Substance abuse and dependence are considered significant problems in society, warranting identification and treatment. However, substance misuse, abuse, and dependence in older adults are complex issues that are often not recognized and, if recognized at all, are undertreated. Substance misuse/abuse, in particular, among elders is an increasing problem. Older adults with these problems are a special and vulnerable population that can benefit from elder-specific strategies focused on their unique issues associated with alcohol and medication/drug misuse/abuse in later life. There are concerns in the field that the standard diagnostic criteria for abuse/dependence are difficult to apply to older adults, leading to underidentification and treatment. This chapter covers four major areas that can benefit both research and clinical professionals working with older adults: (1) prevalence, impact, and correlates of the substance abuse in this population; (2) screening and identification; (3) use of brief interventions to either encourage behavior change or facilitate treatment entry, if needed; and (4) treatment research and related issues.
Prevalence and Impact of Substance Use Among Older Adults
Community surveys have estimated the prevalence of problem drinking among older adults to range from 1% to 16%. These rates vary widely depending on the definitions of older adults, at-risk and problem drinking, alcohol abuse/dependence, and the methodology used in obtaining samples. The National Survey on Drug Use and Health (2002–2003) found that, for individuals 50 years or older, 12.2% were heavy drinkers, 3.2% were binge drinkers, and 1.8% used illicit drugs. Estimates of alcohol problems are much higher among health care–seeking populations, because problem drinkers are more likely to seek medical care. In 2002, over 616,000 adults 55 years of age or older reported alcohol dependence in the past year ( Diagnostic and Statistical Manual of Mental Disorders , Fourth Edition, Text Revision [DSM-IV-TR] definition): 1.8% of those 55–59 years of age, 1.5% of those 60–64 years of age, and 0.5% of those 65 years of age or older. Although alcohol and drug/medication dependence are less common in older adults when compared to younger adults, the mental and physical health consequences are serious. The 2011 National Survey on Drug Use and Health showed a significant level of binge drinking among individuals 60 years of age or older. The authors found that 19% of the men and 13% of the women had two or more drinks a day, considered heavy or at-risk drinking. The survey also found binge drinking in individuals older than 65, with 14% of men and 3% of women engaging in binge drinking.
Misuse of medications by older adults is perhaps a more challenging issue to identify. Older adults are at higher risk than younger groups for inappropriate use of medications. Older adults use more prescriptions and over-the-counter medications than other age groups: in 2000, the average older American received over 20 prescriptions per year, often coming from an average of 4.7 therapeutic classes. It is estimated that up to 33% of older adults receive psychoactive drugs with abuse potential. 58 There over 2 million serious adverse drug reactions annually, with 100,000 deaths per year. Adverse drug reactions are especially prominent among nursing home patients with 350,000 events each year. A survey of social services agencies indicated that medication misuse affects 18%–41% of the older clients served, depending on the agency.
Substance abuse problems among elderly individuals often occur from misuse of over-the-counter and prescription medications. Older adults who misuse prescription drugs may be different from older adults who abuse illegal substances, in that drug misuse in older adults is often unintentional. For example, a recent study found that 32.1% of older participants needed assistance in proper medication use, 15.6% had difficulty recalling the purpose of one or more of their medications, 10.9% reported an incorrect dose for their medications, and 8.2% of participants took medications that were inappropriate for their symptoms. Drug misuse can result from the overuse, underuse, or irregular use of either prescription or over-the-counter medications. Misuse can become abuse relatively easily. In addition, cofactors such as alcohol and/or mental health problems, white race, living in rural areas, poor health status, social isolation, and older age increase vulnerability for misusing prescribed medications. Likewise, being female significantly increases vulnerability, with an estimated 2.8 million (11.0%) of US women older than 60 years of age misusing psychoactive prescription medications.
Vulnerabilities for Substance Use Problems
Older adults have specific vulnerabilities for substance abuse problems due to the physical and psychological changes that accompany aging. These may include bereavement, loneliness, diminished mobility, impaired sensory capabilities, chronic pain, poor physical health, cognitive impairment, and poor economic and social supports. In addition, older adults have an increased sensitivity to alcohol, over-the-counter medications, and prescription medications. The age-related decrease in lean body mass compared to total volume of fat and the decrease in total body volume increase the total distribution of alcohol and other mood-altering chemicals in the body, which increases vulnerability. In addition, central nervous system sensitivity increases with age. Liver enzymes that metabolize alcohol and certain other drugs are less efficient with aging.
Chronic pain presents as a risk factor for prescription drug misuse, specifically in older adults. Although pain reliever misuse is lower in older adults than in younger adults, rates of misuse among individuals older than 50 years of age have been reported at 1.7%. It has been found that as individuals age, their patterns of pain reliever misuse change. A primary theme emerges when considering pain reliever misuse in this population: rather than actively seeking out pain relievers, older adults are likely to report pain reliever possession originating from multiple medical doctors.
A major concern in working with older adults is the interactions between alcohol and medications, particularly psychoactive medications, such as benzodiazepines, barbiturates, and antidepressants. Older adults metabolize drugs more slowly and are more sensitive to drug effects. On top of the natural slowing of the metabolism, alcohol use can interfere with the metabolism of many medications and is a risk factor for the development of adverse drug reactions. A recent study found that 62.2% of older adults taking alcohol-interactive medications used alcohol in combination with their medication; 42.2% of at-risk alcohol users were taking drugs that had the potential to cause significant interactions with alcohol. There are individuals for whom any alcohol use, coupled with the use of specific over-the-counter/prescription medications, can be problematic. For example, it was found that the use of antidepressant medications did not result in a decrease of at-risk drinking among older adults. The concerning issue is that the use of alcohol can decrease the effectiveness of antidepressant medications, and conversely, reducing the consumption of alcohol can be beneficial in reducing some of the symptoms of depression. Furthermore, co-occurring psychiatric conditions including comorbid depression, anxiety disorders, and cognitive impairment can be a complication of alcohol and medication abuse in older adults. It is also possible that alcohol abuse can aggravate medical problems specifically associated with aging.
The medical and emotional consequences of heavy or excessive alcohol consumption have been well documented. These risks include increased risk of coronary heart disease, hypertension, dementia, depression, and insomnia. However, there is now more evidence of the medical risks of moderate alcohol use for some older adults. Moderate alcohol consumption has been demonstrated to increase the risk of strokes caused by bleeding, although it decreases the risk of strokes caused by blocked blood vessels. Moderate alcohol use has also been demonstrated to impair driving-related skills even at low levels of consumption and it may lead to other injuries such as falls. Of particular importance to the elderly is the potential interaction between alcohol and both prescribed and over-the-counter medications, especially psychoactive medications such as benzodiazepines, barbiturates, and antidepressants, as discussed earlier. Alcohol is also known to interfere with the metabolism of medications such as digoxin, warfarin, and metformin, all medications that are commonly prescribed to older adults.
There are a number of physical and mental health comorbidities associated with alcohol/medication/illicit drug misuse/abuse. In working with older adults, the most difficult-to-identify symptoms are often related to mental health. Epidemiological studies have demonstrated that alcohol use in the presence of psychiatric symptoms is a common problem with wide-reaching consequences in younger age groups. There is much less research on the comorbidity of alcohol and psychiatric conditions in later life. In an early study of 216 elderly presenting for alcohol treatment, Finlayson and associates found 25% had an organic brain syndrome (dementia, delirium, amnestic syndrome), 12% had an affective disorder, and 3% had a personality disorder. In a similar study, Blow and colleagues reviewed the diagnosis of 3986 Veterans Administration patients (60–69 years of age) presenting for alcohol treatment. The most common comorbid psychiatric disorder was an affective disorder found in 21% of the patients. The Liverpool Longitudinal Study found a fivefold increase in psychiatric illness among elderly men who had a lifetime history of five or more years of heavy drinking.
In a study of adults entering substance abuse treatment programs, 35% reported having had both internalizing and externalizing problems in the year prior to entering treatment. Older adults seem to be at greater risk of comorbid internalizing problems as these increased with age.
Comorbid depressive symptoms are not only common in late life but are also an important factor in the course and prognosis of psychiatric disorders. Compared to the general adult population, alcohol consumption and problems are substantially higher in individuals with mild to moderate depression. Binge drinking also tends to be more common in individuals with comorbid depression. Individuals who have co-occurring depression and alcohol abuse/dependence have been shown to have a more complicated clinical course of depression, with an increased risk of suicide and more social dysfunction than individuals with alcohol problems with no depression. The risk of suicide is also higher in older adults with early-onset alcohol dependence. Relapse rates for those who were alcohol dependent did not appear to be influenced by the presence of depression. Alcohol use prior to late life has also been shown to influence the treatment of late-life depression.
Sleep disorders and sleep disturbances represent another group of comorbid disorders associated with excessive alcohol use. Alcohol causes well-established changes in sleep patterns such as decreased sleep latency, decreased stage 4 sleep, and precipitation or aggravation of sleep apnea. In addition there are age-associated changes in sleep patterns including increased rapid eye movement episodes, a decrease in rapid eye movement length, decrease in stages 3 and 4 sleep, and increased awakenings.
The age-associated changes in sleep can all be worsened by alcohol use and depression. Moeller and colleagues demonstrated in younger subjects that alcohol and depression had additive effects upon sleep disturbances when occurring together. In addition, alcohol-dependent adults 55 years of age or older have more disturbed sleep than those younger than 55 years of age. Rates of insomnia for this age also increase with binge drinking. Furthermore, sleep disturbances (especially insomnia) have been implicated as a potential etiologic factor in the development of late-life alcohol problems or in precipitating a relapse. Sleep disturbance is relatively common in older adulthood. Separating out the role of alcohol or drugs and psychiatric symptomatology with the overlay of sleep issues requires time and nonjudgmental questioning to elicit the nature of the problems and to work toward positive outcomes.
Identifying Alcohol and Drug Use Problems in Older Adults
Many older individuals have unique drinking patterns and alcohol-related consequences, social issues, and treatment needs, compared to their younger counterparts. Because of this, assessment, intervention, and relapse prevention planning for alcohol problems in late life are likely to require elder-specific approaches. Many older adults who are experiencing problems related to their drinking do not meet Diagnostic and Statistical Manual of Mental Disorders , Fifth Edition (DSM-5) criteria for alcohol use disorder. Alcohol problems are typically thought to occur in persons who consume larger quantities and drink frequently. For some older individuals, any alcohol use can present problems, particularly when coupled with some psychoactive medications. DSM-5 criteria may not be appropriate for many older adults with substance use problems because people in this age group do not often experience the social or psychological consequences specified in the criteria. In addition, a lack of tolerance to alcohol may not be as appropriate an indicator of alcohol-related problems in older ages. Most DSM criteria for tolerance are based on increased consumption over time. This does not take into account physiological changes of aging that can lead to physiological tolerance at lower levels of alcohol consumption. In addition, the physical and emotional consequences of alcohol use, as listed in the DSM-5, may not be as relevant to older adults with alcohol problems.
Table 69.1 shows some of the signs of potential problems related to alcohol use or alcohol/medication misuse in older adults. Although some of these symptoms can be applied to other conditions in older individuals, they are important markers that provide the opportunity for professionals to ask more questions and determine differential diagnoses. Given the high rate of utilization of medical services by older adults, physicians and other health care professionals can be the key to identifying those in need of brief interventions and/or treatments and providing appropriate care based clinical need.
|Anxiety||Increased tolerance to alcohol|
|Depressed feelings||Unusual response to medications|
|Disorientation||New difficulties in decision-making|
|Excessive mood swings||Poor hygiene|
|Falls, bruises, burns||Poor nutrition|
|Family problems||Idiopathic seizures|
|Financial problems||Sleep problems|
Classification of Alcohol Use Patterns and Problems in Older Adults
There are two main methods that have been used over many years to understand alcohol problems in older adults: (1) the medical diagnostic approach and (2) the spectrum-of-use approach. Although the DSM-5 criteria do not differentiate between abuse and dependence, it is still clinically useful to think about the level of risk for individual patients depending on their age, gender, use patterns, and other characteristics. These approaches use criteria that may not always apply to older adults and can lead to underidentification of alcohol use problems in this population. These were originally described in 1990 by Atkinson and have been applied in the literature since then.
The Medical Diagnostic Approach involves applying criteria for alcohol dependence to the older adult population as they are applied to younger adults. Clinicians often rely on the American Psychiatric Association’s DSM-5 when making a substance use disorder diagnosis. These criteria may not apply to older adults with substance use problems because they do not often experience the social or psychological consequences specified in the criteria. For example, one criterion asks if drinking causes issues at work and/or school, which may not be applicable to retired persons with fewer familial and work obligations. A lack of tolerance to alcohol may not indicate that an older adult does not have problems related to alcohol use. Moreover, DSM-5 criteria for tolerance are mostly based on increased consumption over time, which ignores the physiological changes of aging that would account for physiological tolerance in the setting of decreased alcohol consumption.
The spectrum-of-use approach uses definitions of abstinence, low-risk use, at-risk use, and alcohol/drug dependence to help clinicians determine the types of interventions that will be most effective.
Abstinence refers to drinking no alcohol in the previous year. Approximately 60%–80% of US older adults are abstinent. If an older individual is abstinent, it is useful to ascertain why alcohol is not used. Some individuals are abstinent because of a previous problem with alcohol. Some are abstinent because of recent illness, whereas others have life-long patterns of low-risk use or abstinence. Those older adults who have a history of alcohol problems may require preventive monitoring to determine whether any new stressors could exacerbate an old pattern.
Low-risk use is alcohol use that does not lead to problems. Older adults in this category drink within recommended drinking guidelines (no more than one drink/day or seven drinks/week, never more than two drinks on any one drinking day), are able to employ reasonable limits on alcohol consumption, and do not drink when driving a motor vehicle or boat, or when using contraindicated medications. Low-risk use of medications/drugs would generally include using medications following the physician’s prescription. However, a careful check of the number and types of medications, and whether or not the patient is taking psychoactive medications, is important because medication interactions/reactions are not uncommon in older adults and the mix of medications and alcohol can be problematic. These individuals can benefit from preventive messages but may not need interventions.
Use that increases the chances that an individual will develop problems and complications is at-risk use. Persons older than 65 who drink more than seven drinks/week—one per day—are in the at-risk use category. Although they may not currently have a health, social, or emotional problem caused by alcohol, they may experience family and social problems, and, if this drinking pattern continues over time, health problems could be exacerbated. At-risk use can also represent those who use alcohol within healthy limits but whose use can become hazardous due to combined comorbidities and medication use. Brief interventions have been shown to be useful for older adults in this group as a prevention measure. Individuals who begin to experience problems related to their risky use of substances may benefit from brief treatments.
Dependence can include preoccupation with alcohol or drugs, continued use despite adverse consequences, and physiological symptoms such as tolerance and withdrawal. Formal specialized treatments are generally used with individuals who meet the criteria for alcohol abuse or dependence and who cannot discontinue drinking with a brief intervention protocol. Nonetheless, pretreatment strategies are also appropriate for individuals with the highest problem severity. Brief interventions were recommended by the Center for Substance Abuse Treatment’s Treatment Improvement Protocol on brief interventions and brief therapies for substance use disorders, for use either as a pretreatment strategy to assist individuals on waiting lists for formalized treatment programs—in the case of those who meet criteria for a disorder with no physical dependence or withdrawal—or as an adjunct to specialized treatment to assist with specific issues (e.g., completing homework for treatment groups, attendance at work, adherence to the treatment plan).
Drinking Guidelines for Screening
The National Institute on Alcohol Abuse and Alcoholism and the Center for Substance Abuse Treatment’s Treatment Improvement Protocol on older adults recommended that persons 65 years or older consume no more than one standard drink/day or seven standard drinks/week. In addition, older adults should consume no more than two standard drinks on any drinking day.
Screening for Alcohol/Medication Problems in Older Adults
To practice prevention and early intervention with older adults, clinicians need to screen for alcohol use (frequency and quantity), drinking consequences, and alcohol/medication interaction problems. Screening can be done as part of routine mental and physical health care and updated annually, before the older adult begins taking any new medications, or in response to problems that may be related to alcohol or medication. Clinicians can obtain more accurate histories by asking questions about the recent past, embedding the alcohol use questions in the context of other health behaviors (i.e., exercise, weight, smoking, alcohol use), and paying attention to nonverbal cues that suggest the client is minimizing use (i.e., blushing, turning away, fidgeting, looking at the floor, change in breathing pattern). The “brown bag approach”—where the clinician asks the client to bring all of his/her medications, over-the-counter preparations, and herbs in a brown paper bag to the next clinical visit—is often recommended to determine medication use. This provides an opportunity for the provider to determine what the individual is taking and what, if any, interaction effect these medications, herbs, and so on, may have with each other and with alcohol.
Screening questions can be asked by verbal interview, by paper-and-pencil questionnaire, or by computerized questionnaire. All three methods have equivalent reliability, and any positive responses can lead to further questions about consequences. Any positive responses can lead to further questions about consequences. To successfully incorporate alcohol (and other drug) screening into clinical practice with older adults, it should be simple and consistent with other screening procedures already in place.
Before asking any screening questions, the following conditions are needed: (1) the interviewer needs to be empathetic and nonthreatening; (2) the purpose of the questions should be clearly related to health status; (3) the client should be alcohol free at the time of the screening; (4) the information must be confidential; and (5) the questions need to be easy to understand. In some settings (such as waiting rooms), screening instruments are given as self-report questionnaires with instructions for patients to discuss the meaning of the results with their health care providers.
The following interview guidelines can be used. For patients requiring emergency treatment or for those who are temporarily impaired, it is best to wait until their condition has stabilized and they have become accustomed to the health setting where the interview will take place. Signs of alcohol or drug intoxication should be noted. Individuals who have alcohol on their breath or appear intoxicated give unreliable responses, so consideration should be given to conducting the interview at a later time. If this is not possible, findings and conditions of the interview should be noted in the medical record. If the alcohol questions are embedded in a longer health interview, a transitional statement is needed to move into the alcohol-related questions. The best way to introduce alcohol questions is to give the client a general idea of the content of the questions, their purpose, and the need for accurate answers. This statement should be followed by a description of the types of alcoholic beverages typically consumed. If necessary, clinicians may include a description of beverages that may not be considered alcoholic (e.g., cider, low alcohol beer). Determinations of consumption are based on standard drinks. A standard drink is a 12-ounce bottle of beer, a 4-ounce glass of wine, or 1½ ounces (a shot) of liquor (e.g., vodka, gin, whiskey).
Screening for alcohol use and alcohol-related problems does not always follow a standardized format. In addition, not all standardized instruments exhibit good reliability and validity when used with older adults. There are a few screening instruments that have been used effectively with older adults. The Michigan Alcoholism Screening Test (MAST) has been shown to be effective in older adult populations, but is lengthy and requires a paper form, making it difficult to perform in a busy clinical practice. On the other hand, the Alcohol Use Disorders Identification Test (AUDIT) is very brief, but has not performed as well in the elderly population. The Wales Integrated In-depth Substance Misuse Tool (WISSMAT) annexes can be completed by multiple health care providers, creating a broad picture of the patient in the context of substance misuse. The Alcohol-Related Problems Survey (ARPS) not only identifies older people who have symptoms of alcohol abuse/dependence but also identifies those whose use places them at elevated risk due to comorbidities and medication use. This questionnaire how been shown to be easy to understand and an appropriate length according to the majority of participants who completed it. In addition to quantity/frequency questions to ascertain use, the Michigan Alcoholism Screening Test-Geriatric Version (MAST-G), the Short Michigan Alcoholism Screening Test-Geriatric Version (SMAST-G), and the AUDIT are often used with older adults. Of these, the MAST-G and the SMAST-G were developed specifically for older adults. The AUDIT, developed by the World Health Organization, has been tested in a number of countries with various populations.
The MAST-G was developed at the University of Michigan as an elderly alcoholism screening instrument for use in a variety of settings. The MAST-G was the first major elder-specific alcoholism screening measure to be developed with items unique to older problem drinkers. It is a 24-item scale with a sensitivity of 94.9%, specificity of 77.8%, positive predictive value of 89.4%, and negative predictive value of 88.6%. The SMAST-G is a 10-item validated form.
There has been much early work validating the World Health Organizations’ AUDIT in adults younger than 65 years of age in primary care settings and some early validation in a study of older adults. The AUDIT is a 10-item scale with alcohol-related information for the previous year only . The questionnaire is often used as a screener. The recommended cut-off score for the AUDIT has been 8, but Blow and colleagues found a Cronbach’s alpha reliability of 0.95, sensitivity of 0.83, and a specificity of 0.91 in a sample of older adults with a cut-off score of 7.
Broad-Based Assessment of Substance Use Problems
Clinicians can follow-up the brief questions about consumption and consequences such as those in the MAST-G and the AUDIT with more in-depth follow-up questions, where appropriate. In addition, information obtained in the brown bag approach regarding medication use will assist in making any diagnoses and brief intervention or treatment plans.
The use of validated substance abuse assessment instruments will provide a structured approach to the assessment process as well as a checklist of items that should be evaluated, with each older adult receiving a substance abuse assessment. Specialized assessments are generally conducted by substance abuse treatment program personnel or trained mental and physical health care providers. Compared to mental health services, aging services, and substance abuse treatment services, health care providers have the lowest rates of positive screens for alcohol use disorders. In addition, health care providers provide less follow-up to positive screens than do other providers. It is unlikely that one treatment provider will possess the expertise to address the full spectrum of substance use, medical, psychological, and social service needs, suggesting that care coordination as well as the integration of physical and mental health care would be beneficial.