Psychic Medium, Tony Green. Tony Green right here. Psychic Medium right here. So first and foremost, if you would like to join us live, you can head on over to YouTube and join in all the conversations that happen pre-show. We talk about anything and everything you can ask questions before the show even starts. Yep. Or you can call in live the call in numbers<PHONE_NUMBER>. So I just want to take a quick second and say I apologize. I was not on air the past two weeks because I had lost my voice, which I can't even tell you what kind of challenge that is for me. I can't even tell you what kind of personal Haiti that was to go through not being able to talk for two weeks. It was crazy. It was just a little bit crazy. Anyway, the voice is back, lingering symptoms, but the voice is back. The girl can talk now. This morning's healing on TikTok is self-sucking. I don't even remember anymore. I did it like 20 minutes ago. I can't be expected to remember that. Self-doubt or second-guessing or I go to TikTok. Somebody go to TikTok and tell me what it is. Okey-dokey. Today, I will be answering questions live from the TikTok chat. I will also be taking callers and answering their questions. If you are calling in, please have a very, very specific question. It's one question per person or one connection to a loved one on the other side. The question can be about life, love, career, finance, any aspect at all, but one, please don't piggyback questions like I answer a question. Then you go, could I please ask another one? No, you may not. You may not because there are a palethora of people waiting and it's not fair to them.  I go live two times a week, Monday at noon, which right now, right here, Monday at noon central, and then Wednesday at 7pm central time. So I get that daytime crowd. I can get my nighttime peeps. We're just all in it. We're just in it. Okay. So first today, we're going to do names. So these names could be loved ones, somebody who has passed that you know who's on the other side, or it could be your name from somebody on the other side or one of your kiddos names. It happens that way. The first name I keep hearing is Charlotte, Charlotte, Charlotte. The next name I'm here, the next name Daniel or Dan, Dan O. This could be the same person or it could be three different people. And even if one person claims it, it could be for more than one person. So please know that. The next name I'm hearing is Tiffany, Jennifer, Gerard, James. They're just going to go through the James. J, J, J, J, J, J, J, J, J, J, J, J, J, J, J. Somebody on the other side is bringing it today. Okay. Antoinette and or Antoine. So that's Antoinette or Antoine. And then we have Bobby.  Lily, Lily. It could be Liliana or Liliana, but Lily for sure. Kim, Kimber, Kimber. I think that's the kind of gun I have. A Kimber. Was that a little too much? Was that too much information? Okay. Anyway, Kim or Kimber and then Destiny. And then I'm going to do two more names and then we're going to move to songs. The next name is, I don't know if I said this name or not, but Jerome, there are a hell of a lot of J names coming through today. Okay. And then the last name is going to be Blake. Okay. Going on to songs. Now remember, this could be a song they loved, you loved, or this song could answer a question. Like if you've been wondering, what should I do? Blah, blah, blah. It could be the answer to a question because they do communicate through music to us all the time. Okay. So the first song, and I'm hearing it, was a song for Heather who is on YouTube, but they're still singing it. So I'm going to say it. If at first you don't succeed, dust yourself up and try again. Okay. So folks, I know I can't sing and I apologize for that, but they're going to bring it through however they want to bring it through. I don't sing on the show because I think I have a great voice or I even like doing it. It's what they want me to do. And I tend to do what they want me to do because if I don't, they will just force it anyway. It's what they do. It's how they work. And here we go. Next song is, I'm not the one who's so far away when the... Oh gosh, I can hear. I'm not the one who's so far away when the...  But they keep playing it. I've heard this song before. And then I hear the song, I'm the man in the box. Where are they? Who is over there today? We started so good. We started so good with dust yourself up and start again. And we're out. I'm the man in the box. Come on, folks. Okay, seriously, though. Anything by Janet Jackson. I'm hearing Janet Jackson. Anything by Janet Jackson. And the next song is... Okay, the songs went. They're done singing. I think they're done singing. Okay, here we go. We're on to callers. I want to say hi to Frank. Hey, Frankie. How are you, Jay Francis? Hey, Amy Ann, Renee, Rebecca. Hey, Lolly. There are so many people on YouTube right now. Thank you to all the new people for joining in. So happy to have you. Now, once I go to the questions, I will do a question on the call log and then a question from YouTube. And please remember, people on the call log have been waiting since 15 minutes before the show started. So they've been... Well, I've been answering your guys' questions. They've just kind of been sitting on hold. So when I say your area code, please tell me your name and where you're calling from and then have your exact question or connection ready. 480. What's your name and where you're calling from? Or not. 480. We're going to go to the next one. 814. What's your name? Where you're calling from? I wonder if... I wonder if Blog Talk's having an issue today. 814. So if anybody's on Blog Talk and YouTube, can you please let me know so I can click you just to see if they are having an issue? Yeah, the callers aren't coming through. There's like nothing, nothing. If you're on Blog Talk and you can hear me, hang up and call back in 480 and 814 to see if it's a better connection. In the meantime, I'm going to go over to... That sounds for somebody. Rene wants to know... Hi, Tony. Pregnant with my first child. Congratulations, Rene. Will I be having a healthy boy or girl? Oh, you do not want to ask me that. Hoping all goes well with my pregnancy. Thank you. How far along are you, Rene? Is my first question.  I don't mean twins.  What I'm seeing is a baby with a very light blue little beanie hat on. Very long, very long baby. This baby is, but it's not right out the womb. It's like in your arm and sitting up a little bit. I feel like based on the color, it might be a boy. I'm not looking at any private parts here. What I'm going to say is I see it's just in a onesie, a light blue onesie and a light blue beanie.  It's a light blue with, I think, a touch of white. So, that would lead me to believe... It's going to be very, very healthy. Very healthy and strong. Very strong. So, yeah. I'm going to go out on a limb here, even though I've been wrong in the past when I try to see. I'm going to say that this, it's really super possible. This is going to be a little guy. A little guy because I'm hearing all boy names with it. So, we'll see. But you'll know soon enough. They're saying you're going to know soon enough. You're going to know soon enough. And when he's, while you're carrying him, he's going to kick super hard. Oh, it might be a boy because they just had he. I love it. Yeah. He's going to kick super hard. Like a kickbox or something like that. They're saying, hey, Tayneeta. Okay. I called in. I called to test. It's your sounds normal on there. Okay. Everything sounds normal. I'm going to try one more time. 480. 480. What's your name? Where are you calling from? Still nothing. We're going to go try 814 one more time. 814. What's your name? Where are you calling from? Yeah, it's absolutely nothing. I'm going to try the next caller just to make sure you guys, 417. Yes. Yes. 417. What's your name? Where are you calling from? I was starting to panic a little bit. What's your name? Where are you calling from love? My name is Linda. I'm actually from North Carolina. And my question for you is currently I live, I'm not live. I'm sorry. I'm visiting my son and daughter-in-law at their house and I will be bringing our granddaughter back to our house for a little while. Will she be coming back with us permanently? Then also to the mom and some mental and physical issues that she's dealing with. Honestly, we really like to her to live with us if we can. We're okay with her living here only if she can function as a wife to the mom. Okay. So what I'm getting, that was kind of two parts and I'm going to try to break down both parts. The granddaughter, I feel like the granddaughter is going to be with you for a while. It might be a long while. I feel like mom is going to try to do what she can. But I don't, I think even if granddaughter goes back, she's going to end up back with you. Mom, I feel like will not go with you because she can't do what she wants or live how she wants is the message I'm getting. I feel like there are things that she does that she doesn't want people to know. Like I hear that song, uh, ball night, sleep all day. So whatever her habits are, um, she can kind of easily live her lifestyle without question or, um, I'm going to use the word persecution even though you really wouldn't. Um, on her own, she can, she can be an adult teenager. Oh, that is a beautiful, oh my, my, my. She can be an adult teenager where she is, where if she comes by you, she'll be expected to be an adult adult. Okay. Now that we have that done and there it is folks and there it is. Um, if she's with, she might come, she might come visit for a minute, but she's going to want to go back and here in lies the issue. She will miss her daughter, your granddaughter, but, um, knows the situation with you having the granddaughter is the best, but there's a part of her that feels like, well, I should be doing this, but she goes into these time lapses where, yeah, where it seems like a day went by, but it was really a month. So just, you know, um, take, if you take the granddaughter for visits and then just go back, I think that you will have primary care of the granddaughter. If that makes sense to you. I hope that makes sense to you. I hope it does. Yeah. Excellent. Yeah, it does. Okay, Linda, I truly hope that was helpful. I hope it answered all of your questions. Yes, it was. Excellent. And you can appreciate it. Thank you so much. Absolutely. My pleasure. Anytime you need, please feel free to call back in again. Okay. Thank you so much. Oh, my goodness. Thank you so much. Thank you. Okay, I'm going to go now. I'm going to come back online and see where the next question is. Um, uh, Fawn says she's five three zero. That must be a little bit further down. I'm going to get to you. Mike four eight zero phone out out phones out out. Okay. I'm six two three. Everybody's telling me the area code. I love that. But let me get to the area codes then. Uh, la, la, la, la. Oh my gosh. There's like, there's so, so many. Um, oh my gosh, there's just so many people here. Okay. So I'm going to try to go and order everybody. Um, um, I'm going to try to go and order, um, two zero five. What's, what's, what's your, um, hey, two zero five. What's your name? Where are you calling from? Yeah. See folks. I thank you, Tony, for taking my call. Um, um, Patricia and calling from Alabama. And my question is, um, my uncle, um, my sister and I are going for guardianship. Um, we are scheduled for a hearing on October the 26th. Um, we were supposed to have one this past Thursday, but we didn't get the document from the doctor like we were supposed to. We're sort of getting, um, um, um, how can I say this? Someone is fighting on the guardianship. And so I just want to know, do you see when we go on October 26th that we will gain guardianship over my 75 year old uncle, our 75 year old uncle? Okay.  And, um, um, here's what I'm getting. You eventually will get guardianship. It's going to take a little bit longer than you think. You have to be willing to be in it for the long game and not the short game. Um, I do feel like when you go on the 26th, they're going to be looking over everything, but they may not decide on that day. And they may ask for certain things again that you have not brought. So if I, one of the things you might want to do is to go online and look at anything and everything in your state that they could possibly ask you to bring and make sure that you have it available, um, I'm going to say one of the things I'm hearing and then I, I know that you will have this. It's not going to mean what you think it means. I think proof of residency. So what this may mean is if you're taking guardianship, you may have to be able to prove how you're going to residency for him, where you're going to put him, how you're going to put him, what you're going to do. I, I'm not sure, but I just keep hearing proof of residency. So make sure you have your plan in place and you can show that plan, whatever that plan is. Okay. Um, I feel like for, and for his, okay, and for his condition, whatever his condition is, you're going to have to prove that we're, okay, prove wherever his residency is, it's going to be the appropriate care. So like if you're saying, we want him to live with us, or I want him to live with me, we're going to have these healthcare workers coming in, or we want to put him in this facility because it has the best healthcare possible. Okay. So that's maybe that's the proof of residency, but they're, that's the statement I'm hearing. So make sure that you have, you answer questions before they ask them is what I'm getting. You're going to want to answer the questions before they ask them. These are the arrangements that we are looking at and we could have in place at this time. So that that's what, what I'm hearing love. And that's what I'm getting. So if you want him to be able to stay where he is, but you're just taking power of attorney, you have to, you're going to have to prove the care that you're bringing in. But if you want to move him, you're going to have to prove the care and you're going to have to prove why that's what I'm getting. Okay. He's going back home to his home. He was removed out of his home. So he's going back and they do want to know how, you know, will we have caregivers in place? I love you one. And I am interviewing other caregivers for him to be able to go back to his home. He wants to go back to his own home. He don't want to live with anyone. He wants people to come in. So yeah, if I fully understand. Perfect. Make sure you have them lined up from when you go into court that you have them lined up from day one and that you can prove 24 hour care if necessary. Okay, love. Yes. Thank you so much, Tony. I love you. You're always Oh, God, the angel of messages. Thank you so much. Thank you so much. And I will tell you that's all my messages come from angels and loved ones that are on the other side and God. So thank you. And that is such a confirmation for me. And thank you so much, dear. I love you too. And you have an amazing rest of the day. Okay, sweetie. You're welcome. Thank you. Thank you. Okay, guys, I'm going to go to a YouTube question. Okay, I had to remember where I left off on the phone because sometimes I forget. Taneeta wants to know could I please have a message from any of my loved ones that passed. Okay, Taneeta, can you please give me a first name and a relationship of a loved one because I need to start in the energy that way. I can tell you Taneeta I see a thin older woman, like a grandma age or a mom age depending on how old you are.  But it was just like a, you know, whatever house house, not like a rope we wear today, but back in the day, I see that. But if you could just please give me a first name and the relationship that would be great. I can tap into somebody for sure. Now next to her is a man who is thin and taller. I feel like I've seen this man a couple of times. I feel like he's come in a couple of times for a couple of people, but he had hair up until he passed. He had hair. He was a little older also, but he had hair up until he passed. Oh, okay. Taneeta, yes, see, this is why we do this because you I feel like your grandparents or great, your parents, grandparents were coming in and you want to talk to your boyfriend. Okay. So Taneeta, the first thing I hear is a song. I hear a word. I okay. So Taneeta, the first thing I hear is review, review, not review, review. I know what that means. And then I hear the word revolution and then the song. So you say you want a revolution away. We all want something. Okay. Okay. So here's what I'm going to say. He is right now going through a review. He's still around you. Don't get me wrong. Okay, please, please don't get me wrong, love. He's still around you. He is going through a review process on the other side. And he is elevating. So once you're my understanding from what I've heard and the way I explain it may not be the same way other people explain it. But once you're on the other side and you've been there for a minute or so, they have a different type of timeline than we do. They don't really have time. You go through a thing where you review, but you've gone through the process of if there was any harm or pain or suffering, you've gone through the process of fixing that while you're on the other side. And then of equaling the scales, balancing the scales. And then you go through a review and see where you can go and what you can do next to help those that are still here. Well, kind of an assignment review, if you will, is what I'm hearing right now. But you will be feeling him tomorrow night again, feeling him a little bit stronger tomorrow night with a, maybe a dream, but not really a sleep. Like just my imagination running away with me.  It will be very, very strong tomorrow night, not yet tonight. But if it comes tonight, remember, they don't have timeline, but tomorrow night will be the time that that comes in the strongest for you. And then it should stay consistent. Okay, that's what I'm getting, Tanita. Thank you so much for that. The next caller is 216, what's your name and where are you calling from? Hi, Tony. I actually put my message in the YouTube. I thought it'd be easier for you. Okay. Hi. What's your name? Let me just ask you. Did I, did I already answer your question? I don't think so. Okay. What's your name? I can ask you, that's okay. Okay. I know I'm sorry about that. Oh, my name is Sharon. And my question view is, do you see me in the next three to six months be posting for a new position in my company and getting it? Okay. Yeah. Okay. I feel like in November, in October, there won't be a posting you're really interested in November knows December. Yeah. But in January, there's going to be, it'll either be the end of December, beginning of January, where there will be a posting that is going to be relevant posting for you. Okay, sweetie. Okay. So that is the answer for her. And I think she had to take a call at work. So thank you so much for calling in and asking your question. Sal says, I was thinking about taking on, taking an acting class. Any thoughts? Will this help me with starting a podcast? No sale. You got everything you need. You've got everything you need. Just go for it. You don't need the acting class. Just be you, be as genuinely you as you can. I think an acting class will get in the way of it. Just get on and be you. You're not going to be as nervous as you think you're going to be and it's all going to come out beautifully. Okay. I'm going to go to four, seven, five. I think I am four, seven, five. What's your name and where are you calling from? Hi there. And I'm calling from Connecticut. And how can I help you love? Hello. Hello. Yeah. Mine is just a short. Hello. Mine is just a short question is that I would like the most relevant message I can get from my guardian angel or from my spirit guide, which would be like more appropriate for this time in my life when I'm very frustrated. Okay. Thank you. Okay. So the first thing I I'm hearing quite a bit and what I'm going to do is I'm going to do a clearing for frustration. So we're going to clear all stress, frustration, all of that to let that go. But then the message that they want to tell you is this, and I'm, I'm sorry.  I don't love that message because I would be so much, I would be like, who cares about five years? It's bothering me now. They're saying everything is going to work out. You don't need to worry so much about this. I know it seems very overwhelming right now. But if you if you go inside of yourself, you're going to find the answer immediately. You just have to push aside some of the frustration, and then it will be so clear to you. I hope that makes sense, love. I really hope that makes sense to you. I love to think about it. I really, you know, I'll have to meditate upon this message. Yeah. I think that one of the things that they're saying is when we get in that place where we're frustrated, it stops all of our messages, it stops all of our information, and we just have to, like, I don't want to say just breathe, but we do have to go into that meditation. We do have to go within. We have to be there for a minute, and then like a light bulb going on, the answers will be there. Okay. And I just keep hearing whatever this is, it's going to pass very quickly for you, and you don't need to worry about it. Okay. It's going to go very, very quickly, and it will be gone. Okay, sweetie. So did you do that clearance for my frustration? I did. It might take a minute. So when I say we are frustrated, I get, yes, all that causing kept this clear. He'll release it. So it will start to go. You should feel it going very quickly. And the one thing I am also hearing is don't live minute by minute. And we tend to do that. We're supposed to live in the moment, but not hold on to the moment if that makes sense for you. Okay. I hope that makes sense. I hope I said that correctly too. Thank you so much for calling in. I'm really grateful that you did. Thank you for taking my call. I appreciate it. Thanks a lot. Absolutely. My pleasure. And you have an amazing day. And the clearings I do on the show, they are for the caller or the person on YouTube, but therefore they are for everybody. So everybody who is hearing it, seeing it, whether you're watching the show on TV or listening to it on the radio or podcast, you will get that clearing also. So Lisa, Lisa, do I have a message from any loved ones? Lisa, can you do me a favor? Can you give me an exact name of a loved one just to start there? Because I want to make sure, like sometimes, like with Tanita, there's a specific person you want to hear from, but other people, other people are coming through. So a name Sandra, and who is Sandra to you? I see somebody with dark hair. I hear the word. I don't want to even say that word. I feel like when, okay, then I can say it, I can say it. So Sandra is a good friend. I feel the first thing I see is somebody, I don't know if she originally had dark hair or whatever, and voluptuous. Now if that's not her, that's you. So I'm sorry. Please let me know in the chat. What I'm hearing from Sandra is the first thing she's bringing through is a song. And I know this song, but I'm not getting all the words. Oh gosh, I can't hear the words. I can't hear the beat, but I can't hear the words. Anyway, she's bringing through a song that was like a happy, go lucky song. I'll have to come back to it. But the first thing I'm hearing from her, there's like almost like every time she goes to say something, it gets stopped or she's sending me the song and then it gets stopped. I don't know if this had something to do with how she, what was going on toward the end or what, but the communication keeps getting cut, the communication keeps getting cut, which is very abnormal for me because I can, I can talk to almost anybody on the other side, even animals. So what I'm going to say Sandra, what do you, what would you want Lisa to know? What's the most important? I love her. What's the, what's the next most important thing? It's the song, something, something, good time. She had such a good time with you. Like some of her, if I were to put my spin on that, I would say some of her best memories were with you. And that's a song I couldn't get earlier is, and I can't even get the whole song. It's just that, that not a good time. And a guy sings it and I know I'm not doing it justice. Nobody in the world is going to know what song that is. Okay, what's the next thing you would want to say to her, Sandra? Take care, take care of you, take care of the boy, take care of the boy. And what else, Sandra, give her one more message. She's singing that song, don't cry for me, Argentina. So don't, don't be too sad over her passing. Don't, don't spend time in too much mourning for her. And then, okay, I'm going to give one more because I, I don't want that to be the last thing you say to her. What's the last thing you would like for today? You can come back Wednesday, we'll talk to her again for today. I'm sorry, Lisa, this is her next message to you. Take it on the road, baby. If that's the way you want it, baby. And I don't know why she is laughing so hard at this. I think that's REO Speedway again. Take it on the run. Like, that should mean something to you. And she's laughing at that. And so that must, that's something I think, if that doesn't make sense to you, I apologize, it will soon, it will soon, it will soon. Does anybody know, did I do six, three, one yet? Did I take six, three, one yet? We're about to find out, aren't we? Six, three, one. Hello. Hi. What's your name? Where are you? Oh, six, three, one is gone. Five, one, nine. It just dropped. She probably lost me. Five, one, nine. What's your name and where are you calling from? Hi, Tony. It's Jennifer. Hey, Jennifer, how are you? Good. Thank you. I just got to turn off the volume. It's very quiet. I was questioning, I've got a lot of anxiety lately and for no reason, and there's been some dread and foreboding. Is that just me or just am I just picking up energies around me? I think everybody is feeling some level of anxiety, but there is something that is going on. There's a, okay, so what I'm hearing as far as you go, there might be an underlying issue that you kind of don't want to look at, but you're going to have to.  I don't really want to deal with this. But what I'll do right now for you and everybody else, Jennifer, let's clear anxiety, all anxiety, all that cost it, all that's kept it, all that allows it. Let's clear all of that. And let's get it, let's get it gone. So what I see, you guys, it's so crazy when I do clearings and what I see. Every time they show me different ways that they're pulling stuff out of people. So the anxiety, the way they're pulling it out is like with a big super duper industrial, more than industrial vacuum.  So let it go. Just let them take the anxiety, let them have it. We don't need it. Everything is going to be okay. No matter what you're hearing, what you're seeing. And I would say minimize media intake. No matter what media you listen to, I'm not just talking about evening news and stuff, even commercials. If it's not pure music that you love, song after song after song, minimize media intake. And just watch comedies and stuff because right now that's really what we need to raise our frequency, raise our vibration to get us back to where we're supposed to be. So Jennifer, we're going to clear this. And there is something coming in that is not your, it's either something, this is how I'm going to say it. It's either something that has been brought up and there's a feel like, oh, not this again, like not the whole, I don't even want to give it any power by saying it thing again. But or there's something in your personal life that is on it's like you're already aware of it, but you're like, I don't, I don't really want to, I don't really want to deal with this. So whatever that is for you, Jennifer, that's what I'm getting. I hope this was helpful. And this clearing will keep going until it pulls as much out of it as you can let go of at this time. Okay. Thank you for something in my neck. So I'm one. Yeah, I'm thinking that whatever it was was a ripple, such a clearing trying to push through. I love that. Thank you so much. Thank you. That is that's it's amazing. It's amazing what they what the how people feel it. If anybody else is feeling it, please, please, please let me know. I'm happy when that when people feel it and I know that everybody's getting getting it. So thank you so much, Jennifer. Thank you. Thank you. Thank you. Okay, I am going to go to the next Patrick. How are you have you been out golfing Patrick? It seems like you've been out golfing a lot.   Did you lose your voice to Patrick? Okay, Sharon, Sharon is saying she's sorry she got cut off. That's okay. I still answered the question for you. I'm going to go to the next color. Is it 805? Does it 814? I think it's 814. Does anybody know? Is it 814? Yeah, I lost my voice for like two weeks Patrick. It's just coming back. Yeah, same exact thing. See, it's just going around our neighborhood everybody. Did I just do 814 or is it time for 805? Where are my folks? I'm not on top of my game yet. I am not. Here we go. We're just going to find out. 814. Where are you from? What's your name? Hi. Hi, this is Amy and I'm calling from Pennsylvania. Hey, Amy, how can I help you today? I want to see how you feel. How does my current boss feel like feel about my work and that? Good. Good. I get a strong feeling. I also get that your boss has other things going on right now. It might be something in the personal life or something personal with work. So whatever's going on with your boss, just here's the, your name is Amy, right? Yeah. Okay, I'm so sorry. Amy, um, this is the best advice that they can give you go into work, work your booty off, you know, in your allotted time and go home. Your boss has something going on that it might be something that is, it's something that does not involve you, but you might be noticing it because it's carrying over. Okay. So sometimes when people have personal things going on in their life and they try to separate, they can't, but what I'm getting, just go in, do your job. Don't, don't talk to anybody at work about this. Just do you go in and, and don't say anything and then go home and you will be just fine. Um, he likes your work. I hear it's strong and it's good. And you don't have anything to worry about. Um, just stay out of what they're calling coffee clutches. I hope that makes sense to you. It does. Okay. But I work, I do work from home though, but I, I understand what that means. Okay. Because it was bad where I last worked. Yes. Okay. About people always in the other people's business. Yeah. Yeah. And go ahead. Yeah. So since you work from home, just do your work, do your job. It's good. It's strong. Whatever's going, if there, if you're getting a weird vibe from your boss, it's because of something that has absolutely nothing to do with you, but he, your boss likes your work and it is strong. Just keep it that way. Okay. Okay. Okay. Thank you so much. Okay. Thank you. You are welcome. You are welcome. Okay. Everybody. If there's not a question on the log eight zero five is next. So remind me of that before I get lost. Okay. Amy wants to know any info in any something, my current romantic relationship. Are we a good match? Oh my goodness. Amy, Amy has a full friend. Okay. I'm sorry. I'm so immature. Congratulations. Okay. So Amy, don't get too serious too fast. Don't check up too quickly. God, I can, it comes off so immature, but really they're just going for hilarious. Amy, it's seemingly good, but go slow because I feel like, I just feel like you need to take your time and find out a lot about this person before you invest too many feelings. Not that you're going to do, not that you're going to find out anything horrible or bad. It's, you know, we all have our individual personalities of what we, we match and what we don't and what types of relationships we want and don't, you might want this, they might want that. And the slower we go in the beginning, the more time we take to get to know the person, the better it can be in the long run. Now remember, I know sometimes that we, we just want to get in and get it done and let this be the person. But remember if it is the person, there's no hurry. They're going to be there, right? They're just going to be, if this is your person, like if I were to meet someone and it were my person, I wouldn't have a problem going slow because I would know if you truly are my person, we have the rest of our lives. I don't need to rush into anything with this. We can take our time, get to know each other and neither one of us are going to be jumping out of it because it's not going fast enough. If you're going to jump out because it's not going fast enough, guess what? You were my boo thing and it ain't no big thing. And that's it. So just take your time with it. Get to know who they are as a person before all of that. Okay, love. Okay. Okay. I'm going to go to, I said 805, right? 805. 805. What's your name? Where are you calling from? Okay. We're going to go to the next caller who is 610. 610. What's your name? Where are you calling from? Hello. Hi. Yes, this is Sarah. I'm calling from New Jersey. Hey, Sarah. How can I help you today? I'm calling because I just wanted to see what you're picking up as I'm on current relationship with my partner. My partner is a female. Okay. And, you know, something transpired a week ago. I just been wanting to get into it. I just wanted to see what you're picking up as far as the current relationship. We're still living together, by the way. Okay. So the first thing I hear is a song. And the song is, I'm going to tell you the song. And if it makes sense for you, you can tell me and then I'll give you the message. But the song usually is the beginning of the message. It's, any, are you okay? Are you okay? Any, are you okay? You've been hit by a smooth criminal. So that's the song that they're bringing throughout the beginning of that. I think one of you might be a little bit more savvy than the other one when it comes to communicating or how to communicate in a relationship or how to say things in a relationship. Now, I'm gonna, I'm gonna say something here. This could be from a past experience or the current experience because I don't want to upset anybody or accuse anyone of anything. But I think somebody in this situation might be a really good talker. They might be able to manipulate conversations in a certain direction or make the other person a little bit confused about things. Like, wait, did that, was that? Now, if I'm wrong about that, I apologize. But if you sit back and you might see that, what I'm going to tell you is where it's going to go from here. Okay. If there is a case where somebody is a very smooth talker, can communicate really well and the other person is not as good of a talker, I would say pull out a notebook and only write things back and forth to each other to resolve issues. And that way, both of you are heard. You understand what's being said and it's all right there on paper. I feel like this is going to blow over, but I do feel like communication does need to get better between the two of you. There might be misunderstandings in words and or phrases. And I also feel like that if there is somebody else, and I don't mean like a third lover, I mean like a friend, a family member who is putting their input in that, and that could be the person who's a smooth talker also, then you guys need to agree how you need to come to an agreement on how much input that third party gets to have. And if it's possible to, you know, if it's a family member, it's not always easy to get them out.  They're just a poop thrower. And that is not the, that is not the term I would use, but this show does air on TV. So I have to be hella careful how I say things. But they like to start.  They like to like an antagonist, they're in it, they're like an antagonist. And the way they say things can can start problems between people. So you and your partner have to come together and kind of gently discuss that dynamic and go forward from there. Okay. So that's the poop starter. The third party. I can tell you what me and 99% of the population would say. I can tell you what spirit would say, but what I'm going to tell you is what you're going to try to do. Everybody would say just jump out because there was an infidelity. If it happens once, it's going to happen again. It's good. And it is this person, this third party isn't going any place no matter what they say. I'm sorry, I'm going to I'm going to be blatantly and brutally honest. The third party isn't going any place doesn't want to doesn't care. The third party, even if your partner says, no, we have to quit that third party will keep creeping round. Okay. So I would say it's in your best interest for your mental health to try to figure out how you can get to a place where you feel safe and secure. If that means on your own and single, that's the most important thing to do. Now I'm going to say this, the only abuse in relationships is not physical abuse. There's the abuse of infidelity. And a lot of people don't look at that as an abusive behavior, but it 100% is abuse.  Everything they thought they had in this relationship, as far as trust and where the future was going was just ripped out. And it leaves that person in a very unstable place. Okay, you have to decide where you can go with that. I'm going to tell you at this moment, you're trying to figure out how to make it work out. Okay. The other person is not worried about that. Okay. The other person is not worried about that at all. The other person is in a space where whatever happens happens is the best, nicest way I can put that on the air.  Because whether you stay or go, they still have someone. And the only way you can get equal footing again or leverage is to completely separate, which when you're living with someone can be a little bit difficult. Because there will be a lack of respect if you don't. I think you're going to try to make this work. That's what I'm seeing on your end. But and however, even though you try to make this work, that third person isn't going any place. Even if they both say the third person is, that third person isn't going any place. And I'm really sorry, that's the message I have to give you today. But I hope that message helps you make a healthy decision for you. Because at the end of the day, you have to wake up, go to sleep with, and live with you. Anybody else is a choice that you bring.


This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. While we're waiting, there were a few resources that I found when I was getting ready for today's class that are not part of today's class, but I wanted to make you aware in case you do happen to work with this population. We have from SAMHSA. All these are from SAMHSA. You can order them free. They're shipped free. It's awesome. You just go to SAMHSA.store.gov or you can just do Google SAMHSA store and you'll come up with their store page. But one of the resources is linking older adults with medication, alcohol, and mental health resources. There are a bunch in stock, so you can order those. A guide to promoting emotional health and preventing suicide in senior living communities.  Treatment of depression in older adults. This is actually an evidence-based practices kit, and you can get the entire kit from SAMHSA, but this is just one part of it, so you can download the kit and have everything you need to implement this evidence-based practice. Substance abuse relapse prevention for older adults. A group treatment approach. Really helpful if you're working with a specifically older adult population. And alcohol use among older adults. Pocket screening instruments for health care and social service providers. All of these you can order for free. Most of them you can also go to the HTML page and print it out as a PDF if you don't want to wait for it to be shipped. So those are awesome resources that are available for you already. Today's presentation is based off substance abuse among older adults, as well as the course that I did on problem gambling. I kind of merged the two. But that is also a treatment improvement protocol from SAMHSA, which is SAMHSA Tip 26. All that being said, we'll go ahead and get started. I'd like to welcome everybody to today's presentation based on Tip 26, Substance Abuse Treatment in Older Adults. And today we're going to talk about more than substance abuse. We're also going to talk about gambling, because gambling is becoming a significant emerging problem in the older adult population. We'll review data about substance abuse and gambling issues in older adults. And for those of you who haven't had a class with me before, I'm not going to test you on specific percentages. So don't get all caught up in remembering that 20% this, 80% that. I want you to get the big ideas and not down in the weeds. You can come back to the PowerPoint later to look at the weeds if you want to find out that data. We're going to review screening for substance abuse and mental health disorders in the elderly. A little bit of a review from yesterday, but we're going to add on to it, and we're going to add on even more tomorrow when we talk about Alzheimer's and dementias. We'll identify risk factors for substance abuse and mental health issues, and identify placement and treatment issues specific to older adults. Abuse of alcohol and prescription drugs among people age 60 and older is growing quickly. And we talked about this a little bit yesterday. It's not hard for this population to actually access alcohol and prescription drugs. So obviously, you know, path of least resistance, they're probably going to go that way as opposed to heroin and illicit drugs. An estimated 2.5 million older adults have problems related to alcohol and consume more prescribed and over-the-counter medications. So remember, things like pseudofed can be abused. And dextremothorfin, which is the cough-suppressant ingredient in a lot of your DM formulas or the 12-hour cough-suppressant formulas, can be abused. And some of the teenagers are actually taking it rectally to increase their high. But older adults, obviously, if they want some hallucinogenic side effects in addition to whatever, you know, that's an over-the-counter medication that they could get and abuse. A 2006 New Jersey study indicated that 23% of citizens over 55 were disordered gamblers. Now, New Jersey has casinos. So obviously, the percentages are going to be different in places without casinos. Right before class, I Googled Orlando where the villages is, and that's one of the largest retirement communities. And they don't have any casinos, really, of note that are close. There's a day cruise that goes out from Cape Canaveral. So you can go out for four hours and gamble in international waters and come back. And then, otherwise, you have to go all the way down to Tampa, which is quite a haul for somebody. So, you know, the prevalence in the villages is probably going to be different than the prevalence up around Atlantic City. But it's worth noting that 23% of citizens in a community where there are prominent casinos are disordered gamblers. 23% of citizens over 55. Seniors are the fastest growing group of gamblers between 1974 and 1989. Now, this study was done in 1999. The numbers have continued to grow. I haven't found another study that has compared it with other age groups, but it's a big growing group. The study reveals that seniors tend to gamble for extrinsic reasons, including winning money, obvious, gaining independence. If I have enough money, I don't have to live with my children anymore. Or, you know, maybe I can hire somebody to come in and spend time with me instead of having, help me do what I need to have done, instead of having to go to assisted living facility, etc. And supplementing income. So, basically about money and what the independence money can provide. Intrinsic reasons they may gamble include entertainment and excitement. You know, if you gamble, I don't have the stomach for it. I'm far too frugal, we'll say. That's a nice word for it. But I can't take the tension of thinking if I lose. But some people love the tension of it. My father used to go once a year and he would go to Las Vegas and gamble. And, you know, that just made him happy as a clam. Now, he was good about setting limits, but there is a certain group of people who find that it's extremely exciting and entertaining to do. Some people, older people do it to be around others.  So they're missing out on a lot of social stimulation that they used to have. Maybe if they don't live in a retirement community that they're the only one home from 8am until 6pm in their neighborhood. And, you know, it gets kind of lonely and they're knocking around their house by themselves. So they may go to be around other people. It can distract from everyday problems such as loneliness and boredom. My grandfather, when he got older and his eyesight went, and especially once his Parkinson's started setting in, couldn't do, he used to make these beautiful, very intricate miniatures. You know, little wooden dollhouse furniture and everything. I mean, it was amazing what he could do. But once his Parkinson's set in and his eyesight went, he couldn't do it anymore. And he couldn't read anymore. And so there were pretty much everything that he liked to do. His body was saying, no, not so much anymore. So he started getting really bored. And after he watched Every Western Known to Man, he didn't even have TV to watch anymore. So working with people, you know, from a prevention and intervention standpoint, we want to look at why are you gambling? You know, and for some it may not be a problem. It's just something that they do like, like for my daddy. But for others, it may be a problem. So then we want to look at what function is that gambling serving and how else can you meet that need. People also gamble to escape from feelings of grief and loss associated with the death of a loved one or close friend, especially if it's, you know, your spouse. You know, you've been living in a house with somebody for 10, 15, 30 years and they pass on. And, you know, it's really quiet and you don't have anybody to talk to anymore. And it's a big change. So they may not want to knock around that house, but they may not be ready to sell the house either. So those are all things to consider. And those are some of the things that were identified by the Arizona compulsive gambling council for reasons people identify older adults identify that they actually gamble. Among adults over 65 years of age, gambling is the most frequently identified social activity. Let that sink in for a second. So we're not just talking about casinos here. You know, we're talking about poker games. We're talking about, you know, you can gamble on a variety of things, but there is some sort of gambling involved going to the track. So paying attention to what things in your area might promote gambling and also socialization because if it's just gambling itself like playing the lottery. That's generally not as detrimental as doing something social, unless it's like online gambling.  So we want to be aware of what's going on with older adults in communities where there is a casino. A lot of times the casinos will actually send a bus out to the retirement communities to pick people up and bring them there. Because, you know, the retirees, they're around all day long. The people who are working are working. So during the day, there's not much activity at the casino. The retirees go into the casino. They are made to feel like they are super special, important, their friends are there. There's a whole lot of stuff going on and they may get more hooked on it, if you will, than they really anticipated. So some articles I read had a negative twist indicating that maybe the casinos are preying on older adults. But we just kind of need to be cognizant of what's going on with our loved ones and encourage them to be cognizant of what's going on for themselves. Reduced cognitive capacity can make it difficult for older adults to make sound decisions. So if you've got an older adult who also has cognitive decline, and remember it doesn't have to happen, but if they do have cognitive impairment of some sort, it may be more difficult for them to make good choices. And at casinos, there is a lot of inexpensive, most of the time, relatively inexpensive alcohol. Because the casinos want people to be disinhibited, you know, make sense from their point of view. So, you know, you take somebody who's, you know, more susceptible to the effects of alcohol and give them alcohol, they may also have problems making sound decisions. Older adults living on a fixed income with limited savings can't necessarily afford the financial drain of a gambling disorder. And one of the quotes I found that just really stuck with me, this guy named Nour was talking and he said, when you're younger, maybe you gamble, you get $100,000 in debt, but you've got your spouse, you got your kids, you got your job. You still have a reason to get up in the morning. But with older adults, you know, their spouse may have passed on, their children are off leading their own lives now. They're retired, so they may have fewer reasons to get up in the morning. And now they see that they're in debt and they may feel guilty because they're going to leave that debt to their kids. So, it can be a huge trigger for depression and suicidal ideation. Because older adults tend to have less contact with friends and family, gambling problems may go unnoticed. If they're interacting with friends, you know, some of those friends may be going to the same casinos. So it may be sort of a group think sort of situation where nobody really notices a problem. They may gamble at home on the internet, you know, some older adults do get engaged in online gambling. But definitely if they have less contact with family, if they don't see their kids every day or whatever, if they don't live with their kids, then there may be a greater chance for the gambling related problems to be minimized and hidden for a lot longer and go unnoticed. And then all of a sudden there's this crisis point. Gambling should be identified as a problem when it disrupts damages or limits a person's life. Signs of problem gambling are spending more money on gambling than intended, feeling bad sad or guilty about it, not having enough money for food, rent or bills, being unable to account for blocks of time.  Experiencing social withdrawal can be withdrawing and gambling on your own. It can be doing slot machines at the casino. There's a lot of different ways that people can show this and experiencing anxiety or depression. Older adults may try to hide or deny a gambling problem. They may feel hopeless or ashamed about the situation. And or maybe unaware that help is even available. They don't really realize it's a problem. I mean, we're just now in the clinical community starting to recognize gambling as sort of a diagnosable issue. And, you know, if we're looking at people who really don't want to admit that there's mental health problems to begin with, especially mental health problems with a stigma like addiction, then they may really be reluctant to come forward. So you've got gambling. And we've talked about that. It's something to be aware of with the older adult population. If they engage in it and it's not having a negative impact on their life, then, you know, Ducky, encouraging them to be aware of, you know, any warning signs is really important. When they get older, when people get older, alcohol affects you differently. There's a normal decrease in body water that comes with age. So because of this dehydration, the same amount of alcohol can now cause intoxication. And there's increased sensitivity to alcohol and a decreased tolerance, which is basically three different ways of saying the same amount of alcohol is going to get you way drunker than it did before. And there's also a decrease in the rate of metabolism. So whereas the younger person will metabolize one ounce of alcohol roughly per hour, it's not the same with the older adult. So we need to pay attention to that. And if they already have reduced hepatic liver functioning, we need to be aware that that will also slow down the metabolism of alcohol and it could cause all kinds of other problems because, you know, alcohol and the liver not friends. Alcohol can also trigger or worsen serious problems like heart problems. We know that the first part of alcohol intoxication is depressant. It slows down breathing, slows down heart rate. As it starts to wear off, that depressant effect goes away faster than your body can put GABA back into the system. So people tend to have an anxiety response and an increase of blood pressure. If they've been drinking for a long time and they quit cold turkey or decide they're not going to drink today, they could also increase their risk of stroke because of high blood pressure. Alcohol detox is a life-threatening detox and it's not something that should be undertaken lightly. It could cause, alcohol can cause cirrhosis of the liver and other liver diseases. It can also worsen other liver diseases like hepatitis. It can cause gastrointestinal bleeding or make it worse. My grandpa had ulcers from, you know, the time I can remember. But he also drank a lot and I have to believe that that didn't help his ulcers any. But he got ulcers from stress and drank to control stress and the alcohol made the ulcers worse. So you see illogical thinking but logical at the same time. So we want to look again, what function is the alcohol serving for you? And depression, anxiety and other mental health problems can be made worse by the use of alcohol because it messes with those neurochemicals. It messes with the balance of the excitatory and inhibitory neurochemicals, the relaxation and the get up and go neurochemicals. So recognizing that people can have rebound anxiety. And we talked yesterday about the fact that anxiety is the most prevalent mental health disorder in the older adult population. So anything we can do to not make it worse, probably a good thing. Prescription drugs. Now, you know, older adults generally, not always, but generally are on a lot of prescriptions, but not because they're drug seeking because they have multiple issues going on. Many medications interact negatively with alcohol. Painkillers are depressants. Your opiates are system depressants. Alcohol is a system depressant. You mix the two of them together, you get one plus one is five.  If you have the opiate and a drink, it's going to be a whammy. So it's important for people to recognize that it's not safe to mix these medications. High blood pressure medications often need to be adjusted in people who drink alcohol or quit drinking alcohol. There's a lot of a variety of medications, not just your psychotropics and your painkillers that don't do well with alcohol. So encouraging the patient to become informed and talk with their doctor openly about how much they drink. Many, not all, not even most, but many older adults have a dependence on psychoactive medications, psychotropics. Some of them, like we talked about yesterday, may be dependent on benzodiazepines, which also can be a life-threatening withdrawal. People who withdraw too quickly can have seizures. So we don't want people to just say, oh, I'm done with these and quit. We want them to talk with their primary care. But psychoactive medications can also cause other problems because the person misunderstands the directions, how much to take, how often, or they lose track of time. They can't remember, did I take it three hours ago or two hours ago? They may have multiple prescriptions from different doctors and the doctors aren't coordinating. So they've got a pain physician. They've got their general physician that's prescribing blood pressure medication. They've got a psychiatrist and they've got a neurologist. Now, the neurologist may prescribe Gabapentin for pain and the pain management guy may be prescribing opiates for some other kind of pain. And then the psychiatrist may be prescribing benzodiazepines. Well, you have three basic system depressants there that could work together in a bad way and seriously depress the person's respiratory function. And they may have unintentional misuse leading to abuse. And they may just follow doctor's directions and develop a tolerance that ends up getting compounded. So if they're on chronic pain medication, you know, they are going to develop a tolerance and a dependence. Now, are they abusing it or are they taking it as prescribed? Is it causing them negative life consequences or is it helping them have their highest quality of life? Those are all things that we've got to look at when we're looking at prescribed opiates over time. So what do we do? In terms of screening, some of the things that we need to be aware of, and I want to read this to you first.  Those symptoms when you look at them are what people stereotypically think of an older person. So we need to dispel that myth. You know, older people don't have to lose their coordination. They don't have to be falling. You know, this is not necessarily normal aging. So we don't want to assume that any of these symptoms are just normal aging, especially if they come on suddenly. But if you haven't seen the person in a couple of weeks and this is happening, there's a bunch of things that could be going on besides aging that include substance abuse, Huntington's disease, Parkinson's, Alzheimer's, and alcohol-related dementia that could all cause these symptoms. So what are the risk factors? You know, if we're, we started seeing these symptoms, we're going, ooh, I don't know if I should refer this person. Let's look at what else is going on in their life to see if they're at higher risk. Bereavement and sadness, okay. Losses, like we talked about yesterday. Spouses, friends, family members, loss of social status, loss of their sense of professional identity. Loss of hopes for the future. Sometimes they look forward and they go, I've got 20 years left. I can't change and I didn't do two things on my bucket list and I can't accomplish them now, so I give up. And loss of independence or their ability to function. Social isolation and loneliness. And, you know, this is something that happens after they retire, not necessarily because of a death. Reduce self-risk regard or self-esteem because of a lot of these losses, maybe isolation, family conflict and estrangement, problems in managing their leisure time and boredom, and loss of physical attractiveness. Those are all things that have been identified as risk factors for the development of substance abuse problems. Medical problems, loss of hearing and sight can make a lot of people end up being homebound. So when they are homebound, they can get excessively depressed and may end up self-medicating in order to deal with that. Chronic pain can be debilitating and keep people homebound, but it can also make them seek out pain management and narcotic pain management. Physical disabilities and handicapping conditions, reduced mobility, insomnia and cognitive impairment can all set a person up to be in a place where they're at risk for substances of abuse. Practical problems, impaired self-care, dislocation from housing, reduced coping skills, and loss of income or increased health care costs. So, you know, some really practical issues that can add a lot of stress may lead some people to try to self-medicate or disappear from the problem for a while, whether it's with alcohol, opiates, gambling, over-the-counter medications. And yes, I mean ideally the doctors are using the controlled substance monitoring database, but it doesn't happen, you know, it doesn't happen the way it should. So, I mean, that's an ideal situation, but we know that that's actually not occurring. And I don't know if pharmacists or psychiatrists have access to it, but either way, we know that a lot of the people that can prescribe opiates and benzos are not using it. So, just being aware of that. And we also know from talking to people that have worked with this population, as well as from personal experience, that a lot of physicians that treat older people aren't trained in treating older people, which is why they prescribe benzodiazepines at an inappropriately high rate for an overly long period of time, which can cause lots of problems, and other medications. Benzos are just the ones I'm most familiar with. Other issues, older men are at increased risk of depression and addiction when their wives die. High rates of alcoholism occur in medical settings if somebody's in residential care. Sometimes they feel a little bit more claustrophobic, but one of the things that they may do is get alcohol and use it in the medical setting. If there was a substance use disorder earlier in life, there's a greater chance that it will come back later in life. So, if you have two disorders, a family history of addiction, or prescription drug use of psychoactive medications. So, if you're already using them, you know, if you have a prescription for Xanax, for example, my grandmother had one. And, you know, if you're already using them, it's not too big of a leap to start every once in a while taking an additional one, an additional two, and then all of a sudden you're abusing and you're dependent. So, the controlled substance monitoring database is evidently a state requirement in certain states, but evidently not in others, because I know there's a lot of poor prescribing in certain states. What types of early intervention and prevention activities could be done or are being done in your community and where? So, let's not let people get to the point of being addicted or depressed with suicidal ideation. What can we do? Well, one of the first things is to implement regular screenings. So, who do we screen? Every adult annually at their physical. And older adults are more likely to go in for their annual physicals, especially once they're retired because they're not having to take time off from work, but also because they tend to have more somatic complaints, so they don't avoid the doctor quite as much as some of us do. We should also screen people during major life transitions. It's really important to make sure that, you know, people are coping with these transitions.  It could be an older adult getting married. You know, that's a major life transition or an older adult moving to a new house and selling the house that they had lived in with their spouse for 30 years. So, we want to kind of check in with people. And obviously, you know, they may not be seeing their primary care during these times. So, we want to let everybody know, the family, the caregivers, you know, what to kind of look for their friends.  You know, somebody's there to go, that may be a problem. You know, let me have somebody check in on Sally. Or if the person has unexpected or unexplained physical symptoms, it's always good to screen for concurrent or causative addictive disorders. Potential signs of development of an addiction include sleep related problems, cognitive difficulties, seizures, malnutrition, muscle wasting, liver function abnormalities, obviously is only going to come back on blood tests, persistent irritability and altered mood, depression and anxiety. Unexplained complaints about chronic pain and incontinence, urinary retention and difficulty urinating. So, looking at these symptoms, each one individually could be caused by 10 other things, not necessarily just substance use. So, we don't want to like start setting off warning bells because somebody's liver enzymes are too high. They may have taken Tylenol the entire week before because they had the flu. Or if they're becoming incontinent, you know, that happens for some people. And so, we want to look at what may be causing it. Is it a prostate thing? You know, what's going on? But it is definitely worth getting checked out. There's probably, if any of these things happen, there's signs of a problem somewhere and we need to take a look at it. Poor hygiene and self-neglect. That could be depression, that could be tiredness, that could be too much pain. My grandmother had an impingement of one of her nerves in her neck and she couldn't raise her arm above her head. So, she couldn't wash her hair on her own and it was hard for her to get a shirt over her head. So, changing clothes, you know, my uncle noticed that he went over there and she hadn't changed clothes in a couple of days and that's very unlike her. And so, we started talking to her and realized that she couldn't dress herself anymore because the pain was too excruciating. So, we want to pay attention. Unusual restlessness or agitation, complaints of blurred vision or dry mouth, unexplained nausea and vomiting, changes in eating habits, slurred speech, tremors, poor motor coordination, shuffling gate, frequent falls, unexplained bruising. These could be side effects of medication. These could be caused by a variety of physiological conditions or substance abuse. And some of them could even be caused by major depression. So, let's differentially diagnose. Delirium and dementia. When there's a presence of a severe cognitive impairment, it impairs screening. If somebody can't answer the questions well and especially if you don't have a family member there to help you, it's going to be hard to get a good idea about what's going on. Withdrawal-induced delirium is a medical emergency. When somebody is withdrawing from alcohol, the blood pressure can spike, their vitamin B levels can go way down. It can actually cause something that is often called alcohol-related dementia or Wernicke-Korsakov syndrome. It's a medical emergency. Now, the cognitive impairment from this can be stopped and reversed if they get immediate medical attention, but if they don't, it could become permanent. So, it's really, really important to pay attention to older adults who are drinking alcohol. Signs of delirium, disorientation, impaired attention, concentration, memory, anxiety and suspicion or agitation, hallucinations or delusions. Obviously, those are going to be some big warning signs. You don't want to assume that it's just because of a random cognitive impairment or Alzheimer's. We'll get you to see a neurologist later. We want to ask right then and there about alcohol use because if it's due to alcohol, we need to get them to the ER. Dementia is chronic, progressive and irreversible cognitive impairment. It complicates monitoring drinking outcomes. If someone who has already got dementia, it's really hard to see what kind of quality of life progression they're having because their dementia is progressing as their recovery is progressing. It complicates getting clients into treatment and them getting benefit from treatment because every day is a different day with them. And very few places are equipped to handle a client that has dementia. Signs of dementia, impaired short and long term memory, impaired abstract thinking and judgment, language problems, personality changes or alterations and mood disturbances. So we do want to be cognizant of all of those. And again, it could be caused by a variety of things, but it's better to rule out anything that could be physiologically going on right now that needs emergency medical attention. Indications for inpatient hospitalization, especially during detox. If the person has a high potential for developing dangerous abstinence symptoms or seizure or delirium because they've had higher prolonged dosage of benzodiazepines, barbiturates or alcohol. Those are the three that are really life threatening or can be life threatening detoxes. If their substances are abruptly discontinued, if they have a positive past history, now some people will say, well, opiates, you can get really dehydrated and it can be life threatening. If you get really dehydrated and the diarrhea is bad and you get super malnourished. Yeah. But 99% of the time if the person is getting enough fluids and everything, it can be managed on an outpatient basis. I worked in a clinic where we did a lot of outpatient detoxification for opiates. Suicidal ideation or threats, indication for inpatient and any other major psychopathology. Now not, you know, persistent depressive disorder. We're talking major depressive episode with suicidal ideation. You know, if they've got something else major going on that may put them at risk, we want to look at inpatient detoxification. If they have unstable or uncontrolled comorbid medical conditions like renal disease, diabetes or high blood pressure, they need to be inpatient or if they need medications to be administered or need 24-hour care. If they have mixed addictions including alcohol, if they lack social supports in the living situation or are living alone, it's really dangerous for somebody to detox all by themselves if they're living alone. Especially for an older adult who can fall and break a hip or get disoriented. So we want to make sure that their recovery environment can sustain outpatient detox if that's what the medical team decides. And or if the person has continued access to the abused drug. So what do we do with them? We screen, we help them get detox, either inpatient or outpatient. And obviously for gambling, you don't need to detox, but you need to provide a recovery environment that keeps them from having access to gambling. If they do online gambling, then you may need to have somebody come in and block IP addresses for the gambling sites and lock it down. But that's a different topic. The frames approach, you want to provide feedback to the person of their personal risk or impairment as derived from the screening. Tell them what you're concerned about. Put the responsibility for change on them. You can't force them to do diddly squat. So, you know, and I tell them that, I'm like, it's up to you what you want to do here. But, you know, I do have some concerns. You can provide advice about ways they can change, different programs they can enter, different things they might try, provide them a menu of options. Obviously, be as empathic as possible, recognizing that this is a really uncomfortable topic for them. And support self-efficacy and ongoing follow-up, even if they're not ready to enter treatment right now. Or they're not ready to start addressing this problem, or they're still in pre-contemplation with their gambling, for example. And don't quite see it as a problem yet. All right, you know, whatever brought you here today. You know, how can I help you address that issue?  Or, you know, what brought you in for your assessment today? How can I help you deal with that?  And encouraging them to be empowered to come back and feel like they can come back without having to have their tail between their legs and go, okay, you're right, I have a problem. No, we want them to come back and go, all right, I guess I do need some help. But we want to let them know that there are services out there that can help them and that lots of people have problems with whatever the addiction is or the mood disorder. With brief interventions, use a non-confrontational, supportive approach, because we want to have them embrace recovery, not feel ashamed. They already probably do have shame issues, so we don't want them to feel like we're lecturing them or wagging a finger. Provide customized feedback about what could help and, you know, ask those strengths-based questions and solution-focused questions. When you didn't have this problem, what was different? When you've tried to control this, what has worked? Even if for half a day. Provide information based on age, health, and medications about their condition and what your concerns are. Explore their reasons for drinking or gambling or using drugs. Explore the consequences of drinking or gambling or using drugs. So we want to look at the benefits or the reasons for this, but we also want to look at the consequences. And if you approach it that way instead of just looking at the consequences and trying to help them see how bad it is, they tend to be a little less defensive and resistant. Discuss key motivators to cut down or quit, including maintaining independence, physical health, financial security, and mental capacity. Mental capacity, not so much with gambling, but the other three definitely if they lose all their money and they can't pay their bills, they're going to have to move in with their kids, and it could be a whole thing. But with substances, they could actually impair their mental capacity if they're using. So it's important to point out potential benefits of cutting down or quitting. Identify sensible ways to cut down or quit. Developing sober social opportunities, getting reacquainted with hobbies and interests, pursuing volunteer activities. And for some people like my grandfather, it's going to be tough to find alternatives.   He always had two jobs, sometimes three, and he was always a hard worker and did great things with his hands. He was a painter. He made the miniatures. But then when the Parkinson's set in and he couldn't see anymore, he was like, well, what do I do? I don't have any other interests and I'm not into intellectual type clubs. That's just not for me. So I don't know what to do. So it's going to be important and you could even get a vocational rehabilitation specialist involved to look back over there, the history of what they've done for work and identify possible transferable skills to identify hobbies and volunteer activities. And you may develop a drinking agreement, prescription or contract.  And if they're on medications, then we definitely want to get this cosigned by the prescribing physicians. Identify what types of coping methods could be used to deal with social isolation, boredom and negative family interactions. So, you know, what would you suggest for somebody who's, let's say, 70 years old and they're dealing with one of these things? What types of coping skills might you suggest for them or referral sources? Some of the coping skills for social isolation would include support groups, older adult daycare drop-in facilities, as well as looking at... The other word I'm looking for, senior living, not senior living centers, but senior activity centers. And I know we have one in our town and there's one in the next townover. It's like every town has a center where generally has a center where seniors can get together. But if they don't, many churches do. So, and if one doesn't exist, then it's important to look at, you know, how could we get one together? In a really rural community, maybe having a church host a senior gaming day or each month a different church hosts the seniors could be something to do. If they're bored, brainstorm ideas of what they could do. Look at volunteer opportunities. You know, transportation may be an issue, so you're going to have to have solutions for that. If they're bored at home, you know, talking with them about different things that they could do so they don't feel like they're just knocking around in the four walls. With negative family interactions.  Not taking things, everything personally, looking at those cognitive distortions because they may feel guilty. They may feel ashamed. They may feel inadequate or, you know, there's a lot of things they could feel if they have to move in with a family member. Or they may think, you know, my family member hates me because I've got to move in with them and I'm just putting a real crimp in their style, which some of that may exist, but they've got to figure out how to work that out. So identifying different ways that people can start adjusting, encouraging caregivers to go to support groups and get support. So they're able to figure out how to deal with things and encouraging the older adult to do this too. Treatment settings can be inpatient, 24-hour primary medical, psychiatric and nursing care, medically managed, monitored and intensive. So this is your hospital. The indicators are typically if the person is brittle, frail, acutely suicidal, medically unstable or for some reason these constant one-to-one monitoring. Insurance companies are really not fond of this level of care unless it's an absolute emergency and neither are most people. So, you know, that's something to consider. Older people dependent on psychoactive prescription drugs need flexible community-oriented programs with case management services. A lot of times they don't need inpatient. It's important to try to figure out how can we get case management to go out there every day? How can we get a nurse to stop in once a day? It's still going to be far less expensive to do that than have somebody in 24-7 care. Age-specific group treatment can be helpful. It's supportive, non-confrontational and often builds or rebuilds patient self-esteem. And it can be art groups. It doesn't necessarily have to be a therapy group. It can be a psychoeducational group or a, you know, meditation group, Tai Chi is a big one. Anything people can do together where they can form some social bonds and start feeling more like their old selves. We can help them with focus, coping with depression, loneliness and loss from death of a spouse or retirement. You know, that's one area that we can focus some of our treatment activities and prevention activities on. You know, what should you do when this happens? If your spouse is terminally ill or after your spouse has a heart attack, maybe they're not even terminally ill. You know, how do you deal with that? There's a lot of anxiety. What resources are out there? Who can you talk to? Spiritual providers, who's, you know, what churches or spiritual leaders are willing to provide some, you know, counseling and encouragement. We can help them rebuild their social support network. Through all this, though, we need to make sure that we pace it so it's appropriate for the older person. Because remember, they're going to have a little bit of a delay in some of the information processing. They're still gaining new skills, but it may take a little bit longer for everything to click through. The staff working with them should be interested and experienced with older adults. Older adults are very perceptive. They recognize if somebody really doesn't want to be working with them. So we want to have people who really like working with this population and they exist. And we want to provide in a treatment setting, now whether it's a community-based treatment or an inpatient, medical services and services for the aging. We want to make sure that we can help them get hooked up with hearing aids and vision and, you know, regular medical checkups. And, you know, if they need to have medication administered, you know, anything like that they might need, if they need to get diabetic equipment. Making sure that there's a resource at the facility that they can go to, especially if they're having a hard time affording their stuff that can help them get linked with the appropriate companies and agencies that can help them there. We should provide institutional settings for referral into and out of treatment. So, you know, sometimes health waxes and wanes. My grandmother, my best friend's husband, went into the hospital and, you know, was in really bad shape, was in 24-7 care, in acute care. Then came out and was in inpatient, basically, all day assisted living, but it wasn't like medically monitored. And then was able to go back out to the community and then how to relapse, had to go back into the intensive level again. So we want to be able to seamlessly transfer people between these levels of care. And that's going to require case management.  It's going to have to happen to make sure it gets paid for, to make sure that the referrals go through, that the warm handoffs happen and there's no glitches, et cetera. Five principles to remember when you're treating older adults. Treat them in age-specific settings when possible. They're going to feel a lot more comfortable. Create a culture of respect for older clients. Especially if you're in a mixed-age treatment program, we want to make sure that the older clients feel like they're respected and not looked on like, you've got one foot in the grave, you don't have anything to offer me, because they have so much to offer. So we want to respect the elders.  A flexible treatment program allows older people to accommodate their needs if they're having somatic complaints or transportation issues. And we want to adapt treatment to the client's gender. Especially older people, like my grandmother's age, in their 80s, people who grew up in the 30s and 40s and 50s, tend to have stronger traditional gender roles in many cases. So they may feel more comfortable in a unigender group or treatment program. Cognitive behavioral motivational approach works really well to help them identify negative consequences of their behavior. Shift perceptions about the impact of what they're doing. Empower them to generate insights and solutions. How could I keep this from, you know, breaking the bank or causing problems with my family or whatever? Express belief in their capacity for change. You know, they are very wise and they have a lot of experience and they know themselves way better than I know them. So how can I help you change? What motivates you to change? You know that better than I do. Help offset the denial, resentment and shame. And CBT motivational approaches focus on rebuilding social support networks. You know, keep hearing that one. Self-management approaches for overcoming depression, grief or loneliness. So they need to have a toolbox. And I encourage them to write it down so they have a page that's their depression toolbox. And general problem-solving skills. So, you know, maybe they only have two or three skills that they use with any regularity, but they know how to access those tools and they know where to go to find other tools. You know, they may need to drop into the day center or call up their case worker or whatever to get some more tools to use. But they know how to find or how to deal with it if the tools they have aren't working. Group-based approaches. Great for establishing social relationships and helping people regain self-esteem. We'll have an educational theoretical approach and a personal practical application. So we want to teach them the skill, but then we want to have them take it to that next step and say, how does this apply to you? How could you use it? Give me an example of how you might have used it last week. So we want to make sure that, as with any adult learners, we help them apply it to their own situation and actually manipulate it and hypothetically use it so they're sure that they actually understand the process all the way through. Group-based approaches should have a stated goal and purpose of the session and ideally provide a content outline. It doesn't have to be a big one.  It can be a little bit smaller. But a lot of learners will prefer to have a general idea about what we're covering in group. Go sequentially through the topics like building blocks. So you're building on one thing and you take a break, let them digest it for a second, teach the next thing, take a break, and it doesn't have to be, you know, a bathroom break. It can just be, all right, I want you to take 30 seconds and think about how this applies to you and then we're going to talk about the next thing. Begin with a review of previously presented materials so you're still building and they can see how one thing connects to another. Try to incorporate as many senses as possible when you're talking about things in order to help them learn. So let them see it, let them hear it, and let them talk about it. Know more than about 55 minutes for this population is ideal. Make sure the room is well lit without glare, interruptions, or noise because they have problems filtering and the glare can make it difficult to read. And try to keep superfluous material to a minimum. You know, try not to have it in a room that has posters and stuff everywhere all around. Try to have it in a relatively sedate, calm environment. Individual counseling is also obviously going to be helpful. Medical and psychiatric interventions are often needed. We talked yesterday about SSRIs being the first line approach to treating major depressive disorder in the older adult population. But we also want to rule out medical causes of mood-oriented or cognitive-oriented symptoms because it could be something totally medical. Marital and family involvement and family therapy can be really helpful to ease the transition as the older adult may need help caring for themselves and the children have to kind of step up to that responsibility. And case management and community-linked services and outreach are really essential, even if you're not doing a whole lot of intensive therapy in order to prevent the need for intensive therapy. Staffing should have gerontology training to be aware of what these issues are, be aware of how to communicate with the cognitively impaired, yada yada. Enjoy working with older adults. It's imperative to provide training to all staff who's going to interact with older adults on empirically demonstrated principles. You know, help them understand and actually get training, not just read a paragraph on reminiscence therapy. Help them understand the function of, you know, doing any particular intervention that they're doing. Help them understand what sundowning is. So there's many issues that are unique to treating older adults. Substance abuse treatment in this population is very necessary and worthwhile.  You know, they can really prolong their life and increase the quality of life if they deal with any substance abuse issues. Ease clients by providing treatment in peer settings, by persons sensitive to gerontological issues, and by clinicians of similar ages. So if you can provide treatment in the older adult day center, you know, that's perfect. You know, maybe you have a little room off to the side where you can provide treatment services or maybe the big room, maybe everybody needs to participate in the activity. And it's facilitated by a clinician of a similar age. That's going to help in some cases. It doesn't have to be a clinician of a similar age if it's a clinician who really enjoys working with this population, but it still does help because they feel like that person gets it a little bit more. Withdrawal from psychoactive drugs can induce delirium and is a medical emergency. So not just alcohol, but withdrawing from benzos, from barbiturates. And, you know, if they're on Ambien, well, that falls in the barbiturate category or the sedative hypnotics. But, you know, any medications they're withdrawing from, be aware of side effects. Talk with them about potential side effects, nausea, dizziness, anything that may happen. And this can even be if they're withdrawing from tricyclic antidepressants or SSRIs. So don't assume just because it's a standard psychotropic that withdrawal will be no problem. Make sure that you're aware of what the side effects could be and they're aware and preferably their caregivers are aware so somebody can check in on them. Resources, AARP, the National Center on Addiction and Substance Abuse at Columbia University, join together. And the National Aging Information Center at the U.S. Center on Information... National Aging Information Center at the U.S. Administration on Aging. Those are four good resources. SOMPS is another great resource as I was telling you at the beginning of the class. There are a lot of options that people have these days. Now let me see if I can answer that question that came up earlier. Oh, this is...let's see. I was trying to find some of those day cruises and I thought I found one earlier, the one that goes out of Cape Canaveral. But they're really not that expensive so it can be something seniors really get into doing. So even if there isn't a casino nearby, that might be something that seniors end up doing. While I'm looking this up, if you have any questions, please feel free to type them. Okay, so according to this, there are 37 states that have prescription drug monitoring capabilities. 11 states have enacted legislation to establish one but they're not fully enacted. So that's from the Drug Enforcement Administration's website. So being aware, if you're in one of those states that, especially one that doesn't have prescription drug monitoring or controlled substance monitoring that's required of physicians, then you may need to be one of the potential people that keeps an eye out for problems. If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. You can attend and participate in our live webinars with Dr. Snipes by subscribing at allCEUs.com slash Counselor Toolbox. This episode has been brought to you in part by AllCEUs.com providing 24-7 multimedia continuing education and pre-certification training to counselors, therapists, and nurses since 2006.