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Senior contributing writer Joanne Kaldy is a freelance writer in Harrisburg, Pa., and a communications consultant for AMDA and other organizations.
Epidemiologists have suggested that nursing homes will see higher rates of alcoholism and drug abuse among residents as baby boomers age and seek long-term care. To prepare for this challenge, facilities can do much to shore up policies and procedures concerning these substances, identify abuse in new residents, and help them and their families, say experts in substance abuse as well as long-term care.
“Physicians can make questions about a substance or alcohol abuse history a part of the initial assessment,” said Eleanor Feldman Barbera, PhD, psychologist, consultant, and author of the “My Better Nursing Home” blog (http://mybetternursinghome.blogspot.com). “A lot of times, new residents are quitting cold turkey with no support because facility staff doesn't know the person has a problem. If the physician can identify this at admission, he or she can refer the person for help – such as counseling, AA [Alcoholics Anonymous] or NA [Narcotics Anonymous] meetings, or other support.”
But new residents and family members may be hesitant to admit having an alcohol or drug problem or a history of abuse, said addictions clinician Jamie Huysman, PsyD.
“Getting residents to open up about their alcohol or drug issues involves an organic process of relationship building.” A facility's culture should be understanding of substance abuse and alcoholism, he said. Both residents and staff should be made to feel confident that they won't be discriminated against, penalized, or stigmatized if they have such problems. Family members and residents will be more open if they know that the facility has programs to address substance abuse issues, said Dr. Huysman, executive director of the Leeza Gibbons Memory Foundation.
Each facility needs to have clear policies and procedures about the use of alcohol and drugs on the premises, said Dr. Feldman Barbera, and these policies need to be communicated to residents and families on admission. The rules need to balance choice and safety. “Whether people can drink at social hours or meals should be discussed with family members and depends on factors such the resident's ability to make decisions. If a resident has the capacity to make decisions and he wants to have a drink, it is his decision.”
Policies and procedures also should detail what will happen if a resident is caught using or hiding drugs and what sanctions apply to visitors and staff who give abusable substances to residents, said Dr. Feldman Barbera.
If discharge to a treatment center becomes necessary, facility leaders should be prepared for the task of getting residents and families the help they need, she said. “There aren't a lot of treatment facilities that can accommodate someone with a lot of medical problems.”
AA and Beyond
It has never been more important to address alcoholism and drug abuse in nursing homes, said Robert Gibson, PhD, senior clinical psychologist at Edgemoor skilled nursing facility in Santee, Calif. “We see a lot of people coming in with a history of substance abuse or injuries related to substance abuse,” he said. “It is disconcerting that the second largest category of abuse we see is related to prescription medications.”
Practitioners and staff can't make people participate in treatment programs or counseling. “One issue challenging [long-term care facilities] is that people are not coming in for substance abuse treatment,” said Dr. Gibson. “Our patients are coming in because of a disease or accident. Getting them to address a drug or alcohol problem is hard.”
While AA meetings can be useful, Dr. Gibson suggested, facilities should consider alternatives. “One option is SMART Recovery, which has an online program [at www.smartrecovery.org] that may be useful for people restricted to the facility.” He cautioned, however, that facilities and practitioners without addiction-treatment knowledge and experience should seek outside expertise.
Concerns about resident and staff safety magnify the need to address alcohol and drug abuse issues. Dr. Gibson noted, “We had a patient with a power chair go out [of the facility] and come back drunk. We had to set limits for this behavior.”
Dr. Gibson described another patient who was drinking while on pain medications. “We used a Breathalyzer test as a condition to receive pain meds.”
While lectures and verbal reprimands don't tend to work, said Dr. Gibson, the technique called motivational interviewing can help. “You engage the person and talk about what they want out of life, what they want to accomplish, and how their behavior is harming their ability to do what they want to do,” he explained.
It can also be helpful to educate families about the risk that substance abuse poses to their loved one, said Dr. Gibson. “They may respond better if you tell them that their loved one is on these particular meds and that even a small amount of alcohol could be dangerous. … Try to educate and engage them.”
Staff need education too, said Dr. Huysman. “Make sure they know to alert nursing about changes in cognitive status, functioning, etc., that might suggest alcohol or drug use. I sometimes use photographs of drugs to educate staff about what to look for,” he said. “They don't need to be experts, but they should know the basics.”
How to Host an AA Meeting
One way a long-term care facility can help residents deal with alcoholism is to host an Alcoholics Anonymous meeting on-site.
Sheila Rebello-Eian, PhD, a consulting psychologist at Oak Hollow Nursing Center in Long Island, N.Y., said that long-term care residents must be responsible for getting the group started and keeping it running, although she admitted that this can be a challenge. No AA meeting may be advertised, said Dr. Rebello-Eian. Insever, itcan may be announced during resident council meetings. She stressed, “Privacy and anonymity are essential components of the program and must be protected.” She added that a resident's participation should not be formally documented in his or her chart. It is important to note that an effective AA meeting can be held with as few as two or three people, according to the organization.
“My philosophy is that the meeting should be open to the community and not rely solely on residents for participation,” said Dr. Feldman Barbera. “This is a great way for the facility to increase visibility in the community.” If the facility does open the meeting to outsiders, there needs to be a way to maintain security and keep meeting participants isolated from the general facility population. The meeting also should have an entrance that protects the privacy of participants.
If the facility has residents who are interested in AA meetings but can't host these on-site, team leaders can use the AA Web site to find nearby meetings.