According to a recent report by the National Institute on Drug Abuse, as many as 1,800,000 Americans over the age of 65 may be dependent on Medicare-provided prescription drugs. The National Institute on Drug Abuse (NIDA) has released a report that suggests that older adults tend to use prescription medication three times more frequently than the general population and have the poorest compliance rates related to taking medications as directed.

Senior Substance Misuse & Nationwide Health Care Dilemma

Our senior citizens currently are at risk of addiction from regularly using benzodiazepines or a group of central nervous system depressants, such as tranquilizers Xanax, Klonopan, Valium, Ativan and Librum; along with sleeping medications such as Ambien, Halcion, Dalmane and Restoril; muscle relaxants such as Soma, Flexeril and Robaxsin; and alcohol. In addition, opiates and analgesics for pain relief, such as Vicodin, Codiene, Oxycontin, Ultram, Morphine and Duragesics place our seniors at risk.

Causes of Misuse. Our older people may have been misusing or abusing alcohol or drugs for years, or now they may have problems with chronic pain, anxiety and insomnia, or emotionally suffer from the loss of a spouse or other traumatic events, creating feelings of grief or loneliness, possibly complicated by financial or medical problems.

Discontinuation Difficulty. In general, seniors want to feel calmer and sleep better, however, find it difficult to discontinue the use of their drugs and are unaware or ashamed to admit when they are become dependent. What’s worse is that family members tend to ignore their drug problems because they don’t imagine their aging parent or grandparent being hooked on drugs. Maybe it’s depression or they are just getting sick. Could drugs have caused that accident, or was it a simple fall?

Accidents later in life often lead to complications that can become deadly, or seriously hurt someone else if under the influence while driving. In fact, Ambien can cause both retrograde amnesia and antregrade amnesia: seniors will often eat in their sleep, sleepwalk, drive their cars in their sleep and not remember doing it.

Easy Access. It is easy for a senior to get a prescription. All they have to do is mention pain to get the drug they want. Did you know that older adults are prescribed higher doses of some medications for longer periods of time than younger adults, even though there is a decrease in ability to metabolize medication later in life? Unfortunately, it’s easy for seniors to get hooked on drugs from the high numbers of prescriptions they use. Family members may not understand that mood swings, depression, irritability, fatigue, insomnia and the inability to stay focused or involved in a conversation are not just signs of old age, but of misuse or addiction.

Generational Influences. This Baby Boomer generation grew up in a time when hard-core drugs were more widely accepted and were known to use a number of drugs at one time. They believe if a doctor prescribed the drugs, they must be safe, and do not realize that these drugs cause dependency and interact with one another, resulting in confusion. They may also believe they are immune to addiction and experience the misconception that mixing medications or doubling up on their medications are a fast fix to their health problems. It’s also a fast way to an accidental overdose when combining sedatives and opiates with alcohol. Consequently, this fast-fix mentality is leading to a nationwide health-care dilemma.

Have you reached the phase of life where you need to parent your parents? If you have, you are about to face watching your loved ones suffer symptoms of aging, complicated by “solutions” of mixing medications or what we call travelling.

The Slippery Slope of Side Effects to Senility

The slippery slope to senility begins when you notice some common signs and symptoms of aging. Signs and their consequent physical side effects to watch for in your loved ones follow:

Symptoms

• Metabolism Decrease. As seniors mature, their metabolism decreases. Decreases in metabolism cause declines in renal and hepatic functions, which result in more accumulation of the chemicals in their body and for longer periods of time. What this really means is that the drugs attain a higher peak and last longer.
• Dehydration. Seniors often become dehydrated, either from decreasing their fluid intake due to congestive heart failure or renal failure, or even from the use of diuretics. This results in higher peak levels and a longer duration of drug concentration in the blood stream, even though they have not increased their dose of medication.
• Insomnia. Older adults require less sleep and often cat nap during the day, causing a pattern of insomnia and subsequent anxiety. Regarding insomnia, pharmaceutical companies are now directly advertising to consumers. There are frequent ads on television, radio and in magazines for pharmacological sleep aids, such as Ambien or Lunesta. These ads are often accompanied by a coupon for free trial pills, and this is when the free slide to senility starts.

What if a medical provider refuses to give patients prescriptions for free medications? Oftentimes our seniors will see other health care providers, and the dilemma continues. One prescription for Ambien for seven days is just enough time to get a senior dependent on the medication, and if they stop taking it, they will experience rebound insomnia and anxiety.

This situation is similar to seniors being placed on benzodiazepines in the 1980s for anxiety, depression and insomnia, and then the discontinuation of these drugs, which resulted in insomnia and consequently justified their continued use. Stopping these medications cold-turkey could result in seizures and delirium.

• Chronic Pain. As seniors mature, arthritic pains may develop, placing them on opiate analgesics for degenerative back disease and their worn-out hip and knees. In fact, 25 to 45 percent of older adults suffer from chronic pain conditions. However, discontinuation of opiate analgesics is often manifested by a well-documented withdrawal syndrome that includes myalgias and arthralatgies, the same symptoms for which the patients have started to take medication in the first place. The opiates also affect their gastrointestinal track, causing constipation and diaherra when the drug wears off. Now these patients are diagnosed with irritable bowel syndrome when they actually have narcotic bowel syndrome. Relative to constipation, large dosages of opiates can cause such severe constipation that can perforate their bowels.
• Neurological Diseases. Seniors may develop neurological diseases such as Parkinson’s disease, dementia, neuropathy and restless leg syndrome and stroke, which necessitate the need for treatment with psychoactive medication, leading to possible misuse and negative interactions with other medications.

Solutions

• Multiple Specialists. Seniors are often referred to multiple specialists and placed on additional medications that may completely inhibit the metabolism of their existing medications. This is called polypharmacy which often causes the primary care physician to become unaware of all the medications his or her patient may be receiving.
• Polypharmacy. Polypharmacy can result in mixing medications as a solution to our senior’s mixed problems. Several medications will cause several physical effects. For example, opiates cause constipation; antihistamines cause urinary retention; opiate withdrawal causes diarrhea; and benzodiapenes withdrawal causes anxiety and insomnia; and early alcohol withdrawal does the same thing, causing anxiety, insomnia and tremors. Late alcohol withdrawal can cause tremors, seizures and delirium hallucinations.

Side Effect Sequences

• Senior Secrets. Seniors are often reluctant to give their physicians accurate substance abuse histories, or doctors fail to ask the questions. How much do you drink? How often do you drink? If the patient is experiencing mild alcohol withdrawal, he often goes to the doctor and complains of the symptoms of alcohol withdrawal, such as anxiety and insomnia, and is then prescribed a benzodiapene for the anxiety and insomnia, which will only — over time — make things worse if he continues to drink and use pills.
• Misdiagnosis. Sometimes the side effects of a medication may generate a new diagnosis and further treatment with still more medication. For instance, if you look up in the physician desk reference side effects for Klonopin, Valium and Lorazepan, you will find the most common one is depression. The doctors may misdiagnosis the patient, not realizing the depression is caused by the pill, and will treat the depression as a primary disease and start him with an antidepressant, such as Prozac. If the patient is currently taking codeine for his arthritic pain and he is given Prozac, it will inhibit the breakdown of metabolism of the codeine to its active metabolite, which is morphine, and the patient will no longer get pain relief from the medication.
• Many elderly patients are treated with opiate narcotics that cause constipation when you first take them, and diarrhea when they go off of them. This patient is often diagnosed as having irritable bowel syndrome, when he or she actually has narcotic bowel syndrome.
• Using the over-the-counter antihistamines that are often found in cold and allergy medication can cause urinary retention; subsequently, a patient may be diagnosed as having BHP. These patients may be treated with Proscar or Avadar, which decreases the already heavily declining testosterone levels. Long-term opiate analgesics also have been associated with declining testosterone levels through the inhibition of hypothalamic pituitary axis.
• Episodic ailments, such as cold and allergies will often require over-the-counter medication that can further complicate drug metabolism and impair mental gonadal status.
• Chronic back pain is often treated with opiate analgesics that can lower a patient’s serum testosterone, never allowing the patient to regain his strength or muscle tone to recover from his initial injury.
• Patients are given opiates analgesics for back pain. When the medication wears off, the early withdrawal symptoms are often myalgias and arthralgas; the patient receives a diagnosis of fibromyalgia. Subsequently, he or she is treated with more opiate analgesics at higher and higher doses until he or she becomes physically dependent and cannot discontinue the medication without going through opiate withdrawal syndrome. This feels like a bad flu with muscle aches, joint aches, runny nose and sneezing, abdominal cramps and diaherra, severe anxiety and insomnia. All of this justifies continued use and supports the misdiagnosis.

Senility

Drug interactions and mixing medications, as discussed, often mimic medical and psychotic illnesses in the senior citizen. For instance, opiates analgesics and benzos have been associated for a long time with cognitive impairment. Use of opiates and benzos at bedtime can cause sleep disturbances and exasperated sleep apnea, causing a further decline in patient’s cognitive ability.

Usually this process is gradual. So grandma and grandpa are planted on the couch and just thought of to be experiencing simple senility or senile dementia.

Stop Time: Detoxify or Die

Senior drug addiction is something most seniors thought they would not have to overcome. Withdrawal symptoms are devastating, so a safe and slow withdrawal should be the protocol with a board-certified physician trained in addiction medicine who has specific experience with senior addiction issues and medical needs.

Recognizing senior drug addiction is complicated. If you or someone you love is dealing with addiction, know detoxification is better than senility or death. It can be amazing to witness the cognitive improvement a patient will experience once you can assist him through the three to five hard days it takes to detoxify your grandmother or grandfather to get off this medication.

Remember, these patients are better treated by a Board Certified Addiction Medicine Specialist (ABAM) who can treat these patients in an ambulatory setting and in the comfort of their own homes (as opposed to a psychiatric hospital where they do not truly belong). At this time, ABAM is a new specialty board and there are few qualified specialists around. In addition, many HMOs and third-party payers do not recognize the specialty and refer patients to mental health specialists, where they are often diagnosed with bipolar patient and placed on more medications.

Many senior treatment centers are seeing marked improvement in their patients with holistic practices such as yoga, stretching, meditation and relaxation techniques. Using nutritional supplements and exercise also produce exceptional results in recovery from senior drug addiction. After-care works wonders. If you are interested in relaxation and meditation CDs visit: www.mymentalwellcare.com or if you are interested in DNA-based, all-natural nutritional supplements made just for your senior, visit: www.mydnawellcare.com.

For the purpose of continuing education unites, the course objectives for this article are:

• You will be able to identify the three main causes of prescription drug misuse by seniors.
• You will be able to identify the common signs and symptoms of aging and how complications of mixing medications can possibly cause side effects and misdiagnosis.
• You will be able to understand how prescription drugs mimic physical and psychoactive illness by taking too much or too little.
• You will be able to distinguish which medications cause depression and distinguish which medications cause anxiety, insomnia, and withdrawal.

The “traditional” or adult addict is primarily dependent on alcohol and medications.  This is a vastly untreated group that represents tragic loss for millions of individuals and their families.

Why is it that we as a society do not address older adult alcohol or medication addiction?  The reasons vary from ageism to misunderstanding and misdiagnosis. Many people buy into the notion that Grandpa is “happy” this way, which is hardly the case when life is a blur. A number of symptoms of alcoholism mimic other disorders associated with aging.

Look for these signs and relate them to a broader picture of behavior and consequences:

• Insomnia or sleeping too much
• Memory loss
• Signs of frequent falls and accidents, such as bruises, broken bones, cigarette burns
• Cognitive loss
• Memory problems
• Anxiety or depression
• Shaky hands
• Inability to concentrate
• Weight loss
• Haggard appearance
• Lack of interest in activities that were formerly enjoyed
• Chronic pain
• Isolating
• Neglect of appearance and/or hygiene
• Bloated abdomen

If you suspect that the older person has a problem, the time to address it is soon, because delay could be deadly. How we approach the older adult is important: with care; concern; non-blaming; objective reasoning; and always when the person is sober. You can relate the drinking problem to its consequences, such as failing health, accidents and isolation, but avoid using words like “addiction” or addict” because older adults view addiction as a moral failing, not a disease.

When abuse of alcohol or chemicals has not become full-blown addiction, a brief intervention by a trusted physician who is versed in these interventions is often successful. The person is apt to follow directions from a respected doctor.
The MAST-G is the most commonly used diagnostic tool used to identify addiction among older adults, and should only be administered by a professional.  The CAGE questionnaire is also used reliably.

Late onset addiction

Fully one third of all older adult addiction is late onset. Painful or major life transitions, such as loss of spouse or retirement, may result in unhealthy coping behaviors.  Risk factors include depression, loneliness, anxiety and a lack of a sense of purpose.

Often individuals have been “social” drinkers for years, and when painful life transitions occur, they drink more. For others, such as Hanley Center alumnae, Ruth, a pattern of social drinking emerged in later life.  Ruth moved with her husband to a retirement community. Ruth’s husband died suddenly of a stroke. She was lonely and became a regular at daily Happy Hours that the senior community sponsored.  Drinking was part of the thread of social life there, a little “Margaritaville” every day. But Ruth’s drinking escalated beyond “social,” and soon she was isolating, falling, and in failing health. With family intervention, Ruth received treatment, support and the opportunity to enjoy her grandchildren and a renewed interest in life.

Alcoholism is more prevalent among widowers over age 75, but women tend to be more severely affected than men and tend to become addicted faster.

The aging human body simply cannot handle alcohol the way it did in youth, and one drink may have the effect of several. Drugs and alcohol are not metabolized efficiently as we age because the liver shrinks and liver enzymes decline. Alcohol is water soluble, and total body water percentage declines for men and women. Body fat increases, so alcohol and drugs are absorbed into the body fat and stay in the body longer. It is not just the amount, but also the effect that really matters.

Medical conditions are often directly related to alcohol or medication abuse, as was found in an early 1990s study by the U.S. House of Representatives Select Committee on Aging. . At least 70 percent of all hospital admissions of those aged 65+ are the direct result of alcohol or medication abuse. The study also found that 50 percent of all nursing home residents (older adults) have an alcohol problem.  Cancer, lung failure, heart and kidney problems, bleeding ulcers, anemia, perforation of the intestines, gastritis as well as liver disease are all related to heavy alcohol use, and vitamins and minerals are no longer easily absorbed.

Medications and the slide to addiction

Older women are more apt to take psychotropic medications that have been prescribed to them, often long term. Physicians are 37% more likely to prescribe a tranquilizer and 33% likelier to prescribe an anti-depressant for women than men. Benzodiazepines, such as Valium and Xanax make up the largest number of prescriptions. When a doctor prescribes medications, it is often not questioned by the older adult patient. Benzos” taken at high dosages or in combination with alcohol can also be fatal. Interactions of medicines can be dangerous as well.

Generally, older adults take an average of 4.5 medications and several over-the-counter medications.  Physical dependence slides into addiction when the individual is taking more of the drug for the same effect and he or she may doctor-shop to obtain medications. Don’t underestimate the availability of online drugs as well, because many seniors spend lots off time online.

Post-surgical pain poses a risk of relapse for recovering individuals. It is vital to identify a support person prior to surgery.  Someone should also be present to monitor and sometimes administer the medications. Proper tapering of medications is imperative, and all members of the medical team must be apprised of the patient’s history.

Treating the Older Adult

Treatment for older adult age 65+ share some similarities with older Boomer treatment such as, a slower detoxification and treatment process, but the big differences are rooted in drugs of choice and/or generational values.

Those influenced by the depression era and war years learned early to be responsible for themselves and not to air personal problems, family conflicts or “secrets” with others. And in the 50s, “Leave it to Beaver” was thought to be the family norm. Respect for elders and authority were, and still are, important. Older adults feel far more comfortable in a peer age group setting, but not with younger “drug addicts.” Often there are cognition and mobility problems, as well as malnutrition. A holistic and multidisciplinary care plan includes medical and psychological care, wellness, including re-education in nutrition, and customized, gentle exercise.  Spiritual wellness and education about the Twelve Step philosophy are also key to recovery.

Recovery: Older adults who receive quality, gender-responsive treatment have higher success rates in recovery than other age groups. We have found them to be some of the most committed volunteers. Sober Senior support groups are also among the most active Twelve Step groups.

Renewed connections in recovery: Think about the potential of grandparent/grandchild relationships. Renewed connections nurture purpose, as do participating in sober activities.   Purpose makes the difference between getting up in the morning or staying in bed.

Boomers will challenge the system

Boomers have been committed to the concept of continual youth, and have spent billions in pursuit of it. Yet for many, alcohol and drug problems are causing serious consequences in their lives. According to Deborah Tunzo, who coordinates research for the Substance Abuse and Mental Health Services Administration (SAMHSA), the numbers of Boomers who suffer from chemical dependencies may swamp the system. According to a SAMHSA report published in 2005, the number of Americans admitted to treatment who were over 50 years old was up to 10 percent of the total, from eight percent of the total in 2001. The agency predicts 4.4 million 50+ alcohol and chemical abusers by 2020. More than half of those aged 50-54 have used opiates, cocaine, marijuana or methamphetamines at some point in their lives.

What’s different for Boomers

They’ve been called the “Me,” the “Youth” and the Woodstock Generation. They grew up in an age of civil rights, the Vietnam era, the end of the Cold War and the fall of the Berlin Wall, and the birth of Cyber Space. The Boomers’ broad generational values differ, even clash with those of the preceding generation. This “Youth” generation is also idealistic, and believes in service, therapy and self-help.

Boomers who suffer from addiction may take multiple drugs, often with alcohol, and are presenting to treatment with a high rate of dual diagnosis and serious medical complications. We are seeing more cases of hepatitis C as early drug users enter their mid 40s and 50s. Treatment must respond to Boomer values as well as the reality of illicit drugs. Continuing care is often indicated.

How do you engage the Boomer patient in treatment? Following detoxification and stabilization, address this individual not by age, but in relation to his/her current life roles and issues and goals. A grandmother may be 44 years old while another 44 year-old may be a new parent. Second and third marriages bring blended families. Second careers are common. A Life Stages approach within holistic, gender-specific treatment may address such issues as grief and loss, sexuality, and anger in relationships.

We’ve found a wide range of therapies to be effective with Boomer patients, including Motivational Interviewing. We also apply experiential therapies that offer healing outlets for creative and emotional expression. Menopausal and post menopausal women also explore the role hormones play in craving and mood swings as a relapse factor, and we’ve found Hanley’s Hormonal Shift Assessment to be a powerful factor in self monitoring and self care.

Boomers have been and will continue to be a major influencing force in society.  Although health costs associated with their alcohol and chemical dependence could be daunting, we need to help these Boomers reignite their lives. We will all benefit.

From a clinical perspective we may view life as a series of epigenetic challenges that are negotiated with more or less success. The failure to adequately negotiate a life stage may be rightfully seen as a crisis.  I have noted, particularly with the elderly patients we treat, that regardless of whether this is their first treatment or they have long histories with multiple treatment episodes, their entry into treatment is frequently precipitated by loss or impending loss. Frequently, it is the death of a spouse, retirement, or diminished health, often manifested as anxiety, depression, loneliness and boredom. In treating these patients I have come to recognize the disintegrating effects of loss of attachment, identity and purpose.

There would be something comfortable about being able to quote the research and evidence-based practices.  There is little data on the treatment of chemical dependency in the elderly.  In spite of how “sensible” the trend toward evidence-based practices may be and how well advised we would be to be aware of the data, I urge you to return to being equally advised by your clinical judgment.

We have gleaned a number of recommendations from our experience treating elderly patients at Hemet Valley Recovery Center.  The Center for Therapeutic Change promotes the theory that rapport is the single greatest factor in the successful treatment of any patient.  With the elderly patients we’ve treated, generating a solid treatment alliance is the primary task. They often present as diminished and disintegrated.  “How to Fail as a Therapist” offers the notion that a lack of disclosure or too much disclosure, and even the way in which the disclosure is presented, can be damaging to the therapeutic relationship.   The elderly patients I have treated are warm and object-seeking.  I would argue that they are more invested in the therapist and his or her personal life.  With them I tend to disclose more and offer more casual interaction.   Frequently, a patient’s “theory of change” is elicited by asking, “What would you do with you if you were me?”  This simple question generates an approach to treatment.  In my experience the elderly patient is more likely to respond with answers akin to: “you are doing a wonderful job” or “you are the experts, I can’t think of anything that you should do differently.”   Whereas, a practical answer: “don’t let me get away with being evasive, help me understand my family, or just listen to me,” is golden and something to be mindful of during the patient’s treatment.

A thorough clinical interview is important but shouldn’t begin until adequate rapport is established.  A non-threatening warm-up and simple gauge of recent and remote memory is to ask the patient “how long have you been in treatment? who is your case manager? who is your roommate? what was for dinner or lunch?  what’s the most interesting thing you’ve learned?  The responses to these questions and the quality of the response: rate and prosody of speech, confused, sparse, over-inclusive or odd, will begin to inform your understanding of the patient.

Imbedded in the usual clinical interview are questions that I find particularly rich.  I am particularly interested in the stated motivation for entering treatment, the patients’ level of insight, theory of change and motivation in general.  I always ask patients to characterize their childhood, in spite of their age; I rarely find them reluctant to discuss their childhoods.  This question frequently begins them engaging in “life review” which is arguably “therapeutic.”    Some patients generate a narrative about their lives that answers a number of interview questions without the usual battery of questions.  I want to know their history of use: age of first use, nature and quality of use, including their history of abstinence or sobriety.  If there were periods of sobriety, I ask what led to the lapse.   The patients’ educational and occupational history, history of mental health treatment/hospitalization, history of self-injurious behaviors and their history of trauma, I believe offer additional insights.  The patient’s perception of their health, evidence of distress (sleep and appetite disturbance), loss of interest in pleasurable activities, mood and current themes may hint at a disturbance in mood.  Their relationship history, current level of relationship strain and level of perceived social support may illuminate personality issues. As early as possible, without straining rapport, I answer two fundamental questions that need to be asked in every intake/evaluation before letting the patient out of my sight.  First, is the patient at risk of harming himself or others and second, is this patient experiencing psychotic symptoms?  I have found that relatively few of our elderly patients endorse psychotic symptoms and virtually none endorse active suicidal ideation.   Passive suicidal ideation is common. I also find that elderly patients are more sensitive to inquiries about suicidal thinking and thought disturbances than younger patients.  The easy formulation is that they are more sensitive to the suggested stigma.  I generally start with a question to determine if the patient is experiencing passive suicidal ideation:  “Would you care if you didn’t wake up in the morning?”  If you do a less than adequate examination and you are still simply writing SI, HI, please recognize that as woefully inadequate and examine one of the models like that offered by Resnick.  If you are still engaging in “no-harm contracts” seek the advice of a risk management professional immediately.

With any patient and particularly with elderly patients, it is important to know their medical status and to be aware of how it may impact their treatment.  At Hemet, the patients are evaluated daily by a medical doctor.  Do not make the mistake of assuming that cognitive impairments are age-based, or be seduced by the notion that because of a report from home that they have been experiencing confusion or memory problems for a period of time.  Also avoid noting they are “always confused” when they enter treatment at your facility or assuming there isn’t a medical cause. By now, we should have all discarded the idea that a patient cannot have their first psychotic break late in life.  I advocate knowing these patients well. I am vastly better informed by simply discussing the patient with the nursing and case management staff and getting collateral information from the family via the family counselor.

To evaluate cognitive status Folsteins Mini Mental Status examination is a good start.  The Folstein has serious limitations, it is a good measure of orientation, and yet, is very limited in regard to assessing problems with memory and language (often experienced by elderly patients).   In the elderly patients we treat, problems with orientation are common (particularly early in treatment).  I pay little attention to a patient being disoriented to time by a day or two and I consider it to be insignificant that most patients from outside of the area do not know the minute details of their location.  Difficulty recalling three random words obviously suggests memory problems.  It is difficult to ferret out problems with memory from problems with attention and concentration.  If the patient experiences difficulty recalling the three random words, I test the limits by offering contextual cues or phonemic cues and make note of whether the failure appears to be a difficulty with encoding or retrieval.  I follow O’Briens’ advice and offer a couple of additional measures of attention, an additional calculation, and the number of quarters in a particular sum.  To further screen for problems with language, I use a test of verbal fluency.  I ask the patient to name as many items in a category in one minute.  Most patients often start shifting somewhere during the minute.  If their responses are sparse and only cover one venue, I hypothesize a language problem and perhaps, a problem with cognitive flexibility  (the cut-off for dementia is theorized to be 10). Difficulty with naming (anomia) can be assessed with the Boston Naming Test or the NIS Stroke Scale.  There are additional measures of language offered by NIS.  One of the great things about the NIS program is they offer tutoring in the appropriate use of their instruments.  I don’t focus much on assessing visuo-spatial reasoning and I have found little value in the intersecting pentagons at the end of the MMSE.  I am frequently surprised by seeing a reasonable rendition of the intersecting pentagons followed by a highly dysmorphic or confused drawing of a clock face.  It is not wholly uncommon to have the patient solve the problem of indicating the time on the clock by drawing it in digitally.  The digital depiction of the time is consistent with a high level of confusion in my experience.   I briefly examine abstract reasoning with proverbs and similarities.  I like “spilt milk, glass houses and monkeys falling from trees.  Beyond being a measure of abstract reasoning, these proverbs offer clinical material, in that the patient will often offer their world view.  Through the entire assessment make note of intrusion errors, perseveration and cognitive slippage.

I often test the limits at the end of the MMSEand ask the patient to recall the three random words one more time.  If questions remain as to the patient’s memory functioning, I may choose additional tests of memory.  I use digit span forward to test immediate memory and digit span backward to assess working memory.  The Rey Auditory Verbal Learning Test (RAVLT) can be used to further assess memory and to gauge their ability to learn and retain verbal material.  I compare the performance on digit span forward with their first trial of the Rey and note any significant difference.  If the performance on the last trial of digit span is significantly better than the first trial of the RAVLT, I usually attribute it to the “shock” many patients experience at their first exposure to the length of the Rey.

If there is any uncertainty, screen for mood disturbance.  The research suggests that depression and anxiety are common in substance abusing patients and my estimate is that approximately 80% of the elderly patients we treat are depressed.  Do not forget the pseudodementing effects of depression or better said when discussing older adults the dementia syndrome of depression (usually reversible). I have used the Yesavage Geriatric Depression Scale (short form) to assess for depression.  The Yesavage offers the
opportunity for the patient to generate a narrative and hints at the “depressogenic” thinking that may underlie any depression.

Returning to your clinical judgment, the intention of this work is not to diagnose dementia, or identify cortical versus sub-cortical patterns. The intention is to inform the clinical team of your process, while gaining rapport and identifying difficulties that may interfere with the care of your patient.  This includes discovering previously unappreciated cognitive difficulties, mood disturbance, hearing and vision impairment, psychotic symptoms, sequelae of trauma or existential crisis and to generate a treatment plan.  I do not encourage exhausting the patient or making him even more aware of cognitive deficits.   Use your judgment to tailor the battery to your patient and gather the data you need.  I don’t make the patient endure any more testing than necessary.  Be prepared to discuss the results. I find these patients are frequently concerned about their cognitive status, indeed, when they seem unconcerned with memory loss, generally the impairment is severe. I always attempt to offer hope and attempt to follow-up.  As always, the work is to educate, recognize antecedents, offer alternative strategies, increase mindfulness and build resilience through enhanced coping and emotional processing skills.  I still adhere to the notion that any successful treatment requires a “corrective emotional experience” and our job is to facilitate that experience.

The take-home message is simple, generate a sturdy alliance.  Collect enough data to know how to treat the patient, with formal data collection get in and get out.   Be flexible and tailor treatment to the needs of the patient.

To my view of cognitive-behavioral therapy, one of the interventions is to change the individual’s view of their circumstances.  I attempt to find success in the patient’s history and bring it back to their attention. I will point out the success of their children, their work or military service.  When I was a post-doc with the Department of Veterans Affairs, I became accustomed to saying “welcome home” to veterans and thanking them for their service.   I was astounded by how many men told me that I was the first person to welcome them home.  I am always touched by veterans of the “forgotten” Korean War and those caught up in the controversy surrounding the war in Viet Nam.   I am particularly touched by the veterans of the Second World War.  These men are always humble about their service.  I always say, I don’t know how often you think about it but – “You and your generation, saved the world.”  Without fail they would reply “I didn’t see that much combat” or “I only flew in the B-29’s, it wasn’t that scary.” My reply is always the same, “I always try to tell the truth…you saved the world….it’s just a (expletive) fact.”  I get choked up sometimes…I’m alright with it… for me, our work is deeply personal and only works when we feel it.  One of our jobs is to build resilience in our patients and part of our professional survival is to build it within ourselves. This comes from finding meaning in our work.  We must remember that long droughts will end with rain and old men will play the boogey man for little boys; they always have.