Addiction is not a condition that springs to mind when we think of afflictions of the elderly, and yet it probably should be. Until now, alcohol or substance abuse among older patients has received relatively little attention, either as a clinical focus or as a research initiative. But we can no longer afford to neglect this growing cohort of affected individuals. Over the next decade, the number of individuals age 65 or older in the United States will swell from 40 million in 2010 to 55 million in 2020. By 2030, about a quarter of the population will be over the age of 60. This growth is due to increases in life expectancy and the aging of the baby-boomer generation, those born between 1946 and 1964. This cohort has had an unprecedented exposure to drugs and alcohol in their youth, due to cultural shifts in attitudes about substance use. As the baby-boomers age, they’re continuing to use these drugs at higher rates than previous cohorts did. Nearly one quarter of American older adults report using at least one psychoactive medication, and there will be an estimated 100% increase in medication misuse between 2001 and 2020 in this population.
There are many reasons why alcohol and substance use disorders (SUDs) in older individuals are generally misidentified and undertreated. To begin with, older individuals have historically been excluded from clinical trials, so recognizing signs of alcohol or substance abuse in this population relies upon extrapolating from patterns observed in younger cohorts. In addition, social stereotypes we hold about elders promote the false assumption that older adults do not suffer from SUDs. These beliefs serve to decrease suspicion by healthcare providers, who – even if they employ screening measures for alcohol and nicotine use – often neglect to screen for other substance use disorders. As family members and as providers, we carry unexamined biases that older adults do not use illicit drugs, or that they should be allowed to engage in whatever behaviors they choose at their age. Another challenge to accurate diagnosis is that older individuals, because of their reduced social responsibilities and retirement, show fewer of the behavioral disturbances or social “red flags” typically found in younger adults with addictions. In fact, DSM-5 criteria are difficult to apply to this population, as they lack sensitivity for older adults. Presentations may be atypical and resemble other medical or psychiatric disorders – and, indeed, older adults with alcohol or substance use disorders have high rates of concurrent medical and psychiatric disorders, with prevalence of up to 66% in some studies.
What substances are older patients using and misusing? Alcohol and psychoactive medications are the classes of drugs most often implicated in substance use disorders in older individuals, and age-related metabolic changes increase their susceptibility to toxicity. Benzodiazepines are the most frequently prescribed drugs in the elderly for both insomnia and anxiety. Yet studies have shown that older patients disproportionately experience adverse events with benzodiazepines, such as falls and cognitive deficits. Similarly, opiate use in the elderly is rarely hidden, as these medications are generally obtained legally through physician prescriptions. While smoking rates tend to be lower in adults aged 65+ years than in the general population, this is unfortunately thought to be due to premature deaths from smoking-related causes. Approximately 14% of adults aged 65 years and older report using tobacco in the last 12 months. While legal substances such as alcohol and prescribed drugs are the drugs of choice for most older adults with addiction, cannabis is the most commonly used illicit drug in this population – and the number of older adults using cannabis is increasing.
Emerging research supports the benefits of developing and implementing elder-specific alcohol and substance treatment centers or tracks within general treatment programs. Such treatment interventions tailored to the needs of older individuals may include behavioral programs with a focus on the biological, psychological, and social aspects of aging; adjusting medications due to metabolic differences; or consideration of drug–drug interactions in light of the high prevalence of multiple medications (“polypharmacy”). Particularly relevant to older patients are cognitive-behavioral therapy (CBT) skills that take into account issues of memory impairment common in later life, as these may reduce patients’ ability to acquire positive coping skills. Recent research has found that motivational interviewing (MI) can be an effective treatment in older adults. Another important strategy for addressing late-life addiction is family therapy tailored to the needs of older adults (e.g., including adult children, spouses, or siblings). And finally, practitioners working with older adults may need to overcome specific treatment barriers such as medical comorbidity, ageism (i.e. addiction in an older patient may not inspire a sense of urgency to treat), reduced mobility, and transportation issues. When treatment is undertaken, it is important to integrate other relevant therapeutic issues such as loss, grief, isolation, or concerns about poor health.
More research needs to be done regarding evidence-based practices in recommended levels of use, identification, and treatment of hazardous and harmful alcohol use in older individuals. Age-related factors such as concomitant illness, changes in organ functioning, and medication interactions require specific considerations for appropriate prescribing of pharmacotherapy. Pharmacodynamics changes also mean that standard detoxification regimens may not be appropriate for older patients; they may need slower and longer tapers over weeks rather than days, to minimize rebound symptoms, withdrawal, and possible relapse. Above all, assessing and tailoring treatment to the patient’s individual risk factors in a nonjudgmental and collaborative way is the most important step in preventing harm from alcohol use in this population. We also need to better understand the risk factors and potential markers for addiction in later life. A number of risk factors for developing sedative misuse have been identified in older adults: social isolation, advanced age, female gender, receiving many prescriptions, and concurrent physical and mental illness. Older women appear particularly susceptible to late-onset SUDs because of genetic vulnerability or environmental stress, but they also tend to have better treatment outcomes than older men. Future research in the identification and management of addiction in later life should be a strong priority; it is “high time” we offered specific guidance on treatment interventions for clinicians working with older populations.
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