Substance Abuse in the Elderly

SUBSTANCE ABUSE IN THE ELDERLY
by Dr. Karen Reimers, MD, FRCPC; IPA Bulletin Assistant Editor, Around the World

Key highlights:

• Changing patterns of substance abuse make it particularly difficult to detect in older adults. In general, sudden or dramatic changes are red flags that warrant further investigation.
• Common substances of abuse in the elderly include alcohol, prescription medications (particularly correlated with polypharmacy), and illicit drugs.

Substance abuse in the elderly is a growing public health concern and a timely topic for geriatric clinicians. It was the focus of a recent half-day course at the World Psychiatric Association Annual Meeting in Berlin, an interactive case-based workshop highlighting challenges and best practices. At the course, participants from five continents shared clinical experiences and reviewed practical guidelines for geriatric addictions.

Changing patterns of substance abuse

Around the world, increasing numbers of individuals are abusing drugs and alcohol in their later years. Substance abuse may be early or late onset, with some individuals imitating substance use for the first time in old age, perhaps following a stressor such as medical illness or death of their spouse. 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 and in terms of research initiatives. Evidence for best practices in the older population is lacking. Most clinical research trials specifically exclude older participants, and the majority exclude anyone aged 60 or older. In addition, most studies are conducted in developed countries and have limited generalizability.

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

The health effects of substance use in the geriatric population can be more dangerous than in younger substance abusers. Chronic health conditions and prescribed medications can increase the adverse effects of substance use.

Alcohol

One of the most commonly abused substances alongside tobacco, misuse of alcohol is often a hidden phenomenon. 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. Who should never drink alcohol? Many elderly people should avoid alcohol completely, including people taking prescription pain medications, sleeping pills, psychotropic medicines, individuals with memory problems, and people with a history of falls or unsteady walking.

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.

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.

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. It can be more potent than natural strains of cannabis and carries increased risk of psychiatric side effects. Abuse of heroin and cocaine is also on the rise among older people, and is associated with adverse medical and psychiatric consequences including cardiovascular problems and cognitive impairment.

Diagnosis and treatment of geriatric substance abuse

Despite the known trends of increasing substance abuse among elderly people, geriatric addictions remain under-identified and undertreated. In general, primary care physicians and specialists do not routinely assess or screen older adults for substance use disorders. Ageism may contribute to a pattern of under-diagnosis; behavior considered a problem in younger adults often does not engender the same urgency for care in older adults. Warning signs of a substance abuse problem in an elderly individual may include excessive preoccupation with having enough pills or timing of the doses, social withdrawal, unexplained injuries, sleep disturbances and decline in functioning.

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.

Recovery is possible

Older adults can recover from substance abuse. 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.

Statements from elders in recovery suggest that older patients are grateful for a new life in free of substance abuse. Elders in recovery also express feeling relieved to find alternatives to prescription medications for chronic pain and anxiety, glad to contribute to society in meaningful ways, and happy to find new friends and relief from loneliness through engaging in treatment.

Conclusion

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.

For further reading

• Bhatia, U et al. Recent advances in treatment for older people with substance use problems: An updated systematic and narrative review. European Geriatric Medicine 2015 6:6, 580-586.
• Haroutunian, H. Not as Prescribed: Recognizing and facing alcohol and drug misuse in older adults. Hazelden, 2016.
• Mattson, M et al; Substance Abuse and Mental Health Services Administration (SAMHSA). A day in the life of older adults: Substance use facts. The CBHSQ Report, May 11, 2017. Available at https://www.samhsa.gov/data/ sites/default/files/report_2792/ ShortReport-2792.html
• Substance Abuse and Mental Health Services Administration (SAMHSA). Get connected! Linking older adults with medication, alcohol, and mental health resources. 2017 Edition. Available at https://store.samhsa.gov/shin/content//SMA03-3824/SMA03- 3824.pdf
• Sullivan, M and Levin, F, Eds. Addiction in the Older Patient. Oxford University Press, 2016.
• Yarnell, S. Cocaine abuse in later life: a case series and review of the literature. The primary care companion for CNS disorders, v. 17, n. 2, 2015.

Excerpted article as reprint from IPA's newsletter, the IPA Bulletin, Volume 34, Number 4
IPA Members can read the full issue on the members' site.