This case emphasizes the complex needs of aging veterans with multiple medical illnesses, mental health problems, and substance-related disorders, and highlights Veteran Administration treatment models designed to deliver care to this population.
older adults, alcohol use disorder, veteran mental health, aging veterans
A Sample Case at the Department of Veterans Affairs
Mr. R is a 75-year-old male veteran who has been receiving medical and mental healthcare at the Department of Veterans Affairs (VA) since his service in Vietnam. He has a history of alcohol use disorder (AUD), post-traumatic stress disorder (PTSD), atrial fibrillation, liver cirrhosis, chronic neuropathic pain, hypertension, and chronic obstructive pulmonary disease (COPD).
In the past few decades, Mr. R has been admitted to the VA more than 150 times for alcohol detoxification, and often he remains in residential settings for prolonged periods in an effort to help him maintain sobriety. Over the years, he has been given access to nearly every social and mental health service the VA offers, but he tends to not adhere to treatment plans or rejects them altogether. As Mr. R ages, his detoxification admissions have become more complicated because of issues specific to aging and medical comorbidities, which are exacerbated by alcohol consumption.
When Mr. R. appears in the emergency department he is usually intoxicated, malodorous, and disheveled, with bruises on his face and extremities that are in various stages of healing. During subsequent medical workups, he has been found to have significant medical conditions such as high levels of certain liver enzymes, atrial fibrillation with rapid ventricular response, COPD exacerbation, or evidence of a fall with head strike.
Deliberations by the hospital healthcare team typically revolve around concerns about polypharmacy, decision-making capacity, and calls to Adult Protective Services (APS). Due to his underlying mild neurocognitive impairment, which is often exacerbated by delirium during alcohol intoxication or withdrawal, Mr. R. is frequently found to lack the capacity to make various medical decisions during his admissions.
He is financially enmeshed with his estranged-wife, who also serves as his healthcare-proxy. When he is found to be incapacitated, their tumultuous relationship often erupts into threats of violence, warranting APS filings on at least three different occasions.
As a result of the hundreds of alcohol detoxification admissions, Mr. R has been discharged on dozens of different medication regimens. In the few outpatient appointments he has attended, he has expressed confusion about his medication regimen, but subsequently rejects help from a visiting nurse service or relapses before the service can be useful.
This patient’s severe alcohol use disorder (chronic alcoholism) is driven by his ongoing mental health symptoms, specifically PTSD. Mr. R was a combat medic in Vietnam, where he witnessed violence and bloodshed. He has alluded to perpetrating violence against Vietnamese civilians. He has ongoing nightmares, hypervigilance, mood fluctuations, and hyperarousal. His inconsistent treatment adherence, poor coping skills, limited social supports, and severe burden of medical and mental health symptoms present a multitude of needs to be addressed by the treatment team, especially as he ages.
Older Veterans’ Impact on an Aging United States
Older Americans are the fastest growing segment of the U.S. population and U.S. veterans are aging at a similarly staggering rate. By 2035, it is projected that there will be approximately 11 million Vietnam veterans older than age 65 (Richard-Eaglin et al., 2020). Substance-related disorders, specifically AUD, are a growing concern in the older adult population.
Although consumption of alcohol typically declines with age, binge drinking and AUD is becoming increasingly prevalent among older adults in the United States (Grant et al., 2017; Han et al., 2017; Stefanovics et al., 2020). The management of older patients with AUD and their complex medical and social care needs is challenging even for interdisciplinary healthcare teams.
The changes of normal aging involve decreased hepatic and renal function, loss of lean body mass, and declines in cognitive processing speed and visual skills. Because of these age-related physiologic and metabolic changes, the medical consequences of alcohol consumption are accentuated in older individuals (Menninger, 2002). Older adults achieve greater blood ethanol concentrations for a given quantity consumed and are more sensitive to the effects of acute intoxication (Menninger, 2002).
Furthermore, alcohol use is linked to higher rates of various medical conditions including dementia, cerebrovascular accidents, falls with associated subdural hematomas or hip fracture, hepatitis, fatty liver, pancreatitis, cirrhosis, cardiomyopathy, myocardial infarction, arrhythmia, aspiration pneumonia, inadequate nutrition, and vitamin deficiencies (Menninger, 2002). Poor self-care, lack of compliance with treatment, or social factors that prevent engagement in care often contribute to increased medical morbidity in these patients.
In general, older veterans have more comorbid diagnoses when compared to older non-veterans (O’malley et al., 2019). These diagnoses frequently include a combination of medical illnesses, mental health problems, and substance use disorders, along with cognitive impairments. Furthermore, of all veteran populations, aging Vietnam-era veterans have the greatest lifetime prevalence of PTSD (O’malley et al., 2019).
People with PTSD have high rates of comorbid substance use and often use substances as a form of self-medication (Souza and Spates, 2008). PTSD is also linked to long-term deleterious health outcomes. A systematic review found that people with PTSD in mid-life have increased risk of dementia of all types in late life (Desmarais et al., 2020). Veterans with PTSD have been found to have a 45 percent increased risk of cardiovascular disease, a 26 percent increased risk of congestive heart failure, a 49 percent increased risk of myocardial infarction, and a 35 percent increased risk of peripheral vascular disease compared to older veterans without PTSD (Beristianos et al., 2016). The complexity and interplay of these conditions complicates care planning, as well as efforts to maintain or improve health and to keep patients engaged in chronic care (O’malley et al., 2019).
‘The VA has a robust network of mental health residential rehabilitation treatment programs.’
A further complication can be the individual’s ability to make decisions related to healthcare or daily living. Decisional capacity assessments are often conducted to balance patient safety with autonomy, and given the aging population, it is projected that the need for these assessments will increase significantly over the next two decades (Moye and Braun, 2010). These evaluations are generally conducted by a trained healthcare provider and conclusions are supported by the clinical interview, record review, and often, neuropsychological testing and functional assessments. It is important to note that a patient may retain capacity to make a decision in one domain but lack capacity in another. Similarly, decisional capacity may change from day to day depending upon the burden of various conditions such as substance intoxication, delirium, or depression. If a patient lacks decision-making capacity, a healthcare proxy or power of attorney is enacted. As in the case of Mr. R, his healthcare proxy has helped in making some decisions, but her involvement also has led to a cascade of complicating effects.
As the number of older adults in the population grows, it is imperative that healthcare systems develop strategies to manage the complexities of care for older individuals with substance use disorders. The VA long ago identified this challenge and has been developing innovative care-delivery mechanisms to help address it. Studies have found that most older veterans prefer to seek their mental health and addiction care in the primary care setting (O’malley et al., 2019).
Therefore, the VA (broadly speaking) has emphasized integrating psychiatry and other mental health services into primary care and other clinics. Integration at this level promotes team-based approaches to complex patients and brings mental health services to patients instead of patients having to seek out services. Outcomes have been excellent, with better patient engagement and higher scores in patient and provider satisfaction, as well as lower healthcare costs (Gallo et al., 2004; O’malley et al., 2019; Torrence et al., 2014).
The VA has a robust network of mental health residential rehabilitation treatment programs (MH RRTP) to address the needs of veterans who require more intensive treatment for multiple and severe medical conditions, mental illness, addiction, or psychosocial deficits (Veterans Health Administration Handbook, 2020). While these programs treat veterans of all ages, the shifting demographics of VA patients result in many older adults seeking care in these programs. Mr. R has completed several MH RRTP programs and has benefited from the holistic treatments and excellent medical care, as well as from the facilitated prolonged periods of sobriety.
Mr. R’s health status and social problems have posed significant challenges for a healthcare system that prioritizes interdisciplinary care for complex patients. His case presents an opportunity to reflect upon what the VA does well and the models the VA has developed for the rest of the healthcare system. One demonstrated outcome is that when care is brought to patients in settings where they are comfortable, patients tend to be more engaged.
The VA primary care–based mental health services model is a particularly successful one. The VA’s care delivery for older patients is also particularly strong in its robust geriatric services, which include geriatric mental health, dementia care, long-term care with integrated mental health and substance use treatment, respite services for caregivers, caregiver support resources, physical rehabilitation, and access to community-based resources.
As the population ages, and cases like Mr. R’s are more common in hospitals nationwide, our healthcare system might wisely look to the VA for ways to effectively and humanely manage the medical and social needs of older adults with complex histories.
Aaron Greenstein, MD, is a fourth-year psychiatry resident at Harvard South Shore, the chief resident of Geriatric Psychiatry at McLean Hospital, and a fellow in the Health and Aging Policy Fellowship. Haley Solomon, DO, is a fourth-year psychiatry resident at Harvard South Shore and a Livingston Research Fellow at Harvard Medical School. Margo Funk, MD, is the program director at Harvard South Shore and an attending psychiatrist at the Boston VA.
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