The Elderly & Substance Abuse
Substance Abuse in the Elderly Population
Oftentimes, the terms “substance abuse” and “dependence” are not associated with elderly adults; however, many studies state that there is abundant evidence regarding patterns of drug use in the elderly population. In fact, recently it is said to be on the rise. Psychiatrist in the Division of Alcohol and Drug Abuse at McLean Hospital, Olivera Bogunovic, M.D. discusses results from the 2009 study by the Substance Abuse and Mental Health Services Administration (SAMHSA) in her article “Substance Abuse in Aging and Elderly Adults.”1
According to Bogunovic, research has recently revealed the consequences of substance abuse on the elderly population.1 The 2009 SAMHSA National Survey on Drug Use and Health states that alcohol is the most commonly abuse substance in persons aged 50 and older, followed closely by opiates, cocaine, marijuana, and stimulants.1 Also, as one-quarter of the prescription drugs sold in the United States are to elderly patients, abusing agents such as anxiolytics, pain medicines, benzodiazepines, and muscle relaxants are as high as 11 percent.
Diagnosing Elderly with Substance Use Issues
Elderly persons who abuse substances are often categorized as either early-onset or late-onset abusers.1 Early-onset abusers are those who are younger than 65 when the substance abuse develops, and usually this group has more psychiatric and physical problems compared with late-onset abusers.1 Early-onset users make up two-thirds of the geriatric alcohol population.1 On the other hand, late-onset users are those who are older than 65 when the substance abuse develops, and they usually have less psychiatric and physical problems than their counterparts. Oftentimes, the abuse develops due to losses that tend to occur with aging, such as loss of a spouse, retirement, changes in living situations, and social isolation.1
Bogunovic states that oftentimes the clinical presentations of substance abuse may not be clear in elderly patients as they often do not fit the criteria of certain psychiatric stereotypes.1 Although substance abuse is often associated with significant social consequences, rarely is antisocial behavior seen, and users are not often of lower socioeconomic status.1 As elderly patients often have a high number of medical comorbidities, they are at a higher risk of medical consequences, such as liver damage, immune system impairment, and cardiovascular, GI, and endocrinological problems. Regarding alcohol abuse, it is not uncommon for the symptoms of alcohol withdrawal to be confused with other medical problems.1 Alcohol use can lead to cognitive defects and alcohol-related dementia, and substances such as opioids and benzodiazepines may have the serious consequences of cognitive impairment, confusion, and delirium or dementia. Comorbidity of psychiatric disorders and substance abuse are also frequently seen, as the prevalence is between 21 and 66 percent.1 In fact, 25 percent of elderly patients suffer from comorbid depression, and 15 percent suffer from a comorbid anxiety disorder.
According to Bogunovic, substance abuse problems in the elderly population often go undiagnosed.1 However, she recommends physicians completing an in-depth examination upon meeting the patient, in order to correctly diagnose any disorders.1 In fact, Bogunovic states that there are many tools, including the CAGE questionnaire, the Alcohol Use Disorders Identification Test, and the Michigan Alcoholism Screening Test—Geriatric Version (MAST-G), that may be of use. Also, the evaluation should include a physical examination and laboratory analysis, as well as a psychiatric, neurological, and social evaluation.1
Treatment for Elderly Substance Abusers
Unfortunately, once a diagnosis is made regarding substance abuse and dependence, there are few evidence-based treatments available for use in the geriatric population.1 In general, treatment choice depends solely on the individual and the level of functional impairment they have, varying from hospitalization to outpatient care.1 However, it has been found that psychoeducation is an important factor in each individual’s treatment plan, as they need to understand the risks of combining substances with daily medicines and certain health problems.1 Also, psychotherapy is often recommended for the elderly, such as motivational interviewing, cognitive-behavioral therapy, and a few other brief therapeutic interventions. Twelve-step programs are also an integral part, with importance relying on members of the group who are close in age, so that they may rely on each other for support and bonding.1
Regarding psychopharmacology, the same is true—there are not many choices available.1 The opiate agonist naltrexone has shown to reduce alcohol cravings in the elderly population, with a dosage of 50 mg/day found to be safe in a 12-week trial of 44 elderly veterans with alcohol dependence. On the other hand, disulfiram should not be used in elderly patients as it increases the risk of delirium and other serious side-effects. Also, while there have been no extensive studies on buprenorphine/naloxone in elderly persons with opioid dependence, the sublingual form may be administered with caution, as there is an increased risk of respiratory suppression and sedation.1 Therefore, lower dosages are recommended by Bogunovic.1
Overall, Bogunovic states that as we are faced with a growing elderly population, more research needs to be done regarding diagnosis and treatment for those with substance abuse and dependence.1
 Bogunovic, O. (2012, July 27). Substance Abuse in Aging and Elderly Adults: New Issues for Psychiatrists. Psychiatric Times. Retrieved from http://www.psychiatrictimes.com/geriatric-psychiatry/content/article/10168/2092931
 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.
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 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 enhanced referral care for depression, anxiety, and at-risk alcohol use. Am J Psychiatry. 2004;161:1455-1462.
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