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SUBSTANCE ABUSE

The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:

• Background: Substance Use Disorders
• Definitions
• Assessment/Screening Tools
• Nursing Strategies for Substance Use Disorders
• Nursing Care Strategies
• Expected Outcomes
• Follow-up Monitoring

Background: Substance Use Disorders

• In 1998, the prevalence of alcoholism, alcohol abuse or problem drinking in persons aged 60+ was estimated at 5-10% in community studies.¹ Approximately 11% of men and 9% of women 75 years and older report heavy use, placing them "at risk" for a range of problems.²
• Excessive drinking among individuals of all ethnic groups 65+ years is approximately 7%, down from 12% in persons ages 55-64.³
• Five hundred thousand persons ages 55 and over reported monthly use of illicit drugs in the National Household Survey of Drug Use.⁴
• Substance use disorders in older adults are classified in several categories, determined by the substance used, the length of time of use/abuse or dependence, and the consequences for the individual.
• Metabolic changes increase morbidity associated with substance use in advancing age.
• While persons over 65 make up only 14% of the population, they are prescribed more than 30% of all prescription drugs and non-medical use of prescription drugs is increasing in persons over 60.⁴
• Approximately 11% of women over the age of 59 misuse psychoactive drugs.⁵
• An older adult who suddenly discontinues consuming more than 10 ounces of alcohol a day for a week or more is likely to experience more symptoms of withdrawal in greater duration than younger persons. Onset of withdrawal may be as early as 4-8 hrs after the last drink, and persist up to 72 hrs.⁶

Risk factors for Substance Use Disorders in Older Adults

• Family history of dependence on alcohol, tobacco, prescription or illicit drugs
• Co-occurrence with another substance dependence, i.e. alcohol and tobacco
• Life long pattern of substance use
• Male gender
• Social isolation
• Recent and multiple losses
• Chronic pain
• Co-occurrence with depression
• Unmarried and/or living alone

Cost of Substance Abuse and Dependence

• Direct and indirect economic costs of substance abuse and dependence, including costs of illness and crime, are estimated at $414 billion a year with 143. 4 billion attributed to illicit and prescription drugs.⁴
• Alcohol related traffic deaths in adults over age 65 are about 15% of all traffic deaths. Alcohol use is related to the development of chronic diseases, particularly neuro-psychiatric and digestive disorders, as well as cardiovascular disease and cancer. Misuse of medications in persons over 60 costs US $ 60 billion annually.⁴

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Definitions

Substance Use Disorders: a broad category of disorders which include a continuum of use or misuse of alcohol, tobacco, prescription or illicit drugs and the abuse or dependence on these drugs.⁷

Substance Abuse: a maladaptive pattern of substance use evidenced in recurrent and significant adverse consequences related to the repeated use of substances. It is associated with repeated failure to fulfill role obligations, use in situations where use is physically hazardous, and/or when it results in legal and/ or interpersonal problems. ⁷

Substance Dependence: a pattern of self-administration of a drug that is maladaptive and results in the development of tolerance, withdrawal and compulsive drug taking behavior. Dependence is both physiologic and psychological. ⁷

Tolerance: 1) a need for markedly increased amounts of a substance to achieve intoxication or the desired effects or 2) a markedly diminished effects with the continued use of the same amount of a substance.⁷

Withdrawal: a characteristic group of signs and symptoms which has its onset following the sudden cessation of consumption of a drug (including alcohol and nicotine) that induces physiologic dependence.⁷

At-risk drinking: defined as more than 1 drink per day, seven days a week or more than three drinks on any one occasion. For elders, at risk drinking increases the likelihood of negative health consequences.¹

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Assessment/Screening Tools

Screening for alcohol, tobacco and other drug use is recommended for all community dwelling and hospitalized older adults. It is essential that the nurse: 1) state the purpose of questions about substances used and link them to health and safety, 2) be empathic and non-judgmental, 3) ask the questions when the patient is alcohol and drug free, 4) inquire re: patient's understanding of the question.

The Quantity-Frequency Index ⁸
Review all classes of drugs: alcohol, nicotine, illicit drugs, prescription drugs, over-the- counter drugs and vitamin supplements, for each drug used. Record the Types of drugs, including types of beverages; Frequency: the number of occasions on which the drug is consumed (daily, weekly, monthly), Amount of drug consumed on each occasion over the last thirty days. The psychological function that the substance serves for the individual is also important to identify. The Quantity-Frequency Index tool should be part of the intake nursing history. The Brown Bag approach is useful. ⁹ The patient is asked to bring all drugs and supplements listed above to the interview with the provider.

TRY THIS: Short Michigan Alcohol Screening Test-Geriatric Version (SMAST-G)¹⁰ Highly valid and reliable, this is a 10 item tool that can be used in all settings. Three minutes for administration.

Alcohol Use Disorders Identification Test (AUDIT)¹¹ This ten item questionnaire has good validity in ethnically mixed groups and scores classify alcohol use as hazardous, harmful or dependent. Administration: 2 minutes.

Fagerstrom Test for Nicotine Dependence (revised): This six question scale provides an indicator of the severity of nicotine dependence (Scores of 0-2 Very low, to 8-10 Very High). The questions inquire as to first use early in the day, amount and frequency, inability to refrain, and smoking despite illness.¹²

Atypical Presentation

• Men and women over the age of 65 may have substance use and dependence problems even though the signs and symptoms may not correspond to those listed in the DSM-IV TR.⁷
• For the older individual, several factors increase the risks associated with use, making any drug use harmful in circumstances which do not apply at younger ages. Constitutional factors include changes in body composition like decreased muscle mass, decreased organ efficiency (especially kidney and liver), and increased vulnerability of the central nervous system.¹³,¹⁴
• The consequences of excessive alcohol consumption and alcohol use in combination with other drugs include falls, impaired cognition, malnourishment, and decreased resistance to disease, interpersonal and legal problems.
• At-risk drinking for elders increases the likelihood of negative health consequences and is defined as more than 1 drink per day, seven days a week or more than three drinks on any one occasion.
• Smoking at any level places older persons at risk for negative health consequences, and advancing age increases the likelihood of the emergence of respiratory and cardiovascular illnesses.

Assessment and Interventions for Specific Signs and Symptoms in Substance Use Disorders

Sign or Symptom	Assessment and Nursing Intervention
Smoking cigarettes or using smokeless tobacco	Assess for level of dependence using the Fagerstrom Test (See tool above). Apply the 5A's Intervention 1. Ask: Identify and document tobacco use. 2. Advise: Urge the user to quit in a strong personalized manner. 3. Assess: Is the tobacco user willing to make a quit attempt at this time? 4. Assist: If user is willing to attempt refer for individual or group counseling and pharmacotherapy. Implement pharmacotherapy once quit date is established. FDA approved pharamacotherapies for smoking cessation are: Bupropion SR, nicotine gum, nicotine inhalers, nicotine nasal spray and nicotine patch. Communicate Caring and Concern 5. Arrange: Schedule follow-up contact in person or by telephone within one week after planned quit date.
Signs of CNS Intoxication , i.e. slurred speech, drowsiness, unsteady gait, decreased reaction time, impaired judgment, disinhibition, ataxia	Assess in individual or collateral data collection, consumption of amount and type of depressant medications including alcohol, sedatives, hypnotics and opioid or synthetic opioid analgesics. Assess vital signs and determine respiratory, cardiac or neurological depression. Assess for treatable existing medical conditions, including depression. Arrange for emergency room/hospitalization treatment as necessary Obtain urine for toxicology, if possible. Hydrate with clear fluid p.o. as indicated. Limit use of intravenous fluid except as necessary. Hospitalize if: Blood alcohol level (BAL) >100mg/dl Severe withdrawal symptoms Suicidal ideation or attempts Comorbid conditions which compromise treatment Polysubstance dependence
At-risk drinking-consumption of alcohol in excess 1 drink per day for seven days a week or more than three drinks on any one occasion.	Assess for Readiness to Change behavior using Stages of Change Model: 18 Is drinker concerned about amount or consequences of the drinking? Has she/he contemplated cutting down? Does she/he have a plan for cutting down/stopping consumption? Has he/she previously stopped but then resumed risky drinking? Conduct Brief Intervention (FRAMES) 15 Feedback information to the client about current health problems or potential problems associated with their level of consumption. Responsible choice about how to respond to the information provided to the client is his/her choice. Advice must be clear about drinking his/her levels and recommended moderate levels of drinking. Menu of choices is provided by the nurse to the patient/client regarding future drinking behaviors. Empathy is essential to the exchange. Offer information based on scientific evidence, acknowledge the difficulty of change, avoid confrontation. Self-Efficacy of the individual is supported and the nurse helps client explore options for change.
Signs of Withdrawal of CNS Depressant drugs, including alcohol such as tremors, disorientation, tachycardia, irritability, anxiety, insomnia, moderate diaphoresis. May develop extreme CNS stimulation and progress to seizures, hallucinosis, withdrawal delirium, extreme hypertension, profuse diarrhea, from 4-8 hours and for up to 72 hrs. following cessation of alcohol intake (Delirium Tremens/DTs).	Assess neurological signs, using the Clinical Institute Withdrawal Assessment (CIWA-Ar).16 This is a 10 item rating scale that delineates symptoms of gastric distress, perceptual distortions, cognitive impairment, anxiety, agitation and headache. Medicate with a short acting benzodiazepine (Lorazepam or Oxazepam) in doses titrated to patient's score on the CIWA, patient's age and weight.16
Reported sleep disturbance, anxiety, depression, problems with attention and concentration.	Assess for neuro-psychiatric conditions using the Mental Status exam, Geriatric Depression Scale or Hamilton Anxiety Scale. Obtain sleep history (See Sleep Topic) Assess intake of all drugs, including alcohol, OTC, prescription and nicotine. Use "Brown Bag" strategy. If positive for alcohol use, assess for last time of use and amount used. Assess for alcohol or sedative drug withdrawal as indicated.
Concerns about returning to addictive or heavy use of a drug (Relapse)	Refer to community based Alcoholics Anonymous, Narcotics Anonymous, Al-Anon groups and encourage attendance. Educate family and patient regarding signs of risky use or relapse to heavy or alcohol dependent behavior. Counsel patient to reduce drug use (Harm Reduction) and engage in relationship healing/building, community or intellectually rewarding activities, spiritual growth etc. which increase valued non-drinking rewards. Counsel in the development of Coping Skills such as to: Anticipate and avoid temptation. Learn cognitive strategies to avoid negative moods. Make life style changes to reduce stress, improve the quality of life and increase pleasure. Learn cognitive and behavioral activities to cope with cravings and urges to use. Encourage development or expansion of patient's social support system.
Smoking marijuana	Refer to Steps for Smoking Cessation. Refer patient to addiction specialist for counseling for psychological dependence and/or cognitive-behavioral therapy. Refer to community based self-help groups such as Narcotics Anonymous, Alcoholics Anonymous or Al-Anon. Encourage development or expansion of patient's social support system.

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Nursing Strategies for Substance Use Disorders

Detection of a Substance Use Disorder
Screening for alcohol and/or other drug related problems by nurses, physicians and other care providers is infrequent in primary care settings and on admission to hospitals or long term care facilities. Health providers, family members and friends may overlook substance related problems in older persons because they are not disruptive to their lives or clearly linked to physical disorders. Health professionals are often pessimistic about the possibilities of behavioral change in older persons or about the effectiveness of alcohol or drug treatment. Increasingly, alcohol and other drug disorders are being recognized as chronic conditions, which respond to treatment. Interventions and treatment must be repeated at various points in time because addiction is a chronic illness characterized by relapse. Substance use disorders include:

• Dependence (addiction)
• Risky or heavy drinking
• Abuse
• Polysubstance abuse

Assessment Considerations

• Most individuals who are users of and/or dependent on alcohol, nicotine and illicit drugs have developed these disorders before the age of 60.
• Between ½ and 2/3 of elderly alcoholics, for example, are believed to have developed the disease early in life.
• "Late-onset alcoholism" appears to be more closely associated with the losses, chronic illness, psychological traumas and other stresses of advancing age which may increase the use of a substance. A common example of this is change from social use to risky drinking by a woman who has lost a spouse, partner or job, or who is facing serious illness.
• Among older women who misuse substance, however, as high as 30% developed such habits after age 60.¹⁷
• For the nurse in clinical practice, changing patterns reinforce the importance of obtaining a substance use history dating from first use prior to the current situation. It is important to know if the individual ever experienced problems, spontaneously stopped using a drug, or is recovery and participating in self-help programs.
• Older persons may have had many substance free years following addiction, and are vulnerable to relapse for many of the reasons listed above.
  Questions such as 1) "Did you ever feel you had a problem related to alcohol or other drug use?" and 2) "Have you ever been treated for an alcohol or drug problem?" can reveal such information.
• The Michigan Alcohol Screening Test-Geriatric version (MAST-G) is an effective tool for screening elders in all settings.10 The complete drug use history should be used in comprehensive assessment. The AUDIT may be used as well.¹¹ (See Assessment Tools).

Dependence (addiction) on a substance is a maladaptive pattern of substance use which leads to impairment or distress (legal, interpersonal, emotional/mental) occurring in a 12 month period.⁷ It has two components:

1. 1) physiologic dependence, which occurs with alcohol, tobacco, benzodiazepines, barbiturates, amphetamines and opioids, and
2. 2) psychological dependence, the perceived need to use the drug. Physiologic dependence involves "tolerance", the need for increasing amounts of a substance to achieve the desired effect and "withdrawal", manifested in a characteristic pattern of symptoms when the substance is suddenly terminated, including craving.

• An older patient is at risk for withdrawal from alcohol after consuming more than 13 oz a day for a week or more. Onset of withdrawal may be as early as 4-8 hrs after the last drink, and up to 72 hrs.
• Physiologic dependence is addressed in medically supervised detoxification or by "weaning" to low doses of the substance prior to cessation of its use.
• Addiction is a chronic illness characterized by brief "slips" from sobriety and "relapse", a return to regular use of the substance.
• Withdrawal in persons over 65,especially those who are frail, as well as sudden withdrawal of depressant drugs, is characterized by more symptoms of longer duration than in younger people and can be life threatening. Medically supervised detoxification is recommended.
• Psychological dependence also occurs with addiction and is the more difficult dependence to address.

Abuse, risky or heavy drinking. Abuse of a substance is characterized by a maladaptive pattern of use, leading to impairment or distress (legal, interpersonal, emotional/mental) such as failing to fulfill role obligations, use in physically hazardous situations, occurring in a 12 month period.⁷

• Even when an individual; does not meet the DSM-TR-IV criteria for abuse or dependence, alcohol consumption at levels above 7 drinks per week for persons over 65 has health consequences.
• It may place the older individual at risk for falls, self-neglect, diminished cognitive capacity or the development of physical disorders like diabetes, pancreatic or head and neck cancer.
• Because of the high comorbid occurrence of alcohol and nicotine dependence, chronic obstructive pulmonary disease and cancer of the mouth often co-occur. Larynx and esophagus are common co-occurring disorders.
• Heavy drinking is also associated with ulcers, respiratory disease, stroke and myocardial infarction.
• Alcohol interacts with at least 50% of most frequently prescribed drugs and since older persons take many of these, alcohol use may be hazardous.

Polysubstance Abuse

• Consists of misuse, abuse or dependence on three or more drugs.
• In older persons prescription analgesics are frequently prescribed and can induce dependence.
• It is recommended that the prescriber avoid opioids and the synthetic opioid Demerol. The opioids have high potential for addiction and Demerol has been associated with delirium in elders.
• Barbiturates should be avoided for use as hypnotics and benzodiazepines should be used minimally for anxiety.
• Examples of substances which elders often combine in self-administration include alcohol, tobacco, benzodiazepines, marijuana and analgesic opioids.

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Nursing Care Strategies

Individualized care plans should be developed for elders at risk for substance abuse or dependence in accord with the classes of drugs used and the severity of the disorders. Guidelines for all interventions should include:

1. A non judgmental, health oriented approach to substance related problems. Drug/alcohol use and abuse are highly stigmatized in American society particularly in minority communities, leading to denial and/or rejection by family members. When nurses and other health professionals understand addiction as a disease, approaches to care can be more similar to those of other chronic illnesses.

2. A supportive, encouraging approach to the possibilities of changing use habits. Using the Stages of Change Model helps the patient/client understand that change occurs in stages and that support and assistance are available at each stage.¹⁸

3. Education of patient and family on the risks associated with drug misuse in older people. Because use may be less extensive and obvious, its potential health consequences may be minimized in the eyes of others.

4. Assessment of substance use in relation to life style, nutritional patterns, sleep, exercise, sexual patterns and recreation. Counsel the patient and/or family about the effects of substances used on these areas of the patient's life.

5. Set the goal of "Harm Reduction" in the forms of deceased use and supervised use if abstinence is not imperative or achievable.

6. Monitor substance use patterns at each encounter or visit, documenting changes and providing re-.enforcement of positive changes and/or movement toward treatment.

7. Enhance the involvement of members of the patient's support system; including family and friends identified by the patient, community based groups, support groups, appropriate clergy or organizational groups such as senior centers.

8. Support the development of coping mechanisms, including modifications in social, housing and recreational environments, to minimize associations with settings and groups in which substance use and abuse are common.

Treatment Options
Interdisciplinary Collaboration is essential to all treatment modalities for substance use disorders and related problems because drug use affects physical, mental, spiritual and emotional health. Primary care providers, dentists, nurses and social workers may all be equipped to detect and refer a problem and perspectives on all levels of health should be addressed during treatment and aftercare. This is especially true for older persons who are disinclined to seek or continue care with mental health or addictions specialists.

Inpatient Hospitalization
A 10-28 day period of acute care hospitalization in a mental health unit or alcohol and drug treatment center is indicated for the older person addicted to alcohol, benzodiazepines, heroin, amphetamines or cocaine when: 1) access to the drug makes abstinence unlikely, 2) severe withdrawal symptoms are present, 3) co-morbid physical or psychiatric diagnoses such as depression and accompanying suicidal ideation are present 4 )daily ingestion of alcohol or a sedative hypnotic has been above recommended doses for 4 weeks or more. It is helpful if programs specifically designed to meet the needs of older persons are available.

Ambulatory Care
Persons dependent on alcohol, tobacco, and heroin can be successfully withdrawn in community based care through the collaboration of a medical doctor or nurse practitioner and family members/friends. Specialists in addiction should be sought as supervisors/collaborators in the process. Older persons drinking at risky levels or abusing alcohol or other drugs are generally treated in the community. Tobacco cessation protocols are now available directly to consumers as well as to primary care providers and mental health professionals.

Residential Treatment is available in specialty care centers; therapeutic communities and some long term care facilities. Programs designed specifically for the older person are not very numerous but are beneficial in their focus on the specific challenges to abstinence which the older person faces such as the long standing nature of the habits of use, a diminished social network and challenges to financial and health resources.

Therapeutic Communities provide long term (up to 18 months) treatment and are abstinence-oriented programs. They use 12 Step Models of individual and group counseling as well as participation in a social community, to address drug related problems. For the isolated, older drug user with a history of frequent relapse, these are good treatment options.

Pharmacological Treatment agents for pharmacological treatment of substance abuse and dependence are more numerous than previously but not all are appropriate for use with elders. The best outcomes of pharmacological interventions occur when they are used with individual and/or group counseling. Attendance at twelve step programs also enhances adherence to treatment regimens.

Alcohol Abuse/Dependence: Naltrexone, in the form of Revia, is used to decrease cravings in heavy drinkers and is now available in injectable form (Vivitrex). Evidence suggests that it is well tolerated by older people who do not have renal problems. Acamprosate (Campral), a recent addition to prescription drug choices, is reported to be effective in reducing the craving and consumption of alcohol. Antabuse or Disulfiram to deter alcohol consumption produces an elevation in vital signs and severe gastrointestinal symptoms if alcohol is ingested and may be poorly tolerated by alcoholic older than 55. In addition, it must be taken every day if aversive effects on consumption are to occur.

Heroin or Opioid Dependence:

• Older long-term opioid users may relapse and require treatment. Methadone or Buprenorphine are current pharmacological treatment options.
• Treatment with methadone, a synthetic narcotic agonist, suppresses withdrawal symptoms and drug cravings associated with opioid dependence but require daily dosing of 60 mg, minimum. It is dispensed only in specially licensed clinics.
• Buprenorphine (Subutex), recently approved for use in office practice by trained physicians, is an opioid partial agonist-antagonist. Alone and in combination with Naloxone (Suboxone), it can prevent withdrawal when someone ceases use of an opioid drug. Naloxone is an opioid antagonist used to reverse depressant symptoms in opiate overdose and at different dosages to treat dependence.
• Close collaboration with the prescriber is required as neither drug should be abruptly terminated, should not be used with antidepressants, and interact negatively with many prescription medications.
• Naltrexone, a long acting opioid antagonist blocks opioid effects and is most effective with those who are no longer opioid dependent but are at high risk for relapse.
• Treatment of the older patient who has become addicted to oxycontin or other opioids should be done in consultation with an addictions specialist nurse or physician.

Counseling and Psychotherapy

• Older persons tend to seek care from their primary care, medical specialist or nurse/nurse practitioner provider even in regard to assistance with mental health and substance related problems. This practice relates to old beliefs about depression or anxiety being manifestations of weakness or lack of character.
• Excessive use of alcohol or use of an illicit drug or misuse of prescriptions drugs are viewed as highly negative from a social perspective. Counseling done by the nurse using a brief intervention model or supportive counseling is more readily acceptable to older patients than referral to mental health or substance abuse clinics.
• Optimally, short term psychotherapy therapy by a practitioner knowledgeable about substances and their problematic use is extremely helpful. The model of cognitive therapy in particular, has demonstrated good outcomes with excessive drinking and marijuana use. These approaches assist the older person to modify behavior and to deal with t negative feelings and/or chronic pain that often motivate use.

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Expected Outcomes

Patient will have:

• Improved physical health and function.
• Improved quality of life, sense of well-being and mental health.
• Better interpersonal relationships.
• Enhanced productivity and mental alertness.
• Decreased likelihood of falls and other accidents.

Health Care Provider will have:

• Increased accuracy in detecting patient problems related to use/misuse of substances.
• Interventions will be more evidence-based resulting in better outcomes.

Institution will have:

• Increased number of referrals to ambulatory substance abuse/mental health treatment programs.
• Improved links with community based organizations engaged in prevention, education and treatment of elders with substance related disorders.

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Follow-up Monitoring

• Evaluate for anticipated increase in substance use/misuse associated with aging "Baby Boomer" generation.
• Increase outreach to targeted vulnerable populations.
• Document chronic care needs of elders diagnosed with substance related diagnosed with substance related disorders.
• Communicate findings to all members of the involved caregiver team.

References

1. Fleming, M.F., Manwell, L.B., Barry, K.L.. & Johnson, K. (1998). At-risk drinking in an HMO primary care sample. Prevalence and health policy implications. American Journal of Public Health, 88 (1), 90-93.

2. Lyness, J.M., Canine, E.D., King, D.A., Cox, C. & Yoedino, Z. (1997). Psychiatric disorders in older primary care patients. Journal of General Internal Medicine, 14, 249-254.

3. NYCDOHMH, 2005. New York City Department of Health. (2005). Alcohol use in New York City. NYC Vital Signs,4(1). [on-line] available at http://search.nyd.gov/query.html.

4. National Institute of Drug Abuse (NIDA). (2001).The economic costs of drug abuse in the United States, 1992-1998[on-line].available Accessed August 1, 2005 at http://www.nida.nih.gov.

5. Fingeld-Connett, D. (2004). Treatment of substance misuse in older women using a Brief Intervention Model. Journal of Gerontological Nursing, 31-37.

6. Collins, E.D. & Kleber, H.D. Opioids. (2004). In Galanter, M. & Kleber, H.D. (Eds.). Textbook of substance abuse treatment.Washinton, D.C.: American Psychiatric Association.

7. American Psychiatric Association. (2000). Diagnostic and statistical manual of Mental Disorders-IV-TR. 4th ed. Washington, D.C.: American Psychiatric Association.

8. NIAAA Q/F Index. (1995). In Allen, J.P. & Columbus, M. Assessing alcohol problems: A guide for clinicians and researcher. Bethesda, M.D: U.S. Department of Health and Human Services.

9. Substance Abuse among Older Adults Consensus Panel for the Treatment Improvement Protocol Series (TIPS) 1998, 26. Frederic C. Blow, Ph.D., Consensus Panel Chair , U.S. Department of Health and Human Services, Public Health Service, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, Rockwall II, 5600 Fishers Lane, Rockville, Maryland (DHHS Publication No. SMA 98-3170).

10. Blow, F.C., Brower, K.J., Schulenberg, J.E., Demo-Danenberg, L.M., Young, J.P. & Beresford, T.P. (1992). Michigan Alcoholism Screening Test-Geriatric Version: A new elderly specific screening instrument. Alcoholism, Clinical and Experimental Research, 16(2), 372.

11. Saunders, J.B., Asland, O.G., Babor, T.F., et al. (1993). WHO Collaborative project on early detection of persons with harmful alcohol consumption II. Development of the screening instrument "AUDIT". Addiction, 88, 79-804.

12. Heatherton, TF; Kozlowski, LT; Frecker, RC; Fagerstrom, KO.(1991).The Fagerstrom Test for Nicotine Dependence: a revision of the Fagerstrom Tolerance Questionnaire. British Journal Addiction, 86 (9), 1119-27.

13. Lang, M.M. (2001). Screening for cognitive impairment in the older adult. Nurse Practitioner, 26, pp.26, 32-34, 41.

14. Kennedy, G.J. (2000). Geriatric mental health care: A treatment guide for health professionals. New York: The Guilford Press.

15. Dyehouse, J., Howe, S., & Ball, S. (1996). FRAMES model in Training Manual for Nursing Using Brief Intervention for Alcohol Problems. U.S. Department of .Health and Human Services: Rockville, Md.

16. Sullivan, J.T., Sykora, K., Schneiderman, J., Naranjo, C.A. & Sellers, E.M. (1989). Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-AR). British Journal of Addictions, 84, 1353-1357.

17. CASA (Center for Alcohol and Substance Abuse).(1998). Under the rug: Substance abuse and the mature woman. New York: Columbia University.

18. Prochaska, J.O. & Di Clemente, C.C. (1992). Stages of change in the modification of problem behaviors. Progress in Behavior Modification, 28, 183-218.

Last updated - October 2005

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