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The Hidden Epidemic: Substance Abuse in the Elderly

Feature Articles

There is a secret epidemic that targets those who are alone in their homes, suffering from health problems associated with both age and drug use: the elderly. Today thirteen percent of the total United States population is over sixty-five years of age and seventeen percent of this population abuse drugs (Blow, 1998). In 1998, the US Department of Health & Human Services predicted that by 2030 twenty percent of the US population will be over sixty-five and as many as one in four of these older adults will be addicted to drugs.
The aging addict is also very likely to experience one or more lifestyle-associated morbidity. The leading causes of death today are heart disease, cancer, and accidental death. All three are noninfectious lifestyle morbidities, but they often related to addiction. These potential morbidity and mortality problems have enormous cost implications both financial and humane. How do we identify these groups of aging addicts?
The Four Subsets of Aging Addicts  
Early Onset Alcoholics  
These older adults generally began drinking in their early teens and were often alcohol dependent by twenty-five years of age. A high population of this group is male with a heavy genetic component. This subset has many social and medical problems including impulsiveness and aggressiveness (Dom, Hulstijn, & Sabbe, 2006); two-thirds of all older adult alcoholics fall into this group.
Late Onset Alcoholics  
Late onset alcoholics usually do not start drinking until their fifties or sixties and some even later. In a 1991 study, Adams and Waskel described this population as the most educated and most affluent of the subsets. While late onset alcoholism requires genetic predisposition, there appears to be less family history of alcoholism. Late onset alcoholics may be more receptive to treatment and because their drinking years are fewer they have less severe medical complications. 
The Baby Boomer Generation  
The Baby Boomer’s first generation turned sixty-five in 2011. They are expected to have a larger proportion of aging addicts in comparison to previous generations. It appears as though many have carried the substance abuse of their youth into old age. Thus the Boomers have had a longer lifetime experience with drug use. Colliver, Compton, Gfroerer, and Condon projected drug use among the aging Baby Boomers to peak in 2020 (2006). They conclude there will be a marked increase in drug use in the aging population, particularly in the numbers of marijuana and psychotherapeutic drug users. The Substance Abuse and Mental Health Services Administration (SAMSHA) findings for 2010-11 reaffirm the predictions with an estimated 4.8 million adults aged fifty and over using an illicit drug in the past year, marijuana being the most commonly used substance followed by the non-medical use of prescription drugs (2011).
Prescription Drug Abusers  
The elderly consume one-third of the prescription drugs sold in the United States. Eighty-three percent of this population takes at least one prescription drug per day and thirty percent take eight or more (Inaba & Cohen, 2007). Older adults also purchase three-fourths of all the over-the-counter (OTC) medications. This population is at a high risk for prescription drug dependence because they are more likely to have both medical and psychiatric problems. This population may believe they are following doctor’s orders. Poor vision, misunderstanding instructions, and mental confusion account for some drug misuse (Colleran & Jay, 2002). Yet there are other older adults who purposely abuse prescription drugs. There is evidence that people with alcoholic use disorders are at a high risk to abuse prescription drugs (Culberson & Ziska, 2008). Some older alcoholics transition from alcohol to benzodiazepines because this age group is two to three times more likely to be prescribed benzodiazepines than younger age groups (Benshoff, Harrawood, & Koch, 2003). Combining alcohol with benzodiazepines and/or medications can result in death. One study found forty-one percent of hospital inpatients age sixty-five and over, used both alcohol and benzodiazepines in excess of the recommended level (SAMHSA, 2010).

The sixty-five and over population generally seek treatment from more than one physician with one or more chronic health conditions. The older average adult consults at least two specialists in their medical history lifetime besides their primary care physician. This facilitates the aging, drug-seeking addict in physician shopping for multiple prescriptions.      

Physicians play a part in the older adult prescriptions drug dependency. Physicians may renew pain prescriptions routinely even when the prescription was intended for short-term relief. For physicians “time is money” and reexamining the patient takes time that a simple phone call to the pharmacist could save. There are also unethical physicians who readily provide pills to the addicted elder. In 2012, The Washington Times reported that the Los Angeles District County Attorney’s Office charged a doctor with murder in the prescription drug overdose deaths of three patients (Deutsch & Risling, 2012).  
With the steadily increasing abuse of all these drugs among the elderly it is surprising that the epidemic is so silent. Bill Urell, author of an article titled Alcohol Abuse and the Elderly: The Hidden Population, states that “few wish to talk about a problem for which even fewer seek treatment on their own” (n.d.). 
Barriers to Diagnosis  
Endogenous Barriers  
Bereavement: As adults age lifetime relationships fall away, spouses die, best friends relocate perhaps to live with children or to live in retirement communities thus leaving many elders alone and isolated without love and support. It is within this population of elderly men and women, widows and widowers, and divorcees that alcohol and drug abuse is found. In fact, the fastest growing population of alcoholics is the seventy-five year old widower (Colleran & Jay, 2002). 
Retirement: Occupations often provide individuals with their identity. Retirement, even if it is a welcomed occasion, a time to fulfill dreams, travel or pursue hobbies can mean the loss of a social support system, life structure, financial security, and self-esteem.
Health: As adults age, hearing and sight gradually diminish while pain from chronic diseases increase. Many older adults expect to suffer from ill health, so when the aging addict suffers from any of the leading causes of death it is easier to blame age rather than substance abuse for these ailments. The truth is that addiction doesn’t make this process any easier. Alcohol is the most damaging drug of all, as it increases the workload on the heart, elevating the cholesterol and fatty acids level. Alcohol also causes abnormalities of heart rhythms and can cause hypertension and stroke. Cancer of the esophagus is six times greater for alcoholics and thirty-eight times greater for those who both smoke and drink. Cancer of the mouth, stomach, and intestines is highly correlated to heavy alcohol consumption. Hepatitis and cirrhosis of the liver are particularly prevalent with early onset male alcoholics. Alcohol affects the brain as well as judgment; memory, coordination, and speech are all affected by alcohol. When addicts seek treatment for any of these noninfectious lifestyle related diseases and are provided a “legitimate” diagnosis by their physicians, denial of their primary disease (drug abuse) is easier to maintain.
Denial: Denial is known to be part of the disease of addiction for any age, but it is particularly true for the elderly. Those over sixty-five are less likely to be confronted by the consequences of the legal systems as they are less likely to drive or to face the consequences of the workplace. Denial along with the toxic effect of drug abuse on both memory and judgment make the addict the least likely person to recognize and accept his/her condition (Inaba & Cohen, 2007).
Morality: This aging generation may be the last to suffer from the endogenous barrier of “morality” or “sin.” Before World War I, today’s aging alcoholics’ mothers and grandmothers were marching for the “yes” vote on Prohibition. These marching women were often members of The Christian Women’s Temperance Union who viewed their crusade as a war against poverty—poverty caused by men who spent their paychecks in bars. These intoxicated men then abused their wives and children. From this historic view alcoholism was perceived as a character defect of the weak that were born without enough willpower or moral values to resist “the drink.” This is the world in which many aging alcoholics were born. It was not until 1992 that the American Society of Addictive Medicine (ASAM) finally defined alcoholism as a primary chronic disease. It is hard for the aging generation to have this new concept override the moral teachings of their past—a good reason to hide their self-perceived moral failures (Stofle, 1999).
Exogenous Barriers  
Underdetection: Alcohol may affect any body system (Gurnack, Atkinson, & Osgood, 2002). The diagnosis of drug abuse in older adults is made more difficult because the effects of drugs often mimic those effects of aging. Because nonaddicted adults over sixty-five also suffer from confusion, falls, and memory loss, physicians may believe this is normal behavior for the older adult (Colleran & Jay, 2002). 
Misdiagnosis: Misdiagnosis may also occur when the physician diagnosis and treats the secondary, instead of the primary, disease. Epidemiologists label disease primary and secondary when they coexist in a patient’s medical history. For example, gastrointestinal disorders often have alcoholism as their primary disease. When the primary disease is not detected or treated, the secondary condition will escalate in severity or reoccur. 
Complicity: Another exogenous barrier to the recognition of substance abuse is complicity in the abuse process. Family members and caregivers often have a difficult time confronting their elder’s substance abuse. Relatives, like the addict themselves, suffer from denial. Others may view the use with disgust but not as the real problem (Benshoff, Harrawood, & Koch, 2003). Many may be ashamed or fear confrontation of an older loved one. Still others believe that their elders “deserve a little pleasure in their old age” and “they should be allowed to enjoy the little time they have left.”
Physicians also may have difficulty seeing signs of abuse in patients who have never had a substance abuse problem in the past. Physicians may also be reluctant to question the older addict regarding their addiction. This often occurs if the patient does not fit their stereotype of an aging addict or has been a patient for a long time. This happens more frequently among older adults of higher socioeconomic and educational levels (Benshoff, Harrawood, & Koch, 2003).
Primary care practitioners, physician assistants, nurse practitioners, and registered nurses have a potentially powerful role in the screening of aging addicts. The prevalence of alcohol use disorders is significantly higher among elderly patients visiting a primary care practitioner than among the general population.  Obvious symptoms the primary care staff can observe are disorientation, falls, bruises, memory loss, poor hygiene, and poor nutrition. The drug-abusing elderly patient may complain of anxiety, depression, blackouts, elder abuse, incontinence, an increased tolerance to medication, difficulties in decision-making, sleep problems or idiopathic seizures (Dar, 2006). Elevations of liver enzymes often indicate chronic alcohol abusers.
Psychological screening can be accomplished with the Short Michigan Alcoholism Screening Test Geriatric Version (SMASTG). Tests can be self-administered or completed by a clinician or computer. The benefit of the primary care setting is the older addicted adult patient expects inquiry by the primary care staff and a level of trust has already been established (Naegle, 2008). The Alcohol Related Problems Survey (ARPS) is a sixty-question survey that aims to detect the older adult population who is at risk for, or already experiencing, problems with alcohol or drug use in combination with their comorbidities and medication use (Fink et al., 2002). 
Screening should not necessarily be limited to the primary care setting. Clinical specialists and emergency room personnel, as well as members of the helping professions, hospital staff, clergy, and social workers all have opportunities to appropriately screen for substance abuse. Some hospitals already have a substance abuse counselor on staff. Screening does not need to be limited to the medical or psychiatric setting. Other areas may include senior housing and adult senior recreation centers. Dom, Hulstijn, and Sabbe (2006) emphasize three important reasons to screen: the incidence of elder substance abuse is high enough to justify screening; the adverse effects of ongoing abuse are significant; and effective treatment options exist which are cost effective and life changing.  
Regardless of the type of drug abused, preserving an older person’s dignity is a primary goal of age specific treatment (Colleran & Jay, 2002). The older addict’s treatment needs are different from the younger addicted population. The older adult in treatment is both cognitively and physically slower. They may need rest periods or more time between sessions. In process groups this older generation may be reluctant to participate with younger patients and older women may be hesitant to discuss personal issues with men present. 
Both dialectic behavior therapy (DBT) and cognitive behavioral therapy (CBT) have been shown to be successful with older adults (Blow, 2003). These therapy methods can teach relationship skills, allowing patients to rebuild social support networks, as well as using self-awareness approaches to overcome grief, loneliness, and depression. 
The SAMHSA consensus panel summarizes the needs of an elder abuse treatment program as follows: 
  • Age-specific treatment that is supportive and nonconfrontational
  • Focuses on coping with age-related loss or loneliness 
  • Emphasis on rebuilding individual social support
  • Pace and content that is age appropriate 
  • Staff members who are experienced and interested in serving the older population
  • Linkage with medical and aging services 
  • Linkage with other medical services and case management (Blow, 1998)
Types of Treatment  
Whatever the type of treatment selected, the time spent in treatment is directly related to success in recovery (Colleran & Jay, 2002). The choice of treatment setting is influenced both by the physical and mental condition of the patient as well as the ability of the patient to pay. Insurance coverage varies according to plan. Medicare covers most of the cost for acute detoxification and day treatment in a partial hospital program (PHP)—PHP/day treatment is more affordable as the patient returns home at night. Residential or hospital inpatient care may be the most appropriate care for the older adult with comorbid conditions that require medical care.
Selection of treatment type may also be influenced by the aging addict subset. The early onset alcoholic with a long drinking history and accompanying medical issues may need a longer, more intensive program than the late onset alcoholic who has a shorter alcoholic history; research has shown they respond better to treatment and have a higher sobriety success rate. Baby Boomers have been reported to negatively relate to other older alcoholic patients who may be judgmental of the Baby Boomers illicit drug abuse history. One treatment facility has a treatment program specifically for Baby Boomers separate from their program for other older adults. The Boomers could not identify with the seventy-eight-year-olds. As far as prescription drug treatment, Gurnack, Atkinson, and Osgood state “Until we have more data concerning treatment outcomes, we assume much of the experience with alcohol treatment can be translated to prescription drug users” (2002).
Is treatment worth it? Research has shown the elderly can learn new things and have successful treatment results. In fact, Osgood concludes that “the aging addict follows treatment regimens more thoroughly and has good, if not better, treatment outcomes than much younger patients” (2002). 
Remember, it is never too late to develop an alcohol or drug problem, it is never too late to intervene, and it is never too late to recover. 
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