Substance Abuse in Aging and Elderly Adults

Substance Abuse in Aging and Elderly Adults
Published on Psychiatric Times
(http://www.psychiatrictimes.com)
Substance Abuse in Aging and Elderly Adults
July 27, 2012 | Geriatric Psychiatry [1], Addiction [2], Comorbidity In Psychiatry [3], Antisocial
Personality Disorder [4], Opioid Related Disorders [5], Substance Use Disorder [6], Alcohol Abuse [7]
By Olivera Bogunovic, MD [8]
As we are faced with a growing population of older adults, a better understanding of the issues that
they confront is crucial.
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In 2009, the elderly constituted 12.9% of the US population. This
translates to 39.6 million—a number that is growing.1 Perhaps as a result of generational
stereotyping or ageism, the topic of substance abuse and dependence is rarely associated with the
elderly. Although there is a dearth of literature regarding patterns of illicit drug use and abuse in
older adults, recent surveys indicate that abuse of illicit drugs by older adults is on the rise.2 A 2009
study by the Substance Abuse and Mental Health Services Administration (SAMHSA) yielded some
sobering conclusions regarding substance use in individuals aged 50 years or older.2
Consequences of substance abuse in the aging and elderly
Clinical research is beginning to elucidate the consequences of unrecognized substance abuse or
dependence on an aging population. Complications that occur with increasing frequency with age,
such as medical comorbidity, cognitive impairment, and frailty, contribute to the potential adverse
interactions between substance misuse and an aging brain.
The 2009 SAMHSA's National Survey on Drug Use and Health revealed dramatic increases in illicit
drug use in older adults, including nonmedical use of prescription drugs among women aged 60 to
64. Overall, alcohol was the most frequently reported primary substance of abuse for persons aged
50 or older. Opiates were the second most commonly reported primary substance of abuse, reported
most frequently by individuals aged 50 to 59. These individuals also had the highest proportions of
inpatient admissions for cocaine, marijuana, and stimulant abuse.2
One-quarter of the prescription drugs sold in the United States are used by the elderly, and the
prevalence of abuse of these agents may be as high as 11%.3 Commonly prescribed drugs with
abuse potential include those for anxiety, pain, and insomnia, such as benzodiazepines, opiate
analgesics, and skeletal muscle relaxants. A review of medical records of 100 elderly patients who
were dependent on prescription drugs and were admitted to the Mayo Inpatient Addiction Program
between 1974 and 1993 assessed the frequency of abuse by type of prescription drug. The most
commonly abused were sedative/hypnotics (mostly benzodiazepines) and opioid analgesics.4
Aging induces physiological changes that increase susceptibility to the deleterious effects of alcohol
and other illicit substances. Given these changes, the National Institute of Alcohol Abuse and
Alcoholism recommends the following for men aged 65 or older: no more than 1 drink daily (ie, 12 oz
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Substance Abuse in Aging and Elderly Adults
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of beer at 5% alcohol, or 5 oz of wine at 12% alcohol, or a 1.5-oz shot of hard liquor at 40% alcohol),
a maximum of 2 drinks on any occasion, and even lower limits for women. These recommendations
highlight how alcohol use in the elderly can potentially be problematic, even if it does not cause
abuse or dependence.
What is already known about substance abuse in the elderly?
? Recent surveys and studies indicate that alcohol and illicit drug use is on
the rise in the elderly population. Complications that occur with increasing
frequency in the elderly contribute to adverse reactions of substance
misuse.
What new information does this article provide?
? This article discusses the prevalence of substance use disorders in the
elderly and the evidence-based approaches to treatment in this
population.
What are the implications for psychiatric practice?
? Substance dependence is under-recognized in the elderly. Careful
medical and psychiatric assessments are essential for the diagnosis. This
population shows good results once in treatment.
Early vs late onset
Older adult substance abusers can be categorized as early-onset or late-onset abusers. In
early-onset abusers, substance abuse develops before age 65. In these individuals, the incidence of
psychiatric and physical problems tends to be higher than that in their late-onset counterparts. It is
estimated that early-onset substance abusers make up two-thirds of the geriatric alcoholic
population.
In late-onset substance abusers, these behaviors are often thought to develop subsequent to
stressful life situations that include losses that commonly occur with aging (eg, death of a partner,
changes in living situation, retirement, social isolation). These individuals typically experience fewer
physical and mental health problems than early-onset abusers.5
Comorbidities
Clinical presentations of substance abuse in the elderly may not be suspected because the
presenting picture often does not correspond with stereotypes based on younger populations.
Severe substance abuse with major social consequences is certainly seen in elderly patients, but
antisocial behavior and lower socioeconomic status are less common and clinical manifestations are
more variable. Given the higher prevalence of comorbid medical problems, elderly patients are at
greater risk for medical consequences associated with substance abuse.
Common medical consequences include liver damage; immune system impairment; and
cardiovascular, GI, and endocrinological problems.6 Elderly patients often present to the emergency
department with severe illness. Symptoms of alcohol withdrawal are missed and are easily attributed
to a cause other than alcohol abuse. Alcohol withdrawal disorders include tremulous syndrome,
hallucinations, seizures, and delirium tremens. Although there is no evidence that the disorders
occur at different rates in the elderly, data from animal studies show increased severity of
symptoms.
The prevalence of alcohol-related dementia in late life differs depending on the diagnostic criteria
used and the population studied; however, there is general consensus that alcohol contributes to
cognitive deficits.7 Substances such as opioids and benzodiazepines also increase the risk of
cognitive impairment that ranges from confusion to delirium to dementia.8
The coexistence of substance abuse and psychiatric illness has been established in several studies,
although the exact relationship remains unclear. Prevalence is estimated to be between 21% and
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66%. Approximately 25% of elderly patients have comorbid depression. Also common are cognitive
disorders and anxiety disorders, both of which occur in 10% to 15 % of elderly patients.9
The treatment of co-occurring disorders in patients with mental illness presents unique challenges.
The literature, although extensive for younger adults, is almost nonexis-tent for older adults. An
integrated approach to treatment of co-occurring disorders in severe mental illness provides better
outcomes.10 Using a multidisciplinary team to treat co-occurring disorders enhances cohesiveness of
care and reduces conflicts between treaters. Both disorders should be treated as "primary" using a
combination of different modalities, such as effective outreach and case management, motivational
techniques, psychotherapy, and psychopharmacology.
Diagnosis
In older patients, substance abuse problems are often misdiagnosed. Part of the challenge when
working with the older population is to confront one's own biases and beliefs. Another challenge is
denial of substance use by the elderly, which can make accurate diagnosis and treatment more
difficult.11 In addition to a clinical interview, several screening instruments can be used (eg, the
CAGE questionnaire, the Alcohol Use Disorders Identification Test, and the Michigan Alcoholism
Screening Test—Geriatric Version [MAST-G]).12
A comprehensive evaluation should include a thorough physical examination along with laboratory
analysis and psychiatric, neurological, and social evaluation. An increased focus on successful
identification and subsequent treatment is warranted because research indicates that elderly
patients reduce substance use when encouraged by their physician.
Treatment
There is a general lack of evidence-based treatment approaches for substance abuse in the elderly.
As a result, much of what is recommended is based on interventions that have been validated in
younger populations. It is important to understand specific ways to engage the elderly patient. In
general, the choice of treatment depends on the severity of the condition and the level of functional
impairment and varies from hospitalization to outpatient care.
Psychotherapy
Psychoeducation about the risks of combining alcohol with medications and excessive alcohol use is
important. A number of clinical trials have shown that approximately 10% to 30% of problem
drinkers have been able to reduce their drinking after brief 1- to 3-session interventions.13
The need for detoxification and the potential for serious withdrawal symptoms should be carefully
evaluated. Regardless of the treatment modality chosen, psychotherapy and other interventions
need to be tailored for each patient. Groups of patients of similar ages are ideal because they
increase patient comfort and adherence.
Psychotherapy is often recommended on either an outpatient or inpatient basis, depending on the
severity of the problem. Recommendations for specific therapeutic modalities are extrapolated from
studies on younger populations because of the lack of such research on older adults. Motivational
interviewing has been validated as an effective method to ascertain an individual's willingness to
change and to enhance motivation for change.14 Cognitive-behavioral therapy is also widely used in
the treatment of substance abuse.13 In addition, initial studies of brief therapeutic interventions have
shown promise in older adults.15
Psychopharmacology
The opiate antagonist naltrexone reduces cravings for alcohol and is intended to be prescribed as
adjunctive treatment to psychosocial support to reduce the risk of alcohol relapse. A dosage of 50
mg/d was found to be safe in a 12-week, randomized, placebo-controlled trial in 44 older veterans
with alcohol dependence. However, there were no differences in the number of patients who
experienced relapse or who remained abstinent in the naltrexone and placebo groups.16
Generally, disulfiram should not be prescribed for the elderly because of the increased risk of
delirium and other serious adverse effects.17 Acamprosate is thought to exert its therapeutic effect
by modulating the excitatory glutamate amino acid system in the brain. It may be safer and more
effective for patients with liver dysfunction; however, it should be used cautiously in elderly patients
with impaired renal function. A meta-analysis of studies of acamprosate in younger adults showed a
13% improvement in 12-month continuous abstinence rates.18
Finally, there are no known pharmacokinetic studies of buprenorphine/naloxone in older adults with
opioid dependence. Sublingual buprenorphine/naloxone must be administered with caution in the
elderly because of the increased risk of respiratory suppression and sedation. Lower dosages in the
elderly are recommended.
Conclusion
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Participation in Alcoholic Anonymous meetings is an important part of treatment. Meetings that have
an age-matched cohort provide mutual support, allow for peer bonding, and foster the establishment
of peer sobriety networks.
As we are faced with a growing population of older adults, a better understanding of the issues that
they confront is crucial. Studies are needed to identify the best ways to integrate screening into
general medical settings as well as to understand the neurobiology of substance use disorders in the
older adult with medical and cognitive comorbidities and to determine which specific treatment
interventions are safe and effective.
References:
References
1. Administration on Aging. Profile of older Americans: 2009.
http://www.aoa.gov/aoaroot/aging_statistics/profile/2009/2.aspx. Accessed July 10, 2012.
2. Results from the 2009 National Survey on Drug Use and Health: Volume I. Summary of national
findings. www.samhsa.gov/data/NSDUH/2k9NSDUH/2k9Results.htm. Accessed July 9, 2012.
3. Culberson JW, Ziska M. Prescription drug misuses/abuse in the elderly. Geriatrics. 2008;63:22-31.
4. Jinks MJ, Raschko RR. A profile of alcohol and prescription drug abuse in a high-risk
community-based elderly population. DICP. 1990;24:971-975.
5. Brennan PL, Moos RH. Late-life drinking behavior: the influence of personal characteristics, life
context, and treatment. Alcohol Health Res World. 1996;20:197-204.
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impairment. Geriatr Aging. 2008;11:284-289.
9. Bartels SJ, Blow FC, Van Citters AD, Brockmann LM. Dual diagnosis among older adults:
co-occurring substance abuse and psychiatric illness. J Dual Diag. 2006;2:9-30.
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Addict. 2003;12(suppl 1):S26-S40.
11. Pennington H, Butler R, Eagger S. The assessment of patients with alcohol disorders by an old
age psychiatric service. Aging Ment Health. 2000;4:182-184.
12. Moore AA, Seeman T, Morgenstern H, et al. Are there differences between older persons who
screen positive on the CAGE questionnaire and the Short Michigan Alcoholism Screening
Test-Geriatric Version? J Am Geriatr Soc. 2002;50:858-886.
13. Fleming MF, Manwell LB, Barry KL, et al. Brief physician advice for alcohol problems in older
adults: a randomized community-based trial. J Fam Pract. 1999;48:378-384.
14. Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change. 2nd ed. New York:
Guilford Press; 2002.
15. Bartels SJ, Coakley EH, Zubritsky C, et al; PRISM-E Investigators. Improving access to geriatric
mental health services: a randomized trial comparing treatment engagement with integrated versus
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2004;161:1455-1462.
16. Oslin D, Liberto JG, O'Brien J, et al. Naltrexone as an adjunctive treatment for older patients with
alcohol dependence. Am J Geriatr Psychiatry. 1997;5:324-332.
17. Dunne FJ. Misuse of alcohol or drugs by elderly people. BMJ. 1994;308:608-609.
18. Mann K, Lehert P, Morgan MY. The efficacy of acamprosate in the maintenance of abstinence in
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[8] http://www.psychiatrictimes.com/authors/olivera-bogunovic-md
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