Sorry I am so late only time I had a chance to post:
A topic that is becoming more prevalent in the elderly population is alcohol abuse/dependence and suicide. The lack of education of family, friends and professionals about signs and symptoms of alcohol abuse/dependence has caused this issue to be hidden from view. Many times the symptoms for these diagnoses that are presented are confused for another diagnosis. Also, there are concerns about the diagnostic criteria of alcohol abuse/dependence has made this issue the silent epidemic of the geriatric population. The clinical protocols for treatment are not as clear as other medical issues. This confusion about the proper intervention and treatment for this challenging population has caused this population to get lost through the cracks of the medical system.
With the longevity in the elderly population, the number of individuals that are sixty-five and older are staggering. What is even more concerning is the number of elderly that are battling alcohol abuse/dependence without primary care doctors and loved ones knowing. Unfortuneurly, many times the first place it is seen is in the hospital. IN grad school I saw a study shown high rates of alcohol related hospilizations among Medicare beneficiaries. This should cause extreme concern for primary care doctors work in the gerontology field. With many patients on a variety of medicines for other medical conditions, alcohol can cause adverse side effects for the patient.
Unfotunely the material that is out there to assist with diagnosis is not suitable for this population. This causes barriers to effective treatment protocols and confusion to both the patient, family and the primary care provider.
There are several screesnign tools to assess dor alcholism.
After initial screening tool are used, then the clinician usually looks up the criteria in the Diagnostic and Statistical Manuel of Mental Disorders, fourth edition, revised (DSM-IV-TR) to confirm the screening diagnosis. The criteria seen in the DSM-IV-TR was created with the focus on a younger generation.
The numbers of people with alcohol dependence/abuse that have committed or attempted suicide is raising concern among the geriatric field. When I was in grad school I remember reading about different studies about ETOH and suicide in the elderly generation. ETOH abuse/dependence and sucide in elderely men were higher. Many folks that did have a completed sucide typtically had a prior occurance of an attemeped suicide. When learnign about the way folks normally tried to kill themselves were non-violent means: ie carbon monoxide poisioning, drug overdose and drowning. It was very interesting to read that non-violent methods were used primarily as the final act. Many times the non-violent methods are people calling out for help, and not knowing the proper resources that are out there to assist them with battling this disease. For some, the proper intervention could save them from ending their lives.
I think it would be beneficial to have a separate criteria for ETOH abuse and depence for the elderly...
I have had several patients in teh hospital that were elderely that many families did not know or the secrest was kept within the family about the ETOH abuse. Very few times did the patient actaully wanted help..
Kasie excellent work. Thank You for accepting the challenge and putting in the work. Team, this is a great issue and reason number 1 being the the Elderly and ETOH, DEPRESSION, and SUICIDALITY are all three underdiagnosed and so so so interelated and important. In the medical settings I have probably seen cases like this over a thousand times and it is where the medical model goes wrong. In the three hospitals, I have worked at I haven't seen a routine depression screening tool such as Becks Short form geriatric depression screening form. Social workers use this on at an individual level but nothing is uniform so that we are catching and treating more. Kasie, When I was at Evergreen, it was a macro issue that I at one point wanted to take on but I just had so many other irons in the fire at that time. That being said, I regret that I back burnerd it because it was just as important if not more than other things I worked on. Awe, hind sight is 20/20. I wonder if you might demonstrate some leadership in this area one day in this area.
So Kasie, Why does the medical model turn it's back on these issues? Can you give us your clinical impression. Kasie and Team I would like some of your imput on how Erik Erikson might integrate his theories about human development with some of the issues these Elderly may be facing. What stages of development are they in? Have they stagnated or regressed and what stages would illustrate a more healthy integration of coping with some of their life long losses?
Team this topic is really an example of how any topic might come at you on the LICSW exam but if we are well conditioned about using the theories especially and I can't emphasise enough with human development and applying them
According to Erik Erikson's theory, people who are in their late adulthood experience either "integrity" or "despair".
Some older adults can often look back on their lives with happiness and are content, feeling fulfilled with a deep sense that life has meaning and they've made a contribution to life.
On the other hand, some adults may reach this stage and despair at their experiences and perceived failures. They may fear death as they struggle to find a purpose to their lives.
We probably find ETOH,depression, and suicide issues more frequently among the second group of poeple. I believe that their struggle to find a purpose in life resulted in individualistic ideology in this culture and generation. I think many older people find hapiness in their family because that is their legacy. In this culture and time, we find many disfunctional families as we all know. I work with many many elderly patients who have no family members supporting them. ETOH dependence and depression are not as common in cultures that value collectivism and family connections.
I think Family Systems Theory can be so effective as we work with patients like this. This theory suggests that "one cannot be understood in isolation from one another, but rather as a part of their family, as the family is an emotional unit."
Empowering pt and family may lead to a great result...
Yurika, very nice use of theory integration. It's funny how much having that knowledge of the theories begins to illustrate things. Nice Risk taking. Team this is exactly the kind of think I would like to see in this blogging. Don't be afraid to play with these theories. And excellent use of the family systems as well, pulling family's back together and holding them accountable and not just adding to the isolation that the identified pt is already feeling. And I tell you it takes alot of work because physicians and other members of the team in whatever work setting you practice on aren't going to get their hands dirty. But we have the know how to understand that it is the right thing to do albeit the pt is agreeable. Good Work, I love it!
Yurika, I was really interested in your comment on individualism v. communal focus. In my experience this has really been true. When I think about older adult patients with ETOH abuse and suicidal ideology I think of scores of grumpy white men who consider themselves rugged individualists, who value their independence and haven't bonded well with family or friends. Many times the people they consider "friends" are those with similar habits or those who enable them. I think their is a prejudice about older adults that says "they are about to die anyway, let them do what they like." The falacy here is of couse assuming that their addiction is "something they like". Or that somehow the last years of their lives are useless anyway. I think a lot of practitioners give up on older adults as people. We assume that their cognitive skills are diminishing and that learning isn't possible. Also, the system isn't set up to serve them. Even if they do want help it isn't readily available. I also really agree that Erickson hit this one on the head. Dispair is the right word to describe the experience of some of our older patients. We may be seeing family estrangement/abandonment, complicated grief, loss of physical/mental ability, loss of community engagement, etc. This is an instance where you really can't be effective without considering systems theory. Getting patients involved in their own lives sometimes means something as simple as resource brokerage (transportation to church, sr. center, etc) or something as complicated as reinvolving family. Either way I think that recognizing strengths is again the key to identifying motivation. Getting the pt. talking about what it is that they are/were best at, what they are/were proud of, what they still enjoy in their daily lives and helping to reframe. Alcoholism is just the pits. It's such a tough one for me to consider/tackle. I think I do have empathy for those suffering from alcoholism but I get nervous about over identifying/conscious use of self/boundaries etc. because of my family experience. I screen and try to identify and educate my team, but I prefer referal to direct practice. That's just where I'm at.
Denice, thank you for your feedback. I like your thoughts about some of the prejudices Clinician's hold towards elderly patients. I really think this is issue is reallly a systems issue of bringing more awareness to our own providers and on a larger national scale as well. But I think we can have immediate impacts with Nurses, Community Players, MD's, PCP's, Dialysis Centers and so on.
I especially like the point about the assumption of diminishing cognitive skills. Being Hard of Hearing, HOH, Blindness or slowing down physically in no way effects cognitive ability. If I am being honest, I think there is laziness at times of the clinician where if someone isn't able to give me information in the amount of time I want to process it, I will just go to the family member and they will give me the true story. I tell you in the hospital, we rely too much on families to give us the full picture not that they aren't important but it certainly is an easy way at times. By not being patient with your agenda and going into your assessments with fixed agendas, you aren' allowing for patients to take part in the theraputic process where you may have some time to zoom in on some their feelings about depression or alcoholism.
Also, I am always impressed when people are able to recognized their own transference issues because it opens you up for growth and Denice you have been pretty consistent about this with Drug and Alcohol issues and your Family history
Team, For those of you who haven't shared. I was wondering if one of you would comment on this topic and integrate Erickson's Stagnation VS Generativity phase.
Yurika- I agree with your statement re: ETOH dependence and depression are not as common in cultures that value collectivism and family connections. We are part of a society that really does idealize individualism and it is basically "all for one self". The Jones are trying to be better than the Peters in respect to socio-economic status, etc... and this can lead to depression, etoh and drug abuse/dependence. The past 5 years I have worked in the med setting, I have seen many elderly /Senior pt's come in with with related issues. Not only with w/drawl but with multiple co-morbidities (i.e renal failure, endstage liver disease)that have actually lead to an early death. More often than not, they have burned all bridges with their families and nobody is willing to extend a hand again in the fear that they will be burned. These people die alone and/or go back to their terrible living conditions to only revolve back in to the hospital the next month with "etoh w/drawl" as a dx. In my work as a CDP, I saw different "losses" from the disease in the elderly population (and in reality this population was not the major percentage of my clients because of the guilt, shame and stigma attached to the disease). I saw lonley people who had lost most of their family, but most of them had not yet lost their health to the point of being hospitalized. We had one group only at Res XII for this population... that tells you how little of the population they were. They are from such different generations that our current one. Think of all the guilt and moral shaming that they have..... it is still an issue with those of our generation and I feel we have moved leaps in the direction of disease model as opposed to "moral disease" since their generation. Generativity is an extension of love into the future. It is a concern for the next generation and all future generations. When the indiidual is so consumed with their addiction and likely so deep in to their depression, it is hard to give to others when you have nothing to give and you can hardly find purpose for yourself. Stagnation is self-absorption, caring for no-one. The stagnant person ceases to be a productive member of society, which in most (not all) cases can be the story of an addict. There are many "high functioning" etoh addicts who seem to skate by (barely) until they eventually (and they all will) hit bottom. But even if they are still functioning in work, family etc.... on the outside you may not be able to tell, but to those on the inside, the disease is not very good at hiding. It can be sneaky, manipulative and deceitful but it usually can't hide for too long.
Talking about stagnation makes me think of people dependent on drugs or alcohol at any age. Knowing someone while they are hitting "bottom" can really be freeing...traumatic...but freeing. What I mean by that is that sometims accepting the worst possible outcome allows a family member to become vulnerable (vulnerability as a strength...like open) and engage again. Hospitalization can be that time when family feels safe to explore reunification. It is also the time when pt.'s may be most open to change. I think I miss the opportunity to recognize these openings and facilitate this type of reunion.
Sorry I am so late only time I had a chance to post:
ReplyDeleteA topic that is becoming more prevalent in the elderly population is alcohol abuse/dependence and suicide. The lack of education of family, friends and professionals about signs and symptoms of alcohol abuse/dependence has caused this issue to be hidden from view. Many times the symptoms for these diagnoses that are presented are confused for another diagnosis. Also, there are concerns about the diagnostic criteria of alcohol abuse/dependence has made this issue the silent epidemic of the geriatric population. The clinical protocols for treatment are not as clear as other medical issues. This confusion about the proper intervention and treatment for this challenging population has caused this population to get lost through the cracks of the medical system.
With the longevity in the elderly population, the number of individuals that are sixty-five and older are staggering. What is even more concerning is the number of elderly that are battling alcohol abuse/dependence without primary care doctors and loved ones knowing. Unfortuneurly, many times the first place it is seen is in the hospital. IN grad school I saw a study shown high rates of alcohol related hospilizations among Medicare beneficiaries. This should cause extreme concern for primary care doctors work in the gerontology field. With many patients on a variety of medicines for other medical conditions, alcohol can cause adverse side effects for the patient.
Unfotunely the material that is out there to assist with diagnosis is not suitable for this population. This causes barriers to effective treatment protocols and confusion to both the patient, family and the primary care provider.
There are several screesnign tools to assess dor alcholism.
After initial screening tool are used, then the clinician usually looks up the criteria in the Diagnostic and Statistical Manuel of Mental Disorders, fourth edition, revised (DSM-IV-TR) to confirm the screening diagnosis. The criteria seen in the DSM-IV-TR was created with the focus on a younger generation.
The numbers of people with alcohol dependence/abuse that have committed or attempted suicide is raising concern among the geriatric field. When I was in grad school I remember reading about different studies about ETOH and suicide in the elderly generation. ETOH abuse/dependence and sucide in elderely men were higher. Many folks that did have a completed sucide typtically had a prior occurance of an attemeped suicide. When learnign about the way folks normally tried to kill themselves were non-violent means: ie carbon monoxide poisioning, drug overdose and drowning. It was very interesting to read that non-violent methods were used primarily as the final act. Many times the non-violent methods are people calling out for help, and not knowing the proper resources that are out there to assist them with battling this disease. For some, the proper intervention could save them from ending their lives.
I think it would be beneficial to have a separate criteria for ETOH abuse and depence for the elderly...
I have had several patients in teh hospital that were elderely that many families did not know or the secrest was kept within the family about the ETOH abuse. Very few times did the patient actaully wanted help..
Hope this makes sense and helped folks...
Kasie excellent work. Thank You for accepting the challenge and putting in the work. Team, this is a great issue and reason number 1 being the the Elderly and ETOH, DEPRESSION, and SUICIDALITY are all three underdiagnosed and so so so interelated and important. In the medical settings I have probably seen cases like this over a thousand times and it is where the medical model goes wrong. In the three hospitals, I have worked at I haven't seen a routine depression screening tool such as Becks Short form geriatric depression screening form. Social workers use this on at an individual level but nothing is uniform so that we are catching and treating more. Kasie, When I was at Evergreen, it was a macro issue that I at one point wanted to take on but I just had so many other irons in the fire at that time. That being said, I regret that I back burnerd it because it was just as important if not more than other things I worked on. Awe, hind sight is 20/20. I wonder if you might demonstrate some leadership in this area one day in this area.
ReplyDeleteSo Kasie, Why does the medical model turn it's back on these issues? Can you give us your clinical impression. Kasie and Team I would like some of your imput on how Erik Erikson might integrate his theories about human development with some of the issues these Elderly may be facing. What stages of development are they in? Have they stagnated or regressed and what stages would illustrate a more healthy integration of coping with some of their life long losses?
Team this topic is really an example of how any topic might come at you on the LICSW exam but if we are well conditioned about using the theories especially and I can't emphasise enough with human development and applying them
According to Erik Erikson's theory, people who are in their late adulthood experience either "integrity" or "despair".
ReplyDeleteSome older adults can often look back on their lives with happiness and are content, feeling fulfilled with a deep sense that life has meaning and they've made a contribution to life.
On the other hand, some adults may reach this stage and despair at their experiences and perceived failures. They may fear death as they struggle to find a purpose to their lives.
We probably find ETOH,depression, and suicide issues more frequently among the second group of poeple. I believe that their struggle to find a purpose in life resulted in individualistic ideology in this culture and generation. I think many older people find hapiness in their family because that is their legacy. In this culture and time, we find many disfunctional families as we all know. I work with many many elderly patients who have no family members supporting them. ETOH dependence and depression are not as common in cultures that value collectivism and family connections.
I think Family Systems Theory can be so effective as we work with patients like this. This theory suggests that "one cannot be understood in isolation from one another, but rather as a part of their family, as the family is an emotional unit."
Empowering pt and family may lead to a great result...
Yurika, very nice use of theory integration. It's funny how much having that knowledge of the theories begins to illustrate things. Nice Risk taking. Team this is exactly the kind of think I would like to see in this blogging. Don't be afraid to play with these theories. And excellent use of the family systems as well, pulling family's back together and holding them accountable and not just adding to the isolation that the identified pt is already feeling. And I tell you it takes alot of work because physicians and other members of the team in whatever work setting you practice on aren't going to get their hands dirty. But we have the know how to understand that it is the right thing to do albeit the pt is agreeable. Good Work, I love it!
ReplyDeleteYurika, I was really interested in your comment on individualism v. communal focus. In my experience this has really been true. When I think about older adult patients with ETOH abuse and suicidal ideology I think of scores of grumpy white men who consider themselves rugged individualists, who value their independence and haven't bonded well with family or friends. Many times the people they consider "friends" are those with similar habits or those who enable them.
ReplyDeleteI think their is a prejudice about older adults that says "they are about to die anyway, let them do what they like." The falacy here is of couse assuming that their addiction is "something they like". Or that somehow the last years of their lives are useless anyway. I think a lot of practitioners give up on older adults as people. We assume that their cognitive skills are diminishing and that learning isn't possible. Also, the system isn't set up to serve them. Even if they do want help it isn't readily available.
I also really agree that Erickson hit this one on the head. Dispair is the right word to describe the experience of some of our older patients. We may be seeing family estrangement/abandonment, complicated grief, loss of physical/mental ability, loss of community engagement, etc. This is an instance where you really can't be effective without considering systems theory. Getting patients involved in their own lives sometimes means something as simple as resource brokerage (transportation to church, sr. center, etc) or something as complicated as reinvolving family. Either way I think that recognizing strengths is again the key to identifying motivation. Getting the pt. talking about what it is that they are/were best at, what they are/were proud of, what they still enjoy in their daily lives and helping to reframe.
Alcoholism is just the pits. It's such a tough one for me to consider/tackle. I think I do have empathy for those suffering from alcoholism but I get nervous about over identifying/conscious use of self/boundaries etc. because of my family experience. I screen and try to identify and educate my team, but I prefer referal to direct practice. That's just where I'm at.
Denice, thank you for your feedback. I like your thoughts about some of the prejudices Clinician's hold towards elderly patients. I really think this is issue is reallly a systems issue of bringing more awareness to our own providers and on a larger national scale as well. But I think we can have immediate impacts with Nurses, Community Players, MD's, PCP's, Dialysis Centers and so on.
ReplyDeleteI especially like the point about the assumption of diminishing cognitive skills. Being Hard of Hearing, HOH, Blindness or slowing down physically in no way effects cognitive ability. If I am being honest, I think there is laziness at times of the clinician where if someone isn't able to give me information in the amount of time I want to process it, I will just go to the family member and they will give me the true story. I tell you in the hospital, we rely too much on families to give us the full picture not that they aren't important but it certainly is an easy way at times. By not being patient with your agenda and going into your assessments with fixed agendas, you aren' allowing for patients to take part in the theraputic process where you may have some time to zoom in on some their feelings about depression or alcoholism.
Also, I am always impressed when people are able to recognized their own transference issues because it opens you up for growth and Denice you have been pretty consistent about this with Drug and Alcohol issues and your Family history
Team, For those of you who haven't shared. I was wondering if one of you would comment on this topic and integrate Erickson's Stagnation VS Generativity phase.
ReplyDeleteYurika- I agree with your statement re: ETOH dependence and depression are not as common in cultures that value collectivism and family connections. We are part of a society that really does idealize individualism and it is basically "all for one self". The Jones are trying to be better than the Peters in respect to socio-economic status, etc... and this can lead to depression, etoh and drug abuse/dependence. The past 5 years I have worked in the med setting, I have seen many elderly /Senior pt's come in with with related issues. Not only with w/drawl but with multiple co-morbidities (i.e renal failure, endstage liver disease)that have actually lead to an early death. More often than not, they have burned all bridges with their families and nobody is willing to extend a hand again in the fear that they will be burned. These people die alone and/or go back to their terrible living conditions to only revolve back in to the hospital the next month with "etoh w/drawl" as a dx.
ReplyDeleteIn my work as a CDP, I saw different "losses" from the disease in the elderly population (and in reality this population was not the major percentage of my clients because of the guilt, shame and stigma attached to the disease). I saw lonley people who had lost most of their family, but most of them had not yet lost their health to the point of being hospitalized. We had one group only at Res XII for this population... that tells you how little of the population they were. They are from such different generations that our current one. Think of all the guilt and moral shaming that they have..... it is still an issue with those of our generation and I feel we have moved leaps in the direction of disease model as opposed to "moral disease" since their generation.
Generativity is an extension of love into the future. It is a concern for the next generation and all future generations. When the indiidual is so consumed with their addiction and likely so deep in to their depression, it is hard to give to others when you have nothing to give and you can hardly find purpose for yourself. Stagnation is self-absorption, caring for no-one. The stagnant person ceases to be a productive member of society, which in most (not all) cases can be the story of an addict. There are many "high functioning" etoh addicts who seem to skate by (barely) until they eventually (and they all will) hit bottom. But even if they are still functioning in work, family etc.... on the outside you may not be able to tell, but to those on the inside, the disease is not very good at hiding. It can be sneaky, manipulative and deceitful but it usually can't hide for too long.
Talking about stagnation makes me think of people dependent on drugs or alcohol at any age. Knowing someone while they are hitting "bottom" can really be freeing...traumatic...but freeing. What I mean by that is that sometims accepting the worst possible outcome allows a family member to become vulnerable (vulnerability as a strength...like open) and engage again. Hospitalization can be that time when family feels safe to explore reunification. It is also the time when pt.'s may be most open to change. I think I miss the opportunity to recognize these openings and facilitate this type of reunion.
ReplyDelete