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Introduction
The population of older adults is rapidly growing, in large part due to the aging of the baby boomer generation who comprise 30% of the US population and the first of whom turned 65 years old in 2011.[1] This cohort engages in higher rates of alcohol and drug use compared to older cohorts,[2] and it also has a higher prevalence of substance use disorders and treatment admissions for substance use disorders.[3, 4] Although older adults use alcohol and illicit drugs at lower rates than younger adults, the sheer numbers of the older adult population and the aging of the baby boomer generation are expected to drive up the prevalence rates of substance use disorders among older adults.[3, 5] Because of these facts, it is increasingly understood that health-care professionals need to know how to identify, assess, and intervene in regard to substance use disorders among aging adults.
Prevalence of alcohol, tobacco, illicit and nonmedical prescription drug use, unhealthy use, and use disorders
Definitions
One of the challenges in the literature on substances is the multitude of terminology used to refer to various types of substance use. Here we will define “current use” as the use of substance within the past 12 months. “Unhealthy use” has been defined for alcohol as the use of alcohol that exceeds recommended drinking limits and includes a spectrum of risk.[6] At-risk or heavy use includes use that carries risk but has not resulted in harm. Problem drinking is the use of alcohol that has resulted in harm but does not meet Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for an alcohol use disorder (AUD). All substance use disorders (SUD) now have the same diagnostic criteria using DSM-5 criteria (e.g., must meet 2 or more of 11 criteria).[7] For tobacco and illicit drugs, there is no recognized safe limit for use so any use of these substances would be considered unhealthy use. Finally, “nonmedical use of prescription-type drugs” is defined by the National Survey of Drug Use and Health as the use of these drugs without a prescription or use that occurs simply for the experience or feeling the drug causes.[3] Another definition that may be more relevant for older adults is use without a prescription, in greater amounts, more often or longer than prescribed, or for a reason other than a doctor said you should use them.[8]
Alcohol
Alcohol is the most commonly used substance among older adults.[8, 9] Although the amount of alcohol consumed declines with age,[10–13] and the prevalence of abstention increases with age, about 50% of adults aged 65 and older consume alcohol.[13, 14] Recommended guidelines for low-risk drinking from the National Institute on Alcohol Abuse and Alcoholism are that adults aged 65 and older drink no more than seven standard drinks (i.e., 12-oz beer, 4-to 5-oz glass of wine, 1.5-oz of 80-proof liquor) per week and no more than three drinks on any day.[15] Even these drinking thresholds many not be safe for older adults who have comorbid conditions that could be worsened or caused by any amount of alcohol use. Using these definitions, prevalence rates for those who exceed recommended drinking limits and are therefore considered unhealthy drinkers are estimated to be 10% for women and 12% for men aged 65 and older.[8, 14] Older adults have low rates of alcohol use disorders; approximately 1%–2% of persons aged 65 and older have a current diagnosis of alcohol abuse or dependence.[16] These rates are lower than younger persons due to the older adult maturing out of alcohol use disorders, increased mortality among those with longstanding AUDs, difficulty with accurate diagnosis, and diagnostic criteria being less well suited for older adults.
Tobacco
Approximately 12%–14% of adults aged 65 and older use tobacco.[17, 18] Data from the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) indicate that 4% of this age group have a tobacco use disorder.[19] Tobacco and alcohol are frequently used together in both younger and older adult populations; 6% of older adults both drink alcohol and use tobacco. Those older adults who use tobacco are twice as likely to be binge drinkers.[18]
Illicit drugs
It is expected that the use of illicit drugs will rise among persons aged 65 and older in the United States. Data from the 2012 National Survey on Drug Use and Health (NSDUH) show that rates of past month use of illicit drugs doubled from 1.9%–3.4% to 3.6%–7.2% among those aged 50–65 in the 10-year period between 2002 and 2012.[3] Also, 19% of adults aged 65 and older in 2012 reported ever having using illicit drugs, whereas 48% of adults aged 60–64 reported this behavior. Among older adults who do use illicit substances, 12% meet the criteria for past year substance use disorder.[18] Cannabis is the most commonly used illicit drug (0.7% of those aged 65 and older compared to 3.9% of those 50–64) followed by cocaine (0.04% of those aged 65 and older compared to 0.7% of those 50–64).[18, 20]
Prescription drugs
In 2012, 2.9 million adults aged 50 and older reported nonmedical use of psychotherapeutic medication in the past year.[4] Using NSDUH, 1.4% of adults aged 50 and older used prescription opioids nonmedically in the past year, which was higher than sedatives, tranquilizers, and Stimulants (all <1%).[21] Benzodiazepines are the most commonly prescribed sedative medication for older adults, and rates of their use among older adults range from 15% to 32%.[22] It is likely that nonmedical use of prescription drugs is underreported, as many older adults may not view use of medications for longer durations or at higher amounts than prescribed as a problem.
Older adult vulnerabilities
Although rates of substance use disorders and use of substances is lower among older adults compared to younger adults, aging is associated with specific risks for harm with substance use. Some risks are related to changes that occur with aging (e.g., changes in substance metabolism and distribution); however, the nature of some risks may vary considerably depending on the type and amount of the substance used (e.g., one drink a day for seven days vs. seven drinks on one day), the context in which it is used (e.g., a sedating substance such as alcohol used with other sedating substances like benzodiazepines), and the characteristics of the older person (e.g., cognitive impairment, gait disorder).
Alcohol
With increasing age, the percentage of lean body mass and total body water decrease; blood-brain barrier permeability and neuronal receptor sensitivity to alcohol in the brain increase.[23] Because of these changes, older adults have higher blood alcohol concentrations and increased brain sensitivity compared to younger adults given the same dose of alcohol.[24–30] Increases in morbidity and medication use also increase risks associated with alcohol.[31]
Tobacco
Older adults who use tobacco have higher risks for death, cardiac events, lung disease, cancer, and poorer physical function compared to younger adults.[32, 33] They are also less likely to think that smoking harms their health.[34]
Medications and illicit drugs
The same physiological changes that affect alcohol’s effects among older adults pertain to other substances and increase their vulnerability to adverse effects from substances. In addition, older adults have an increased percentage of total body fat compared to younger adults, so fat soluble substances such as benzodiazepines have a longer duration of action in older adults compared to younger adults and have been associated with increased sedation and an increased risk for falls.[35] Other risks pertain to older adults with multimorbidity and multiple medication use. There is the potential for drug–drug interactions (e.g., benzodiazepine and opioid increase risk for confusion), and condition–drug interactions (e.g., gait impairment and sedative increase risk for falls). The increasing acceptance of marijuana use will pose unique risks in older adults. Marijuana may cause impairment of short-term memory; increased heart rate, respiratory rate, elevated blood pressure; and increased risk for heart attack.[36] These risks are likely to be heightened in older adults.
Risk factors for unhealthy substance use
Most research on correlates and predictors of unhealthy substance use among older adults has been conducted on alcohol and, to a lesser extent, on prescription drugs, but such factors may also apply to other substances. Table 20.1 lists some of the known and potential risk factors for older adults associated with the unhealthy use of alcohol and other substances.
Being male,[38] more affluent,[14, 39, 40] Caucasian,[38, 41] and young-old are consistently associated with exceeding recommended drinking limits among older adults. Female gender is associated with prescription drug abuse.[35]
Alcohol use has been associated with being in better overall health and abstention with poorer health.[38, 39] It has been suggested this is so because many abstainers stop drinking when they become sick. Older heavy drinkers have poorer physical and mental health compared to those older adults whose drinking does not exceed recommended limits.[24, 38, 42, 43] Some older adults drink alcohol to manage pain.[40]
Older adults who rely on avoidance to cope with stress have a greater likelihood of having a late-life alcohol use disorder compared to those who coped in other ways.[39] Similar to younger adults, older adults with past histories of an alcohol use disorder are at higher risk of a recurrence and/or heavy drinking.[39, 40]
Being other than married is associated with increased or unhealthy drinking in later life,[8, 38] while being socially engaged is also associated with drinking.[44] Particular life events or social transitions common in later life may heighten the risk of unhealthy substance use including bereavement, ill health, loneliness, retirement, and caregiving.[45–49]
Diagnosis of substance use disorders
The formal diagnosis of a substance use disorder generally relies on the criteria outlined by the DSM.[7, 50] Table 20.2 outlines several of the criteria used to diagnose SUD. Because of the biologic and social factors unique to older adults, these criteria may be less relevant to them and so present challenges for an accurate diagnosis.[12] For example, because of age-associated physiologic changes that increase the effects of alcohol and other substances, older adults generally experience a reduction in tolerance to substances. Also, interruption in social and occupational roles or other consequences of substance use may be less likely to occur or less noticeable in older adults.[51, 52] The criterion related to continued use despite persistent or recurrent problems may not apply to many older adults. Additionally, older adults and their health-care providers may not recognize that problems such as depression or falls are related to substance use.[12]
| DSM-5 criterion for SUD | Consideration for older adults |
|---|---|
| A substance is often taken in larger amounts or over a longer period than was intended. | Cognitive impairment can prevent adequate self-monitoring. Substances may more greatly impair cognition among older adults than younger adults. |
| There is a persistent desire or unsuccessful efforts to cut down or control substance use. | Same as a general adult population |
| A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects. | Recovery from effects of a substance may be longer in older adults. |
| Craving or a strong desire to use the substance. | Older adults with entrenched habits may not recognize cravings in the same way as the general adult population. |
| Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or at home. | Role obligations may not exist for older adults in the same way as for younger adults, due to life stage transitions such as retirement. Role obligations more common in late life are caregiving for an ill spouse or family member, such as a grandchild. |
| Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance. | Older adults may not realize the problems they experience are from substance use. |
| Important social, occupational, or recreational activities are given up or reduced because of substance use. | Older adults may engage in fewer activities regardless of substance use, making it difficult to detect. |
| Recurrent substance use in situations in which it is physically hazardous. | Older adults may not identify or understand that their use is hazardous, especially when using substances in smaller amounts. |
| Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. | Older adults may not realize the problems they experience are from substance use. |
| Tolerance, as defined by either of the following: 1. A need for markedly increased amounts of the substance to achieve intoxication or the desired effect. 2. A markedly diminished effect with continued use of the same amount of the substance. | Due to increased sensitivity to substances as they age, older adults will appear to have a decrease rather than an increase in tolerance. |
| Withdrawal, as manifested by either of the following: 1. The characteristic withdrawal syndrome for the substance. 2. The substance or a close relative is taken to relieve or avoid withdrawal symptoms. | Withdrawal symptoms can manifest in ways that are more “subtle and protracted”[61]. Late onset substance users may not develop physiological dependence or non-problematic users of medications, such as benzodiazepines, may develop physiological dependence. |
Screening and assessment
The US Preventive Services Task Force in 2013 reviewed the evidence and recommended that clinicians screen adults aged 18 or older for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling intervention to reduce alcohol misuse.[54] Despite this recommendation, older adults are less likely to be screened for substance use and less likely to have substance use and abuse identified compared to younger adults.[55, 56] Reasons for this include limited time to see older adults who have multimorbidity, stigma related to and discomfort assessing for addiction or unhealthy use, the similarity of the symptoms of alcohol and other substance use with illnesses common in older age,[57, 58] and the perception among older adults that symptoms experienced by the use of substances are part of normal aging rather than resulting from the substance itself.[59] Further, many older adults and their families view use of alcohol and other substances as being their one last pleasure, and a sense of time running out may reduce motivation to make changes in substance use.[60]
Potential indicators of unhealthy substance use
Several physical, cognitive, psychiatric, and social indicators for unhealthy substance use have been defined (see Table 20.3).[61, 57, 51]
| Physical indicators | Cognitive indicators | Psychiatric indicators | Social indicators |
|---|---|---|---|
| Falls, bruises, and burns | Disorientation | Sleep disturbances, problems, or insomnia | Family problems |
| Poor hygiene or impaired self-care | Memory loss | Anxiety | Financial problems |
| Headaches | Recent difficulties in decision making | Depression | Legal problems |
| Incontinence | Overall cognitive impairment | Excessive mood swings | Social isolation |
| Increased tolerance to alcohol or medications or unusual response to medications | Running out of medication early | ||
| Poor nutrition | Borrowing medication from others | ||
| Idiopathic seizures | |||
| Dizziness | |||
| Sensory deficits | |||
| Blackouts | |||
| Chronic pain |
When assessing older adults about substance use it is important to use a supportive, nonconfrontational approach rather than a more assertive style.[62–64] Further discussion of alcohol and other substance use should occur in the context of an overall assessment and in reference to the presenting problem with the goal of health promotion and a complete understanding of their health behaviors.
Assessment should start with questions about substances. One approach to assessment is recommended by the US Department of Health and Human Services, and the National Institute on Alcohol Abuse and Alcoholism. In 2005, these organizations published an updated version Helping Patients Who Drink Too Much: A Clinician’s Guide.[65] This approach has four steps: (1) ask about alcohol use; (2) assess for alcohol use disorders; (3) advise and assist; and (4) at follow-up, continue support. These steps may also be used for other substances.
Step 1: ask about substance use
The recommended question for alcohol use is the following: Do you sometimes drink beer, wine, or other alcoholic beverages? If no, stop; if yes, ask: “How many times in the past year have you had four or more drinks in a day?” (for those aged 65 and older). If no, it is recommended to give advice to stay within recommended drinking limits and/or to recommend lower limits if the person takes medications that may interact with alcohol and/or have a health conditions that alcohol may worsen. If yes, the person is an at-risk drinker and the person’s weekly average of drinking should be assessed by asking: “On average, how many days a week do you have an alcoholic drink” and “On a typical day, how many drinks do you have?” Then multiply these two numbers to calculate the weekly average.
For other substances, the provider may ask about the quantity and frequencies of substances used and ask a specific question about nonmedical use of prescription drugs.
Step 2: assess for substance use disorders
Questions about symptoms of an SUD should be asked, and for older adults, additional questions should be asked to obtain information on risk factors for problematic use as well as reasons for use of the substance. An evaluation of safety of substance use in the context of the person’s functional status, comorbid conditions, medication used, and symptoms should be performed.
Screening instruments
Brief screening tools can assess the level of risk caused by substances. Screening tools such as the Alcohol Use Disorders Identification Test (AUDIT);[66, 67] the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST);[68] and the Comorbidity-Alcohol Risk Evaluation Tool (CARET) [69–71] may also be used to assess quantity and frequency of use as well as level of risk. The AUDIT and the CARET have been validated in older adults. The CAGE [72, 73] and the Michigan Alcohol Screening Test-Geriatric Version (MAST-G) [74] have also been validated in older adults, but they do not include questions on quantity and frequency of substance use.
The CAGE and CAGE-AID
The CAGE questionnaire is the most common screening tool for alcohol misuse, and a version has been developed to assess for alcohol and other drugs called the CAGE-AID.[75, 76] Both of these tools have four questions. The CAGE-AID questions include (1) Have you ever felt that you could Cut down on your drinking or drug use? (2) Have people Annoyed you by criticizing your drinking or drug use? (3) Have you ever felt bad or Guilty about your drinking or drug use? (4) Have you ever had a drink or used drugs first thing in the morning to steady your nerves or get rid of a hangover (Eye opener). Although the CAGE-AID has not been validated in older adults, the CAGE has with a sensitivity of 86% and specificity of 78% at a cut point of one positive question.[72, 73] One major limitation is the inability of the instrument to distinguish between current and lifetime problems.
The MAST-G and SMAST-G
The MAST-G[77] is designed to identify drinking problems for the older adult by modifying it from the Michigan Alcohol Screening Test. It contains 24 questions with yes/no responses; five or more positive responses indicate problematic use. It has good test characteristics, and it also has a short form – the SMAST-G – that has 10 questions with two positive responses indicating a problem with alcohol.[77]
The AUDIT
Developed by the World Health Organization (WHO), the AUDIT assesses for current alcohol problems.[66] It contains 10 questions about quantity and frequency of use, alcohol dependency, and consequences of alcohol abuse. Each of the questions is scored on a four-point continuum, with total scores ranging from 0 to 40. The cutoff threshold of five is used to indicate an alcohol problem in older adults.[67, 78]
The ASSIST
The ASSIST was also developed by WHO to screen for substances that may be abused including tobacco, alcohol, cannabis, cocaine, amphetamine type stimulants, inhalants, sedatives, hallucinogens, opioids, as well as another category.[68] It includes eight questions that identify the level of risk to guide decisions for intervention. For each substance, a score is calculated to indicate low (0–3), moderate (4–26), and high (27 or higher) risk use of the substance. It is not been validated in older adults.
The CARET
The CARET is a screening instrument that identifies older adults whose use of alcohol places them at risk for harm.[69–71] It is derived from another measure, the Short Alcohol Related Problems Survey.[79] It includes algorithms to identify at-risk drinkers within seven domains of risk: (1) amount of drinking, (2) episodic heavy drinking, (3) driving after drinking, (4) others being concerned about the respondent’s drinking, (5) medical and psychiatric conditions, (6) symptoms that could be caused or worsened by alcohol, and (7) medications that could interact negatively with or whose efficacy could be diminished by alcohol. Respondents who have one positive response in any of the seven risk categories are considered at-risk drinkers. Because it includes items on medications and comorbid conditions common in older adults, it identifies older adults who would not be identified as at risk on other screening measures such as the AUDIT and MAST-G.
Interventions
A variety of treatment options exist for older adults.[51] Although there are a limited number of studies, older adults have demonstrated treatment outcomes as good as or better than those seen in younger age groups.[80–81] There are a spectrum of treatment interventions including brief interventions developed to address less severe substance use disorders and addiction specialty programs for those who are dependent on substances. However, there are few programs tailored specifically for older adults with substance use disorders,[82, 83] in part because their utilization of such programs is lower than other age groups.[22]
Brief interventions
Brief interventions have been well studied in younger and older age groups, usually in primary care settings.[71, 84, 85] They have been tested primarily for alcohol and are proven to reduce drinking amount. They vary in frequency and length from a single five-minute session to multiple longer sessions. Their purpose is to provide education about the substance and how it might be harmful, enhance motivation to change, and connect severe users with more intensive treatments when needed. Most brief interventions use aspects of motivational interviewing (MI) or motivational enhancement therapy (MET),[86, 87] which encourage a patient-centered, nonjudgmental approach to discussing substance use and encouraging ambivalence by assisting the patient to identify the perceived pros and cons to making a change versus maintaining the status quo.[51] For older adults, the reasons for change may include maintaining independence, optimal health, and mental capacity.[58]
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