U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Substance Abuse and Mental Health Services Administration 

Center for Substance Abuse Treatment 

www.samhsa.gov 

CSAT’s 

Knowledge Application Program 

KAP KEYS Based on TIP 26 

Substance Abuse Among Older Adults 

KAP Keys
 For Clinicians
 

Based on TIP 26 

Substance Abuse Among 

Older Adults 
KAP KEYS Based on TIP 26 

Substance Abuse Among Older Adults 

Introduction 

These KAP Keys were developed to accompany the Treatment 

Improvement Protocol (TIP) Series published by the Center for 

Substance Abuse Treatment (CSAT), Substance Abuse and 

Mental Health Services Administration. These KAP Keys are 

based entirely on TIP 26 and are designed to meet the needs 

of the busy clinician for concise, easily accessed "how-to" information. 

For more information on the topics in these KAP Keys, readers 

are referred to TIP 26. 

Other Treatment Improvement Protocols (TIPs) 

that are relevant to these KAP Keys: 

TIP 6, Screening Instruments for Infectious Diseases Among 

Substance Abusers (1993) BKD131 

TIP 9, Assessment and Treatment of Patients With Coexisting 

Mental Illness and Alcohol and Other Drug Abuse (1994) 

BKD134 

TIP 11, Simple Screening Instruments for Outreach for Alcohol 

and Other Drug Abuse and Infectious Diseases (1994) 

BKD143 

TIP 27, Comprehensive Case Management for Substance 

Abuse Treatment (1998) BKD251 

TIP 35, Enhancing Motivation for Change in Substance Abuse 

Treatment (1999) BKD342 
KAP KEYS Based on TIP 26 

Substance Abuse Among Older Adults 

Physical Symptom Screening 

Triggers 

1 

• Sleep complaints; observable changes in sleeping patterns; 

unusual fatigue, malaise, or daytime drowsiness; apparent 

sedation (e.g., a formerly punctual older adult begins oversleeping and is not ready when the senior center van arrives 

for pickup) 

• Cognitive impairment, memory or concentration disturbances, disorientation or confusion (e.g., family members 

have difficulty following an older adult's conversation, the 

older adult is no longer able to participate in the weekly 

bridge game or track the plot on daily soap operas) 

• Seizures, malnutrition, muscle wasting 

• Liver function abnormalities 

• Persistent irritability (without obvious cause) and altered 

mood, depression, or anxiety 

• Unexplained complaints about chronic pain or other somatic 

complaints 

• Incontinence, urinary retention, difficulty urinating 

• Poor hygiene and self-neglect 

• Unusual restlessness and agitation 

• Complaints of blurred vision or dry mouth 

• Unexplained nausea and vomiting or gastrointestinal distress 

• Changes in eating habits 

• Slurred speech 

• Tremor, motor uncoordination, shuffling gait 

• Frequent falls and unexplained bruising 
KAP KEYS Based on TIP 26 

Substance Abuse Among Older Adults 

Applying DSM-IV Diagnostic Criteria 

to Older Adults with Alcohol Problems 

2 

Diagnostic criteria for alcohol dependence are subsumed within the DSM-IV's general criteria for substance dependence. 

Dependence is defined as a "maladaptive pattern of substance 

use, leading to clinically significant impairment or distress, as 

manifested by three (or more) of the following, occurring at any 

time in the same 12-month period" (American Psychiatric 

Association 1994, p. 181). There are special considerations 

when applying DSM-IV criteria to older adults with alcohol problems. 

Criteria Special Considerations for 

Older Adults 

Tolerance May have problems with even low 

intake due to increased sensitivity to 

alcohol and higher blood alcohol levels 

Withdrawal Many late onset alcoholics do not 

develop physiological dependence 

Taking larger Increased cognitive impairment can 

amounts or over a interfere with self-monitoring; drinking 

longer period than can exacerbate cognitive impairment 

was intended and monitoring 

Unsuccessful efforts 

to cut down or control use 

Same issues across life span 

Spending much time 

to obtain and use 

alcohol and to recover from effects 

Negative effects can occur with relatively low use 

Giving up activities May have fewer activities, making 

due to use detection of problems more difficult 

Continuing use May not know or understand that probdespite physical or lems are related to use, even after 

psychological prob- medical advice 

lem caused by use 
KAP KEYS Based on TIP 26 

Substance Abuse Among Older Adults 

Clinical Characteristics of Early and 

Late Onset Problem Drinkers 

3 

Variable Early Onset Late Onset 

Age at onset Various, e.g., 

< 25, 40, 45 

Various, e.g., 

> 55, 60, 65 

Gender Higher proportion 

of men than 

women 

Higher proportion 

of women than 

men 

Socioeconomic 

status 

Tends to be lower Tends to be higher 

Drinking in response 

to stressors 

Common Common 

Family history of 

alcoholism 

More prevalent Less prevalent 

Extent and severity 

of alcohol problems 

More psychosocial, legal problems, greater 

severity 

Fewer psychosocial, legal problems, lesser 

severity 

-

tis, cancers) 

Alcohol-related 

chronic illness (e.g., 

cirrhosis, pancreati

More common Less common 

Psychiatric comorbidities 

Cognitive loss 

more severe, less 

reversible 

Cognitive loss less 

severe, more 

reversible 

Age-associated medical problems aggravated by alcohol 

(e.g., hypertension, 

diabetes mellitus, 

drug–alcohol interactions) 

Common Common 

Treatment compliance and outcome Possibly less compliant; Relapse 

rates do not vary 

by age of onset 

Possibly more 

compliant; 

Relapse rates do 

not vary by age of 

onset 

Source: Atkinson et al. 1990; Blow et al. 1997; Schonfeld and 

Dupree 1991. 
KAP KEYS Based on TIP 26 

Substance Abuse Among Older Adults 

Effect of Aging on Response 

to Drug Effect 

4 

Drug Action Effects of 

Aging 

Analgesics 

Aspirin Acute gastroduodenal mucosal 

damage 

No change 

Morphine Acute analgesic effect Increased 

Pentazocine Analgesic effect Increased 

Anticoagulants 

Heparin Activated partial thromboplastin 

time 

No change 

Warfarin Prothrombin time Increased 

Bronchodilators 

Albuterol Bronchodilation No change 

Ipratropium Bronchodilation No change 

Cardiovascular Drugs 

Adenosine Minute ventilation and heart rate No change 

Diltiazem Acute antihypertensive effect Increased 

Enalepril Acute antihypertensive effect Increased 

Isoproterenol Chronotropic effect Decreased 

Phenylephrine Acute vasoconstriction No change 

Acute antihypertensive effect No change 

Prazocin Chronotropic effect Decreased 

Timolol Chronotropic effect No change 

Verapamil Acute antihypertensive effect Increased 

Diuretics 

Furosemide	 Latency and size of peak Decreased 

diuretic response 

Psychotropics 

Diazepam Acute sedation Increased 

Diphenhydramine Psychomotor function No change 

Haloperidol Acute sedation Decreased 

Midazolam Electroencephalographic activity Increased 

Temazepam Postural sway, psychomotor 

effect,and sedation 

Increased 

Triazolam Psychomotor activity Increased 

Others 

Levodopa Dose elimination due to side 

effects 

Increased 

Tolbutamide Acute hypoglycemic effect Decreased 

Source: Adapted from Cusack and Vestal 1986. 
KAP KEYS Based on TIP 26 

Substance Abuse Among Older Adults 

Michigan Alcoholism Screening 

Test—Geriatric Version (MAST-G) 

5 

1. After drinking have you ever noticed an increase YES NO 

in your heart rate or beating in your chest? 

2. When talking with others, do you ever underesti- YES NO 

mate how much you actually drink? 

3. Does alcohol make you sleepy so that you often YES NO 

fall asleep in your chair? 

4. After a few drinks, have you sometimes not YES NO 

eaten or been able to skip a meal because you 

didn't feel hungry? 

5. Does having a few drinks help decrease your YES NO 

shakiness or tremors? 

6. Does alcohol sometimes make it hard for you to YES NO 

remember parts of the day or night? 

7. Do you have rules for yourself that you won't YES NO 

drink before a certain time of the day? 

8. Have you lost interest in hobbies or activities you YES NO 

used to enjoy? 

9. When you wake up in the morning, do you ever YES NO 

have trouble remembering part of the night 

before? 

10. Does having a drink help you sleep? YES NO 

11. Do you hide your alcohol bottles from family YES NO 

members? 

12. After a social gathering, have you ever felt YES NO 

embarrassed because you drank too much? 

13. Have you ever been concerned that drinking YES NO 

might be harmful to your health? 

14. Do you like to end an evening with a nightcap? YES NO 

15. Did you find your drinking increased after YES NO 

someone close to you died? 

16. In general, would you prefer to have a few YES NO 

drinks at home rather than go out to social 

events? 

17. Are you drinking more now than in the past? YES NO 

18. Do you usually take a drink to relax or calm YES NO 

your nerves? 

19. Do you drink to take your mind off your prob- YES NO 

lems? 

Continued on back 
KAP KEYS Based on TIP 26 

Substance Abuse Among Older Adults 

20. Have you ever increased your drinking after YES NO 

experiencing a loss in your life? 

21. Do you sometimes drive when you have had YES NO 

too much to drink? 

22. Has a doctor or nurse ever said they were wor- YES NO 

ried or concerned about your drinking? 

23. Have you ever made rules to manage your YES NO 

drinking? 

24. When you feel lonely, does having a drink help? YES NO 

Scoring 

Five or more "yes" responses are indicative of an alcohol problem. 

Source: Blow, F.C., Brower, K.J., Schulenberg, J.E., DemoDananberg, L.M., Young, J.P., and Beresford, T.P. The Michigan 

Alcoholism Screening Test—Geriatric Version (MAST-G): A new 

elderly-specific screening instrument. Alcoholism: Clinical and 

Experimental Research 16:372, 1992. 

©The Regents of the University of Michigan, 1991. 
KAP KEYS Based on TIP 26 

Substance Abuse Among Older Adults 

The AUDIT Questionnaire 6 

Circle the number that comes closest to the patient's answer. 

1. How often do you have a drink containing alcohol? 

(0) Never (1) Monthly or less 

(2) Two to four times a month (3) Two to three times a week 

(4) Four or more times a week 

2. How many drinks containing alcohol do you have on a typical 

day when you are drinking? [Code number of standard drinks.1

] 

(0) 1 or 2 (1) 3 or 4 (2) 5 or 6 

(3) 7 to 9 (4) 10 or more 

3. How often do you have six or more drinks on one occasion? 

(0) Never (1) Less than monthly 

(2) Monthly (3) Weekly (4) Daily or almost daily 

 How often during the last year have you found that you were 

not able to stop drinking once you had started? 

4.

(0) Never (1) Less than monthly 

(2) Monthly (3) Weekly (4) Daily or almost daily 

 How often during the last year have you failed to do what 

was normally expected from you because of drinking? 

5.

(0) Never (1) Less than monthly 

(2) Monthly (3) Weekly (4) Daily or almost daily 

6. How often during the last year have you needed a first drink in 

the morning to get yourself going after a heavy drinking session? 

(0) Never (1) Less than monthly (2) Monthly 

(3) Weekly (4) Daily or almost daily 

7. How often during the last year have you had a feeling of guilt 

or remorse after drinking? 

(0) Never (1) Less than monthly (2) Monthly 

(3) Weekly (4) Daily or almost daily 

8. How often during the last year have you been unable to 

remember what happened the night before because you had 

been drinking? 

(0) Never (1) Less than monthly (2) Monthly 

(3) Weekly (4) Daily or almost daily 

9. Have you or someone else been injured as a result of your 

drinking? 

(0) No (2) Yes, but not in the last year 

(4) Yes, during the last year 

10. Has a relative or friend or a doctor or other health worker 

been concerned about your drinking or suggested you cut down? 

(0) No (2) Yes, but not in the last year 

(4) Yes, during the last year 

1 In determining the response categories it has been assumed that one drink 

contains 10 g alcohol. In countries where the alcohol content of a standard 

drink differs by more than 25 percent from 10 g, the response category 

should be modified accordingly. 

Continued on back 
KAP KEYS Based on TIP 26 

Substance Abuse Treatment Among Older Adults 

Scoring 

Question 1 Never 0 

Monthly or less 1 

2 to 4 times per month 2 

2 to 3 times per week 3 

4 or more times per week 4 

Question 2 1 or 2 0 

3 or 4 1 

5 or 6 2 

7 or 9 3 

10 or more 4 

Question 3-8 Never 0 

Monthly or less 1 

Monthly 2 

Weekly 3 

Daily or almost Daily 4 

Question 9-10 No 0 

Yes, but not in the last year 2 

Yes, during the last year 4 

The minimum score (for nondrinkers) is 0 and the maximum 

possible score is 40. A score of 8 or more indicates a strong 

likelihood of hazardous or harmful alcohol consumption. 

In some patients, the AUDIT questions may not be answered 

accurately because they refer specifically to alcohol use and 

problems. Some patients may be reluctant to confront their 

alcohol use or to admit that it is causing them harm. 

Individuals who feel threatened by revealing this information 

to a health worker, who are intoxicated at the time of the 

interview, or who have certain kinds of mental impairment 

may give inaccurate responses. Patients tend to answer 

most accurately when: 

• The interviewer is friendly and nonthreatening 

• The purpose of the questions is clearly related to a diagnosis of their health status 

• The patient is alcohol- and drug-free at the time of the 

screening 

• The information is considered confidential 

• The questions are easy to understand 

Source: Saunders, J.B., Aasland, O.G., Baabor, T.F., de la 

Fuente, J.R., and Grant, M. WHO collaborative project on early 

detection of persons with harmful alcohol consumption. II. 

Development of the screening instrument "AUDIT." British 

Journal of Addictions, in press. 
KAP KEYS Based on TIP 26 

Substance Abuse Among Older Adults 

The CAGE Questionnaire 7 

1. Have you ever felt you should cut down on your drinking? 

2. Have people annoyed you by criticizing your drinking? 

3. Have you ever felt bad or guilty about your drinking? 

4. Have you ever had a drink first thing in the morning to steady 

your nerves or to get rid of a hangover (eye opener)? 

Scoring 

Item responses on the CAGE are scored 0 for "no" and 1 for 

"yes" answers, with a higher score an indication of alcohol 

problems. A total score of 2 or greater is considered clinically 

significant. 

Note: Although two or more positive responses are considered indicative of an alcohol problem, a positive response to 

any one of these questions should prompt further exploration among older adults. 

Source: Ewing 1984. 
Ordering Information
 

TIP 26 

Substance Abuse Among 

Older Adults
 

Easy Ways to Obtain Free Copies 

of All TIP Products 

1. Call SAMHSA’s National Clearinghouse for Alcohol and 

Drug Information (NCADI) at 800-729-6686, 

TDD (hearing impaired) 800-487-4889. 

2. Visit CSAT’s Web site at www.csat.samhsa.gov 

Do not reproduce or distribute this publication for a fee without specific, written authorization from the Office of 

Communications, Substance Abuse and Mental Health 

Services Administration, U.S. Department of Health and 

Human Services. 

DHHS Publication No. (SMA) 01-3586 

Printed 2001