Journal of Addictive Behaviors,Therapy & RehabilitationISSN: 2324-9005

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Review Article, J Addict Behav Ther Rehabil Vol: 2 Issue: 1

Get Ready for the Boom: Why Rehabilitation Professionals Should Expect to See More Older Adults with Addiction Related Disorders and what Needs to be Done to be Prepared to Serve them Well

D. Gent Dotson1*, J. Chad Duncan1, Shawn Ricks2, Dennis Bunton3, Sharon J. Davis4 and Ann Melvin5
1Department of Rehabilitation Studies, Alabama State University, USA
2Rehabilitation Studies, Winston-Salem State University, USA
3Rehabilitation Institute, Southern Illinois University, USA
4Arkansas State University, USA
5University of Illinois Springfield, US
Corresponding author : D. Gent Dotson, Ph.D
Department of Rehabilitation Studies, Alabama State University, USA
E-mail: [email protected]
Received: September 09, 2012 Accepted: November 28, 2012 Published: December 02, 2012
Citation: Dotson DG, Duncan JC, Ricks S, Bunton D, Davis SJ, et al. (2013) Get Ready for the Boom: Why Rehabilitation Professionals Should Expect to See More Older Adults with Addiction Related Disorders and what Needs to be Done to be Prepared to Serve them Well. J Addict Behav Ther Rehabil 2:1. doi:10.4172/2324-9005.1000101

Abstract

Get Ready for the Boom: Why Rehabilitation Professionals Should Expect to See More Older Adults with Addiction Related Disorders and what Needs to be Done to be Prepared to Serve them Well

Due to the large number of individuals in the emerging cohort of older adults in the United States, known as the Baby Boom generation, rehabilitation professionals from all disciplines should expect to deal frequently with older individuals in the upcoming years; therefore, professionals in such fields should be equipped with the knowledge and skills to successfully care for the needs of this growing population. The purpose of this article is to outline some of the key differences between the current cohort of older adults and the emerging cohort of older adults in regards to their use of addictive substances and their willingness to seek help for addiction related issues. Additionally, the researchers outline some of the key issues and needed competencies for rehabilitation professionals to be able to provide quality services to this growing population of consumers.

Keywords: Rehabilitation, Addiction, Addictive substances

Introduction

By the beginning of the 21st century, trends in life expectancy had changed drastically from the previous century. During the early 20th Century, life expectancy increased due to reductions in mortality of younger individuals, with life expectancy rising from 47.3 years of age in 1900 to 68.2 years of age in 1950; however, because of the reductions in mortality of older individuals, life expectancy reached an all-time high of 76.9 years of age by the year 2000 [1,2]. Additionally, in recent decades, developments in disease prevention, such as cancer screenings, vaccinations, diet, and physical activity, coupled with improvements in the treatment of chronic illnesses, such as heart disease, have caused a further reduction in the mortality rate of older individuals, resulting in longer life expectancies for individuals in the future [1,3]. A person born in the United States at the turn of the 20th Century could have expected to only live to around the age of 47, and in 1900, the population of seniors (persons 65 years of age and older) numbered 3.1 million; however, throughout the 20th Century, the senior population was the largest expanding population in the United States, with the growth of the older population far surpassing the growth of other age groups [1,4]. Due to this reality, rehabilitation professionals from the human services (Social Work, Counseling, Rehabilitation Counseling, etc.) and health sciences (Physical Therapy, Occupational Therapy, Prosthetics and Orthotics, etc.) should expect to deal frequently with older individuals in the coming years; therefore, professionals in such fields should be equipped with the knowledge and skills to successfully care for the needs of this growing population. The purpose of this article is to outline some of the key differences between the current cohort of older adults and the emerging cohort of older adults in regards to their use of addictive substances and their willingness to seek help for addiction related issues. Additionally, the researchers outline some of the key issues and needed competencies for rehabilitation professionals to be able to provide quality services to this growing population of consumers.

Current Aging Cohort

The current aging cohort is made up of two aging populations: a younger aging population, known as the Silent Generation (individuals born between 1925 and 1945), and an older aging population, known as the G.I. Generation or the Greatest Generation (individuals born between 1901 and 1924) [5-7]. Because individuals in these generational groups came of age during times that demanded great sacrifice, namely the Great Depression and World War II, they developed conservative spending habits, which demonstrated their need for security; as they have aged, they have become even more conservative [5-7]. For example, as individuals in this cohort entered into their 50s, they began saving more and spending less, which reflected their desire to age in a secure world where they could avoid the dangers and catastrophes that they experienced during their early years [8].
The current cohort is known for being conservative in moral matters as well. The ultra-conservatism of the 1950s was a reflection of this groups’ belief-system since a majority of the individuals in the current cohort were young and middle-aged adults in that decade [9]. These individuals not only respected the authority of the government (demonstrated by their extreme patriotism and support of the “American way”), but they also respected the authority of traditional religion, which resulted in the large surge of church construction and growth during the 1950s [9,10]. Along the same lines, during the 1950s, church attendance reached new heights [9]. These individuals attended church, and they took their children with them; as a matter of fact, as children, 95 percent of Baby Boomers (people born between 1946 and 1964) participated in some form of traditional religious services during the post-war years [9]. It is no surprise then that, as the current cohort of seniors have aged, they have continued to cling to conservative values.
Current aging cohort and substance use disorders (SUDs)
It has long been known that the primary area of concern for the current cohort of older adults in regards to the use and abuse of substance has to do with their use and misuse of “licit”, or legally acquired substances, with the most common substance causing problems being alcohol [11]. Exacerbating problem drinking in older adulthood is the fact that the natural aging process is associated with key physiological changes, such as lower water solubility, that have a direct effect on the body’s ability to absorb and tolerate alcohol and other substances [11,12]. Therefore, when older individuals drink even small amounts of alcohol, they increase their risk of other negative consequences happening, such as a fall or automobile accident; moreover, the risk of other negative consequences is greater for older individuals when alcohol consumption is coupled with over-the-counter or prescription medications [11,12].
In addition to alcohol, researchers have found that other “licit” drugs can be problematic for members of the current cohort of older adults. Shorr et al. [13] found that inappropriately high doses of benzodiazepines were routinely being prescribed to elderly patients. Isacson et al. [14] noted that elderly patients were more likely to be prescribed medication for longer time periods than younger patients, which could lead to increased tolerance and dependence. Finally, Devor et al. [15] found an association between age related physical morbidity and physical dependence on licit drugs; older individuals are more likely to become dependent on narcotic analgesics to relieve pain or benzodiazepines to help with sleep difficulties.
Diagnosing of SUDs in the current cohort of older adults
Diagnosing SUDs in the current cohort of older adults is problematic in several ways. First, in general, the use of licit drugs and alcohol is much more socially acceptable than the use of illicit drugs; therefore, individuals in this population and those close to them may not see the use of licit substances as even a potential problem, resulting in these individuals not being referred to or seeking treatment. Second, because there is little research on alcohol abuse and dependency in older adults of the current cohort, treatment providers may not be aware that some individuals in this population may be in need of treatment services. Lastly, if and when the individuals in this population do seek treatment, the current criteria for diagnosing an SUD are not catered to the lifestyle of older adults. According to Briggs et al. [16], the current Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) [17] criteria were developed and validated using middle-aged samples of adults. While the current criteria includes increased tolerance to substances that is caused by increased consumption over time, older individuals are more likely than their younger counterparts to experience problems with substance use due to changes in their physiological makeup and pharmacokinetics [16,18,19]. Moreover, other DSM-IV-TR criteria, such as adverse consequences due to substance use, may fail to consider age related differences. For example, adverse consequences, such as poor work performance, absence from work, suspensions or expulsions from school, and neglect of children, will in most cases not apply to older individuals who live alone, are retired, or are unemployed due to disability [16,18,19].
Current aging cohort and treatment for SUDs
The current cohort’s attitude toward mental health disorders and the treatment of mental health disorders of any kind, including SUDs, proves to be an obstacle to this population receiving treatment for SUDs. Most individuals in the current cohort are known to underutilize treatment services for any type of mental health disorder, and receiving services for SUDs is no different [20]. For example, only 1,556 (8.81%) of veterans aged 60 and over received inpatient treatment for SUDs through Veterans’ Health Services in 1998 [21], and a more recent study conducted by Satre et al. [22] found that age was negatively associated with pre-treatment evaluation, treatment interest and treatment completion.
Many factors associated with this cohort’s attitude toward mental health are important in understanding their limited use of treatment for SUDs. First, the current cohort of older adults generally has a negative attitude toward mental health treatment of any kind and they attach a high level of stigma to taking part in such services [23]. Another possible explanation for the limited use of treatment for SUDs by the current cohort may be the cohort’s conservative values. In the United States, drug use is often associated with the use of illicit drugs, and illicit drug use is usually associated with a lack of morality or simply as bad behavior. Since most of the individuals in this cohort cling to conservative values based in traditional religious beliefs, they may find partaking in treatment for SUDs a mark against their moral character. Furthermore, the conservative beliefs of this population are founded in the idea that one should be able to deal with problems on his/her own, and this idea may lead to individuals in this cohort attempting to deal with their problems with substances by themselves.
Emerging aging cohort
The emerging cohort of aging individuals in the United States differs from the current cohort in many ways. First, the emerging cohort is much larger than the current cohort. The emerging cohort of older adults primarily consists of the Baby Boom generation, which is the largest generational cohort in American history [5-7]. Only recently did this group of individuals begin to turn 65; according to U.S. Census Bureau projections, with Baby Boomers entering the 65 and older age bracket, the senior population is expected to increase substantially during the years 2010 to 2030 [1,24]. In 2010, 35 million people, or 1 in 8 Americans, were 65 years or older, but by 2030, the senior population is projected to double what it was in 2000, reaching 72 million people, or 1 in 5 Americans, representing nearly 20 percent of the total U.S. population [1,3].
Not only is the Baby Boomer cohort of aging individuals expected to be much larger than the current cohort of older adults, it is also expected to be the healthiest aging cohort in American history, and therefore, people in this cohort are expected to live longer than the current group of seniors [25]. The longer life expectancy of the emerging cohort will influence the aging population further. With Baby Boomers living longer, the U.S. Census Bureau has projected an increase in the future population of “the oldest-old” (individuals aged 85 and older) [1]. In 2003, there were 4.7 million people aged 85 or older in the United States, and the Census Bureau projected the number of the oldest-old to double to 9.6 million people in 2030 [1]. Furthermore, the Census Bureau has projected that 9 million (or one in nine) of the 80 million Baby Boomers would endure into their late 90s, and 3 million (or 1 in 26) are expected to live to be 100 years of age [26]. By 2050, when a majority of Baby Boomers move into the oldest-old age group, the oldest-old population is expected to double yet again to 20.9 million people, accounting for 24 percent of the aging population (or nearly 1 of every 4 older people) [1].
In addition to living longer, the emerging cohort of older adults is also more liberal than the current cohort in both spending habits and belief systems. First, in contrast to the current aging cohort, the Baby Boomers came of age during the period that followed World War II; the 1950s and 60s were periods of unprecedented prosperity for Americans [5]. Because of their reasonably affluent upbringing, Boomers developed more consumerist patterns than their parents, and unlike their parents, they maintained their spending habits in later life, continuing to spend and take out loans after they entered the 50-year-old age bracket [8].
Another difference between the current and emerging cohorts is found in the way the two identify and participate in religious and social matters with the emerging cohort being much more liberal in these areas than their parents. Although a majority of Baby Boomers participated in church when they were children, they began to redefine themselves as they entered their teens and early twenties. During the mid-1960s, the Boomers began questioning their parents’ ideologies and breaking from traditional, institutionalized beliefs, choosing instead a more individualistic form of spirituality, which combined elements of Eastern religion, meditation, Native American practices, and, last but certainly not least, drugs [9]. Furthermore, their privileged circumstances allowed the Baby Boomer generation to focus their time on societal concerns and participate in the radical social changes that occurred during the 1960s and 70s, such as the Civil Rights movement, the women’s movement, and protests against the Vietnam War [5,6]. Green [23] proclaimed that as these individuals started to reach older adulthood, they have not adhered to their parents’ religiosity, choosing instead to hold fast to their consumerist habits by seeking products and services that empower, such as communication tools, motivational programs, and educational travel.
Yet another way the emerging cohort of aging individuals differs from the current cohort is the way in which they have approached aging. According to Rosowsky [27], as the Baby Boomer generation has moved into the 65 years and older age bracket, they have not been “as passively accepting of the ‘vicissitudes’ of aging” as their parents were. Overall, this cohort was better educated than the current group of individuals 65 years and older, but more importantly, in comparison with their parents, Baby Boomers have been more proactive consumers of healthcare; they are more likely to educate themselves on aging issues, which has resulted in a higher skepticism toward aging stereotypes [24]. Moreover, the fact that this cohort has reinvented the connotations associated with every age bracket into which it has moved, makes researchers believe that these individuals will also strive to redefine what it means to be “old” [23,27]. Baby Boomers have already coined phrases, such as “50 is the new 35,” which attempts to differentiate the image of middle-aged Baby Boomers from the image of their aging parents, and as they have entered the aging population, they have created new phrases, such as “70 is the youth of old age” in an attempt to distinguish themselves from the stereotypes of their senior parents [27]. As a matter of fact, Baby Boomers are so obsessed with aging differently than their parents (or aging less and possibly not aging at all) that market researchers predict more growth in the already booming anti-aging industries [23]. Plastic surgery, nutraceuticals (designer nutritional supplements known to alleviate the effects of aging), cosmeceuticals (designer cosmetics infused with antioxidants), physical aids, such as invisible bifocals and hearing aids, that simultaneously control and hide the appearance of aging disabilities, and other businesses promoting products and services designed to help Baby Boomers deal with the effects of aging are some of the businesses considered most likely to become extremely successful in the upcoming years because of marketers’ beliefs that the Baby Boomers’ have a strong desire to mitigate the consequences of growing old [23].
The last key difference between the two cohorts that is very important for rehabilitation professionals to be aware of is the way in which each group has approached mental health issues, such as SUDs. Baby Boomers are known for overcoming many of the stigmas associated with counseling, support groups and other mental health services; therefore researchers project that this group will continue to be consumers of mental health services, including treatment services for SUDs, as they age [23]. Moreover, researchers project that the Baby Boomers will continue to look for service providers that promote the acquisition of more youthful, optimistic mental health in an attempt to overcome or come to terms with the changes occurring in their aging bodies [23]. If this knowledge were to be applied to treatment programs for SUDs, there is no reason to think that we could not see a large uptake in older consumers desiring to receive treatment.

The Emerging Aging Cohort and SUDs

The SUDs of the emerging cohort of older adults are different from the SUDs of the current cohort. Although the emerging population of older adults is similar to the current cohort in that both use and become dependent on licit drugs, the data suggest that members of the emerging cohort use prescription medications at higher rates than the current cohort did at the same age; therefore, this cohort will have been using licit drugs for longer periods of time than the current cohort when they become older adults and are therefore more likely to have higher rates of complications associated with physical dependency and age than the current cohort [19].
Illicit drug use is another major difference between the emerging cohort and the current cohort. Unlike most individuals in the current cohort, members of the emerging cohort of older adults have used illicit drugs when they were younger and have continued using illicit drugs even as they have aged [19]. This reality has caused the National Institute on Drug Abuse (NIDA) director Dr. Dora D. Volkow to warn that it is very important for all rehabilitation professionals to be prepared to deal with this emerging problem in an effective way [28]. It seems clear then that rehabilitation professionals will, in all likelihood, be seeing a lot more older individuals with SUDs and that the severity of those SUDs are going to be much more serious than what rehabilitation professions who have experience working with older adults from the current cohort are accustomed to seeing. When you combine that reality with the very likely reality that older individuals from the emerging cohort will be seeking SUD treatment in much higher numbers, it is clear that failure to prepare for this new, emerging reality could have disastrous consequences for everyone (older consumers, their families and loved ones, rehabilitation professionals, rehabilitation agencies and society as a whole).
Diagnosing of SUDs in the emerging cohort of older adults
The problems in diagnosing SUDs in the emerging cohort of older adults are similar to the current cohort in two ways. First, problems with diagnosing SUDs in the emerging cohort are associated with the social acceptance of licit drugs. Just as the current cohort may not seek treatment for licit drug use and dependency based on the idea that licit drugs are not problematic because they are not illegal, the emerging cohort may also not see the use of licit substances as a potential problem. Furthermore, the higher rates of licit drug use among this population may add to a lack of individuals in this cohort seeking treatment for such drug use because if more people are using those substances, their use is more likely to be socially acceptable. Secondly, the current DSM-IV-TR criteria for diagnosing SUDs create the same problems for the emerging cohort as they do for the current cohort.
One problem that arises in the diagnosis of SUDs among the emerging cohort that does not arise in the diagnosis of SUDs among the current cohort is when mental health professionals use stereotypes associated with the current cohort of older adults in the diagnosis and treatment of individuals from the emerging cohort of older adults. Although there is a greater amount of research on SUDs throughout the lifetime of individuals in the emerging cohort of older adults, societal attitudes about older adults that were developed by observing the current cohort may be a hindrance to individuals in the emerging cohort being diagnosed and treated for SUDs.
One of the more popular and well known theories about illicit drug users over the years has been the “maturing out theory” (MOT) proposed by Winick [29]. The MOT is based on the idea that individual’s with SUDs become abstinent, or change their drug use behavior to more socially acceptable levels or make a change to more socially acceptable substances as they age. The problem is that the MOT has never been broadly supported by the empirical data. Nevertheless, it continues to be a prominent belief, even among some rehabilitation professionals, and it therefore continues to affect the way both practitioners and researchers approach SUDs among older adults [19]. While it is known that individuals with SUDs have higher mortality rates than individuals who do not abuse substances, there is no proof that older individuals who have been addicted for more than five years become abstinent as they age [19]. It seems then that a major problem has been that some researchers have failed to acknowledge the very important clinical differences between individuals who have substance abuse disorders and those who have a substance dependence diagnosis. While it may very well be that some substance abusers mature out of their substance abusing behaviors as they age, there is no clear evidence in regards to individuals with substance dependence disorders doing the same.
The emerging aging cohort and treatment for SUDs
The emerging cohort’s attitude toward SUD treatment is also drastically different than the current cohort’s. The Baby Boomer generation as a whole has overcome many of the stigmas associated with mental health services, which may contribute to this cohort seeking treatment for SUDs in higher numbers than the current cohort of older adults [23]. In addition, this cohort of aging individuals is more educated than the current cohort and they are more proactive consumers of healthcare services. In addition, research has shown that they are more likely to educate themselves on issues such as SUDs, which could then lead to them seeking professional help at higher rates [24]. Therefore, researchers expect that treatment for SUDs will be important for the emerging cohort of older adults, not only because they are more open-minded to such programs, but also because they took part in the dramatic increase in the use and abuse of illicit drugs during the 1960s and 1970s [19]. To put it simply, they are more likely to have a problem with drug use (both licit and illicit), they are more likely to become aware of that problem, and then they are more likely to seek help for that problem.

Types of SUD Treatment Currently Available to Both Cohorts of Older Adults

Currently, older adults seeking treatment for SUDs have three primary options: 1) Public, community based programs; 2) Private, for profit programs; 3) Services through the Veterans Administration (VA). Because there are so many different treatment programs in the United States, it is difficult to keep track of the total number of facilities; however, according to SAMHSA’s Substance Abuse Treatment Facility Locator, there are currently 11,000 addiction treatment programs in the U.S. [30]. What they do not make clear is which of those programs are “non-profit community based”, and which ones are private “for-profit” facilities.
Community based programs for SUDs
Community based SUD programs offer some benefits for older adults in both aging cohorts. For the current cohort, one advantage would be the ease of transferring from primary care, which is where most individuals in that cohort receive mental healthcare services, to SUD treatment. With the current cohort not seeking specialized treatment for SUDs very often, one of the more promising ways for this cohort to receive treatment is to be screened by their primary care healthcare provider. According to Kim et al. [20], one program designed to successfully utilize the power of primary care healthcare providers’ referral to SUD treatment is the Screening, Brief Intervention, and Referral to Treatment Initiative (SBIRT). SBIRT was designed based on suggestions made by the Treatment Improvement Protocols (TIP) 26 and 34 issued by the Substance Abuse and Mental Health Services Administration’s Center for Substance Abuse Treatment (SAMHSA-CSAT). The program consists of a brief intervention that includes screening followed by 1 to 5 sessions of education, advice, and motivational interviewing (which in and of itself has been found to reduce older adults’ alcohol problems) [20]. SBIRT services are most often given in primary care and hospital settings, making it ideal for the current cohort of older adults, who tend to abuse alcohol and licit drugs as their drugs of choice, and, as mentioned earlier, are currently not seeking specialized treatment for SUDs in high numbers. SBIRT referral for SUD treatment is made on an as needed basis, with problems of abuse or potential abuse being dealt with through brief intervention sessions [20].
Community based SUD programs also offer benefits for the emerging cohort of aging adults. With more programs available, than there is for example through the VA, which may or may not have services available in an individual’s area, it is likely that there will not be a need to travel too far away from home to receive services. Another obvious advantage of community based treatment is that, generally speaking, such programs are open to individuals from all backgrounds. SUD programs through the VA, for example, only provide services to eligible veterans. For older adults in the emerging cohort that are not veterans, or who may have been discharged in a way from military service that makes them ineligible for VA services, and/or have limited financial resources limiting any private treatment options, community based programs may in fact be the only treatment choice that is available to them.
Unfortunately, progressive programs, such as SBIRT, are currently the exception rather than the rule in regards to community based efforts to reach out to the current cohort of aging adults who have SUDs. Another major problem with many community based programs is that they are not prepared to effectively address the needs of the current cohort of older adults. Gunter et al. [31] found in a survey of 13,749 community treatment programs for SUDs that only 17.7% of them offered programs that were specifically tailored to the treatment of older individuals. In addition, their research revealed that some of the common problems experienced by such programs were a lack of transportation options to get older consumers to and from program facilities and that oftentimes the distance from where the older consumers lived to the facility where the program was being housed was an additional barrier to program participation [31]. Adding to those problems is the fact that the current cohort tends to seek mental health treatment of all types through their primary care physician, who often attributes such issues as normal aspects of age-related diseases and not to the possibility of problematic substance use [32].
Private programs for SUD treatment
In addition to public programs offered through the VA and community mental health agencies, there is a vast array of private, for profit, rehabilitation centers throughout the United States that are focused on the treatment of SUDs. While the most obvious mitigating factor for many older adults (from either cohort) is cost (it is not unusual for such programs to cost tens of thousands of dollars), the advantages of such programs, when they can be afforded, include privacy, comfort and choice. Many private programs are known for treating specified, professional groups of consumers or for having very nice, resort like accommodations and amenities. Some advertise certain ways of doing SUD treatment, such as the use of a non-12-step based approach that may appeal to some consumers. What is important to consider from the perspective of rehabilitation professional, when considering making a referral to such a program, is not simply the issue of affordability, but also whether or not there is good, solid, reliable and valid research backing the modality of treatment that is being espoused and used by the treatment provider. While consumer choice should always be an important consideration in any referral, we as ethically practicing rehabilitation professionals have an obligation to our consumers to only refer them to programs that have a proven track record of showing positive outcomes and, above all else, not putting them in harm’s way by using treatment methods of untested or unknown effectiveness.
SUD treatment through the VA
The Veterans Administration (VA) provides many different health and mental health services, including treatment for SUDs, to any older adult who is a veteran with qualified service in the armed forces. Qualified service generally means that the individual was honorably discharged at the time they left their branch of service; however, it is very important to have the consumer contact the VA directly to inquire into their eligibility for such programs, as policies are subject to change and/or the individual may not be correctly aware of their status. Currently, there are 1630 VA facilities nationwide; these facilities are divided amongst 23 Veterans Integrated Service Networks (VISN) (United States Department of Veterans Affairs, 2010) [33].
Two key advantages to seeking SUD treatment through the VA, for both the current and emerging cohort of older adults who are veterans, are convenience and cost; however, veterans who are a part of the first wave of older adults in the emerging cohort (those individuals who have only recently started turning 65) may benefit more from VA services for SUD treatment than the veterans from the current cohort due to several factors. First, SUD treatment through the VA might prove to be more convenient for veterans who already receive other services through the VA. Although convenience could be an important benefit for both cohorts, Vietnam- era veterans, who are members of the emerging cohort, already receive VA services in large numbers and have shown that convenience is particularly important for them in regards to receiving help with any kind of mental health issue. For example, Virgo et al. [34] found that the VA has treated large numbers of Vietnam-era veterans for mental health issues, such as post-traumatic stress disorder (PTSD). In fact, in 1998 the VA recorded services for mental health disorders reached 90,250 admissions of Vietnam-era veterans through its inpatient hospitalization services and an additional 1,598,000 admissions of Vietnam-era veterans through its outpatient programs. Moreover, in the past, high numbers of Vietnam-era veterans, who were receiving other VA services, have also sought help for SUDs. In 1996, 36.1% of the nearly 250,000 discharges attributed to Vietnam-era veterans were related to substance abuse or dependence [34].
Low cost is another key advantage for both cohorts receiving SUD treatment through the VA. Because VA services are often available at little or no charge, receiving treatment for SUDs through the VA is a viable option for all aging veterans no matter what their socio-economic status. This is especially important for the emerging cohort because many of these veterans were unable to transition back into civilian life as easily as the current cohort; therefore, many of them were not able to establish themselves in a career that would then enable them to have the financial resources to pursue other, more costly treatment options for SUDs.
Although SUD services through the VA provide some benefits for both cohorts of aging veterans, VA services as they currently exist and function are far from providing consistently effectual SUD treatment for older consumers. First, since one of the main concerns associated with aging veterans in the current cohort is their underutilization of SUD treatment, based in large part on stigma, which often associates SUD treatment with illicit drug use and in turn with immorality, the presence of Vietnam era veterans, who have often used illicit drugs, in SUD treatment through the VA, could prove to be a barrier to the current cohort seeking the same services. In other words, VA programs for SUDs currently provide most of their services to members of the emerging cohort, and individuals in the current cohort, who primarily have problems with licit drugs, such as alcohol, may perceive an inability to relate to individuals from the emerging cohort who are younger and have had more experience with the use of illicit drugs.
Another major problem with VA services for the treatment of SUDs, which primarily concerns the emerging cohort, stems from the fact that during the mid-1990s the Department of Veterans Affairs (VA) started moving to a primarily outpatient system of treatment for SUDs [35]. While this move was sure to save the VA money, it is not clear that it led to a better quality of services, especially in regards to the treatment of emerging cohort, Vietnam-era veterans who are known to have higher rates of co-occurring disorders, such as PTSD combined with SUDs [34]. The high attrition rates that are common in outpatient programs and the fact that early attrition from SUD treatment programs often leads to poorer outcomes are two of the major concerns regarding the VA’s move to outpatient programs [35].
Implications of ageism on SUD treatment for older adults
Ageist beliefs have been prevalent in American society for quite some time. The concept of ageism first appeared in Max Lerner’s 1957 book, America as a Civilization, but the term “ageism” was not coined until 1969, when psychiatrist, Butler [38], used it to explain why Washington, D.C. citizens opposed the construction of public housing for older people [36,37]. Narrowly defined, ageism has been a process of systematic stereotyping, prejudice, and/or discrimination against a category of people based on their age [36,38,39]. According to this narrow definition, ageism has been similar to other “-isms,” such as sexism, which disadvantages and oppresses women, and racism, which disadvantages and oppresses minority ethnic groups, because younger groups of people have used stereotyping, prejudice, antilocution, avoidance, and discrimination when interacting with aging individuals [36,38,40]. According to Bytheway [36], ageism’s effect on older individuals manifested itself through discrimination and prejudice based on a person’s chronological age and his/her body image. For instance, society has discriminated against older individuals by including age bars in insurance plans that make policies available only to adults under the age of 65 and by formally rejecting the images of older individuals in advertising, and society’s prejudice against the aging population has been demonstrated by the inclusion of age in the calculation of statistical priorities and by the avoidance of older individuals at social events [36].
However, the narrow definition of ageism does not take into account the complicated nature of this concept. Expressions of ageism can range from subtle to overt, and both formally and informally affect systems and individuals [27]. In a broader context, Bytheway B [36] defined ageism as “a set of beliefs about how people vary biologically as a result of the aging process” [36]. This broader definition includes how this set of beliefs has generated and reinforced a lifelong fear of the aging process, how the fear of aging has lead individuals to unconsciously project presumed associations between age and competence onto other age groups, and how such projections have underpinned the actions of individuals and organizations towards different age groups [36,41]. In this context, ageism differs from other forms of prejudice and discrimination in two ways; for one, every person (no matter their sex or ethnic background) may become a target of ageism, and second, because ageism has been a relatively recent and subtle concept, many people have been unaware of its existence and implications on society [36,39,41]. The broader definition portrays ageism as a double-sided phenomenon, with younger people projecting beliefs about older individuals (to rationalize their fears of aging) and older people projecting beliefs about younger individuals (to diminish their fears of becoming helpless and/or dependent) [41]. Moreover, unlike racism and sexism, ageism has not been brought to the public’s consciousness through extensive media attention or a massive social action campaign; therefore, individuals have been unconscious of their ageist beliefs and such beliefs have been more difficult to detect because these views have been inadvertently woven into the very thread of our society [36,40]. For example, ageism has not only included the negative assessments of an individual’s capacity based on his/her age, it has also included the dismissive or absolving attitudes, known as “benign or compassionate ageism” [42]. Many of the positive stereotypes about age groups (especially those held about older individuals) have been just as dehumanizing as the negative stereotypes because in both cases people have been placed into extreme categories that result in invisibility of the individual [42]. Although the broader definition of ageism has proven to be complicated, the implication of this broader definition on SUD treatment for the aging population is simple: the dominant expectations about older adults can dictate how rehabilitation workers (usually younger) and consumers (usually older) behave and relate to each other [36].
In the U.S. ageism has manifested itself in ageist discourse, age discrimination, and faulty ageist beliefs, expressed through verbal and non-verbal language rooted in intentional and non-intentional biases of aging and aging persons [40]. Various prejudice behaviors, such as the antilocution and avoidance of older persons, have been prevalent characteristics of ageist practices based on ageist beliefs [40]. Some examples of antilocution expressed by younger people included the following beliefs: “Many old people are stingy and hoard their money and possessions”; “Most old people should not be trusted to take care of infants”; “Teenage suicide is more tragic than suicide among the old”; and “Complex and interesting conversation cannot be expected from most old people” [40]. Some examples of avoidance included the following beliefs: “It is best that old people live where they don’t bother anyone”; “There should be special clubs set aside within sports facilities so that old people can compete at their own level”; and “I don’t like it when old people try to make conversation with me” [40].
A study by Palmore [39] found that ageism was perceived as frequent and widespread in the majority of older respondents surveyed. In fact, over 77 percent of the older adults (aged 60 and older) in his study (N=84) reported experiencing ageism “one or more times,” with more than half of the respondents reporting incidents that had occurred “more than once” [39]. Ageist events that occurred varied from the more benign, such as being told a joke that made fun of older people, to more serious events, such as being treated with less dignity and respect, being ignored, and being denied employment, promotion and medical care [39]. In addition, Ragan et al. [43] contended that ageism has been a major problem that needed to be both confronted and overcome. They noted that one major problem in combating ageism was the fact that many older individuals have seen age-related discrimination as coming from other causes such as minority ethnic backgrounds, gender, or sexual orientation (such as being part of the LGBTQ community).
The research clearly suggest that the ageist views held by rehabilitation professionals play a major role in there being a lack of effective treatments for all older adults with SUDs. In the United States there is currently a shortage of mental health professionals from all disciplines and all specializations, including SUDs, desiring to work with older adults. For example, Rosowsky [27] found that rehabilitation care providers of all educational backgrounds, including mental healthcare professionals (such as counselors, social workers, and psychologist) often devalued care specialties related to aging. Furthermore, when asked why they did not want to work with older adults, individuals training to be rehabilitation care workers gave the following ageist responses: “Gerontology is not chic”; “Old people are not a sexy population to work with”; “Old people often have poor prognoses and respond less well to treatment”; “Old people are a poor investment in the future”; “Old age seems a painful and sad time of life, and it would be painful and sad to work with old people”; “Old age is stage of deterioration; older adults are inevitably and inexorably going to age and decline further, and clinical work with the old is like ‘shoveling sand’ against the tide” [27].
Not only does ageism prevent rehabilitation workers from entering into positions that work with older individuals, it also affects the quality of care provided by rehabilitation professionals who are currently working with the aging population. Because of ageist attitudes towards older adults, older individuals are much less likely to be formally diagnosed with a mental health disorder, such as an SUD [44]. As a matter of fact, only 25 percent of older adults who needed mental healthcare have been found by researchers to have received any form of diagnosis that could have then lead to them receiving specialty treatment [44].

Conclusions

The large number of individuals in the emerging cohort of older adults in the United States will undoubtedly greatly increase the need for rehabilitation professionals trained to help individuals with SUDs. SUD treatment will be particularly important for the individuals in the emerging cohort of older adults, which was responsible for the dramatic increase in the use of illicit drugs during the 1960s and 1970s [19]. Many individuals in the emerging cohort have continued to use illicit drugs as they have aged, and data has shown that the prevalence of prescription medication use was higher for the emerging cohort than it was for the current cohort of older persons when they were the same age [19]. With this in mind, and because of the sheer number of individuals in the emerging cohort, researchers expect an increase for the need of treatment programs and other addiction-related resources geared toward the specific needs of older adults [19].
In addition to the numbers, another reason rehabilitation professionals should expect to see more older adults with addiction related disorders is because the emerging cohort of older adults are much more open to seeking services for such issues. The question for us today then should be: “Are we prepared to offer older adults with SUDs quality services?” While the answer to that question may seem like an easy yes at first thought, when we consider the fact that we currently have very few programs specifically designed for older consumers, it becomes obvious that this assertion is not accurate. Unless we start to prepare immediately for the inevitable large influx of older consumers, we risk the chance of having our already taxed and habitually underfunded, public rehabilitation programs in the United States completely overwhelmed.
So then, the question becomes: “How do we become ready?” Since we know that ageism has hindered the quantity and quality of the SUD treatment provided to the current cohort of aging individuals we can easily project that it also has a very high potential of obstructing the emerging cohort of aging individuals from receiving quality SUD treatment. In addition, when we consider the emerging cohort’s past experiences, such as their desire to live their lives on different terms than the lives of their parents, or their desire to mitigate any and all effects of the aging process, we can further conclude that ageism may have an even deeper impact on this cohort of older adults than on the current one [27]. Furthermore, when we consider the fact that most ageism is rooted in misconceptions about the aging process, and then that most of the misconceptions about aging represent negative stereotypes about the aged, then the obvious tool in combating those negative stereotypes is education. The answer then to the before mentioned question becomes: “Education, education and more education!”
If you are an educator in a rehabilitation related program, don’t wait; go ahead and add fact based, aging specific knowledge into your curriculum, develop an aging related lecture for an already existing class, or use someone else’s lecture that covers aging related facts significant to the topic of your class (with their permission of course). The point is to do something and that sooner would be better than later! It is a fact that it doesn’t take much time or effort to make a real, positive, verifiably significant effect that can be retained. For example, Dotson [45] found that a brief (1 hour and 30 minutes) educational intervention, followed by a brief structured discussion lasting approximately 20 minutes in duration, was enough to increase overall aging knowledge and reduce negative aging bias among 40 MRC students from three different universities, even though all of the study measures were given a full three weeks after the educational interventions were given.
If you are a student in a rehabilitation related degree program, don’t wait; you need to be quick to do all that you can to learn everything that you can about older adults, SUDs, how best to design and implement effective treatment strategies for these individuals, best practices in individual counseling, issues related to chronic pain management, etc.,. You never know, your ability to find gainful employment after you complete your degree program may very well depend on your ability and willingness to work with older consumers.
If you are a practitioner, the same holds true. Learn all that you can as soon as you can. When you are at that next professional conference trying to earn all of the continuing education credits you can, look to see if there are any aging and SUD related presentations. After all, having a heavy workload will not serve as an acceptable excuse when it comes to learning how to serve the largest, fastest growing population of potential consumers that is going to be around for years and years to come.
In conclusion, if we as rehabilitation professionals are to thrive moving forward and do good work, it is imperative that we be both willing and able to serve older consumers with SUDs. The good news is that there is a plethora of consistent and reliable evidence that suggest that a person’s knowledge about aging and older adults, tends to reflect his or her attitude toward these individuals; when a person has a great deal of correct knowledge about aging, he or she tends to hold more positive beliefs towards older individuals [46-54]. It is then that ever important connection between those positive beliefs and attitudes, the willingness to learn, and the ability to act in meaningful and effective ways, that is so essential to being ready for the boom in older consumers coming to us in need of help with SUDs. We recommend that anyone who thinks that they may desire (or be willing) to work with older adults with SUDs at the current time, or in the near future, concentrate on educating themselves with facts about older adults of both cohorts mentioned in this article (current and emerging). Furthermore, we stress the point that rehabilitation professionals should not use information and research based on experiences and observations made about the current cohort of older individuals in regards to SUDs and their treatment as the basis for their work with individuals from the emerging cohort of older adults (with the exception being information about adult physiology and pharmacokinetics). It is important to remember that members of the emerging cohort have attempted to try and differentiate themselves from their parents throughout their lives and there is no reason to believe that that will not continue to be the case as they age. Failure to recognize that very important dynamic could result in rehabilitation professionals having a very hard time developing rapport with this very important, growing population of consumers. After all, if we don’t have rapport with our consumers, if they won’t listen to what we say, how can we expect to truly make a difference in their lives? – at any age!

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