9.19: Substance Abuse and the Elderly

Alcohol and drug problems, particularly prescription drug abuse, have become a serious health concern among older adults. Although people 65 years of age and older make up only 13% of the population, they account for almost 30% of all medications prescribed in the United States. According to the National Council on Alcoholism and Drug Dependence (NCADD) (2015), the following statistics illustrate the significance of substance abuse for those in late adulthood:

• There are 2.5 million older adults with an alcohol or drug problem.
• Six to eleven percent of elderly hospital admissions, 14 percent of elderly emergency room admissions, and 20 percent of elderly psychiatric hospital admissions are a result of alcohol or drug problems.
• Widowers over the age of 75 have the highest rate of alcoholism in the U.S.
• Nearly 50 percent of nursing home residents have alcohol-related problems.
• Older adults are hospitalized as often for alcohol-related problems as for heart attacks.
• Nearly 17 million prescriptions for tranquilizers are prescribed for older adults each year. Benzodiazepines, a type of tranquilizing drug, are the most commonly misused and abused prescription medications.

Risk factors for psychoactive substance abuse in older adults include social isolation, which can lead to depression (Youdin, 2016). This can be caused by the death of a spouse/partner, family members and/or friends, retirement, moving, and reduced activity levels. Additionally, medical conditions, chronic pain, anxiety, and stress can all lead to the abuse of substances.

Diagnosis Difficulties:

Using criteria from the DSM-5-TR (American Psychiatric Association, 2022), diagnosing older adults with a substance use disorder can be difficult (Youdin, 2016). For example, compared to adolescents and younger adults, older adults are not looking to get high, but rather become dependent by accident. Additionally, stereotypes of older adults, which include memory deficits, confusion, depression, agitation, motor problems, and hostility, can result in a diagnosis of cognitive impairment instead of a substance use disorder. Further, a diagnosis of a substance use disorder involves impairment in work, school, or home obligations, and because older adults are not typically working, in school or caring for children, these impairments would not be exhibited. Stigma and shame about use, as well as the belief that one's use is a private matter, may keep older adults from seeking assistance. Lastly, physicians may be biased against asking those in late adulthood if they have a problem with drugs or alcohol (NCADD, 2015).

Abused Substances:

Drugs of choice for older adults include alcohol, benzodiazepines, opioid prescription medications and marijuana. The abuse of prescription medications is expected to increase significantly. Siriwardena et al. (2006) found that family physicians prescribe benzodiazepines and opioids to older adults to deal with psychosocial and pain problems rather than prescribe alternatives to medication such as therapy. Those in late adulthood are also more sensitive to the effects of alcohol than those younger because of an age-related decrease in the ratio between lean body mass and fat (Erber & Szuchman, 2015). Additionally, "liver enzymes that metabolize alcohol become less efficient with age and central nervous system sensitivity to drugs increase with age" (p.134). Those in late adulthood are also more likely to be taking other medications, and this can result in unpredictable interactions with the psychoactive substances (Youdin, 2016).

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Cannabis Use:

Blazer and Wu (2009) found that adults aged 50–64 were more likely to use cannabis than older adults. These "baby boomers" with the highest cannabis use included men, those unmarried/unpartnered, and those with depression. In contrast to the negative effects of cannabis, which include panic reactions, anxiety, perceptual distortions and exacerbation of mood and psychotic disorders, cannabis can provide benefit to the older adult with medical conditions (Youdin, 2016). For example, cannabis can be used in the treatment for multiple sclerosis, Parkinson's disease, chronic pain, and the fatigue and nausea from the effects of chemotherapy (Williamson & Evans, 2000).

COVID-19 and Substance Use:

Since the COVID-19 pandemic began, increases in substance use and drug overdoses in the United States have been well documented by the National Institute of Health (NIH) (2022). While illicit drug use typically declines after young adulthood, nearly one million adults aged 65 and older now live with a substance use disorder (NIDA, 2020). An estimated 5.7 million older adults in the United States required addiction treatment in 2020 (Dufort & Samaan, 2020), and as many as 9% of adults age 65 and older take an opioid for pain (Liao, 2021). Increases in alcohol consumption in recent years have been greater for people aged 50 and older relative to younger age-groups (NIDA, 2020). Alcohol is the most used drug among older adults, with about 65% of people 65 and older reporting high-risk drinking. Additionally, more than 10% binge drink, which is defined as five or more drinks on the same occasion for men, and four or more drinks on the same occasion for women. The number of older adults with substance use disorders is expected to continue to rise, and having a substance use disorder is considered an underlying medical condition that makes one more susceptible to COVID-19 (NIH, 2022).

Future Substance Abuse Concerns:

There will be an increase in the number of seniors abusing substances in the future because the baby boomer generation has a history of having been exposed to, and having experienced, psychoactive substance use over their adult life. This is a significant difference from the previous generations of older adults (National Institutes of Health, 2014c). Efforts will be needed to adequately address these future substance abuse issues for the elderly due to both the health risks for them and the expected burden on the health care system.