The patterns of substance use and associated problems vary among the older adults, as well as the reasons for abusing substances. For some of the elders, substance abuse is linked to the stresses of aging. In behavioral terms, the best predictor of future behavior is past behavior, especially true for how someone will handle growing old. For example, those who have demonstrated flexibility throughout their lives will adapt well to stresses associated with aging. In addition, individuals with strengths and resiliency will adjust more readily to age-related stresses (Kinney 2011). Stresses of aging include, but are not limited to the following: (a) social stresses in which aging is equated with obsolescence and worthlessness, the process of receiving medical care and paying medical bills, and inadequate insurance coverage, especially for preventive services; (b) psychological stresses, with the greatest one for the elderly being loss (e.g., illness and death of family and friends, geographical separation of family, earned income, losses accompanying retirement); (c) biological stresses including physical disability, depressive illness with a physiological basis such as changes in the levels of neurochemicals, and dementia; and (d) iatrogenic stresses (harm caused by efforts to heal), which are by-products of the healthcare system and its insensitivities to elders’ unique physiological and psychological changes. Usually, iatrogenic stresses are the result of overprescribing medication, failing to take into account the way the elderly metabolize medications, and ignoring that alcohol is also a toxic drug (Kinney). Kinney points out that as people age, they become less similar to one another and more individualistic; therefore, service providers should pay more attention to individual differences among elders.

Attention to alcohol use among older adults is important even when it does not qualify as abuse because it may cause or aggravate a range of health problems (Doweiko 2015; Kinney 2011). As people age, they become more sensitive to the effects of alcohol and medication, requiring less of the substance to feel its effects. Also, older adults have more physical and mental health issues than do younger adults (Ruscavage et al. 2006). Medical comorbidity in the older adults requires adequate monitoring, especially because the addition of substance abuse (resulting in multimorbidity) can complicate accurate diagnoses, including the length of time in order to make one. Multimorbidity makes it difficult to find a treatment that takes into account contradictions, side effects, and drug interactions between substances, and affects the evolution of disease and the patient’s functional status and his or her survival (Incalzi et al. 1997; Valderas et al. 2009).

Addiction rates are high among LGBT populations because of higher rates of depression, a need to escape from the constant presence of social stigma and homo/transphobia, efforts to either numb or enhance sexual feelings, to ease shame and guilt related to LGBT identity, and for some LGBT persons, peer pressure (www.recovery.org/topics/find-the-best-gay-lesbian-bisexual-transgender-lgbt-addiction-recovery-centers/#). Most LGBT elders report societal factors (e.g., discrimination, hate crimes, historical legal prohibitions on sexual behavior) as the reason for an increased prevalence of SUDs. Other anti-LGBT discrimination in situations that are unique to or particularly difficult for older people includes discrimination in housing, medical treatment, and public accommodations. Many LGBT elders are open about their sexuality and gender identity, but others remain closeted because they feel vulnerable and fear discrimination, abuse, or social condemnation. In addition, closeted LGBT elders may experience a certain level of stress when they come out later in life. These feelings lead to stressors for which they might use AOD as a means of coping or to reduce stress. LGBT persons across the age spectrum experience stigma, minority stress, and anti-gay/anti-trans social prejudice (Stevens 2012).

Today’s older LGBT persons came of age when there were very few places in which they could safely express their sexuality or identity. One such place was gay bars, which play a central role in the LGBT community. Gay bars offer a place where LGBT persons might go to socialize without fear of ridicule, to meet potential partners, to relax, or to learn about one’s sexuality and its implications for daily life (Doweiko 2015). Gay bars serve multiple functions for LGBT persons and have been described as a combination of bar, country club, and community center (http://​www.​agingincanada.​ca/​lgbt_​older_​adults.​htm). Substance abuse, especially alcohol , is a large part of life of some segments of the LGBT community (SAMHSA 2012).

The effects of AOD on older adults are quite different than on younger adults, the majority of which stem from physiological changes associated with the aging process. Adults over the age of 65 have at least one chronic illness, which can increase their vulnerability to the negative effects of alcohol and/or drug consumption. In addition, specific age-related changes affect the way an older person responds to alcohol: (a) decrease in body water and increase in fat content, (b) increased sensitivity and decreased tolerance to alcohol, and (c) decrease in the metabolism of alcohol in the gastrointestinal tract. Each of these physiological changes results in a greater concentration in the blood system and quicker intoxication for older adults (SAMHSA 2008). The effects of alcohol on reaction time in older adults may well be responsible for some of the accidents, falls, and injuries that are prevalent in this age-group (Doweiko 2015). The interaction of age-related physiological changes and the consumption of high levels of AODs can trigger or exacerbate other serious health issues among older adults (see Table 24.2). Conversely, small amounts of alcohol have been shown to provide health benefits in older adults who do not have certain medical conditions, taking certain medications, or a history of AOD abuse. For example, alcohol has been shown to be a protective factor against coronary heart disease, heart failure, and myocardial infarction, particularly in older men (Djousse and Gaziano 2007; Gronbaek 2006). For postmenopausal women, moderate drinking can contribute to an improvement in bone density and a reduction in the risk of osteoporosis (Rapuri et al. 2000). In both elderly women and men, light-to-moderate drinking is associated with a reduced incidence of type 2 diabetes mellitus (Djousse et al. 2007). Elders who consume moderate amounts of alcohol have demonstrated improved cognitive functioning compared to those who abstain or report heavy drinking (Deng et al. 2006; Stampfer et al. 2005; Xu et al. 2009), and delay in cognitive decline in older women (Stott et al. 2008). Other studies support psychological benefits of moderate alcohol consumption among the elders, including reduced stress and improved mood and sociability (Bond et al. 2005; McPhee et al. 2004).

Because of age-related physical changes, moderate alcohol consumption is defined as one standard drink (e.g., 1 ½ oz of liquor, 12 oz of beer, or 5 oz of wine) (National Institute on Alcohol Abuse and Alcoholism [NIH] 2005) in a 24-hour period, and hazardous alcohol use is defined as more than three drinks in one sitting or more than seven drinks in a 7-day period (Drew et al. 2010). It is important to note that, depending on factors such as the type of alcohol and the recipe, one mixed drink can contain from one to three or more standard drinks (NIH). Although moderate alcohol consumption has demonstrated some beneficial effects, elders should not increase their alcohol consumption for health reasons. Alcohol consumption among the older adults requires careful monitoring along with other lifestyle factors (ICAP 2014).

The age at which a person begins to use substances and eventually progresses to abuse has implications for effects in later life. Elderly persons with SUDs can be categorized as early-onset or late-onset abusers. For early-onset abusers, substance abuse develops before age 65. Early-onset abusers show higher incidences of psychiatric and physical problems than do late-onset abusers. For late-onset abusers, substance abuse behaviors are thought to develop subsequent to stressful life situations (e.g., death of a partner, retirement, social isolation). Late-onset abusers typically have fewer physical and mental health problems than early-onset abusers (Martin 2012). In both early- and late-onset abusers, the physical changes associated with aging can skew tolerance in elders. The more alcohol or drugs used by a person is an indication of an increase in tolerance. The signs of tolerance include more substance consumed, in large quantities, and over a longer period of time than initially intended. The case of Stanley (below) illustrates an elder gay man presenting risk factors and comorbidities of substance abuse.

Comorbidities in LGBT elders with mental illness present unique challenges. These elders have quadruple stigma (e.g., sexual orientation/gender identity or expression, mental health disorder, SUD, age). The stigma faced may affect LGBT elders’ psychological health, adding additional stress and anxiety and leading to increases in substance use and other high-risk behaviors. Research Box 24.1 contains a study of the prevalence of mood, anxiety, and SUDs for older adults. Keep in mind that the level of minority stress varies depending on the life content and experiences of the individual (Stevens 2012). Literature suggests that LGBT elders with comorbidities experience life circumstances and exhibit responses to circumstances that may exacerbate their internalized stereotypes, making them less likely to seek help for substance abuse or mental health issues.

Detection of substance abuse in the older adults is difficult because the signs and symptoms of substance abuse and aging are similar. Older adults have more medical problems than do younger persons, which in the early stages of SUDs often mimic the symptoms of other health conditions. In addition, older adults who abuse substances tend to attribute the physical complications caused by their substance use to the aging process. Similarly, physicians and family members aid in this assumption because they do not inquire about possible substance abuse in elderly persons (Doweiko 2015; Drew et al. 2010). Some family members believe that the elders have reached an age in life in which they have earned the right to drink and to not have their behavior questioned (Kinney 2011). Another reason for difficulty with detection is that social isolation is often both a reason for and consequence of substance abuse (see Chaps. 22 and 31). However, for older adults who are socially active, their peers might encourage drinking well into their later adult years (Brennen et al. 2010). Other ways in which detection of SUDs are difficult to detect are that they have non-specific presentations and rarely demonstrate the traditional warning signs of an addiction (e.g., legal problems, workplace behaviors) (Drew et al.). For elders still in the workforce who have SUDs, missing days from work because of substance abuse problems are explained away as age-related conditions or stress of taking care of a sick spouse or partner (Doweiko). After retirement, typically elders have more time on their hands and, for those who may have been functioning substance abusers while working and able to manage their addiction, may begin to manifest symptoms in retirement as their substance abuse progresses (Zak 2010).

Elders tend to hide inappropriate AOD usage, making detection more difficult. The SAMHSA Guidelines (i.e., Screening, Brief Intervention, Referral to Treat [SBIRT], http://​www.​samhsa.​gov/​prevention/​sbirt/​) recommends that the first step in a process of detection is a screening, using a test like the Short Michigan Alcohol Screening Instrument-Geriatric Version (SMART-G) (Blow et al. 1992), which is tailored to the needs of older adults. The SMART-G contains ten questions about the person’s estimation about quantity of alcohol consumed, eating habits, physical response after drinking, memory, reasons for drinking, conversations with medical personnel about one’s drinking, and the use of rules to manage one’s drinking. If an elderly patient answers “yes” to two or more of the items on the SMART-G, it is indicative of an alcohol problem. Another commonly used screening instrument is the CAGE (Ewing 1984). The CAGE contains four “yes/no” question about drinking: (a) feeling one should “cut down” on drinking, (b) felt “annoyed” by others criticizing one’s drinking, (c) felt “guilty” about one’s drinking, and (d) needing a drink in the morning as an “eye opener.” A “yes” response of two or more is considered clinically significant. The patient’s responses are used to discuss the need to cut down on the amount of alcohol consumed. If the patient does not see a need for change, a referral should be made to a mental health practitioner or a geriatric psychiatrist (Naegle 2012). Both the SMART and CAGE are psychological screening instruments. It is important to note that a screening is not a diagnosis, rather a means to identify at-risk AOD use.

If the screening process suggests the presence of a SUD, the next step in the process is to determine the severity of the SUD. This step is known as assessment. A comprehensive assessment involves collection of data about the quantity and frequency of use, and the social health consequences of drug use, including nicotine, prescription, over-the-counter, herbal and food supplements, recreational drugs, and alcohol (Naegle 2012). In addition, a comprehensive assessment should include a through physical examination along with laboratory analysis and psychiatric, neurological, and social evaluations (Martin 2012). Given that many elders take numerous medications, a basic assessment of their medications may require the shopping bag approach in which elders bring in all of their medications (i.e., a shopping bag filled with medication). The assessment of elderly substance abusers involves a biomedical, psychosocial approach in which it is determined whether the patient has a biological disease (e.g., depression that is producing the abuse) or whether the substance abuse has produced a biochemical brain disorder (e.g., dementia, delirium). Both the medical complications from the abuse and medical problems exacerbated by drug dependence must be examined. Psychological distress (e.g., anti-gay/anti-trans prejudices) can induce addictive behavior, requiring psychological interventions to address the problem. Elderly LGBT persons may have a complex combination of functional and social behaviors that exacerbate substance abuse and complicate treatment. Thus, the treatment team must elicit basic biomedical psychosocial information during the diagnostic phase and then use these data to construct an appropriate treatment approach (Geriatric Substance Abuse-Dementia Education & Training Program n.d.). Finally, assessment should consider the spiritual concerns and beliefs of LGBT elders (see Chap. 27). This understanding may aid in the recovery process and relapse prevention.