INTRODUCTION

Electronic gaming machines (EGMs) account for a significant amount of the gambling losses made by Australians every year, with 2016-2017 Australian figures reporting that losses to EGMs account for approximately 82% of all gambling activities (including casinos and lotteries) and are over 5 times greater than gambling losses on horse and greyhound racing (Queensland Government Statistician's Office, 2018). Accordingly, concerns have been raised by many gambling advocacy groups, government, and the community itself around the rapid expansion of gambling and gaming products in Australia, the level of losses accrued by individuals, and the amount of advertising for gambling and gaming products within arenas such as sports broadcasting (Armstrong et al., 2018; Thomas et al., 2018). In 2015, Australia was reported to be home to 6.8 million regular gamblers, with those reporting EGMs as their main gaming activity spending, on average, $1,292 per person per year. Furthermore, EGM use in 2015 was overrepresented among individuals who reported welfare payments as their main source of income (Armstrong & Carroll, 2017).

Historically, EGMs were not electronic but mechanical machines, typically lever operated, with the object being to align symbols on physical reels to win a prize; these machines were also generally operated by inserting a coin per spin (pull of the lever), with coins being dispensed into a tray when a winning combination was made (Livingstone, 2017). These machines, colloquially known as "pokies" (a shortened form of "poker machine") or perhaps ironically as "one-arm bandits" (in reference to their lever operation and the operator's tendency to lose money using the machine), were historically confined to key locations in Australia. During this time, many individuals took bus trips to state borders to play these machines at clubs typically offering golf, lawn bowling, or other activities with gambling as a lucrative side industry (Delfabbro & King, 2012).

Other states in Australia eventually legalized EGMs in their jurisdiction progressively, with the State of Victoria being the most controversial in 1991. The Victorian process led to a duopoly where local venues were allowed to operate EGMs and a large casino housed approximately 2,500 machines (Livingstone, 2015). During this time, EGMs changed substantively to the modern version known today, which are controlled by sophisticated computer logic, utilizing a number of psychological techniques to keep players gaming for longer periods (Livingstone, 2017). Gambling on EGMs is by far the highest contributor to gambling losses in Australia, with statistics for the years 2016-2017 showing gaming machines accounting for approximately 14 billion Australian dollars lost; these data show the next closest contributor to gambling losses as casino gambling, at approximately 2.4 billion Australian dollars (Queensland Government Statistician's Office, 2018). As mentioned above, much media attention has been paid to gambling in Australia recently, especially around the estimated per capita losses accrued on EGMs.

EGMs have evolved from mechanical machines utilizing spinning reels and often operated by inserting a single coin to computerized machines capable of banking money as "credit" and allowing the player to wager on multiple lines and combinations. Operators are often able to increase their stake on each playing line, wagering up to maximums that approach bets placed on table games (N. Dowling et al., 2004). Modern EGMs incorporate a number of strategies to keep players wagering; by law, machines must return a percentage of the stake wagered (in Victoria, Australia, this rate is set by law at 85%). Strategies such as "near misses," where the player has only one symbol spin past the playing line so the winning combination is broken, and "losses disguised as wins," where lights and sounds play for a win that is smaller than the original stake, have been recognized as techniques employed in the design of EGMs to keep players playing longer (Leino et al., 2016; Livingstone, 2017).

Landon et al.'s (2018) focus group study conducted in New Zealand asked those who gambled on EGMs to report the features they found appealing, supporting the findings noted above. Participants in this study (N = 40) described winning and seeing others winning as positive characteristics of EGM gaming, going further to describe features such as free spins, jackpots, and lights and sounds as being attractive attributes of EGM use. Many participants described these features as being incentives to stake higher bets or described a belief that these lights, sounds, and features were indicative of pending winnings on EGMs. Small wins were also reported as being attractive features, described by participants as keeping play continuing and keeping the notion of a pending win continuing in the mind of the EGM gambler.

Scant literature exists exploring EGMs and problem gambling in the older adult cohort, particularly in regard to prevalence and issues specific to older people. This is an interesting finding given existing literature describes role loss, boredom, and marketing gaming specifically to older adults to be significant issues for problem gambling in this group (Botterill et al., 2016; Clarke & Clarkson, 2008; Frederick et al., 2007). EGMs are described as the primary mechanism of gambling harm for those described as problem gamblers, of whom up to 80% are reported to use them (Prior Jonson et al., 2012). In this article, we aim to provide an overview of EGMs in the context of older adults and make recommendations for addiction nurses to improve practice around recognition and referral to treatment for older adults with problematic EGM use.

METHODS

Searches of the Scopus, Medline, and CINAHL electronic journal databases were used as the primary methodology for this literature review. Searches were made by using the search string "older adult problem gaming" and then using the "search within" function with "Australia" as the keyword. The search string "electronic gaming machine" was also used, with the "search within" function with "older adult" as the key phrase. Finally, the word "pokies" was used as this is the colloquial Australian term for EGMs. Abstracts were manually checked for relevance, with attention paid to studies exploring EGM use and their relevance to this discussion. A comprehensive search of the gray literature freely available by the Google search engine was also conducted to find relevant government, health department, and community organization data. Searches were conducted during November 2019. Both authors reviewed the shortlisted articles to develop consensus for relevance to the topic.

EGM USE IN OLDER ADULTS

As outlined above, the prevalence of problem gambling and EGM use in older adults is difficult to identify. Clarke's (2008) New Zealand study on gambling motivation that collected demographic statistics from 104 older adults (aged 65 years and over) found that 64% of respondents gambled at least weekly or more frequently; however, 74% spent 10 New Zealand dollars (around U.S. $6.60) or less during each wagering session. Fifty percent of this sample played EGMs as their primary form of gambling, with 7.7% of the overall sample reported to be categorized as problem gamblers using the Revised South Oaks Gambling Screen, a screening instrument that presents 20 problem gambling symptoms; recording a score of 4 or more results in a probable problem gambling diagnosis.

A study examining calls (N = 1,084) to a Connecticut problem gambling helpline found that older adults, defined as those 55 years old and over for the purpose of the study, comprised 16.5% (n = 168) of those seeking help (Potenza et al., 2006). When compared with their younger counterparts, older adults were both more likely to report having gambled for longer durations and to report casino slot machine (EGM) gambling as their source of problem gambling; 66.2% of the older adults calling the helpline described EGM gambling as their chief source of gambling. Furthermore, 42.8% reported daily tobacco use and 18.4% reported alcohol use problems in addition with problem gambling. The study also listed limitations in the sample, primarily the supposition that older adults were less likely to seek help and therefore were potentially underrepresented in the data.

Southwell et al.'s (2008) research into older adult EGM players, discussed in depth in the next section in regard to the consequences of problematic EGM use, also explored the effect of venue promotions on gambling behavior. A high number of the sample (N = 414) explored in the study had participated in promotions such as discount meals (72%), entertainment (56%), and prize draws associated with membership of the gaming venue (54%). Although there was no association found between participation in venue promotions and EGM player personal characteristics, 71% of gaming venues surveyed in the research acknowledged targeting promotions specifically at older adults; this included activities that appeared to be designed to encourage older people to attend the venue for extended periods, such as all-day bus trips or EGM credits enabling them to play machines for longer periods or encourage EGM participation. Furthermore, 18% of those participating in promotions described spending more time playing, and 14% reported spending more money on EGMs than they would without the promotion. These figures indicate the value in providing these promotions for venues, where the provision of token "rewards" such as cheap meals or EGM credit leads to extended gaming machine use in the older adult cohort.

Bus trips, as described in the introduction, have also been identified as tools used by gambling providers to increase patronage. In a study conducted in Central and Southwestern Ontario, Canada, van der Maas et al. (2017) surveyed 1,978 adults aged 55 years and over frequenting gaming venues including a casino and six-horse racing tracks with EGMs and table games. The presence of problem gambling was identified by using the Problem Gambling Severity Index, with participants also asked whether they had attended an organized bus tour or gaming trip in the past 12 months. Using regression analysis, the authors found that participating in a bus tour in the past 12 months was associated with higher odds of problem gambling and more frequent EGM play. This finding further illustrates that promotions geared toward older adults require more investigation in respect of enabling ongoing EGM gambling.

Exploring preferences in both EGM venue and machine type, Thorne et al. (2016) conducted semistructured interviews with 59 EGM gamblers recruited from venues in New South Wales and Queensland, Australia. Supporting the finding that many older adults attend EGM venues to gamble as a social outlet, the study found that many of the female participants sought venues with a perceived good atmosphere, with personable staff who appeared to care about gamblers described as being an important factor in venue selection. Furthermore, many of the participants reported preferring physical EGM venues to playing EGM-style games online as they liked gambling with, and winning, real cash as opposed to virtual credits. There was also an element of protection from overspending described by the participants, who were concerned about the accessibility of Internet-based gaming, particularly in respect of "any time" access. High-risk gamblers in the study described venue selection as being based largely on superstition, with EGM venues chosen for the perception that they were lucky and associated with a greater likelihood of winning. Although based on a small sample size, this study provides very good insight into the motivation and preferences of older adults who use EGMs to gamble.

CONSEQUENCES OF PROBLEMATIC EGM USE

Research involving older adult pathways from recreational gaming to problem gambling has been scant, with existing literature tending to focus on age-related concerns such as loss, loneliness, and depression. Although the marketing of EGMs often portrays this means of gambling as a recreational activity, Tirachaimongkol et al. (2010) set out to determine how older adults transitioned from recreational to problem gamblers using a pathways model, describing three distinct clusters: individual vulnerability factors, such as distressing situations or an urgency to "fix" a financial crisis; social and environmental factors, such as an unsupportive environment consisting of isolation and a lack of recreational activities; and behavioral regulation factors, such as impulsivity and disinhibition caused by neurological deterioration or damage. The authors argue that the context in which older adults move from using gambling as a recreational outlet to problem gambling needs to be understood when approaching assessment and treatment. Extending this to EGM gambling specifically, it is important to understand contextual factors leading to problematic EGM gambling in older adults, arguably essential when considering both the motivation to continue to gamble on EGMs and the motivation to cease this behavior when it becomes detrimental to individual function.

Pietrzak et al. (2007) found a number of correlations between gambling and both physical and mental ill health when examining data on older adults from the 2007 National Epidemiologic Survey on Alcohol and Related Conditions. This study, one of the largest of its kind conducted in the United States, uses face-to-face interviews of 43,093 noninstitutionalized, civilian adults. Analysis of these data found strong associations between both recreational and problem gambling in older adults and obesity, and lifetime alcohol, nicotine, anxiety, and mood disorders. In problem gambling specifically, older adults were more likely than nongamblers to have major depressive disorders, mania and hypomania, generalized anxiety disorder, and panic disorder in addition to drug and alcohol use disorders.

Pattinson and Parke's (2017) qualitative study of "high-frequency" female older adult problem gamblers in the United Kingdom (N = 10) found that many described gambling as a means of emotional escape from age-related negative experiences such as loneliness, declining physical health, and demanding caring roles. During the semistructured interview process, the participants recounted that gambling provided an escape from these negative experiences, with gambling described as providing an ability to escape from reality and to evoke positive mental states. Furthermore, the participants reported that gambling provided a sense of peer understanding, with some describing gaming venues as a safe space and retreat from the pressures encountered in their lives. The authors argue that this is a dangerous situation for older adults, with gambling participation increasing as negative events related to older age increased in the sample. Although the study was based on a small sample size, the notion of gambling as escape has been mentioned in other studies presented in this review. This requires further investigation, particularly in regard to older adults presenting to both addiction and mental health treatment and the impact of this finding on screening for problem gambling.

The results of Pattinson and Parke's (2017) study are echoed by earlier research conducted with older adult EGM players in Queensland, Australia (Southwell et al., 2008). As part of a wider study, 414 EGM players aged 60 years and over were surveyed on-site across seven gaming venues in the capital of the state of Queensland, Brisbane. Largely, participants reported that playing EGMs provided a social environment. Approximately a third of participants went on to describe EGMs as either a mechanism to alleviate boredom, a means to reduce a sense of isolation, or a means to escape from problems or negative mental states such as depression. Retirement and not being in current employment were found to be associated with motivation to gamble on EGMs, with a significant association described when compared with those in employment. Of the sample interviewed, 22% described betting more than they could afford when they played EGMs; 64 of the sample were described as being problem gamblers (approximately 15.5%).

SCREENING AND TREATMENT

To commence treatment for problematic EGM use, it is essential to first detect problem gambling. There are a number of screening tools available to assist clinicians in assessing problem gambling; however, few of these cater specifically to older adults. Furthermore, research conducted into screening notes that assessing for problematic gambling is often sporadic and neglected; Guilcher et al.'s (2020) work exploring screening practices in a cohort of Canadian healthcare providers found that an interplay of several factors created this situation. Primarily, staff participating in the concept mapping process (N = 43) reported that enhancing staff skills in working with problem gamblers and the use of screening tools were considered the most important factors to improve screening for problem gambling. This finding highlights the substantial need for improved education and tools if the identification of problem gambling is to improve.

A systematic review of brief screening instruments for problem gambling conducted by N. A. Dowling et al. (2019) found there is limited evidence for selecting a specific tool for screening populations of interest. Within the review, evidence for the use of one- and two-item screens was found, with high rates of sensitivity in detecting problem gambling. The authors do state that the use of one- and two-item "very brief" screening tools should trigger a more comprehensive assessment as opposed to being a definitive diagnostic tool, pointing to the need for clinical skills when assessing problematic gambling identified by any screening tool.

Current treatment approaches for problematic EGM gambling include cognitive therapies (including cognitive behavioral therapy and graduated exposure therapy), with limited research conducted into the use of pharmacotherapy (Wynn et al., 2014). Of the pharmacotherapy approaches that have been historically used for problem gambling, selective serotonin reuptake inhibitors, mood-stabilizing agents, and opiate receptor antagonists are the most common choices where this approach is taken (Lowengrub et al., 2006).

An older study of gamblers seeking treatment in Connecticut found a number of differences between older adult problem gamblers (N = 343) and their younger counterparts (Petry, 2002). Notably, older gamblers were more likely to be female, with female gamblers having later onset of problem gambling behaviors often related to psychosocial difficulties than their younger counterparts. Proportionally, older female gamblers spent the highest amount of their income on gambling activities, with 57.1% of the older adult cohort sampled in the study (n = 49) nominating EGMs as their preferred type of gambling. In contrast, 77% of older male gamblers had a lifelong history of gambling, often associated with comorbid alcohol misuse. The findings of this study show that older adults cannot necessarily be considered a homogenous cohort, requiring effort in matching treatment and addressing comorbid psychosocial issues when planning care.

RELEVANCE FOR ADDICTION NURSES

Addiction nurses are in a unique position to respond to problematic gambling in older adults. As discussed earlier in this article, problematic gambling use is often associated with alcohol abuse and, in addition, nicotine dependence (Granero et al., 2019). This association was tested by Rodda et al. (2004), who sampled 81 EGM players in Melbourne, Australia, finding higher rates of smoking in those who used EGMs when compared with the general population. Furthermore, problem EGM gambling in this sample was associated with anxiety and higher rates of nicotine dependence. Although there are limitations in the sample size and region of this study, several other studies discussed in this article identify strong associations with mental ill health and alcohol and other drug use disorders, indicating that addiction nurses need to be aware that co-occurring problem gambling is likely to be present in the cohort of older adults they provide care to.

Further studies have noted that problem gambling has been associated with poorer physical and mental health in older adults. Erickson et al. (2005) screened 343 older adults attending senior citizen and other community activity centers in Connecticut, finding an overall prevalence of 6.4% with problematic gambling as defined by the South Oaks Gambling Screen. Of those identified as problem gamblers, high rates of physical and mental ill health were observed, including lower self-reported measures of physical functioning, general health, and vitality. A number of studies support these findings and point to reports of increased alcohol use and drug use, poor mental health, and generally lower reported levels of well-being (Ford & Hakansson, 2020; Goodyear-Smith et al., 2006; Kerber et al., 2008).

Further highlighting the importance of assessment and detection of problem gambling in older adults, Parke et al. (2018) found an association between later life anxiety and depression and problem gambling. The study was conducted by interviewing 595 older adults in the United Kingdom, using a number of validated instruments to determine gambling status, frailty, pain, loneliness, depression, and anxiety. The findings in this study provide further evidence that problem gambling often incurs substantial comorbid conditions in older adults and is essential to explore as a possibility in older adults presenting to health services with these conditions, including those presenting to addiction treatment services who frequently show clinically significant symptoms of depression and anxiety (Outlaw et al., 2012).

DISCUSSION

After legalization, EGM use has taken off in Australia, particularly in the state of Victoria where a large number of EGMs were made available in a short space of time, leading to changes in gambling behavior and increasing losses on this type of gambling (Billi et al., 2015). Complicating the issue, the move from the traditional "mechanical reel" type machine to highly sophisticated computer-based games, with alluring graphics, sounds, features, and increased play speeds, has been reported to create a gaming experience that is said to take advantage of the psychological vulnerability of the player to increase play time and monetary losses (Delfabbro & King, 2019). Although this review has been framed around Australian older adult EGM use, increasing sophistication and market share for EGMs sees this gambling method as a key driver for problem gambling in many other jurisdictions around the world (Medeiros et al., 2015).

Problematic EGM use in older adults is a concerning issue, with a lack of screening and recognition of the issue overall. Legalization of commercial gambling, the evolution of machines with immersive features, and the availability and ease of use of contemporary EGMs mean assessment is key in recognizing the effects of problematic EGM use in older adults. It should be noted that problematic EGM use often results in financial distress for older adults; however, it is commonly associated with psychological vulnerabilities such as mental ill health and alcohol or substance use (Dennis et al., 2017). Accordingly, addiction nurses should be aware of problematic EGM use in older adults they screen, assess, and treat in their daily practice.

Treatment options remain limited for problematic EGM use, largely focusing on cognitive behavioural therapy and graded exposure-therapy-type approaches, with limited evidence for psychopharmacological approaches. As outlined above, comorbidities related to problem gambling in the older adult cohort, in addition to psychosocial factors, will likely need to be addressed when attempting to treat problematic EGM gambling. The prevalence of alcohol, tobacco, and substance use with problem gambling in other cohorts should not be neglected and may necessitate the use of a harm reduction approach, where hard limits are placed on gambling or venue exclusion is considered, although adherence to these approaches is said to be variable (McMahon et al., 2019).

Awareness of relapse when treating older adults for problematic EGM use is essential; studies across adult EGM users show a tendency for "habitual" relapse to problematic EGM gambling (Oakes et al., 2019). Like most forms of addictive behavior, desire to change is fluctuating and requires a distinct skill in assessment and treatment matching to achieve changes in problem gambling behavior (Smith et al., 2018). However, the desire for matching treatment to readiness to change does not necessarily preclude the use of brief interventions, which have been shown to have utility in concerning gambling behavior, are easily applied in a wide variety of settings, and are readily taught and performed by a wide variety of healthcare staff (Quilty et al., 2019).

CONCLUSION

Given the comorbidities associated with problem gambling, including substance, alcohol, and tobacco dependence, and poor mental and physical health, addiction nurses are in a unique position to provide care for older adults affected by problematic EGM gambling. Addiction encompasses many realms beyond drugs and alcohol, and addiction nurses must be prepared to address and treat problematic EGM gambling in older adults. The trend of increasing sophistication in EGMs, combined with ready availability and incentives for older adults to attend gambling venues, means that all healthcare professionals must be prepared to screen and enquire about gambling behavior in older adults.

REFERENCES