Substance Abuse Among Older Adults (geriatrics/psych 57058)

Substance abuse among adults 60 and older is one of the fastest growing health problems in the United States (US). The situation remains underestimated, underidentified, underdiagnosed, and undertreated (DHHS, n.d.). Until relatively recently, alcohol and prescription drug misuse was not discussed in either the substance abuse or the gerontological literature. The health care system in the US does not appear to have recognized or to be effectively dealing with the increasing use and abuse of licit and illicit psychoactive substances by older adults (Korper & Raskin, 2003).

There are approximately 35 million people in the US that are 65 or older. This accounts for about 12.4 percent of the total population. That percentage is expected to increase to approximately 70 million people by 2030, which is projected to be 20 percent (Korper & Raskin, 2003).

There are approximately 1.7 million current substance dependent and abusing adults over age 50. That is expected to increase to 4.4 million by 2020 (Korper & Raskin, 2003). As the baby boomer generation ages the percentage of older adults substance abusers is expected to increase. This is because baby boomers are more experienced with drugs than their predecessors and some studies report that baby boomers have 3 to 4 times the rate of emotional disorders than is found in the current elderly population (Korper & Raskin, 2003), (Benshoff, Harrawood, & Darwin, 2003).

Frail health is often the reason for discontinuing alcohol and drug use among the older adults. Failing health may keep the older adult from leaving home to acquire drugs and alcohol, or may result in placement in a long-term care facility where drugs or alcohol are prohibited. There is evidence that individuals in poor health may be more likely to consume medications that negatively interact with alcohol or mood-altering illicit drugs which may lead to discontinuing alcohol or drug use (Benshoff, et al. 2003).

Healthcare providers who currently care for Americans age 60 and older mainly encounter abuse or misuse of alcohol or prescribed drugs. Abuse of heroin and other opioids by older adults is rare. Individuals "age out of" drug use and relatively few individuals maintain illicit drug use beyond his thirties or forties. However, some experts are expecting that to change as the baby boomers age, because baby boomers had a greater exposure to illicit drugs than did the previous generation (DHHS, n.d.).

Individuals who begin substance abuse after age 65 are most likely to abuse alcohol (Benshoff, et al., 2003). Some older adults misuse over-the-counter drugs that have a high alcohol content, such as cough suppressants. Many over-the-counter drugs negatively interact with other medications and alcohol (DHHS, n.d.).

Older adults on a low fixed-income may spend money for alcohol or drugs and neglect more basic needs like adequate food or medication. Therefore, alcohol or drug abuse may cause greater problems because of poor nutrition and lack of medical care (Benshoff, et al., 2003). 

Substance abusers over the age of 65 are identified as early onset or late onset abusers, or as chronic or situational. Early onset abusers began drinking or drug abuse behavior before the age of 65 and continued to consume thereafter. Early onset abusers frequently have significant physical and mental health problems, usually associated with their substance abuse history. About two-thirds of older adults with alcoholism problems are early onset drinkers (Benshoff, et al., 2003).

Late onset abusers are individuals who begin their substance abuse after 65, usually in response to a negative life situation or event such as retirement, death of a spouse, decline in status in the community, or health setbacks.

  “It is unclear; however, if a causal relationship exists... For example, do individuals begin drinking after the loss of a spouse because of grief, or because the death resulted in the loss of a control mechanism? Does increased drinking after retirement result from despair in the change of life status or an inability to manage unstructured free time? Does a significant health crisis trigger increased alcohol consumption as a coping mechanism or as a way to supplement pain medication” (Benshoff, et al., 2003, p 43)?

The adoption of illicit drug abuse in the later years is a rare phenomenon. Almost all newly acquired substance abuse problems in older adults are alcohol related. Late onset drinkers have fewer physical and mental health problems. They have stronger societal connections and are less likely to have ever been in drug or alcohol treatment (Benshoff, et al., 2003).

There is minimal incentive for widely shared information technologies to counter the trend in polypharmacy and adverse prescription drug interactions. Therefore, there are few such programs (Korper & Raskin, 2003). One study estimated that 30 percent of persons over 65 take eight or more prescription drugs daily. Many of these drugs may be psychoactive, taken for sleep disorders, chronic pain, or mood disorders (Henderson, 2003). Prescription drug misuse and abuse is prevalent among older adults not only because more drugs are prescribed to them but also because aging makes the body more vulnerable to drugs' effects (DHHS, n.d.).

The use of licit or illicit drugs in combination with alcohol carries risk, and multiple drug use increase that risk. Since about 50 percent of older adults are light or moderate drinkers, interaction between alcohol and other drugs is likely (Korper & Raskin, 2003). There is a wide fluctuation in symptoms over time for elderly alcoholics and a greater level of associated medical, psychiatric, and social dysfunction, in contrast with younger substance abusers. This makes it more difficult to diagnose alcohol abuse in older adults (Korper & Raskin, 2003).

  “When psychoactive substances are used to excess, mental problems are inevitable…Mental confusion, perceptual distortion, even hallucination can follow directly from psychoactive substance misuse. With prolonged lifelong use and abuse, physical problems also begin, involving almost every organ of the body. The consequences of drug use, therefore, can masquerade as almost anything. Unless the drug problem is recognized and successfully treated (recovery), life will be shortened by probable accidents and accumulated health problems (early death)” (Ray, 2003, p 1).
 

Every 60-year-old should be screened for alcohol and prescription drug abuse as part of his or her regular physical examination (DHHS, n.d.). There are measurement instruments to screen and assess substance abuse. However, physiological changes, as well as changes in the kinds of responsibilities and activities pursued by older adults, make established criteria for classifying alcohol problems often inadequate for this population (DHHS, n.d.). Most of the measurement instruments have not been validated for use with older adults and so must be used with caution (Korper & Raskin, 2003). 

The CAGE Questionnaire and the Michigan Alcohol Screening Test-Geriatric Version (MAST-G) should be used to screen for alcohol use among older adults. The Alcohol Use Disorders Identification Test (AUDIT) is should be used for identifying alcohol problems among older members of ethnic minority groups (DHHS, 2003) (Benshoff, et al., 2003).

The CAGE is an easy to use interview. It is the most widely promoted standard screening test for clinical practice. The CAGE questions are (Benshoff, et al., 2003, p 43):

When consumers answer yes to any of the CAGE questions, further exploration of their use is indicated

The MAST and AUDIT are questionnaires that provide a more detailed description of alcohol use. The MAST has 23 questions to which the consumer responds with either yes or no answers. Questions explore negative consequences related to alcohol use. The AUDIT is a 10- question survey that measures negative alcohol related consequences and allows for a limited description of total alcohol consumption. All three of these instruments rely on client self-report and should be viewed with the usual skepticism (Benshoff, et al., 2003).

Healthcare providers often overlook substance abuse and misuse among older adults, because of insufficient knowledge, limited research data, failure to obtain or record an accurate drug history, reluctance to ask potentially embarrassing questions, hurried office visits, and a lack of initiation of any action regarding an older adult’s substance use (Benshoff, et al., 2003). Healthcare providers tend to mistake substance abuse and misuse among older people for symptoms of dementia, depression, or other problems common to older adults. Older adults are more likely to hide their substance abuse and less likely to seek professional help. Many relatives of older individuals with substance use disorders, particularly their adult children, are ashamed of the problem and decide not to address it (DHHS, n.d.).

The number and the interconnectedness of older adults' physical and mental health problems make diagnosis and treatment of their substance abuse more complex than for other populations. That complexity contributes directly or indirectly to the following barriers to effective treatment (DHHS, n.d.):

	Ageism
	Lack of awareness
	Clinician behavior
	Comorbidity.

The term ageism describes the tendency of society to assign negative stereotypes to older adults and to explain away their problems as a function of being old rather than looking for specific medical, social, or psychological causes. In American culture, ageism reflects a personal revulsion about growing old, comprising in part fear of powerlessness, uselessness, and death. Older adults often internalize such stereotypes and thus are less likely to seek out mental health and substance abuse care (DHHS, n.d.).

A lack of awareness or denial of the signs of alcohol abuse, combined with the personal or community-specific stigma of the disease, may effectively raise one or more barriers to treatment. Stigma, shame, or denial associated with substance abuse may be related to generation, religion, gender, culture, or a combination of these and other factors. Many older adults formed their attitudes about alcohol before the 1950s, when advertising and wider accessibility helped change the use of alcohol from a moral failing to an accoutrement of postwar prosperity. If adults attribute their alcohol problems to a breakdown in morals, they are not likely to seek substance abuse treatment.

Despite the frequency of substance abuse among older adults, there is often a low index of suspicion for this problem. Even when there is the suspicion of a substance abuse disorder, the healthcare provider may have difficulty applying the diagnostic criteria to a wide variety of nonspecific symptoms. With a younger patient, serious physical problems, like heart disease or diabetes can be more easily ruled out, leading quickly to a diagnosis of substance abuse in the presence of certain symptoms. With an older patient, healthcare providers are often in a quandary. Symptoms such as fatigue, irritability, insomnia, chronic pain, or impotence may be produced or influenced by substance abuse, common medical and mental disorders, or a combination of these conditions. Another clinician barrier to diagnosing alcohol problems in older adults is stereotyping. Clinicians are less likely to detect alcohol problems in women, the educated, and those with higher socioeconomic status (DHHS, n.d.).

Medical and psychiatric comorbidities present yet another challenge to the effective treatment of the older substance abuser. Comorbid conditions such as medical complications, cognitive impairment, mental disorders such as major depression, sensory deficits, and lack of mobility not only can complicate a diagnosis but can sway the provider from encouraging older patients to pursue treatment for their substance abuse problems.

For many older minority adults in urban areas, health care is delivered in busy hospital outpatient departments or in emergency rooms. These settings further diminish the likelihood that alcohol and other drug issues will be addressed.

Language is another major issue in identifying and treating substance abuse among minority elders because many of them were first-generation immigrants who never learned English. In order to access services, these patients need an interpreter or a family member who can serve as an interpreter. This raises an additional issue: Interpreters can bias communications, adding yet another barrier to effective treatment.

Other barriers to treatment of the older adults are (DHHS, n.d.).

	Transportation (may be available to go to a hospital but not to AA or aftercare or evening programs): This is especially problematic in rural communities that lack public transportation or in poor urban communities where accessing transportation can be dangerous.
	Shrinking social support network: Fewer friends to support them, participate in the treatment process, or take them places.
	Time: Despite the assumption that older adults have an excess of free time, they may well have to provide 24-hour supervision to a spouse, other relative, or friend, or have to care for grandchildren while the parent works.
	Lack of expertise: Few programs have specialists in geriatrics, treat many older adults, or are designed to accommodate functional disabilities such as hearing loss or ambulation problems.
	Financial: The structure of insurance policies can be a barrier to treatment. The carving out of mental health services from physical health services under managed care in particular can prevent older adults from receiving inpatient substance abuse treatment.

Substance abuse treatment is often provided at several levels of care. Services are usually provided in the least restrictive level possible. The levels of care are (Benshoff, et al., 2003, p 43):

A brief intervention is the recommended first step in treating an older alcohol abuser. Because many elderly are ashamed about their drinking, intervention strategies need to be nonconfrontational and supportive.

A brief intervention is one or more counseling sessions, which may include motivation for change strategies, patient education, assessment and direct feedback, contracting and goal setting, behavioral modification techniques, and the use of written materials such as self-help manuals. The U.S. Department of Health and Human Services (DHHS) and the Substance Abuse and Mental Health Services Administration (SAMHSA) (n.d.) recommend the following steps to conduct an older adult-specific brief intervention.

If the older problem drinker does not respond to the brief intervention, two other approaches, a more formal intervention and motivational interviewing, should be considered

In a more formal intervention several significant people in a substance-abusing patient's life should confront the patient with their firsthand experiences of his drinking or drug use. The formalized intervention process includes a progressive interaction by the counselor with the family or friends. For interventions for with older patients no more than one or two relatives or close associates should be involved along with the health care provider. Having too many people present may be emotionally overwhelming or confusing for the older person. Inclusion of grandchildren is discouraged, because many older alcoholics resent their problems being aired in the presence of much younger relatives (DHHS, 2003).

Motivational counseling acknowledges differences in readiness and offers an approach for "meeting people where they are" that has proven effective with older adults. An understanding and supportive counselor listens respectfully and accepts the older adult's perspective on the situation as a starting point, helps him to identify the negative consequences of drinking and prescription drug abuse, helps him shift perceptions about the impact of drinking or drug-taking habits, empowers him to generate insights about and solutions for his problem, and expresses belief in and support for his capacity for change. Motivational counseling is an intensive process that places the responsibility for change on the client (DHHS, n.d.).

Some older patients should be withdrawn, or detoxified, from alcohol or from prescription drugs in a hospital setting. Indicators for that are (DHHS, n.d.):

	A high potential for developing dangerous abstinence symptoms such as a seizure or delirium because the dosage of a benzodiazepine or barbiturate has been particularly high or prolonged and has been discontinued abruptly or because the patient has experienced these serious symptoms at any time previously
	Suicidal ideation or threats
	The presence of other major psychopathology
	Unstable or uncontrolled comorbid medical conditions requiring 24-hour care or parenterally administered medications (e.g., renal disease, diabetes)
	Mixed addictions, including alcohol
	A lack of social supports in the living situation or living alone with continued access to the abused drug(s).

The initial dose of a drug for suppression and management of withdrawal symptoms in older adults should be one-third to one-half the usual adult dose, sustained for 24 to 48 hours to observe reactions, and then gradually tapered with close attention to clinical responses (DHHS, n.d.). Medications used to modify drinking behavior in older adults must take into account age and disease related increases in vulnerability to toxic drug side effects, as well as possible adverse interactions with other prescribed medications. Disulfiram (Antabuse) is not generally recommended for use in older patients because of the hazards of the alcohol-disulfiram interaction, as well as the toxicity of disulfiram itself. Naltrexone (ReVia) is well tolerated by older adults and may reduce drinking relapses (DHHS, n.d.).

The following are recommended general approaches for effective treatment of older adult substance abusers (DHHS, n.d.):

	Cognitive-behavioral approaches
	Group-based approaches
	Individual counseling
	Medical/psychiatric approaches
	Marital and family involvement/family therapy
	Case management/community-linked services and outreach.

Cognitive-behavioral treatment for older adults should focus on teaching skills necessary for rebuilding the social support network; self-management approaches for overcoming depression, grief, or loneliness; and general problem solving.

When working with older adults in group settings, give a clear statement of the goal and purpose of the session and an outline of the content to be covered. This helps older adults receive, integrate, and recall information. Groups should accommodate older adults’ sensory decline and deficits by maximizing the use of as many senses as possible. Use simultaneous visual and audible presentations of material, enlarged print, voice enhancers, and blackboards or flip charts. It is important to recognize older adults’ physical limitations. Group sessions should last no longer than about 55 minutes. The area should be well lighted, without glare, interruptions, or noise, and superfluous material should be kept to a minimum (DHHS, n.d.).

Substance abuse among older adults is a serious, but under diagnosed problem. Every person over 60 should be screened. However, diagnosis is difficult in the older population because of comorbid conditions. There are multiple screening tools available, but they should be used with caution because they are self-reporting tools and may not be as applicable to older adults.

There are multiple barriers to treatment. These barriers include perceptions and actions by healthcare providers and the perceptions and environment of the older adult patient. Treatment should be initiated at different levels based on the severity of the problem. When interventions or medication is used for the older population, the impact of their age and physical condition should be considered.

Benshoff, J., Harrawood, L. & Darwin, S. (2003). Substance abuse and the elderly: Unique issues and concerns. Journal of Rehabilitation. 69(2), 43. Retrieved December 16, 2003 from here

Henderson, L. (2003). Chapter 4. Age differences in multiple drug use: National admissions to publicly funded substance abuse treatment. Retrieved December 16, 2003 from here.

Korper, S. & Raskin E. (2003). Chapter 10. Conclusions and policy implications. Retrieved December 16, 2003 from here .

Korper, S. & Raskin, I. (2003). Chapter 1. The impact of substance use and abuse by the elderly: The next 20-30 years. Retrieved December 16, 2003 from here.

Ray, B. (2003). Chapter 2. A conceptual model for measuring substance misuse and abuse through the life cycle: The importance of recovery and death rates. Retrieved December 16, 2003 from here.

U.S. Department of Health and Human Services (DHHS) and Substance Abuse and Mental Health Services Administration (SAMHSA). (n.d.) Substance Abuse Among Older Adults Treatment Improvement Protocol (TIP) Series 26. Retrieved December 16, 2003 from here.

U.S. Department of Health and Human Services (DHHS) and Substance Abuse and Mental Health Services Administration (SAMHSA). (n.d.) Substance Abuse Among Older Adults Treatment Improvement Protocol (TIP) Series 26. Retrieved December 16, 2003 from here.