GPSolo Magazine - October/November 2004
Growing Old Is Not for the Fainthearted
As we age, we lose our youthful vitality, including eyesight, hearing, stamina, and mobility. Our memories fade and our critical thinking skills slow down. Most of us will suffer from at least one major illness, and many of us will endure several chronic conditions. We will be treated by multiple doctors, be prescribed multiple medications, and take numerous over-the-counter medications in the never-ending search to feel and function better.
In addition to these bodily breakdowns, we must adjust to ever-increasing personal losses. Loved ones and friends become ill, are incapacitated, and die. Each loss will take its toll. The buildup of losses through the years can trigger severe emotional discomfort. Some of us are better able to accept and adapt to life on life’s terms. But all of us are vulnerable to extended periods of bereavement, anxiety, or depression when too many losses accumulate. Many of us will use alcohol and other drugs to help ease the emotional pain.
Unintentional Alcohol Abuse
As we become older, alcohol use may unintentionally become alcohol abuse. Unknowingly, we inflict additional harm upon ourselves if we continue to drink as we did when younger. By age 50, we experience a decrease in gastric alcohol dehydrogenase enzyme, a decrease in body water, and an increase in fat cells combined with a decrease in lean cells. The net result of these physiological changes is that a little alcohol now goes a long way. Amounts we used to drink with no ill effect may now cause intoxication or other complications. By age 65, it is generally recommended that a man should limit himself to one drink per day and a woman to even less.
Risk Factors for Substance Abuse or Depression
• More than one drink a day (for people over 65 years of age).
• Prior history of alcohol or drug abuse or addiction.
• Coexisting psychiatric illness.
• Starting new medications or changing medications.
• Taking multiple medications (prescription or over-the-counter).
• Use of multiple physicians and/or pharmacies.
• Illness, injury, or a major traumatic event.
• Loss of vision, hearing, or mobility.
• Divorce or death of spouse.
• Retirement (voluntary or mandatory).
• Change in living circumstances (reduced social life or community support; increased social/drinking life).
Accidental Prescription Drug Misuse
The use of sleep aids or tranquilizers creates another high-risk situation. Often a primary- care physician will prescribe these drugs to help us cope with insomnia, grief, or anxiety. This approach treats only the symptoms and not the cause. If they are to be used, these medications should be taken only for short periods of time and with carefully monitoring by the prescribing physician. Some sleep aids and nearly all tranquilizers carry a high risk for abuse and dependency. Inadequate instructions on the proper method of taking these medications, coupled with a poor memory often made worse by illness or fatigue, make the elderly vulnerable to unintentional misuse. When combined with alcohol and other medications, the interaction can be devastating and sometimes deadly. Anyone with a personal history of substance abuse or chemical dependency should avoid these medications. Before using sleep aids or tranquilizers, ask your physician if there are “safer” alternatives to help you sleep or relax.
Adverse Drug Reactions
In addition to substance abuse and dependency, we must be aware of drug reactions. What do we mean by “adverse reactions”? For this discussion we are referring to a false appearance of dementia or depression—cognitive impairment, confusion, forgetfulness, indecision, anxiety, worry, irritability, a quick temper, and either an over- or under-reaction to serious events. “Younger” adults are all too quick to shrug off these symptoms merely as signs of “getting old.” Their thoughts turn to finding facilities that can provide proper care for the “senile” rather than finding a specialist to evaluate the older adult for a possible adverse reaction to the many medications he or she is taking. Such interactions may be further complicated by the use of alcohol.
Preventing Adverse Drug Reactions
When you are prescribed new medications of any type, insist that your physician review all prescription and over-the-counter medications that you are taking. Potential adverse reactions or interference with the efficacy of your various medications should be carefully explained to you. If your physician refuses to conduct this review with you, find a physician who is willing to help you understand the effects of these drugs. The benefits of taking these medications should clearly outweigh the risks of an adverse reaction. If you must take these medications despite the risks, you will at least be informed and aware of what to look for should your medications cause you problems.
When taking multiple medications, it is easy to forget which pills to take, how many to take, or when or if you took them. The risk of inadvertent misuse resulting in adverse reactions to the medication is very high for the elderly. The consequences can be devastating. A written schedule and clear instructions can reduce the chances of accidental drug misuse. Some older adults, however, may require monitoring to ensure medication compliance.
Warning Signs for Older Lawyers
• Complaints about medications not working.
• Confusion, forgetfulness, indecisiveness.
• Anxiety, worry, fretting.
• Irritability or quick temper
• Over-reaction to events.
• Under-reaction to events.
• Poor hygiene.
• Clothes that are unclean or in disrepair.
• Insomnia or daytime sleeping pattern.
• Reduced physical activity.
• Unsteady gait, poor balance, tremors.
• Weight loss, skipping meals, forgetting to eat.
• Illness, injury, accidents.
• Being unprepared for meetings.
• Being financially irresponsible (bouncing checks, violating escrow accounts).
• Failure to complete work, missing deadlines.
• Failure to return calls or correspondence.
• Memory lapses.
• Decline in quality of work.
Recognizing That a Problem Exists
We need to catch ourselves whenever we automatically assign a diagnosis that someone is simply “getting old” and that there is nothing we can do to help. That is just not true. In many cases we can help, and it is relatively easy to do. Take a moment to read the risk factors (sidebar above) that foretell a possible problem. Now look at the warning signs (sidebar on page 40) specific to older lawyers who are still practicing law. If your colleague has experienced a few of the risk factors or displays a few of the warning signs, there is cause for concern. What do you do if you think your older colleague is impaired?
First, assess their risk of harm to themselves or others. When in doubt, take immediate action—call an ambulance or your community crisis intervention center if you think your colleague is in immediate danger.
For the most part, however, we are talking about a colleague whose functioning is worsening but not life threatening at this time. Keep in mind that continued, albeit unintentional, misuse of drugs and alcohol will sooner or later become life threatening.
Become informed and get the best advice available on how to approach your colleague. Contact your state’s lawyer assistance program and ask for help. Do they have qualified clinical staff that can assist? If not, can they refer you to a specialist? Do any of their volunteers have experience with these kinds of situations? Can they recommend literature or websites?
You may or may not choose to involve family members or other colleagues at this time. Sometimes they are embarrassed or fearful. They may want to protect their friend or relative by denying or minimizing any problems. However, if they are concerned, willing and able to help, and discreet, keep them informed and use them as needed.
A private meeting with the “impaired” attorney may be best. Start off with general conversation. Then share something personal about your health, and work on winning confidence and trust. Blend in questions about his or her overall health, health-related behaviors, use of medications, and consumption of alcohol.
Here is where you may encounter the older lawyer’s coping mechanisms (which become stronger as we get older). Expect the lawyer to minimize or deny problems as well as misreport any emotional dis-comfort in terms of physical pain. Older lawyers generally fear losing their independence and feelings of self-worth, symbolized by their law practice. They may cling to their practice well beyond their ability to serve clients competently. Their practice becomes their only proof that their lives still have value. Understand that they will utilize very strong denial and coping mechanisms to protect their practice.
Try to elicit something they are concerned about. Listen patiently. Acknowledge and validate their concerns and complaints. Build upon their concerns in an effort to convince them to see their primary- care physician. If they reveal nothing, tell them that you have noticed some problems and are concerned with how they are doing. Cite specific examples. Don’t come across as judgmental. Watch your tone of voice and body language, and make eye contact. Your primary goal is to show them that you sincerely care and are worried about them. Be careful not to give a “diagnosis.” Stick to the facts. Avoid terms that carry a stigma—alcoholic, drunk, drug abuser, addict. Put the focus on helping them to feel better and function better. Be patient and gentle. More than one meeting may be needed before they confide in you.
Enlisting Professional Assistance
You have now started the process of making them aware that they have some health-related problems that can be treated to help them feel and function better. If they acknowledge that they can use some help, either you or their family should assist them in scheduling and keeping an appointment with their personal physician. Call the doctor in advance and present your concerns about possible adverse reactions to their use of alcohol and medications. The doctor may not be able to respond because of privacy laws, but he or she will likely listen to your concerns and address these issues when meeting with your older colleague. Hopefully there is a bond of trust between the physician and patient that will come into play if the physician recommends a second opinion and refers the patient to a specialist.
Either you or another concerned person should take all medications (prescription and over-the-counter drugs) to the doctor’s appointment and provide them to the physician. Obtain required authorizations for you or the family to stay informed and involved.
Keep in mind that the physician may likely not be a specialist in substance abuse and dependency. If this is the case, encourage him or her to refer the patient to a health-care professional who is knowledgeable in both aging and addiction. This expert can diagnose the problem and make appropriate treatment recommendations.
Diagnosing an alcohol or drug problem in the elderly can be tricky because of failing memory owing to the aging process or as a result of alcohol or drug misuse. Sometimes family members or friends can fill in the missing details. But if your colleague lives alone, even those closest to the person may not be able to provide complete and accurate information.
Hospitalization and Treatment
If an adverse alcohol/drug reaction is suspected, the question is whether or not hospitalization is required while the senior is taken off the drugs (“detoxification”) and a new medication regimen implemented. Detoxification is medically riskier for older adults, especially when multiple chronic illnesses exist. A hospital setting is recommended when concerns for medical safety and removal from access to alcohol or mood-altering medications exist.
The need for extended alcohol/drug treatment must be addressed. Those who do not require hospitalization and have strong social support systems may be able to remain at home and attend outpatient services. Others may need the safety and reinforcement that comes with an inpatient stay at a traditional rehabilitation facility. Those who are frail, suicidal, or medically unstable should be placed in a medically managed and monitored intensive care facility. All treatment settings should incorporate age-specific group treatment; be supportive and nonconfrontational; aim to build or rebuild the patient’s self-esteem; place an emphasis on coping with depression, loneliness, and loss; use a pace and content of treatment that is appropriate for the elderly; have staff that are experienced in working with and are supportive of the elderly; and arrange appropriate aftercare for the patient upon the return home.
Help for the Recalcitrant Colleague
But what do you do if after your private meeting your older colleague rebuffs your expressions of concern, denies having any problems, and tells you to mind your own business? Walking away is not an option. Your friend’s life may be in jeopardy. The quality of his or her life is already being harmed. It is time to recontact your state lawyer assistance program and request additional help. Bring in a professional who can help determine the best approach to motivate your colleague to change his or her attitude and behavior—behavior that is contributing to physical, mental, and emotional decline. Some circumstances may call for an “intervention”—a carefully planned and orchestrated meeting of a few concerned parties and the impaired lawyer. Interventions seek to stop friends and family from “enabling” the inappropriate behavior to continue. They also seek to help the impaired individual see the reality of their situation (“piercing the denial”) and agree to be evaluated by a qualified healthcare professional.
The intervention may lead to hospitalization and treatment if the person’s behavior, including misuse of alcohol and medications, places him or her at high risk of harm. In less severe cases, an intervention may be the first of several “motivational counseling” sessions. This approach acknowledges differences in each person’s readiness to address problem behaviors. Responsibility for change is placed on the individual. Although this is a slower approach, it can result in sincere, long-term, healthy changes.
You Can Make a Difference
There is no silver bullet. Bar associations must establish programs on identifying and assisting the impaired, older lawyer. The bar should be prepared to appoint a conservator and, in some cases, close the practice. These are not the type of projects with which the average member of the bar wants to be involved. But this is a problem that is unlikely to go away. Baby boomers used or abused alcohol, prescription medications, and illicit drugs unlike any generation before; the prevalence of older lawyers in distress will dramatically increase during the next 25 years. We need to start preparing for this now.
You can make a difference. Create a committee of older lawyers, a judge, your state lawyer assistance program, and local health-care providers who specialize in aging, depression, and substance abuse. Establish a plan and procedure for helping elderly, impaired lawyers before they get into serious trouble with their clients and their health. Educate the bench and bar on how to identify an attorney in distress. Teach them how to reach out and help their impaired colleague. Help them to help others and in doing so allow them to experience the joy of having helped saved a lawyer’s life.
Kenneth J. Hagreen is a licensed attorney and executive director of Lawyers Concerned for Lawyers of Pennsylvania, Inc.; he can be reached at firstname.lastname@example.org. Cindy S. Reigle is a licensed social worker and deputy executive director of Lawyers Concerned for Lawyers of Pennsylvania, Inc.; she can be reached at email@example.com . This article originates from a talk given at the ABA Commission on Lawyer Assistance Programs 2003 Annual Workshop. It draws heavily from the information presented in “Substance Abuse Among Older Adults: Treatment Improvement Protocol Series 26,” from the Center for Substance Abuse Treatment, www.health.org/govpubs/BKD250.
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