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Abstract
Substance abuse among older adults is a rapidly growing health problem and will burden the health system in the few coming years.
Old age group commonly abuse nicotine, prescription drugs (benzodiazepines and opiates), illicit drugs (hashish and opium) and alcohol. Smoking and tobacco misuse is the most common among older persons.
Misuse and abuse of prescription drugs by older adults is of great importance. They are more likely to use prescription drugs due to a variety of chronic illnesses. Benzodiazepine sedative-hypnotics and the opioid analgesics are the commonest prescription drugs to be abused in old age.
The use of illicit drugs is still largely perceived to be behavior of the young despite of many studies have found that a significant proportion (approximately 30%) of heroin users continue to use heroin even into old age.
Brain systems involved in substance abuse is affected by aging. And at the same time these changes itself affect the responsiveness of brain systems to drugs.
There are several factors (biological, medical, psychiatric, psychosocial and cultural) specific to old age group putting them at a greater risk for substance abuse.
Of the biological factors, there is an age-related decrease in lean body mass and total body water in relation to total fat volume and age-related changes in kidney and liver function increasing the serum concentration of alcohol and other substances making older adults more susceptible to substance abuse problems at low dosage levels.
Geriatric patients having physically painful illnesses (e.g., arthritis, osteoporosis, neuropathies, cancer and gout) are at higher risk of substance abuse. As patients grow older and develop medical conditions that require prescription and over-the-counter medication, opportunities for substance abuse increase.
Depression among the elderly is a risk factor for inducing or increasing their alcohol use. Also, Cognitive impairment may interfere with the ability of the older adult to self-monitor intake or interpret feedback from health care providers, increasing the risk for dependence. Other psychiatric diagnoses associated with prescription drug dependence include a personality disorders, anxiety, sleep and adjustment disorders.
Older adults experiencing emotional and social problems (e.g. bereavement, loneliness and social isolation) are at greater risk for substance use. Older problem drinkers typically begin abusing alcohol and medications following a major life change (chronic stress), such as the death of a spouse, a divorce, or retirement. Moreover, elder abuse is a risk for substance misuse problems. Elder abuse includes physical abuse, sexual abuse, emotional or psychological abuse, financial or material exploitation or neglect by a caretaker.
Having a family history of alcohol or drug use disorders or genetic predisposition is a risk factor for development of alcohol and drug use problems throughout one’s lifespan.
This older adult generation grew up during an era of increased illicit drug and alcohol use, so they are more prone to have substance use problems. Also, the widespread use, effectiveness of many prescription medications and increased awareness of these medications appears to be driving increased use.
Protective factors in the individual, family and environment that can guard against risky behaviors include close communication with family members, family support, high self-esteem, assertiveness and social competence.
Elderly subjects with a dual diagnosis of substance abuse disorders and mental illness, compared to those without a dual diagnosis, need more treatment during and following the index episode, need a greater number of outpatient visits for substance abuse issues and had a longer length of inpatient stay.
Older adults with serious mental disorders, such as schizophrenia, bipolar disorder, and major depression, who have co-occurring substance use problems have more functional and cognitive impairment, compared with those without substance use problems.
Problematic substance use has a large impact on health outcomes, increasing the risk of cognitive impairment and other mental and physical disorders. It is also associated with higher health care utilization, increased complexity of the course and prognosis of many mental and physical illnesses, increased disability and impairment, compromised quality of life, increased caregiver stress and increased mortality.
Alcohol, drugs and prescription medications, may cause a range of cognitive impairments from confusion to delirium, and may even mimic dementia.
Mood disorders, and anxiety disorders are common mental health problems in older adults and both may be exacerbated by alcohol or drug use.
There is evidence to show that drug use exacerbates, or accelerates the onset of, medical conditions which are more prevalent in older age. Neurological and respiratory disorders, cancer, and many other age-associated diseases may be exacerbated by drug abuse.
Specific knowledge related to abuse of or dependence on opiates and benzodiazepines is paramount. These drugs can cause confusion and unsteadiness in this population, predisposing them to falls and serious injuries.
Dysfunction of the immune system leading to infections is a consequence of long standing drug abuse making older adults susceptible to opportunistic diseases such as pneumonia and other infections when compared to younger drug users or older people who do not use drugs.
Studies have demonstrated that the mortality in drug users are several times that of the general population and that older addicts are between two and six times more likely to die compared with younger ones.
Screening tools for substance abuse typically involves broad-based questionnaires designed to determine whether or not individuals are experiencing problematic substance use.
CAGE asks four questions and if an individual answers yes to any of the questions, further exploration of their alcohol use is indicated.
Michigan Alcohol Screening Test-Geriatric version (MAST-G) is a 24-item self-report questionnaire, scored dichotomously (yes/no), which takes into account some of the changes in social and physiological behavior associated with older populations.
S-MAST-G is a short version of the MAST-G which has been reduced to a 10-item questionnaire, scored dichotomously (yes/no). Three or more positive responses are indicative of a recent or current alcohol use problem.
Alcohol Use Disorders Identification Test (AUDIT) questionnaire was developed by the World Health Organization (WHO) and is a 10-item pen and paper survey that measures negative alcohol related consequences as well as total alcohol consumption.
Alcohol-Related Problems Survey (ARPS) is an 18-item self-administered screening measure that focuses on the relationship between alcohol use and medical problems, medication use, and functional status
Drug Abuse Problem Assessment for Primary Care (DAPA-PC) is a new computerized screening tool that allows primary care practitioners to detect older substance-abusing adults. It first answers a brief series of questions about trauma, and then progress to a brief questionnaire about alcohol and drug use.
Health care professionals need to rely on their diagnostic skills to screen and diagnose the use of illegal or prescription psychoactive drugs in older adults. Thus, providers must ask about the drugs patients are using, any side effects experienced, where the prescriptions are filled, and the use of over-the-counter, supplemental, or alternative medications (including medical marijuana and other herbal substances).
Special approaches may be necessary when treating substance use disorders in older adults, the least intensive approaches should be considered first.
Older adults, families and caregivers all need to be aware of the signs and symptoms of substance use problems. Other educational initiatives have encouraged pharmacists and physicians to give increased attention to the ongoing use of medications by their patients and clients.
Group therapy is based on the idea that recovery is aided by learning from the experiences of others. Self-help can foster a sense of optimism and help build social relationships that are not based on substance use.
Brief interventions range from fairly unstructured counseling to structured approaches aimed at motivating behavioral change. An initial approach of this sort can function as either a pretreatment or treatment strategy (Blow, 2001).
Cognitive approach helps older adults examine the Antecedents, Behaviours and Consequences (A-B-C paradigm) of their substance use. Provision of substance use education, skills training in problem solving and social reinforcement may also be helpful.
Psychosocial treatment begins by focusing on aspects that are important to the individual, and aspects that they feel confident in. By building self-efficacy and social networks, the person will develop the necessary skills to be able to address the substance use problem.
Harm reduction aims for general decreases in consumption, slowly changing the individuals drinking or substance use pattern, which may eventually lead to abstinence.
Pharmacological intervention is often undertaken as a precaution because of the life-threatening risks associated with alcohol and other substance withdrawal.
Some older adults experience physical limitations that make traveling to treatment sessions difficult, so outreach services approaching the client in their own environment rather than expecting them to come to treatment providers is of great help.
In the areas of substance abuse and geriatrics, there is a recognized benefit of a team approach to care, with nurses playing an important role in the detection and management of older adults.
Moreover, the family and client working together will serve to enhance recovery.