![](media/image1.png){width="4.004861111111111in"
height="1.1888888888888889in"}

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

Excerpt: Prevention of Substance Misuse Problems: Medication Misuse

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.

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.^4-10^ An estimated one in five older
Americans (19%) may be affected by combined difficulties with alcohol
and medication misuse.^11-14^ 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.^15-18^

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.^19,20^ 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.^21-23^ 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.^24^ 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.^24^ Consistent with younger
populations, older women have lower smoking rates than older men.^25^
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;^26^ an
estimated 60 percent to 70 percent of older male alcohol users smoke a
pack or more of cigarettes each day.^27^ Smoking is a major risk factor
for many of the leading causes of death among individuals age 60 and
older,^28,29^ and is associated with increased risk of losing mobility
^30^ and premature death.^31^ Smoking also affects the performance of
some prescription drugs. For example, smokers tend to require higher
doses of benzodiazepines to achieve efficacy than nonsmokers.^32^

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.^33^ 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.^34^
A study of older smokers using transdermal nicotine patches found that
29 percent of the subjects quit smoking for 6 months.^35^ 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.^36^

# 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.^37^ 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.^38,39^ 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.^40^ 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 1 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.^41^ 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).^42^ 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
^43^ 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^44^ 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 ^45^ 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 ^46^
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.) ^47-50^ and use of calendar blister packs compared to
standard bottles or packets among older patients.^51^ Schlenk and
colleagues ^46^ 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 2 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 ^52^ 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 ^53^ 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 ^53^ 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 ^54^ 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 ^55^
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 ^56^ 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 ^57^ 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 ^58^ 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.^59^ 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.^60^
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 ^61,62^ and one showed a
non-significant increase in admissions.^63^ 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 ^64^
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.^65^ 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 ^66^
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.^67^ 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 2). Fielo and Warren ^68^ 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 ^69^ 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 ^70^ 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 ^71^ found that clients
demonstrated improved knowledge regarding medications 1 week after a
teaching session (no control group). Finally, Wolfe and Schirm ^72^
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.^73^ 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."^74^ 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.^74^ 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 1. 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  |    | adults  | ad    | 82%         | size.   |
| a   | me | of      | M  | newly   | minis |             | Stand   |
| l., | nt | older   | ea | a       | tered | Test-retest | ardized |
| 1   | E  | adults  | n: | dmitted | 1     | reliability | ins     |
| 998 | va | admin   | 72 | to a    | week  | 92%         | trument |
| ^   | lu | istered |    | home    | later |             | to      |
| 45^ | 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 |
| ^   | st | and     | .8 | parti   | sel   | drug and    | ed      |
| 42^ | 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  |
| ^   | du |         | .8 | parti   | t-int | lf-efficacy | content |
| 41^ | 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 1. 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 |
| ^   | E  | ttended | .7 |         | phone | and had     | ualized |
| 44^ | 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 |
| ^   | P  | omputer | n: | senior  |       | 32% took    | r       |
| 43^ | 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 2. Early intervention with late-life medication misuse

+-----+----+---------+----+---------+-------+--------------+--------+
| Ref | S  | Mo      | A  | Sample  | Fol   | Outcome      | L      |
| ere | tu | del/Con | ge |         | lowup | Measures and | imitat |
| nce | dy | ditions |    |         |       | Results      | ions/\ |
|     | De |         |    |         |       |              | Co     |
|     | si |         |    |         |       |              | mments |
|     | 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     |
| ^   | -b | 1: No   | n: | m       | visit | medic        | some   |
| 65^ | 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 |
| ^   | ca | inc     | t: | to 4    | (90%  | pill counts. | term   |
| 55^ | 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 |
| ^   | ch | atients | an | at      | made  | incidence of | for    |
| 57^ | 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 2. Early intervention with late-life medication misuse (continued)

+-----+----+---------+----+---------+-------+--------------+--------+
| Ref | S  | Mo      | A  | Sample  | Fol   | Outcome      | L      |
| ere | tu | del/Con | ge |         | lowup | Measures and | imitat |
| nce | dy | ditions |    |         |       | Results      | ions/\ |
|     | De |         |    |         |       |              | Co     |
|     | si |         |    |         |       |              | mments |
|     | 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; |
| ^   | of | respons | en | in      | lphia | serious med  | longer |
| 54^ | 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%   |
| ^   | sc | and     | .4 | gestive |       | controls     | for    |
| 56^ | 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 2. Early intervention with late-life medication misuse (continued)

+-----+----+---------+----+---------+-------+--------------+--------+
| Ref | S  | Mo      | A  | Sample  | Fol   | Outcome      | L      |
| ere | tu | del/Con | ge |         | lowup | Measures and | imitat |
| nce | dy | ditions |    |         |       | Results      | ions/\ |
|     | De |         |    |         |       |              | Co     |
|     | si |         |    |         |       |              | mments |
|     | 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 |
| ^   | Re | c       | ea | edicine | pu    |  \< 0.0001). | medi   |
| 64^ | 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  |
| ^   | of | plus    | .2 | units   | onths | controls at  | zation |
| 53^ | 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 |
|     | Ph | ocedure | rl | meds    | lowup | the Int.     | visits |
|     | ar | (below) | in |         | rate  | group. Int.  | and    |
|     | ma |         | e} | Interv: | for   | group had    | ho     |
|     | ­ce | Co      | 5  | 45      | both  | s            | spital |
|     | ut | ntrols: | .7 |         | vi    | ignificantly | admiss |
|     | ic | S       |    | Co      | sits) | fewer        | ions). |
|     | al | tandard | C  | ntrols: |       | unplanned    | R      |
|     | Co | di      | on | 44      |       | trips to     | andomi |
|     | un | scharge | tr |         |       | doctor and   | zation |
|     | se | pro     | ol |         |       | hospital     | by     |
|     | li | cedure, | s: |         |       | admissions   | unit   |
|     | ng | which   | 81 |         |       | (19 and 5,   | inc    |
|     |    | 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 2. Early intervention with late-life medication misuse (continued)

+-----+----+---------+----+---------+-------+--------------+--------+
| Ref | S  | Mo      | A  | Sample  | Fol   | Outcome      | L      |
| ere | tu | del/Con | ge |         | lowup | Measures and | imitat |
| nce | dy | ditions |    |         |       | Results      | ions/\ |
|     | De |         |    |         |       |              | Co     |
|     | si |         |    |         |       |              | mments |
|     | 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     |
| 58^ | 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 |
| ^   | E  | r       | [  | d       |       | aids. No     | for    |
| 66^ | 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 |
| ^   |    | rmacist |    | to 10   | ital- | compared to  | needed |
| 60^ |    | 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  |         |       |              |        |
+-----+----+---------+----+---------+-------+--------------+--------+

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.^75^
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.^76-78^ 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.^79-85^ Mental health services are infrequently utilized by older
minority populations ^86^ and lower utilization rates may be associated
with limited access, stigma, distrust of mental health providers, and
limited availability of culturally-competent services.^87,88^ 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

+-----------------------------------------------------------------------+
| **To receive the other excerpts or the complete "Evidence-Based       |
| Practices for Preventing Substance Abuse and Mental Health Problems   |
| in Older Adults," please contact:**                                   |
|                                                                       |
| SAMHSA Older Americans Substance Abuse and Mental Health              |
|                                                                       |
| Technical Assistance Center                                           |
|                                                                       |
| 1-888-281-8010                                                        |
|                                                                       |
| OlderAmericansTAC@westat.com                                          |
|                                                                       |
| www.samhsa.gov/OlderAdultsTAC                                         |
+-----------------------------------------------------------------------+