I recall when I was doing a field placement in a geriatric care facility in Joliet, Illinois, I encountered a resident who kept a flask of whiskey in his robe pocket and seemed to always have a ready replacement when one was empty. Often the patient was in a stupor and had several incidents in which falls and other accidents had impacted his health. When discussing this with one of the administrators, I was surprised to find that instead of concern about the abusive pattern, or how the alcohol was being supplied, the staff person suggested that this behavior didn’t hurt anyone. The patient had been a regular drinker his entire life, this staff person continued, and why should anyone begrudge him a little pleasure in his final years of life. This was forty years ago, and at the time I was a student, trying to learn about geriatric care, with little knowledge or self-confidence. I didn’t realize either the gross misunderstanding this administrator’s statement represented, or the shocking lack of appropriate care. Even people advanced in age can benefit from life changes that increase health and resilience. As the U.S. population ages, increasingly we are going to have to come to terms with problems of alcohol and substance use that were once the province of younger people. Trends reported to SAMHSA’s Treatment Episode Data Set (TEDS) show an increase of 32% in the number of older adult admissions from 1995 to 2002 and that trend is accelerating. Primary drug admissions among older adults increased 106% for men and 119% for women in the same period.
Results of the National Household Survey on Drug Abuse suggest that more than two million people 65 and older had some sort of alcohol problem. Likewise, a study titled “Substance Use by Older Adults: Estimates of Future Impact” (Korper, 2002) estimated that by the year 2020, the number of problem substance abusers aged 50 or older will reach five million.
Changes in the aging body – lower tolerance, decreased water content, and less efficient metabolism – mean that an aging person may not be able to use alcohol or other drugs in the same quantity or frequency without increased consequences (Hawkins, 2008). These exaggerated reactions may not appear as typical “alcoholism” or “substance abuse” because of the smaller amounts involved, but may exacerbate problems that already are prevalent in older adults, such as hypertension, diabetes, gastrointestinal problems, lower bone density, sleep problems, as well as various mental health diagnoses. It has been many years since the clinical community recognized that children are not just “small adults” and need to be treated by professionals with special knowledge and skills. A similar realization is needed that elderly persons are not clinically equivalent to “young people with more wrinkles.”
Overdose, medications errors, and such aside, there are a number of interesting modalities in incidence of actual dependency, but two important categories are early and late onset. Early onset describes the history of individuals who have abused substances for many years and now are joining the ranks of the elderly. Though this group is partially self-winnowed by the number who die from their addiction or develop such catastrophic medical consequences they are forced to abstain, there are increasing numbers entering the geriatric age set, whose baby-boomer lifestyle included regular use of illegal drugs or excessive alcohol use.
More problematic in some ways, is late onset dependency, because a life of responsible use makes both the individual and his/her support system hesitant to apply a label that never before fit. Seniors are less ready to admit a problem that had an even greater stigma during their youth than it does today.
Yet healthcare providers, themselves, sometimes maintain ageist attitudes. They may not be trained to recognize signs of substance abuse, may be unwilling to listen attentively to older patients, and often dismiss older patients’ observations about their own attempts at diagnosis, while attributing all complaints or changes in health status merely to the aging process. (Walker, 2004)
With over 30% of seniors taking eight or more prescriptions medications, as well as over-the-counter drugs and supplements, many seniors are not only in danger of over-medication, but may fit the definition of abuse, because they use more than their health conditions require and become victims of dependency. The potential for harmful interactions and overmedication are so wide reaching that one researcher stated, “Any symptom in an elderly patient should be considered to be a drug side effect until proven otherwise.” (Gurwitz, et. al, 1997)
There is plenty of good news along with the alarms. Increasing resources are available to train clinicians in the specific needs of the aging. Furthermore, seniors tend to respond well to intervention, with those needing treatment completing at a higher rate than younger people. Also, those who may not have crossed the line into addiction often benefit from interventions that may change patterns or frequency of use. (Promoting Older Adult Health, SAMHSA, 2002).
The following features are recommended for incorporation into the treatment of older persons:
- Age-specific group treatment that is supportive and non-confrontational, which aims to build or rebuild self-esteem.
- A focus on coping with depression, loneliness, and loss.
- A focus on rebuilding the client’s social network.
- A pace and content appropriate to the older person (noting potential sensory and cognitive losses).
- Staff who are interested and experienced working with older adults.
- Linkages with medical services, services for the aging, and institutional settings for referral in and out of treatment, including case management. (Schonfeld and Dupree, 1996)
Elements of specialized treatment elements, including modality specific strategies and phase appropriate interventions for older adults are described and organized in a excellent guides available from the Center For Substance Abuse Treatment, including the valuable Treatment Improvement Protocol (TIP) #26.
Barry T. Hawkins, Ph.D. is the Director of Chemical Dependency Services for Orange County, New York, and the Mental Health liaison to the Orange County Geriatric Mental Wellness Alliance.