Baby Boomers and Substance Abuse
Baby Boomers and Substance Abuse
Addiction specialists and organizations for the elderly anticipate a tidal wave of baby boomers who will need help fighting addictions, often for different substances and with different attitudes toward treatment than the generation that came before them.1 The leading edge of the baby boom generation is rapidly moving into the treatment realm of geriatric psychiatry.2 As a cohort, baby boomers experimented more with alcohol and illicit drugs than did previous generations. It is therefore hypothesized that this group will have more lenient attitudes about alcohol and illicit drug use than previous generations.
When one pairs open attitudes about alcohol and illicit drug use with older adults’ exposure to and misuse of prescribed medications, elderly substance abuse presents a challenging and widespread public health problem.3 In this review, I will discuss the epidemiology, assessment, medical implications, and treatment of substance abuse in older adults.
The most current community samples of alcohol use disorders come from the National Epidemiologic Survey on Alcohol and Related Conditions, in which rates for past alcohol abuse and dependence were presented by age and sex categories. Among those 65 years and older, 2.36% of men and 0.38% of women met criteria for alcohol abuse. Averaging the sexes, 1.21% of the population 65 years or older met criteria for alcohol abuse; rates for alcohol dependence were lower—0.39% in men and 0.13% in women.
It can be argued that alcohol use disorders represent one end of a continuum of problematic alcohol use. The terms “hazardous use” and “harmful use” have been used to
define consumption of alcohol in amounts that are harmful or potentially harmful to physical health but that do not necessarily meet DSM-IV criteria for abuse or dependence. These terms are defined according to number of drinks consumed. Measures that are based on quantity and/or frequency of alcohol consumption may more accurately describe the extent of problematic alcohol use in the elderly.
Several quantity- and frequency-based surveys of alcohol use have been conducted in the past decade. Each of these surveys attempted to sample the civilian elderly in the community, although survey methods differed from one study to another. Using pooled data from 1997 through 2001, the National Health Interview Survey describes the drinking patterns of those 60 years or older.4 Of those who reported drinking alcohol during the year before the survey, half of the men and 39% of the women were almost daily drinkers; 5.9% of all men aged over 60 years and 0.9% of all women aged over 60 years reported binge drinking once a month or more.
In treatment settings such as doctors’ offices and emergency departments, substance abuse diagnosis is perhaps 10-fold more frequent than in the community setting.5 Although data are scarce on illegal drug use or prescription medication misuse among the elderly, evidence suggests that misuse and abuse of prescription drugs by older adults is a growing problem.6 Colliver and colleagues7 demonstrated that up to 11% of older women misuse prescription drugs and that nonmedical use of drugs among adults older than 50 years will increase to 2.7 million by the year 2020.
There is growing evidence that female sex is a major risk factor for problems associated with prescription drug abuse.6 Older women are more likely than men to consume benzodiazepines. This may be associated with recent divorce or widowhood, lower educational level, lower income, poorer health status, depression, and/or anxiety.6,8,9
Assessing substance abuse in the elderly
It is difficult to assess substance abuse in the elderly. Often clinicians and family members are hesitant to ask whether the older adult is having problems with substance use or misuse of prescription medications. Traditionally accepted ways of detecting problems with substances (eg, time lost from work, legal problems, or decreased participation in important social activities) are not helpful in older adults because they generally have fewer activities and obligations.2 Older adults are likely to experience more problems with relatively small amounts of substances because of increased sensitivity, slower metabolism, and a smaller volume of distribution.2,3 Cognitive impairment may interfere with the ability of the older adult to self-monitor intake or interpret feedback from health care providers. A more complete assessment to detect and treat substance abuse problems may be needed for older patients.
Types of alcohol problems in older adults
There are 2 groups of older alcohol-dependent patients—those who became dependent before and those who became dependent after age 60 years.10 There is also a group of older adults who do not meet criteria for dependence but are at risk for drinking problems. Other terms used in the elderly include “problem drinking” and “hazardous drinking.” These terms have recently been described in the literature. Findings from these studies suggest that a preventive model may be superior to a disease model in identifying older adults at risk for a drinking problem.3
Patients with early-onset alcohol-dependence appear to have a more severe course of illness. They make up about two-thirds of the dependent drinkers in the elderly, are predominantly male, and have more alcohol-related medical problems and psychiatric comorbidities.2 They tend to be less well-adjusted and have more antisocial traits, and they may need more treatment based on traditional medical disease models.
Patients with later-onset alcohol-dependence tend to have a milder clinical picture and fewer medical problems because of the shorter exposure to alcohol. They are more affluent, include more women, and are likely to begin their alcohol use after a stressful event, such as loss of a spouse, job, or home. Other risk factors for the development of later-life alcohol dependence include a personal and family history of alcohol abuse or dependence, chronic pain, predisposition to affective or anxiety disorders, and decreased alcohol
Hazardous or at-risk use of alcohol is that which exceeds the National Institute on Alcohol Abuse and Alcoholism (NIAAA) guidelines. For adults 65 years and older, hazardous use is 3 or more drinks at one sitting or more than 7 drinks a week. These guidelines are the same for men and women. With the new NIAAA guidelines for alcohol consumption in the elderly, hazardous use of alcohol is a problem that likely needs more attention using a preventive model in the primary care setting.11
Alcohol abuse and alcohol dependence in older adults are often underdetected in medical practice. Despite the US Preventive Services Task Force recommendation for routine alcohol screening, there is insufficient screening for excessive alcohol consumption in the elderly. Only 13% of primary care physicians use a formal screening tool for alcohol problems.12
Several questionnaires have been developed for assessment of substance abuse. The CAGE questionnaire is the most widely studied alcohol-screening instrument that was initially validated in young and middle-aged persons.13 A score of 2 or more on this simple yes/no questionnaire of 4 items is considered the cutoff for probable alcoholism. The test can be quickly administered and assesses lifetime prevalence of alcohol problems. However, past versus current problems are not differentiated.13 The CAGE questionnaire provides higher specificity for the most severe cases, but it is of less value for the broader spectrum of alcohol misuse or hazardous use.3
The AUDIT (Alcohol Use Disorders Identification Test) is a 10-item self-report screening instrument that specifically identifies current use disorders. It was developed to identify people with hazardous levels of drinking. A shorter version of the test, the AUDIT-5, is often used with older adults.3
The MAST-G (Michigan Alcohol Screening Test–Geriatric Version) is a 24-item self-report screening tool with elderly-specific questions. The MAST-G and its shorter version (SMAST-G) were designed to identify a population that drinks less than heavy drinkers or those with alcohol dependence.13 A larger proportion of women may have been screened with these instruments.14 The MAST-G does not distinguish recent from past drinking, and the length of the test may prevent its routine use.
When CAGE and SMAST-G were compared in one study, people who screened positive on SMAST-G alone were older than those who screened positive on CAGE alone or those who screened positive on both CAGE and SMAST-G. This may indicate that SMAST-G identifies a larger number of older persons with alcohol use disorders than does CAGE.14 The same study showed that fewer than half of persons who screened positive on either CAGE or SMAST-G screened positive on both measures. This finding suggests that a screening strategy that uses both measures may identify more alcohol use disorders in older adults with various demographic characteristics.14
The Alcohol-Related Problems Survey (ARPS) is an 18-item self-administered screening measure that focuses on the relationship between alcohol use and medical problems, medication use, and functional status. The results classify patients as nonhazardous, hazardous, or harmful drinkers. There is also a short version—shARPS.13 This screening instrument showed very good sensitivity but only moderate specificity in a population of internal medicine clinical patients. The time taken to administer the test may be a limitation.13
High mean corpuscular volume is commonly used as a simple screening instrument for alcohol misuse. However, this test was found to be a poor screening instrument for older adults with alcohol use disorders.12,15
There are few, if any, validated screening instruments for detecting problems related to prescription medication abuse. Blow11 recommends screening elderly patients who may be abusing prescription medication by collecting a detailed history and looking for signs of prescription misuse (eg, excessive worry about whether the medication is working, attachment to a particular psychoactive medication, or excessive anxiety about the supply and timing of medications). In addition, clinicians need to monitor patients for excessive daytime sleeping; declines in personal grooming and hygiene; and withdrawal from family, friends, and normal social activities.
Factors associated with prescription medication misuse and drug abuse in the elderly include female sex, social isolation, history of substance use or mental health disorder, medical exposure to prescription drugs with abuse potential, poor health status, and polypharmacy. Other general indicators of prescription medication misuse may include loss of motivation, memory problems, family or marital discord, new difficulties with activities of daily living, drug-seeking behavior, and doctor shopping.6
Medical assessment and implications
The medical evaluation of older adults who may be drinking alcohol excessively requires attention to the unique physiological features of the elderly and their increased susceptibility to alcohol. The NIAAA considers 1 drink daily to be the maximum amount for moderate alcohol use in men and women older than 65 years.16,17 An age-related decrease in the volume of distribution results in 20% higher blood alcohol concentration per volume.18,19 Evidence from clinical and preclinical studies indicates that aging interferes with the body’s ability to adapt to the presence of alcohol.20
There is a U- or J-shaped curve association between alcohol consumption and all-cause mortality.21 Nearly every organ can be adversely affected by hazardous alcohol intake. As we consider the medical consequences of alcohol in the elderly, 3 areas deserve particular attention: mental status, risk of falls, and medication interactions.
Cognitive dysfunction can be caused by a number of organic and external conditions, including medications. Alcohol causes cognitive impairment in a dose-related fashion in the acute setting. Chronic alcohol consumption has been shown to cause persistent cognitive deficits with associated cortical atrophy and ventricular dilatation on brain scan. Consequently, it is important to recognize the underlying incidence of diminished mental function in the elderly, which ranges from mild cognitive impairment to dementia.
Dementia is prevalent and is characterized by a decline in cognition that affects memory and by at least 1 of the following cognitive disturbances: agnosia, aphasia, apraxia, or disturbance in executive functioning. The strongest risk factor for dementia is older age. The 1% prevalence of dementia among individuals aged 60 to 69 years doubles every 5 years to about 39% in those aged 90 to 95 years.22 The acute and chronic effects of alcohol are additive to any underlying cognitive infirmity in the geriatric patient.
Falls occur in approximately 30% of community-living adults who are older than 65 years and who are at increased risk of serious injury, functional decline, and increased health care use; this rate increases to 50% for those 80 years and older.23 The elderly are more at risk for falls because of impaired balance, judgment, arthritis, myopathy, neuropathy, CNS atrophy, cerebellar degeneration, and hypotension. Also, because of osteopenia and osteoporosis, falls are more likely to lead to fractures. Inability to get up after a fall adds to mortality and morbidity. A history of problem drinking is associated significantly with greater risk of falls.24
The geriatric population consumes a disproportionate percentage of medication. A survey in 2002 showed that 94% of women 65 years or older took at least 1 medication, 57% took 5 or more, and 12% took 10 or more medications; men 65 years or older also reported high rates of medication use.25 Geriatric patients are subject to increased risk of medication-related misadventures: if all the medications are taken, the risk of adverse effects and drug-drug interactions is increased; if the medications are not taken, a disease state can worsen and may prompt a clinician to add or change medications inappropriately. Adverse effects (including those of over-the-counter medications) rank fifth among the greatest and most preventable health threats to older adults.26 Confusion may be an early sign of an adverse effect. Alcohol use can directly or indirectly affect the pharmacodynamics and pharmacokinetics of medications and add potential for toxicity. Thus, older adults who drink and who have medical illness or disability and who are taking a medication are at great risk for adverse effects.
Age-specific treatment approachesresult in better adherence and fewer relapses.27 Treatment guidelines from the Substance Abuse and Mental Health Services Administration indicate that treatment should include age-appropriate group therapy, address loss early in treatment, and teach skills to rebuild social support networks. It is recommended that staff be experienced in working with the elderly and use a slower pace and age-appropriate content. A culture of respect with an atmosphere of support and change rather than confrontation should be created within the therapeutic setting.26,28
Kashner and colleagues29 assessed participants in the older alcoholics rehabilitation program of the US Department of Veterans Affairs who were randomly assigned to reminiscence therapy versus traditional care programs. They found that developing patient self-esteem and peer relationships was superior to confrontational approaches typical of traditional care programs. Several studies have evaluated elder-specific Brief Alcohol Intervention (BAI) projects. The Table provides some characteristics of BAI. The Guiding Older Adult Lifestyles project that used brief physician advice for 156 at-risk drinkers was shown to reduce alcohol consumption by 34% at 12-month follow-up.30
Results of the Health Profile Project demonstrated that a motivational enhancement session reduced at-risk drinking at 12 months (N = 454).31 The Staying Healthy Project undertaken by the American Society on Aging noted that about 6% of the older adults sampled were drinking more than recommended and that a brief intervention resulted in about 40% reduced consumption of alcohol.32 The Gerontology Alcohol Project targeted adults with late-life onset alcohol abuse. Using day treatment and a group format (cognitive-behavioral therapy), 75% of the participants maintained drinking goals and no one returned to steady drinking.33
The Computerized Alcohol-Related Problems Survey demonstrated that a brief intervention that provided feedback and psychoeducation to at-risk drinkers was effective in primary care settings.34 The Primary Care Research in Substance Abuse and Mental Health (PRISM) trial randomized 414 older at-risk alcohol users to integrated primary care intervention or to referral to a specialist provider, such as a substance abuse clinic. The trial showed that alcohol users who received the integrated intervention were twice as likely to remain in treatment.35
Three medications have been approved for treatment of alcohol problems; however, there are few pharmacological treatment studies of alcohol dependence in older adults and no known studies of other drugs of abuse. Disulfiram, which blocks the action of acetaldehyde dehydrogenase, causes a buildup of acetaldehyde in the body. If alcohol is ingested, the reaction is too dangerous for older persons. Hypotension and cardiac adverse effects are the main problems. Naltrexone is a γ opioid antagonist that has been shown to help prevent relapse in older adults who drank alcohol excessively.36,37
Acamprosate is a glutamatergic medication that received FDA approval for the treatment of alcohol dependence in abstinent drinkers. There have been no studies using this medication to treat older adults who are alcohol-dependent. The drug is metabolized renally and thus kidney function should be monitored in patients taking this medication. Topiramate, an anticonvulsant medication that potentiates g-aminobutyric acid has shown recent success in treating initiation of abstinence (the period of treatment directly following acute detoxification from alcohol when patients may be most vulnerable to relapse).38 However, because it may cause cognitive impairment, it is an unlikely treatment for the elderly.
The 2 agents used to treat opioid dependence are methadone and buprenorphine/naloxone. Although these harm-reduction pharmacological treatments are widely used for opioid addicts, there are no studies of these medications in the elderly population.
The well-documented prevalence of elderly substance abuse and the aging of the baby boom generation indicate that substance abuse and its treatment in the elderly will shortly be one of the most pressing public health concerns. Consequently, there is a need to develop more time-efficient and valid screening instruments to help identify older adults who are at risk.
Clinical trials of medications to treat substance abuse in the elderly are lacking, and more needs to be learned about how our current medication armamentarium can be used in this aging population. Treatment trials with cholinesterase inhibitors and memantine may offer more information about the interplay of cognitive impairment and at-risk alcohol use in the elderly. Treatment trials of opiate substitution therapy are needed as well.
Tailoring substance abuse treatment approaches for an aging population will help with treatment retention and will emphasize integrated approaches that combine primary care and substance abuse models to enhance screening and treatment.
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