with Olivera J. Bogunovic, MD

Recent statistics indicate that substance use in the elderly is a leading public health problem, according to Olivera J. Bogunovic, MD, assistant professor of psychiatry at Harvard Medical School. Her Psych Congress 2020 virtual presentation was titled “Substance Use in the Elderly and Comorbid Psychiatric Conditions.”

Combined data from the 2007 to 2014 National Surveys on Drug Use and Health, for example, indicated that on an average day, 6 million adults over age 50 drank alcohol, 132,000 used cannabis, and 4,300 used cocaine. The proportion of older adults reporting heroin as their primary substance of abuse more than doubled from 7.2% in 1992 to 16% in 2017. For cocaine, the proportion almost tripled – from 2.8% to 11.4%.1

Today, there are 56.4 million adults aged 65 years and older living in the United States and as many as 1.7 million of these individuals suffer from alcohol use disorder (AUD), a disorder that is only expected to rise as the number of baby boomers increases. Of note, nicotine use has been deemed most prevalent among older adults compared to other substances.2 By 2060, the population of older Americans is expected to reach 98.2 million, and as many as 3.05 million individuals are projected to have AUD. Substance use disorders such as AUD may become more difficult to manage in this population due to coexisting psychiatric disorders, anxiety, and depression.2

“Although the prevalence of substance use in the elderly population is increasing, treatment is available, and it can be successful,” Dr. Bogunovic told the Psych Congress audience.

The Spectrum of Alcohol Use Disorders

Older adult drinking encompasses a spectrum of drinking that ranges from moderate drinking – no more than one standard drink per day – to at-risk drinking – that is, having more than seven drinks per week, or three drinks per occasion, to dependence. “In the elderly, there may be a low prevalence of dependence, but a significant incidence of problem drinking,” explained Dr. Bogunovic.

Problem drinking contributes to comorbidities in the elderly. Alcohol-related issues related to older individuals are responsible for 14% of visits to accident and emergency departments and affect up to 11% of medical inpatients, 20% of psychiatric inpatients and 49% of nursing home patients.1 Older women generally drink less often and less heavily than men but may start drinking heavily later in life. Older men are at greater risk of developing alcohol-related problems.3

Two-thirds of older patients with AUD are considered early-onset drinkers, for whom a history of heavy use has led to psychiatric comorbidities and severe medical complications. Late-onset drinkers, on the other hand, may begin drinking in response to a stressful life event, such as retirement (or these days, the pandemic). This milder type of drinking is associated with fewer medical problems and may be more amenable to treatment.3 

AUD Screening Should Start in the Primary Care Setting

“It is important that primary care clinicians consider AUD in their patients at risk, as 87% of diagnoses are made in the primary care setting,” advised Dr. Bogunovic. Screening instruments, such as CAGE, AUDIT, and SMAST-G are useful to identify AUD in the elderly and assess its impact.4 Skillful interviewing techniques can also help the clinician evaluate a patient’s readiness for change and provide referrals to the appropriate level of care.3

Patients at increased risk for AUD include those with a prior history or family history of AUD, individuals with medical and psychiatric disorders, and those who may have experienced a personal loss. Older patients are more vulnerable to the intoxicating effects of alcohol and other drugs because they generally have a lower lean body mass, lower total body water, and decreased levels of gastric alcohol dehydrogenase.3 AUD can also increase the impact of other medical complications in older patients, such as cardiovascular disease, cancer, thrombocytopenia, and neurological complications. For example, 60% of patients older than 60 years who have cirrhosis are expected to die from their disease compared to 7% of younger patients.3

The Psychiatric Impacts of Drinking in Older Age

Older adults who struggle with alcohol dependence are three times more likely to suffer from depression than those without. In a national survey, 13% of individuals with a lifetime diagnosis of depression also met the criteria for lifetime alcohol abuse.5 People over age 65 years are 16 times more likely to die from suicide.6

In general, patients with both depression and AUD are increasingly prevalent in clinical practice and have a poorer response to treatment than those with AUD alone. AUD, especially early-onset alcohol use, is a predictor of severe depression and dementia later in life.7 Mood disorders sometimes precipitate or maintain AUD in late-onset problem drinkers, especially women. Cognitive and anxiety disorders coexist with AUD in 10% to 15% of patients. Suicide is often associated with illicit substances or AUD.1

Alcohol-related dementia is an underrecognized mental disorder with both clinical and public mental health aspects. Chronic alcoholism is associated with deficits in executive function and visuospatial ability.8

The Risks of Prescription Drug Use on Top of Alcohol Use

While alcohol use in older patients is on the rise, prescription medications such as opioids and benzodiazepines are also problematic. On average, 8.7% of older patients are prescribed benzodiazepines and as many as 9% are prescribed opioids. Research shows a linear increase in rates of opioid misuse and suicide intent.9

When older adults are prescribed psychoactive drugs, they tend to continue using them for longer periods. Benzodiazepines, for example, may be prescribed for insomnia during a hospital stay, but a patient may continue to take them on an outpatient basis for another 5 to 10 years. Clinicians should be aware that risk factors for substance use disorder (SUD) include chronic pain, depression, isolation, concurrent use of multiple medications, age, and alcohol dependence.10

Older adults generally do not seek help for SUD. However, unlike the high rate of early drop out in younger patients, older adults, particularly those receiving age-specific programming, are more compliant with their treatment.2 Certain factors have been shown to be protective against SUD, including being married, living in a supportive and safe living environment, having adequate income to meet one’s needs, access to transportation, participation in age-specific activities, and factors contributing to wellness such as diet, sleep, exercise, and spiritually.

On the other hand, there are several barriers to the diagnosis of SUD in older individuals. Physical symptoms of dependence and withdrawal are often misinterpreted as normal consequences of aging. In addition, commonly used screening questionnaires and even some social markers, such as employment, are not applicable to the elderly population. “Older patients generally are not working and may be socially isolated, so families may not know what is happening,” said Dr. Bogunovic.

Approaching Treatment for AUD and SUD

“The most important element in treatment is assessing the patient’s need for detoxification,” said Dr. Bogunovic. “If this is not addressed, you will see an increase in morbidity and mortality.”

Keep in mind that “abstinence results in improvement within months in men, but it takes longer in women,” said Dr. Bogunovic.

Additional effective treatment tactics for substance use disorders include:

  • matching the severity of SUD to the level of care
  • using strategies such as motivational interviewing to engage the patient in treatment
  • avoiding confrontation
  • expressing empathy
  • identifying an important motivator for the patient
  • involving the family.

Overall, “It’s very important to engage patients in treatment, particularly in this vulnerable group,” advised Dr. Bogunovic. “That includes integrating substance abuse, health, mental health, and aging services to provide comprehensive, holistic care that is tailored to the needs of the older consumer who presents with co-occurring, multiple needs.”

Psych Congress 2020 Highlights

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Last Updated: May 7, 2021