Health Habits and Concerns for Caregivers
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1
. How many of the clients (or family members) that you care for are 60 years old or older?
How many of the clients (or family members) that you care for are 60 years old or older?
2
. Of all the clients you care for who are 60 or older, how many do you suspect may misuse alcohol or other substances? (Consuming more than four alcoholic drinks at one time, or drinking more than one drink per day for females; two per day for males, is considered risky drinking for older adults.)
Of all the clients you care for who are 60 or older, how many do you suspect may misuse alcohol or other substances? (Consuming more than four alcoholic drinks at one time, or drinking more than one drink per day for females; two per day for males, is considered risky drinking for older adults.)
3
. Of your older (60 or over) clients who may misuse substances, how many misuse:
Of your older (60 or over) clients who may misuse substances, how many misuse:
Alcohol only?
Alcohol plus other drugs or medications?
Other drugs or medications only?
4
. Of your older clients who may misuse substances other than alcohol, how many do you suspect misuse each of the following?
Of your older clients who may misuse substances other than alcohol, how many do you suspect misuse each of the following?
Barbiturates: Amytal, Nembutal, Seconal, Phenobarbital
Benzodiazepines: Ativan, Halcion, Librium, Valium, Xanax, Rohypnol
Codeine
Fentanyl: Actiq, Duragesic, Sublimaze
Morphine: Roxanol, Duramorph
Ocycodone HCL: Oxycontin
Hydrocodone bitartrate: Vicodin
Amphetamines: Biphetamine, Dexedrine, Adderall
Mehylphenidate: Ritalin
Dextromethorphan (DXM)
Cannabis: Marijuana, Hashish
Other (please name)
5
. Of your older clients, how many do you believe may suffer from:
Of your older clients, how many do you believe may suffer from:
Depression?
Chronic Anxiety?
Grief/Loss?
Social Isolation?
Other emotional problems (please list)?
6
. Of your older clients, how many do you believe may use medications differently than as prescribed – for example, taking more or less than the amount prescribed, or taking the medication at inappropriate times?
Of your older clients, how many do you believe may use medications differently than as prescribed – for example, taking more or less than the amount prescribed, or taking the medication at inappropriate times?
7
. Of your older clients who use medications other than as prescribed, how many do so for the following reasons?
Of your older clients who use medications other than as prescribed, how many do so for the following reasons?
Using less than the amount prescribed to save money
Using less than the amount prescribed because of unwanted effects from the full dosage
Using more than the amount prescribed because more is needed to alleviate the symptom
Using more than the amount prescribed to help them sleep
Using more than the amount prescribed to help them relax
Using more than the amount prescribed to help them wake up or feel more alert
Other reason (please list)
8
. Of all of your clients who are 60 years of older, how many do you think might be likely to participate in the following types of outside assistance? Please provide a number for each type of assistance.
Of all of your clients who are 60 years of older, how many do you think might be likely to participate in the following types of outside assistance? Please provide a number for each type of assistance.
1. Educational/Informational Presentations on Health or Quality of Life and Aging
2. Outpatient Group Counseling for Older Adults only
3. Individual Counseling on General Issues of Mental Health/Quality of Life
4. Marital/Family Therapy
5. Self-Help Group Meetings like Alcoholics Anonymous or Narcotics Anonymous for Older Adults Only
6. Medically-Supervised Residential Treatment for Older Adults Only to Help Reduce the Use of Substances
7. Private In-Home Counseling by a Psychotherapist
8. Private In-Home Assistance by a Home Health Care Provider Tained to Help Reduce the Use of Substances
Thank You Very Much for Completing This Survey
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