Substance Use Disorder Treatment Month
Substance abuse in the elderly is a growing public health concern. Around the world, increasing numbers of individuals are abusing drugs and alcohol in their later years. Substance use among older adults has been on the rise for years. Between 2001 and 2013, alcohol misuse increased 107%, then continued to rise during the Covid-19 pandemic. By 2022, 1 in 11 adults over 60 had a substance use disorder. As the population ages, psychologists expect that upward trend to continue.
Alcohol and other substances may be seen as a way to cope with later in life challenges, including the death of a spouse or the onset of a chronic health problem. They may also be used as a pastime or a way to enhance social outings. Problematic substance use in this group can fit a few different profiles. Some people may start using substances for the first time to deal with a change or loss; others have a decades-long history of use and tend to be harder to treat. Still others used substances at a low level throughout their life, with that use rising to a problematic level as they age. Substance abuse in the elderly has many negative consequences including physical and mental health problems, social and family strain, legal problems, and death from alcohol or drug overdose.
Evidence suggests that the current “Baby Boom” cohort of aging adults, born from the mid-1940s to mid-1960s, abuses alcohol and psychoactive prescription medications at a higher rate than previous generations did. The “Baby Boomers” generally have more favorable attitudes towards substance use, and in their lifetimes, have had easy access to and increased reliance on prescription medication. This current cohort of aging adults will continue to grow at a rapid rate, in many developed nations constituting almost a doubling in numbers from 2008 to 2030.
Alcohol and drug use among older or elderly patient has received relatively little attention clinically. Unfortunately, older adults struggling with substance use are often overlooked and undertreated, despite the serious mental and physical health risks those habits pose. Physiological changes, including decreases in muscle mass and liver function, alter the way the body processes alcohol and drugs as we age. That can, in turn, increase the risk of medication interactions, falls, and vehicle accidents, and may even exacerbate cognitive decline. Smaller amounts of substances have bigger effects in older individuals because of changes in absorption and metabolism. Even low levels of use—one or two drinks, for example—can have a big impact on everyday functioning.
Identifying addictions in the elderly can be challenging, since substance abuse in older people is frequently hidden. In routine care settings, identifying substance use disorders in older adults can be difficult to detect. Clinicians may be unaware that their geriatric patients are abusing alcohol or other substances, including prescription medications. Distinguishing between normal aging, polypharmacy and addition is often challenging due to symptom overlap, for example with neglecting responsibilities, problems in relationships, memory issues, changes in sleep patterns or deterioration in physical appearance. One rule of thumb is that normal aging is generally quiet and slow, involving subtle changes over time, whereas sudden or dramatic changes are red flags that warrant further investigation.
Common substances of abuse in the elderly include:
- Alcohol: Older adults may experience marked intoxication symptoms following ingestion of amounts of alcohol that would be judged safe among younger adults, due to increased effects of alcohol on the central nervous system in the elderly.
- Prescription Medications: Among older people, addiction to prescription medications, particularly opioids and benzodiazepines, is an increasingly urgent public health concern. Polypharmacy is a common problem among elderly people and can itself lead to addiction. Adverse reactions from polypharmacy are common and include confusion, falls, and death. Opioids in particular have high addictive potential. Their abuse has reached epidemic proportions in parts of the USA. In older people, opioids can cause breathing complications, confusion, drug interaction problems, and falls. Opioids should be avoided for chronic non-cancer pain management if possible.
- Cannabis and Illicit Drugs: Trends suggest that aging Baby Boomers embrace marijuana and illicit drugs in far greater numbers than previous generations did. Seniors who dabbled with drugs in their youth may be more likely to turn to similar drugs, particularly marijuana, to treat ailments of old age including chronic pain. Synthetic marijuana use is not limited to young people and often involves dangerous chemicals with unpredictable composition.
How can we help? First and foremost, care partners should routinely ask patients of all ages about their substance use. This should be done while taking a nonconfrontational approach. For example, saying something like, "You're talking about your health issues, which makes me wonder about medications. A lot of people are unaware that their medications make them more vulnerable to the effects of alcohol." That could lead to an educational conversation about alcohol metabolism-or it could alert the provider to a mental health emergency. Suicide rates are highest among adults ages 75 and older, and alcohol use is a key risk factor.
To help prevent problems related to polypharmacy and prescription medication abuse in elderly patients, clinicians may want to consider a "brown bag" medication audit. This involves asking the patient to gather all home medications including pill bottles, nasal spray, supplements and over the counter drugs, and collect all of these into a brown paper bag. In the clinic, the clinician sorts through all of the medications in the brown bag, eliminates all old and expired medications, and enters medication names into database.
Treatment for substance abuse in elderly people may consist of brief interventions, Cognitive Behavioral Therapy, contingency management, motivational enhancement therapy, family and community-based treatment mutual support, 12-step therapies, and residential treatment facilities. Programs should consider the special needs of elderly people including medical and social service needs. Barriers to treatment for older people include lack of transportation, physical disabilities, reluctance to go out in the evening, and greater dependence on their spouse.
The good news is that recovery is possible. Denial of addiction may be stronger in older adults than in younger people, but it is worth the effort to engage the patient and the patient's family in recovery efforts and learn new ways of communicating. Outcomes for older people are often as good as or better than for younger people. Elders are able to utilize offered treatments and benefit from the positive effects of brief interventions, education, counseling and inpatient treatment.
As demographics change, cases of geriatric addictions are more frequently encountered in clinical practice. Substance abuse can complicate all aspects of the aging process physical and mental health. As clinicians, we can improve our skills at diagnosing and treating substance abuse in the elderly as we increase our awareness of the scope of this problem and gain better understanding in this important area of practice.
