As Elderly Population Surges, So Will Substance Abuse

ACEP News
May 2010

By Renee Matthews
Elsevier Global Medical News

BETHESDA, MD. -- Current trends in the increase in the number of Americans aged 65 years and older could have significant implications for managing substance abuse in this population.

By 2030, 20% of the population in the United States will be older than 65 years (currently, that percentage is 13) and in 2 years' time, the first wave of Baby Boomers will be eligible for Social Security. Both trends will place pressure on retirement and health care systems in general, and on substance abuse prevention and treatment in particular, Frederic C. Blow, Ph.D., said at the annual meeting of the Association for Medical Education and Research in Substance Abuse. The conference was jointly sponsored by Brown Medical School.

"The number of adults with substance abuse disorders is projected to double from [an annual average of] 2.8 million in 2002-2006 to 5.7 million in 2020," he said. In addition, elderly adults who abuse alcohol or drugs are more likely to have mental health comorbidities, especially depression, cognitive loss, or anxiety or sleep disorders, as well as other comorbidities such as heart disease, diabetes, or conditions that require treatment for pain, all of which add another level of complexity in managing substance abuse in this growing population.

The most common addictions among older adults are to nicotine, alcohol, psychoactive prescription drugs, and other illegal drugs, such as marijuana, cocaine, and narcotics. Estimates suggest that about 19% of older Americans might be affected by combined alcohol and medication abuse, which is more prevalent among men and those aged 50-64 years.

Dr. Blow, of the University of Michigan, Ann Arbor, said aging-related changes make older adults more vulnerable to the adverse effects of alcohol, so that even moderate amounts of alcohol can be riskier for elderly drinkers.

Timely recognition, intervention, and management of substance problems in this growing population are paramount.

When it comes to screening for alcohol abuse problems, one should ask direct questions, though in doing so, it is preferable to frame the question so that it is linked to a medical condition and avoid using stigmatizing terms such as alcoholic, Dr. Blow advised.

Patients also should be warned that some conditions can be caused or worsened by alcohol use. For example, one or more drinks a day could aggravate or cause gastritis, ulcers, and liver or pancreas conditions; two or more daily might affect depression, gout, insomnia, memory problems; and three or more a day could affect hypertension, stroke, diabetes, gastrointestinal diseases, and some cancers.

"Every person over 60 should be screened for alcohol and prescription drug abuse as part of the regular physical examination--and screen or rescreen if certain physical symptoms are present or if the older person is undergoing major life transitions," he added.

Among the tools that can be used for screening and assessing alcohol use in the elderly are the Alcohol-Related Problems Survey and its shorter version, the shARPS; the Computerized Alcohol-Related Problems Survey, which combines screening assessment with health education; AUDIT-C, which screens for alcohol consumption; and two that are "elder-specific"--the Michigan Alcoholism Screening Test-Geriatric Version and the Short Michigan Alcohol Screening Instrument-Geriatric Version.

In regard to drinking limits, older men should have no more than one drink a day on average, and older women should have less than one drink a day, Dr. Blow said, adding that for beer or ale, one standard would be 12 oz.; for spirits, 1.2 oz.; wine, 5 oz.; and sherry or liqueur, 4 oz.

Brief interventions focusing on physician lifestyle guidance or in-home motivational enhancement have both been found to reduce alcohol use in at-risk older adults and alcohol-related harm, and as a result, health care use.

However, when it comes to treatment, age-appropriate treatment models are essential. "The current bias toward institution-based services conflicts with expressed preferences and needs of older persons," said Dr. Blow. Home and community-based settings are preferable for older adults, as are mixed-age treatment settings when individualized psychotherapeutic approaches are included.

Compared with their younger counterparts, older at-risk adults have greater attendance at therapy sessions, better medication adherence, and their relapse rates are lower, he said.

Dr. Blow said that he had no financial disclosures.
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