Symptoms of alcoholism and drug abuse are difficult to detect in the elderly. Sleeplessness, shaky hands, memory loss and chronic health complaints are often misread merely as signs of aging. In addition, many older people are no longer in a working environment and have little social contact, and so, they are not as likely to encounter others who will recognize their symptoms and intervene.

According to a Columbia University study of women over age 59, only 1 percent of primary-care physicians considered a substance-abuse diagnosis when encountering common symptoms of alcohol abuse.

Instead, symptoms such as insomnia, poor concentration and coordination, confusion and depression are blamed on "old age."

"Elderly alcoholics are more common than people realize or want to believe," says Peg Krach of Purdue University. "It's a serious problem that's being ignored."

So, although family, friends and even the family doctor are not aware of an older person's drinking or drug use, why don't the elderly seek treatment on their own?

Stigma. Many older adults raised on the philosophy that they should be able to solve their own problems, are embarrassed by their problem and shun counseling.

Even if elderly people do seek help, they most likely will not find any program tailored to their special needs. According to Robert Bozzone, CAP, MAC, the executive director and CEO of the Comprehensive Alcoholism and Rehabilitation Programs (CARP) for Palm Beach and Martin Counties, Florida, these needs include the identification and focus on the addiction problem, and the psychological, medical, social and family problems that face elderly people.

But, elderly substance abusers who do seek and find treatment are usually receptive to and compliant with treatment, and have good outcomes.

According to a May, 1998 report by the Center for Substance Abuse Treatment, the abuse of alcohol and legal drugs is an "invisible epidemic" that affects up to 17 percent of adults age 60 or older.

"Alcohol slows down brain activity, affects judgment, coordination and reaction time and increases risks of falls and accidents . . . over time it permanently damages the brain and nervous system, as well as the liver, heart, kidneys and stomach," the AgePage of the National Institute on Aging explains. "Alcohol's effects makes some medical problems hard to diagnose- including dulling the warning pain of a heart attack.

Besides alcohol, drugs most commonly used by adults over 65, the Mayo Clinic's department of geriatric medicine reports, are "cardiovascular drugs, antihypertensive agents, analgesics, anti-inflammatory drugs, sedatives and gastrointestinal preparations . . . Drug use among institutionalized elderly is even more prevalent." This chemical cocktail leaves older adults vulnerable to adverse drug reactions, inadvertent addiction, and puts a toxic load on the liver and kidneys.

Difficult to diagnosis and treat

Alcohol and substance-abuse cases in older adults are harder to diagnose because one-third of the people with problems didn't abuse alcohol in earlier years, or have the associated health problems, or problems with the law or dysfunctional families. They aren't generally in the workforce where poor performance might reveal a problem. This dispels the myth that all older alcoholics are "the guy under the bridge."

The World Health Organization's charter on alcohol describes three types of elderly drinkers:

• early-onset drinkers who have ongoing problems which shorten their life span;
  
• late-onset drinkers (or "reactors") who drink later in life, in response to grief, loneliness and pain.
  
• intermittent or binge drinkers who use alcohol occasionally "and sometimes drink to excess, which may cause problems."

Not only are older adults living longer these days, increasing the elderly population, studies show they are drinking more alcohol at a time when physical changes due to aging cause them to be less tolerant to it.

"The same amount of alcohol can have a more detrimental effect than it would on a younger person," WHO's charter report on alcohol notes. Body water levels are less so the alcohol is not as diluted by the body; there is more fat; there is decreased hepatic blood flow and an inefficiency of liver enzymes; altered brain responsiveness and other metabolic changes.

"Aging tends to be associated with a growing burden of disease and prolonged heavy drinking is itself a cause of health problems such as liver disease, raised blood pressure and some forms of cancer. Alcohol misuse may also lead to an increased likelihood of falls, incontinence, cognitive impairment, hypothermia and self-neglect. These problems may be regarded by health professionals and family members merely as signs of aging," according to the 1997 report.

There are approximately 3 million older adults in America who abuse drugs and alcohol, Carol Colleran, CAP, ICADC tells Counselor. She is director of Older Adult Services at Hanley-Hazelden in West Palm Beach, Florida.

Colleran explains: "Florida has the highest population of older adults in this country, therefore it also has the largest number of older adults suffering from alcohol or drug problems. There are approximately 300,000 people in Florida alone with alcohol and drug dependencies."

The early-onset group consists of older, chronic cases who are usually alone and "in need of more intensive care," explains Bozzone. They have multiple health problems such as liver disease, complications due to malnutrition and more.

For seven years, CARP ran the Domiciliary, a 20-bed residence for indigent, late chronic elderly alcohol and drug addicts. Due to lack of funds the residence closed in 1997.

"Not a lot of people know how to treat the elderly, who have multiple diagnoses, and this also makes them expensive to treat," says Bozzone. Some residents at the Domiciliary spent one to two years in treatment, "and had serious organic problems. Some could eventually be capable of functioning well within that environment, but not in the community. They needed ongoing support."

This is in vivid contrast to the other level of older substance abuser, who might have just begun drinking heavily once he or she retired and discovered that you can only play so much golf or cards, and that in these circles social drinking begins midday. These are late-onset alcoholics.

Elderly, late-onset alcoholics drink for different reasons than their younger counterparts. The elderly often begin drinking heavily as a social thing, something to fill their time. Or they may begin drinking more after the death of a spouse, as a reaction to grief and loss. They may become an invalid, and find that alcohol soothes physical pain when mixed with their prescriptions - or when their prescription painkiller runs out. Some retirement communities "are hotbeds of alcohol problems," Colleran says. And, since many older people don't drive at night anyway and isolate themselves during the day, their substance use goes undetected.

Another group may have had an alcohol problem on and off, but remained somewhat functional, until old age and medical problems caught up with them. Now they're not only drinking more, they're taking 15 prescription meds a day plus over-the-counter preparations.

With the latter two groups, although they may speak with adult children over the phone, for example, and the kids may notice slurred speech, these adult children didn't grow up in an alcoholic home and don't consider this as a possibility.

The following physical and mental problems often associated with aging are exacerbated or in a few cases can be triggered by substance abuse: hypertension, stroke, a greater susceptibity to illness due to impaired immune systems, cirrhosis and other liver disease, brittle bones, gastrointestinal bleeding, sleep disorders, depression, anxiety and other mental-health problems.

"More older adults are admitted to hospitals as a result of alcohol or drug-related injuries than for heart problems," notes Colleran, but the diagnosis may reflect the presenting problem (broken hip) rather than the cause (poor coordination due to substance abuse that caused a fall).

"In one year, 70 percent of all elderly hospitalizations were alcohol or medication related, a 1991 study showed. This includes broken hips from falls, etc."

Rx Addiction

Now consider that "Eighty-three percent of the elderly take prescription medications, 50 percent of this group take sedatives or some sort of prescriptions that are addictive," notes Colleran.

"Although they comprise 11 percent of the population at this time (and this figure will rise rapidly as baby boomers age), older adults take 36 percent of all of the prescriptions written, as much as 15 prescriptions per year per older adult."

"Elderly individuals use prescription drugs approximately three times as frequently as the general population, and the use of over-the-counter medications by this group is even more extensive . . . making the elderly the largest consumers of legal drugs in the United States," the Psychiatric Times reported in the April, 1999 issue.

The most common drug addiction, Colleran says, is to the benzodiazepines (minor tranquilizers), which are highly addictive.

"Every chemical has a half life in the system, which is how long it stays stored in receptor sites in the body. Valium, Xanax and Librium have the highest half lives. This means they build up more, hence withdrawal is very slow and difficult and long.

Many people think Valium is a harmless medication, but it is highly addicting. It was initially designed to be a 14-day trauma drug," she says, "but doctors prescribe it far too readily. I have older adults who have Valium addictions of 20, 25, even one woman 30 years. Because of metabolism changes, a decrease in body water content and increase in fat content, when it comes to older adults and drugs, less does more.

"Prescribing benzodiazepines for the elderly may be particularly risky because there are some reports of a positive correlation between the use of benzodiazepines and confusion, falls and hip fractures," the Psychiatric Times noted.

"Prescription drugs are the most common addiction; illegal drugs tend to be quite rare," Colleran says, with benzodiazepines and then pain medications accounting for the largest group of abused meds.

"This makes drug dependency even more difficult to treat, because older people process through treatment more slowly. They take longer to clear cognitively and when you add a drug addiction to the process, you find the withdrawal protocol needs to fit the situation. This means an extended drug detox process, often taking the majority of the month-long stay. This process is normally a 10-day taper protocol. Interestingly, the number of prescriptions for benzodiazepines have gone down in all age groups except in older adults."

Older women are 37 percent more likely to get a prescription of benzodiazepines than men, according to a two-year study by the Center for Alcohol and Substance Abuse at Columbia University.

The elderly may see half a dozen doctors and get prescriptions from each and think there's nothing wrong with taking all these drugs because "my doctor prescribed it." Besides different absorption rates due to age, lessened absorption of nutrients, when you add alcohol to many drugs the picture is even cloudier. Benzodiazepines, for example, "depress the rate of alcohol breakdown so that the effect of alcohol may be increased" and alcohol taken with certain antidepressants may worsen depression (Alcohol and the Elderly, WHO).

Alcoholism often undetected

The National Institute of Alcohol Abuse and Alcoholism (NIAAA) reports that "Hospital staff are significantly less likely to recognize alcoholism in an older patient than in a younger patient." This despite studies which show that 6 to 11 percent of elderly patients admitted to hospitals exhibit symptoms of alcoholism, "as do 20 percent of elderly patients in psychiatric wards." (Alcohol and Aging, April 1998).

Shaky hands are attributed to Parkinson's; cognitive dysfunction, confusion, slurred speech or memory loss to a TIA or ministroke, Alzheimer's or other dementia. Irritability and agitation or sadness may be blamed on depression or Alzheimer's. Sleep disorders, very prevalent in the elderly, can be aggravated or caused by alcohol (for example, sleep apnea or early waking and an inability to go back to sleep at night).

Because of ageism (the tendency of society to assign negative attributes to older adults), Colleran of Hanley-Hazelden believes doctors are more likely to try and treat the symptoms - often with another drug - than look for an underlying cause. Adverse drug reactions from polypharmacy or an individual medicine can look like strokes, panic attacks, substance abuse or another illness, perpetuating the cycle of prescribing for symptoms.

"Often professionals are just not aware of it, they see a little old grandmother and don't think of substance abuse. We need to educate professionals as well as the public," Colleran says.

To this end, she teaches a physician-in- residence program at Hanley-Hazelden that is partly experiential. "Many doctors have no idea of how to treat older adults for alcohol or drug addiction. I teach a class from one to two hours about dependency, barriers to treatment, we do an aging sensitivity exercise. I also do workshops and keynote speaking with counselors and other professionals across the country, to help them understand older adults' values and issues, what it's like to have macular degeneration, to lose hearing, touch, taste. Most doctors have no idea what this feels like."

There is another barrier to treatment for the elderly: the bias of professionals. Studies show that doctors are less likely to detect substance abuse in women, in professionals, in educated people and those with higher socioeconomic standing.

"They think of the old man living under a bridge" when they think of elderly substance abusers, says Colleran.

Another barrier to treatment is that even if doctors or family members do recognize that someone appears to have an alcohol problem, the attitude is often "Why bother? Leave them alone, let them enjoy it."

But Colleran says, "Being isolated, steeped in the disease of alcoholism or a drug fog is not fun, they are not happy. But professionals are willing to close their eyes to that."

"It's a mistaken belief that older persons have little to gain from alcoholism treatment," NIAAA director Enoch Gordis told Aging Today in 1999.

"In one CASA report where 400 doctors were interviewed, they were given a hypothetical case of an older woman who had symptoms of possible alcohol and substance abuse," Colleran notes. "Doctors studied the symptoms and picked their five top diagnoses. Over 90 percent said depression, and less than 1 percent even mentioned the possibility of alcohol or substance abuse."

And of course, depression and substance abuse can also go hand in hand, in which case patients need treatment for both disorders.

At Hanley-Hazelden, Colleran was instrumental is setting up a separate unit, a building designed strictly for people 55 and older, after watching older adults leave treatment prematurely.

"These people did not grow up in the self-help age, sharing feelings, telling secrets. They're not comfortable in group therapy; they don't discuss their problems. Their families may have had an alcoholic Aunt Hilda they kept in a back room, but they didn't talk about it. You just can't plunk these people into traditional treatment.

"They don't know what treatment is, don't understand alcoholism as a disease. To them it's a moral issue. Shame is a major issue for them because of this. You can't throw the retired CEO who lives on a golf course in with a 20-years younger heroin or crack addict. They can't relate and won't share. To the retiree, these addicts' stories of living on the street are so much worse than their situation."

However, outcome studies show that age-appropriate treatment is very helpful, especially if combined with after care and a continuing program, Colleran says. That's because this generation grew up with respect for authority, following orders and strict values. Interventions with family, physicians and clergy tend to be effective with older adults.

But family interventions aren't as common because the older adults often move away so family members don't see the drinking or confusion due to polypharmacy. It's rare that an older adult will present him- or herself for treatment.

Ironically, this respect for authority also contributes to their substance abuse, Colleran notes. Unlike baby boomers who "question everything," older adults take prescriptions from doctors without question, and may be reluctant to reveal symptoms or problems that could point to adverse drug reactions or a pattern of addiction.

Peg Krach, a professor of nursing at Purdue University who specializes in elder care, agrees that the elderly should attend AA meetings with peers. They also need to be educated about alcoholism and how drinking and taking prescription meds can threaten their health.

"Confrontations should be less aggressive with an older drinker," warns Krach. "This age group grew up in a time when alcohol was considered a sin or social stigma. So it's best to refer to it as a "drinking problem" rather than alcoholism."

Family members should make a list of all the prescriptions and OTC medications the person is taking to present to his or her doctor, and tell the physician that their relative is drinking, Krach suggests.

Sadly, another reason substance abuse may continue is that family members don't want to "rock the boat" - and risk losing an inheritance - by exposing the older adult's addiction to the rest of the family and their physician, adds Colleran.

"Although it takes longer and is more difficult to treat the older adult, once they get in treatment they have the highest rate of recovery of any age group," says Colleran, "I think because of their values and willingness to follow directions."

How to detect substance abuse

When it comes to detecting substance abuse, "There are no major diagnostic tools for screening this population," according to Colleran.

"Physicians ask few questions, don't probe and are unlikely to even consider the diagnosis or explore alcohol use among patients. There is a lack of education in this area and a lack of comfort dealing with the subject."

She recommends several tools for counselors, including the MAST-G (the G is for geriatric) for alcoholism, and the Geriatric Depression Scale. The Millon Clinical Multi-Axial Inventory III has shorter questions geared toward older adults.

During Project GOAL (Guiding Older Adult Lifestyles), a randomized controlled clinical trial to test the effectiveness of brief counseling on older problem drinkers, researchers at the University of Wisconsin Medical School based part of their health screening on CAGE:

 C— How do you feel about Cutting down on your drinking?
 A— Are you Annoyed by others criticizing your drinking?
 G— Do you feel Guilty about drinking?
 E— Have you ever felt the need for an Eye-opener?

This study showed that "brief intervention can reduce alcohol consumption in problem drinkers aged 65 years and older," as reported in the Journal of Family Practice (volume 48, number 5, 1999).

Patients in an intervention group received a general health booklet and saw their personal physician for two, 10- to 15-minute interventions one month apart which included a workbook for feedback, drinking diary and a drinking contract - "in the form of a prescription." Two weeks after each visit, they got a follow-up phone call from a nurse.

Study leader Michael Fleming, M.D. reported that the intervention group experienced a 34 percent reduction in weekly use of alcohol and a 74 percent reduction in the number of binge-drinking episodes. He concluded: "Efforts should be undertaken to incorporate brief intervention protocols into routine clinical practice."

A simple way of monitoring polypharmacy to avoid abuse could be just to ensure that all of the adult's prescriptions come from one pharmacy, and insisting that different specialists communicate with each other regarding what is absolutely necessary for the patient.

Whenever possible, consider alternatives. Acetaminophen combined with alcohol is more dangerous to the liver; an arthritic patient could ask about another drug for pain relief during and after treatment.

A physician must be involved when counseling an older adult for substance abuse, because of all these factors. But the counselor may find they have to educate the physician along with the patient!

What does the future look like, with the baby-boomer generation about to enter old age?

Psychiatric Times warns: "Increasing proportions of younger substance abusers are surviving into late life. These substance-abusing survivors and individuals who develop drug problems later in life will cause an increase in the number of elderly drug abusers in our population" (April, 1999).

By 2030, according to a U.S. House of Representatives study, one-third of our population will be older adults, Carol Colleran notes. Baby boomers are more active and mobile, but we have to have a plan for and with them for the future, she says.

"I really encourage professionals to look in the direction of older adults and chemical dependency, not only on what's needed to treat them, but also with an eye toward developing more age-appropriate screening and assessment tools and writing about this."

Mary Ellen Hettinger is a freelance writer and
editor who specializes in health and wellness issues.

No one has commented on this article.

Please keep your comments brief and on topic, and remember that this is not a discussion thread.
Name :
Comment(s) :

J! Reactions 1.09.00 • Professional Site License
Copyright © 2006 S. A. DeCaro

---