    | by      |    |         | count |              |        |
|     |    | nursing |    |         | also  |              |        |
|     |    | staff); |    |         | ass   |              |        |
|     |    | 20-min  |    |         | essed |              |        |
|     |    | cou     |    |         | at    |              |        |
|     |    | nseling |    |         | home  |              |        |
|     |    | by      |    |         | foll  |              |        |
|     |    | pha     |    |         | owup. |              |        |
|     |    | rmacist |    |         |       |              |        |
|     |    | 72      |    |         |       |              |        |
|     |    | hours   |    |         |       |              |        |
|     |    | before  |    |         |       |              |        |
|     |    | dis     |    |         |       |              |        |
|     |    | charge. |    |         |       |              |        |
+-----+----+---------+----+---------+-------+--------------+--------+
| R   | RC | Int:    | 7  | 156     | Home  | Int. group   | O      |
| ich | T. | Compre  | 0+ | p       | visit | compliance   | verall |
| et  |    | hensive |    | atients | 30    | rate (87.9%) | comp   |
| a   | Mu | patient | Me | hospi   | days  | s            | liance |
| l., | lt | edu     | an | talized | after | ignificantly | rates  |
| 1   | i- | cation, |    | with    | disc  | higher       | high   |
| 996 | di | dietary | 79 | con     | harge | compared to  | (85%   |
| ^1  | sc | and     | .4 | gestive |       | controls     | for    |
| 18^ | ip | social  | [  | heart   |       | (81.1%).     | both   |
|     | li | service | +] | failure |       | Int. group   | gr     |
|     | na | co      | {. |         |       | also         | oups); |
|     | ry | nsults, | un | Interv: |       | achieved     | a      |
|     | In | med     | de | n=80    |       | s            | uthors |
|     | te | review, | rl |         |       | ignificantly | s      |
|     | rv | and     | in | Co      |       | higher       | uggest |
|     | en | in      | e} | ntrols: |       | compliance   | number |
|     | ti | tensive | 6  | n=76    |       | rate (85%    | of     |
|     | on | post-dx |    |         |       | reached \>/= | fa     |
|     | on | f       |    |         |       | 80 %         | ctors. |
|     | Me | ollowup |    |         |       | compliance)  |        |
|     | di |         |    |         |       | compared to  |        |
|     | ca | Co      |    |         |       | controls     |        |
|     | ti | ntrols: |    |         |       | (69.7%).     |        |
|     | on | S       |    |         |       |              |        |
|     | Co | tandard |    |         |       |              |        |
|     | mp | care    |    |         |       |              |        |
|     | li |         |    |         |       |              |        |
|     | an |         |    |         |       |              |        |
|     | ce |         |    |         |       |              |        |
+-----+----+---------+----+---------+-------+--------------+--------+

Table 5. Early intervention with late-life medication misuse (continued)

+-----+----+---------+----+---------+-------+--------------+--------+
| Ref | S  | Mo      | A  | Sample  | Fol   | Outcome      | Li     |
| ere | tu | del/Con | ge |         | lowup | Measures and | mitati |
| nce | dy | ditions |    |         |       | Results      | ons/Co |
|     | De |         |    |         |       |              | mments |
|     | si |         |    |         |       |              |        |
|     | gn |         |    |         |       |              |        |
+=====+====+=========+====+=========+=======+==============+========+
| L   | RC | Two     | 6  | 161     | Meds  | Compliance   | Study  |
| owe | T. | groups  | 5+ | p       | taken | in Int.      | shows  |
| et  |    | r       |    | atients | and   | group 91.3%  | p      |
| a   | Me | eceived | In | from    | und   | compared to  | romise |
| l., | di | 3       | t: | British | ersta | controls     | of     |
| 2   | ci | visits  |    | general | nding | 79.5%        | home   |
| 000 | ne | from a  | M  | m       | of    | (P           | -based |
| ^1  | Re | c       | ea | edicine | pu    |  \< 0.0001). | medi   |
| 26^ | vi | linical | n: | p       | rpose | Number of    | cation |
|     | ew | phar    | 77 | ractice | of    | Int. group   | review |
|     | a  | macist. | .5 | taking  | meds  | patients     | and    |
|     | nd |         | Ra | 3 or    | ass   | correctly    | p      |
|     | E  | Visit   | ng | more    | essed | u            | atient |
|     | du | 1:      | e: | meds    | at    | nderstanding | edu    |
|     | ca | Survey  |    |         | v     | the purpose  | cation |
|     | ti | of meds | 6  | Interv: | isits | of meds      | by a   |
|     | on | for     | 5- | 77      | 1 and | increased    | cl     |
|     | P  | both;   | 96 |         | 3 (94 | from 58% to  | inical |
|     | ro | ass     |    | C       | %     | 88% compared | pharm  |
|     | gr | essment | C  | ontrol: | fol   | with 67% to  | acist. |
|     | am | of      | on | 84      | lowup | 70% in       | Fo     |
|     |    | ability | tr |         | rate) | controls     | llowup |
|     |    | to use  | ol |         |       | (P           | period |
|     |    | medi    | s: |         |       |  \< 0.0005). | short. |
|     |    | cations |    |         |       |              |        |
|     |    | (open   | M  |         |       |              |        |
|     |    | b       | ea |         |       |              |        |
|     |    | ottles, | n: |         |       |              |        |
|     |    | etc.)   | 75 |         |       |              |        |
|     |    | and     | Ra |         |       |              |        |
|     |    | a       | ng |         |       |              |        |
|     |    | ppropri | e: |         |       |              |        |
|     |    | ateness |    |         |       |              |        |
|     |    | of meds | 6  |         |       |              |        |
|     |    | for     | 5- |         |       |              |        |
|     |    | Int.    | 88 |         |       |              |        |
|     |    | group   |    |         |       |              |        |
|     |    |         |    |         |       |              |        |
|     |    | Visit   |    |         |       |              |        |
|     |    | 2: 1    |    |         |       |              |        |
|     |    | month   |    |         |       |              |        |
|     |    | supply  |    |         |       |              |        |
|     |    | meds to |    |         |       |              |        |
|     |    | both;   |    |         |       |              |        |
|     |    | dis     |    |         |       |              |        |
|     |    | cussion |    |         |       |              |        |
|     |    | and     |    |         |       |              |        |
|     |    | r       |    |         |       |              |        |
|     |    | eminder |    |         |       |              |        |
|     |    | chart   |    |         |       |              |        |
|     |    | for     |    |         |       |              |        |
|     |    | Int.    |    |         |       |              |        |
|     |    | group   |    |         |       |              |        |
|     |    |         |    |         |       |              |        |
|     |    | Visit   |    |         |       |              |        |
|     |    | 3:      |    |         |       |              |        |
|     |    | Another |    |         |       |              |        |
|     |    | 1 month |    |         |       |              |        |
|     |    | supply  |    |         |       |              |        |
|     |    | (3 wks  |    |         |       |              |        |
|     |    | after   |    |         |       |              |        |
|     |    | visit   |    |         |       |              |        |
|     |    | 2),     |    |         |       |              |        |
|     |    | survey  |    |         |       |              |        |
|     |    | of      |    |         |       |              |        |
|     |    | meds,   |    |         |       |              |        |
|     |    | and     |    |         |       |              |        |
|     |    | pill    |    |         |       |              |        |
|     |    | count   |    |         |       |              |        |
|     |    | of both |    |         |       |              |        |
+-----+----+---------+----+---------+-------+--------------+--------+
| Al- | RC | Int: 30 | 6  | 99      | Fol   | Knowledge    | One of |
| Ras | T. | min     | 5+ | p       | lowup | and          | few    |
| hed |    | pre-di  |    | atients | home  | compliance   | s      |
| et  | Ev | scharge | In | from 2  | visit | s            | tudies |
| a   | al | cou     | t: | British | \~ 3  | ignificantly | to     |
| l., | ua | nseling | Me | general | weeks | better in    | m      |
| 2   | ti | w/phar  | an | in      | and 3 | Int. group   | easure |
| 002 | on | macist, | 80 | patient | m     | compared to  | utili  |
| ^1  | of | plus    | .2 | units   | onths | controls at  | zation |
| 15^ | I  | s       | [  | to be   | post  | visit 1;     | as     |
|     | np | tandard | +] | dis     | -disc | compliance   | o      |
|     | at | di      | {. | charged | harge | also had     | utcome |
|     | ie | scharge | un | with 4  | (84 % | improved at  | (      |
|     | nt | pr      | de | or more | fol   | visit 2 for  | doctor |
|     | P  | ocedure | rl | meds    | lowup | the Int.     | visits |
|     | ha | (below) | in |         | rate  | group. Int.  | and    |
|     | rm |         | e} | Interv: | for   | group had    | ho     |
|     | a- | Co      | 5  | 45      | both  | s            | spital |
|     | ce | ntrols: | .7 |         | vi    | ignificantly | admiss |
|     | ut | S       |    | Co      | sits) | fewer        | ions). |
|     | ic | tandard | C  | ntrols: |       | unplanned    | R      |
|     | al | di      | on | 44      |       | trips to     | andomi |
|     | Co | scharge | tr |         |       | doctor and   | zation |
|     | un | pro     | ol |         |       | hospital     | by     |
|     | se | cedure, | s: |         |       | admissions   | unit   |
|     | li | which   | 81 |         |       | (19 and 5,   | inc    |
|     | ng | i       | .1 |         |       | r            | reases |
|     |    | ncluded | [  |         |       | espectively) | c      |
|     |    | med     | +] |         |       | compared to  | hances |
|     |    | info    | {. |         |       | controls (27 | of     |
|     |    | di      | un |         |       | and 13).     | po     |
|     |    | scharge | de |         |       | Fewer Int.   | ssible |
|     |    | summary | rl |         |       | group        | sel    |
|     |    | and med | in |         |       | patients     | ection |
|     |    | r       | e} |         |       | altered      | bias.  |
|     |    | eminder | 5  |         |       | their own    |        |
|     |    | card    | .8 |         |       | meds         |        |
|     |    |         |    |         |       | compared to  |        |
|     |    |         |    |         |       | controls.    |        |
+-----+----+---------+----+---------+-------+--------------+--------+

Table 5. Early intervention with late-life medication misuse (continued)

+-----+----+---------+----+---------+-------+--------------+--------+
| Ref | S  | Mo      | A  | Sample  | Fol   | Outcome      | Li     |
| ere | tu | del/Con | ge |         | lowup | Measures and | mitati |
| nce | dy | ditions |    |         |       | Results      | ons/Co |
|     | De |         |    |         |       |              | mments |
|     | si |         |    |         |       |              |        |
|     | gn |         |    |         |       |              |        |
+=====+====+=========+====+=========+=======+==============+========+
| Pe  | Qu | Int: 2  | 6  | 3718    | All   | Patients who | Interv |
| ter | as | 6-week  | 5+ | p       | a     | received     | ention |
| son | i- | study   |    | atients | ssess | meds during  | inc    |
| et  | Ex | periods | In | from    | ments | intervention | reased |
| a   | pe | of      | t: | t       | occ   | period had   | presc  |
| l., | ri | high    | Me | ertiary | urred | increased    | ribing |
| 2   | me | lighted | an | care    | d     | prescription | pa     |
| 005 | nt | dosing  | 74 | h       | uring | of           | tterns |
|     | al | and     | .6 | ospital | inpa  | recommended  | in     |
|     | Ev | fr      | +  | whose   | tient | daily dose   | concu  |
|     | al | equency | /- | adm     | stay  | (29% vs.     | rrence |
|     | ua | of      | 6  | issions |       | 19%),        | with   |
|     | ti | psych   | .8 | were    |       | decreased    | expert |
|     | on | otropic |    | co      |       | 10-fold      | guide  |
|     |    | meds in | C  | ntained |       | dosing       | lines; |
|     | Gu | h       | on | within  |       | incidence    | po     |
|     | id | ospital | tr | one of  |       | (2.8% vs.    | sitive |
|     | ed | c       | ol | the     |       | 5.0%),       | p      |
|     | Ps | omputer | s: | 6-week  |       | reduced      | atient |
|     | yc | Rx      | 74 | study   |       | prescribing  | ou     |
|     | ho | order   | .8 | periods |       | of           | tcomes |
|     | tr | system  | +  |         |       | non          | res    |
|     | op |         | /- | Interv: |       | -recommended | ulted. |
|     | ic | Co      | 6  | 1793    |       | drugs (10.8% | Phy    |
|     | Do | ntrols: | .9 |         |       | vs. 7.6% of  | sician |
|     | si | 2       |    | Co      |       | total        | u      |
|     | ng | 6-week  |    | ntrols: |       | orders), and | nwilli |
|     | Sy | periods |    | 1925    |       | fewer        | ngness |
|     | st | with    |    |         |       | in-hospital  | to     |
|     | em | usual   |    |         |       | falls. No    | accept |
|     |    | compu   |    |         |       | effects      | comput |
|     |    | terized |    |         |       | found for    | erized |
|     |    | order   |    |         |       | length of    | dosing |
|     |    | entry   |    |         |       | stay or days | gu     |
|     |    |         |    |         |       | of altered   | idance |
|     |    |         |    |         |       | mental       | a      |
|     |    |         |    |         |       | status.      | f      |
|     |    |         |    |         |       |              | actor. |
|     |    |         |    |         |       |              | Not    |
|     |    |         |    |         |       |              | rando  |
|     |    |         |    |         |       |              | mized. |
+-----+----+---------+----+---------+-------+--------------+--------+
| Gri | Pr | Parti   | 6  | 24      | Fol   | Participants | Only   |
| ffi | et | cipants | 5+ | parti   | lowup | demonstrated | 50%    |
| ths | es | ide     |    | cipants | inte  | increase in  | (24 of |
| et  | t/ | ntified | Me | ide     | rview | knowledge,   | 48)    |
| a   | Po | through | an | ntified | at 4  | some         | su     |
| l., | st | survey  |    | with    | weeks | alteration   | bjects |
| 2   | te | ass     | 76 | demon   |       | in           | el     |
| 004 | st | essment | .7 | strated |       | compliance   | igible |
| ^1  | E  | r       | [  | d       |       | aids. No     | for    |
| 28^ | va | eceived | +] | eficits |       | significant  | fo     |
|     | lu | co      | {. | in      |       | change in    | llowup |
|     | at | mmunity | un | kn      |       | medication   | agreed |
|     | io | nursing | de | owledge |       | regime       | to     |
|     | n. | med     | rl | or      |       | complexity.  | partic |
|     |    | ication | in | s       |       |              | ipate. |
|     | N  | review  | e} | elf-man |       |              | Interv |
|     | ur | and     | 6  | agement |       |              | ention |
|     | si | individ | .1 | ability |       |              | not    |
|     | ng | ualized |    | out of  |       |              | s      |
|     | In | inter   |    | 111     |       |              | tandar |
|     | te | vention |    | a       |       |              | dized. |
|     | rv |         |    | ssessed |       |              | Small  |
|     | en |         |    | parti   |       |              | sample |
|     | ti |         |    | cipants |       |              | size.  |
|     | on |         |    | taking  |       |              |        |
|     |    |         |    | oral    |       |              |        |
|     |    |         |    | meds    |       |              |        |
|     |    |         |    | and     |       |              |        |
|     |    |         |    | re      |       |              |        |
|     |    |         |    | ceiving |       |              |        |
|     |    |         |    | co      |       |              |        |
|     |    |         |    | mmunity |       |              |        |
|     |    |         |    | nursing |       |              |        |
|     |    |         |    | visits  |       |              |        |
+-----+----+---------+----+---------+-------+--------------+--------+
| H   | RC | Int:    | 8  | 872     | Out   | S            | A      |
| oll | T. | Hom     | 0+ | p       | comes | ignificantly | uthors |
| and |    | e-based |    | atients | ass   | fewer        | con    |
| et  | H  | med     | In | a       | essed | emergency    | cluded |
| a   | OM | ication | t: | dmitted | at 6  | readmissions | f      |
| l., | ER | review  |    | as      | m     | at 6 months  | urther |
| 2   |    | with    | Me | "eme    | onths | for controls | re     |
| 005 |    | pha     | an | rgency" | (hosp | (178)        | search |
| ^1  |    | rmacist |    | to 10   | ital- | compared to  | needed |
| 22^ |    | at 2    | 85 | UK      | based | Int. group   | to     |
|     |    | and 8   | .4 | co      | data; | (234). Int.  | e      |
|     |    | weeks   | [  | mmunity | 97%   | group        | xplain |
|     |    | p       | +] | or      | follo | (sub-sample) | coun   |
|     |    | ost-dis | {. | acute   | wup); | also had     | terint |
|     |    | charge, | un | care    | tele  | more home    | uitive |
|     |    | in      | de | hos     | phone | visits by GP | f      |
|     |    | cluding | rl | pitals, | call  | doctors.     | inding |
|     |    | edu     | in | to be   | with  | Int. did not | and    |
|     |    | cation, | e} | dis     | m     | s            | id     |
|     |    | remove  | 4  | charged | ailed | ignificantly | entify |
|     |    | out of  |    | with 2  | qu    | improve      | more   |
|     |    | date    | C  | or more | ality | quality of   | eff    |
|     |    | drugs,  | on | meds    | of    | life or      | ective |
|     |    | obtain  | tr |         | life  | reduce       | m      |
|     |    | com     | ol | Interv: | s     | deaths       | ethods |
|     |    | pliance | s: | 429     | urvey | compared to  | of med |
|     |    | aid     | Me |         | at 3  | controls.    | r      |
|     |    |         | an | Co      | and 6 |              | eview. |
|     |    | Co      |    | ntrols: | m     |              | Med    |
|     |    | ntrols: | 85 | 426     | onths |              | review |
|     |    | Usual   | .5 |         | (     |              | visit  |
|     |    | care    | [  |         | \~80% |              | (Int.) |
|     |    |         | +] |         | fol   |              | was    |
|     |    |         | {. |         | lowup |              | vol    |
|     |    |         | un |         | rate) |              | untary |
|     |    |         | de |         |       |              | and    |
|     |    |         | rl |         |       |              | patien |
|     |    |         | in |         |       |              | t-init |
|     |    |         | e} |         |       |              | iated. |
|     |    |         | 4  |         |       |              |        |
+-----+----+---------+----+---------+-------+--------------+--------+

Prevention of Mental Health Problems

One in five older adults has a significant mental disorder, including
more than 16 percent with a primary psychiatric illness and 3 percent
with dementia complicated by psychiatric symptoms.^11^ Depression and
anxiety disorders are among the most common mental health problems in
older persons and affect approximately 3-7 percent and 11 percent of the
general older adult population, respectively.^12^ The prevalence of
other mental health disorders such as schizophrenia and bipolar disorder
is much lower (less than 1%), although these disorders impart
significant functional impairments in older persons. As with substance
abuse, the prevalence of these disorders is heightened among persons
receiving health care in the primary care system, in outpatient mental
health settings, and in nursing homes.^136,137^

This review focuses on the universal, selective, and indicated
prevention of the most common mental health problems in older adults. We
specifically address the most prevalent conditions (mood and anxiety
disorders) and suicide. Similar to the mental health *treatment*
literature, most *prevention* programs target depressive symptoms and do
not address late-life anxiety or other mental health conditions.
Programs that target the reduction of depressive symptoms also heavily
inform our reviews of suicide prevention. We specifically excluded the
prevention of cognitive disorders, such as dementia, as this area
includes a relatively large, rapidly growing, and complex research
literature that is outside the scope of this review. The exclusion of
dementia is based on the premise that the prevention and treatment of
cognitive impairment disorders are most commonly addressed outside of
the mental health care system and are, thus, less pertinent to state and
local substance abuse and mental health care service providers and
administrators.

# Depression and Anxiety

Risk factors for late-life depression have been identified through a
systematic review of the research literature and a longitudinal study.
In a review of 20 studies, Cole and Dendukuri ^138^ noted that
bereavement, sleep disturbance, disability, prior depression and female
gender were all significant predictors of depression. Risk factors for
depression have also been identified through a survey of older persons
living in the community. Using data collected from two questionnaires
administered 5 years apart to 1,947 older adults, Strawbridge and
colleagues ^139^ noted that older adults who were more likely to be
depressed included those with low and medium physical activity, physical
disability or mobility impairment, one or more chronic conditions, fewer
than three close friends or relatives, and those who were somewhat
satisfied or not satisfied with friendships.^139^ Several of these risk
factors may be mitigated by preventive efforts, including programs that
attend to persons that are currently suffering from depression or that
have a history of recurrent depression, undertreated conditions that
commonly precipitate depression, vascular disease, functional
impairment, and nutritional deficiencies.^140^

Several search strategies were used to identify programs addressing the
prevention and early intervention of late-life depression or anxiety.
The PubMed, PsychInfo, CINAHL, Ageline, Social Services Abstracts, and
ERIC databases were used to identify published literature using the
search terms: depression, minor depression, sub-syndromal depression,
anxiety, and prevention. Other search strategies were also employed,
including searches conducted through Google and federal grant databases.

The following section describes the evidence supporting prevention and
early intervention programs for late-life depression and anxiety. In
overview, there are several substantive differences in the evidence base
for prevention compared to early intervention for depression and anxiety
in older adults. The research literature describing the prevention of
depression is relatively small and is largely focused on health
promotion and positive aging and includes programs such as exercise,
life review, reminiscence therapy, educational classes, and mind-body
wellness. Much of this literature is based on the reduction of known
risk factors for depression. In contrast, much of the literature on
early interventions for depression reflects research findings on the
treatment of minor depression or sub-syndromal depression. Early
intervention strategies include problem-solving therapy, interpersonal
counseling, exercise, nurse case management, and caregiver training. Of
note, Cole and Dendukuri ^141^ recently conducted a systematic review of
controlled trials of time-limited brief (less than 12 weeks)
interventions to prevent depression. They identified several brief
interventions that have the potential to prevent depression in older
people (these trials are included within Table 7). Finally, there is
little available information to guide the prevention of late-life
anxiety.^142^ Table 6 and Table 7 provide an overview of prevention and
early intervention programs for late-life mental illness. In addition,
these studies are reviewed within the text.

## Universal Prevention Programs

#### *Exercise*

Physical activity has been shown to be a protective factor against the
development of depression.^139^ In addition, findings from at least two
programs show that exercise can help prevent depression in older adults.
Wallace and colleagues ^97^ evaluated a multi-component intervention
wherein participants received a 30- to 60-minute visit at a senior
center with a registered nurse to review risk factors for disability,
develop a targeted health promotion plan, and introduce a supervised
exercise program. This visit focused on current exercise habits, alcohol
and tobacco use, dietary habits, and home safety issues. The nurse
contacted subjects by telephone to review progress toward goals,
motivate continued behavior change, and identify problems with
compliance. The exercise program was conducted in groups of 10-15 older
adults led by a trained exercise instructor. Each 60-minute exercise
session occurred at the senior center and consisted of 10 minutes of
warm up, 15-20 minutes of strength training, 20 minutes of
walking/aerobic activity, and a flexibility and cool-down phase. As
shown in Table 6, positive outcomes included improved health functioning
and a reduction in depressive symptoms. A second study conducted by
Penninx and colleagues ^143^ evaluated the effectiveness of exercise in
preventing depression in older adults with osteoarthritis. They compared
a 3-month facility-based aerobic or resistance exercise program to a
control group receiving education on arthritis management. The aerobic
exercise program consisted of an indoor walking program that was
conducted under the supervision of an exercise leader and that was
scheduled three times per week for 1 hour. Each session had 10 minutes
of warm up and cool down including flexibility stretches and 40 minutes
of walking at an intensity equivalent to 50-70 percent of the heart rate
reserve. The resistance exercise program included three 1-hour sessions
per week. Each session consisted of a 10-minute warm up and cool down
and 40 minutes of repetitions of various upper and lower body exercises
using dumbbells and cuff weights, with weights increased in a stepwise
fashion. The aerobic and resistance exercise programs were each followed
by a 14-month home exercise program with support and supervision from an
exercise leader. Evaluation of these programs found that aerobic
exercise, but not resistance exercise, significantly reduced depressive
symptoms. Together, these findings complement research showing that
exercise is an effective treatment for late-life depression ^144^ and
identify benefits of exercise in preventing depressive symptomatology in
non-depressed older adults.

#### *Educational Classes*

Several educational programs were evaluated to determine their
effectiveness in preventing depression, including two that were directly
targeted at increasing knowledge of specific medical conditions. A
10-week arthritis education class was associated with significant
reductions in depressive symptoms compared to a control group at 1- and
2-year followup evaluations.^145^ Similarly, a 6-week diabetes education
class combined with a support group was associated with lower incidence
of depression at 2-year followup compared to a control group.^146^
Finally, classroom and home-based multi-component mind-body wellness
courses, including relaxation training, cognitive restructuring, problem
solving, communication, behavioral treatment for insomnia, nutrition,
and exercise, and instruction on mind-body relationships, were
associated with a reduction in depression and anxiety symptoms compared
to a control group.^142^

#### *Life Review*

Zauszniewski and colleagues ^147^ examined the effectiveness of a
focused reflection reminiscence program in reducing negative emotions in
older adults living in retirement communities. The program, entitled
"Reflections for Seniors," included members of a retirement community
who met for 2 hours per week over a 6-week period. A similar life review
program evaluated by Haight and colleagues ^148^ included nursing home
residents who met for 1 hour per week over a 6-week period. Both studies
found small effects on the reduction of depressive symptoms in older
adults.

#### *Screening and Assessment*

Early detection of depression and anxiety disorders among older adults
may be a useful strategy for identifying older adults who may benefit
from indicated prevention efforts (early intervention). Screening for
depression is recommended by the U.S. Preventive Services Task Force in
health care settings where providers are prepared to confirm an accurate
diagnosis and provide effective treatment and followup.^149^ However,
evidence suggests that screening alone may be associated with a lowering
of depression levels.^150^

A brief review of the literature suggests that several instruments have
been used to screen for depression (Geriatric Depression Scale:
GDS^151,\ 152^; Short Zung Scale Interview-Assisted Depression
Scale;^153^ Patient Health Questionnaire-9: PHQ-9^154,\ 155^). Of note,
the PHQ-9 has been promoted as a practical depression screening
instrument among primary care settings.^156^ In addition, the Hopkins
Symptom Checklist-25 is an effective method for identifying different
categories of depressive symptoms, including sub-threshold depression,
minor depression, and major depression.^157^ Preliminary research
suggests that the Center for Epidemiological Studies -- Depression
(CES-D) scale can be used to detect sub-threshold anxiety in older
adults.^158^ In addition, the Short Anxiety Screening Test (SAST) ^153^
also has validity in detecting anxiety disorders in older adults.

## Indicated and Selective Prevention Strategies (Early Intervention)

Estimates suggest that sub-threshold or minor depression is present in
8-16 percent of older adults residing in the community, 15-20 percent of
those receiving primary care services, 25-33 percent of older adults in
an acute care hospital, and up to 50 percent of older adults in
long-term care facilities.^136,137^ Moreover, the prevalence of anxiety
symptoms among older adults may be as high as 20 percent and diagnosable
anxiety disorders affect nearly 6 percent of older adults.^159^ While
this review identified several programs for the indicated and selective
prevention of geriatric depression, little information is available on
the prevention and early intervention of late-life anxiety.

#### *Targeted Outreach for Vulnerable Older Adults*

The Gatekeeper program was developed to train and encourage
non-traditional referral sources to identify and refer older adults
living in the community who are at risk for serious substance abuse and
mental health problems.^36,37,160^ Gatekeepers are the employees of
local businesses and community organizations who have contact with older
adults (e.g., letter carriers, police officers, bank tellers, landlords,
meter readers, and many others). The "gatekeeper" model has been
compared with traditional referral sources (e.g., medical providers,
family members, informal caregivers, or other concerned persons) to
determine its efficacy in identifying vulnerable older adults in need of
services.^36,37,161,162^ Studies of the Gatekeeper program have found
differences in individual characteristics between those referred by
gatekeepers and those referred by medical or other traditional sources.
Older adults (age 60+) referred by gatekeepers were significantly more
likely to live alone, were more often widowed or divorced, and were
significantly more likely to be affected by economic and social
isolation. These findings suggest that the gatekeeper model may uniquely
provide outreach to individuals who are less likely to access services
through conventional referral approaches. At the time of referral,
individuals referred by gatekeepers were also significantly less likely
to use needed services than individuals referred through traditional
sources, had similar service needs, and thus had a larger gap between
services needed and services received.^36,161,162^ At 1-year followup,
older persons referred from gatekeepers had no difference in service
utilization or out-of-home placements compared to individuals referred
by traditional sources.

[]{.mark}

A study conducted in urban senior congregate housing settings also used
gatekeepers to identify older adults at high-risk of psychiatric
problems.^163,164^ The Psychogeriatric Assessment and Treatment in City
Housing (PATCH) model incorporates components of the Gatekeeper program
and assertive community treatment. The PATCH psychiatric nurse met with
the building administrator, an education program was provided to housing
personnel to enhance recognition of high-risk residents and to clarify
procedures for making referrals of high-risk residents, and weekly nurse
visits included in-home psychiatric evaluation and case management
services for residents ages 60 and older. This study of the PATCH model
found that outreach services were associated with a decrease in overall
psychiatric symptom severity for individuals with a variety of
psychiatric disorders.^165^

#### *Psychotherapeutic Interventions*

Disability associated with chronic medical disorders in late life is
often a precursor to depressive symptoms. As such, interpersonal and
problem-solving therapies hold promise for preventing depression among
individuals with specific late-life medical illnesses^166^ (also see
section on Ongoing Selective Prevention Programs Under Evaluation). In
addition, these psychotherapeutic approaches have promise in preventing
the progression from minor or sub-syndromal depression into major
depression.

#### *Problem-Solving Therapy*

Two studies have evaluated the effectiveness of problem-solving therapy
(PST) for older adults with dysthymia or minor depression.^167,168^ The
PEARLS program, evaluated by Ciechanowski and colleagues,^169^ was found
to be associated with improved depressive symptoms and functional and
emotional well-being. In addition, compared to a control group, those
receiving PST were more likely to achieve remission of depressive
symptoms (36% vs. 12%). In contrast, Williams and colleagues ^168^
evaluated PST compared to an antidepressant medication (paroxetine) or a
placebo. They found that neither treatment was associated with a
difference in rates of remission compared to placebo. However, for those
patients with minor depression, both paroxetine and PST improved mental
health functioning in patients with initial low functioning. Only
paroxetine was associated with improvement for persons with dysthymia.

#### *Interpersonal Therapy*

One study found interpersonal therapy (IPT) to be effective at
preventing an increase in depressive symptoms.^169^ Mossey and
colleagues compared IPT to usual care. IPT was associated with improved
self-rated health and after 6 months, three-fifths of the intervention
group, compared to approximately one-third of the control group, had
experienced a reduction in depressive symptoms.

#### *Exercise*

In contrast to the universal prevention study evaluated by Penninx and
colleagues that found that resistance training was no more effective
than placebo in preventing depression,^170^ a study of older persons
with pre-existing depressive symptoms (59% with minor depression or
dysthymia) found that resistance training was more effective than health
education alone in preventing the worsening of depression.^171^
Remission was achieved by six of seven (86%) participants in the
resistance exercise group, compared to 4 of 10 (40%) participants in the
health education control group.^171^

#### *Interventions for Care Providers*

Two studies evaluate whether modifications to the provision of care can
affect depressive symptoms. Cuijpers and colleagues ^172^ evaluated a
multifaceted education and support program administered in a residential
care setting, compared to usual care. The intervention included training
for caregivers and other employees of the residential home,
informational meetings for residents and their relatives, support
groups, and discussion and feedback sessions for care providers. The
target population included older persons who were incapable of living
independently due to physical, psychiatric, or psychosocial constraints;
yet did not require extensive nursing home care. Results indicate that
an intervention providing education, support and feedback to residential
care providers can reduce depressive symptoms and maintain
health-related quality of life for older persons.^172^ Waterreus ^173^
and Blanchard ^174^ evaluated the effectiveness of care delivered
through a nurse case management system in which the care plan was
developed through coordination of a multidisciplinary psychogeriatric
team. Compared to a usual care control group, the intervention group
exhibited greater reduction in depression severity, but was not
associated with fewer cases of depression.

#### *Interventions for Family Caregivers*

Family caregivers, such as spouses or children caring for loved ones
with dementia are also at risk for developing depressive disorders. In
the early 1990s, Mittelman and colleagues developed and tested an
intervention consisting of scheduled individual and family counseling
sessions, unlimited consultation on request, and continuous support
group participation for family caregivers of persons with dementia.^175^
This intervention was found to delay nursing home placement by an
average of 329 days, prompting researchers to develop, refine, and test
similar interventions to support the capacity of natural caregivers to
care for their loved one in the home environment. In addition to
improving outcomes for the individual with Alzheimer's disease, this
intervention also has been found to reduce stress and psychological
symptoms for caregivers. The counseling and support provided to families
is associated with greater satisfaction with assistance received from
others, as well as decreased caregiver depression.^176^ In addition, PST
has been successfully used to enhance the ability of caregivers to cope
with stress and to decrease the incidence of depression and other
adverse outcomes. For example, Teri and colleagues studied the
effectiveness of PST as an intervention for reducing depression among
individuals with dementia and their caregivers. Caregivers who
participated in PST decreased their levels of depression and burden over
a 6-month period.^177^ Of note, a recent systematic review evaluated
major outcomes in family caregiving interventions for dementia, as
published in 43 studies since 1996. Findings indicate that the major
impact on caregivers includes decreased incidence and severity of
depression, moderate decreases in reported anger, moderate improvement
in stress management, positive changes in clinical health indicators
such as blood pressure and stress, and small improvements in caregiver
burden.^178^

## Ongoing Selective Prevention Programs Under Evaluation

A search of ongoing research grants identified two projects that are
specifically designed to prevent depression in older adults. These
studies examine approaches to preventing depression in older adults who
have increased risk due to debilitating medical conditions. In the
first, Rovner and colleagues ^179^ are conducting a National Institute
of Mental Health (NIMH) supported clinical trial, entitled "Preventing
Depression in Macular Degeneration," to evaluate the efficacy of PST
among non-depressed older adults with bilateral age-related macular
degeneration. Macular degeneration is a progressive eye disease that
results in blindness and is associated with high rates of physical
disability; up to one-third of older adults with bilateral vision loss
develop depression ^180^. In this study, older adults who have developed
macular degeneration are randomly assigned to either PST or a usual care
control condition. The primary outcome measure is a DSM-IV diagnosis of
depression. Patients are evaluated at baseline, month 2 (immediately
post-intervention), month 6 (for the primary efficacy analysis), and
month 12 (to evaluate sustained effects). The study will also assess the
impact of PST on levels of disability and vision-related quality of
life. Approximately 230 participants are expected to enroll in this
trial, which should reach completion in 2005. Preliminary results are
not yet available.^179^ The second ongoing study designed to prevent
depression targets older persons who are at-risk for depression due to a
previous stroke. In this study, Robinson and colleagues ^181^ are
evaluating the relative effectiveness of antidepressant medications and
PST in preventing depression among older persons who have suffered a
stroke. This randomized, double-blind, placebo-controlled trial,
entitled "Prevention of Post-Stroke Depression - Treatment Strategy,"
will treat non-depressed stroke patients with antidepressants or PST to
determine the most effective treatments for preventing depression.
Participants in this study will be randomly assigned to receive PST, an
antidepressant medication (escitalopram), or placebo for 12 months.
Participants who display depressive symptoms for 2 weeks or more will be
removed from the study. After 12 months, treatment will be discontinued
and participants will be monitored for an additional 6 months.
Approximately 200 participants are expected to enroll in this study,
which began in 2002.^181^

## Conclusions

This review highlights the scientific evidence for the prevention and
early intervention of depression and anxiety in older adults. As shown,
several programs have identified positive effects in preventing
depression or reducing depression symptoms. The best evidence exists for
the effectiveness of exercise and psychotherapeutic interventions, such
as problem-solving therapy and interpersonal therapy. In addition, there
is evidence to suggest that targeted outreach to older adults is
effective in engaging isolated and vulnerable older persons in treatment
for mental health and substance abuse problems. Other potentially
effective strategies include life review, reminiscence therapy,
educational classes, mind-body wellness, and provider education. Many of
these approaches require further evaluation prior to establishing their
effectiveness among older adults. Our review also revealed that there is
minimal evidence for programs that target the prevention of anxiety
among older adults. As one in five older adults experiences symptoms of
anxiety,^159^ programs are needed in this area.

It is important to acknowledge that several programs developed to
prevent depression have not demonstrated effectiveness. For instance,
among the brief interventions for older adults with minor depression
reviewed by Cole and Dendukuri,^141^ several trials showed no effect in
the prevention of depression. These studies were primarily focused on
bereavement support groups or life review. The lack of effect on the
prevention of depression was also noted in a social support network
intervention for seniors.^182,183^ Finally, it is likely that many
ineffective programs are never published or disseminated as they have
not demonstrated positive effects on the prevention or reduction of
symptoms of depression or anxiety.

It is also important to note that several of the programs evaluated in
this review have shown positive effects on reducing depressive symptoms,
however these effects have often been small and the design of some of
the studies brings into question the validity of their findings (i.e.,
small sample sizes, inclusion and exclusion criteria, evaluation
instruments). However, despite these limitations, it appears that some
programs have merit in preventing depression at a universal, selective,
and indicated level. As indicated by the studies in progress, there is a
great deal to be learned about effective prevention efforts. Bird and
Parslow ^140^ suggest that programs designed to increase understanding
of late-life depression for providers and for older adults may hold
promise. For example, physician education could include information on
the prevalence and costs of depression, warning signs, and available
treatments. Older adults could be educated to improve their ability to
recognize the symptoms of depression, to reduce stigma, and to access
effective mental health treatments.^140^ However, to our knowledge, the
effectiveness of such programs has not been rigorously evaluated among
older adults. Finally, system-wide quality improvement efforts may offer
benefits in preventing late-life mental illness. A treatment guideline
was recently released that discusses appropriate care of older persons
who are moving to a continuing care facility or who are awaiting
hospital discharge. This treatment guideline focuses on promoting nurses
awareness of depression in older people, promoting positive mental
health and well-being, assessment and care-planning, and education and
training. Specific recommendations include: (a) nursing staff attention
to physical and mental health needs, (b) easing the transition to
assisted living and increase independence and control, (c) minimizing
the perceived losses that the person may experience in moving into the
care home, (d) care planning focusing on the individuals strengths,
coping patterns, and daily activities, (e) enabling access to advocacy
services, (f) providing psychosocial support, (g) maintaining community
linkages, and (h) engagement in meaningful activities.^184,185^ Despite
the promise of these approaches, many remain to be tested.

Finally, it is important to remember that late-life depression is often
chronic or characterized by a relapsing course. Although this review
focuses on the universal prevention of late-life depression and
selective and indicated prevention of the exacerbation of minor
depression into major depression, an important area of research
addresses the prevention of further disability among older adults who
have developed depression. Prevention strategies should focus attention
on preventing relapse, recurrence, and residual symptoms among older
adults with current or remitted major depression ^166^.

Table 6. Universal prevention of late-life depression or anxiety

+-----+----+------+----+---------+----------+------------+-----------+
| Ref | S  | Mode | A  | Sample  | Followup | Outcome    | Li        |
| ere | tu | l/Co | ge |         |          | Measures   | mitations |
| nce | dy | ndit |    |         |          | and        | /Comments |
|     | De | ions |    |         |          | Results    |           |
|     | si |      |    |         |          |            |           |
|     | gn |      |    |         |          |            |           |
+=====+====+======+====+=========+==========+============+===========+
| H   | R  | Life | 5  | Ho      | 8-week   | No change  | Small     |
| aig | CT | Re   | 0+ | mebound | program. | in         | sample    |
| ht, |    | view |    | elderly | 51 of 60 | d          | size.     |
| et  |    | (    | Me | s       | ra       | epression. | Minimal   |
| a   |    | LR); | an | ubjects | ndomized | Life       | d         |
| l., |    | Frie | a  | r       | c        | sa         | epressive |
| 1   |    | ndly | ge | andomly | ompleted | tisfaction | symptoms  |
| 988 |    | V    | ra | s       | the      | and        | in any    |
| ^1  |    | isit | ng | elected | study    | psy        | group at  |
| 86^ |    | (    | ed | from    | (85%).   | chological | baseline. |
|     |    | FV); | fr | M       |          | well-being |           |
|     |    | No   | om | eals-On |          | were       |           |
|     |    | t    | 73 | -Wheels |          | improved   |           |
|     |    | reat | to | rec     |          | in the LR  |           |
|     |    | ment | 79 | ipients |          | group.     |           |
|     |    | con  | ye | and     |          |            |           |
|     |    | trol | ar | persons |          |            |           |
|     |    | (NT) | s. | re      |          |            |           |
|     |    |      |    | ceiving |          |            |           |
|     |    | LR   |    | home    |          |            |           |
|     |    | and  |    | health  |          |            |           |
|     |    | FV   |    | se      |          |            |           |
|     |    | met  |    | rvices. |          |            |           |
|     |    | for  |    | 78%     |          |            |           |
|     |    | 1    |    | female. |          |            |           |
|     |    | h    |    |         |          |            |           |
|     |    | our/ |    | LR:     |          |            |           |
|     |    | week |    | n=16    |          |            |           |
|     |    | for  |    |         |          |            |           |
|     |    | 6    |    | FV:     |          |            |           |
|     |    | we   |    | n=16    |          |            |           |
|     |    | eks. |    |         |          |            |           |
|     |    |      |    | NT:     |          |            |           |
|     |    |      |    | n=19    |          |            |           |
+-----+----+------+----+---------+----------+------------+-----------+
| G   | Pr | DE   | Ra | Male    | 6-week   | Incidence  | S         |
| ild | e- | C+S: | ng | at      | program, | of         | elf-rated |
| en, | po | 6-   | e: | tendees | 24-month | depression | d         |
| et  | st | week | 57 | at a    | f        | (based on  | epression |
| a   |    | diab | -8 | Ve      | ollowup. | Zung       | outcomes. |
| l., |    | etes | 2, | teran's | 100%     | Depression | Did not   |
| 1   |    | e    |    | d       | f        | Scale      | adjust    |
| 992 |    | duc. | DE | iabetes | ollowup. | \>50)      | for       |
| ^1  |    | cla  | P+ | clinic. |          |            | d         |
| 46^ |    | ss + | S: | Groups  |          | DEC+S: 17% | epression |
|     |    | sup  | 69 | matched |          |            | or        |
|     |    | port | [+ | for age |          | DEC: 45%   | exclude   |
|     |    | g    | ]{ | and     |          |            | depressed |
|     |    | roup | .u | d       |          | Control:   | persons   |
|     |    | foll | nd | iabetes |          | 75%        | at        |
|     |    | owed | er | du      |          |            | baseline. |
|     |    | by   | li | ration. |          |            | Baseline  |
|     |    | 18   | ne |         |          |            | rates of  |
|     |    | mo   | }1 | DEC+S:  |          |            | d         |
|     |    | nths |    | n=13    |          |            | epression |
|     |    | of   | DE |         |          |            | are not   |
|     |    | sup  | P: | DEC:    |          |            | noted.    |
|     |    | port |    | n=11    |          |            |           |
|     |    | gr   | 69 |         |          |            |           |
|     |    | oup; | [+ | C       |          |            |           |
|     |    |      | ]{ | ontrol: |          |            |           |
|     |    | DEC: | .u | n=8     |          |            |           |
|     |    | 6-   | nd |         |          |            |           |
|     |    | week | er |         |          |            |           |
|     |    | diab | li |         |          |            |           |
|     |    | etes | ne |         |          |            |           |
|     |    | e    | }1 |         |          |            |           |
|     |    | duc. |    |         |          |            |           |
|     |    | c    | Co |         |          |            |           |
|     |    | lass | nt |         |          |            |           |
|     |    | foll | ro |         |          |            |           |
|     |    | owed | l: |         |          |            |           |
|     |    | by   |    |         |          |            |           |
|     |    | 18   | 67 |         |          |            |           |
|     |    | mo   | [+ |         |          |            |           |
|     |    | nths | ]{ |         |          |            |           |
|     |    | of   | .u |         |          |            |           |
|     |    | sup  | nd |         |          |            |           |
|     |    | port | er |         |          |            |           |
|     |    | gr   | li |         |          |            |           |
|     |    | oup; | ne |         |          |            |           |
|     |    |      | }3 |         |          |            |           |
|     |    | Con  |    |         |          |            |           |
|     |    | trol |    |         |          |            |           |
+-----+----+------+----+---------+----------+------------+-----------+
| Eme | R  | E    | 5  | P       | 10-week  | EXESM      | Small     |
| ry, | CT | xerc | 0+ | atients | program. | greater    | sample    |
| et  |    | ise, |    | with    | 92%      | reduction  | size. WL  |
| a   |    | ed   | EX | stable  | co       | in         | also      |
| l., |    | ucat | ES | COPD    | mpletion | depression | showed    |
| 1   |    | ion, | M: | for 6+  | rate.    | than ESM.  | improved  |
| 998 |    | and  |    | months. | (Dr      | S          | de        |
| ^1  |    | st   | 65 | 53%     | op-outs: | ignificant | pression. |
| 87^ |    | ress | .4 | female. | 4 in     | time and   | Short     |
|     |    | mgmt | [+ |         | EXESM    | time by    | duration  |
|     |    | (EXE | ]{ | EXESM:  | due to   | group      | makes it  |
|     |    | SM); | .u | n=29    | medical  | effect.    | difficult |
|     |    | E    | nd |         | illness; | EXESM and  | to        |
|     |    | duca | er | ESM:    | 2 in ESM | WL         | determine |
|     |    | tion | li | n=25    | due to   | decreased  | the       |
|     |    | and  | ne |         | transp   | d          | duration  |
|     |    | st   | }6 | WL:     | ortation | epression, | of the    |
|     |    | ress | .4 | n=25    | issues.) | but not    | effect.   |
|     |    | mgmt |    |         | Among 25 | ESM.       |           |
|     |    | (E   | ES |         | persons  | Greater    |           |
|     |    | SM); | M: |         | co       | reduction  |           |
|     |    |      |    |         | mpleting | in anxiety |           |
|     |    | Wait | 67 |         | EXESM,   | for EXESM  |           |
|     |    | list | .4 |         | they     | than for   |           |
|     |    | (WL) | [+ |         | attended | ESM or WL. |           |
|     |    |      | ]{ |         | a mean   |            |           |
|     |    |      | .u |         | of 29.7  |            |           |
|     |    |      | nd |         | s        |            |           |
|     |    |      | er |         | essions. |            |           |
|     |    |      | li |         |          |            |           |
|     |    |      | ne |         |          |            |           |
|     |    |      | }5 |         |          |            |           |
|     |    |      | .9 |         |          |            |           |
|     |    |      |    |         |          |            |           |
|     |    |      | W  |         |          |            |           |
|     |    |      | L: |         |          |            |           |
|     |    |      |    |         |          |            |           |
|     |    |      | 66 |         |          |            |           |
|     |    |      | .6 |         |          |            |           |
|     |    |      | [+ |         |          |            |           |
|     |    |      | ]{ |         |          |            |           |
|     |    |      | .u |         |          |            |           |
|     |    |      | nd |         |          |            |           |
|     |    |      | er |         |          |            |           |
|     |    |      | li |         |          |            |           |
|     |    |      | ne |         |          |            |           |
|     |    |      | }6 |         |          |            |           |
|     |    |      | .5 |         |          |            |           |
+-----+----+------+----+---------+----------+------------+-----------+
| H   | R  | Life | Ra | Nursing | 6-week   | S          | S         |
| aig | CT | re   | ng | home    | program  | ignificant | elf-rated |
| ht, |    | view | e: | re      | with     | difference | d         |
| 1   |    | for  | 60 | sidents | 12-month | between    | epression |
| 998 |    | 1    | -1 |         | f        | the        | outcomes. |
| ^1  |    | h    | 04 | Interv: | ollowup. | in         | No        |
| 48^ |    | our/ | M  | n=60    | 53%      | tervention | d         |
|     |    | week | ea |         | co       | and        | ifference |
|     |    |      | n: | C       | mpletion | control    | in        |
|     |    |      | 79 | ontrol: | rate.    | group at   | suicide   |
|     |    |      | .6 | n=60    |          | 12 months  | ideation, |
|     |    |      |    |         |          | in         | life      |
|     |    |      |    |         |          | d          | sati      |
|     |    |      |    |         |          | epression, | sfaction, |
|     |    |      |    |         |          | hop        | or        |
|     |    |      |    |         |          | elessness, | sel       |
|     |    |      |    |         |          | and        | f-esteem. |
|     |    |      |    |         |          | psy        |           |
|     |    |      |    |         |          | chological |           |
|     |    |      |    |         |          | w          |           |
|     |    |      |    |         |          | ell-being. |           |
|     |    |      |    |         |          | Only       |           |
|     |    |      |    |         |          | depression |           |
|     |    |      |    |         |          | improved   |           |
|     |    |      |    |         |          | at 8-week  |           |
|     |    |      |    |         |          | a          |           |
|     |    |      |    |         |          | ssessment. |           |
+-----+----+------+----+---------+----------+------------+-----------+

Table 6. Universal prevention of late-life depression or anxiety
(continued)

+-----+----+------+----+---------+----------+------------+-----------+
| Ref | S  | Mode | A  | Sample  | Followup | Outcome    | Li        |
| ere | tu | l/Co | ge |         |          | Measures   | mitations |
| nce | dy | ndit |    |         |          | and        | /Comments |
|     | De | ions |    |         |          | Results    |           |
|     | si |      |    |         |          |            |           |
|     | gn |      |    |         |          |            |           |
+=====+====+======+====+=========+==========+============+===========+
| Wa  | R  | Di   | 6  | Senior  | 6-month  | Outcome    | Im        |
| lla | CT | sabi | 5+ | center  | program. | measures   | provement |
| ce, |    | lity |    | at      | 10%      | (SF-36     | in        |
| et  |    | Pr   | I  | tendees | dropout  | subscales  | d         |
| a   |    | even | nt |         | rate.    | and CES-D  | epression |
| l., |    | tion | er | Interv: | Data     | scores)    | only      |
| 1   |    | Pro  | v: | n=53    | c        | improved   | noted as  |
| 998 |    | gram | 71 |         | ollected | in the     | mean      |
| ^   |    | (i   | .1 | C       | at       | in         | CES-D     |
| 97^ |    | nclu | [+ | ontrol: | b        | tervention | scores.   |
|     |    | ding | ]{ | n=47    | aseline, | group and  | Pr        |
|     |    | e    | .u |         | 2        | declined   | oportions |
|     |    | xerc | nd |         | months,  | in the     | were not  |
|     |    | ise, | er |         | and 6    | control    | p         |
|     |    | nu   | li |         | months.  | group.     | resented. |
|     |    | trit | ne |         |          | Most       | Fe        |
|     |    | ion, | }4 |         |          | d          | asibility |
|     |    | home | .3 |         |          | ifferences | improved  |
|     |    | saf  |    |         |          | were found | by use of |
|     |    | ety) | Co |         |          | at 2       | low-cost  |
|     |    |      | nt |         |          | months,    | community |
|     |    |      | ro |         |          | with       | sites     |
|     |    |      | l: |         |          | smaller    | that      |
|     |    |      |    |         |          | i          | offer     |
|     |    |      | 72 |         |          | ncremental | social    |
|     |    |      | .9 |         |          | im         | a         |
|     |    |      | [+ |         |          | provements | ctivation |
|     |    |      | ]{ |         |          | at 6       | and other |
|     |    |      | .u |         |          | months.    | r         |
|     |    |      | nd |         |          |            | esources. |
|     |    |      | er |         |          |            |           |
|     |    |      | li |         |          |            |           |
|     |    |      | ne |         |          |            |           |
|     |    |      | }4 |         |          |            |           |
|     |    |      | .8 |         |          |            |           |
+-----+----+------+----+---------+----------+------------+-----------+
| R   | R  | Mu   | 5  | Members | 6-week   | Classroom  | Only 270  |
| yba | CT | ltic | 0+ | of an   | program. | and home   | of 527    |
| rcz |    | ompo |    | urban   | Pre- and | course     | patients  |
| yk, |    | nent | Ra | staff   | post-t   | resulted   | referred  |
| et  |    | m    | ng | model   | reatment | in         | to the    |
| a   |    | ind- | e: | HMO     | measures | decreased  | study     |
| l., |    | body | 5  | with 6+ | ad       | pain,      | agreed to |
| 1   |    | well | 0- | primary | dressed. | sleep      | pa        |
| 999 |    | ness | 87 | care    | 15% of   | dif        | rticipate |
| ^1  |    | cou  |    | visits  | part     | ficulties, | and only  |
| 42^ |    | rse. | Me | in the  | icipants | and        | 210 and   |
|     |    | Cl   | an | past    | dropped  | depression | 178       |
|     |    | assr | A  | year    | out.     | and        | completed |
|     |    | oom, | ge | and     |          | anxiety    | pre- and  |
|     |    | Home |    | r       |          | symptoms,  | po        |
|     |    | cou  | Cl | eferred |          | compared   | st-questi |
|     |    | rse, | as | by the  |          | to control | onnaires, |
|     |    | and  | s: | primary |          | group.     | resp      |
|     |    | W    | 6  | phy     |          |            | ectively. |
|     |    | ait- | 7. | sician. |          |            | Length of |
|     |    | list | 6; | 82%     |          |            | followup  |
|     |    | Con  |    | female. |          |            | difficult |
|     |    | trol | H  |         |          |            | to        |
|     |    | co   | om | Cla     |          |            | i         |
|     |    | ndit | e: | ssroom: |          |            | nterpret. |
|     |    | ions |    | n=54    |          |            | No        |
|     |    |      | 6  |         |          |            | intent    |
|     |    |      | 1. | Home:   |          |            | -to-treat |
|     |    |      | 5; | n=61    |          |            | analysis. |
|     |    |      |    |         |          |            | H         |
|     |    |      | Wa | C       |          |            | ome-based |
|     |    |      | it | ontrol: |          |            | course    |
|     |    |      | -l | n=63    |          |            | has lower |
|     |    |      | is |         |          |            | costs,    |
|     |    |      | t: |         |          |            | greater   |
|     |    |      | 64 |         |          |            | acces     |
|     |    |      | .7 |         |          |            | sibility, |
|     |    |      |    |         |          |            | and       |
|     |    |      |    |         |          |            | potential |
|     |    |      |    |         |          |            | for       |
|     |    |      |    |         |          |            | greater   |
|     |    |      |    |         |          |            | disse     |
|     |    |      |    |         |          |            | mination. |
+-----+----+------+----+---------+----------+------------+-----------+
| Bur | R  | G    | A  | Me      | 2-year   | Both       | Mostly    |
| ns, | CT | eria | ge | dically | ev       | groups had | male      |
| et  |    | tric | 6  | ill     | aluation | improved   | sample.   |
| a   |    | Ev   | 5+ | p       | of GEM   | d          | General   |
| l., |    | alua | Ra | atients | program. | epression, | izability |
| 2   |    | tion | ng | a       | 128      | but        | limited   |
| 000 |    | and  | e: | dmitted | people   | sig        | by VA     |
| ^1  |    | Ma   | 6  | to      | entered  | nificantly | sample.   |
| 88^ |    | nage | 6- | m       | study.   | greater    | Most      |
|     |    | ment | 95 | edical, | 30 died  | i          | lived     |
|     |    | (    |    | su      | before   | mprovement | within 60 |
|     |    | GEM) | GE | rgical, | 2-year   | in GEM     | miles of  |
|     |    | and  | M: | and     | f        | group. GEM | a large   |
|     |    | U    |    | neuro   | ollowup. | also had   | met       |
|     |    | sual | 71 | logical | Analyses | more       | ropolitan |
|     |    | Care | .7 | s       | on 98    | i          | center.   |
|     |    | (    | [+ | ervices | r        | mprovement | The level |
|     |    | UC). | ]{ | at a VA | emaining | than UC in | of        |
|     |    | GEM  | .u | clinic. | p        | general    | d         |
|     |    | incl | nd | Ran     | atients. | w          | epression |
|     |    | uded | er | domized |          | ell-being, | was low   |
|     |    | i    | li | at      |          | life       | at study  |
|     |    | nter | ne | dis     |          | sat        | rand      |
|     |    | disc | }6 | charge. |          | isfaction, | omization |
|     |    | ipli | .3 | 3%      |          | global     | (mean     |
|     |    | nary |    | female. |          | social     | CESD of   |
|     |    | pri  | U  |         |          | activity,  | 11).      |
|     |    | mary | C: | GEM:    |          | and had    |           |
|     |    | care |    | n=49    |          | fewer IADL |           |
|     |    | team | 70 |         |          | im         |           |
|     |    | with | .8 | UC:     |          | pairments. |           |
|     |    | j    | [+ | n=49    |          | In         |           |
|     |    | oint | ]{ |         |          | addition,  |           |
|     |    | c    | .u |         |          | UC used    |           |
|     |    | ompr | nd |         |          | 40% more   |           |
|     |    | ehen | er |         |          | clinic     |           |
|     |    | sive | li |         |          | visits     |           |
|     |    | as   | ne |         |          | than GEM.  |           |
|     |    | sess | }3 |         |          |            |           |
|     |    | ment | .7 |         |          |            |           |
|     |    | and  |    |         |          |            |           |
|     |    | co   |    |         |          |            |           |
|     |    | ntin |    |         |          |            |           |
|     |    | uing |    |         |          |            |           |
|     |    | l    |    |         |          |            |           |
|     |    | ong- |    |         |          |            |           |
|     |    | term |    |         |          |            |           |
|     |    | c    |    |         |          |            |           |
|     |    | are. |    |         |          |            |           |
+-----+----+------+----+---------+----------+------------+-----------+
| Phi | R  | 1.5  | Ra | Older   | 10-week  | S          | Did not   |
| lli | CT | hr/  | ng | African | program  | ignificant | adjust    |
| ps, |    | week | e: | Am      | with 12- | difference | for       |
| 2   |    | a    | 6  | ericans | and      | at 12 and  | d         |
| 000 |    | rthr | 7- | with    | 24-month | 24 months  | epression |
| ^1  |    | itis | 75 | ar      | f        | based on   | or        |
| 45^ |    | e    | M  | thritis | ollowup. | CESD.      | exclude   |
|     |    | duca | ea |         | 98%      |            | depressed |
|     |    | tion | n: | Interv: | co       |            | persons   |
|     |    | clas | 69 | n=101   | mpletion |            | at        |
|     |    | ses. | .3 |         | rate.    |            | baseline. |
|     |    |      |    | C       |          |            | Multidis  |
|     |    |      |    | ontrol: |          |            | ciplinary |
|     |    |      |    | n=101   |          |            | team with |
|     |    |      |    |         |          |            | each      |
|     |    |      |    |         |          |            | member    |
|     |    |      |    |         |          |            | re        |
|     |    |      |    |         |          |            | sponsible |
|     |    |      |    |         |          |            | for two   |
|     |    |      |    |         |          |            | lectures. |
|     |    |      |    |         |          |            | Done in a |
|     |    |      |    |         |          |            | community |
|     |    |      |    |         |          |            | center.   |
+-----+----+------+----+---------+----------+------------+-----------+

Table 6. Universal prevention of late-life depression or anxiety
(continued)

+-----+----+------+----+---------+----------+------------+-----------+
| Ref | S  | Mode | A  | Sample  | Followup | Outcome    | Li        |
| ere | tu | l/Co | ge |         |          | Measures   | mitations |
| nce | dy | ndit |    |         |          | and        | /Comments |
|     | De | ions |    |         |          | Results    |           |
|     | si |      |    |         |          |            |           |
|     | gn |      |    |         |          |            |           |
+=====+====+======+====+=========+==========+============+===========+
| Pe  | RC | Aer  | 6  | Older   | 3, 9,    | Aerobic    | Unknown   |
| nni | T. | obic | 0+ | adults  | and 18   | exercise,  | general   |
| nx, | S  | e    | M  | with    | months.  | but not    | izability |
| et  | ub | xerc | ea | knee    | At 18    | resistance | to all    |
| a   | an | ise; | n: | o       | months,  | exercise,  | older     |
| l., | al |      | 68 | steoart | 20% of   | sig        | adults.   |
| 2   | ys | Re   | .8 | hritis. | aerobic  | nificantly | Unable to |
| 002 | is | sist | [+ | 70%     | group    | decreased  | control   |
| ^1  | of | ance | ]{ | female. | and 17%  | depressive | for       |
| 70^ | F  | e    | .u | High    | of       | symptoms   | social    |
|     | AS | xerc | nd | dep     | re       | compared   | support.  |
|     | T: | ise; | er | ressive | sistance | to         | No        |
|     | Fi | E    | li | s       | group    | controls.  | d         |
|     | tn | duca | ne | ymptoms | dropped  | Better     | iagnostic |
|     | es | tion | }5 | (n=98); | out. No  | results    | e         |
|     | s, | con  | .6 | Low     | di       | for        | valuation |
|     | Ar | trol |    | dep     | fference | persons    | of        |
|     | th |      |    | ressive | in       | who are    | de        |
|     | ri |      |    | s       | co       | most       | pression. |
|     | ti |      |    | ymptoms | mpliance | compliant  |           |
|     | s, |      |    | (n=340) | or       |            |           |
|     | a  |      |    |         | drop-out |            |           |
|     | nd |      |    | AE:     | between  |            |           |
|     | S  |      |    | n=149;  | high and |            |           |
|     | en |      |    |         | low      |            |           |
|     | io |      |    | RE:     | de       |            |           |
|     | rs |      |    | n=146   | pressive |            |           |
|     | T  |      |    |         | groups.  |            |           |
|     | ri |      |    | Educ:   |          |            |           |
|     | al |      |    | n=144   |          |            |           |
+-----+----+------+----+---------+----------+------------+-----------+
| Zau | Qu | Remi | 6  | 43      | 6-week   | Depressive | Small     |
| sni | as | nisc | 5+ | members | program; | symptoms   | sample    |
| ews | i- | ence |    | of      | followup | reduced    | size. No  |
| ki, | ex | the  | Ra | ret     | 12 weeks | from       | c         |
| et  | pe | rapy | ng | irement | po       | baseline   | omparison |
| a   | ri | thr  | e: | commu   | st-inter | to 6 weeks | c         |
| l., | me | ough | 6  | nities. | vention. | post-int   | ondition. |
| 2   | nt | 6    | 7- | 79%     | 21%      | ervention, | The ESC   |
| 004 | al | we   | 98 | female. | dropped  | based on   | is not a  |
| ^1  |    | ekly |    |         | out.     | the        | commonly  |
| 47^ |    | 2-   | M  |         |          | Emotional  | used      |
|     |    | hour | ea |         |          | Symptom    | i         |
|     |    | g    | n: |         |          | Checklist  | nstrument |
|     |    | roup | 84 |         |          | (ESC)      | for       |
|     |    | s    |    |         |          |            | measuring |
|     |    | essi |    |         |          |            | de        |
|     |    | ons. |    |         |          |            | pression. |
|     |    | "Ref |    |         |          |            | No change |
|     |    | lect |    |         |          |            | in        |
|     |    | ions |    |         |          |            | anxiety   |
|     |    | for  |    |         |          |            | or        |
|     |    | Seni |    |         |          |            | a         |
|     |    | ors" |    |         |          |            | gitation. |
+-----+----+------+----+---------+----------+------------+-----------+

Table 7. Early intervention of late-life depression or anxiety

+-----+----+------+----+---------+----------+------------+-----------+
| Ref | S  | Mode | A  | Sample  | Followup | Outcome    | Li        |
| ere | tu | l/Co | ge |         |          | Measures   | mitations |
| nce | dy | ndit |    |         |          | and        | /Comments |
|     | De | ions |    |         |          | Results    |           |
|     | si |      |    |         |          |            |           |
|     | gn |      |    |         |          |            |           |
+=====+====+======+====+=========+==========+============+===========+
| W   | R  | N    | M  | Older   | 3, 6,    | In         | Small     |
| ate | CT | urse | ea | adults  | and 14.5 | tervention | sample,   |
| rre |    | case | n: | living  | months.  | group had  | low       |
| us, |    | ma   | 76 | at      | After 3  | greater    | power,    |
| 1   |    | nage | [+ | home.   | months,  | reduction  | variable  |
| 994 |    | ment | ]{ | 85%     | 8.5% of  | on         | followup  |
| ^1  |    | im   | .u | female. | inte     | sho        | length,   |
| 73^ |    | plem | nd | Di      | rvention | rt-CARE^6^ | low       |
|     |    | enta | er | agnoses | group    | depression | imple     |
| B   |    | tion | li | i       | had      | scores,    | mentation |
| lan |    | of a | ne | ncluded | dropped  | but no     | of social |
| cha |    | care | }6 | 58%     | out and  | difference | and       |
| rd, |    | plan | .8 | with    | 20.4% of | in case    | antid     |
| 1   |    | cre  |    | minor   | the      | vs.        | epressant |
| 995 |    | ated |    | depr    | control  | non-case.  | t         |
| ^1  |    | by a |    | ession; | group    | With       | reatment, |
| 74^ |    | ho   |    | 23%     | had      | followup   | most      |
|     |    | spit |    | with    | dropped  | of both    | analyses  |
|     |    | al-b |    | major   | out. At  | groups     | showed no |
|     |    | ased |    | depr    | 14.5     | receiving  | di        |
|     |    | psy  |    | ession, | months,  | care mgmt  | fference. |
|     |    | chog |    | and 6%  | 25.5% of | protocol   |           |
|     |    | eria |    | with    | inte     | by general |           |
|     |    | tric |    | de      | rvention | physician, |           |
|     |    | team |    | mentia. | and      | depression |           |
|     |    |      |    |         | 40.8% of | d          |           |
|     |    |      |    | Interv: | control  | ifferences |           |
|     |    |      |    | n=47    | group    | only       |           |
|     |    |      |    |         | had      | remained   |           |
|     |    |      |    | C       | dropped  | in the     |           |
|     |    |      |    | ontrol: | out.     | subgroup   |           |
|     |    |      |    | n=49    |          | with       |           |
|     |    |      |    |         |          | long-term  |           |
|     |    |      |    |         |          | depression |           |
+-----+----+------+----+---------+----------+------------+-----------+
| M   | R  | I    | 6  | P       | 6-month  | 61% of the | UC        |
| oss | CT | nter | 0+ | atients | f        | IPT group  | included  |
| ey, |    | pers |    | a       | ollowup. | and 35% of | variable  |
| et  |    | onal | Ra | dmitted | 20% of   | the UC     | contact   |
| a   |    | co   | ng | to      | the IPT  | group had  | with a    |
| l., |    | unse | e: | m       | group    | a GDS \<   | primary   |
| 1   |    | ling |    | edicine | and 9%   | 11 at      | care      |
| 996 |    | (    | 6  | or      | of the   | 6-month    | physician |
| ^1  |    | IPT) | 0- | surgery | UC group | followup.  | and low   |
| 67^ |    | vs.  | 91 | at      | did not  | IPT group  | use of or |
|     |    | u    |    | three   | have 3-  | also had   | adherence |
|     |    | sual | M  | a       | or       | improved   | to        |
|     |    | care | ea | cademic | 6-month  | self-rated | antid     |
|     |    | (UC) | n: | hos     | followup | health,    | epressant |
|     |    |      | 71 | pitals. | data.    | but not    | me        |
|     |    |      | [+ | 78%     |          | physical   | dication. |
|     |    |      | ]{ | female. |          | or social  |           |
|     |    |      | .u | P       |          | fu         |           |
|     |    |      | nd | atients |          | nctioning. |           |
|     |    |      | er | had a   |          |            |           |
|     |    |      | li | GDS     |          |            |           |
|     |    |      | ne | greater |          |            |           |
|     |    |      | }7 | than 10 |          |            |           |
|     |    |      | .7 | but     |          |            |           |
|     |    |      |    | didn't  |          |            |           |
|     |    |      |    | meet    |          |            |           |
|     |    |      |    | c       |          |            |           |
|     |    |      |    | riteria |          |            |           |
|     |    |      |    | for     |          |            |           |
|     |    |      |    | major   |          |            |           |
|     |    |      |    | depress |          |            |           |
|     |    |      |    | ion/dys |          |            |           |
|     |    |      |    | thymia. |          |            |           |
|     |    |      |    |         |          |            |           |
|     |    |      |    | IPT:    |          |            |           |
|     |    |      |    | n=35    |          |            |           |
|     |    |      |    |         |          |            |           |
|     |    |      |    | UC:     |          |            |           |
|     |    |      |    | n=41    |          |            |           |
+-----+----+------+----+---------+----------+------------+-----------+
| Sin | R  | Pro  | 6  | Co      | 10-week  | Remission  | Small     |
| gh, | CT | gres | 0+ | mmunity | f        | achieved   | sample    |
| et  |    | sive |    | vol     | ollowup. | by 86% of  | size.     |
| a   |    | re   | I  | unteers | No       | in         | Hete      |
| l., |    | sist | nt | with    | part     | tervention | rogeneous |
| 1   |    | ance | er | major   | icipants | group and  | group of  |
| 997 |    | trai | v: | (n=13)  | dropped  | 40% of     | d         |
| ^1  |    | ning |    | or      | out.     | control    | iagnoses. |
| 71^ |    | of   | 70 | minor   | Median   | group with | Likely    |
|     |    | l    | [+ | dep     | co       | minor      | subject   |
|     |    | arge | ]{ | ression | mpliance | d          | to        |
|     |    | mus  | .u | (n=17)  | with     | epression. | selection |
|     |    | cles | nd | or      | sessions | Remission  | bias as   |
|     |    | 3    | er | dy      | was 93%  | achieved   | only 1%   |
|     |    | d    | li | sthymia | in the   | by 59% and | of        |
|     |    | ays/ | ne | (n=2).  | inte     | 26% in the | persons   |
|     |    | week | }1 | 63%     | rvention | full       | contacted |
|     |    | ve   | .5 | female. | group    | sample.    | by a      |
|     |    | rsus |    |         | and 95%  | Strength   | re        |
|     |    | "ed  | Co | Resi    | in the   | and SF-36  | cruitment |
|     |    | ucat | nt | stance: | control  | scales of  | letter    |
|     |    | ion" | ro | n=17    | group.   | bodily     | were      |
|     |    | con  | l: |         |          | pain,      | eligible  |
|     |    | trol |    | C       |          | vitality,  | and       |
|     |    |      | 72 | ontrol: |          | social     | joined    |
|     |    |      | [+ | n=15    |          | fu         | the       |
|     |    |      | ]{ |         |          | nctioning, | study.    |
|     |    |      | .u |         |          | and role   |           |
|     |    |      | nd |         |          | emotional  |           |
|     |    |      | er |         |          | were all   |           |
|     |    |      | li |         |          | sig        |           |
|     |    |      | ne |         |          | nificantly |           |
|     |    |      | }2 |         |          | improved   |           |
|     |    |      | .0 |         |          | by         |           |
|     |    |      |    |         |          | exercise.  |           |
+-----+----+------+----+---------+----------+------------+-----------+
| Flo | Co | Ga   | 6  | 777     | No       | GK made    | No        |
| rio | mp | teke | 0+ | older   | followup | 40.5% of   | symptom   |
| &   | ar | eper |    | adults  | period   | referrals  | outcomes  |
| Ra  | is | (GK) | G  | with    | employed | to elder   | reported. |
| sch | on | vs.  | K: | em      | in the   | services.  | P         |
| ko, | G  | med  | 7  | otional | study.   | GK         | revention |
| 1   | ro | ical | 4. | distu   |          | referrals  | of poor   |
| 998 | up | refe | 0[ | rbances |          | had        | health    |
|     |    | rral | +] | (63%)   |          | greater    | outcomes  |
| Ra  |    | (MD) | {. | or      |          | economic   | not       |
| sch |    | vs.  | un | co      |          | and social | reported. |
| ko, |    | refe | de | gnitive |          | isolation, |           |
| 1   |    | rral | rl | imp     |          | less       |           |
| 997 |    | by   | in | airment |          | physical   |           |
|     |    | ot   | e} | (60%)   |          | and ADL    |           |
| F   |    | hers | 10 | living  |          | i          |           |
| lor |    |      | .4 | in home |          | mpairment, |           |
| io, |    |      |    | or      |          | and fewer  |           |
| et  |    |      | M  | co      |          | had a      |           |
| a   |    |      | D: | mmunity |          | family     |           |
| l., |    |      |    | se      |          | physician  |           |
| 1   |    |      | 7  | ttings. |          | or social  |           |
| 996 |    |      | 6. | 68%     |          | support.   |           |
| ^   |    |      | 8[ | female  |          | GK         |           |
| 36, |    |      | +] |         |          | referrals  |           |
| \ 1 |    |      | {. | GK:     |          | were       |           |
| 61, |    |      | un | n=315   |          | younger,   |           |
| \ 1 |    |      | de |         |          | female,    |           |
| 62^ |    |      | rl | MD:     |          | more       |           |
|     |    |      | in | n=217   |          | likely to  |           |
|     |    |      | e} |         |          | live       |           |
|     |    |      | 12 | Other:  |          | alone, and |           |
|     |    |      | .5 | n=245   |          | fewer were |           |
|     |    |      |    |         |          | married.   |           |
|     |    |      | Ot |         |          | GK         |           |
|     |    |      | he |         |          | referrals  |           |
|     |    |      | r: |         |          | had        |           |
|     |    |      |    |         |          | greater    |           |
|     |    |      | 7  |         |          | unmet need |           |
|     |    |      | 6. |         |          | for        |           |
|     |    |      | 6[ |         |          | services.  |           |
|     |    |      | +] |         |          |            |           |
|     |    |      | {. |         |          |            |           |
|     |    |      | un |         |          |            |           |
|     |    |      | de |         |          |            |           |
|     |    |      | rl |         |          |            |           |
|     |    |      | in |         |          |            |           |
|     |    |      | e} |         |          |            |           |
|     |    |      | 12 |         |          |            |           |
|     |    |      | .5 |         |          |            |           |
+-----+----+------+----+---------+----------+------------+-----------+

Table 7. Early intervention of late-life depression or anxiety
(continued)

+-----+----+------+----+---------+----------+---+------------+-----------+
| Ref | S  | Mode | A  | Sample  | Followup |   | Outcome    | Li        |
| ere | tu | l/Co | ge |         |          |   | Measures   | mitations |
| nce | dy | ndit |    |         |          |   | and        | /Comments |
|     | De | ions |    |         |          |   | Results    |           |
|     | si |      |    |         |          |   |            |           |
|     | gn |      |    |         |          |   |            |           |
+=====+====+======+====+=========+==========+===+============+===========+
| F   | C  | Ga   | 6  | 88      | 1 year   |   | Older      | Clinician |
| lor | on | teke | 0+ | older   | followup |   | adults     | ass       |
| io, | tr | eper |    | adults  | on 100%  |   | referred   | essments. |
| et  | ol | (GK) | G  | with    | of       |   | by GK, MD, | No        |
| a   | pr | vs.  | K: | d       | parti    |   | and Other  | a         |
| l., | e- | refe | 7  | ementia | cipants. |   | sources    | djustment |
| 1   | po | rral | 8. | (53%),  |          |   | had        | for       |
| 998 | st | by   | 2[ | dep     |          |   | similar    | severity, |
| ^   |    | med  | +] | ression |          |   | service    | or        |
| 37^ |    | ical | {. | (16%),  |          |   | u          | baseline  |
|     |    | or   | un | or      |          |   | tilization | dif       |
|     |    | o    | de | bipolar |          |   | and        | ferences. |
|     |    | ther | rl | d       |          |   | o          | Model had |
|     |    | sou  | in | isorder |          |   | ut-of-home | been in   |
|     |    | rces | e} | (5%)    |          |   | p          | place for |
|     |    | (M   | 11 | living  |          |   | lacements. | many      |
|     |    | D/Ot | .2 | in home |          |   | Sig        | years.    |
|     |    | her) |    | or      |          |   | nificantly | P         |
|     |    |      | M  | co      |          |   | more GK    | revention |
|     |    |      | D/ | mmunity |          |   | referrals  | of poor   |
|     |    |      | Ot | se      |          |   | lived      | health    |
|     |    |      | he | ttings. |          |   | alone (70% | outcomes  |
|     |    |      | r: | 68%     |          |   | vs. 35%)   | not       |
|     |    |      |    | female. |          |   | and fewer  | reported. |
|     |    |      | 7  |         |          |   | were       |           |
|     |    |      | 9. | GK:     |          |   | married    |           |
|     |    |      | 5[ | n=40    |          |   | (20% vs.   |           |
|     |    |      | +] |         |          |   | 49%).      |           |
|     |    |      | {. | MD      |          |   |            |           |
|     |    |      | un | /Other: |          |   |            |           |
|     |    |      | de | n=48    |          |   |            |           |
|     |    |      | rl |         |          |   |            |           |
|     |    |      | in |         |          |   |            |           |
|     |    |      | e} |         |          |   |            |           |
|     |    |      | 10 |         |          |   |            |           |
|     |    |      | .0 |         |          |   |            |           |
+-----+----+------+----+---------+----------+---+------------+-----------+
| R   | R  | Mu   | 6  | 298     | 26-month |   | In         | No single |
| abi | CT | ltid | 0+ | older   | study.   |   | tervention | sta       |
| ns, |    | is-c |    | adults  | Followup |   | group had  | ndardized |
| 2   |    | ipli | PA | in      | data was |   | more       | t         |
| 000 |    | nary | TC | senior  | a        |   | i          | reatment. |
| ^1  |    | dev  | H: | low     | vailable |   | mprovement | Rand      |
| 63^ |    | elop | 75 | -income | on 50%   |   | in         | omization |
|     |    | ment | .0 | public  | of the   |   | p          | after     |
|     |    | of   | [+ | h       | PATCH    |   | sychiatric | ident     |
|     |    | care | ]{ | ousing. | group    |   | (BPRS) and | ification |
|     |    | p    | .u | 85%     | and on   |   | depressive | of mental |
|     |    | roto | nd | female  | 58% of   |   | symptoms   | illness,  |
|     |    | col. | er | in the  | the      |   | (MADRS).   | thus      |
|     |    | Nur  | li | PATCH   | control  |   | No         | weighting |
|     |    | se-b | ne | group,  | group.   |   | difference | to        |
|     |    | ased | }8 | c       |          |   | in         | original  |
|     |    | outr | .4 | ompared |          |   | u          | sample    |
|     |    | each |    | to 70%  |          |   | ndesirable | size.     |
|     |    | --   | Co | female  |          |   | moves.     | Dropout:  |
|     |    | (PAT | nt | in the  |          |   |            | 33% death |
|     |    | CH). | ro | Control |          |   |            | or moved; |
|     |    | Comp | l: | group.  |          |   |            | 13%       |
|     |    | ared | 75 |         |          |   |            | refusal.  |
|     |    | to   | .8 | PATCH:  |          |   |            | P         |
|     |    | u    | [+ | n=131   |          |   |            | revention |
|     |    | sual | ]{ |         |          |   |            | of mental |
|     |    | care | .u | C       |          |   |            | health    |
|     |    | con  | nd | ontrol: |          |   |            | outcomes  |
|     |    | trol | er | n=167   |          |   |            | not       |
|     |    | gr   | li |         |          |   |            | reported. |
|     |    | oup. | ne |         |          |   |            |           |
|     |    |      | }8 |         |          |   |            |           |
|     |    |      | .5 |         |          |   |            |           |
+-----+----+------+----+---------+----------+---+------------+-----------+
| Wil | R  | Pa   | Pa | Primary | 11-week  | P |            | Response  |
| lia | CT | roxe | ro | care    | tr       | r |            | to PST    |
| ms, |    | tine | x: | p       | eatment. | o |            | was       |
| et  |    | vs   | 71 | atients | 25%      | p |            | highly    |
| a   |    | pro  | [+ | with    | dropped  | o |            | variable  |
| l., |    | blem | ]{ | minor   | out.     | r |            | across    |
| 2   |    | sol  | .u | dep     |          | t |            | study     |
| 000 |    | ving | nd | ression |          | i |            | sites.    |
| ^1  |    | t    | er | or      |          | o |            |           |
| 68^ |    | reat | li | dys     |          | n |            |           |
|     |    | ment | ne | thymia. |          | o |            |           |
|     |    | (    | }6 | 41%     |          | f |            |           |
|     |    | PST) | .8 | female. |          | p |            |           |
|     |    | vs   |    |         |          | a |            |           |
|     |    | pla  | PS | Paro    |          | t |            |           |
|     |    | cebo | T: | xetine: |          | i |            |           |
|     |    | (    |    | n=137   |          | e |            |           |
|     |    | PBO) | 71 |         |          | n |            |           |
|     |    |      | [+ | PST:    |          | t |            |           |
|     |    |      | ]{ | n=138   |          | s |            |           |
|     |    |      | .u |         |          | i |            |           |
|     |    |      | nd | PBO:    |          | n |            |           |
|     |    |      | er | n=140   |          | r |            |           |
|     |    |      | li |         |          | e |            |           |
|     |    |      | ne |         |          | m |            |           |
|     |    |      | }7 |         |          | i |            |           |
|     |    |      | .0 |         |          | s |            |           |
|     |    |      |    |         |          | s |            |           |
|     |    |      | PB |         |          | i |            |           |
|     |    |      | O: |         |          | o |            |           |
|     |    |      |    |         |          | n |            |           |
|     |    |      | 71 |         |          | w |            |           |
|     |    |      | [+ |         |          | i |            |           |
|     |    |      | ]{ |         |          | t |            |           |
|     |    |      | .u |         |          | h |            |           |
|     |    |      | nd |         |          | e |            |           |
|     |    |      | er |         |          | i |            |           |
|     |    |      | li |         |          | t |            |           |
|     |    |      | ne |         |          | h |            |           |
|     |    |      | }7 |         |          | e |            |           |
|     |    |      | .2 |         |          | r |            |           |
|     |    |      |    |         |          | p |            |           |
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+-----+----+------+----+---------+----------+---+------------+-----------+
| Cui | Qu | Trai | I  | Resi    | 12       | I |            | Not       |
| jpe | as | ning | nt | dential | months.  | n |            | ra        |
| rs, | i- | for  | er | care    | 40.6% of | t |            | ndomized, |
| 2   | ex | ca   | v: | fa      | part     | e |            | high      |
| 001 | pe | regi |    | cility. | icipants | r |            | dropout,  |
| ^1  | ri | vers | A  |         | dropped  | v |            | unknown   |
| 72^ | me | and  | ge | 78.5%   | out      | e |            | which     |
|     | nt | o    | 71 | female. | within 1 | n |            | par       |
|     | al | ther | -8 | All     | year of  | t |            | ticipants |
|     |    | e    | 0: | re      | the      | i |            | received  |
|     |    | mplo |    | sidents | program. | o |            | group     |
|     |    | yees | 2  | in      |          | n |            | therapy   |
|     |    | of   | 0. | cluded, |          | g |            | c         |
|     |    | res  | 2% | but     |          | r |            | omponent. |
|     |    | iden |    | t       |          | o |            | Change in |
|     |    | tial | A  | argeted |          | u |            | GDS is    |
|     |    | h    | ge | on      |          | p |            | not       |
|     |    | ome, | 81 | dep     |          | h |            | c         |
|     |    | i    | -9 | ressive |          | a |            | linically |
|     |    | nfo. | 0: | sy      |          | d |            | sig       |
|     |    | mee  |    | mptoms. |          | g |            | nificant. |
|     |    | ting | 6  |         |          | r |            |           |
|     |    | for  | 2. | Interv: |          | e |            |           |
|     |    | r    | 9% | n=213   |          | a |            |           |
|     |    | esid |    |         |          | t |            |           |
|     |    | ents | A  | C       |          | e |            |           |
|     |    | and  | ge | ontrol: |          | r |            |           |
|     |    | re   | 90 | n=211   |          | i |            |           |
|     |    | lati | +: |         |          | m |            |           |
|     |    | ves, |    |         |          | p |            |           |
|     |    | g    | 1  |         |          | r |            |           |
|     |    | roup | 3. |         |          | o |            |           |
|     |    | i    | 6% |         |          | v |            |           |
|     |    | nter |    |         |          | e |            |           |
|     |    | vent | Co |         |          | m |            |           |
|     |    | ions | nt |         |          | e |            |           |
|     |    | off  | ro |         |          | n |            |           |
|     |    | ered | l: |         |          | t |            |           |
|     |    |      |    |         |          | i |            |           |
|     |    |      | A  |         |          | n |            |           |
|     |    |      | ge |         |          | d |            |           |
|     |    |      | 71 |         |          | e |            |           |
|     |    |      | -8 |         |          | p |            |           |
|     |    |      | 0: |         |          | r |            |           |
|     |    |      |    |         |          | e |            |           |
|     |    |      | 2  |         |          | s |            |           |
|     |    |      | 4. |         |          | s |            |           |
|     |    |      | 2% |         |          | i |            |           |
|     |    |      |    |         |          | o |            |           |
|     |    |      | A  |         |          | n |            |           |
|     |    |      | ge |         |          | ( |            |           |
|     |    |      | 81 |         |          | G |            |           |
|     |    |      | -9 |         |          | D |            |           |
|     |    |      | 0: |         |          | S |            |           |
|     |    |      |    |         |          | ^ |            |           |
|     |    |      | 5  |         |          | 1 |            |           |
|     |    |      | 2. |         |          | ^ |            |           |
|     |    |      | 1% |         |          | ) |            |           |
|     |    |      |    |         |          | a |            |           |
|     |    |      | A  |         |          | n |            |           |
|     |    |      | ge |         |          | d |            |           |
|     |    |      | 90 |         |          | H |            |           |
|     |    |      | +: |         |          | e |            |           |
|     |    |      |    |         |          | a |            |           |
|     |    |      | 1  |         |          | l |            |           |
|     |    |      | 9. |         |          | t |            |           |
|     |    |      | 9% |         |          | h |            |           |
|     |    |      |    |         |          | - |            |           |
|     |    |      |    |         |          | R |            |           |
|     |    |      |    |         |          | e |            |           |
|     |    |      |    |         |          | l |            |           |
|     |    |      |    |         |          | a |            |           |
|     |    |      |    |         |          | t |            |           |
|     |    |      |    |         |          | e |            |           |
|     |    |      |    |         |          | d |            |           |
|     |    |      |    |         |          | Q |            |           |
|     |    |      |    |         |          | u |            |           |
|     |    |      |    |         |          | a |            |           |
|     |    |      |    |         |          | l |            |           |
|     |    |      |    |         |          | i |            |           |
|     |    |      |    |         |          | t |            |           |
|     |    |      |    |         |          | y |            |           |
|     |    |      |    |         |          | o |            |           |
|     |    |      |    |         |          | f |            |           |
|     |    |      |    |         |          | L |            |           |
|     |    |      |    |         |          | i |            |           |
|     |    |      |    |         |          | f |            |           |
|     |    |      |    |         |          | e |            |           |
|     |    |      |    |         |          | ( |            |           |
|     |    |      |    |         |          | S |            |           |
|     |    |      |    |         |          | F |            |           |
|     |    |      |    |         |          | - |            |           |
|     |    |      |    |         |          | 2 |            |           |
|     |    |      |    |         |          | 0 |            |           |
|     |    |      |    |         |          | ^ |            |           |
|     |    |      |    |         |          | 2 |            |           |
|     |    |      |    |         |          | ^ |            |           |
|     |    |      |    |         |          | ) |            |           |
|     |    |      |    |         |          | . |            |           |
+-----+----+------+----+---------+----------+---+------------+-----------+
| Ci  | RC | PST  | 6  | Older   | 12       | I |            | Int       |
| ech | T. | d    | 0+ | adults  | months.  | n |            | ervention |
| an- |    | eliv |    | in      | 7% of    | t |            | group had |
| ows | PE | ered | I  | senior  | the      | e |            | a greater |
| ki, | AR | by   | nt | public  | inte     | r |            | p         |
| 2   | LS | so   | er | h       | rvention | v |            | roportion |
| 004 | M  | cial | v: | ousing. | group    | e |            | of        |
| ^1  | od | wor  |    | 79%     | and 9%   | n |            | dysthymia |
| 69^ | el | kers | 72 | female. | of the   | t |            | than      |
|     |    | with | .6 | Di      | control  | i |            | control   |
|     |    | psyc | [+ | agnoses | group    | o |            | group.    |
|     |    | hiat | ]{ | i       | dropped  | n |            | The       |
|     |    | rist | .u | ncluded | out.     | g |            | authors   |
|     |    | sup  | nd | dy      |          | r |            | believe   |
|     |    | ervi | er | sthymia |          | o |            | it to be  |
|     |    | sion | li | (49%)   |          | u |            | feasible  |
|     |    | &    | ne | and     |          | p |            | to add a  |
|     |    | coor | }8 | minor   |          | h |            | d         |
|     |    | dina | .4 | dep     |          | a |            | epression |
|     |    | tion |    | ression |          | d |            | m         |
|     |    | with | Co | (51%).  |          | m |            | anagement |
|     |    | PCP  | nt |         |          | o |            | service   |
|     |    |      | ro | Interv: |          | r |            | to usual  |
|     |    |      | l: | n=72    |          | e |            | case      |
|     |    |      | 73 |         |          | i |            | m         |
|     |    |      | .5 | C       |          | m |            | anagement |
|     |    |      | [+ | ontrol: |          | p |            | p         |
|     |    |      | ]{ | n=66    |          | r |            | ractices. |
|     |    |      | .u |         |          | o |            |           |
|     |    |      | nd |         |          | v |            |           |
|     |    |      | er |         |          | e |            |           |
|     |    |      | li |         |          | m |            |           |
|     |    |      | ne |         |          | e |            |           |
|     |    |      | }8 |         |          | n |            |           |
|     |    |      | .5 |         |          | t |            |           |
|     |    |      |    |         |          | i |            |           |
|     |    |      |    |         |          | n |            |           |
|     |    |      |    |         |          | d |            |           |
|     |    |      |    |         |          | e |            |           |
|     |    |      |    |         |          | p |            |           |
|     |    |      |    |         |          | r |            |           |
|     |    |      |    |         |          | e |            |           |
|     |    |      |    |         |          | s |            |           |
|     |    |      |    |         |          | s |            |           |
|     |    |      |    |         |          | i |            |           |
|     |    |      |    |         |          | v |            |           |
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|     |    |      |    |         |          | s |            |           |
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|     |    |      |    |         |          | N |            |           |
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|     |    |      |    |         |          | 3 |            |           |
|     |    |      |    |         |          | 6 |            |           |
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|     |    |      |    |         |          | 2 |            |           |
|     |    |      |    |         |          | % |            |           |
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|     |    |      |    |         |          | . |            |           |
+-----+----+------+----+---------+----------+---+------------+-----------+

# Suicide Prevention

Suicide is the ninth leading cause of death among all persons in the
United States ^189^ and is disproportionately common among older adults.
Older adults (age 65+) represent 13 percent of the U.S. population,^190^
yet account for nearly one fifth of U.S. suicides.^189^ Men account for
82 percent of suicides among older adults and have a higher suicide rate
than women (38 vs. 5.7 per 100,000 persons).^189^ Lethal means are often
used in late-life suicide. The most frequent methods of suicide among
older adults include the use of firearms (men: 77%; women: 34%) and
poisoning (men: 12%; women: 29%).^189,191^

Despite the disproportionate rate of suicide among older adults, most
suicide prevention programs have focused on younger persons.^192^
However, prevention of suicide in older adults is of special importance
for several reasons. Older adults are less likely to report suicidal
ideation compared to younger adults, and suicide attempts are more
likely to be deliberate and lethal.^193^ Compared to younger adults,
older adults make fewer attempts per completed suicide.^189^ In
addition, more than half (58%) of older adults (age 55+) contact their
primary care provider within 1 month of completing suicide. This rate is
more than twice as high as that for younger persons (23%; age \< 35). In
contrast, only 11 percent of older persons contact a mental health
provider in the month prior to suicide, a rate that is three times less
frequent than that of younger persons.^194^ It is noteworthy that older
adults with active suicidal ideation are more likely to engage in
integrated mental health and substance abuse services provided in a
primary care setting, as opposed to services provided through specialty
mental health clinics (83% vs. 54%).^195^

Early research has identified several risk factors for suicide.
Non-modifiable risk factors include older age, male sex, race, and
ethnicity.^193^ However, several risk factors are modifiable, including
the presence of suicidal thoughts and behavior, the presence of a
physical or mental illness, alcohol consumption, difficulty adjusting to
transitional life events, social support problems, personality
vulnerability factors, hopelessness, bereavement, and access to lethal
means.^193,196^ Significant risk factors for suicide also include
depression ^197-199^ and substance abuse.^14,200^ Of note, co-occurring
substance abuse and mental disorders are associated with an increased
risk for suicide among older adults.^199,201^ Moreover, benzodiazepines
have been linked with suicide among older adults who have poisoned
themselves.^202^

Several search strategies were used to identify programs addressing the
prevention of suicide among older adults. The PubMed, PsychInfo, CINAHL,
Ageline, Social Services Abstracts, and ERIC databases were used to
identify published literature using a combination of search terms:
suicide, suicidal ideation, prevention, and older adults. Bibliographic
searching helped identify additional references. Other search strategies
were also employed, including searches through Google, federal and
foundation grant databases, the Center for the Study of the Prevention
of Suicide (CSPS), the American Foundation for Suicide Prevention
(AFSP), and the online registry of the Evidence-based Practices in
Suicide Prevention Program.^192^ *(Of note, the online registry reviewed
14 suicide prevention programs through January 2005. Future reviews of
suicide prevention programs will be conducted through the SAMHSA NREPP
process. Among the 14 prevention programs, only one focused on older
persons (age 60+) and nine focused on school-aged children. Four
programs were identified as effective, eight were identified as
promising, and two did not receive a rating.)*

The following section describes the evidence supporting approaches to
the prevention of suicide among older adults. Although national
strategies have been developed to address suicide ^203-205^ and many
sources have discussed the prevention of suicide among older
adults,^193,196,206-215^ only a handful of studies have evaluated the
effectiveness of interventions on reducing completed suicide or suicidal
ideation among older adults. The literature describing universal
prevention of suicide among older adults is largely based on Japanese
studies, with results from indicated and selective interventions derived
from American and Italian studies. Universal prevention programs are
described in Table 8 and consist of screening for depression,
psychoeducation, and group activities. Indicated and selected prevention
strategies are described in Table 9 and include treatment of depression
and the provision of telephone-based support. A review of these programs
is also provided within the text.

## Universal Prevention Strategies

The evidence base supporting the universal prevention of geriatric
suicide is minimal. Very few programs have attempted to reduce the rate
of suicide among older adults using a community-wide approach. However,
studies by Oyama and colleagues describe universal prevention programs
that provide screening for depression, psychoeducation, and group
activities. Please see Table 8 for further details regarding each study.

Oyama and colleagues ^216^ evaluated the effectiveness of a universal
depression screening program, followed by mental health or psychiatric
care, and depression education in a rural, agricultural community in
Japan. Older residents (age 65+) completed the Japanese version of the
Zung Self-Rated Depression Scale. Those individuals who screened
positive were evaluated or provided treatment by a public health nurse
or a psychiatrist (if warranted). Educational health workshops were
offered to residents, including information regarding the signs,
symptoms, and potential treatments for depression, along with
information on using the mental health system, and developing
relationships with other community members and neighbors. The
intervention was associated with a reduction in suicide rates of 73
percent among older men and 76 percent among older women, compared to no
risk reduction in older men or women in the comparison regions. Suicide
completion in the pre-implementation to post-implementation phase
decreased from 11 to 4 for men and from 16 to 6 for older women. In
contrast to other suicide prevention programs, this program showed
effectiveness for both genders.^216^

Oyama and colleagues ^217^ also evaluated the effectiveness of a
three-component universal prevention program targeting older members of
a rural agricultural community in Japan (age 65+). The first component
included local and regional mental health workshops at which a public
health nurse or psychiatrist provided group psychoeducation on
depression and risk for suicide. The second component included a group
activity program that provided opportunities for older adults to
participate in social, volunteer, recreational, and exercise activities
and was designed to promote and enhance the development of social
relationships. Finally, a self-report depression questionnaire was
distributed to older adults. Older adults were provided a description of
how to evaluate their responses and a referral to a psychiatrist or
public health nurse was provided to those who required a consultation.
Evaluation of this program showed that the incidence of suicide
decreased in older women during the 8-year period following program
implementation, as compared to the 8-year period prior to program
implementation. No reduction in suicide was seen among the control
group, nor was it seen among older men in the intervention region.^217^

#### *Assessment*

Few scales have been developed specifically for the assessment of
suicide risk or suicidal ideation among older adults. The Harmful
Behaviors Scale (HBS) is a 20-item scale that is scored based upon
observations of direct and indirect self-destructive behavior among
nursing home residents. While this instrument has internal consistency
and interrater reliability, it is limited in its reliance on observer
ratings.^218,219^ Two other instruments have been developed that have
potential merit in detecting and measuring suicidal ideation among older
adults; however, these instruments are longer and have yet to be fully
evaluated. They include the Reasons for Living Scale -- Older Adults
version (RLS-OA) and the Geriatric Suicide Ideation Scale (GSIS).^193^
The development and testing of additional tools for evaluating suicide
and its prevention may be a useful addition to this field.^212^

## Selective and Indicated Prevention Strategies

The evidence base for indicated and selective prevention of suicide
among older adults is also small. Programs that target the reduction of
modifiable risk factors include depression treatment and telephone-based
social support. Please see Table 9 for further details.

Szanto and colleagues ^220^ recently examined the course of suicidal
ideation among older adults (ages 59 -- 95) receiving short-term
treatment for depression. This secondary analysis evaluated 395 persons
with major depression receiving inpatient or outpatient treatment with
antidepressant medication alone or in combination with interpersonal
psychotherapy. Suicidal ideation rapidly decreased during the initial
stages of treatment and then declined more gradually. After 12 weeks of
treatment, only 18.4 percent of participants reported suicidal ideation,
thoughts of death, or feelings that life is empty, compared to 77.5
percent at the beginning of treatment. Moreover, after 12 weeks of
treatment, only 4.6 percent continued to report thoughts of death,
compared to 36.2 percent at the beginning of treatment. The decrease in
suicidal ideation was more gradual for those with a recent suicide
attempt or current suicidal ideation (median response time: 6 weeks) or
with recurrent thoughts of death (median response time: 5 weeks),
compared to those with no suicide attempt, suicidal ideation, or
thoughts of death (median response time: 3 weeks). This study suggests
that suicidal ideation can resolve among older adults receiving active
treatment for depression. However, it is noteworthy that individuals
with the most severe risk for suicide require treatment for an average
of 1½ months to see significant reductions in suicidal ideation.

Bruce and colleagues ^221^ evaluated the effect of the Prevention of
Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) on
reducing suicidal ideation among older adults (age 60+) with depression.
PROSPECT combines depression treatment guidelines with depression care
management. Guidelines consist of a clinical algorithm for treating
geriatric depression in a primary care setting and are modified to
address the special circumstances associated with the treatment of
depression in older adults, including adverse events, medical
comorbidity, functional disability, cognitive functioning, and social
stigma. A "depression care manager" who works with the primary care
physician and a supervising psychiatrist conducts care management. Data
suggest that suicidal ideation resolves more quickly in patients
receiving care through a depression care management model employing
geriatric specific guidelines, compared to those receiving usual care.
PROSPECT participants had significant reductions in suicidal ideation by
4 and 8 months, compared to usual care. Of note, reductions were greater
among those diagnosed with major depression, compared to those with
minor depression. The intervention was also associated with reductions
in depression at 4, 8, and 12 months, compared to usual care. Specific
protective factors increased through the PROSPECT intervention included
the effective clinical care for mental, physical, and substance use
disorders as well as easy access to a variety of clinical interventions
and support for help-seeking. The intervention sought to decrease risk
factors, including barriers to accessing health care and the presence of
untreated mental illness. PROSPECT has been identified as an "effective"
selective and indicated prevention program by the registry of
evidence-based suicide prevention programs.^39^

DeLeo and colleagues ^222^ evaluated the effectiveness of the
TeleHelp-TeleCheck service for suicide prevention among older persons in
Italy (age 65+). The program targeted older persons with a variety of
risk factors, including disability, social isolation, psychiatric
problems, poor compliance with hospital outpatient care instructions, or
individuals waiting for institutional admission. At-risk older persons
were referred by their health care physician or social worker to the
TeleHelp-TeleCheck service. Participants were provided with a remote
alarm device used to trigger a response network (TeleHelp). In addition,
TeleCheck included short, informal, twice-weekly telephone interviews by
trained staff. These checks were used to evaluate participant welfare
and to provide emotional support. Participants were also able to call
the TeleCheck line on a 24-hour basis. This service was evaluated over
an 11-year period among more than 18,000 older Italians. The
intervention was successful in reducing the number of observed suicides
among older women, though it did not significantly lower the rate of
completed suicides among older men. In addition, the TeleCheck component
of the intervention has been associated with fewer requests for
physician home visits, hospital admissions, and depression
severity.^222^

In addition to the few studies that have specifically addressed the
reduction of suicide or suicidal ideation among older adults, several
other programs have concurrently targeted both younger and older adults
(not shown in tables). For example, a program in Gotland, Sweden
provided education to primary care physicians to improve treatment of
depression and lower rates of suicide. The rate of suicide decreased
following physician training; however, the rate of suicide increased 2
years after the completion of training. The small number of completed
suicides and the lack of focus on older adults makes it difficult to
draw conclusions from this study.^223,224^ In contrast, placing limits
on analgesic packaging has been defined as an "effective" universal
prevention program within the registry of evidence-based suicide
prevention programs.^225^ Due to high numbers of self-poisoning
associated with analgesics, the United Kingdom passed legislation in
1998 to limit pack sizes of analgesics to 32 tablets per sale at a
pharmacy and 16 tablets per sale at non-pharmacy locations. Printed
warnings regarding dangers of overdose were also provided. Rates of
self-poisoning in the United Kingdom among persons aged 12 and above
were evaluated over a 6-year period through a naturalistic design.
Packaging limitations, which restricted access to a lethal means of
suicide, were associated with a significant decrease (22%) in
self-poisoning with analgesics.^226,227^ The effectiveness of this
approach has not been evaluated in the United States, nor has it been
evaluated specifically among older adults.

## Conclusions

A review of the current evidence supporting the universal, selective,
and indicated prevention among older adults suggests that current
prevention programs can reduce the rate of suicide among older women,
but have shown more limited effectiveness among older men. Supportive
interventions appear to be effective for older women. There is a need,
however, for alternative interventions targeting suicide prevention
among older men. Of note, several of the prevention strategies have been
developed and evaluated in other countries (including Japan and Italy).
While these programs have shown effectiveness in their original setting,
it is possible that differences in health care systems and
characteristics of the older adult populations may limit their
generalizability to samples and settings in the United States.

Although there is little data to support the prevention of older adult
suicide, national strategies endorse science-based suicide prevention
initiatives. The following goals and objectives have been specifically
adapted from the National Suicide Prevention Strategy to meet the needs
of older adults:^205,212^

-   Promote awareness that suicide in older adults is a public health
    problem that is preventable;

-   Develop broad-based support for elder suicide prevention;

-   Develop and implement strategies to reduce the stigma associated
    with aging and with being a senior consumer of mental health,
    substance abuse, and suicide prevention services;

-   Develop and implement community-based suicide prevention programs
    for older adults;

-   Promote efforts to reduce access to lethal means and methods of self
    harm by older adults;

-   Implement training for recognition and assessment of at-risk
    behavior and delivery of effective treatment to older adults;

-   Develop and promote effective clinical and professional practices;

-   Improve access to and community linkages with mental health,
    substance abuse, and social services designed for the evaluation and
    treatment of older adults in primary and long-term care settings;

-   Improve reporting and portrayals of suicidal behavior, mental
    illness, and substance abuse among older adults in the entertainment
    and news media;

-   Promote and support research on late-life suicide and suicide
    prevention;

-   Improve and expand surveillance systems;

-   Implement interventions that improve social relations and decrease
    isolation in older adults; and

-   Increase access to geriatric specialty health care.

Future directions for the prevention of suicide among older adults may
include community-based educational initiatives that attempt to
de-stigmatize help-seeking, greater use of mental health screening and
treatment among older adults, education of stakeholders (including
gatekeepers who could serve an important role in identifying at-risk
older adults), and training of health care providers in suicide risk and
protective factors.^193^ Prevention of suicide should focus on
age-specific risk and protective factors that address differences
associated with race, ethnicity, and gender.^189^ While emphasis should
be placed on universal prevention strategies that stress educational
interventions, their combination with selective and indicated strategies
offers the most hope for effecting significant reductions in late-life
suicide rates.^212^ For instance, preventing or reducing problem
drinking and depressive symptoms, particularly in combination, is likely
to reduce risk for suicidal ideation and suicide. Finally, special
attention should be placed on the identification and treatment of older
adults with suicidal ideation in primary care.

Table 8. Universal prevention of late-life suicide

  ---------------------------------------------------------------------------------------------------------------------------------
  Reference   Study Design         Model/Conditions   Age   Sample           Followup        Outcome         Limitations/Comments
                                                                                             Measures and    
                                                                                             Results         
  ----------- -------------------- ------------------ ----- ---------------- --------------- --------------- ----------------------
  Oyama, et   Quasi-experimental   Screening for      65+   7,070 residents  5-year          Suicide         Non-randomized, time
  al., 2004                        depression,              of a rural       intensive       mortality in    series analysis could
  ^216^                            followup with            agricultural     period; 5-year  the             allow for a regression
                                   mental health care       region in Japan  maintenance     intervention    to the mean; program
                                   or psychiatric           covering         period,         area decreased  not utilized by all
                                   treatment, and           multiple         compared to     by 73% among    older members in the
                                   health education         municipalities   5-year          men and 76%     region.
                                   on depression.           (Joboji),        preparation     among women     
                                   Comparison group         compared to a    period and      over 10-year    
                                   did not receive          neighboring      5-year baseline study period    
                                   these services.          region (Iwate).  period.         compared to the 
                                                                             Approximately   10-year         
                                                                             30-60% of       baseline and    
                                                                             eligible older  preparation     
                                                                             adults          periods. No     
                                                                             participated in change was seen 
                                                                             program.        in rate of      
                                                                                             suicide among   
                                                                                             residents of    
                                                                                             the comparison  
                                                                                             region.         

  Oyama, et   Quasi-experimental   Group activities,  65+   6,817 residents  8-year period   A 76% reduction Non-randomized, time
  al., 2005                        psychoeducation,         of a rural       prior to        in suicide was  series analysis could
  ^217^                            and                      agricultural     intervention,   seen among      allow for a regression
                                   self-assessment of       region in Japan  compared to     females         to the mean,
                                   depression               covering         8-year period   (age-adjusted   intervention only
                                   available to all         multiple         after beginning incident rate   effective for females,
                                   older members of a       municipalities   of              reduction of    program not utilized
                                   region. Comparison       (Yuri town),     intervention.   0.24;           by all older members
                                   group did not            compared to a                    confidence      in the region.
                                   receive these            neighboring                      interval (0.10  
                                   services.                region (Chokai                   -- 0.58). No    
                                                            town).                           change seen in  
                                                                                             rate of suicide 
                                                                                             among men or in 
                                                                                             the comparison  
                                                                                             region.         
  ---------------------------------------------------------------------------------------------------------------------------------

Table 9. Selective and indicated prevention of late-life suicide

+-----+-----+--------+----+----------+-------+------------+----------+
| Ref | St  | Mode   | A  | Sample   | Fol   | Outcome    | Limi     |
| ere | udy | l/Cond | ge |          | lowup | Measures   | tations/ |
| nce | Des | itions |    |          |       | and        | Comments |
|     | ign |        |    |          |       | Results    |          |
+=====+=====+========+====+==========+=======+============+==========+
| De  | Qua | TeleHe | 6  | 18,641   | 11    | Observed   | Non-ran  |
| L   | si- | lp-Tel | 5+ | older    | -year | suicides   | domized, |
| eo, | exp | eCheck |    | adults   | pe    | were       | inte     |
| et  | eri | se     | M  | in the   | riod. | sig        | rvention |
| a   | men | rvice: | ea | Veneto   | 13%   | nificantly | only     |
| l., | tal | Twice  | n: | region   | of    | lower than | e        |
| 2   |     | weekly | 80 | of       | the   | expected   | ffective |
| 002 |     | tel    | .0 | Italy.   | pa    | (o         | for      |
| ^2  |     | ephone | [+ | Most     | rtici | bserved=6; | females. |
| 22^ |     | s      | ]{ | part     | pants | exp        | A        |
|     |     | upport | .u | icipants | st    | ected=21). | previous |
|     |     | and    | nd | were     | opped | Resulted   | exa      |
|     |     | eme    | er | widowed  | using | in         | mination |
|     |     | rgency | li | (68%),   | the   | sig        | of this  |
|     |     | re     | ne | females  | se    | nificantly | program  |
|     |     | sponse | }6 | (84%),   | rvice | fewer      | resulted |
|     |     | for up | .8 | lived    | d     | suicides   | in       |
|     |     | to     | y  | alone    | uring | among      | re       |
|     |     | 20,000 | ea | (73%),   | the   | women      | ductions |
|     |     | p      | rs | and were | fol   | (n=2) than | in       |
|     |     | ersons |    | p        | lowup | expected,  | requests |
|     |     | re     |    | artially | (45%  | but no     | for home |
|     |     | ferred |    | self-su  | due   | difference | visits   |
|     |     | by     |    | fficient | to    | in         | by       |
|     |     | g      |    | (63%).   | d     | suicides   | general  |
|     |     | eneral |    |          | eath, | among men  | practi   |
|     |     | p      |    |          | 21%   | (n=4),     | tioners, |
|     |     | ractit |    |          | due   | compared   | hospital |
|     |     | ioners |    |          | to    | to         | adm      |
|     |     | or     |    |          | i     | expected   | issions, |
|     |     | social |    |          | nstit | number     | and      |
|     |     | wo     |    |          | ution | (n=9).     | de       |
|     |     | rkers. |    |          | aliza |            | pression |
|     |     |        |    |          | tion, |            | scores.  |
|     |     |        |    |          | and   |            |          |
|     |     |        |    |          | other |            |          |
|     |     |        |    |          | due   |            |          |
|     |     |        |    |          | to a  |            |          |
|     |     |        |    |          | move  |            |          |
|     |     |        |    |          | out   |            |          |
|     |     |        |    |          | of    |            |          |
|     |     |        |    |          | the   |            |          |
|     |     |        |    |          | a     |            |          |
|     |     |        |    |          | rea). |            |          |
+-----+-----+--------+----+----------+-------+------------+----------+
| S   | Sec | Active | 5  | 395      | 12    | Reports of | R        |
| zan | ond | tre    | 9+ | in       | w     | suicidal   | eduction |
| to, | ary | atment |    | patients | eeks. | ideation,  | in       |
| et  | an  | for    | Ra | and      |       | thoughts   | suicidal |
| a   | aly | depr   | ng | out      |       | of death,  | ideation |
| l., | sis | ession | e: | patients |       | or         | took an  |
| 2   | of  | with   |    | with     |       | feelings   | average  |
| 003 | th  | an     | 5  | major    |       | that life  | of 1.5   |
| ^2  | ree | tidepr | 9- | de       |       | was empty  | months.  |
| 20^ | R   | essant | 95 | pression |       | decreased  | S        |
|     | CTs | medi   |    | and      |       | from 77.5% | econdary |
|     |     | cation | M  | active   |       | to 18.4%.  | analysis |
|     |     | or     | ea | t        |       | Decrease   | of       |
|     |     | i      | n: | reatment |       | in         | outcome  |
|     |     | nterpe | 72 | with     |       | suicidal   | data     |
|     |     | rsonal | .0 | antide   |       | ideation   | from a   |
|     |     | ps     | [+ | pressant |       | took more  | com      |
|     |     | ychoth | ]{ | me       |       | time for   | bination |
|     |     | erapy. | .u | dication |       | those with | of       |
|     |     |        | nd | alone or |       | a recent   | studies. |
|     |     |        | er | in       |       | suicidal   |          |
|     |     |        | li | com      |       | attempt or |          |
|     |     |        | ne | bination |       | current    |          |
|     |     |        | }7 | with     |       | ideation.  |          |
|     |     |        | .4 | inter    |       |            |          |
|     |     |        |    | personal |       |            |          |
|     |     |        |    | therapy. |       |            |          |
+-----+-----+--------+----+----------+-------+------------+----------+
| Bru | Mul | PR     | 6  | Urban    | 4-,   | Rates of   | The      |
| ce, | tis | OSPECT | 0+ | primary  | 8-,   | suicidal   | inte     |
| et  | ite | trial  |    | care     | and   | ideation   | rvention |
| a   | RCT | (Prev  | Ra | patients | 12-   | differed   | group    |
| l., |     | ention | ng | with     | month | at         | had      |
| 2   |     | of     | e: | major or | foll  | baseline,  | greater  |
| 004 |     | S      |    | minor    | owup. | but were   | suicidal |
| ^2  |     | uicide | 6  | dep      | After | similar by | ideation |
| 21^ |     | in     | 0- | ression. | 12    | 4-, 8-,    | at       |
|     |     | P      | 94 | 72%      | mo    | and        | baseline |
|     |     | rimary |    | female.  | nths, | 12-month   | and thus |
|     |     | Care   |    | 28%      | 31%   | i          | greater  |
|     |     | El     |    | min      | of    | nterviews. | imp      |
|     |     | derly: |    | orities. | the   | Raw rates  | rovement |
|     |     | C      |    | Part     | in    | of         | in the   |
|     |     | ollabo |    | icipants | terve | suicidal   | inte     |
|     |     | rative |    | ra       | ntion | ideation   | rvention |
|     |     | T      |    | ndomized | and   | declined   | group    |
|     |     | rial). |    | to       | 31%   | 12.9% in   | may      |
|     |     | Depr   |    | PROSPECT | of    | the        | r        |
|     |     | ession |    | or usual | the   | in         | epresent |
|     |     | tre    |    | care by  | usual | tervention | re       |
|     |     | atment |    | site.    | care  | and 3.0%   | gression |
|     |     | guid   |    |          | group | in usual   | to the   |
|     |     | elines |    | Inter    | had   | care.      | mean.    |
|     |     | for    |    | vention: | dr    | Among only | De       |
|     |     | older  |    | n=320    | opped | those      | pression |
|     |     | adults |    |          | out.  | patients   | scores   |
|     |     | c      |    | UC:      |       | with       | also     |
|     |     | oupled |    | n=278    |       | suicidal   | improved |
|     |     | with   |    |          |       | ideation   | more in  |
|     |     | care   |    |          |       | at         | the      |
|     |     | manag  |    |          |       | baseline,  | inte     |
|     |     | ement, |    |          |       | there was  | rvention |
|     |     | co     |    |          |       | sig        | group.   |
|     |     | mpared |    |          |       | nificantly | Effects  |
|     |     | to     |    |          |       | greater    | on       |
|     |     | usual  |    |          |       | reduction  | suicidal |
|     |     | care   |    |          |       | in         | ideation |
|     |     | (UC).  |    |          |       | suicidal   | were     |
|     |     |        |    |          |       | ideation   | more     |
|     |     |        |    |          |       | at 8       | pr       |
|     |     |        |    |          |       | months in  | onounced |
|     |     |        |    |          |       | the        | in those |
|     |     |        |    |          |       | in         | with     |
|     |     |        |    |          |       | tervention | major    |
|     |     |        |    |          |       | group      | de       |
|     |     |        |    |          |       | compared   | pression |
|     |     |        |    |          |       | to the     | compared |
|     |     |        |    |          |       | usual care | to those |
|     |     |        |    |          |       | group.     | with     |
|     |     |        |    |          |       | D          | minor    |
|     |     |        |    |          |       | ifferences | dep      |
|     |     |        |    |          |       | in         | ression. |
|     |     |        |    |          |       | suicidal   | It is    |
|     |     |        |    |          |       | ideation   | not      |
|     |     |        |    |          |       | among this | known    |
|     |     |        |    |          |       | subgroup   | how      |
|     |     |        |    |          |       | did not    | suicidal |
|     |     |        |    |          |       | differ at  | ideation |
|     |     |        |    |          |       | 4 or 12    | is       |
|     |     |        |    |          |       | months.    | r        |
|     |     |        |    |          |       |            | eflected |
|     |     |        |    |          |       |            | in       |
|     |     |        |    |          |       |            | suicidal |
|     |     |        |    |          |       |            | b        |
|     |     |        |    |          |       |            | ehavior. |
+-----+-----+--------+----+----------+-------+------------+----------+

Prevention of Co-occurring Substance Abuse and Mental Health Problems

The prevalence of older adults with comorbid substance abuse and mental
disorders varies by population, and ranges from 7 percent to 38 percent
of those with psychiatric illness and from 21 percent to 66 percent of
those with substance abuse.^228^ Co-occurring mental health and
substance use disorders are associated with an increased risk of poor
health outcomes, greater inpatient and outpatient service utilization,
and increased suicidal ideation and attempts, compared to either
disorder alone.^199,201,229^ Depression and alcohol use are the most
commonly cited co-occurring disorders in older adults.

Several search strategies were used to identify programs that address
the prevention and early intervention of co-occurring disorders in older
adults. The PubMed, PsychInfo, CINAHL, Ageline, Social Services
Abstracts, and ERIC databases were used to identify published literature
using a combination of the search terms: co-occurring disorders, dual
diagnoses, alcohol, substance abuse, depressive disorders, and mental
illness. Other search strategies were also employed, including searches
conducted through Google and federal and foundation grant databases.

The following section describes the evidence supporting approaches to
the prevention and early intervention of co-occurring substance abuse
and mental health problems. Data on the prevention and early
intervention of co-occurring disorders in older adults are limited. We
were unable to locate universal prevention programs for older adults.
The absence of universal prevention programs for late-life dual
diagnosis is expected, because pre-existing substance abuse or mental
health problems places preventive efforts at a selective or indicated
level. The research literature describing the early intervention of
co-occurring disorders is small and is largely focused on the
comorbidity of depression and alcohol abuse. Early intervention
strategies include programs that combine medication with psychotherapy
for depression and integrated service delivery approaches. Table 10
provides an overview of intervention programs for older adults with
co-occurring substance abuse and mental health problems. A review of
these programs is also provided within the text.

# Indicated and Selective Prevention Strategies (Early Intervention)

#### *Effect of Alcohol Use on Depression Treatment Outcomes*

Oslin and colleagues found that concurrent treatment of depression and a
reduction in alcohol use was effective in achieving positive treatment
outcomes.^230^ In this large study of older persons (age 60+)
hospitalized for late-life depression, outcomes were evaluated 3 to 4
months following discharge. Treatment during hospitalization for the
vast majority (88%) included concurrent treatment with antidepressants
and abstinence from alcohol. Surprisingly, those with a history of
moderate and high alcohol consumption (compared to light consumption)
had significantly better social functioning and energy outcomes and a
lower proportion used antidepressant medications. The authors found that
the vast majority of those in the moderate and high alcohol consumption
group significantly decreased their alcohol consumption at the same time
as receiving treatment for depression, with approximately 80 percent of
patients reducing their drinking by more than 90 percent.^230^ Of note,
reducing alcohol use was associated with a modest benefit on depression
outcomes, compared to older adults who continued to drink. The results
of this study suggest that older adults with co-occurring depression and
substance abuse benefit from treatment of depression, especially when
consumption of alcohol is decreased.

#### *Effectiveness of Naltrexone Combined With Treatment for Depression*

Oslin and colleagues recently conducted a randomized clinical trial
among alcohol dependent older adults with co-occurring depression.^231^
In this study, older adults (age 55+) were randomized to either
sertraline (an antidepressant medication) combined with psychosocial
support or sertraline combined with psychosocial support plus adjunctive
naltrexone (an opioid antagonist). This study failed to find any
additional benefit of naltrexone as an adjunctive agent in the treatment
of alcohol dependence. However, the investigators found a strong
association between reduced depression and lower rates of drinking and
relapse during treatment. The authors concluded that appropriate and
optimal treatment of co-occurring depression and alcohol dependence
should consist of concurrent treatment of both the alcohol dependence
and depressive symptoms.

#### *Effect of Integrated Care Compared to Enhanced Referral Care*

The Primary Care Research in Substance Abuse and Mental Health for
Elderly (PRISM-E) study compared treatment engagement of older primary
care patients (age 65+) receiving care through two distinct services
models, including integrated substance abuse and mental health treatment
and enhanced referral to a specialty mental health clinic.^195^ A
subgroup of participants in this study had co-occurring at-risk alcohol
use and depression or anxiety (n=148). Of note, older adults with
co-occurring disorders were significantly more likely to engage in the
integrated model of treatment (4.0 mean treatment visits) compared to
the enhanced model of referral to specialty mental health clinics (1.8
mean treatment visits).^195^ Both the integrated and enhanced referral
conditions were effective in decreasing alcohol use (as measured by
number of drinks per week and the number of binges per month) and
improving mental health status (as measured by the mental component
score of the SF-36).^232^ Unfortunately, it is not possible to determine
(in the absence of a non-treatment control group) if the positive
outcomes were due to the treatment, or a non-specific study effect.
However, these results suggest that co-occurring at-risk alcohol use and
depression or anxiety can significantly improve over 6 months among
older adults receiving mental health and substance abuse services in
primary care or specialty mental health settings.

#### *Screening*

A recent study by Philpot and colleagues ^233^ examined the
effectiveness of three screening tests to identify problem drinking in
older adults with mental illness. This examination evaluated the Alcohol
Use Disorders Identification Test (AUDIT), the AUDIT-5, and the CAGE
among 128 older adult patients with a mean age of 77 years. Mental
health problems among this sample included dementia (54%), affective
disorders (25%), schizophrenia/delusional disorders (11%),
substance-related psychiatric disorders (3%), and other psychiatric
disorders (7%). The sensitivity, specificity, and positive predictive
value of the AUDIT (cut-point 7/8) and AUDIT-5 (cut-point 4/5) were
similar and were superior to the CAGE (cut-point 1/2). In comparison
with clinical case criteria, the AUDIT-5 performed better than either of
the other scales and had a sensitivity of 75 percent, specificity of 97
percent, and positive predictive value of 83 percent using a 4/5
cut-point.^233^ This study suggests that the AUDIT and AUDIT-5 are both
appropriate screening instruments for detecting problem drinking in
older adults with mental illness.

# Ongoing Prevention Programs Undergoing Evaluation

A search of the NIH Clinical Trials database did not identify any
studies that are currently evaluating the effectiveness of preventing or
treating co-occurring substance abuse and mental illness in older
adults. A broadened search using the terms "co-occurring disorders, dual
diagnoses, alcohol and mental illness, and substance and mental illness"
identified only six studies, all of which were focused on younger
persons. Entry criteria limited enrollment to individuals ages 18-65 in
three studies, 18-70 in one study, 21-60 in one study, and 12-15 in one
study. Three of the studies are evaluating the effectiveness of a
pharmacological intervention, while three are evaluating the
effectiveness of a psychosocial intervention. In addition, a review of
current grants supported by the Robert Wood Johnson Foundation and the
Hartford Foundation did not identify any projects focused on the
prevention or early intervention of co-occurring disorders in older
adults.

# Conclusions

Dual diagnosis consisting of co-occurring substance abuse and mental
illness among older adults is a growing public health problem. The
empirical data on interventions for co-occurring depression or anxiety
disorders and alcohol use disorders in older adults is limited.
Well-designed prevention, early intervention, and treatment studies are
needed that specifically address co-occurring disorders in older adult
populations. Further research is needed that provides valid criteria for
differentiating the diagnostic subtypes that comprise co-occurring
disorders and the corresponding treatment interventions. Moreover,
selective and indicated prevention efforts that focus on late-life
mental illness alone and substance abuse alone should be applied to
older adults with co-occurring disorders. Establishing an evidence base
for the treatment of comorbid substance abuse and mental health problems
represents a critical area of need for older persons with a mental
illness or with a history of alcohol dependence, with current alcohol
dependence, or with at-risk drinking.^234^

Table 10. Early intervention of co-occurring substance abuse and mental
health problems

+-----+----+---------+----+---------+-------+-------------+---------+
| Ref | S  | Model/  | A  | Sample  | Fol   | Outcome     | Limit   |
| ere | tu | Con     | ge |         | lowup | measures    | ations/ |
| nce | dy | ditions |    |         |       | and Results | C       |
|     | De |         |    |         |       |             | omments |
|     | si |         |    |         |       |             |         |
|     | gn |         |    |         |       |             |         |
+=====+====+=========+====+=========+=======+=============+=========+
| Osl | Pr | Effect  | 6  | P       | 3-4   | Patients    | Inter   |
| in, | e- | of      | 0+ | atients | m     | with        | vention |
| 2   | po | con     |    | a       | onths | mo          | not     |
| 000 | st | current |    | dmitted | foll  | derate/high | clearly |
| ^2  |    | alcohol |    | to      | owing | alcohol     | d       |
| 30^ |    | use on  |    | in      | disch | consumption | efined. |
|     |    | tr      |    | patient | arge. | (vs light   | Low     |
|     |    | eatment |    | ge      | 39%   | c           | com     |
|     |    | of      |    | riatric | with  | onsumption) | pletion |
|     |    | dep     |    | psyc    | both  | had better  | of      |
|     |    | ression |    | hiatric | admi  | energy and  | f       |
|     |    |         |    | tr      | ssion | social      | ollowup |
|     |    |         |    | eatment | and   | functioning | data.   |
|     |    |         |    | pr      | fol   | outcomes    |         |
|     |    |         |    | ograms. | lowup | and fewer   |         |
|     |    |         |    | 72%     | data. | used        |         |
|     |    |         |    | female. |       | anti        |         |
|     |    |         |    | All     |       | depressants |         |
|     |    |         |    | p       |       | at          |         |
|     |    |         |    | atients |       | followup.   |         |
|     |    |         |    | had a   |       | 80% of      |         |
|     |    |         |    | DSM-IV  |       | patients in |         |
|     |    |         |    | di      |       | the         |         |
|     |    |         |    | agnosis |       | moderate/   |         |
|     |    |         |    | of a    |       | high        |         |
|     |    |         |    | dep     |       | consumption |         |
|     |    |         |    | ressive |       | group       |         |
|     |    |         |    | d       |       | si          |         |
|     |    |         |    | isorder |       | gnificantly |         |
|     |    |         |    | and a   |       | decreased   |         |
|     |    |         |    | ge      |       | alcohol     |         |
|     |    |         |    | riatric |       | consumption |         |
|     |    |         |    | dep     |       | (by 90% or  |         |
|     |    |         |    | ression |       | more) while |         |
|     |    |         |    | scale   |       | receiving   |         |
|     |    |         |    | score   |       | treatment   |         |
|     |    |         |    | \> 10.  |       | for         |         |
|     |    |         |    |         |       | depression. |         |
|     |    |         |    | 2,666   |       |             |         |
|     |    |         |    | with    |       |             |         |
|     |    |         |    | ad      |       |             |         |
|     |    |         |    | mission |       |             |         |
|     |    |         |    | data;   |       |             |         |
|     |    |         |    | 1,048   |       |             |         |
|     |    |         |    | with    |       |             |         |
|     |    |         |    | f       |       |             |         |
|     |    |         |    | ollowup |       |             |         |
|     |    |         |    | data.   |       |             |         |
+-----+----+---------+----+---------+-------+-------------+---------+
| Ba  | RC | Int     | 6  | Primary | 6     | Greater     | Unpu    |
| rte | T. | egrated | 5+ | care    | mo    | engagement  | blished |
| ls, | P  | su      |    | pa      | nths. | and more    | data    |
| 2   | RI | bstance | 73 | tients. |       | treatment   | showed  |
| 004 | SM | abuse   | .5 | 74%     |       | visits in   | that    |
|     | -e | and     | [+ | male.   |       | the         | both    |
| ^1  | St | mental  | ]{ | S       |       | integrated  | groups  |
| 95^ | ud | health  | .u | ubgroup |       | condition   | reduced |
|     | y. | tre     | nd | with    |       | than in the | number  |
|     |    | atment. | er | co-oc   |       | referral    | of      |
|     |    |         | li | curring |       | condition.  | drin    |
|     |    | E       | ne | at-risk |       | (79.5% vs.  | ks/week |
|     |    | nhanced | }6 | alcohol |       | 51.4%       | and     |
|     |    | r       | .2 | use and |       | engaged)    | binge   |
|     |    | eferral |    | dep     |       | (4.0 vs.    | s/month |
|     |    | to a    |    | ression |       | 1.8 mean    | and had |
|     |    | sp      |    | or      |       | treatment   | i       |
|     |    | ecialty |    | anxiety |       | visits)     | mproved |
|     |    | mental  |    | (n=148) |       |             | overall |
|     |    | health  |    |         |       |             | mental  |
|     |    | clinic. |    | Inte    |       |             | health  |
|     |    |         |    | grated: |       |             | status  |
|     |    |         |    | n=73    |       |             | ^232^.  |
|     |    |         |    |         |       |             | Not     |
|     |    |         |    | Re      |       |             | p       |
|     |    |         |    | ferral: |       |             | ossible |
|     |    |         |    | n=75    |       |             | to      |
|     |    |         |    |         |       |             | de      |
|     |    |         |    |         |       |             | termine |
|     |    |         |    |         |       |             | if      |
|     |    |         |    |         |       |             | o       |
|     |    |         |    |         |       |             | utcomes |
|     |    |         |    |         |       |             | from    |
|     |    |         |    |         |       |             | the     |
|     |    |         |    |         |       |             | int     |
|     |    |         |    |         |       |             | egrated |
|     |    |         |    |         |       |             | or      |
|     |    |         |    |         |       |             | e       |
|     |    |         |    |         |       |             | nhanced |
|     |    |         |    |         |       |             | r       |
|     |    |         |    |         |       |             | eferral |
|     |    |         |    |         |       |             | con     |
|     |    |         |    |         |       |             | ditions |
|     |    |         |    |         |       |             | were    |
|     |    |         |    |         |       |             | di      |
|     |    |         |    |         |       |             | fferent |
|     |    |         |    |         |       |             | than    |
|     |    |         |    |         |       |             | usual   |
|     |    |         |    |         |       |             | care.   |
+-----+----+---------+----+---------+-------+-------------+---------+

Table 10. Early intervention of co-occurring substance abuse and mental
health problems (continued)

+-----+----+---------+----+---------+-------+-------------+---------+
| Ref | S  | Model/  | A  | Sample  | Fol   | Outcome     | Limit   |
| ere | tu | Con     | ge |         | lowup | measures    | ations/ |
| nce | dy | ditions |    |         |       | and Results | C       |
|     | De |         |    |         |       |             | omments |
|     | si |         |    |         |       |             |         |
|     | gn |         |    |         |       |             |         |
+=====+====+=========+====+=========+=======+=============+=========+
| Osl | R  | Sertr   | 5  | Outp    | 12    | No evidence | Strong  |
| in, | CT | aline + | 5+ | atients | w     | for         | asso    |
| 2   |    | psych   |    | meeting | eeks. | efficacy of | ciation |
| 005 |    | osocial | Pl | DSM-IV  | 83.8% | naltrexone  | between |
| ^2  |    | support | ac | c       | comp  | when added  | reduced |
| 31^ |    | in      | eb | riteria | leted | to          | dep     |
|     |    | a       | o: | for     | 3     | sertraline  | ression |
|     |    | ddition |    | alcohol | m     | and         | and     |
|     |    | to:     | 62 | dep     | onths | p           | lower   |
|     |    |         | .5 | endence | of    | sychosocial | rates   |
|     |    | placebo | [+ | and a   | ps    | support for | of      |
|     |    | (PBO)   | ]{ | dep     | ychos | relapse,    | d       |
|     |    |         | .u | ressive | ocial | abstinence, | rinking |
|     |    | or      | nd | d       | treat | depression  | and     |
|     |    | nal     | er | isorder | ment. | remission,  | relapse |
|     |    | trexone | li | who had | Dro   | or overall  | during  |
|     |    |         | ne | succe   | p-out | i           | tre     |
|     |    |         | }5 | ssfully | rate  | mprovement. | atment. |
|     |    |         | .6 | co      | did   |             | Small   |
|     |    |         |    | mpleted | not   |             | sample  |
|     |    |         | N  | alcohol | d     |             | size.   |
|     |    |         | al | detoxif | iffer |             | O       |
|     |    |         | tr | ication | be    |             | utcomes |
|     |    |         | ex | (3      | tween |             | ev      |
|     |    |         | on | cons    | PBO   |             | aluated |
|     |    |         | e: | ecutive | and   |             | for     |
|     |    |         |    | days of | n     |             | re      |
|     |    |         | 64 | absti   | altre |             | mission |
|     |    |         | .2 | nence). | xone. |             | and not |
|     |    |         | [+ | 80%     |       |             | for a   |
|     |    |         | ]{ | male.   |       |             | con     |
|     |    |         | .u |         |       |             | tinuous |
|     |    |         | nd | PBO:    |       |             | outcome |
|     |    |         | er | n=37    |       |             | m       |
|     |    |         | li |         |       |             | easure. |
|     |    |         | ne | Nalt    |       |             |         |
|     |    |         | }6 | rexone: |       |             |         |
|     |    |         | .9 | n=37    |       |             |         |
+-----+----+---------+----+---------+-------+-------------+---------+

Summary

# The Current State of the Evidence

In summary, this review highlights programs and practices that have been
shown to be effective in preventing substance use and mental health
problems and suicide among older adults. The paragraphs below provide a
summary of the findings of this review.

#### *Alcohol Misuse*

Alcohol misuse is a problem that can potentially be reduced or
eliminated among many older adults through prevention and early
intervention strategies. Selected prevention strategies such as brief
advice by primary care physicians and other health care providers have
proven effectiveness in reducing alcohol misuse among older adults.
Specifically, brief interventions in health care settings have reduced
alcohol consumption among older adults, with these reductions sustained
over time (up to 12 months). Few universal prevention programs targeted
at the prevention or reduction of alcohol misuse among older adults have
been evaluated rigorously. Health education programs have demonstrated
increased knowledge among older adults about risky drinking practices
and ways to limit hazardous alcohol use. The effect of these programs on
behavior change, however, has not been evaluated. A number of screening
and assessment instruments have been developed and shown to be reliable
and feasible for use with this population. These measures show promise
to improve the quality of clinician-initiated discussions regarding
patients' substance misuse as well as to increase knowledge and motivate
behavior change among older adults. While progress has been made in
understanding the effectiveness of preventive alcohol screening and
brief interventions with older adults, there are challenges to matching
these models to different service settings and different subgroups of
older adults. Three research studies currently underway are focused on
the identification of and brief intervention with at-risk older drinkers
in health care settings.

[]{.mark}

[]{.mark}

#### *Medication Misuse*

Medication misuse is an important arena for prevention and early
intervention among older adults. Many medication-related problems are
predictable and thus potentially preventable,^135^ but the mechanisms
underlying the development of medication problems are complex. The
evidence base for prevention of medication misuse among older adults is
limited, but there are indications of some promising advances.
Computer-based health education tools have increased knowledge and
improved self-efficacy regarding potential drug interactions, as well as
improving several self-medication behaviors and reducing adverse
self-medication behaviors among older adults. A variety of promising
strategies and interventions to address medication non-adherence have
been evaluated, such as improving the formatting and effectiveness of
medication instructions, nursing-based education interventions,
compliance aids, and assessment tools, but the strength of the evidence
varies considerably. The development of assessment and screening tools
for medication misuse is limited. Clinical trials for early intervention
with older adults who are at risk for medication misuse have shown mixed
results. Studies have examined several types of early interventions,
including interventions with older patients prior to hospital discharge,
interventions targeted at provider prescription patterns, home-based
medication review, and patient education. Clinical pharmacy
interventions have been shown to reduce the occurrence of drug-related
problems but have shown limited evidence that they have an impact on
morbidity, mortality, or health care costs. Decision support systems for
prescribing are another promising avenue to decrease inappropriate or
excessive medication use and to prevent related adverse drug events
among geriatric populations. No studies were identified currently
underway addressing the prevention of, or early intervention with,
medication misuse among older adults.

[]{.mark}

[]{.mark}

#### *Depression and Anxiety*

Depression and anxiety disorders are the most prevalent mental health
problems among older adults. Although one in five older adults
experiences symptoms of anxiety,^159^ little is known about how to
prevent the onset of late-life anxiety or worsening of anxiety symptoms.
In contrast, several programs have been developed to prevent the
development or exacerbation of late-life depression. Among these
programs, a moderate amount of evidence supports the effectiveness of
PST, exercise, and targeted outreach to vulnerable older adults. Studies
of PST have found it to be effective for older persons with minor
depression or dysthymia and for reducing depressive symptoms among
caregivers of persons with dementia. The effectiveness of PST is also
currently being evaluated among persons with macular degeneration and a
previous stroke. Aerobic and resistance exercise programs have also been
associated with a reduction in depressive symptoms among the general
population of older adults, as well as among older adults with minor
depression or dysthymia. Other potentially effective strategies include
life review, reminiscence therapy, educational classes, mind-body
wellness, and provider education. Most of these approaches require
further evaluation to demonstrate their potential effectiveness among
older adults.

#### *Suicide*

Suicide is disproportionately common among older adults and the rate of
suicide completion is particularly high among older men. The research
literature describes several programs that have shown moderate
effectiveness among older adults. Supportive interventions that include
screening for depression, psychoeducation, and group-based activities
for older adults have been associated with reduced rates of suicide
among older adults. Telephone-based supportive interventions have also
been associated with a reduction in the rate of completed suicide.
Finally, protocol-driven treatment of depression delivered by a care
manager has been associated with reduced suicidal ideation. Of note,
several suicide prevention programs have been associated with reductions
in the rate of suicide among older women, but have shown more limited
effectiveness among older men. Efforts are needed to adapt and evaluate
suicide prevention programs developed overseas to meet the needs of
older Americans.

#### *Co-occurring Disorders*

The research literature describing the early intervention of
co-occurring disorders is small and is largely focused on the
comorbidity of depression and alcohol abuse. Preliminary studies suggest
that concurrent treatment of substance abuse and depression may be
effective in reducing alcohol use and improving depressive symptoms.
Early evidence also suggests that adding naltrexone, an anti-craving
medication, to antidepressant medication and psychosocial support does
not improve outcomes. In summary, little is known about the most
effective ways to prevent or treat co-occurring substance abuse and
mental health disorders. In addition, we were unable to identify any
ongoing studies that are evaluating interventions or treatments for
older adults with co-occurring disorders. The high prevalence of
substance abuse among persons with mental illness, and the high
prevalence of mental illness among persons with substance abuse,
suggests that this is an area that should receive further attention.

# Dissemination -- Translation, Implementation, and Diffusion 

Translating research into clinical practice has been highlighted in
reports from the IOM ^235^ and NIMH ^236^ as one of the most important
priorities in health care. "All too often, clinical practices and
service system innovations that are validated by research are not fully
adopted in treatment settings and service systems for individuals with
mental illness."^236^ These reports note that health care services can
be continually improved by focusing on the transitions between basic
science, the development of new treatments, clinical trials, and
implementation into practice settings. Yet, a "Quality Chasm" in health
care separates research defining the most effective treatments from
actual clinical practice in usual care.^235^ It takes over a decade for
research findings on effective treatments to be routinely implemented by
health care providers.^237^ Barriers to disseminating and implementing
evidence-based practices across mental health settings include a lack of
specific skills and knowledge among clinical staff, limited time
available for training, and a lack of dedicated financing to support
implementation and sustainability of systems change.^238^

A first step in bridging the quality chasm is the identification of
effective practices and programs supported by scientific evidence. This
document provides a current, systematic review of evidence-based
practices pertaining to the specific area of prevention and early
intervention for substance use disorders and selected mental health
problems for older adults. In order to support the process of widespread
dissemination, the content of systematic reviews will need to be
standardized and widely accessible.

The National Registry of Evidence-Based Programs and Practices (NREPP)
is a developing national resource for contemporary and reliable
information on the scientific basis and practicality of interventions to
prevent and/or treat mental and addictive disorders. To date, NREPP has
evaluated few programs that target the prevention and early intervention
of substance abuse and mental health problems in older persons. Given
the lack of programs specific to older adults, SAMHSA's Older Americans
Substance Abuse and Mental Health Technical Assistance Center has
prioritized the evaluation of prevention programs and the fostering of
NREPP review for these programs. NREPP has established high standards
for establishing the scientific merit of programs. In rating the
effectiveness of a program or practice, several factors are considered.
These include the effect size of the intervention, independent
replications, and the quality of the evidence. The quality of evidence
incorporates a review of multiple criteria, including: theory-driven
measure selection, reliability, validity, intervention fidelity,
comparison group fidelity, nature of comparison condition, assurances to
participants, participant expectations, standardized data collection,
data collector bias, selection bias, attrition, missing data, analysis
that meets data assumptions, theory-driven selection of analytic
methods, and anomalous findings. It is our hope that several of the
practices identified through this review will be evaluated and
nationally promoted through the NREPP program.

#### *Challenges to Dissemination and Implementation of Evidence-Based Practices and Programs for Older Adults*

The challenges associated with dissemination and implementation are
especially pronounced for services provided to older adults. While the
evidence base supports a variety of preventive strategies and early
interventions for substance use and mental health disorders in older
adults, there are numerous barriers to access and delivery of services.
Older adults are particularly vulnerable to age-related economic and
physical barriers to care, gaps in services, and inadequate financing of
mental health treatments and services.^239-241^ Furthermore, the lack of
providers with geriatric expertise represents a significant challenge to
providing effective substance abuse and mental health services. Although
community-based service providers are increasing their capacity to
respond to the mental health concerns of older adults, they often lack
adequate reimbursement and the staff necessary to provide appropriate
prevention and early intervention services.^241^

One of the greatest challenges to improving treatment of mental
disorders in older persons lies in the fragmentation of services.
Frequently, poor communication and coordination, differences in
expertise, and different mechanisms of reimbursement or funding across
providers, service settings, and agencies impede implementation of best
practices. These significant differences between providers across the
array of residential and service delivery settings complicate the
implementation of evidence-based treatments. For example, more than half
of older persons who receive any substance abuse or mental health
services are treated by primary care physicians,^242,\ 243^ yet these
providers often have inadequate time to address substance use/abuse and
mental health problems with the full range of competing patient
needs.^244^

#### *Evidence-Based Implementation*

The science of implementation has been extensively studied in commercial
industry, and more recently has been extended to implementation of
evidence-based practices and programs in health care and health service
organizations. Carefully designed reviews and multiple studies have
partially determined *what does not work* with respect to successful
implementation. These reviews have determined that: (1) information
dissemination alone (e.g., distribution of guidelines, algorithms, or
summaries of the research literature) is an ineffective approach to
implementation; and (2) training by itself is also ineffective as a
method of implementation.^245,246^ It is noteworthy that these are two
of the most widely used approaches by health and human services for
attempting to implement programs and practices, despite an extensive
literature that has repeatedly shown that they are ineffective. There
are literally hundreds of guidelines, algorithms, and protocols that
have been developed and disseminated regarding substance abuse and
mental health (www.guidelines.gov). Similarly, health service
organizations invest substantial resources and valuable time to conduct
workshops, conferences, continuing professional education programs, and
day-long trainings, despite a lack of evidence that these approaches
produce any significant or sustained changes in provider behavior.

Research has also identified core components and organizational change
interventions that are effective in achieving successful implementation.
There is strong evidence that *what does work* in achieving the adoption
of evidence-based practices and programs is a longer-term and sustained
multilevel approach. This multilevel approach includes core
implementation components at the level of the provider, and
organizational components at the level of the organization or system.
Core (practitioner-level) components of successful implementation
include: (1) selecting appropriate individuals who have the necessary
qualifications or characteristics to carry out the practice or program;
(2) pre-service training to introduce background information, values,
and key components of the practice or program; (3) on-the-job learning
with the help of a consultant or coach including behavior change at the
level of the practitioner and supervisor; and (4) evaluation of fidelity
(accurate application and use of the practice or program) and outcomes
(desired impact or objective for the consumer). Organizational
(system-level) components include: (1) administrative supports
consisting of organizational "buy-in", leadership, and changes that
facilitate the practice or program; and (2) systems change to ensure
that the practices or programs are supported with the necessary
financial, decision support, and human resources to support and sustain
the practice or program over time.^245^

Core implementation components cannot be installed nor sustained in the
absence of supportive organizational structures and necessary funding or
reimbursement. In particular, states and large human service
organizations often fail to identify and address policy interventions
that are required to minimize barriers and facilitate implementation of
evidence-based practices.^247,248^ In summary, regardless of the
evidence base supporting the effectiveness of a specific practice and
amount of resources devoted to dissemination and conventional trainings,
implementation is likely to fail and the service will disappear in the
absence of a multi-level approach that includes organizational changes,
targeted resources, and appropriate funding.

# Research Needs and Future Directions

Attention to the prevention and appropriate treatment of substance abuse
and mental health problems was identified as a major priority for older
adults by the President's New Freedom Commission on Mental Health.^249^
As identified in this review, there is a need for organizing,
disseminating, and understanding evidence-based prevention and early
intervention programs for late-life substance abuse and mental illness.
While progress has been made in understanding the effectiveness of these
programs and practices for older adults, there are challenges to
matching these models to different service settings and different
subgroups of older adults.

The growth in the aging population will have a significant impact on the
substance abuse and mental health service delivery systems.^11,18,190^
In anticipation of this growing problem, it is essential that substance
abuse and mental health services meet the specific needs of older
adults. For instance, cohorts of the young-old (e.g., baby boomers) and
the old-old have different patterns of service utilization and different
perceptions of stigma associated with receiving care for substance use
or mental health disorders. Moreover, the prevalence of substance abuse,
mental health disorders, and suicidal ideation vary across ethnic
groups.^199,250-255^ Mental health services are infrequently utilized by
older minority populations ^256^ and lower utilization rates may be
associated with limited access, stigma, distrust of mental health
providers, and limited availability of culturally-competent
services.^257,258^ The lack of information on specific ethnic
differences and culturally-appropriate service provision represents a
limitation of the current evidence base. A greater understanding of
cultural and ethnic differences is needed to enhance the ability to
provide appropriate prevention and early intervention to older
minorities with substance use and mental health disorders. For instance,
social marketing associated with universal prevention interventions
should be specifically tailored to cultural and language differences of
ethnic groups. In addition, cultural competence should be enhanced
across the full spectrum of prevention interventions.

This report provides a comprehensive review of the evidence for
prevention and early intervention of alcohol abuse, medication misuse,
depression and anxiety, suicide, and co-occurring disorders in older
adults. As indicated by our findings, the development of preventive
interventions associated with substance abuse surpasses that associated
with mental health problems. However, the development and rigorous
evaluation of programs that target both of these areas are sorely
needed. In addition, there is a need to identify methods to
appropriately translate information from clinical trials and research
settings into the health care arenas where older adults most frequently
receive care, and into social services settings where they receive other
needed services. Likewise, population-based programs that target broad
audiences of older adults may also offer hope for the universal
prevention of substance use and mental health problems. In summary,
substance use and mental health problems pose significant risks for the
functioning and well-being of older adults. Although several prevention
and early intervention programs have been developed, there is a
considerable need for dissemination and implementation of effective
programs, as well as for further research aimed at the development and
testing of novel programs.

Works Cited