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How does substance abuse affect older adults?

There has been a lot of concern in recent years about a potential silent epidemic of substance abuse among older adults.

stack of multicolored pills laid out on table
Photo by freestocks.org

By Frederick Y. Wu, MD

Frederick Y. Wu, MD, is a board-certified psychiatrist with the Mid-Atlantic Permanente Medical Group. He sees patients at the Kaiser Permanente Northwest DC Medical Center.   

The substance abuse epidemic in America is no secret, but the fact that many facing addiction are seniors may come as a surprise. It may be a bit of an overstatement, as it can be difficult to get reliable data on rates of substance use in older populations, however, baby boomers came of age in an era of unprecedented permissiveness around drug use, and they represent more than a fifth of the population.  So, even a slightly higher rate of substance use disorders in this group could translate into significantly more people who will need treatments tailored to the special needs of older adults.

What are those special needs? As a geriatric psychiatrist, I see a wide range of potential issues. With aging, the brain is more sensitive to the effects of drugs and alcohol, and the body is less efficient at metabolizing them. There’s a relative decrease in body muscle and water with a relative increase in fat tissue, meaning the concentration of alcohol and other drugs in the body tends to be higher, increasing potential impairment. Older patients tend to have more chronic health problems that can be worsened by drug and alcohol use, and they usually take more prescription medications that can interact badly with these substances. So, we worry about increased risks for confusion and falling, and potentially catastrophic reactions when older adults mix alcohol or other recreational drugs with medications they may take for anxiety and pain.

It can be challenging for physicians to identify older adults with substance use disorders. Some physicians may not screen for problems, fearing it might convey disrespect, or because of misconceptions about substance use and aging.  Some of the guidelines and methods used to gauge substance use problems in younger populations may not apply as well for older adults.  For example, we often look at the impact of substance use on social and job functioning, but many older adults are retired or already less socially active. So, the very things that put them at higher risk for substance use disorder may also make their overuse of alcohol and other drugs less obvious to others.

Alcohol has always been and continues to be the most commonly used and abused substance among older adults. Everyone’s tolerance is different, but the 2015–2020 U.S. Dietary Guidelines for Americans defines moderate drinking as no more than one drink a day for women and two for men. (One drink means 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of liquor.)

The National Institute on Alcohol Abuse and Alcoholism further states that the following people should never drink alcohol:

  • Anyone taking prescription pain medicine, sleeping pills or over-the-counter sleep aides
  • Anyone taking prescription medicine to treat anxiety or depression
  • Anyone with memory problems
  • Anyone with a history of falling or unsteady walking

Mixing alcohol and other drugs with pain meds or sleeping pills can be fatal, plus alcohol and other drugs can interfere with medications used to treat anxiety and depression. They can also interact in unexpected ways with other medications, including things like antihistamines that would be relatively benign in the younger population. And alcohol can exacerbate any number of medical conditions, including heart disease and diabetes.

Something new we are seeing with the aging of the baby boom generation is an increase in the use of marijuana in people over 65. With the growing acceptance of cannabis, both legally and socially, I find patients are increasingly using it to manage anxiety, insomnia and loss of appetite. However, there’s limited evidence for marijuana’s benefits, and we definitely don’t have a great understanding of all the risks. There are potential cardiac effects, increased fall risk and psychiatric effects such as anxiety, panic attacks and impaired memory. We just don’t know enough about its impact on the vulnerable aging brain.

In terms of other drugs, including cocaine, inhalants, hallucinogens and methamphetamine, there do appear to be increasing rates of use with older adults compared to prior generations, though reported rates can vary widely, depending on the study. And the entire nation is grappling with the opioid crisis, which affects older adults as well.

If you are worried about your own or a loved one’s substance use, one question you might ask is how difficult it would be to stop using. Other red flags may include medication misuse, and symptoms like blackouts, forgetfulness or trouble concentrating, frequent falls, unexplained bruising, tremors, slurred speech, poor hygiene or self-neglect, sleep problems and changes in mood. Risk factors to be aware of include a history of substance abuse, as well as the many losses that accompany aging, including the loss of spouses, friends and family members, retiring from a job, moving out of a family home, children moving away, reduced physical mobility and declining health.

One of the wonderful things about the baby boom generation is that they are much more open than their parents were about discussing their use of alcohol and drugs, as well as the emotional issues that surround big life transitions, as long as doctors and family members are caring and supportive, and not judgmental. It’s important to remember there are options for treatment. Researchers have even found that in certain settings, older adults may respond better to treatments than younger people, although there’s a real need to develop and implement more programs specific to the needs of older adults.

Some older adults (and their adult children) can be fatalistic when it comes to confronting a substance use disorder—a “Why bother?” mentality.  But, we know that older people with alcohol or substance-use problems who are able to cut back or stop entirely are not only likely to live longer, they are likely to sleep better, think more clearly, have fewer balance issues and just generally live healthier, more comfortable lives.

To read more about substance abuse and misuse among older adults, visit the website of the Geriatric Mental Health Foundation.

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