Mental health disorder, pain, and pain treatment among long-term care residents: Evidence from the Minimum Data Set 3.0.

Objective: This study evaluated: (a) associations between long-term care residents' mental health disorder diagnoses and their pain self-reports and pain treatments, and (b) the extent to which communication, cognitive, and physical functioning problems help explain disparities in the pain and pain treatments of long-term care residents with and without mental health disorders. Method: Minimum Data Set 3.0 records of 8,300 residents of Department of Veterans Affairs Community Living Centers were used to determine statistically unadjusted and adjusted cross-sectional associations between residents' mental health diagnoses and their pain and pain treatments. Results: Residents diagnosed with dementia and serious mental illness (SMI) were less likely, and those diagnosed with depressive disorder, post-traumatic stress disorder (PTSD), and substance use disorder (SUD) were more likely, to report recent, severe, and debilitating pain. Among residents affirming recent pain, those with dementia or SMI diagnoses were twice as likely to obtain no treatment for their pain and significantly less likely to receive as-needed pain medication and non-pharmacological pain treatments than were other residents. Those with either depressive disorder or PTSD were more likely, and those with SUD less likely, to obtain scheduled pain medication. In general, these associations remained even after statistically adjusting for residents' demographic characteristics, other mental health disorder diagnoses, and functioning. Conclusion: Long-term care residents with mental health disorders experience disparities in pain and pain treatment that are not well-explained by their functioning deficits. They may benefit from more frequent, thorough pain assessments and from more varied and closely tailored pain treatment approaches.

Implementing a cornerstone of culture change: Consistent staff assignment in VHA community living centers.

In 2011, the Veterans Health Administration (VHA) began implementing consistent staff assignment in its nursing homes (called Community Living Centers or CLCs). Consistent assignment, a cornerstone of culture change, minimizes the number of staff who provide a resident's care. The present research assessed the level and stability of consistent assignment in units within VHA CLCs and identified unit characteristics related to implementation of this staff assignment model. Schedulers in 185 of 335 organizational units that make up VHA CLCs completed a Staffing Practices Survey. For the month prior to the survey, 53% of CLC units had full implementation of consistent assignment. Tracked back over time, 37% of CLC units had stable high consistent assignment, 29% had stable low consistent assignment, and 34% were variable. Units with stable high consistent assignment were most likely to use care teams with stable membership and to obtain staff input for care assignments. Schedulers in these units reported more positive experiences with consistent staff assignment and better unit functioning in terms of staff absences, complaints about workload fairness, and resolution of scheduling problems. Units with stable low and variable consistent assignment were similar in most of these respects; however, units with variable consistent assignment made greater use of stable care teams and were less likely to change assignments at a staff member's request. Overall, consistent assignment implementation was not related to unit size, nursing hours per resident day, or specialty focus. Findings can help guide consistent staff assignment implementation in VHA and community nursing homes. (PsycINFO Database Record

Measurement-based management of mental health quality and access in VHA: SAIL mental health domain.

We outline the development of a Mental Health Domain to track accessibility and quality of mental health care in the United States Veterans Health Administration (VHA) as part of a broad-based performance measurement system. This domain adds an important element to national performance improvement efforts by targeting regional and facility leadership and providing them a concise yet comprehensive measure to identify facilities facing challenges in their mental health programs. We present the conceptual framework and rationale behind measure selection and development. The Mental Health Domain covers three important aspects of mental health treatment: Population Coverage, Continuity of Care, and Experience of Care. Each component is a composite of existing and newly adapted measures with moderate to high internal consistency; components are statistically independent or moderately related. Development and dissemination of the Mental Health Domain involved a variety of approaches and benefited from close collaboration between local, regional, and national leadership and from coordination with existing quality-improvement initiatives. During the first year of use, facilities varied in the direction and extent of change. These patterns of change were generally consistent with qualitative information, providing support for the validity of the domain and its component measures. Measure maintenance remains an iterative process as the VHA mental health system and potential data resources continue to evolve. Lessons learned may be helpful to the broader mental health-provider community as mental health care consolidates and becomes increasingly integrated within healthcare systems. (PsycINFO Database Record

Using organizational and clinical performance data to increase the value of mental health care.

U.S. health systems, policy makers, and patients increasingly demand high-value care that improves health outcomes at lower cost. This study describes the initial design and analysis of the Mental Health Management System (MHMS), a performance data and quality improvement tool used by the Veterans Health Administration (VHA) to increase the value of its mental health care. The MHMS evaluates access to and quality of mental health care, organizational structure and efficiency, implementation of innovative treatment options, and, in collaboration with management, resource needs for delivering care. Performance on 31 measures was calculated for all U.S. VHA facilities (N = 139). Pearson correlations revealed that better access to care was significantly associated with fewer mental health provider staffing vacancies (r = -.24) and higher staff-to-patient ratios for psychiatrists (r = .19) and other outpatient mental health providers (r = .27). Higher staff-to-patient ratios were significantly associated with higher performance on a number of patient and provider satisfaction measures (range of r = .18-.51) and continuity of care measures (range of r = .26-.43). Relationships observed between organizational and clinical performance measures suggest that the MHMS is a robust informatics and quality improvement tool that can serve as a model for health systems planning to adopt a value perspective. Future research should expand the MHMS framework to measure patient and health systems costs and psychosocial outcomes, as well as evaluate whether quality improvement solutions implemented as a result of using organizational information leads to higher-value mental health care. (PsycINFO Database Record

Automated Perimetry and Visual Dysfunction in Blast-Related Traumatic Brain Injury.

PURPOSE: To evaluate feasibility and results of automated perimetry in veterans with combat blast neurotrauma. DESIGN: Prospective, longitudinal, observational case series. PARTICIPANTS: Sixty-one patients in a Veterans Affairs Polytrauma Center diagnosed with traumatic brain injury (TBI) from combat blast exposure. METHODS: Study participants underwent automated perimetry at baseline (median interval, 2 months after injury) (Humphrey Field Analyzer, Carl Zeiss Meditec, Dublin, CA, Swedish Interactive Threshold Algorithm 30-2 Standard or Fast), and 36 of them were followed up (median interval, 10 months after baseline). Presence of significant mean deviation and pattern standard deviation was determined for testing with reliability indices ≤20% for fixation loss, 15% for false-positives, and 33% for false-negatives. Test-retest stability of global visual field indices was assessed for tests with these cutoffs or with elevated fixation loss. Associations between global visual field defects and predictors were examined. MAIN OUTCOME MEASURES: Global visual field indices (mean deviation and pattern standard deviation). RESULTS: Among 61 study participants (109 study eyes) with baseline testing, a field that met reliability cutoffs was obtained for 48 participants (79%) and 78 eyes (72%). Fixation loss was found in 29% of eyes in initial testing. Nine study participants (15%) demonstrated hemianopia or quadrantanopia, and an additional 36% had an abnormal global visual field index. Global indices were relatively stable at follow-up testing for tests meeting fixation-loss cutoffs and tests that did not. Visual scotomas due to post-chiasmal lesions were associated with moderate to severe TBI or penetrating head injury, but other visual field deficits were prevalent across the range of mild to severe TBI. Ocular injury to the retina or choroid, poorer visual acuity, and pupillary defect were associated with visual field defects. Participants with depressed visual field sensitivity reported lower visual quality of life. CONCLUSIONS: Reliable automated perimetry can be accomplished in most patients with TBI from combat blast exposure and reveals high rates of visual field deficits, indicating that blast forces may significantly affect the eye and visual pathways.

Alcohol Use Predicts 10-Year Depressive Symptom Trajectories in the Health and Retirement Study.

OBJECTIVE: To determine effects of late-middle-aged adults' baseline drinking behavior on their subsequent 10-year depressive symptom trajectories. METHOD: Health and Retirement Study participants (N = 7,939) were assessed on baseline demographic, health, and drinking characteristics, and biennially assessed for the next 10 years on their depressive symptoms. RESULTS: Growth mixture modeling generated four classes of depressive symptom trajectories: Consistently low (72%), consistently elevated (6%), increasing (12%), and decreasing (10%). Baseline abstinence from alcohol, possibly enforced by poorer health and a history of drinking problems, and heavier drinking, "binge" drinking, and having a history of drinking problems, raised risk of membership in the "consistently elevated" class. Abstinence by participants without history of drinking problems-and light, moderate, and heavier drinking-protected against membership in the "increasing" class. Abstinence by participants without history of drinking problems elevated-and moderate drinking reduced-likelihood of membership in the "decreasing" class. DISCUSSION: Late-middle-aged adults' alcohol use is associated with the subsequent long-term course of their depressive symptoms.

Closed-globe injuries of the ocular surface associated with combat blast exposure.

PURPOSE: To describe closed-globe conjunctival and corneal injuries and endothelial cell abnormalities associated with blast exposure and their relationships to other closed-globe injuries and blast-event characteristics. DESIGN: Observational cross-sectional study. PARTICIPANTS: Veterans with a history of blast-related traumatic brain injury (TBI). METHODS: History and ocular examination, including slit-lamp biomicroscopy, gonioscopy, specular microscopy. MAIN OUTCOME MEASURES: Type and location of blast injuries to the conjunctiva and cornea. RESULTS: Ocular surface injuries were present in 25% (16 of 65) of blast-exposed veterans with TBI. Injuries included partial-thickness anterior stromal corneal scars (15 eyes), Descemet membrane ruptures (6 eyes), and conjunctival or corneal foreign bodies (7 eyes). Based on normative information from an age-matched comparison group, endothelial cell abnormalities were identified in 37% of participants. Eyes with ocular surface injury were more likely to have lower endothelial cell density, higher coefficient of variation of cell area, and lower percentage of hexagonal cells compared with eyes without injury. Presence of ocular surface injury or endothelial cell abnormalities was associated with elevated rates of other anterior and posterior segment injuries, as well as impairment of visual acuity. We found no relationship between ballistic eyewear use or severity level of TBI and presence of ocular surface injuries from blast. CONCLUSIONS: Independent of TBI severity or use of protective eyewear, ocular surface injuries and endothelial cell abnormalities were found in significant numbers of veterans with blast-related brain injury. Descemet membrane ruptures from blast exposure were described. Ocular surface trauma was associated with other ocular injuries throughout the globe. Potential mechanisms for the types and locations of ocular injuries seen were discussed. Any corneal or conjunctival injury in a blast survivor should prompt a thorough ocular trauma examination, including gonioscopy and specular microscopy, with appropriate follow-up for associated injuries. Longitudinal studies are required to determine long-term visual outcomes after blast exposure.

Visual quality of life in veterans with blast-induced traumatic brain injury.

IMPORTANCE: Traumatic brain injury (TBI) is an important cause of morbidity worldwide, with increasing awareness of the role of blast exposure in military and civilian casualties. Visual problems have been reported in TBI and may affect functioning and quality of life. OBJECTIVE: To evaluate the 25-item National Eye Institute Visual Functioning Questionnaire and Neuro-Ophthalmic Supplement for utility in assessing the effect of blast exposure on perceived visual functioning among veterans with TBI. DESIGN, SETTING, AND PARTICIPANTS: Observational cohort study from a tertiary care Veterans Health Administration hospital. Reported visual quality of life was compared with existing norms, and relationships between perceived visual quality and ocular injury, diplopia, visual performance, and blast exposure characteristics were examined. Participants included inpatients with blast-induced TBI who underwent baseline examination between December 7, 2006, and January 11, 2012, at a multiple-trauma rehabilitation center and who had at least 1 intact eye and were able to undergo psychometric testing and ocular examination. Among 64 sequentially eligible patients, 60 completed visual quality testing, 1 declined study participation, and 3 were evaluated prior to inclusion of visual quality testing in the protocol. Thirty-nine patients returned for outpatient follow-up, with a median test-retest interval of 11 months. EXPOSURE: Combat blast exposure with documented TBI. MAIN OUTCOMES AND MEASURES: Composite and subscale scores on the 25-item National Eye Institute Visual Functioning Questionnaire and Neuro-Ophthalmic Supplement. RESULTS: Both tests had high test-retest reliability. Blast-exposed veterans reported significantly poorer visual quality compared with healthy samples and some patient samples with known eye disease. Scores tended to be worse for participants with identified visual performance deficits (poorer visual acuity or spatial contrast sensitivity, visual field depression or defects). Scores were not related to the extent of ocular injury or to blast exposure characteristics such as use of protective eyewear or TBI severity level. CONCLUSIONS AND RELEVANCE: Individuals with blast-induced TBI reliably completed both tests and reported significant decrements in their subjective visual experiences. Measures of subjective visual quality may be useful to identify patients needing additional visual or neurologic evaluation and to monitor the effect of visual rehabilitation on patients with blast-related visual disabilities.

Visual performance and the ocular surface in traumatic brain injury.

The pathophysiology of neurotrauma is reviewed and an original study investigating the prevalence of dry eye disease in a sample of veterans with traumatic brain injury (TBI) is presented. Fifty-three veterans with TBI were evaluated by history of injury, past ocular history, and medication use. Ocular Disease Surface Index (OSDI), ocular examination, cranial nerve evaluation, tear osmolarity, tear film break-up time (TFBUT), ocular surface staining and tear production testing were performed. A matched comparison group underwent similar testing. TBI causes were blast (44) or non-blast (9). TBI subjects scored significantly worse on the OSDI (P<.001), and ocular surface staining by Oxford scale (P<.001) than non-TBI subjects. Scores for tear film breakup (P=.6), basal tear production less than 3 mm (P=.13), and tear osmolarity greater than 314 mOsm/L (P=.15) were all higher in TBI subjects; significantly more TBI subjects had at least one abnormal dry eye measure than comparisons (P<.001). The OSDI related to presence of dry eye symptoms (P<.01). These effects were present in both blast and non-blast TBI. Seventy percent of TBI subjects were taking at least one medication in the following classes: antidepressant, atypical antipsychotic, anticonvulsant, or h1-antihistamine. There was no association between any medication class and the OSDI or dry eye measures. Reduced corneal sensation in 21 TBI subjects was not associated with OSDI, tear production, or TFBUT, but did correlate with reduced tear osmolarity (P=.05). History of refractive surgery, previous contact lens wear, facial nerve weakness, or meibomian gland dysfunction was not associated with DED. In summary, we found a higher prevalence of DED in subjects with TBI, both subjectively and objectively. This effect is unrelated to medication use, and it may persist for months to years. We recommend that patients with TBI from any cause be evaluated for DED using a battery of standard testing methods described in a protocol presented in this article. Further research into the pathophysiology and outcomes of DED in neurotrauma is needed.

Substance use disorders and health care costs among veterans affairs nursing home residents.

BACKGROUND: Research on the relationship between substance use disorders (SUDs) and older adults' health care costs is equivocal. A large-scale study comparing health care costs among older adults with and without SUDs has never been conducted. OBJECTIVE: To determine the relation of SUDs to health care costs in a large sample of adults following entry into a Veterans Affairs (VA) nursing home. METHODS: We performed a retrospective analysis of 29,997 adults aged 45+ who entered a VA nursing home in 2000. Total costs were tallied over fiscal years 1997 to 2000 by setting (outpatient, nursing home, other inpatient, and total) and included all care paid by VA. RESULTS: Relative to non-SUD patients, those with SUDs aged 75 to 84 years had significantly higher total costs of care (+$10,020), as did those aged 85 and above (+$16,052). Yet, SUD diagnosis was not a significant predictor of total cost or nursing home cost among persons 65 and above after controlling for demographic, clinical, and financial factors. CONCLUSIONS: SUDs do not directly increase health care costs among older adults entering nursing homes, although they may affect cost of care indirectly through factors such as income and marital dissolution. The generational increase in SUD rates occurring in the United States may not lead to substantially greater health care expenses if appropriate assistance can be provided before nursing home entry.

Predictors of anatomical patency following primary endonasal dacryocystorhinostomy: a pilot study.

PURPOSE: To identify factors influencing early anatomical patency following primary endonasal dacryocystorhinostomy (DCR) for nasolacrimal obstruction. METHODS: A prospective study of 50 patients who underwent primary endonasal DCR for nasolacrimal obstruction was undertaken. Age, gender, dacryocystitis, endonasal access, clearance (bony clearance superiorly from the common canaliculus after bone removal), mobility (mobility of the flaps created from the lacrimal sac once opened), marsupialization (degree of reflection of the lacrimal sac following surgical opening) and a combined score (incorporating clearance, mobility and marsupialization) were examined. Outcomes were measured 10 weeks postoperatively by assessing anatomical patency via probe and syringe and modified functional endoscopic dye test. RESULTS: Using the Kendall's tau-beta test, there was a significant relationship between greater mobility and better outcome (p<.03) and greater marsupialization and better outcome (p=.03). A higher combined score (incorporating mobility, marsupialization and bony clearance) was also related to better outcome (p<.02). There was no significant relationship between outcome and age, gender, dacryocystitis, endonasal access or bony clearance. Overall, 47 patients (94%) had complete or partial patency at 10 weeks and 3 patients (6%) had complete nasolacrimal obstruction at 10 weeks. CONCLUSIONS: Greater flap mobility and greater lacrimal sac marsupialization in endonasal DCR are associated with better rates of early anatomical patency. A novel scoring system incorporating mobility, marsupialization and bony clearance also showed a significant relationship to early outcome, with higher scores being associated with better outcomes. These results may enable greater understanding of the perioperative features associated with better outcomes in endonasal DCR.

VA nursing home residents with substance use disorders: Mental health comorbidities, functioning, and problem behaviors.

OBJECTIVES: This research addresses whether residents with substance use disorders (SUDs) in VA nursing homes (VANHs) are distinctive in terms of their demographic characteristics, medical and mental health comorbidities, functioning, and problem behaviors. METHODS: Residents over age 55 admitted to VANHs (n = 27,002) were identified in VA administrative files, and SUD and non-SUD residents were compared. RESULTS: Compared with other residents, the residents with SUDs (18% of admissions over age 55) were more likely to be younger, male, African-American, unmarried, have low income and a tobacco use disorder. Controlling for demographic factors and smoking, SUD residents were more likely to have mental health comorbidities (dementia, serious mental illness, depressive disorders, and post-traumatic stress disorder), as well as AIDS/hepatitis, pulmonary disease, gastro-intestinal disorders, and injuries. SUD residents were less likely to have cancer, diabetes, neurological disorders, heart failure, and renal failure. SUD residents were more independent in activities of daily living, such as mobility and toileting. They were more likely to engage in verbal disruption but not in other problem behaviors such as aggression. With demographic factors and comorbidities controlled, the functioning differences were diminished, and SUD and non-SUD residents did not differ in the levels of problem behaviors. DISCUSSION: VANH residents with SUDs have distinctive patterns of comorbidities and functioning. SUD appears to represent a separate risk factor for VANH admission. Residents with SUDs present challenges but may have good potential for positive discharge outcomes if their substance use problems and limited resources can be addressed.

Recent changes in the prevalence of psychiatric disorders among VA nursing home residents.

OBJECTIVE: This study identified recent changes in the prevalence of psychiatric disorders among Department of Veterans Affairs (VA) nursing home residents. METHODS: Psychiatric diagnoses in administrative databases were summarized for nursing home residents in 1998, 2002, and 2006. Census prevalence rates were compared with findings from earlier VA nursing home surveys. Prevalence rates were compared for age groups and birth cohorts of VA nursing home admissions in 1998 (N=27,734) and 2006 (N=32,543). RESULTS: Among residents in the census samples, prevalence rates for dementia and schizophrenia fluctuated moderately from 1990 to 2006, depression prevalence increased sharply, alcohol use disorder prevalence declined, and drug use disorder prevalence increased. Among 1998 and 2006 admissions, dementia prevalence increased for most birth cohorts but declined for most age groups (35% to 32% overall). Depression prevalence increased for all age groups and birth cohorts (27% to 37% overall), as did posttraumatic stress disorder prevalence (5% to 12% overall). Serious mental illness prevalence increased among the oldest residents and birth cohorts (19% to 22% overall). Alcohol use disorder prevalence declined for all birth cohorts and most age groups (18% to 16% overall), but drug use disorder prevalence increased substantially for younger age groups (6% to 9% overall). CONCLUSIONS: Examining differences in prevalence between birth cohorts and age groups can clarify trends in nursing home resident characteristics and improve projections of their future needs.

Gender differences in social influences and stressors linked to increased drinking.

OBJECTIVE: To explore reasons for gender differences in problem-drinking prevalence and to compare the experiences of problem-drinking women and men, this article examines gender differences in exposure and drinking reactivity to social influences and stressors during adulthood. METHOD: A community sample of 831 older adults (347 women and 484 men; average age=69), comprising problem and nonproblem drinkers, provided information about their drinking histories. Respondents indicated whether they had experienced particular social influences and stressors during adulthood (exposure) and, if so, whether they had increased alcohol consumption in response (reactivity). RESULTS: Overall, women were more likely than men to report exposure to a partner's drinking, family interpersonal problems, death of someone close, and emotional distress. Men reported more exposure to peers' drinking and workplace problems and were more likely to report drinking reactivity to social influences and stressors. Among problem drinkers, gender differences in exposure to social influences and stressors paralleled those in the overall sample, but gender differences in reactivity were minimal. CONCLUSIONS: Gender differences in exposure to social influences and stressors generally do not help explain men's higher problem-drinking prevalence, but men's overall greater drinking reactivity corresponds with their propensity to develop problem drinking. Problem-drinking women and men tend to be exposed to somewhat different social influences and stressors but share a tendency to respond to these experiences with increased drinking. Information about experiences that may place upward pressure on drinking for men and women can inform efforts to prevent and treat alcohol-use disorders.

Upward pressures on drinking: exposure and reactivity in adulthood.

OBJECTIVE: The purpose of this study was to identify the situations most commonly linked with increased drinking for different life periods and for nonproblem and problem drinkers. METHOD: A community sample of older adults (average age 69 years; 42% women), consisting of 480 nonproblem and 351 problem drinkers, provided information about their life history of drinking. For each of three life periods (early adulthood, early middle age, and late middle age), respondents indicated whether they experienced particular situations (exposure) and, if so, whether they increased their alcohol consumption in response to these situations (reactivity). These situations included social influences and stressors. RESULTS: Exposure to social influences and to stressors varied across life periods, as did drinking reactivity. Overall, the social influences of having peers or a partner who drank and the stressors of family interpersonal problems and emotional distress were common experiences and also were among the most likely to be linked with increased alcohol consumption. Compared with nonproblem drinkers, problem drinkers reported significantly higher levels of exposure to social influences and to stressors and also were much more reactive to them. CONCLUSIONS: Prevention and treatment of alcohol use disorders can be tailored to take into account variations in exposure and reactivity to situations that may place upward pressure on drinking.

Sequencing the lifetime onset of alcohol-related symptoms in older adults: is there evidence of disease progression?

OBJECTIVE: The purpose of this study was to evaluate evidence of orderly symptom progression in alcohol-use disorders (disease-progression model). METHOD: A sample of community-residing older problem drinkers provided information about their life history of drinking, including the age at which they had experienced alcohol-related symptoms that correspond to criteria for alcohol abuse and dependence. Symptom sets and possible sequences were formulated separately for women and men, based on the average number of years from drinking initiation to symptom onset and on symptom prevalence. We assessed how well the ordering of symptoms experienced by individual respondents matched the sequences derived with these group-level measures; we also assessed whether individuals progress from alcohol abuse to dependence as is implied in some conceptualizations of alcohol-use disorders. RESULTS: Half or more of these older adults experienced symptom onset in an order that was inconsistent with the possible symptom sequences derived from group-level analysis (e.g., reversals from the expected order or concurrent onset of symptoms expected to occur sequentially). Similarly, alcohol abuse did not appear to be a precursor to the development of alcohol dependence in individual patterns of symptom onset. CONCLUSIONS: Although group-level results based on the number of years from drinking initiation to symptom onset or on symptom prevalence may seem to point to orderly progression in the development of alcohol-related symptoms, these group-level results do not capture individual experiences very well. In this community-residing sample of problem drinkers, most of whom had never sought treatment, there was marked variability in the course of symptom development, which raises questions about the utility of a disease-progression model.

Treatment and outcomes of older patients with alcohol use disorders in community residential programs.

OBJECTIVE: To determine whether older patients with alcohol use disorders receive equitable treatment in community residential facilities. METHOD: Older male veterans with alcohol use disorders who were treated in 63 community residential facilities (CRFs) were matched with young and middle-aged male veterans in these programs (n = 190 in each age group) on demographic variables and dual-diagnosis status. Patients were assessed at program intake and were followed 1 year and 4 years after treatment entry. Program staff provided information on use of services and on program characteristics. RESULTS: Although they had similar alcohol consumption and dependence symptoms at treatment entry, older patients experienced fewer alcohol-related problems and had fewer symptoms of psychological distress than did young and middle-aged patients. Controlling for initial differences, older patients did at least as well as young and middle-aged patients at both follow-ups. Older, middle-aged and young patients had equivalent treatment involvement in the CRF, participation in continuing outpatient care and involvement in self-help groups. Similar factors predicted better outcomes for older and younger patients, including a longer stay in the CRF, more counseling, involvement in supportive relationships with other residents, continuing outpatient substance abuse care and participation in self-help groups following residential treatment. Both older and younger patients showed similar benefits across varied treatment orientations. CONCLUSIONS: Older patients fare at least as well as younger patients in these age-integrated, community-based programs, and they respond in similar ways to treatment experiences and program factors.

Outcomes at 1 and 5 years for older patients with alcohol use disorders.

Older patients with alcohol use disorders who had gone through residential treatment were compared with matched groups of young and middle-aged patients (N = 432 in each age group) on their 1- and 5-year outcomes, use of continuing care services, and outcome predictors. Older patients had better outcomes than did young and middle-aged patients but had comparable levels of continuing substance abuse care and 12-step self-help group involvement. Similar factors predicted outcomes across the age groups. Longer duration of continuing substance abuse care and greater self-help group involvement were related to better outcomes, as were patients' attitudes and coping strategies at program discharge. The findings indicate that older patients with alcohol use disorders respond to age-integrated substance abuse treatment programs at least as well as do younger patients and are equally involved in formal and informal continuing substance abuse care.

Prognosis of older patients in mixed-age alcoholism treatment programs.

Older patients were compared with matched groups of younger and middle-aged patients in inpatient alcohol treatment programs (N=432 in each age group). Compared with other patients, older patients had poorer physical health and lower cognitive status at treatment entry, but they were drinking less and reported fewer drinking-related problems, fewer psychological symptoms, more social support, more adaptive coping, and fewer barriers to abstinence. Older patients had positive views of the programs and, except for less family therapy and problem-focused counseling, received comparable treatment to that received by other patients. At discharge, older patients showed significant change in most areas targeted for treatment. Better initial status was the strongest predictor of better discharge functioning. Patients with higher cognitive functioning and stronger treatment motivation and those who experienced more interpersonal support and who received more specialized treatment services showed better-than-expected improvement. The age groups showed similar outcomes, prognostic factors, and response to different treatment orientations.