|Year : 2015 | Volume
| Issue : 2 | Page : 74-82
Substance use disorders in the elderly: A review
Siddharth Sarkar, Arpit Parmar, Biswadip Chatterjee
Department of Psychiatry and NDDTC, All India Institutes of Medical Sciences (AIIMS), New Delhi, India
|Date of Web Publication||18-Jan-2016|
Department of Psychiatry and NDDTC, All India Institute of Medical Sciences, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
The population of elderly substance users is gradually increasing over the years in India due to the aging population and changing demographics. Hence, clinicians are likely to encounter a larger proportion of elderly substance users with time. This narrative review aims to provide an overview of the substance use disorders in the elderly with a focus on the Indian population. The epidemiology of substance use disorders in the elderly is discussed, as is the unique features of specific substances of use in this population. The overlay of medical comorbidities in the elderly substance users is highlighted. This is followed by the discussion of the key issues in the assessment and management of elderly substance users. The directions of future research in this field are subsequently highlighted.
Keywords: Alcohol, geriatric psychiatry, India, substance-related disorders
|How to cite this article:|
Sarkar S, Parmar A, Chatterjee B. Substance use disorders in the elderly: A review. J Geriatr Ment Health 2015;2:74-82
|How to cite this URL:|
Sarkar S, Parmar A, Chatterjee B. Substance use disorders in the elderly: A review. J Geriatr Ment Health [serial online] 2015 [cited 2018 Oct 19];2:74-82. Available from: http://www.jgmh.org/text.asp?2015/2/2/74/174271
| Introduction|| |
Demographic observations suggest that the Indian population is gradually ageing. , The slowing of the death rate along with greater longevity has led to an increase in the elderly population. Such an increase is likely to translate into greater health care needs of the elderly population, including those of mental health care.  The absolute numbers of individuals with substance user disorders among the geriatric population is thus increasing with time. This would call to attention the need to apprise health care professionals about the various substances used by the geriatric population.
The presence of substance use disorders in the elderly would need to be addressed in a different manner as compared to young adult and middle-aged individuals. , Substance use is found to be associated with altered brain structure and function, leading to mood, consciousness, and perceptual abnormalities. This may lead to impairment in the physical as well as psychological well-being of a person, more so in an elderly. Elderly substance users are more likely to have comorbid medical illnesses, which might complicate the presentation of both the substance use disorder and the medical illness. , The types of substances of abuse encountered in the elderly tend to differ from those of other age groups. The major sources of concern among the elderly are use of alcohol, prescription benzodiazepine, and opioids. Elderly substance users have different needs with regard to treatment services, and accessibility issues are among their major concerns. 
It has been seen elsewhere that the numbers of elderly seeking treatment for substance use disorders are gradually increasing. , Given the unique features of elderly substance users and the growing enormity of the problem of elderly substance users, this narrative review aims to discuss issues related to substance use disorders in the elderly. This review discusses the epidemiology of substance users in the elderly, followed by the specific clinical aspects of elderly substance use. The review thereafter discusses the screening- and diagnosis-related issues, followed by an approach to the treatment of elderly substance users.
| Epidemiology of Substance Use Disorders In The Elderly|| |
Substance use disorders have been described in the elderly population. The most common substances reported to be abused by the elderly population include alcohol and prescription opioids. Among the large-scale systematic surveys, the National Surveys on Drug Use and Health (NSDUH) conducted in the USA showed that more than two-third of men and half of women aged 50 and above used alcohol in the preceding year.  In this age group, 12.2% could be classified as heavy drinkers and 3.2% were considered binge drinkers. About 6.7% of those older than 65 years were considered as heavy drinkers or binge drinkers. Subthreshold abuse or dependence was found in about three-fourth of alcohol users of the past year, with tolerance toward alcohol being the most commonly endorsed symptom.  The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) sample of older "current drinkers" found a prevalence of 3.9% of past-year alcohol abuse or dependence. Based upon the number of abuse/dependence criteria endorsed, the sample was divided into low-, moderate-, and high-risk drinkers. The presence of major depression in the past year, being the child of an alcoholic, and being a current smoker were factors associated with the chances of being a high-risk drinker, while female gender, college education, and older age were associated with a lower risk. Several other studies have reported the occurrence of alcohol use disorder in the elderly and have found that alcohol use disorder affects a nonnegligible proportion of the geriatric population. 
The use of illicit substances in the elderly has also received attention. The Epidemiologic Catchment Area (ECA) study reported a lifetime prevalence of illegal drug use of 7% among persons aged 45-64 years, while the lifetime prevalence among the elderly (>65 years) was reported to be 1.6%. However, the active use of these substances was reported in only 0.8% of people aged 45-64 years and 0.1% in older adults.  Similarly, the NSDUH study reported that almost 2.6% of subjects reported using marijuana and 0.41% reported using cocaine during the past year. However, the abuse of or dependence on marijuana or cocaine was very low (0.12% and 0.18%, respectively).  The abuse or dependence further decreased as the age advanced (4% for the 50-64-years group as compared to 0.7% for >65 years for marijuana use). As the prevalence of illicit drug use among the elderly is increasing, the burden on health care is likely to increase because of substance-related health problems in the elderly.
| Alcohol Use in Elderly|| |
As discussed already, alcohol use in the elderly is frequent with a prevalence of alcohol abuse/dependence around 11% in people aged 50-64 years and 6.7% in people aged >65 years (NSDUH 2005-2007). Recommendations for drinking limits are also different in the elderly as compared to the younger population. The National Institute of Alcohol Abuse and Alcoholism (NIAAA) recommends the limit of 1 drink per day, as more than that constitutes at-risk drinking for men and women above 65 years as compared to more than 14 standard drinks per week for men and more than 7 standard drinks per week for woman under 65 years of age, which is in accordance with risk-free drinking among the elderly.  Similar to men, elderly women who drink more alcohol are at a greater risk of social isolation and economic deprivation. "Telescoping" dependence has also been suggested in elderly female alcohol users. The combined use of alcohol and misuse of prescription drugs is an important issue considering the higher potential for poorer outcome. Up to 12.3% of elderly alcohol users are heavy/binge drinkers, mostly to cope with depressive symptoms, which in turn may lead to more social isolation and depressive symptoms.  The occurrence of pain, anxiety, or sleep disturbances may hasten the progression from use of alcohol to misuse and abuse. The serious mental/physical consequences of heavy alcohol use are also higher among the elderly. 
| Prescription Drug Misuse in Elderly Population|| |
It has been suggested that elderly individuals have high rates of prescription medication misuse. However, studies assessing the prevalence of prescription psychoactive drug use/misuse are infrequent. The elderly are more susceptible to misuse such medications because of a variety of reasons. Among the elderly (>65 years), the prescription drug misuse is even more common than marijuana use (0.8% vs 0.4%).  Among these, benzodiazepines (such as alprazolam, clonazepam, diazepam, and lorazepam) and opiate analgesics are most commonly used/misused. Other drugs that are commonly misused are codeine-based cough syrups, antihistaminics, and painkillers such as dextropropoxyphene. Abuse/misuse of these drugs is usually unintentional in these populations.  Studies also suggest that being female, being socially isolated, and having a history of substance abuse/other psychiatric illness are factors more likely to be associated with prescription drug abuse or misuse among the elderly. ,, Another important issue with benzodiazepine misuse in the elderly is its association with cognitive loss and mood symptoms (especially depressive symptoms). It may even lead to confusion and falls in the elderly.  Because of the larger proportion of the elderly population using these medications and its potential health effects, it is important to do early interventions to avoid the serious consequences among them. Important risk factors associated with prescription drug misuse are as highlighted in [Figure 1].
|Figure 1: Risk factors associated with increased risk of prescription drug misuse|
Click here to view
| Other Illicit Drug Use By Elderly|| |
There is a scarcity of literature regarding the use of illicit opioids and other drugs by the elderly. In fact, the use of such drugs appears to be rare. The NSDUH found 1.8% prevalence of illicit drug use among individuals aged >50 years.  The reasons for this low prevalence include capping of methadone maintenance treatment at 40 years, high mortality associated with heroin use (>27% 24-year mortality),  and also the process of the "growing out" of substance use. Similarly, rates of cocaine abuse are also low, with one report suggesting a prevalence of 0.2% among patients aged 60-65 years and 0.1% among patients aged >65 years entering the treatment. 
| Physiological Changes in Elderly and Substance Use|| |
Normal aging has been associated with a variety of changes, leading to increased sensitivity to substance use as well as decreased tolerance.  Because of the lower body mass in the elderly, a smaller amount of a substance produces profound psychological and physical effects. Similarly, the concentrations of lipid-soluble drugs such as benzodiazepines are increased, leading to increased psychotropic effects. This is the reason why the typical adult dose of a particular drug, especially benzodiazepines, may be too high for the elderly. Other pharmacokinetic changes increased absorption because of decreased blood flow to gastrointestinal (GI) system, decreased metabolism by liver because of age-related decline in liver function, and decreased elimination by the kidneys because of slow nephritic function in the elderly, leading to higher and prolonged drug concentrations in the body, in turn leading to excess sensitivity to its effects. All these factors make the elderly individual more susceptible to the effects of the psychoactive substances.
| Other Salient Features of Substance Use Disorders in The Elderly|| |
There are some important features that need to be kept in mind while dealing with the elderly person using substances. As an elderly person is more likely to suffer from age-related stressful life situations, he or she is more likely to use drugs to cope with these problems. Some authors assert that substance use problems in the elderly are often mistaken for the symptoms of depression, dementia, or other disorders associated with aging, thus the elderly substance abuse problem has been called an "invisible epidemic."  Even the family of such an elderly person may consider him/her as a "nice little old man/lady" who cannot have a drug/alcohol problem, leading to nondisclosure of the problem.
The general trend among the elderly appears to be a reduction of substance use after the age of 50 years successively. This has been described as a "growing out of" or "aging out of" substance use. For example, Indian studies on alcohol use disorders have shown the downward trend of prevalence from 65-69 years to 85 years onward.  Similar findings have also been reported in other studies done in urban  and rural  populations of over-60-year-olds. Moreover, "aging out of" substance has been suggested with the use of illicit drugs.  Another salient feature of elderly substance use is that they rarely turn to illicit drug use, though recent evidence suggests an increase in the proportion of elderly individuals with illicit substance use.  However, it is important to note that illicit drug use, especially the use of opioids, is a more recent phenomenon in the Indian context and so it is probable that the current cohort of 65 years or older is less likely to use such substances. It will be interesting to note drug abuse in the forthcoming age cohorts to determine if the exposure to different levels of substances will have an impact on other substances of abuse.
| Elderly Substance Use and Medical Comorbidities|| |
The comorbidity of substance use and medical illnesses (including other psychiatric illnesses) has frequently been mentioned in the literature. Anxiety and depression are among the common mental health issues in the elderly. Not only can they be a cause of substance use, but they can also be exacerbated by substance use, especially alcohol use. This may in turn lead to rapid progression from use to abuse/misuse.  Injuries related to falls are among the common causes for elderly hospitalizations and decreased mobility. Studies suggest a significant link between falls and psychoactive substance use among the elderly.  These have been linked to confusion caused by the use of substances, especially benzodiazepines. Further, medical illnesses such as cognitive decline, GI illnesses, hepatic/renal disorders, and sleep disorders are more common in the elderly, which may further complicate the diagnosis and management of substance use disorders. For example, benzodiazepines and alcohol have been associated with cognitive decline in the elderly population using these substances. ,, Dementia when present may pose a great challenge in screening for substance use/abuse among the elderly. Symptoms of dementia, such as mood swings, agitation, and cognitive decline may also be associated with substance use, making it difficult to ascertain the extent of the substance use problem. Mortality related to alcohol use is also higher in moderate drinkers as compared to abstinent moderate drinkers. 
| Substance Use in Elderly in India|| |
Many Indian studies report data regarding the prevalence of substance use in the elderly in India. Most of these provide data about alcohol use in the elderly. The initial epidemiological study by Sethi and Trivedi  found alcohol misuse of 11.3% in the 55-64 years age group and 16.8% in the 65-74 years age group. A community-based study reported 10% prevalence of alcohol use in the population >60 years of age.  Similarly, a study done in 1117 North Indian elderly (>60 years), the prevalence of regular alcohol intake was found to be 16.3%.  The prevalence of alcohol use disorders is generally higher in the urban population as compared to the rural elderly population in India. , A more recent nationwide survey about the use of psychoactive substances reported around 70% of current users to be aged 40 years or less, while only 30% were in the middle years of their life and elderly.  Similarly, a few studies also report prevalence estimates for alcohol use/abuse among Indian women, which range from 0% to 11.6%. , This variations can be explained by the fact that studies used differing definitions to study alcohol use for alcohol consumption,  alcohol abuse,  current users,  etc. Studies also suggest a downward trend of alcohol use after the age of 65-85 years. ,,
Studies have also been conducted in a treatment-seeking elderly population. A study done on 63 subjects aged 60 years and above who were seeking treatment at a drug deaddiction center in Chandigarh reported alcohol (60%) to be the most common substance of abuse, followed by opioids (35%).  However, as the study design was a retrospective chart review, the generalizability of the findings is limited. A similar study done at a deaddiction center of a tertiary care institute in North India (N = 3071) reported that almost 44.3% of treatment seekers aged 40-60 years reported using alcohol "currently," while 72% of them reported "ever" use of alcohol.  Meanwhile, the current use was reported for heroin (42.5%), opium (15.8%), cannabinoids (17.3%), and tobacco (84.3%). A significant difference noted between this age group and others in terms of their "current" alcohol use, with this particular age group reporting significantly higher "current" alcohol use. Interestingly, this study reported a significant increase in polysubstance use over 5 years (between 2007 and 2011). This study reported that almost a tenth of treatment seekers (9.5%) were injecting drug users.
Some studies also report medical issues among elderly substance users. One study reported higher odds of experiencing visual, auditory, or locomotor impairment in the elderly.  Another Indian study suggested higher rates of asthma in adults more than 60 years of age (14% in alcohol users as compared to 7% in nonusers).  A study done on the rural elderly population reported higher chronic energy deficiency in tobacco and alcohol users as compared to those who were only alcoholics (62.2% vs 47%).  Similarly, a study done by Grover et al. (2008)  reported current medical complications in 16% of substance users aged 60-95 years, with the most common complication being delirium tremens (16%). However, almost 35% of subjects reported a lifetime complication, diabetes mellitus being the most common among them (11.1%).
A few retrospective studies also talk about management. One such study reported that more than 80% of subjects coming to the treatment setting were detoxified (using benzodiazepines for alcohol and benzodiazepines and clonidine plus benzodiazepine for opioids).  Although postdetoxification prophylactic medications were advised in 45% of cases, only a few (11%) accepted its use. The most important reasons for not advising pharmacoprophylaxis were extreme age and physical complications. The majority of the sample responded well to the treatment and were abstinent at follow-up (58.7%).
| Management Strategies for Substance Use Disorders in The Elderly|| |
Although many approaches for treatment have been proposed, evidence for each of them and the studies on comparative efficacy are almost nonexistent. One of the reasons is the small number of patients coming to a treatment setting.  However, some observational studies suggest a good prognosis in the short term and the long term in the elderly with drug use problems. , Various reasons are cited in the literature for quitting drug use and treatment seeking in this population. In a study done on the rural Indian community, the most common reasons for quitting alcohol use were reported to be self-desire and relatives' advice. The other reasons reported were advice by friends, religious reasons, financial problems, and the advice of doctors. 
The management for substance use in the elderly can be broadly divided into screening and diagnosis, pharmacological treatment, and psychotherapeutic interventions. The treatment part is often ingrained in the assessment process, which is often a continuous and evolving one, and informs the treatment options. The presence of concurrent medical problems also needs to be addressed and managed accordingly in the same setting or in another, specialized one. Psychosocial needs and additional psychiatric illnesses may also need to be looked into and dealt with. A flowchart summarizing the treatment of elderly substance users is presented in [Figure 2]. The do's and don'ts of treatment of elderly with substance use disorders are mentioned in [Box 1 [Additional file 1]].
|Figure 2: Assessment and treatment of elderly patients with substance use disorders|
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| Screening and Diagnosis of Substance Use in Elderly|| |
It has been suggested that the clinical presentation of substance use in the elderly might be different from that of other age groups. Problems related to work and social interaction are likely to be endorsed less frequently by the elderly population, many of whom have retired out of active occupational pursuits and have limited social interaction due to attrition of their previous circle of friends and relatives. Hence, the threshold of diagnosis of substance use disorder may be higher in the elderly as compared to the younger population. In addition, most of the elderly with substance use problems are unaware of it and so do not seek services on their own. Another issue is that the likelihood of detection by primary care physicians is also low, and misdiagnosis as anxiety, depression, or stress can further complicate the picture.
Some otherwise validated questionnaires have been utilized in the elderly population. This include the "Cut down, Annoyed, Guilty, Eye opener" (CAGE) questionnaire, a brief, 4-item screener for identifying problematic alcohol use; the Alcohol Use Disorders Identification Test (AUDIT), a 10-item instrument assessing hazardous alcohol use; and the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST), which has been modified for the elderly to address psychoactive prescription medication misuse. The Michigan Alcoholism Screening Test - Geriatric Version is a well-known screening tool validated for use in older adults.  However, no specific instrument has been validated for assessing prescription drug misuse or illegal drug use in the elderly till date. Hence, details about over-the-counter use, side effects faced, details of prescription filled, and warning signs such as excessive worry about and attachment to a particular drug may be helpful as potential indicators of substance misuse in the elderly.
The presence of medical disorders can complicate the assessment of patients with substance use disorders, especially in medical settings, when the available history might be inadequate and one might have to rely on the findings of the physical examination. The presence of alcohol intoxication may be confused with delirium due to a range of conditions, including head trauma. The presence of benzodiazepine withdrawal may result in a bout of seizure. The clinical team may, however, like to evaluate for other causes of seizure, including metabolic causes and cerebrovascular accidents given the age of the patient. Thus, assessment of elderly patients with substance use disorder may pose as a clinical challenge, and this needs cautious elaboration when the history is inconsistent or doubtful.
Substance use disorders may have an etiological role in certain medical disorders. These may include hepatic dysfunction, dyspepsia, hypertension, and cardiovascular disorders due to alcohol use; chronic obstructive lung disease and peptic ulcer due to tobacco use; and malnutrition due to chronic opiate use. The treating team needs to address the concurrently present medical condition while managing such patients.
While making a diagnosis of substance use disorder in the elderly, some of the following issues need to be kept in mind. For example, a few of the standard criteria for substance dependence might not apply to the elderly. Many of the elderly live alone, do not work, and have limited mobility, because of which interpersonal problems are less likely. Similarly, elderly persons might not operate dangerous equipment (e.g., driving cars) and thus legal consequences related to substance use (e.g., drunken driving) may be less apparent.  Because of these, the use of current diagnostic system criteria for detecting substance use in the elderly is problematic. Such problems with diagnostic criteria along with an absence of validated tools to assess elderly substance use (especially prescription drug use) leave a clinician to rely more on his/her own diagnostic skills.
Because of factors such as old age, more severe dependence, and comorbid medical illnesses, elderly substance users require special attention during treatment. Usually, the least intensive options are explored first for its treatment. For example, because of the changes in drug metabolism and excretion, they may require a lower dose of a particular medication (e.g., benzodiazepine for detoxification). It is often advisable to do inpatient opioid detoxification in the elderly. In order to avoid withdrawals, it is required to do very gradual tapering. Withdrawal symptoms may be different in the elderly, and they suffer from disorientation and confusion more commonly than restlessness, sleep disturbances, and tremors.  Potential drug-drug interactions should also be kept in mind, as the elderly are likely to be on several medications due to comorbid medical and psychiatric illnesses.  Adverse events need to be closely monitored in elderly patients with substance use disorders, and hence follow-ups should be closely spaced.
For the management of prescription drug misuse, nonpharmacological approaches are also employed to improve treatment outcome. These may include brief intervention, patient psychoeducation, motivational counselling, and rehabilitation. Brief intervention has been found to be effective even in "real world" clinical situations in the elderly.  Various randomized trials have also indicated its efficacy in the treatment of alcohol abuse among the elderly. , Brief intervention and motivational counselling are usually done in a similar manner as in adults. However, in all the steps (in case of prescription misuse), it is important to also add patient education about the prescription drug and the associated problems. These may include the reasons for altered compliance, medication management information, dosing details, and the consequences of misuse. Other treatment modes, such as psychotherapy, individual/group counselling, and 12-step programs, are less studied in the elderly.
| Conclusions and Future Directions|| |
It is well known that the elderly population is particularly vulnerable to misuse psychoactive substances. However, studies on factors associated with such abuse and the screening/management of it are scarce. Failure to obtain an adequate sample to study this population is among the most common reasons for these problems. Alcohol and prescription drugs are the most commonly found substances of abuse among the elderly. Age-related changes in the elderly associated with medical comorbidities make the use of substances a more problematic issue in this age group. The lack of validated screening and diagnostic tools is another barrier. Though treatment of substance use proceeds along similar lines as in adults, specific caution may be helpful in instituting pharmacological management.
Further research is needed to characterize elderly substance users. Often, such populations are "hidden" because of their limited mobility, hence community-based studies can best assess their prevalence, the impact of substance use on their health, the sources of procuring the substance, the individuals' motivation of continuation, and other associated contextual factors may be assessed for better understanding of the facets of substance use in the elderly. Locally relevant screening tools may be developed for the screening of substance use in the elderly. The efficacy and effectiveness of interventions of substance use may be studied, along with the practical barriers faced in the access and delivery of the services. The expertise of the physicians may also be strengthened by increasing competence in dealing with elderly substance users. Increasing the awareness of physicians about substance use disorders in the elderly and the methods available to address them may help in provision of better care to the geriatric substance users.
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Conflicts of interest
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[Figure 1], [Figure 2]