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Issues Associated with Mental Health in Older Adults: Problem Gambling

Issues Associated with Mental Health in Older Adults: Problem Gambling. Debbie Rull, M.A., CCGC-I, NCGC-I Project Coordinator, UPAC Problem Gambling Prevention UPAC Problem Gambling Prevention TA and Training Project Funded by the State of California Office of Problem Gambling. Overview.

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Issues Associated with Mental Health in Older Adults: Problem Gambling

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  1. Issues Associated with Mental Health in Older Adults:Problem Gambling Debbie Rull, M.A., CCGC-I, NCGC-I Project Coordinator, UPAC Problem Gambling Prevention UPAC Problem Gambling Prevention TA and Training Project Funded by the State of California Office of Problem Gambling

  2. Overview • Gambling/Problem Gambling Overview • Impacts of problem gambling • Gambling Risk factors • Assessment & diagnosis • Vulnerable population: Older Adults • Clinical Issues & Treatment • Resources

  3. Availability of Gambling 1975 3

  4. 2008 Casino only (incl. tribal) (5) Lottery only (12) Lottery & casino (15) Lottery & tribal casino (14) Racetrack only (1) Availability of Gambling, 2008 Timothy Fong, UCLA

  5. “Gambling Nation” • Wagered $600 billion annually • Revenue Comparisons (2005) • Gambling (Legal) $83 Billion per year • DVDs: $22 Billion per year • Cigarettes: $19 Billion per year • NIH Annual Budget: $30 Billion per year (American Gaming Association, CDC, Hollywood Reporter)

  6. Types of Gambling in California • State lottery (18,000+ locations) • Card rooms (102) • 1,515 gaming tables • Indian casinos (58) • 58,100 slot machines • 1,820 gaming tables • Horse Tracks (33 includes simulcast facilities) • Sports bets • Internet (estimated 2,300 online gambling sites) • Cell phone gambling (the next wave) • Bingo and other charitable gaming • Cockfights, dog fights, numbers

  7. San Diego Tribal Gaming 18 Indian reservation: largest in the country 10 casinos 5 new or expanded casinos planned 1.5 billion annual gross revenue 13,000 workers with an annual payroll of $270 million Attract 40,000 people daily 7

  8. Gambling: Past and Present

  9. Gambling in Recent Years Gambling: incredibly accessible and attractive. • life changing amount of $ to be won • glamorous casinos • advanced technology “The changes are sorapid thatmany of us are ill-equipped to dealwith them. This canmake us vulnerable to problem gambling and its effects. Problem gambling can bring severe consequences for individuals, familiesand communities.” Addictions Foundation of Manitoba 2001

  10. PROBLEM GAMBLING: “Gambling behavior which causes disruptions in any major area of life: psychological, physical, social or vocational" (National Council on Problem Gambling) PATHOLOGICAL GAMBLING: A chronic disorder that results in the loss of control over gambling (DSM-IV)

  11. California Prevalence Survey (2006) n=7,121 respondents, 18 years and older Problem gambling 2.2% Pathological gambling 1.5% Almost 1 million problem/pathological gamblers Another 2.5 million at risk CA is 37% higher than the national rate

  12. Negative Impacts of Problem Gambling • Financial$30.000 average in CA • Legal1 in 4 • Physical Health • Mental Health Depression/Suicide 1 in 5 attempted (DSM-IV) • Relationship 1 in 4 • Employment 1 in 4 • Concurrent alcohol 1 in 3 & /or drug problems 1 in 7 7 in 10 use tobacco

  13. Financial • Loss of income • Inability to pay bills • Increased bankruptcy 11% of problem gamblers ever filed bankruptcy (2006 CA Survey) • Increased debt Average Gambling Debt:$30,000 (2009 CCPG Helpline) • Many seniors are on fixed incomes with little opportunity to recover financial losses

  14. Physical Health/Older Adults • Fail to take care of one’sneeds when gambling such as: eatingproperly, taking needed medication, takingneeded breaks • Back and neck pain • Sleep disorders • High blood pressure (untreated then Stroke, kidney failure, and heart attack) • Heart and lung disease (Florida Council on Compulsive Gambling) • Reported overall poor physical health (2007 Desai)

  15. Mental Health/Older Adults Among older adult problem gamblers: • 40% Mood Disorder (depression, bi-polar) among general population: 20% attempted suicide (DSM IV)(GA Survey) • 35% Anxiety Disorder (phobia, social phobia, generalized anxiety disorder) • 43% Personality Disorder (anti-social, schizoid, obsessive-compulsive) (2007 Grant, Petry)

  16. Substance Addictions/Older Adults Among older adult problem gamblers: 43.2% Nicotine Dependence 53.2% Alcohol/Abuse Dependence 4.6% Non-Alcohol Drug disorder (2007 Grant, Petry)

  17. Diagnosis & Assessment Tools

  18. Pathological Gambling (312.31) DSM-IV Diagnostic Criteria More than 5 = pathological gambler 3 to 4 = problem gambler 1 or 2 = “at risk” gambler

  19. 2-Question Gambling Screen • 2-Question Screening Tool (lie/bet): 1) Have you ever felt the need to bet more and more money? 2) Have you ever had to lie to people important to you about how much you gamble? Answering “yes” to 1 or both questions suggests a problem deserving further assessment.

  20. Types of Gamblers:Action & Escape Action gambler: addicted to the thrill of risk-taking, perceived skill & identity as a “winner.” Engages in competitive games (poker, sports bets, craps). Starts gambling at a young age & progress through stages over 10-30 years. 21

  21. Action & Escape Gamblers Escapegambler: seeks to blot out uncomfortable feelings or situations. Prefers singular outlets (slot machines & video poker). Becomes a problem later in life Faces faster progression, often becoming problematic almost immediately, hitting bottom within 1-3 years. 22

  22. Machine Gambling = “Crack Cocaine of Gambling” • Video poker/slots • Internet • Click & Play Lottery games • Quickest road to addiction: 15 months! • Impulsivity • Isolation • Intermittent rewards: • rapid reinforcement patterns of unpredictable small wins generate excitement & encourage continued play. • Can bet $4.50 every 5 seconds on a ¢5 machine 23

  23. Phases of Problem Gambling • Phase 1: Winning – Occasional gambling, followed by more frequent gambling, big win, gambling is exciting, increasing bet amount, unreasonable optimism. • Phase 2: Losing – Thinking about gambling a lot, inability to stop gambling, "chasing", borrowing money, covering-up, lying, home and work life affected, personality changes – irritable, restless, withdrawn. • Phase 3: Desperation – Unable to pay debts, alienation from family and friends, illegal acts. • Phase 4: Hopelessness –Suicidal thoughts and attempts, major depression, co-morbid substance abuse, divorce, arrests, emotional breakdown.

  24. Older Adults & Problem Gambling

  25. Older Adult Gamblers - Facts • This fastest-growing age group is gambling more than ever. • Average adult age 65+ has 7.7 free hours per day. • Older adults now form the largest group of annual visitors to Las Vegas. • Among adults over 65, gambling is the most frequently identified social activity.

  26. PrevalenceAge 65 and Older • 10.5% (3.8 million) of California: higher population than any other states • Florida (2.9 million) • New York (2.5 million) • Texas (2.2 million) (2005 US Census Bureau) • 3.8% (135) California helpline callers were age 66 and older. (2009 CCPG)

  27. California Prevalence Survey 2006

  28. The Windsor Problem Gambling Screen For Older Adults • Since you started gambling, have you felt more depressed, either after gambling or in general? • Does gambling give you a sense of excitement or a ‘high,’ which makes you feel more alive? • When you lose money gambling do you return to try and win it back? • Have you ever been surprised by the amount of time that has passed when you’ve finished gambling? • Have you ever spent more money than planned when gambling? • Have you ever hidden your gambling activities, for example, where you were or how much you won or lost? • Each time you go gambling, do you believe that you could win big? • When you’re feeling “bad” does gambling make you feel better? • Has gambling filled a void in your life and helped you feel less lonely?

  29. Older Adult Gamblers - Risk Factors Gambling can become a coping mechanism after a life change: • Onset of retirement and unstructured time • Loss of family members and other supports • Memory challenges • Physical limitations • Lack of alternative activities • Feelings of isolation • Inability to recover financial losses • Marketing by gambling industry • Recreational offerings by senior centers and other organizations (Florida Council on Compulsive Gambling)

  30. Older Adults GamblersRisk Factors Marketed by the gaming industry: • provide transportation • easy entry to facility • easy access to machines • wheelchair access • incentives for frequent players: • money to gamble • free meals • free accommodation • even discounts on prescription drugs (in Canada)

  31. Older Adult Gamblers Characteristics Many older adult gamblers reported: • Major financial losses, family crises, and suicidal ideation • Fewer non-gambling activities, poorer mental health, lower income and less social support (Zarenek & Chapleski, 2005) • Lower expenditure on gambling but higher sense of guilt (Robert Williams, 2006)

  32. Older Adult Gamblers Characteristics Less likely to seek help: • View treatment more negatively than other age groups • Have much shame/stigma • View the problem as lack of moral strength or willpower (“bad” or “weak”) • May go unnoticed until later stages due to their isolated living situations • Have higher suicidal ideation rate due to physical illness, functional impairment, and lack of social support • Most likely to ban themselves from casinos because of their fear of suicide (Nower, 2009)

  33. Link between Parkinson’s Meds and Compulsive Behaviors New research found certain medications to treat both Parkinson’s Disease and Restless Leg Syndrome (RLS) may cause compulsive behaviors such as: • pathological gambling • compulsive shopping • binge eating • compulsive sexual behavior (2010 University of Pennsylvania)

  34. Function of Dopamine Boosted by the Meds The dopamine agonist medication: • Boosts the level of dopamine in the brain, a chemical the body naturally produces • Dopamine’s primary function is to control movement • Dopamine is also linked to the pleasurable feelings • Considered to play a role in compulsive behaviors as a side effect • When discontinued, compulsive behavior often dissipates. (Florida Council on Compulsive Gambling)

  35. Older Adult Gamblers – Parkinson’s A study was conducted at the National Institute for Neurologic Diseases and Stroke in MD in 2006 • 300 Parkinson patients with levodopa or dopamine agonists treatment • 10 patients developed pathological gambling (3.4 %) double the number based on population-wide surveys • Lost an average of $150,000 • 7 patient hypersexuality • 2 patients compulsive shopping (2006 American Academy of Neurology)

  36. Older Women & Problem Gambling • The National Advisory Council on Aging indicates that women living alone are especially vulnerable. • In a study of the link between caregiving responsibilities and compulsive gambling, many older women begin gambling as a means of reducing the social isolation they feel. However, as the problem progresses, most women gamble alone and further increase their isolation. • “Many women gamble in search of a way to numb emotions, shut out the world, and orchestrate a time out.”

  37. “It’s an opportunity to be around other people. You’re treated well. The parking lots are well lit. The marketing is very friendly to seniors. The people at the casino learn and call you by name. It can be a nice feeling.”

  38. Older Adults - Types ofGambling Activities • Casino • Slot Machines • Lottery-Keno • Bingo • Sweepstakes • Other: cards, horses, sports, internet

  39. Older Adults - Barriers toGetting Help (Lemay, 2002) • Transportation issues • Psychological health issues (e.g., depression & isolation) • Physiological health issues (e.g., mobility limitations, acute/chronic conditions) • Cultural practices &/religious beliefs • Comfort issues (e.g., time to travel to services, difficulty sitting in office chairs) • Lack of independent living (lack of privacy or use of vehicle)

  40. Older Adults - Signs OfProblem Gambling • MONEY ISSUES • Less money available for outings with friends and family, buying gifts for grandchildren, or to meet their basic needs. • Many unexplained unpaid bills, i.e.: phone, rent/mortgage, house and car insurance. • Constantly receiving phone calls from collection agencies & subsequently not answering their phone. • Money missing in their bank account; they have cashed in their IRA’s and life insurance. • Valuables disappearing. • Asking to borrow money and focuses only on money issues.

  41. Older Adults - Signs OfProblem Gambling • BEHAVIORAL ISSUES • Slowly withdraw from family or social events. • Neglect their daily household duties and personal needs. • Disappear for many hours at a time. • Shift all their interest on gambling activities. • A change of eating and sleeping habits. • A decline in physical and emotional health.

  42. Older Adults - Signs OfProblem Gambling • RELATIONSHIP ISSUES • Decrease contact with family and friends except to ask for money. • Seem more depressed to family members and friends. • Always appear to be very busy. • Secretive about their whereabouts and their daily activities, as well as avoid answering any uncomfortable questions.

  43. Clinical Issues in Problem Gambling

  44. Modes of Therapy Self-Help Manuals • Help-Line Counseling 1-800-GAMBLER • Financial Counseling • Cognitive Behavioral Therapies • Motivational Enhancement Therapies • Spiritual (GA, churches, eastern religions) • Pharmacological Treatment (naltrexone, anti-depressants) • Multimodal treatment shows substantial effectiveness • 81% of clients reported either no gambling or reduced gambling at 6-months post-treatment (Moore & Marotta, 2007)

  45. Clinical Approaches with Older Adults • Indirect, nonconfrontational approach: • What do you do for fun? • Do you ever go to the casino or play bingo or lottery? • What do you like about…? Anything you don’t like? • I’ve heard gambling can cause problems for many people and there are specialists who treat gambling problems Martin, Wayne State University, 2009

  46. Clinical Approaches with Older Adults • Incorporate pain, grief & loss, a sense of meaning, hopelessness • Feelings of abandonment by ones children if placed in assisted living facilities • Importance of empathy: nonjudgmental, nonthreatening, active listeners Nower, Rutgers Gambling Studies Program, 2009

  47. Clinical Approaches with Older Adults • Be aware of the possibility of depression or other mental health concerns, and encourage clients to talk to their doctors • Frame gambling as a health issue to reduce resistance. “Planting the seed” as a possible health matter may prevent progression of gambling behavior even if help is refused at this time.

  48. Older Adults:Outreach/Treatment • Encourage help seeking behaviors and use of counseling, decreasing the stigma attached to seeking help. • Provide information through public education to demonstrate how gambling becomes a problem and where one can seek help. • Establish more support groups for older adults as an opportunity for them to share issues/problems in a safe environment. • Replace casino visits as a social activity, substituting other group activities that provide social networking. July 2006, Problem Gambling Foundation of New Zealand

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