Identification and Treatment of Alcohol or Drug Dependence in the Elderly

Medication Misuse

Misuse of medications by older adults is perhaps a more challenging issue to identify. Older adults are at higher risk than younger groups for inappropriate use of medications. Older adults use more prescriptions and over-the-counter medications than other age groups: in 2000, the average older American received over 20 prescriptions per year, often coming from an average of 4.7 therapeutic classes. It is estimated that up to 33% of older adults receive psychoactive drugs with abuse potential. ⁵⁸ There over 2 million serious adverse drug reactions annually, with 100,000 deaths per year. Adverse drug reactions are especially prominent among nursing home patients with 350,000 events each year. A survey of social services agencies indicated that medication misuse affects 18%–41% of the older clients served, depending on the agency.

Substance abuse problems among elderly individuals often occur from misuse of over-the-counter and prescription medications. Older adults who misuse prescription drugs may be different from older adults who abuse illegal substances, in that drug misuse in older adults is often unintentional. For example, a recent study found that 32.1% of older participants needed assistance in proper medication use, 15.6% had difficulty recalling the purpose of one or more of their medications, 10.9% reported an incorrect dose for their medications, and 8.2% of participants took medications that were inappropriate for their symptoms. Drug misuse can result from the overuse, underuse, or irregular use of either prescription or over-the-counter medications. Misuse can become abuse relatively easily. In addition, cofactors such as alcohol and/or mental health problems, white race, living in rural areas, poor health status, social isolation, and older age increase vulnerability for misusing prescribed medications. Likewise, being female significantly increases vulnerability, with an estimated 2.8 million (11.0%) of US women older than 60 years of age misusing psychoactive prescription medications.

Vulnerabilities for Substance Use Problems

Older adults have specific vulnerabilities for substance abuse problems due to the physical and psychological changes that accompany aging. These may include bereavement, loneliness, diminished mobility, impaired sensory capabilities, chronic pain, poor physical health, cognitive impairment, and poor economic and social supports. In addition, older adults have an increased sensitivity to alcohol, over-the-counter medications, and prescription medications. The age-related decrease in lean body mass compared to total volume of fat and the decrease in total body volume increase the total distribution of alcohol and other mood-altering chemicals in the body, which increases vulnerability. In addition, central nervous system sensitivity increases with age. Liver enzymes that metabolize alcohol and certain other drugs are less efficient with aging.

Chronic pain presents as a risk factor for prescription drug misuse, specifically in older adults. Although pain reliever misuse is lower in older adults than in younger adults, rates of misuse among individuals older than 50 years of age have been reported at 1.7%. It has been found that as individuals age, their patterns of pain reliever misuse change. A primary theme emerges when considering pain reliever misuse in this population: rather than actively seeking out pain relievers, older adults are likely to report pain reliever possession originating from multiple medical doctors.

A major concern in working with older adults is the interactions between alcohol and medications, particularly psychoactive medications, such as benzodiazepines, barbiturates, and antidepressants. Older adults metabolize drugs more slowly and are more sensitive to drug effects. On top of the natural slowing of the metabolism, alcohol use can interfere with the metabolism of many medications and is a risk factor for the development of adverse drug reactions. A recent study found that 62.2% of older adults taking alcohol-interactive medications used alcohol in combination with their medication; 42.2% of at-risk alcohol users were taking drugs that had the potential to cause significant interactions with alcohol. There are individuals for whom any alcohol use, coupled with the use of specific over-the-counter/prescription medications, can be problematic. For example, it was found that the use of antidepressant medications did not result in a decrease of at-risk drinking among older adults. The concerning issue is that the use of alcohol can decrease the effectiveness of antidepressant medications, and conversely, reducing the consumption of alcohol can be beneficial in reducing some of the symptoms of depression. Furthermore, co-occurring psychiatric conditions including comorbid depression, anxiety disorders, and cognitive impairment can be a complication of alcohol and medication abuse in older adults. It is also possible that alcohol abuse can aggravate medical problems specifically associated with aging.

The medical and emotional consequences of heavy or excessive alcohol consumption have been well documented. These risks include increased risk of coronary heart disease, hypertension, dementia, depression, and insomnia. However, there is now more evidence of the medical risks of moderate alcohol use for some older adults. Moderate alcohol consumption has been demonstrated to increase the risk of strokes caused by bleeding, although it decreases the risk of strokes caused by blocked blood vessels. Moderate alcohol use has also been demonstrated to impair driving-related skills even at low levels of consumption and it may lead to other injuries such as falls. Of particular importance to the elderly is the potential interaction between alcohol and both prescribed and over-the-counter medications, especially psychoactive medications such as benzodiazepines, barbiturates, and antidepressants, as discussed earlier. Alcohol is also known to interfere with the metabolism of medications such as digoxin, warfarin, and metformin, all medications that are commonly prescribed to older adults.

Comorbidities

There are a number of physical and mental health comorbidities associated with alcohol/medication/illicit drug misuse/abuse. In working with older adults, the most difficult-to-identify symptoms are often related to mental health. Epidemiological studies have demonstrated that alcohol use in the presence of psychiatric symptoms is a common problem with wide-reaching consequences in younger age groups. There is much less research on the comorbidity of alcohol and psychiatric conditions in later life. In an early study of 216 elderly presenting for alcohol treatment, Finlayson and associates found 25% had an organic brain syndrome (dementia, delirium, amnestic syndrome), 12% had an affective disorder, and 3% had a personality disorder. In a similar study, Blow and colleagues reviewed the diagnosis of 3986 Veterans Administration patients (60–69 years of age) presenting for alcohol treatment. The most common comorbid psychiatric disorder was an affective disorder found in 21% of the patients. The Liverpool Longitudinal Study found a fivefold increase in psychiatric illness among elderly men who had a lifetime history of five or more years of heavy drinking.

In a study of adults entering substance abuse treatment programs, 35% reported having had both internalizing and externalizing problems in the year prior to entering treatment. Older adults seem to be at greater risk of comorbid internalizing problems as these increased with age.

Comorbid depressive symptoms are not only common in late life but are also an important factor in the course and prognosis of psychiatric disorders. Compared to the general adult population, alcohol consumption and problems are substantially higher in individuals with mild to moderate depression. Binge drinking also tends to be more common in individuals with comorbid depression. Individuals who have co-occurring depression and alcohol abuse/dependence have been shown to have a more complicated clinical course of depression, with an increased risk of suicide and more social dysfunction than individuals with alcohol problems with no depression. The risk of suicide is also higher in older adults with early-onset alcohol dependence. Relapse rates for those who were alcohol dependent did not appear to be influenced by the presence of depression. Alcohol use prior to late life has also been shown to influence the treatment of late-life depression.

Sleep disorders and sleep disturbances represent another group of comorbid disorders associated with excessive alcohol use. Alcohol causes well-established changes in sleep patterns such as decreased sleep latency, decreased stage 4 sleep, and precipitation or aggravation of sleep apnea. In addition there are age-associated changes in sleep patterns including increased rapid eye movement episodes, a decrease in rapid eye movement length, decrease in stages 3 and 4 sleep, and increased awakenings.

The age-associated changes in sleep can all be worsened by alcohol use and depression. Moeller and colleagues demonstrated in younger subjects that alcohol and depression had additive effects upon sleep disturbances when occurring together. In addition, alcohol-dependent adults 55 years of age or older have more disturbed sleep than those younger than 55 years of age. Rates of insomnia for this age also increase with binge drinking. Furthermore, sleep disturbances (especially insomnia) have been implicated as a potential etiologic factor in the development of late-life alcohol problems or in precipitating a relapse. Sleep disturbance is relatively common in older adulthood. Separating out the role of alcohol or drugs and psychiatric symptomatology with the overlay of sleep issues requires time and nonjudgmental questioning to elicit the nature of the problems and to work toward positive outcomes.