Treating Substance Misuse in Older Adults Participating in PACE

Programs of All-inclusive Care for the Elderly (PACE) are innovative, capitated Medicare–Medicaid programs. These programs provide impoverished older adults who qualify for nursing home placement an option of community-based long-term care. PACE helps adults ages 55 and older to keep living in the community by providing for their comprehensive healthcare needs and supporting family caregivers.

Through interprofessional team-based care, PACE provides integrated, comprehensive person-centered care: primary care, rehabilitation services, medications, specialty services, and transportation to social activities and adult daycare at the PACE center. While PACE is required to address participants’ mental health issues, PACE models do not have a standard system for addressing the prevention and care of specific mental health problems, particularly substance use issues. What follows are two exemplars of team-based approaches applied to substance use within PACE programs.

Ms. V Gets a Handle on Her Mental Health

Ms. V is a 65-year-old Latina with a history of Bipolar 1 disorder with depressive symptoms, general anxiety disorder, post-traumatic stress disorder (PTSD), complicated grief, and alcohol and opioid use disorders. Her PTSD stems from childhood adverse experiences. When her parents separated, Ms. V. was forced to move in with relatives, and separate from her siblings. She reported that she was repeatedly sexually molested by a relative.

Due to these childhood experiences she developed an eating disorder, characterized by compulsive overeating. Her past medical history includes Type 2 Diabetes Mellitus, mitral valve disorder, hypertension, heart disease, obesity, functional incontinence, past gastric bypass surgery, and pressure ulcers. She is functionally impaired and can only walk short distances. 

Ms. V has been enrolled in PACE for more than ten years. Early in her membership, she was hospitalized twice for psychiatric conditions, including an opiate overdose, after which the mental health team initiated a relationship with her that remains in place. A behavioral plan was implemented with collaboration among the patient, her primary care team, and the mental health team regarding her psychiatric conditions. This included addressing her history of opioid use disorder.

The advanced practice nurses worked together closely, providing problem-solving therapy and quickly recognizing illness exacerbations as well as managing her medications. The geropsychiatrist was certified to prescribe Suboxone (this prescription requires the practitioner to have been certified to prescribe by the Substance Abuse and Mental Health Services Administration). The prescription of Suboxone initiated her engagement in medication-assisted therapy (MAT). Thus, the geropsychiatrist remained involved in her care and collaborated with Ms. V’s team.

Social work staff also engaged Ms. V. in psychotherapy and life-skills training. She was referred to an accessible, community-based Narcotics Anonymous (NA) group, she continued engaging in bible study, and attended a bereavement group run by the chaplain at the PACE center.

When asked about the mental health care she received, Ms. V responded, “because of PACE my mental health conditions do not rule my life anymore.”

The interprofessional team applied the expertise of each discipline to work together to address Ms. V’s dual diagnoses: Bipolar disorder and opioid use disorder, severe. Medication-assisted treatment with Suboxone helps Ms. V to successfully avoid further opioid overdoses and to fully engage in her life outside the hospital, as well as remaining active in the PACE center. 

Mr. F Lives a Fuller Life Due to Interventions

Mr. F is a 74-year-old African American male who more than fifteen years ago, just prior to the winter holidays, lost his entire family in a house fire. He developed significant PTSD with intrusive thoughts and flashbacks. He self-medicated his symptoms with alcohol and experienced multiple hospital admissions for gastrointestinal bleeding, followed by prolonged stays for detoxification. 

He joined PACE approximately eight years ago, and the hospitalization pattern continued until his alcohol use and PTSD was recognized and addressed by the mental health team at PACE. The holidays were particularly difficult for Mr. F and he used alcohol excessively, experiencing many flashbacks with intrusive thoughts. 

Following Mr. F’s detoxification hospitalization and six weeks of outpatient alcohol rehabilitation, a PACE nurse practitioner provided a short treatment course of Motivational Interviewing focused on harm reduction with Mr. F.  

The intervention was six weekly visits at the PACE center with booster treatment sessions each year over the holiday season. This was necessary but not sufficient to treat his alcohol use disorder. He then agreed to a trial of Naloxone, which decreases the euphoric effects of alcohol. Mr. F also developed a close relationship with the PACE chaplain and now participates in the men’s group, where he receives dignity therapy and emotional support and enjoys the ongoing socialization.

Through additional individual counseling with the chaplain, Mr. F has been afforded a non-judgmental setting in which to confront his spiritual distress by sharing his anger with God “for taking my children from me.”  

His hospitalizations have decreased, but he continues to struggle and frequent triggers from the news precipitate his distress. For example, a news report of the tragic deaths of four children in a house fire brought back painful memories of the deaths of his own children and revealed clearly that the emotional scars have not healed. 

But Mr. F responded well to Naloxone therapy, motivational interviewing provided by the Nurse Practitioner, individual counseling with the chaplain, and, as needed, age appropriate rehabilitation and an outpatient twelve-step program. All the interventions seem to have improved Mr. F’s chances to live a full life, despite his tragic experiences.

The history of trauma, substance misuse, and the need for comprehensive approaches to treatment are common threads for both of these older adults. Psychotherapy, medication-assisted treatment and community-based resources have meant improvements to the quality and length of their lives.

Pamela Z. Cacchione, PhD, CRNP, BD, FGSA, FAAN, is the Ralston House Endowed Term Chair in Gerontological Nursing, and an associate professor of Geropsychiatric Nursing at University of Pennsylvania School of Nursing in Philadelphia.