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The Changing Face of Substance Misuse in Older Adults

The Changing Face of Substance Misuse in Older Adults

Addictive disorders are among the leading causes of disability worldwide; however, misuse of and addiction to alcohol and illicit substances is often not appreciated as relevant to the care of older adults.1 Unfortunately, the public health impact of alcohol and substance use disorders is rapidly changing as baby boomers age. The most recent National House hold Survey on Drug Use and Health demonstrated a 1.7-fold increase from 2002 to 2005 in illicit drug use for those aged 55 to 59 (Figure 1).2 The rise in prevalence is likely to continue over the next decade, reflecting a substantial generational change. There were declines or no change in alcohol and substance use in all other age groups.

Similar changes have occurred in the prevalence of alcohol abuse or dependence among those aged 65 and older. From the early 1990s until 2002, the prevalence of alcohol abuse or dependence rose to 3.1%, a 3-fold increase.3 Again, this age group had the highest increase in abuse or dependence of all age groups. Excessive drinking or binge drinking has also risen to a rate of 8.3% among seniors.2 Within primary and specialty care settings, particularly specialty mental health care, the incidence of substance misuse is rapidly increasing in the senior population. Health care providers in the aging services are no longer insulated from the consequences of illicit drug use, smoking, and alcohol misuse by patients.

Different effects and different concerns
Older adults present unique challenges to health care providers. Compared with younger persons, older adults have an increased sensitivity to alcohol and over-the-counter and prescription medications. There is an age-related decrease in lean body mass and total body water in relation to total fat volume, and the resultant decrease in total body volume increases the serum concentration of alcohol and other mood-altering chemicals. In addition, interactions between medication and alcohol are a particular concern in this age group. Medications of concern for mental health providers can include antidepressants, antipsychotics, benzodiazepines, and mood stabilizers.

Because of these issues, alcohol use recommendations for older adults are generally lower than those for adults younger than 65. The National Institute on Alcohol Abuse and Alcoholism and the Center for Substance Abuse Treatment's protocols for treatment improvement in older adults recommend that persons aged 65 and older consume no more than 1 standard drink per day, and that on no occasion should an older adult drink more than 4 drinks in 1 day.4,5 Persons drinking above these limits are at increased risk for falls, medication interactions, and other alcohol-related problems. In the absence of defined alcohol-related problems, someone drinking over these limits would be considered an at-risk or excessive drinker. Reducing alcohol consumption or abstaining entirely can lead to sub stantial improvements in health and overall well-being for patients with this type of drinking pattern. It is note worthy that these drink ing limit recommendations are consistent with the current evidence of the beneficial health effect of low-risk drinking.6,7

Individuals with clearly defined problems related to substance misuse are considered to have either abuse (1 or 2 related problems) or dependence (3 or more problems). While there are no differences in the definition of abuse or dependence for older versus younger adults, some problems may be less rel e vant to the former, such as problems related to work or family if the person is retired or a widow(er). Problems related to health are usually more prominent for older adults and can be a key to motivating patients to change their drinking or drug use. Finally, it is worth emphasizing that there are no accepted safe limits for the use of tobacco, marijuana, or other illicit drugs.


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