The Changing Face of Substance Misuse in Older Adults

Addictive disorders are among the leading causes of disability worldwide; however, misuse of and addiction to alcohol and illicit substances is often not appreciated as relevant to the care of older adults.¹ Unfortunately, the public health impact of alcohol and substance use disorders is rapidly changing as baby boomers age. The most recent National House hold Survey on Drug Use and Health demonstrated a 1.7-fold increase from 2002 to 2005 in illicit drug use for those aged 55 to 59 (Figure 1).² The rise in prevalence is likely to continue over the next decade, reflecting a substantial generational change. There were declines or no change in alcohol and substance use in all other age groups.

Similar changes have occurred in the prevalence of alcohol abuse or dependence among those aged 65 and older. From the early 1990s until 2002, the prevalence of alcohol abuse or dependence rose to 3.1%, a 3-fold increase.³ Again, this age group had the highest increase in abuse or dependence of all age groups. Excessive drinking or binge drinking has also risen to a rate of 8.3% among seniors.² Within primary and specialty care settings, particularly specialty mental health care, the incidence of substance misuse is rapidly increasing in the senior population. Health care providers in the aging services are no longer insulated from the consequences of illicit drug use, smoking, and alcohol misuse by patients.

Different effects and different concerns
Older adults present unique challenges to health care providers. Compared with younger persons, older adults have an increased sensitivity to alcohol and over-the-counter and prescription medications. There is an age-related decrease in lean body mass and total body water in relation to total fat volume, and the resultant decrease in total body volume increases the serum concentration of alcohol and other mood-altering chemicals. In addition, interactions between medication and alcohol are a particular concern in this age group. Medications of concern for mental health providers can include antidepressants, antipsychotics, benzodiazepines, and mood stabilizers.

Because of these issues, alcohol use recommendations for older adults are generally lower than those for adults younger than 65. The National Institute on Alcohol Abuse and Alcoholism and the Center for Substance Abuse Treatment's protocols for treatment improvement in older adults recommend that persons aged 65 and older consume no more than 1 standard drink per day, and that on no occasion should an older adult drink more than 4 drinks in 1 day.^4,5 Persons drinking above these limits are at increased risk for falls, medication interactions, and other alcohol-related problems. In the absence of defined alcohol-related problems, someone drinking over these limits would be considered an at-risk or excessive drinker. Reducing alcohol consumption or abstaining entirely can lead to sub stantial improvements in health and overall well-being for patients with this type of drinking pattern. It is note worthy that these drink ing limit recommendations are consistent with the current evidence of the beneficial health effect of low-risk drinking.^6,7

Individuals with clearly defined problems related to substance misuse are considered to have either abuse (1 or 2 related problems) or dependence (3 or more problems). While there are no differences in the definition of abuse or dependence for older versus younger adults, some problems may be less rel e vant to the former, such as problems related to work or family if the person is retired or a widow(er). Problems related to health are usually more prominent for older adults and can be a key to motivating patients to change their drinking or drug use. Finally, it is worth emphasizing that there are no accepted safe limits for the use of tobacco, marijuana, or other illicit drugs.

Recognizing substance/alcohol abuse in the elderly
Despite the common occurrence of addiction problems in elderly persons, these problems are often overlooked by their health care providers. It is imperative that mental health and aging services providers screen for and consider substance misuse in the care of older adults. Given the high use of general medical services by the elderly, physicians and other health care professionals can play a crucial role in identifying those in need of treatment and providing appropriate interventions based on clinical need.⁸ Not only do clinicians need to do a better job of identifying substance abuse in older adults, but those conducting aging research need to better quantify current and past substance use as a potential factor in understanding health and disease in the elderly.

Nicotine dependence (past and current) is exceedingly common in patients with depression and must be considered when interpreting the impact of depression on mortality and morbidity in the elderly. In addition, it is a myth that older problem drinkers necessarily have a lifelong history of alcohol abuse. This is more likely to be true for illicit drugs or tobacco use, whereas a substantial proportion of older problem drinkers-perhaps as many as one third of those seeking treatment-have only developed problems later in life. The relevance of late-onset substance abuse is still debated, and treatment approaches for late-onset and lifelong abuse are no different; however, the distinction between lifelong versus late-onset problems is still important be cause the latter are more easily overlooked by clinicians.

Screening for substance abuse should be done as part of routine mental and physical health care and should be updated annually, before the older adult begins taking any new medications, or in response to problems that may be alcohol- or medication-related. To successfully incorporate alcohol (and other drug) screening into clinical practice with older adults, choose a method that is simple and consistent with other screening procedures already in place.⁹ The Alcohol Use Disorders Identification Test consumption questions (AUDIT-C) is a simple and convenient screening method (Figure 2). A score of 3 or more suggests the need for further assessment or the need to conduct a brief alcohol intervention.

Providers should also recognize that there are a variety of treatment options for addressing these issues and that one need not be a professional in treating substance abuse in order to play a significant role in addressing the issues and improving the lives of patients. Indeed, one of the myths about addiction in older adults is that treating such patients is more difficult and of limited value to their well-being. Older adults actually fare much better in treatment than younger adults and can experience substantial benefits, such as reduced rates of stroke after smoking cessation and improved quality of life, and are more successful in changing their behavior.^10-13

Practical interventions and treatment strategies
Because there are many misconceptions about excessive alcohol use and because patients who abuse alcohol are most likely to be identified outside of spe cialty addiction programs, the use of structured brief interventions or brief therapies should be considered as a first-line intervention. Brief alcohol interventions may lead to reductions in the patient's alcohol abuse or improved engagement in specialty services. They are a cost-effective and practical technique that can be used in various clinical settings for the initial treatment of at-risk and problem drinking.¹⁴ A number of large randomized controlled trials studying brief alcohol interventions have demonstrated efficacy among younger adults in a variety of clinical settings.¹⁴ Both Fleming and colleages¹⁵ and Blow and Barry¹⁶ have conducted randomized clinical brief intervention trials that demonstrate efficacy among older adults. Two recently completed studies of depression, anxiety, and excessive alcohol use showed that allied health staff, including nurses and social workers, can provide concurrent disease management for depression and alcohol misuse (integrated services) and that delivery of these services by telephone is very effective.^17,18

Relatively little formal research has been conducted on the comparative effectiveness of various approaches to addiction treatment in older adults. Several naturalistic studies suggest that older adults who do engage in treatment can have outcomes that are as good as or substantially better than those obtained in younger adults.^12,19-21 Other treatment outcome research on older adults with substance use disorders has focused on adherence to treatment program expectations, including drinking behavior.²² Results from adherence studies have shown that age-specific group therapy is more effective than mixed-age groups in improving treatment completion.²³ Older adults with substance use disorders were also significantly more likely to complete treatment than younger patients.^24,25

Traditionally, pharmacologic treatments have not played a major role in the long-term treatment of older alcohol-dependent adults. The opioid antag onist naltrexone has been shown to be efficacious both in large samples that included older adults and in studies focused specifically on older adults.²⁶ Recently, acamprosate has been studied as a promising agent in the treatment of alcohol dependence. Although the exact action of acamprosate is still unknown, it is thought to reduce glutamate response.²⁷ The clinical evidence favoring acamprosate is impressive, although there have been no studies of its efficacy or safety in elderly patients.

The need for action
Over the past several years, there has been a growing awareness that addictive disorders among the elderly are a common public health problem. Epidemiologic studies suggest that alcohol dependence is present in up to 4% of community-dwelling elderly per sons. Moreover, problem or hazardous drinking is estimated to be even more common among the elderly than alcohol dependence.^28,29 However, there continues to be a gap in the number of older adults who are referred for treatment or who receive treatment for addictive disorders.

While many factors contribute to patients' lack of engagement, the decision to recommend treatment is partially based on its availability. Toward this end, there needs to be better dissemination of information regarding available and effective treatments for at-risk drinking and alcohol dependence, as well as other addictive disorders, in conjunction with continued development of effective treatments. It is no longer appropriate to think of 12-step programs as the only available treatment option. There is also a clear need to conduct research and clinical training beyond the problems of alcohol use. Current and past nicotine dependence, as well as illicit drug and medication abuse, are increasingly recognized for their impact on the elderly and will need similar focus in treatment trials, epi demiology, and neuroscience.

Dr Oslin is associate professor in the section of geriatric psychiatry and the center for the study of addiction, department of psychiatry at the University of Pennsylvania in Philadelphia and acting director of the VISN 4 MIRECC at the Phildelphia VA Medical Center. He reports no conflicts of interest concerning the subject matter of this article.

References:

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