# Presentation: 656409

## Drug and Alcohol Treatment Outcomes in Older Adults 

- Derek D. Satre, Ph.D.
- Jennifer Mertens, M.A.
- Sujaya Parthasarathy, Ph.D.
- Constance Weisner, Dr.PH., M.S.W.
- University of California, San Francisco *and*
- Kaiser Permanente Division of Research

## Study Support

-   Studies were supported by the National Institute on Drug Abuse (R01 DA08728 and R37 DA10572) and the National Institute on Alcohol Abuse and Alcoholism (R37 AA10359).
- The first author was supported by a National Institute on Drug Abuse training grant (T32 DA07250) and center grant (P50 DA09253).
- The Drug and Alcohol Research Team at the Kaiser Division of Research and the staffs of the Kaiser Chemical Dependency Recovery Programs provided essential support for these studies.

## Key Older AdultTreatment Research Gaps

- Clinical needs of older adults in treatment
- Studies of private programs
- Factors associated with treatment success
- Gender differences
- Long term outcomes
- Cost impacts

## Research Questions

- How are older patients different from others at baseline and at 6-month follow-up?
- How do older patients differ by gender?
- How are 5-year outcomes of older adults in treatment different from those of other patients?
- How do health service utilization and cost offset associated with treatment differ by age group?

## Sample

- 1204 patients at Kaiser completed CD treatment intakes at outpatient facilities in Sacramento, from 1994 to 1996. (Day Hospital Study)
- 							-Weisner et al., 2000
- Drug testing was used to validate self-report
- 80% of patients completed six-month follow-up
- response rate increased with age: 77% of younger, 83% of middle-aged, and 91% of older adults

## Treatment Program

- Randomized to day hospital outpatient or lower-intensity outpatient care
- Abstinence-based, 12-step informed, group format included education, relapse prevention and family-oriented therapy
- Individual counseling and physician appointments were available as needed

## Theoretical Framework for Analyses

- Treatment outcome is determined by
- Individual characteristics
- Treatment
- Extra-treatment factors
- How are older adults different from other patients in these domains that influence outcome?

## Analyses

- Compared three age groups:
- 736 patients ages 17-39, mean age = 30.4 (sd = 6.3)
- 379 patients ages 40-54, mean age = 45.1 (sd = 3.8)
- 89 patients ages 55-81, mean age = 61.6 (sd = 6.0)
- Examined gender differences within the older adult group
- Tested predictors of abstinence using logistic regression

## Key Baseline Age Differences

- Older adults (55-81):
- Married, Caucasian, retired
- ASI score means (vs. younger adults):
- Higher alcohol severity
- Lower drug severity
- Greater medical problems
- Fewer social and family problems
- Less psychiatric distress (ASI and SCL-66)
- More likely to have abstinence goal
- 							   -Satre et al., 2003

## Length of Stay in Treatment 

- Treatment length was measured in days
- Older and middle-aged stayed longer than younger, p < .001

## Abstinence Rates at Six Months

- Significant overall age group differences,       _p_ = .03

## Factors Associated with Greater Age, and with Abstinence at Six Months

- Being married*
- Dependence criteria not met*
- Less hostility on SCL-66*
- Abstinence goal***
- Greater length of stay***
- (Age was NS)

## Implications

- Older adults bring several strengths to treatment that younger adults lack, such as lower hostility and greater abstinence motivation, and they stay in treatment longer
- However, these advantages do not translate into substantially higher abstinence rates

## Why Study Older Women?

- Fastest growing segment of the population
- Heavy users of health services
- Concerns about prescription drug use
- May be more sensitive to alcohol or drugs than men
- May have different treatment needs and access issues

## Gender Differences in Six-Month Outcome

- N = 92 (29 women and 63 men)
- Alcohol dependent adults age 55 and over
- Data drawn from two outcome studies (Day Hospital Study and Integrated Care Study) to increase sample size									-Weisner et al., 2000, 2001.

## Baseline Characteristics of Older Women versus Older Men

- Lower income (53% vs. 33% earn under 40K)*
- Not married (38% vs. 62% married)*
- Later onset of heavy drinking (5+) (age 35 vs. 28)*
- Comparable baseline alcohol consumption (16 days per month of 5+ drinks)
- Comparable tranquilizer use (25% vs. 29%)
- Perhaps more distress (78% vs. 60% anxiety, NS)
- Comparable abstinence goal (100% vs. 90%)
- 							-Satre et al., 2004a

## Length of Stay by Gender

- Older women stayed an average of 24 days longer in treatment than older men (NS)

## Abstinence at Six Months by Gender

- 79% of older women abstinent at six months, vs. 54% of older men (_p_ < .05)

**Notes:**
Among those who were not abstinent, women had lower frequency of heavy drinking (5+). 

## Clinical Implications for Older Women

- Strengths
- Abstinence goal
- Length of stay
- Good abstinence outcomes
- Special needs
- Social support (living alone)
- Economic support
- Depression and anxiety treatment

**Notes:**
Also are implications for older men: may need more assistance of some kind. 

## Day Hospital Sample at Five Years

- 77% of the sample completed 5-year follow-up
- Older adults more likely to maintain Kaiser membership (91% vs. 80%, 59%)
- Mortality by age group:
- 1% of younger
- 5% of middle-aged
- 11% of older
- 						                 -Satre et al., 2004b

## Five Year Outcomes

- Older adults had lower legal and family/social ASI scores than younger adults
- No difference on other ASI scores
- Higher 30-day and 1-year abstinence rates than younger adults (all substance diagnoses)
- No age difference in abstinence among those only dependent on alcohol

## 30-day Abstinence Rates at Five Years by Age Group

- Significant overall age group differences, _p_ = .02

**Notes:**
Outcome measure was 30-day total abstinence from alcohol and drugs. Alcohol dependent only: no age difference. 

## 30-day Abstinence at Five Years by Age and Gender

**Notes:**
Older women were more likely to be abstinent than older men or younger women. 

## Age Differences in Social Networks

|  | Younger | Middle | Older |
| --- | --- | --- | --- |
| Married (%)*** | 39 | 54 | 59 |
| AA groups in past 12 months  | 89 (96) | 93 (99) | 61 (77) |
| Ever called AA for help (%)*** | 47 | 42 | 19 |
| Recovery helpers | 8 (11) | 9 (13) | 5 (8) |
| Encourages use (% saying yes)* | 17 | 12 | 8 |
| Kaiser coverage** | 59 | 80 | 91 |

## Predictors of Abstinence at Five Years

- Female gender**
- Length of stay***
- Nobody encouraged drinking or drug use***
- Not significant
- Age group
- CD diagnosis
- Treatment intensity
- Married at year five
- Kaiser membership at year five

## Five-Year Study Key Points 

- Older women have the best outcome
- Greater length of stay in treatment has long-term benefits
- Older adults show strengths and weakness in social networks

## Proposed Intervention 

- Based on profile of social networks
- Lower AA use in older adults
- Activate or expand informal support
- Supplement mixed-age program
- Age-specific interpersonal psychotherapy group (K award study)

## Medical Conditions

- Study compared CD patients in treatment to demographically matched control from the Kaiser membership
- One third of medical conditions examined were more prevalent in CD patients, especially:
- Hypertension, liver cirrhoses, COPD, asthma, injuries, lower back pain, arthritis, headache, depression, anxiety, psychosis
- 		                                                             -Mertens et al., 2003

## Medical Conditions in Patients Age 55 and Over

- CD patients had higher rates than age- and sex-matched controls:
- Ischemic heart disease
- Depression
- Anxiety

## Health Care Utilization and Cost

- Records of CD patients were examined 18 months pre- and post-intake
- Compared to utilization and cost records in a non-patient control group, using automated health plan records
- Examined age group differences
-                                                  -Parthasarathy et al., 2001

## Utilization and Cost Findings

- Greater age was positively associated with pre-treatment cost in both samples
- Post-treatment, decline in cost was larger in the treatment sample than in the matched sample for those aged 40 to 49, but not in older age groups

## Areas for Further Investigation in Older Adults

- Improving outpatient CD treatment
- Social network intervention
- 9 and 11 year Day Hospital study follow-up
- Remission, alcohol vs. drug use
- How CD (and treatment) affects health
- Health conditions and psychiatric disorders
- Services utilization and cost
- Primary care study
- Dual diagnosis study funded by RWJF

## References

- Mertens, J. R., Lu, Y. W., Parthasarathy, S., Moore, C., & Weisner, C. (2003). Medical and psychiatric conditions of alcohol and drug treatment patients in an HMO. *Archives of Internal Medicine, 163,* 2511-2517.
- Parthasarathy, S., Weisner, C., Hu, T.W., & Moore, C. (2001). Association of outpatient alcohol and drug treatment with health care utilization and cost: Revisiting the offset hypothesis. *Journal of Studies on Alcohol, 62,* 89-97.
- Satre, D. D., Mertens, J. R., Areán, P. A., & Weisner, C. (2003). Contrasting outcomes of older versus middle-aged and younger adult chemical dependency patients in a managed care program. *Journal of Studies on Alcohol, 64,* 520-530.
- Satre, D. D., Mertens, J. R., & Weisner, C. (2004a). Gender differences in older adult treatment outcomes for alcohol dependence. *Journal of Studies on Alcohol, 65*, 638-642.

## References (cont.)

- Satre, D. D., Mertens, J. R., Areán, P. A, & Weisner, C. (2004b). Five-year alcohol and drug treatment outcomes of older adults versus middle-aged and younger adults in a managed care program. *Addiction, 99*, 1286-1297.
- Weisner, C., Mertens, J., Parthasarathy, S., Moore, C., Hunkeler, E. M., Hu, T.-W. & Selby, J. V. (2000) The outcome and cost of alcohol and drug treatment in an HMO: day hospital versus traditional outpatient regimens. *Health Services Research, 35,* 791-812.
- Weisner, C., Mertens, J., Parthasarathy, S., Moore, C., & Lu, Y. (2001) Integrating primary medical care with addiction treatment: a randomized controlled trial. *Journal of the American Medical Association, 286,* 1715-1723.
- 	_Contact:_ Derek Satre, Ph.D., UCSF, 401 Parnassus, Box 0984-OVS, San Francisco, CA 94143. Email: dereks@lppi.ucsf.edu