Introduction to Older Adults and Substance Use

20% of men 55 to 64 years, 12% 65 to 74 years and 5% over  75 years were considered heavy drinkers (5 or more drinks  on a single occasion at least once per month in the last  year) (The Canadian Community Health Survey 2003)

In Ontario, there has been a significant upward trend in  past year alcohol use by those aged 65 years and older  from 58.5 percent in 1997 to 73.5 percent in  2007(Ialomiteanu et al., 2009)

Low Risk Drinking Guidelines recommend no more than two  standard drinks on any one day and no more than fourteen  drinks per week for men and 9 drinks per week for women

The guidelines advise that people drink less or not at all if  they are using medications, have health problems or are  planning to drive or use complex machinery.

Older adults are generally less likely to report drinking  harmfully however across Canada, 10.9 percent and 13.6  percent of those aged 65-74 and 75+ years respectively  report exceeding low risk drinking guidelines (Adlaf, 2005)

The DSM-IV diagnostic criteria can be inadequate for  diagnosing older adults with substance use problems (Oslin  & Holden, 2001 in Royal College of Psychiatrists, 2011)

Alcohol and prescribed and over the counter psychoactive  medications are currently the drugs of most concern for  seniors (Christensen, Low & Anstey, 2006)

The number of seniors with a history of illicit drug use is  projected to increase as the baby boomer generation, the  first generation with significant exposure to recreational  drugs, ages (Shah & Fountain, 2008)

Cannabis is increasingly prevalent in older populations with  the new cohort of ageing “baby boomers”

Cannabis use by Ontarians aged 50 years and older has  increased significantly, from 1.4 percent in 1998 to 4.6 percent  in 2007 (Ialomiteanu et al, 2009)
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Impact of Substance Use

Older adults have a higher blood alcohol concentration than  younger people after consuming an equal amount of alcohol  (Barnes et al., 2010; National Institute on Alcohol Abuse and  Alcoholism, 1998; Simoni-Wastila & Yang, 2006)

Older adults who continue the same pattern of drinking  into their senior years may not be aware that they have less  tolerance than when they were younger

Older adults who continue to use illicit drugs such as  cannabis, heroin and cocaine are also at risk when these  substances are mixed with medications for physical health  problems (Boddiger, 2008)

Alcohol commonly accompanies/exacerbates mental  health issues:

• seniors who experience depression are 3-4 times more  likely to develop alcohol-related problems
• Alzheimer Disease and other forms of dementia (alcohol/ vascular) can combine with a long history of depression
• Depression is both a precursor and consequence of heavy  drinking (Statistics Canada, 2004)  

WHY AGE SPECIFIC APPROACHES TO MANAGING  SUBSTANCE USE

Substance Use  

Many older adults begin to have problems with their  substance use during times of transition or loss (e.g.  forced retirement, bereavement, new or escalating health  concerns, loss of independence)

Their relationship to the substance is based on an  emotional need to feel better or deal with loss

Some older adults cannot access and/or do not feel  comfortable in mainstream addictions services

Problems with substance use are often not recognized  by health and community service providers so help is not  offered

The older generation is more likely to experience self  stigmatization which reduces the chance of seeking  treatment and service

Health and Aging

Older adults often have complex and/or chronic health  conditions that require they take pharmaceutical  medications that can interact with each other and non  prescribed substances (e.g. alcohol, marijuana)

Older adults metabolize substances in a different way

Psychosocial factors such as boredom, loneliness and  homelessness are linked to higher alcohol use (Royal  College of Psychiatrists, 2011)

Anecdotal clinical experience is that elderly have more  prolonged and severe withdrawal than younger patients, and  are more likely to develop complications such as delirium  

It is not uncommon to find that older people with chronic  substance misuse have had multiple head injuries resulting  in symptoms of acquired brain injury that is affecting their  reasoning and decision making capabilities.

Older adults with some degree of cognitive impairment and/or  functional losses are often misdiagnosed with dementia when  in fact there may be a substance misuse or addictions issue.  

OLDER ADULT SPECIFIC APPROACHES

Goals

The end goal of abstinence is not necessary or realistic for  many older adults with substance use problems. Instead  a harm reduction goal that is related to quality of life  improvement as defined by the older person is the aim

Treatment/counseling should be focused on what can make  life better, more comfortable and happier, not only on the  substance use

Screening and Assessment  

Problematic use is not defined by amount but by the negative  effect on the person’s daily life

When working with older adults, a full and thorough history is  always the first step and as a matter of course substance use  should be part of this discussion  

If an older person presents with repeated falls, head injuries  and/or failure to thrive a discussion of use of substances  should be initiated in a non threatening way as part of a  comprehensive history

There are some particular risk factors for older adults that  clinicians should be aware of, these include depression, recent  loss of loved ones, isolation and chronic painful illnesses  (Atkinson, 2002 in Royal College of Psychiatrist, 2011)  

Although some diagnostic criteria may not be sensitive to  differences of aging screening tools are available (e.g. The  Short Michigan Alcoholism Screening Test –Geriatric Version),  and screening for alcohol, medication and other drug use  should be part of medical assessment. A full list of screening  and assessment tools is available in Improving our Response  to Older Adults, CAMH, 2008

Treatment/Counseling

Harm Reduction must be approached in a broad fashion,  looking primarily at reducing the harm to quality of life (e.g.  using a taxi to get to the liquor store in the winter to reduce  the chance of breaking a hip)

Treatment and/or counseling must begin with a conversation  about the person’s daily life and feelings, with the role of the  substance(s) as an aspect of the person’s whole life

Isolation and marginalization must be addressed through  practical and psychosocial methods (e.g. ensuring appropriate  personal care services through CCAC and involvement in social  activities such as day programs, outings and groups)

• Health Canada (2002) states best practices identified  through research demonstrates that treatment of high  need older adults includes:  
• a harm reduction and holistic problem solving approach, •  home visiting known as “outreach”
• intensive case management and social and recreational programs

KEY FACTS

Demographics

We have an aging population, the proportion of those aged  65 years and older has almost doubled in the last fifty years  from 7.7 percent to 13 percent in 2006; 13.6 percent in  Ontario (Statistics Canada, 2007)

Population projections indicate that by 2036 almost a  quarter (24.5%) of the Canadian population will be 65 years  or older (Statistics Canada, 2007)

Baby boomers’ are the largest age cohort in Canada and  the oldest baby boomers are now entering their retirement  years (Statistics Canada, 2007)

Substance Use

A US study has estimated that the number of adults 50  years and older requiring substance abuse treatment will  more than double by 2020 driven in part by the increase in  the number of older adults with illicit drug problems and the  non-medical use of prescription drugs (Gfroerer et al., 2003)

6-10% of older adults who drink will experience problems  (CAMH 2008)

Prepared by

The Addictions Sub Group of the SHRTN Collaborative Geriatric Mental Health,  Addictions and Behavioural Issues Community of Practice