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Excerpt: Prevention of Substance Misuse Problems: Alcohol 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.^4-6,^ ^7-10^ 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^

# 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 1 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.^37^ 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 ^38^ 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.^39^ 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).^40,41^ 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.^42^ In particular, despite the common occurrence of
alcohol problems, health care personnel often fail to recognize problem
drinking among older patients.^4,43^ 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.^44-46^ 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.^4,47,48^

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.^49^ 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 ^50^ 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.^51^ 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.^52^ 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.^1,53-56^ To date, three randomized clinical
trials have examined brief interventions to reduce hazardous drinking
among older adults in primary care settings. Please see Table 2 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 ^57^ 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.^58^ 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.^59^ 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).^60^ 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.^61^ 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.^62^ 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^63^ 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.^1,52,64^
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,^65^ 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 1. Prevention and screening of late-life alcohol misuse

+----+------+--------+----+---------+-------+--------------+---------+
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| ef | tudy | l/Cond | ge |         | lowup | Measures and | tions/C |
| er | De   | itions |    |         |       | Results      | omments |
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|    | lity | asked  | 89 |         |       | of           | plicate |
|    | Ev   | to     |    |         |       | satisfaction | easily. |
|    | alua | come   | M  |         |       | and interest |         |
|    | tion | earl   | ea |         |       | with         |         |
|    |      | y/stay | n: |         |       | materials.   |         |
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|    |      | 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     |
| ^3 | Pr   | ears + | A  | Problem | (7    | alcohol use. | problem |
| 9^ | 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      |
| 40 |      | pro    | ge | "       | ser   | p            | those   |
| ,\ |      | motion | 65 | alcohol | vices | articipants' | older   |
|  4 |      | se     | -6 | coun    |       | use of free  | adults  |
| 1^ |      | 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 1. 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 |          |
| ^3 |      |        |    |         | sponse | moderate to | i |          |
| 8^ |      |        |    |         | rate). | heavy       | z |          |
|    |      |        |    |         |        | drinkers,   | e |          |
|    |      |        |    |         |        | improved    | . |          |
|    |      |        |    |         |        | knowledge   | N |          |
|    |      |        |    |         |        | sig         | o |          |
|    |      |        |    |         |        | nificantly. | m |          |
|    |      |        |    |         |        |             | e |          |
|    |      |        |    |         |        |             | a |          |
|    |      |        |    |         |        |             | s |          |
|    |      |        |    |         |        |             | u |          |
|    |      |        |    |         |        |             | r |          |
|    |      |        |    |         |        |             | e |          |
|    |      |        |    |         |        |             | o |          |
|    |      |        |    |         |        |             | f |          |
|    |      |        |    |         |        |             | b |          |
|    |      |        |    |         |        |             | e |          |
|    |      |        |    |         |        |             | h |          |
|    |      |        |    |         |        |             | a |          |
|    |      |        |    |         |        |             | v |          |
|    |      |        |    |         |        |             | i |          |
|    |      |        |    |         |        |             | o |          |
|    |      |        |    |         |        |             | r |          |
|    |      |        |    |         |        |             | , |          |
|    |      |        |    |         |        |             | a |          |
|    |      |        |    |         |        |             | l |          |
|    |      |        |    |         |        |             | t |          |
|    |      |        |    |         |        |             | h |          |
|    |      |        |    |         |        |             | o |          |
|    |      |        |    |         |        |             | u |          |
|    |      |        |    |         |        |             | g |          |
|    |      |        |    |         |        |             | h |          |
|    |      |        |    |         |        |             | s |          |
|    |      |        |    |         |        |             | o |          |
|    |      |        |    |         |        |             | m |          |
|    |      |        |    |         |        |             | e |          |
|    |      |        |    |         |        |             | p |          |
|    |      |        |    |         |        |             | a |          |
|    |      |        |    |         |        |             | r |          |
|    |      |        |    |         |        |             | t |          |
|    |      |        |    |         |        |             | i |          |
|    |      |        |    |         |        |             | c |          |
|    |      |        |    |         |        |             | i |          |
|    |      |        |    |         |        |             | p |          |
|    |      |        |    |         |        |             | a |          |
|    |      |        |    |         |        |             | n |          |
|    |      |        |    |         |        |             | t |          |
|    |      |        |    |         |        |             | s |          |
|    |      |        |    |         |        |             | d |          |
|    |      |        |    |         |        |             | i |          |
|    |      |        |    |         |        |             | d |          |
|    |      |        |    |         |        |             | i |          |
|    |      |        |    |         |        |             | n |          |
|    |      |        |    |         |        |             | d |          |
|    |      |        |    |         |        |             | i |          |
|    |      |        |    |         |        |             | c |          |
|    |      |        |    |         |        |             | a |          |
|    |      |        |    |         |        |             | t |          |
|    |      |        |    |         |        |             | e |          |
|    |      |        |    |         |        |             | b |          |
|    |      |        |    |         |        |             | e |          |
|    |      |        |    |         |        |             | h |          |
|    |      |        |    |         |        |             | a |          |
|    |      |        |    |         |        |             | v |          |
|    |      |        |    |         |        |             | i |          |
|    |      |        |    |         |        |             | o |          |
|    |      |        |    |         |        |             | r |          |
|    |      |        |    |         |        |             | a |          |
|    |      |        |    |         |        |             | l |          |
|    |      |        |    |         |        |             | i |          |
|    |      |        |    |         |        |             | n |          |
|    |      |        |    |         |        |             | t |          |
|    |      |        |    |         |        |             | 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 |
| ^5 | ARPS | s      |    | group   |        | (median     |   | of CARPS |
| 2^ |      | 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   |
| ^5 | ARPS | AUDIT; | 65 | care    |        | AUDIT;      |   | subset   |
| 0^ |      | 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    |
| ^5 | and  | MAST-G | .3 | i       |        |             |   | and      |
| 1^ | 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 2. 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     |
| ^5 | of   | cement |    | dr     | tele   | \# of       | erventi |
| 7^ | 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       |
| e  | He   | 1      |    | bjects | 3, 6,  | show        | nalysis |
| t\ | alth | 20-25  | M  | (26 %  | 12, 18 | si          | still   |
| al | Prof | min    | ea | Afric  | mos.   | gnificantly | being   |
| ., | iles | interv | n: | an-Ame |        | more        | com     |
| in | Pro  | appt   |    | rican) | 92%    | reduction   | pleted. |
| pr | ject | with   | 66 |        | pa     | in          | I       |
| og |      | cli    | [+ | Male   | tients | frequency   | ncludes |
| re |      | nician | ]{ | and    | com    | and         | broader |
| ss |      | to     | .u | female | pleted | quantity    | age     |
| ^5 |      | review | nd | pa     | 12     |             | group   |
| 8^ |      | 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 2. 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 |
| ^5 | ject |        | 81 | (defined |      | st-interv). | and     |
| 9^ |      |        |    | 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 |          |      |             |         |
+----+------+--------+----+----------+------+-------------+---------+

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.^66^
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.^67-69^ 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.^70,71-76^ Mental health services are infrequently utilized by
older minority populations ^77^ and lower utilization rates may be
associated with limited access, stigma, distrust of mental health
providers, and limited availability of culturally-competent
services.^78,\ 79^ 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

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| Practices for Preventing Substance Abuse and Mental Health Problems   |
| in Older Adults," please contact:**                                   |
|                                                                       |
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|                                                                       |
| Technical Assistance Center                                           |
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| 1-888-281-8010                                                        |
|                                                                       |
| OlderAmericansTAC@westat.com                                          |
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