Invisible Epidemic

Substance abuse among older adults creeps quietly toward crisis

by Matt Mahady

Although substance abuse is usually perceived as a younger person's affliction, its prevalence is rising at an alarming rate among the elderly--both in the long-term care setting and in the community at large. Current estimates of alcohol-related problems range as high as 22% of the senior population.¹ According to the Center for Substance Abuse Prevention, Silver Spring, Md., up to 17% of the elderly abuse or misuse prescription drugs.

Scope of the Problem

Experts predict that the problem of substance abuse in the elderly will worsen as the over-65 population increases and as more baby boomers (many with pre-existing histories of substance abuse) enter long-term care. Some researchers believe that, due to their heightened exposure to drugs and alcohol, baby boomers may drink or use drugs at greater rates after age 65 than previous generations.²

"A significant number of baby boomers continue to use both illicit drugs and prescription drugs non-medically as they age," reported Charles G. Curie, administrator, Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services, Rockville, Md.

The approximately 35 million individuals over age 65 represent the fastest growing age cohort in America.³ And the Administration on Aging has reported that seniors will nearly double in number by the year 2030.³

"We have been seeing a steady increase of substance abuse among the elderly since the early 1990s," reported Sharon E. Friedman, executive director, Mental Health Association of Montgomery County (Rockville), Md. "Overall, we're dealing with a larger cohort size and larger percentage of substance abuse within that cohort. I definitely foresee a need for more treatment (in the future). There is already a need for more treatment."

According to Oscar Morgan, chief operating officer, National Mental Health Association, Alexandria, Va., long-term care facilities are ill equipped to deal with the coming deluge of senior substance abuse.

"I don't think our health-care system is addressing this issue in a concerted and organized manner. We're not ready. We don't have systems in place for those currently in need so we are definitely not ready for the increased treatment demands we will face in the future," he said. "I'm referring to the health-care system as a whole, but particularly to long-term care institutions. This [treatment of substance abuse] is not what long-term care institutions were created for. As the population becomes older, we may find ourselves in the midst of a major health-care crisis."

Invisible Epidemic Presents Myriad Challenges

A number of diagnostic obstacles contribute to what researchers term "an invisible epidemic" of untreated elderly substance abusers.²

"In the elderly population, symptoms of substance abuse may be masked by other symptoms," said Morgan, who said substance abuse signs are often mistaken for the natural ravages of time, symptoms of age-related problems (i.e., dementia, depression), or other maladies commonly suffered by older adults.²

Conversely, medical problems, such as elevated liver enzymes, hepatitis, pancreatitis, hypertension, arrhythmia, and a variety of pulmonary problems, may be indicative of substance abuse.

"Are symptoms a natural result of aging versus the result of the use of a substance?" asked Morgan. "We need to find ways to tease that out better from a clinical point of view."

Negative social consequences that can motivate younger substance abusers to seek help don't apply to most seniors. Example: Most long-term care residents don't drive and are, therefore, unlikely to be arrested for drunk driving. For a substance abuser who is beyond retirement age, job-related problems aren't a factor, either.

The difficulty of detecting substance abuse in the elderly is often compounded by the patients themselves. They may be reluctant to report substance abuse because they view the problem as an embarrassing moral failure rather than a health-care issue.

Within the long-term care setting, chronic staffing shortages and formidable workloads leave little time for staff members to identify substance-abusing residents. The subject is also inherently difficult to discuss. It can be highly uncomfortable for staff to raise the issue and for the resident and the resident's family to face.

Family, caregiver, and clinician complicity in the abuse process, however, can contribute to the perpetuation of substance abuse in the elderly.⁴

"All involved parties must find ways to bridge the reluctance to talk about this topic," explained Morgan. "It is important to desensitize this sensitive subject for families and patients in a non-threatening and supportive manner, so that all parties are comfortable."

Elders Largely Overlooked

Even if a substance abuse diagnosis can be established, current treatment modalities are generally not tailored to meet the special needs of the elderly population.

"Even once diagnosis has been established, then what do you do?" asked Morgan. "There need to be dollars devoted toward establishing age-appropriate treatment facilities."

Despite the fact that substance abuse in the elderly population has evolved into an increasingly serious health concern, a glaring paucity of elder-specific treatment options persists. In addition, clinical research, outcomes data, and medical literature concerning the subject of substance abuse in the elderly is virtually nonexistent.

An article published in the Journal of Rehabilitation pointed out that the clinical literature currently utilized as medical school and continuing education curriculum for long-term care professionals features minimal content concerning the alcohol problems of the elderly and largely ignores drug problems altogether.⁴

A University of Iowa study, which appeared in a recent issue of the International Journal of Geriatric Psychiatry, reported that fewer than one in five existing substance abuse programs in the United States offer services specifically designed for older adults. All known public and private facilities listed as providing substance abuse services were surveyed. Of the 13,749 eligible programs, only 17.7% reported specialized substance abuse treatment provisions for elders.

According to Stephan Arndt, PhD, author of the study, professor of psychiatry, University of Iowa, and director, Iowa Consortium for Substance Abuse Research and Evaluation, Iowa City, Iowa, the data demonstrate how difficult it is to properly diagnose and treat older people who have substance abuse problems.

"Either people are not getting the necessary care or they may be receiving improper care by visiting treatment facilities without elderly specific programs in mind," wrote Dr. Arndt.

Senior-Specific Issues

"There are significant differences between substance abuse in the elderly and younger cohorts," explained Friedman. "As you get older, substance abuse can be more complicated from a number of perspectives. Various mental, emotional, and physical comorbidities become major issues."

Mood and anxiety disorders--relatively common mental health problems in older adults--may be exacerbated by alcohol or drug use. The intense feelings of loss and isolation experienced by seniors can both aggravate and be aggravated by substance abuse.

"It is important to remember that this population--especially those within long-term care facilities--is experiencing tremendous loss and loss of control," said Friedman. "Part of the aging process is the experience of loss. Many of these patients have experienced the loss of a spouse, loss of a best friend, loss of vitality, and the loss of the work that made them feel worthwhile and productive."

In addition to exacerbating mental illnesses in the elderly, alcohol and drug use also affects the physical health of the elderly at a higher rate than other populations. Between 11% and 20% of acute-care hospital admissions among the elderly are alcoholism related.¹ Drinking can contribute to accidents and falls, resulting in institutionalization or death.

"People may end up in long-term [care] for other apparent reasons, but many times, the underlying cause may be substance abuse," said Morgan.

Another senior-specific consideration likely to result from the myriad mental and physical comorbidities is polypharmacy and potential overmedication.

"It is infinitely important that seniors have a care manager actually managing all the many, many substances that they are ingesting for various physical and emotional illnesses," counseled Friedman.

Finally, natural physiological changes associated with aging increase sensitivity and decrease tolerance to alcohol and drugs in older individuals.⁴ As a result, smaller amounts of drugs and alcohol have more profound effects, potentially rendering elderly adults more vulnerable to substance abuse issues.

Targeted Approach Key

For various reasons, substance abuse in the elderly population has not been accorded the attention that it deserves. However, there are reasons to hope that the tide of neglect is beginning to turn.

"The good news is that people are starting to become more aware," wrote Dr. Arndt. "Substance abuse programs targeting [the] elderly will become more specialized, involving more close medical monitoring and interaction with peers."

As the need for customized strategies specifically designed to target late-life alcoholism and drug abuse has increased in urgency and importance, a number of organizations and individuals have begun to respond with innovative ideas and experimental initiatives.

In an effort to address the glaring lack of data concerning the subject of elder substance abuse, Dr. Arndt has called for a meta-analysis, examining the benefits and drawbacks of existing treatments that currently target elderly populations. Such information, he asserted, would be useful in making treatments more effective and readily available.

Other experts propose efforts aimed at increasing levels of prevention, education and awareness. "At SAMHSA, we are working to expand treatment capacity in communities nationwide to provide baby boomers the opportunity to recognize their dependence and seek help now--before their drug abuse is complicated by the illnesses of old age," said Curie.

Friedman concurred. "One way to combat substance abuse in the elderly is to prevent it before it happens or to catch it before it becomes too severe," she said. "The Mental Health Association believes that screening for substance abuse is very important. Just as one screens for diabetes, heart disease, and other physical conditions common in the elderly, one should also screen for dependency and addiction. Substance abuse screening should be standard procedure in long-term care facilities and in all health-care settings where a great deal of elderly are cared for."

Conclusion

In the final analysis, more work remains. "Public awareness must be increased," advised Morgan. "Elders who suffer from substance abuse require better treatment and dollars to provide the treatment.

"The subject of substance abuse in the elderly needs to be introduced into medical professional curriculum--including those for physicians, nurses, and pharmacists," he said. "Training needs to begin within medical schools and other professional schools. There needs to be more awareness and training concerning this issue."

Contributing Writer Matt Mahady is based in Florida.

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