Comorbidities
Clinical presentations of substance abuse in the elderly may not be suspected because the presenting picture often does not correspond with stereotypes based on younger populations. Severe substance abuse with major social consequences is certainly seen in elderly patients, but antisocial behavior and lower socioeconomic status are less common and clinical manifestations are more variable. Given the higher prevalence of comorbid medical problems, elderly patients are at greater risk for medical consequences associated with substance abuse.
Common medical consequences include liver damage; immune system impairment; and cardiovascular, GI, and endocrinological problems.6 Elderly patients often present to the emergency department with severe illness. Symptoms of alcohol(Drug information on alcohol) withdrawal are missed and are easily attributed to a cause other than alcohol abuse. Alcohol withdrawal disorders include tremulous syndrome, hallucinations, seizures, and delirium tremens. Although there is no evidence that the disorders occur at different rates in the elderly, data from animal studies show increased severity of symptoms.
The prevalence of alcohol-related dementia in late life differs depending on the diagnostic criteria used and the population studied; however, there is general consensus that alcohol contributes to cognitive deficits.7 Substances such as opioids and benzodiazepines also increase the risk of cognitive impairment that ranges from confusion to delirium to dementia.8
The coexistence of substance abuse and psychiatric illness has been established in several studies, although the exact relationship remains unclear. Prevalence is estimated to be between 21% and 66%. Approximately 25% of elderly patients have comorbid depression. Also common are cognitive disorders and anxiety disorders, both of which occur in 10% to 15 % of elderly patients.9
The treatment of co-occurring disorders in patients with mental illness presents unique challenges. The literature, although extensive for younger adults, is almost nonexis-tent for older adults. An integrated approach to treatment of co-occurring disorders in severe mental illness provides better outcomes.10 Using a multidisciplinary team to treat co-occurring disorders enhances cohesiveness of care and reduces conflicts between treaters. Both disorders should be treated as "primary" using a combination of different modalities, such as effective outreach and case management, motivational techniques, psychotherapy, and psychopharmacology.
Diagnosis
In older patients, substance abuse problems are often misdiagnosed. Part of the challenge when working with the older population is to confront one's own biases and beliefs. Another challenge is denial of substance use by the elderly, which can make accurate diagnosis and treatment more difficult.11 In addition to a clinical interview, several screening instruments can be used (eg, the CAGE questionnaire, the Alcohol Use Disorders Identification Test, and the Michigan Alcoholism Screening Test—Geriatric Version [MAST-G]).12
A comprehensive evaluation should include a thorough physical examination along with laboratory analysis and psychiatric, neurological, and social evaluation. An increased focus on successful identification and subsequent treatment is warranted because research indicates that elderly patients reduce substance use when encouraged by their physician.
Treatment
There is a general lack of evidence-based treatment approaches for substance abuse in the elderly. As a result, much of what is recommended is based on interventions that have been validated in younger populations. It is important to understand specific ways to engage the elderly patient. In general, the choice of treatment depends on the severity of the condition and the level of functional impairment and varies from hospitalization to outpatient care.
