Substance Abuse Among Older Adults: an Invisible Epidemic

1 Substance Abuse Among Older Adults: An Invisible Epidemic ubstance abuse, particularly of alcohol use and misuse of substances, along with a and prescription drugs, among adults 60 reluctance to seek professional help for what S and older is one of the fastest growing many in this age group consider a private health problems facing the country. Yet, even as matter. Many relatives of older individuals with the number of older adults suffering from these substance use disorders, particularly their adult disorders climbs, the situation remains children, are also ashamed of the problem and underestimated, underidentified, choose not to address it. Ageism also contributes underdiagnosed, and undertreated. Until to the problem and to the silence: Younger relatively recently, alcohol and prescription adults often unconsciously assign different drug misuse, which affects up to 17 percent of quality-of-life standards to older adults. Such older adults, was not discussed in either the attitudes are reflected in remarks like, substance abuse or the gerontological literature “Grandmother’s cocktails are the only thing that (D’Archangelo, 1993; Bucholz et al., 1995; makes her happy,” or “What difference does it National Institute on Alcohol Abuse and make; he won’t be around much longer Alcoholism, 1988; Minnis, 1988; Atkinson, 1987, anyway.” There is an unspoken but pervasive 1990). assumption that it’s not worth treating older Because of insufficient knowledge, limited adults for substance use disorders. Behavior research data, and hurried office visits, health considered a problem in younger adults does care providers often overlook substance abuse not inspire the same urgency for care among and misuse among older adults. Diagnosis may older adults. Along with the impression that be difficult because symptoms of substance alcohol or substance abuse problems cannot be abuse in older individuals sometimes mimic successfully treated in older adults, there is the symptoms of other medical and behavioral assumption that treatment for this population is disorders common among this population, such a waste of health care resources. as diabetes, dementia, and depression. Often These attitudes are not only callous, they rest drug trials of new medications do not include on misperceptions. Most older adults can and older subjects, so a clinician has no way of do live independently: Only 4.6 percent of predicting or recognizing an adverse reaction or adults over 65 are nursing home or personal unexpected psychoactive effect. home care residents (Altpeter et al., 1994). Other factors responsible for the lack of Furthermore, Grandmother’s cocktails aren’t attention to substance abuse include the current cheering her up: Older adults who “self- older cohort’s disapproval of and shame about medicate” with alcohol or prescription drugs are 1 Chapter 1 more likely to characterize themselves as lonely for men (U.S. Bureau of the Census, 1996). Not and to report lower life satisfaction (Hendricks only are adults in general living longer, et al., 1991). Older women with alcohol substance abusers are also living longer than problems are more likely to have had a problem- ever before (Gomberg, 1992b). Thus, more drinking spouse, to have lost their spouses to Americans face chronic, limiting illnesses or death, to have experienced depression, and to conditions such as arthritis, diabetes, have been injured in falls (Wilsnack and osteoporosis, and senile dementia, becoming Wilsnack, 1995). dependent on others for help in performing The reality is that misuse and abuse of their activities of daily living (U.S. Bureau of the alcohol and other drugs take a greater toll on Census, 1996). affected older adults than on younger adults. In Alcohol use was less common in the 1930s, addition to the psychosocial issues that are 1940s, and 1950s than it has been since the 1960s. unique to older adults, aging also ushers in Many of those who are now 60 and older, biomedical changes that influence the effects influenced by prevailing cultural beliefs and that alcohol and drugs have on the body. Prohibition, never drank at all, and a negligible Alcohol abuse, for example, may accelerate the number used illicit drugs. Younger birth normal decline in physiological functioning that cohorts in this century tend to have increasingly occurs with age (Gambert and Katsoyannis, higher rates of alcohol consumption and 1995). In addition, alcohol may elevate older alcoholism (Atkinson et al., 1992). Thus, “the adults’ already high risk for injury, illness, and prevalence of alcohol problems in old age may socioeconomic decline (Tarter, 1995). increase, especially among women, for birth cohorts entering their 60s in the 1990s and The Problem Projected beyond”(Atkinson and Ganzini, 1994, p. 302). A recent study in Sweden found that the male-to- It will be increasingly difficult for older adults’ female ratio among older alcohol abusers substance abuse to remain a hidden problem as admitted for addiction treatment decreased the demographic bulge known as the Baby from 7.8:1 to 3.4:1 in the span of a decade Boom approaches old age early in the next (Osterling and Berglund, 1994). century. Census estimates predict that 1994’s Because there is a clear relationship between older adult population of 33 million will more early alcohol problems and the development of than double to 80 million by 2050 (Spencer, 1989; alcohol problems in later life, drinking among U.S. Bureau of the Census, 1996). Most of that older adults is likely to become an even greater growth will occur between 2010 and 2030, when problem in the near future (Rosin and Glatt, the number of adults over 65 will grow by an 1971; Gomberg, 1992; Zimberg, 1974; Helzer et average of 2.8 percent annually (U.S. Bureau of al., 1991a; Beresford, 1995a). Liberto and the Census, 1996). In 1990, 13 percent of colleagues concluded that the overall increase in Americans were over 65; by 2030, that bloc will alcohol problems throughout the population, represent 21 percent of the population (U.S. coupled with the aging of the Baby Boomers, Bureaus of the Census, 1996). The demographic suggests that the number of older adults with increases among older adults are summarized alcohol-related problems will rise alarmingly below and in Figure 1-1. (Liberto et al., 1992). Taken together, these Life expectancy in the United States has factors raise the prospect of tomorrow’s health increased. In 1950, it was 68 years, and by 1991, services facing a “potentially preventable ‘tide’ it had reached 79 years for women and 72 years of alcohol-induced morbidity” (Saunders, 1994, 2 Substance Abuse Among Older Adults p. 801). Further research is needed on the will mainly encounter abuse or misuse of physiological effects of marijuana on older alcohol or prescribed drugs. Abuse of heroin adults, because many children of the 1960s can and other opioids is rare, although some older be expected to carry this habit into old age. adults misuse over-the-counter drugs that have a high alcohol content, such as cough The Problem Now suppressants. Many of these over-the-counter drugs negatively interact with other medications Health care and social service providers who and alcohol. currently care for Americans age 60 and older Figure 1-1 Percentage Distribution of the U.S. Population by Age: 1995, 2010, and 2025 Ye a r 1995 2010 60 2025 50 40 30 Percentage 20 10 0 Und er 20 Years 20–64 Years 65 Years and Over Source:U.S. Census Bureau, 1996 3 Chapter 1 use—specifically targeted to this population— Alcohol Disorders: Older Adults’ are discussed in Chapter 4. Major Substance Abuse Problem Problems stemming from alcohol consumption, Prescription Drugs including interactions of alcohol with prescribed The abuse of narcotics is rare among older and over-the-counter drugs, far outnumber any adults, except for those who abused opiates in other substance abuse problem among older their younger years (Jinks and Raschko, 1990). adults. Community prevalence rates range from Prescribed opioids are an infrequent problem as 3 to 25 percent for “heavy alcohol use” and from well: Only 2 to 3 percent of noninstitutionalized 2.2 to 9.6 percent for “alcohol abuse” depending older adults receive prescriptions for opioid on the population sampled (Liberto et al., 1992). analgesics (Ray et al., 1993), and the vast (Chapter 2 defines levels of use and adjusts majority of those do not develop dependence. them for older adults.) A recent study found One study, for example, found that only 4 of that 15 percent of men and 12 percent of women nearly 12,000 patients who were prescribed age 60 and over treated in primary care clinics morphine for self-administration became regularly drank in excess of limits addicted (Hill and Chapman, 1989). The use of recommended by the National Institute on illicit drugs is limited to a tiny group of aging Alcohol Abuse and Alcoholism (i.e., no more criminals and long-term heroin addicts (Myers than one drink per day) (Saunders, 1994; Adams et al., 1984). Although little published et al., 1996; National Institute on Alcohol Abuse information exists, Panelists report that a far and Alcoholism, 1995). greater concern for drug misuse or abuse is the The differences in the prevalence rates above large number of older adults using prescription illustrate the difficulty in identifying how drugs, particularly benzodiazepines, sedatives, widespread the current problem is. One and hypnotics, without proper physician researcher suggests that alcohol abuse among supervision (Gomberg, 1992). Older patients are older adults is easily hidden, partly because of prescribed benzodiazepines more than any other its similarities to other diseases common as one age group, and North American studies ages and partly because elders remind clinicians demonstrate that 17 to 23 percent of drugs of a parent or grandparent (Beresford, 1995b).

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