Summer 2008

Substance Abuse and Misuse in Older Adults
By Kimberly A. Steinhagen, LMSW, and Michael B. Friedman
Aging Well
Vol. No. 3 P. 20

Surprising numbers of older adults struggle with drug and alcohol issues. Would you know the warning signs specific to this demographic?

Substance abuse problems have a terrible impact on social relationships, health, and emotional well-being. They can lead to other serious illnesses, worsen medical conditions, and increase healthcare costs. However, substance use is often unrecognized as an issue, let alone a priority issue, for older adults.

In fact, a substantial and growing percentage of older adults knowingly or unknowingly misuse alcohol, medications, and illegal substances. And as the number of older adults in the United States surges over the next quarter century, so will the number of elders with substance abuse problems. There were 1.7 million substance abusers over the age of 50 in 2001, a number that is expected to more than double to 4.4 million by 2020, according to statistics from Drug and Alcohol Dependence.

Demographics and Prevalence
Substance abuse problems in older adults are most often associated with the misuse of alcohol and over-the-counter (OTC) and prescription drugs. According to current estimates, the rate of diagnosable alcohol abuse disorders is 2.75% for older men and 0.51% for older women. But upward of 15% of community-dwelling older adults have problems with drinking, and up to 20% of older adults misuse a combination of alcohol and medications.

A few older adults also use illegal substances, mostly marijuana. The most recent national study on substance use found that 1.7% of older adults use illegal substances, up from less than 1% a decade ago. This appears to support the widespread expectation that the use of illegal substances by older adults will increase as the baby boomer generation ages. According to David Oslin, MD, a geriatric psychiatrist at the University of Pennsylvania, both a history of substance dependence and continued use will have physical and mental health consequences for this cohort as it ages.

Physical and Psychological Aspects of Substance Abuse Among Older Adults
Substance misuse among older adults is generally different from that of younger adults. As people age, their bodies metabolize alcohol more slowly. Therefore, older adults have increased sensitivity to and decreased tolerance for alcohol.

The misuse of medications is far more common among older adults because they have more chronic medical conditions and are prescribed more medications. Adjustments to allow for correct, age-appropriate dosages and information on contraindications are often missing in the communication between a prescribing physician and the older patient. Interactions between medication and alcohol are of particular concern among older adults as they can cause serious medical and psychological problems.

Alcohol Misuse and Abuse
In older adults, even small amounts of alcohol can have serious consequences. While alcohol consumption can have physical and psychological benefits for older adults, it can also create danger by causing or complicating medical conditions, producing unsafe medication interactions, and increasing falls, confusion, depression, and premature mortality. Factors that contribute to alcohol use among older adults include changing life roles such as retirement, loss of family and friends, and mental or physical decline. Additional factors that make older adults vulnerable to inappropriate alcohol use include insomnia, family history of substance abuse, and having a psychiatric illness such as depression or anxiety. Men are more likely than women to have alcohol problems at later ages.

Prescription and OTC Medication Misuse
Older adults use prescription drugs nearly three times as frequently as the general population, according to a report from the Special Committee on Aging. They also purchase nearly three quarters of all OTC medications. Medication misuse includes consuming extra doses, failing to fill prescriptions, misunderstanding the physician’s instructions, missing doses, consuming medication at the incorrect time, and stretching out medications to last longer. Older adults are particularly at risk of unintentional medication misuse because of the simultaneous use of multiple medications and sensitivity to their effects due to the aging process. As the body ages, changes in digestion, liver, and kidney function impact the way that medications are absorbed and metabolized, creating greater risks of physical and mental damage for older adults. Medical factors such as the use of multiple medications and sensory decline, psychological factors such as cognitive decline or a mental disorder, and cultural and linguistic barriers can impact an older adult’s ability to take medication correctly.

Many older adults have several physicians prescribing different medications who may be unaware of the multiple medications the patients are taking, which could lead to dangerous interactions. In addition, some healthcare providers lack training and education about working with older adults and therefore may prescribe inappropriate medications or dosage.

Commonly misused prescription and OTC medications include painkillers, antianxiety drugs, sleeping pills, diet aids, and decongestants. Antipsychotic drugs, which are commonly and often inappropriately prescribed to older adults with behavioral problems, are of particular concern because their continual use leads to problematic and sometimes dangerous symptoms and side effects.

Illegal Drug Use
The use of illegal substances by older adults is on the rise. Over the past decade, it appears that use has grown from under 1% of the population to 1.7%, probably reflecting the aging of those who grew up in the generation of “sex, drugs, and rock and roll.” It may also reflect the number of people whose lives have been saved by methadone treatment programs and by improved medical care for HIV/AIDS and other diseases and injuries to which hard-core drug addicts are exposed.

Lifelong recreational drug users—particularly those who use marijuana—may find their drug use becoming more problematic due to changing physiology and life circumstances that increase isolation, such as retirement or no longer having child-rearing responsibilities or nearby friends to maintain regular, healthy interpersonal socialization.

Hard-core drug addicts who manage to survive into old age may suddenly discover with great sadness that they have lost life’s major opportunities and seek to redeem themselves by reconnecting with long estranged family and finding some way to make a productive contribution to society in their final years. Of course, those who continue to abuse drugs such as cocaine and heroin are at a very high risk of physical decline resulting in disability and premature death.

Barriers to Identification and Treatment
Providers working with older adults, including primary care physicians, often miss substance abuse and misuse. They often don’t know that substance use problems affect 15% or more of the elders they serve. Some providers refuse to see substance abuse as a real problem among older adults and therefore do not view treatment as important or successful for this population. At the American Academy of Addiction Psychiatry’s annual meeting in 1999, Oslin raised the question that some providers ask—“Why change anything in their lives, considering their age?” He answered by pointing out that this is a quality of life issue.

Even if providers are aware of the need to look for signs of substance abuse and misuse, they often lack the professional training or skills to recognize them in the older population. Signs and symptoms of alcohol abuse and misuse are similar to those of other common medical conditions and to what is often mistakenly believed to be part of the normal aging process. They include memory problems, fatigue, sleep problems, confusion, depression, anxiety, and irritability. Signs of medication misuse include mood changes, irritability, lack of energy and concentration, loss of short-term memory, and general loss of interest.

In addition, many retired elders drink unnoticed at home or in local bars or social settings. They are not nearly as likely to get in trouble with the law or their places of employment as younger people. Many older adults and their family members don’t realize that they have a drinking problem or are misusing medications. And when they do, they often feel shame or guilt and don’t want to be stigmatized as alcoholics or drug addicts are. Family members may also fail to view drinking or medication abuse as harmful. For all these reasons, many older adults with substance use problems don’t seek the help they need.

As a result of failures of screening, lack of training in the signs and symptoms of substance misuse, stigma, ageist assumptions, and ignorance about substance abuse problems among older adults, such problems often go undiagnosed and untreated. In 2001, only 11.9% of an estimated 1.7 million older adults with substance abuse treatment needs had received treatment within the previous year.

Addressing Substance Abuse Problems in Older Adults
In engaging older adults in substance abuse treatment, it’s important to understand that older adults who do not have a history of lifelong, hard-core addiction are usually reluctant to be associated with what are stereotypically known as down-and-out alcoholics or drug addicts. They need to be understood and treated in contexts that are more comfortable for them.

Identification and Treatment of Alcohol Misuse and Abuse
After years of inattention, there is now a growing body of research into effective best-practice models to treat alcohol abuse in older adults, and more practices that have proven effective are emerging. Health education programs targeting older adults have been effective in providing them with knowledge about alcohol misuse. Several screening instruments are usually accurate in identifying alcohol misuse. Screening tools effective in detecting older adults who may have an alcohol problem are the Cut down, Annoyed, Guilty, Eye-opener (CAGE); the Short Michigan Alcoholism Screening Test—Geriatric version (SMAST-G); and the Alcohol Use Disorder Identification Test (AUDIT). Selecting a screening tool depends on its purpose. While screening is important, it should but does not always effectively lead to treatment. Brief interventions in primary care settings, including counseling and education, are also successful.

Psychosocial treatments including interventions, such as cognitive behavioral therapy and motivational interviewing, as well as supportive, nonconfrontational approaches and separate groups for older adults, are likely to be effective. Fred Blow, MD, of the University of Michigan, commented at the previously mentioned American Academy of Addiction Psychiatry meeting that in his studies he found it difficult to get older adults to talk about alcohol-related problems, although they would discuss other issues, such as social interactions, family activity, and general concerns. The implication of this finding is that therapists may need to explore their patients’ concerns about these areas of life to help them find the motivation to deal with their drinking problems.

Peer self-help approaches, such as Alcoholics Anonymous, are often better when they are comprised exclusively of older adults. More specialized treatment designed to adapt existing outpatient, detoxification, inpatient, residential, and recovery services models are also useful approaches for older consumers depending on the level of need. While little research addresses medication interventions for alcohol abuse, naltrexone reduces the craving for alcohol and has been shown to reduce alcohol relapse. It is critical to understand that there is no one-size-fits-all approach. Treatment and other interventions must be tailored to the needs of the individual.

Managing Medication Misuse
Research on the prevention of medication misuse is limited; however, computer-based and group health education have been shown to be useful. In addition, medication management tools are helpful, such as recording information about prescribed and OTC medications on a passport-size card that older adults can carry with them at all times and share with their healthcare providers.

There is limited research on effective treatment interventions. Possible promising programs include hospital discharge programs, prescription guidelines for providers, and medication review procedures in settings such as home care and nursing homes. Brief informational and intervention sessions represent viable and nonthreatening opportunities to provide support and relief.

Electronic medical records and databases that connect the information systems of physicians and pharmacists may also prove helpful.

Needed Actions
Unfortunately, there is little recognition in our society about the seriousness and extent of substance misuse in older adults. It is currently severe, and as the number of older adults with substance abuse problems grows, there will be an even greater need to address the numerous barriers to effective identification and treatment by doing the following:

• improving access via increased service capacity and offering services in home and community-based settings where older adults congregate, such as senior centers and naturally occurring retirement communities;

• improving quality of care, including training and broadening dissemination of effective practices;

• integrating substance abuse, health, mental health, and aging services to provide comprehensive care tailored to the needs of the individual consumer who presents with co-occurring, multiple needs;

• building a clinically and culturally competent workforce through education and training of providers, increasing the supply of competent providers, especially those who are bilingual and culturally competent, and using older adults in peer-to-peer service roles more extensively;

• increasing support for family caregivers, including education about medication management and signs of alcohol and drug abuse;

• providing public education to address ageism, stigma, ignorance, and fears about treatment and its effectiveness;

• improving research on effective prevention, intervention, and recovery support strategies;

• designing finance models that support best practices, integrated service delivery, parity, and incentives to enter the workforce; and

• developing governmental and private sector readiness including leadership, planning, and program development.

It is of utmost importance to mobilize resources and prepare for the significant impact that the growth of the aging population will have on our mental health and substance abuse delivery systems. To adequately address the need, our supporting systems need to join forces now to advocate for appropriate planning and funding. With our unified voice we can make a difference in the lives of elders with behavioral problems.

To speak with a qualified professional about a client or patient’s substance abuse problem, call 800-662-HELP (4357), the 24-hour hotline of the Substance Abuse and Mental Health Services Administration’s National Treatment Referral Services or visit the Web site For additional resources, visit

— Kimberly A. Steinhagen, LMSW, is the director of the Geriatric Mental Health Alliance of New York based in New York City (

— Michael B. Friedman is the director of the Center for Policy and Advocacy of The Mental Health Associations of New York City and Westchester. He is also chairman of the Geriatric Mental Health Alliance.