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Substance abuse in older adults
Substance abuse is considered a psychiatric disorder and is therefore diagnosed by medical and mental health providers using the criteria found in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) (American Psychiatric Association, 2013). Drug abuse is difficult to diagnose in older individuals because current diagnostic criteria were developed for young and middle-aged persons (Wu & Blazer, 2011). There is a need for addiction treatment programs tailored to older adults, and the need for proper diagnostic measures of substance abuse symptoms in older adults. Chronic medical or psychological problems can be worsened by drug use and even mistaken as physical or psychological issues rather than addiction (Morgan, Brosi & Brosi, 2011).
Relevant History
In 2011, the generation of people who were born between 1946 and 1964, often referred to as baby boomers, started turning 65 years old at a rate of 10,000 per day and will continue to do so for the next twenty years. Ultimately, this will double the number of individuals aged 65 and older in the United States by 2050 (United States Census Bureau, 2012). Many baby boomers were involved with drugs, and as a result the Drug Enforcement Administration (DEA) was formed in 1973 and numerous anti-drug laws were created (Hawn, 2014). Hawn goes on to say that “while these new laws stopped some Baby Boomers, research shows that there will be an estimated 5. 7 million adults aged 50 and older with a substance abuse disorder by 2020” (2014, p. 7). Baby boomers experimented with more illegal drugs than any previous generation, with marijuana, cocaine, and opioid analgesics (painkillers) being the most commonly abused substances (Wu & Blazer, 2011).
Prevalence
As the baby boomers continue to age and life expectancy increases, substance abuse among older adults is also increasing. The Substance Abuse and Mental Health Services Administration (SAMHSA) noted that as many as 17 percent of older adults are currently affected by alcohol and/or prescription drug misuse (2002). Alcohol use may be more problematic among aging adults simply because even minimal use of alcohol can exacerbate many medical conditions seen in those age 65 and older (Finch & Barry, 1992; Korrapati & Vestal, 1995). Even light or moderate drinking can put older adults at clinical risk, especially if they are taking prescription or over-the-counter medications (Forster, Pollow, & Stoller, 1993).
Among the elderly, one study found that alcohol related hospitalizations are as common as hospitalizations related to heart attacks (Adams, Yuan, Barboriak, & Rimm, 1993). Closser and Blow (1993) note results from the Epidemiological Catchment Area Study indicating that the incidence of alcoholism coexisting with a medical or psychiatric diagnosis ranged between 15 and 58 percent for older adults. Another study suggested that the increased need for prescription medications that accompanies aging contributes to the risk of over-the-counter and prescription drug abuse (Ruben, 1992). In addition, the routine use of over-the-counter pain relievers and sedatives can be harmful whenever alcohol is also consumed (Forster et al., 1993; Finch & Barry, 1992). Forster et al. (1993) found that, for aging adults, the most common risk for adverse alcohol related drug reaction was from the use of over-the-counter pain medications in combination with alcohol.
Potential Causes
There are numerous things that could contribute to substance abuse issues later in life. These could be health-related issues or life-changing events that take an emotional toll. These events may incite drug-abusing conduct that can ultimately become addiction (Briggs, Magnus, Lassiter, Patterson, & Smith, 2011). Some common precursors for drug or alcohol dependence in the elderly are:
• Retirement,
• Death of a family member, spouse, pet or close friend,
• Loss of income,
• Relocation or placement in a nursing home,
• Trouble sleeping,
• Family conflict, and
• Mental or physical health decline (depression, memory loss, major surgeries, etc.) (Briggs et al., 2011).
Issues related to Diagnosis in the Elderly Population
While media attention and public health initiatives largely focus on substance misuse in younger members of society, research suggests that substance abuse in older populations is under-recognized, under-diagnosed, and under-treated. A variety of issues need to be addressed to accurately diagnose alcohol abuse and dependence in older adults. Many diagnostic criteria for substance dependence may not apply or may mimic signs of physical or mental impairment common in older adults (Morgan et al., 2011). For example, although tolerance of a substance is one diagnostic criterion for substance dependence, it may not apply to older people because of inherent changes in metabolism of alcohol, greater sensitivity to alcohol, and higher blood alcohol levels, which may result in less alcohol intake with no apparent reduction in intoxication (Menninger, 2002).
There are other specific conditions that might complicate drug abuse assessment of older adults. For example, “with dementia affecting 5.2 million (or one in six) older adults over 65, an older individual might continue to forget having already taken an addictive prescription medication, and accidentally build dependence” (Hawn, 2014, p. 17). Social seclusion is another indication of substance abuse that might present a problem when diagnosing older adults; “the ageist myth that people become less social as they age might influence medical professionals to ignore decreased social activity as a normal side-effect of aging as opposed to drug abuse caused by social isolation” (Hawn, 2014, p. 17).
Types of Substances
Blow and Barry (2014) claim that illicit drug use is low among the older adult population, but speculate that as the baby boomers age, use of illegal drugs will become more prevalent.
Opioids, heroin, cocaine, and marijuana are the illicit drugs most commonly used by older adults (Wu & Blazer, 2011). An increasing number of older adults are seeking treatment for combined alcohol and drug abuse, which might be a result of the fact that most older adults that abuse opioids, heroin, cocaine, and marijuana also abuse alcohol. Treatment for’ substance abuse is most often sought by older adults that abuse alcohol, opioids, heroin, and cocaine, with very few older adults seeking treatment for marijuana addiction (Wu ; Blazer, 2011).
As previously mentioned, most older adults take prescription and/or over-the-counter drugs (Kuerbis, Sacco, Blazer ; Moore, 2014): Many of the drugs commonly prescribed to older adults are addictive, especially those treating depression, pain, and sleeplessness (Administration on Aging, 20l3). According to Dowling, Weiss, and Condon (2008), aging-related physical changes can increase sensitivity to certain substances, and chronic medical conditions can be worsened or even triggered by drug abuse. With the prevalent use of addictive psychoactive medications such as anti-depressants, anti-anxiety medication, and sleep aids, among older adults, there is a high probability of substance abuse evolving as a result (Simoni-Wastila ; Yang, 2006).

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