Lesson 12: Substance Abuse in Late Adulthood

Attention

Learning Outcomes

Upon completion of this lesson's material, students will be able to:

  • Identify barriers to successful substance abuse treatment from a rehabilitation provider's perspective
  • Research alternative treatments and interventions for elderly clients

Teaching

Reading

Read Chapter 6 - Integrity: Death be not Proud in Vaillant

There is a myth that substance abuse is not common among the elderly. Abuse may be mistaken for other assumed disorders such as dementia. As with any age, there are dire consequences related to untreated substance abuse.

Substance abuse among the elderly: A growing problem (LINK: http://www.hazelden.org/web/public/ade60220.page)
Article published on the Hazelden website

Potential consequences of substance abuse include:

  • complications of medical conditions
  • impaired quality of life
  • domestic violence
  • intentional or unintentional injury
  • long-term family problems

One confounding issue is that as we age we become more susceptible to the effects of substances. So, if someone is used to drinking a case of beer in a sitting, as they age this has a more severe impact on them.

Sensitivity is related to total body mass and total body water, both of which decrease as we age. Interactions with medications that the older person may be taking may also cause problems. There is also a decrease in the metabolism of alcohol in the gastrointestinal tract which affects an individual's ability to process the alcohol.

Alcohol Abuse

As part of the changes within the DSM-5 there were a number of changes to the Alcohol Abuse category from the DSM-IV-TR. The changes are outlined in the document below:

Alcohol Use Disorder: A Comparison Between DSM–IV and DSM–5

This fails to capture the unique characteristics of alcohol abuse in older populations.
  • older cohorts are not as educated as to the effects of alcohol on medical conditions
  • consumption thresholds are different
  • lack of tolerance may be present due to late onset of the substance use problem

Positive Effects of Alcohol Consumption

Small amounts of alcohol have been shown to provide some health benefits, although abstinence is still recommended for anyone who has a history of alcoholism or drug abuse, who is taking certain medications (see Chapter 3), or who is diagnosed with certain chronic diseases such as diabetes and congestive heart failure. Some studies, largely conducted on male samples, show that low levels of alcohol consumption (one standard drink per day or less) reduce the risks of coronary heart disease (Shaper et al., 1988). However, this cardiovascular benefit may not apply to adults already diagnosed with heart disease. Older adults in this category should not drink unless their physician says otherwise.

"An intriguing epidemiologic finding is the association of regular, but moderate, alcohol use (up to two drinks per day) with lower morbidity and mortality from coronary artery disease," especially in men, when compared with heavy alcohol users and abstainers (Atkinson and Ganzini, 1994, p. 302). (http://www.ncbi.nlm.nih.gov/books/NBK64412/)

Substance abuse among older adults

We often feel that alcoholism is a way of escape or coping with the many issues that people may have. We have already identified that the elderly may have a lot on their plate. Consider the following scenarios related to drinking:

Early Onset vs. Late Onset Drinking

Most elderly people with drinking problems have had drinking problems for a long time. These people are different from late onset drinkers (about 1/3). This 1/3 are usually more willing to seek help.

Intermittent Problem Drinking

Characterized by a history of periods of heavy drinking. May occur as a response to events.

"Another way of understanding the patterns of drinking over a life span is to look at the time frames in which people drink and the frequency of their drinking. In contrast to ongoing, continuous drinking, intermittent drinking refers to regular, perhaps daily, heavy drinking that has resumed after a stable period of abstinence of 3 to 5 years or more (National Institute on Alcohol Abuse and Alcoholism, 1995).

Intermittent drinking problems are easy to overlook, but crucial to identify. Even those problem drinkers who have been sober for many years are at risk for relapse as they age. For this reason, during routine health screenings, it is important for clinicians to take a history that includes both current and lifetime use of alcohol in order to identify prior episodes of alcoholism. When armed with this information, caregivers can help their older patients anticipate situations that tend to provoke relapse and plan strategies for addressing them when they occur" (http://www.ncbi.nlm.nih.gov/books/NBK64412/).

Problem Focused Drinking

This is the type of drinking that is related to a specific situation, such as loneliness, loss, health issues, legal and financial issues, etc. (Incidentally, these are also all risk factors related to drinking).

"For many adults, the phenomenon of aging, with its accompanying physical vulnerabilities and distinctive psychosocial demands, may be the key risk factor for alcohol problems. To differentiate older drinkers, the Consensus Panel recommends using the terms at-risk and problem drinkers only. As discussed above, not only do the concepts of quantity/frequency implicit in the term heavy drinking have less application to older populations, but the "distinction between heavy and problem drinking narrows with age" (Atkinson and Ganzini, 1994, p. 300). In the two-stage conceptualization recommended by the Panel, the problem drinker category includes those who would otherwise fall into the heavy and problem classifications in the more traditional model as well as those who meet the DSM-IV criteria for abuse and dependence" (http://www.ncbi.nlm.nih.gov/books/NBK64412/).

Screening Tools

Many of you may have taken the Substance Abuse class and have come across some of these tools. The CAGE, AUDIT, and MAST tests are some of the screening tools used to assess substance abuse issues in individuals. Review the content of the tools below.

Click HERE to view the CAGE
Click HERE to view the AUDIT
Click HERE to view the MAST

Treatment

The potential impact of the baby-boom generation on substance abuse among elderly persons
Read the part on the issues related to treatment

Substance Abuse and the Elderly: Unique Issues and Concerns
Read the part on treatment that is on P. 47 of this article

Assessment

Lesson 12 Discussion (online course only)

In this discussion I would like each of you to reflect on the section titled "Treatment" in the article "Substance Abuse and the Elderly: Unique Issues and Concerns". Of particular interest is the section on what "Rehabilitation Professionals" tend to do. That is US! Your next step is to research other options for substance abuse treatment for our older adult consumers and share those in your discussion post.

Lesson 12 Quiz

Most individuals have had exposure to someone in their lives who has had or currently has a substance abuse problem. Please share an example of an individual you know who has stuggled and how you processed (what you thought) about their substance abuse problem. This is an opportunity to explore your potential biases. Now, imagine that person was your client. How would your thinking and behavior towards him/her change if you were that person's community integration worker?