December 1, 2012

Mental Health and Addiction Issues in Older Adults

By: Joan Bibelhausen

As baby boomers age, many lawyer assistance programs (LAPs) are receiving more calls for help from and on behalf of older adults. This article will provide observations and resources that may be helpful in offering assistance.

Alzheimer’s Disease and Dementia

Some of the calls to LAPs are related to lawyers and judges who need to retire because of Alzheimer’s disease or related illnesses. Discipline counsel and malpractice carriers have their own stories of lawyers who may have had illustrious careers but who were no longer competent. Just as with depression and addiction, LAPs hope to reach these people before their condition becomes a professional responsibility or malpractice issue. These interventions are tough. Although we can talk about legacy and retirement with dignity, we don’t have experience, strength, and hope to share that things can be much better. And sometimes the lawyer or judge does not remember what he agreed to and tries to go back to work. Resources such as the Alzheimer’s Association at www. alz.org and the U.S. Department of Health and Human Services’ Administration on Aging at www.aoa.gov can be helpful. Both of these sites, as well as many that they link to, offer resources for caregivers as well. The LAP client may in fact be the caregiver who is under extreme stress because of the illness of her colleague or family member.

Addiction and Dependency

Several years ago, CoLAP conference attendees were treated to a presentation by Carol Colleran, coauthor with Debra Jay of Aging and Addiction (Hazelden, 2002). We learned that older adults’ bodies process alcohol and other drugs (prescription and over the counter) differently than when they were younger. As baby boomers age, the percentage of use of street drugs in the older population is rising as well. Many combinations of drugs and alcohol can be toxic and potentially life threatening, and misuse of alcohol, with or without other drugs, accelerates aging in all major organs.

Triggers for older adults include the isolation of retirement, grief at the loss or a spouse or partner, pain, and other physical changes. According to TIP 26: Substance Abuse Among Older Adults at www.ncbi.nlm.nih. gov/bookshelf/br.fcgi?book=hssamhsatip&part=A48302 the usual DSM criteria may not be adequate in assessing older adults or late-onset addicts. Some additional factors include tolerance because of increased sensitivity, lack of physiological dependence in many late-onset alcoholics, fewer activities to review in assessing impact, and a lack of understanding or refusal to acknowledge that health problems are related to use, even after medical advice. Barriers to getting help include not only the resistance of the individual but the resistance of concerned persons. This resistance often relates to a lack of understanding of the level of devastation, as well as a reluctance to confront the older adult.

Many prescription drugs may also be addictive, and some are not recommended for individuals over 65 but may be prescribed anyway. Additional resources on older adults are accessible at www.agingandaddiction. net. The site includes guidelines for intervention and additional resources. Numerous other reports are available at www.oas.samhsa.gov/aging.cfm.

Gambling is normative behavior for many adults and a problem for some. Just as with other addictions, problem gambling needs to be assessed differently in the older population. People who are vulnerable due to loneliness, major life changes, and transitions or isolation are at higher risk to become problem gamblers, yet this age group may be less informed about addiction generally and more reluctant to recognize a problem and ask for help due to shame or stigma. In states with casinos, bus trips make travel inexpensive, convenient, and very attractive to someone who is lonely or bored. Casinos are accessible and surrounded by security so the older adult can feel safe and protected while there.

Some warning signs of problem gambling in older adults include vagueness, resistance or even hostility when talking about money, inattention to personal care, talking of wins but hiding losses, increased isolation from family and friends due to preoccupation, stigma about losses, borrowing money, or unexplained absences of possessions. People on fixed incomes may be much more financially devastated and will not have options for making up their losses later in life. Concern about being a burden to others is a major factor in older adult suicide, and the rates of suicide and suicidal ideation are much higher for problem gamblers than for the general population. More information abut problem gambling is available at the website for the National Council on Problem Gambling at www.ncpgambling.org. Many states also have resources. One example of a state resource is a Minnesota site that includes a fact sheet about older adults at www.northstarproblemgambling.org/pdf_files/signs_ of_a_problem_gambler_older_adults.pdf.

Depression, Anxiety, and Suicide

Depression is another significant issue for older adults. In addition to loss of interest in normally pleasurable life activities and other typical depression signals, there are additional symptoms for older adults. These include loss of self-worth and fear of being a burden to others, excessive anxiety or worrying about one’s own or another’s future, diminished interest in personal care, social withdrawal and isolation, slow movements, and self-medication. Additional risk factors include grief and loss, loneliness, isolation and loss of identity or purpose, health problems, and triggering medications. There are also some medical issues that can trigger depression such as chronic or threatening conditions; illnesses that impact the brain; nutritional imbalances or malnutrition; and specific diseases or conditions such as stroke, Parkinson’s disease, cancer, and heart disease.

Symptoms of depression may be missed in older adults, particularly when there is a loss because it is assumed that grief is the cause of the behavior. Grief is caused by a recognizable loss. The symptoms are temporary and can include misdirected anger, weeping, and preoccupation. The person responds to comfort and finds some pleasure. Depression may not relate to a loss. The feelings are pervasive and sleep and eating disturbances are long lasting. Support is not accepted and isolation is likely to occur.

Depression and Alzheimer’s disease or other dementia may also be misdiagnosed. To compare, depression can be characterized by rapid decline; awareness of time, date, and place; awareness of memory problems; difficulty concentrating; and slow but normal movements. In contrast, dementia is marked by a slow mental decline, confusion and disorientation in familiar locations, failure to notice or care about memory issues, loss of short-term memory, and impaired motor and communication skills.

Barriers to seeking help for depression in older adults are in many ways similar to those for addiction and dependency. There is certainly a stigma, especially among the “greatest generation,” about needing help for something they may not understand. Developing trust can be a challenge and pride may stand in the way of asking for that help from someone who will almost certainly be younger. There can be a reluctance to be a burden (including financially) and a feeling that “I should be able to do it on my own.” Depression may be misdiagnosed or underdiagnosed for reasons listed previously and the very nature of depression is a limiting factor. A good resource for depression in older adults is at helpguide.org/mental/ depression_elderly.htm. More general information is at www.nimh.nih.gov/topics/topic-page-olderadults.shtml.

Like depression, anxiety disorders may present differently in older adults. Some symptoms for the individual are a feeling of dread, panic of being on the edge, constant worry and fears of dying, and preoccupation with relationships and issues. Physical symptoms include agitation, shaking, trembling or hand wringing, heart pounding or racing, chest pain, muscle pain or tension, disturbed sleep, chills or hot flashes, and panic attacks.

Suicide is a very real concern in the older adult population. According to a recent study, people age 65 and older comprise 12 percent of the U.S. population but accounted for 16 percent of suicide deaths. See www. nimh.nih.gov/health/publications/older-adults-depression-and-suicidefacts-fact-sheet/index.shtml. Risk factors include depression, loss, illness, perceived illness, isolation, and role changes. While older adults generally need more medical attention, it is interesting to note that 20 percent seek medical help the day they die, 40 percent the week they die, and 70 percent the month they die. A resource list on depression and suicide in older adults may be found at www.apa.org/pi/aging/resources/ guides/depression.aspx.

Aging issues are likely to be a larger percentage of the work of LAPs in future years. By recognizing and accessing some of the excellent resources that are available, we can be better prepared to respond.

Joan Bibelhausen is executive director of Lawyers Concerned for Lawyers, Minnesota’s Lawyer Assistance Program. This article originally appeared in Highlights, published by the American Bar Association. Copyright 2011© by the American Bar Associa- tion. Reprinted with permission.