Currently more than eight million older adults are dependent on alcohol or medications — one-third of them suffer from late onset addiction. By 2030, one-third of the population will be older adults. If trends continue at current rates, there will be millions more seniors by then with alcohol or other chemical addictions.

Multiple factors contribute to this burgeoning problem. For one, older adults are currently under-treated for addiction, and specific treatment for older adults is rare. Second, they are more apt to be isolated, so symptoms of addiction aren’t obvious. Third, older adults also are resistant to treatment, feeling it is immoral to be alcoholic or have an addiction. Fourth, families fail to acknowledge the problem and physicians misdiagnose it (Califano, J., 2000; Colleran, C. and Jay, D. 2002; Blow, F., 1998).

Not surprisingly, physicians, other health care professionals, and caregivers commonly mistake symptoms for other conditions. Older adults take an average of 13 prescriptions annually. They may be fearful or find it difficult to discuss their problems with alcohol or medications. In addition, they suffer from co-morbid disorders at a higher rate (Jacobs, 2002), and often have medical or mental complications that mimic or mask symptoms of addiction.
Complicating matters, family members may not realize the extent of their older loved one’s drinking, or they may react with ambivalence. Relatives and friends often subscribe to this myth: “It’s all the pleasure she has. Leave her alone.” Or, “There is nothing we can do about it; I can’t even bring it up.” When these myths play out, the results are tragic.

But certain steps — if the addiction field takes them — can help prevent the tragedies associated with late-onset addiction. This progress begins with frontline professionals knowing the risk factors and solidifying their understanding of generational values. Further, by understanding the risk and protector factors relative to late onset addiction, we can open a dialogue and encourage older adults to incorporate healthy behaviors and coping strategies into their daily lives.

Late-onset addiction: risk factors
While biological age is an obvious risk factor, all risk factors are associated with an individual’s medical, emotional, social, and practical problems, as well as with gender.

Medical factors: In older adults, adverse medical situations often result in chronic pain, physical disabilities and handicaps, insomnia, sensory deficit, reduced mobility, and cognitive impairment. In addition, medications, both over-the-counter and prescription, pose a risk in the sheer numbers of different medications taken by a single person. Often multiple physicians prescribe different medications to a single person, sometimes without the awareness of all the medications being taken by that person. Noncompliance with prescriptions is common, including unintentional or uninformed choices, like sharing drugs. Also, many older people intentionally self-dose — cutting up pills or tampering with capsules.

Alcohol also can cause complications with medicines. Moreover, a lessened physiological ability to handle alcohol comes with age. As people age, their bodies absorb, metabolize, distribute and eliminate drugs differently than younger people, so a “normal” dose can cause dangerous side effects and toxicity, and stay in the body longer. Someone may be addicted to psychoactive medications, having taken them for years, but since a doctor prescribed it, “It must be okay.” And when an older person is actively addicted to and seeks these drugs, they will try to manipulate the doctor into prescribing them.

Emotional and social factors: Reduced health or economic status, as well as major life transitions (e.g., the death of a spouse, or moving out of their home of 50 years) are potential emotional and social landmines for seniors. Retirement or other job loss may be devastating to someone who is emotionally unprepared. Some seniors have described feeling like a “non-person.” The loss of social status and sense of professional identity can be intense, resulting in a lack of self-esteem. Self-esteem issues also relate to feeling unattractive when one looks his or her age; not surprising in a society obsessed by youth. Certainly loneliness and a lack of life purpose, even problems in managing leisure time are common with retired people, as are escalating conflicts with family or spouse.

Bereavement over the loss of a spouse can result in ongoing depression and loneliness as well as the loss of connections that the couple may have enjoyed. When an older person or couple moves to a retirement home, perhaps in a different geographic location, this may mean moving away from family, friends, and the family home. Retirement communities, though they offer social activities and support services, may pose new risks with their heavy reliance on alcohol-related activities. The daily happy hour may become a ritual and often the social hub.

Practical factors: Practical risk factors include: impaired self-care and reduced coping skills; decreased economic status and security; or actual poverty due to income loss or increased health care costs.

Gender factors: Research from the U.S. Department of Health and Human Services (DHHS), Office of Applied Studies, shows that older women are more apt than men to suffer from depression. Women tend to outlive men, so bereavement affects them in greater numbers. Women also have a tendency to become affected by alcohol faster than men and suffer worse physical consequences. Older women also are prescribed at least one-third more psychoactive medications, and for longer periods of time (CASA, 1998). Socio-economic status is not an indicator of the scope of late onset addiction.

Late onset addiction protector factors
By definition, protector factors promote healthy behaviors that empower an individual to manage life events and, thus, encourage resilience. Protector factors related to alcohol abuse include social, psychological, physiological and life transition issues, such as the following:

• embracing a sense of purpose and identity
• an ability to live independently
• access to housing and healthcare resources
• supportive family relationships
• involvement in community activities
• availability of social bonds and support networks
• engaging in hobbies, interests or volunteering

Medication misuse can be improved with better patient/physician communication. Healthcare professionals need to carefully explain how and when medications must be taken and what must be avoided. Consolidating a patient’s prescriptions at one pharmacy should be advised, and specialists can be requested to communicate with each other about prescriptions. Older patients, for their part, are hardly pro-active in asking doctors questions about their healthcare or medications. They need encouragement to speak up. Helping seniors to understand the importance of sharing prescription and over-the-counter medication information with pharmacies and health care providers is vital. Better discipline in a physician’s refill policies also can prevent many problems.

Mental health issues are more prevalent in older populations, including situational depression and chemical imbalance, and proper medication management is necessary. Sometimes, psychoactive medications are prescribed when therapy and more social interaction would help a person to recover from situational depression. Also key to a healthy mental balance are: physical activity — matched to an individual’s capacity; mental stimulation and exercises; and stress reduction techniques, from yoga, to meditation, to appropriate exercise. The role of good nutrition includes maintaining a healthy diet, reducing or eliminating tobacco use, and moderating caffeine intake.

When social activities center on drinking, a dangerous pattern is set, even for those who traditionally haven’t been heavy or even social drinkers. Education programs are needed for social directors of senior residences as much as they are for older adults.

Relating to an older generation’s world view
Whenever counseling older adults, it is essential to not patronize them — to be sensitive to the values and tone of this generation and communicate appropriately. Older people generally resist being associated with alcohol abuse on moral grounds, and those entering treatment don’t want to be lumped with anyone addicted to illicit drugs. These are clues to this generation’s behaviors and attitudes.

Today’s older adults reached adulthood before the age of widespread psychotherapy. To air your “dirty laundry” was not done, since you were expected to “pull yourself up by the bootstraps,” instead of embarrassing yourself by complaining. Hard work, sacrifice, achievement have all been valued by older adults. When approaching an older person about a problem with alcoholism, put yourself in his/her shoes. The reaction is going to be defensive, because “alcoholism” resonates with “bum” or “wino.” “Addiction” conjures up visions of derelict drug addicts. Presenting addiction as a disease and not a moral issue is vital. Direct confrontation rarely works with this patient, and rapport is apt to build more slowly between counselor and client.

Because older adults generally respect authority figures, a physician is in an appropriate position to perform a brief intervention when a person’s drinking is problematic but not alcoholic. These interventions have been shown to reduce or even halt the behavior, according to Dr. Fred Blow, senior associate research scientist and associate professor, University of Michigan Department of Psychiatry. Convincing the older alcoholic to seek help can be a daunting task. In the counseling room, successful assessment includes using age-appropriate tools, such as the Michigan Alcohol Screening Test-Geriatric Version (MAST-G), which respects the individual and avoids charged words and terms.

Age-responsive treatment
Age-responsive treatment for older adults has been found to have a higher rate of success than with other age groups. It starts with the setting — a comfort zone for older peers, where they feel safe sharing concerns and histories.

Residential treatment in this type of program is slower paced, due to older patients’ general physical status, decreased mobility and co-existing medical and psychological conditions. Interactions between alcohol and medications may have caused serious medical complications, and patients are often malnourished or cognitively impaired. A full assessment takes into consideration these factors, and when possible, includes meetings with family members, because the patient may be delusional, or is unwilling or unable to describe his or situation or history. The patient’s medical condition and medications are closely monitored.

A holistic treatment approach that addresses mind, body, and spirit helps older patients in their recovery process. As primary treatment progresses, many patients derive physical and emotional benefits from mild exercises such as yoga, hydrotherapy, stretching, and walking outdoors.

Co-morbid conditions such as depression and anxiety are common among older patients, and should be addressed in therapy. Many have lost touch with friends and interests, and benefit from sharing stories. Learning to share grief, which is difficult for many older adults, is also therapeutic. Early in treatment, they are often reluctant to talk about problems with alcohol or medications, but are more comfortable talking about heir lives. This can become the important segue to discussing how alcohol abuse caused problems in their lives. Visits from volunteer older adult alumni bring inspiration for life in recovery, and describe how Alcoholics Anonymous (AA) can be supportive. The patient leaves primary treatment, with an aftercare plan that encourages participation in AA. Many of these older adult alumni come out of treatment with a renewed sense of self and purpose, and often volunteer their services or seek another career.

Raising the bar in prevention and treatment
As people live longer, require more social and health services and the baby boom cohort ages, the number of older adults who suffer from addictions will swell. Will resources be able to respond? Prevention of late onset addiction seems vital. Because addiction in older adults is often overlooked or misunderstood, the need for awareness, educated assessment and diagnosis, and quality treatment must be addressed now. The associated costs in financial and personal terms for older adults in addiction are already huge. The “Golden Years” for untreated older adults are anything but, yet with age-responsive treatment, older adults can recover, often to enjoy life for many years.

Carol Colleran, CAP, ICADC, serves as Executive Vice-President of Public Policy and National Affairs at Hanley Center, West Palm Beach, Fla., and is co-author (with Debra Jay, PhD) of Aging and Addiction: Helping Older Adults Overcome Alcohol or Medication Dependence. For more information about Hanley Center’s older adults program, call 1-800-444-7008 or 561-841-1000, or visit the web site at www.HanleyCenter.org.

References
Blow, F.C. (1998). Substance Abuse Among Older Adults, TIP #26, SAMHSA.
Califano, J. (2000). Missed Opportunity: National Survey of Primary Care Physicians and Patients on Substance Abuse. The National Center on Addiction and Substance Abuse at Columbia University.
Colleran, C. and Jay, D. (2002). Aging and Addiction: Helping Older Adults Overcome Alcohol or Medication Dependence. Hazelden Publishing.
Jacobs, Nancy. (2002). Achieving Outcomes: A Practitioner’s Guide to Effective Prevention. DHHS/
SAMSHA/CSAP, Conference Edition.
The National Center on Addiction and Substance Abuse (CASA) at Columbia University. (1998). Under the Rug: Substance Abuse and the Mature Woman.

This article is published in Counselor,The Magazine for Addiction Professionals, October 2005, v.6, n.5, pp.48-55.

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