Enhancing Behavioral Health Care for Older Adults: Practical Strategies for Agencies and Clinicians

More so than ever before, older adults need behavioral healthcare services. Since 2010, the population of adults over the age of 65 has increased by 33% in America, and it is estimated that at least 20% will experience mental health symptoms requiring integrated co-occurring disorder care (SAMHSA, 2019.)  Federal rules increased access to substance use disorder treatment services (USDHSS, 2023), reducing barriers for Medicare beneficiaries to receive the care they need. However, seniors often encounter programs built to serve a younger demographic. The rising prevalence of co-occurring disorders in older adults requires providers to adapt their services. Is your program prepared to meet the unique needs of older adults?

A Silver Wave: Addressing the Growing Behavioral Health Needs of Older Adults

Our community of senior citizens is growing at a fast pace. In fact, throughout the past 100 years, the population of people age 65 and older grew 1,000%, nearly five times faster than the total population.  According to the 2020 Census, there are 55.8 million people over the age of 65 in the United States. That’s 16.8% of the population.  The rapid growth is primarily due to the aging baby boomer generation (born between 1946 and 1964), who started reaching 65 in 2011 (Caplan, 2023).  As providers of behavioral health services, we must consider how we care for this aging population and whether or not the way we care for our senior patients is best meeting their needs. 

Just as the population of older adults is growing, the prevalence of substance use disorders among older adults is growing too.  The National Survey on Drug Use and Health found that 5.6 million Americans ages 65 and older binge drank alcohol in the past month, and 1.5 million seniors engage in heavy alcohol use (CBHSQ, 2020). 2.7 million adults age 65 and older reported past-year marijuana use, up by 250% prior to widespread legalization.   Today’s seniors are more likely than previous generations of older adults to use marijuana, heroin, cocaine, and methamphetamine, putting them at greater risk of substance use-related health consequences (SAMHSA, 2020).

The number of older adults in need of substance use disorder treatment is rapidly increasing, and this number is anticipated to continue to rise.  The National Survey on Drug Use and Health reported that 1.7 million Americans ages 50 and older have a co-occurring mental illness and substance use disorder (CBHSQ, 2020).  37% of seniors who have a substance use disorder also have a mental health condition (SAMHSA, 2020).  Seniors with co-occurring substance use and mental health disorders are at greater risk for negative outcomes (SAMHSA, 2020) and face a 50% greater likelihood of readmission within 3 months compared to those who have a mental health condition alone (Hutchison, et al., 2019).   Treatment providers must consider how effectively they care for this growing population of seniors with co-occurring treatment needs.

Navigating Complexity: Tackling the Unique Challenges of Co-Occurring Disorders in Seniors

To effectively care for senior patients with co-occurring disorders, treatment providers must address their age-specific challenges. Older adults share unique vulnerabilities, including the risks of polypharmacy, health co-morbidities, and emotional challenges including isolation and grief that increase their risks for co-occurring disorders. Adverse effects of substance misuse in this population include gait instability leading to heightened fall risk, cognitive impairment, increased risk of heart attack and stroke, psychotic episodes, accidental overdose, and suicide.

The percentage of adults who take prescription medication is greater for seniors than for any other adults. 87.5% of older adults in America take at least one prescribed medication, and 39.8% take at least five. This is concerning because older adults are also more likely to take prescribed medications that interact poorly with alcohol.  These medications, termed “alcohol-interactive” are taken by more than half of the individuals who report regular alcohol use. Among older adults, 77.8% who drink alcohol also take prescribed “alcohol-interactive” meds.  These patients are more likely to experience severe negative reactions including heart complications, liver damage, gastrointestinal bleeding, low blood pressure, and falls.   In addition, drinking alcohol while taking any of these medications can make the prescriptions less effective in treating the condition for which they were prescribed (SAMHSA, 2020).  

Co-occurring mental disorders can worsen a substance use disorder or result from substance misuse.  The most common co-occurring disorders among seniors are depression with co-occurring alcohol misuse. 29.7% of seniors who misuse alcohol also meet the criteria for depression. These patients have higher rates of liver disease and suicidality than older adults with depression who do not drink.  For seniors, depression is associated with cognitive problems including memory impairment, attention deficits, difficulty problem-solving, and reduced ability to quickly think and react. Such cognitive symptoms can make it harder for older adults to recognize their substance use problem, reducing the likelihood of independently seeking help (SAMHSA, 2020). 

Designing with Dignity: Creating Age-Sensitive Treatment Environments

Take a few minutes to walk through your agency to view it through the eyes of an older person in need of care. How easy or difficult is it to navigate through your facility? Consider the availability of public transportation and the proximity of accessible parking to your agency’s front door. Evaluate the lighting and comfort of the furnishings for an older person who may have diminished vision or ambulation difficulties. Does the facility feel welcoming to an older adult? Are there large print materials available? While engaging in treatment, will you encounter group peers with similar age and life experiences? 

Agencies can create a treatment environment more responsive to the needs of older adult patients by assessing the physical environment to identify and resolve any barriers for patients with ambulation or learning difficulties.  Strive to create an environment that is easy for older adults to navigate, well-lighted, and accessible.  Consider creating an advisory team of older adult members to help plan and implement an age-sensitive environment and specialized services. (SAMHSA, 2020) 

Healing Through Loss: Addressing Grief and Pain in Older Adults

Losses that often occur with age, such as the death of a spouse or other loved-ones may trigger grief which exacerbates mental health symptoms and increases relapse risk (Kelly, et al., 2018, SAMHSA, 2019).  Age-sensitive care should include grief counseling as well as spiritual support to meet the needs of older adults who are navigating loss  (SAMHSA, 2019).  

Strategies for coping with chronic pain is another area where older adults require specialized support. The most commonly misused medications by seniors are pain relievers. An estimated 900,000 adults aged 65 and older misused prescription opiates in the past year, making  pain reliever misuse the 4th most common type of substance misuse among older adults in the United States.  Although many seniors do use prescription opiates to “get high,” many develop dependence from misusing opiates to address sleep problems, chronic pain, or anxiety. 

In 2018, more than 9,200 Americans over the age of 55 died from opioid overdose (SAMHSA, 2020). From 2019 to 2020, synthetic opioid overdose deaths among seniors rose by 53% (Kramarow & Tejada-Vera, 2022). Seniors are also at heightened risk for alcohol-opioid interactions (SAMHSA, 2020).  Treatment providers must address this vulnerability by educating senior patients about safe medication use in recovery.

Comprehensive Screening and Assessment for Senior Patients

Routine mental health screening and comprehensive assessments are fundamental steps in identifying and treating co-occurring disorders early. Implementing routine mental health screenings for all senior patients entering SUD treatment programs allows for the early detection of mental health issues that may otherwise go unnoticed. Some screening tools validated for use with older adults include the Alcohol Use Disorders Identification Test (AUDIT), the Geriatric Depression Scale (GDS-15), the Geriatric Anxiety Scale (GAS), the Patient Health Questionnare-9 (PHQ-9) for depression, the Mini-Cog for cognitive impairment, and the Positive and Negative Syndrome Scale (PANSS) for schizophrenia. (SAMHSA, 2020).

Factors that impact senior patients’ engagement in treatment include the acuity and severity of their symptoms, physical health status, degree of cognitive impairment, and recovery capital (Yule & Kelly, 2019).  Assessing the acuity of our patients’ symptoms is vitally important.  In addition to immediately assessing and treating the acute symptoms of substance withdrawal, assess for any urgent medical needs and active suicidal ideation.  Consider the impact of co-occurring substance misuse and assess to what degree the substance use is associated with the psychiatric symptom presentation.  Assess for cognitive impairment and determine if it is due to substance misuse, head trauma, or age-related cognitive decline.  Finally, consider each patient’s level of recovery capital.  What resources do they have available at home and in their community to support ongoing recovery? 

Tailored Care: Age-Sensitive, Evidence-Based Interventions for Senior Recovery

Utilizing age-sensitive, evidence-based interventions is crucial for effectively managing co-occurring disorders in senior patients.   Cognitive Behavioral Therapy (CBT) and Motivational Interviewing (MI) are therapeutic modalities well-suited to address both substance use disorders and mental health conditions.  Other evidence-based psychotherapies for use with older adults include Twelve-Step facilitation therapy, person-centered therapy, relapse prevention therapy, and brief solution-focused therapy. Regardless of the modality used, age-sensitive therapies are those that are non-confrontational, flexible, sensitive to the patient’s level of physical and cognitive functioning, and focused on helping the patient improve their coping and social skills. Be responsive to the older patient’s values and needs, giving them choice in services they would like to receive.  

Psychoeducation and skills training are also integral components of treatment for co-occurring disorders, providing patients and their families with essential knowledge and practical tools for managing their conditions.  Educational programs can inform patients and their families about the nature of co-occurring disorders, including how substance use and mental health conditions interact and impact each other. Skills training programs focus on equipping senior patients with practical strategies for coping with their mental health symptoms and managing substance use cravings. These programs teach vital skills such as stress management, emotional regulation, and problem-solving, which are crucial for maintaining sobriety and mental stability.  By providing both education and skills training, treatment providers can enhance senior patients’ ability to navigate their recovery journey, leading to improved outcomes and sustained well-being. 

Integrated Care for Seniors: Building a Path to Recovery and Well-Being

Specialized services producing superior outcomes are those that offer age-sensitive care delivered by mental health and substance use disorder treatment staff who are knowledgeable about aging issues as well as the special needs of older adults with co-occurring substance use and mental health disorders. Such programs are shown to engage older patients in treatment better than those with a traditional treatment approach (SAMHSA, 2020).  By focusing on these strategies, agencies can effectively enhance their capacity to provide comprehensive, integrated care to older patients with co-occurring disorders. 

Specialized, integrated, senior co-occurring disorder care can improve senior patients’ mental health symptoms, overall functioning, and quality of life while supporting long-term substance use disorder recovery.  Implementing changes to provide specialized, integrated co-occurring disorder treatment for senior patients does require a multi-pronged approach. This should include increased availability of health promotion services, specialized medical care, enhanced family services, and a focus on case management to coordinate care among resources (SAMHSA, 2021). 

Family involvement in the treatment process is particularly important for this population.  Family involvement is shown to enhance treatment engagement and improve outcomes. Consider providing training to family members and other caregivers to help them identify resources and services in their communities to support the patients after discharge from your care. 

Case management is particularly important when delivering integrated co-occurring disorder treatment for senior patients.  Timely aftercare is associated with reduced readmission and increased length of time between inpatient treatment episodes (Hutchison, et al., 2019).  

Coordinating care between providers and linking patients and their families to community resources is necessary to best address the needs of seniors with co-occurring mental health disorders (SAMHSA, 2021). Lower rates of readmission to substance use disorder treatment are found when patients receive comprehensive case management support (Hutchison, et al., 2019). 

Bridging Gaps: Enhancing Integrated Care for Seniors Through Strategic Resources

Many older adults, approximately 35%, report some difficulty with independent living, self-care, hearing, vision, mobility, or cognition, so it is important that integrated care for this co-occurring population also includes assessment and accommodations to meet these needs (SAMHSA, 2019).  For agencies with limited resources aiming to provide integrated care for older patients with co-occurring disorders, strategic resource allocation is key.  One effective approach is to leverage community resources by partnering with local organizations and services. Collaborations with community mental health centers, social service agencies, and non-profits can extend the range of available support without incurring significant additional costs. These partnerships can provide access to supplemental services such as housing assistance, transportation, and additional therapeutic activities, thereby enhancing the overall care offered to patients. Developing volunteer programs can also augment support and services. Volunteers can assist with administrative tasks and offer peer support, thus freeing up professional staff to focus more on direct patient care. 

Implementing telehealth services is another cost-effective strategy, particularly beneficial for reaching older adults in rural or underserved areas. Telehealth can provide access to behavioral health care and support services, reducing barriers related to transportation and mobility issues. 

Shared Journeys: The Power of Peer Support and Age-Sensitive Groups 

Peer support staff play a crucial role in the treatment of older adults with substance use disorders, particularly those with co-occurring mental health conditions.  Employing peer support staff who have personal experience with similar challenges provides older adult patients with relatable mentors who understand their struggles firsthand. These peers offer invaluable mentorship and emotional support, helping to foster a sense of community and understanding that is particularly beneficial for older adults who may feel isolated or misunderstood.  

Because older adults tend to be more private, they may be more comfortable participating in group sessions with other patients near their age.  Age-sensitive groups allow senior patients to share their experiences and recovery strategies in a safe and supportive environment.  Consider providing a Silver Recovery support group – a space for older adults to connect with others who are facing similar challenges, promoting mutual support and the sharing of practical advice.  This age-sensitive approach can enhance motivation, reduce stigma, and improve engagement in treatment, ultimately contributing to better outcomes and a more resilient recovery process for older adults. 

Case Example

Case example: Imagine a 68-year-old, married, Caucasian female who was brought to treatment by her adult daughter after she fell down her basement stairs.  The patient’s drinking had escalated to at least 4 beers daily after her husband passed away three years ago.  Combined with the valium her doctor prescribed to help her sleep and the mood stabilizer prescribed for her agitated depression, the patient’s alcohol use poses a significant risk to her health and well-being.  She presents with cognitive confusion, poor memory, and depressed mood.  She has difficulty ambulating and is deemed a fall risk. Do we consider discharging the patient midway through her treatment due to our assessment that she is not able to sufficiently engage in our services?  Has she reached “maximum therapeutic benefit?” Has she received the care she needs to adequately address her alcohol use disorder, co-occurring depressive disorder, and unresolved grief?  

Integrated care for senior patients improves their clinical outcomes. Early discharge to mental health services is appropriate if the severity or type of mental illness is beyond what you can treat. However, older patients with depression, anxiety, or other mental disorders may be more likely to succeed in treatment if those conditions are managed in an integrated, age-sensitive way. (SAMHSA, 2020). 

The Time is Now

Seniors with co-occurring substance use and mental health disorders are an underserved population.   Misbelief that seniors do not suffer from substance use disorder, denial on the part of the older adult, and lack of provider awareness about effective treatment interventions to serve this population have been barriers to providing the care they need.  Yet, the demand of services for older adults is steadily rising, and senior admissions for the treatment of alcohol, prescription opioid, cocaine, and heroin have increased in recent years (SAMHSA, 2020).  Unfortunately, only one-quarter of addiction treatment centers in America offer services tailored to meet the needs of older adults (SAMHSA, 2020). The time is now: As the demand for specialized care for seniors with co-occurring disorders continues to grow, we must ensure our services are equipped to meet their unique needs. Start today by evaluating your agency’s approach and implementing strategies to provide more effective, age-sensitive treatment for older adults.

References

Caplan, Z. (2023, May 25). 2020 Census: 1 in 6 people in the United States were 65 and over. United States Census Bureau. https://www.census.gov/library/stories/2023/05/2020-census-united-states-older-population-grew.html  

Center for Behavioral Health Statistics and Quality (CBHSQ). (2020). Results from the 2019 National Survey on Drug Use and Health: Detailed tables. Rockville, MD: Substance Abuse and Mental Health Services Administration. www.samhsa.gov/data/ 

Hutchison, S. L., Flanagan, J. V., Karpov, I., Elliott, L., Holsinger, B., Edwards, J., & Loveland, D. (2019). Care management intervention to decrease psychiatric and substance use disorder readmissions in medicaid-enrolled adults. Journal of Behavioral Health Services & Research, 46(3), 533–543. https://doi.org/10.1007/s11414-018-9614-y

Kramarow, E.A. & Tejada-Vera B. (2022). Drug overdose deaths in adults aged 65 and over: United States, 2000–2020. NCHS Data Brief, no 455. National Center for Health Statistics. DOI:  https://dx.doi.org/10.15620/cdc:121828.

Kelly, S., Olanrewaju, O., Cowan, A., Brayne, C., & Lafortune, L. (2018). Alcohol and older people: A systematic review of barriers, facilitators and context of drinking in older people and implications for intervention design. PLoS One, 13(1), e0191189.

Substance Abuse and Mental Health Services Administration (SAMHSA). (2019). Older adults living with serious mental illness: The state of the behavioral health workforce (HHS Publication no. PEP19- OLDERADULTS-SMI). https://store.samhsa.gov/ sites/default/files/d7/priv/pep19-olderadults-smi.pdf 

Substance Abuse and Mental Health Services Administration (SAMHSA). (2020). National Survey of Substance Abuse Treatment Services (N-SSATS): 2019, Data on substance abuse treatment facilities. Retrieved from https://wwwdasis.samhsa.gov/dasis2/nssats/NSSATS_2019/2019-NSSATS-R.pdf

Substance Abuse and Mental Health Services Administration (SAMHSA). (2020). Treating substance use disorder in older adults. Treatment Improvement Protocol (TIP) Series No. 26, SAMHSA Publication No. PEP20-02-01-011. Rockville, MD: Substance Abuse and Mental Health Services Administration.

Substance Abuse and Mental Health Services Administration (SAMHSA). (2021). Psychosocial interventions for older adults with serious mental illness. SAMHSA Publication No. PEP21-06-05-001. Rockville, MD: Substance Abuse and Mental Health Services Administration.

U.S. Department of Health and Human Services. (2023, November 22). Federal Register: Treatment standards for opioid use disorder. https://www.govinfo.gov/content/pkg/FR-2023-11-22/pdf/2023-24293.pdf

Yule, A. M., & Kelly, J. F. (2019). Integrating treatment for co-occurring mental health conditions. Alcohol Research: Current Reviews, 40(1), 61–73.