Recognizing Addiction in Older Adults
Older Adults and Addiction
Millions of Americans have an alcohol use disorder (AUD), substance use disorder (SUD), or both. While the rate of addiction climbs each year, more and more addiction treatment centers are seeing the need for more specialized treatment programs for certain groups. The older adult or elderly population is one such group.
The National Institute on Drug Abuse (NIDA) reported in 2018 that 1 million American adults over the age of 65 had a SUD. What’s more, over a 12-year period the percent of older adults admitted to treatment centers grew from 3.4% to 7%. However, as there exists a problem with accurate identification of an AUD or SUD in the senior population, experts estimate that there are actually more like 8 million American elderly with an addiction to alcohol, a prescription drug, or an illicit drug.
One of the most significant contributing reasons for the growing demographic of older adults with addiction issues is due to the transition of the “Baby Boomer” generation into this age group. Baby Boomers are classified as individuals born between the years of 1946 and 1964. The first group of Baby Boomers to enter their "senior years" was in 2011. Not only does this group comprise 30% of the United States' population, but they’re also expected to live longer. It is imperative as more and more enter this age group, that effective identification and treatment of addiction in older adults begin.
Not only are there larger numbers of this generation than others, when it comes to Baby Boomers they have a higher rate of drug use than their predecessors entering retirement age. This group of individuals grew up in the 60s and 70s when social acceptance of, and experimenting with drugs, was the norm. Substance abuse in this group has remained high as they age. In addition, the older adult age group also has more chronic physical ailments and thus more prescriptions than any other group.
This trend in the growing number of illicit drug use amongst senior citizens is not typical of what has been seen before. Generally, drug use declines with age, but as the Baby Boomers enter this age group, this is not the case.
Recognizing Addiction in Older Adults
Older adults are less likely to be screened for and diagnosed with an alcohol or substance use issue. It’s vital to understand what both SUD and AUD look like in older adults. When it comes to addiction of any kind, the sooner help is sought the better. Older adults with addiction issues can often go undiagnosed for years. And, drugs or the excessive consumption of alcohol, can cause more serious health complications for seniors as their bodies are more vulnerable to the harmful effects of both.
With older adults visiting emergency rooms (ERs) more than 750,000 times in 2011 for drug-related problems, it’s essential that both healthcare professionals and family members know how to recognize the signs of an AUD or SUD in older adults. The senior population experiences physical and mental changes that can mask, as well as mimic, problems with alcohol and drugs—both illicit and prescription.
Additionally, isolation is something that plagues many seniors. After losing their spouses or significant others, having their kids move away,, or become busy with their own families, seniors are often left alone. Not only does this loneliness sometimes contribute to the development of an alcohol or substance use disorder, but it also enables the individual to ‘hide’ their drinking or drug use—both of which are contributing factors to the lack of identification of both AUDs and SUDs in seniors.
Here are some of the most common symptoms of alcohol use disorder and substance use disorder in seniors, categorized into five groups; physical, cognitive, psychiatric, social risk, and general risk factors.
- Loss of weight, poor nutrition, and decrease in appetite
- Personal hygiene issues and unkempt appearance
- Slurred speech
- Falls and bruises (occurring more often without explanations)
- Sensory issues
- Complaints about health without any real evidence of any issues
- Forgetfulness that seems to be increasing
- Being disoriented
- Trouble making decisions
- Overall cognitive issues
- Moodiness and irritability
- Mental health issues like depression and anxiety
- Sleep disturbances
- Problems with family or relationships
- Legal issues
- Money problems
- Social isolation or withdrawing from social activities
- Lying about drinking or drugs
- Hiding drinking or pills
- Filling prescriptions at multiple places
- Visiting different doctors for the same issue
- Running out of medication too soon
- Finding reasons to increase dosage or take more frequently
- Talking about the benefits of the drug or drinking
- Increased drinking frequency and/or amounts
- Uncomfortable or defensive when confronted about drinking or drug use
Identifying an alcohol or substance use disorder in older adults can be challenging. Some of the signs associated with addiction such as memory loss and other cognitive issues can also be signs of other medical problems like Alzheimer’s Disease. It is more common for both health professionals and family members to look to those in their youth for drug or alcohol issues. Many family members and even caring physicians can’t imagine that their beloved gray-haired grandma or long-time patient is addicted to drugs. Yet, millions of American seniors are addicted to alcohol or another substance.
Some of these seniors have always had a dependency on alcohol or a drug, while others have never had an issue until they experience grief after losing a loved one or begin to experience chronic pain. These are just two factors that commonly contribute to an older adult developing an AUD or SUD.
Risk Factors for Alcohol and Substance Use Disorders in Older Adults
The research into how mind-altering substances impact older adults is in its infancy. Most research on this topic has been centered around the misuse and abuse of alcohol in older adults. There has been some research into both illicit and prescription drug use amongst this group, but it’s minimal.
When it comes to alcohol use disorder and some of the substance use disorders and older adults, there appears to be a number of correlating factors. Demographics associated with alcoholism and substance use disorders reveal that later life alcoholism is most associated with affluent, Caucasian, males. While females have a higher rate of abusing prescription drugs. Overall, the strongest demographic indicating any type of alcohol or substance abuse issue in later life are those having more financial resources.
However, there are more risk factors contributing to a higher chance of developing an addiction to alcohol or drugs later in life. Generally, these risk factors are categorized into three groups; physical, psychiatric, and social risk factors.
Physical Risk Factors
- Poor overall health
- Chronic pain
- Compromised mobility or physical disability
- Chronic illness
- High number of prescription medications being taken
- Change in living situation or caregiver change
Chronic pain and chronic illness in older adults are both significant contributing risk factors for addiction. With both chronic pain and chronic illness often come multiple prescriptions. According to a study by Medicare, it was reported that 15% of older adults receive an opioid prescription after any type of hospitalization. And, what’s more, half of those individuals were still getting those prescriptions filled 90 days later. Opioids are quickly becoming one of the most abused types of prescription medications in seniors.
Prescription Safety: Importance of Clear Communication with Your Doctor
In addition, many primary care providers are now not only tasked with knowing all of the multiple prescription medications their patients are taking, but they also must have a solid understanding of the possible interactions of these medications with each other. Older patients tend to visit multiple doctors for different aging issues. Some of these doctors may prescribe medications while the primary care providers are unaware. This can cause multiple prescriptions to treat the same problem, but just as dangerous can be the interactions between various medications.
Many physicians simply aren’t fully educated about medication interactions. This is particularly true when it comes to mood-altering medications like benzodiazepines and opioids. These two drugs can make an individual become very lethargic, easily fatigued, lacking energy or motivation. If a physician doesn’t understand this interaction well, they may prescribe the patient yet another medication to help increase their energy. Too often, this results in adverse reactions that require an ER visit or even hospitalization.
Another example is the way in which beta-blockers can work on the body. Often, these medications used to help patients with heart disease will cause drowsiness. Pair this prescription with an opioid or benzo and this patient becomes at a substantially higher risk for a fall.
Many seniors are also reluctant to reveal the truth about their drinking or drug use to their physicians. This is often because addiction to any substance or alcohol is attached with numerous stigmas which often bring shame to the individual with the issue. This can lead to the sometimes deadly mixing of not just too many medications, but also of medications and alcohol. Mixing certain medications and alcohol can be dangerous—even fatal—for any age group. The elderly, whose bodies metabolize much more slowly, are even more susceptible.
Many in this age group implicitly trust their doctors and while this trust may be valid, if seniors forget to reveal another prescription they are taking or don’t disclose their drinking, the doctor is unable to protect them. This is another reason why it’s so vital for both providers and family members to learn more about what addiction in the elderly really looks like.
Psychiatric Risk Factors
- History of alcohol or substance use disorder
- Mental health issues such as anxiety, depression, bipolar disorder, post-traumatic stress disorder (PTSD), etc. (current or prior)
- Coping style of avoidance
For any seniors or other age groups, who have had a prior issue with alcohol or another substance, there is always a greater risk of having an AUD or SUD again. And, like other age groups as well, having mental health issues such as anxiety or depression increases the risk of substance abuse. Many people who have these types of mental health disorders will turn to alcohol or another substance to cope. This can often lead to dependence and addiction.
It is also common for adult women to be prescribed benzodiazepines for anxiety. This is common with seniors too, and often well-meaning prescribers don’t understand the high rate of addiction to benzos. What is helpful for some in the short-term becomes a long-term addiction for many.
Social Risk Factors
- Being affluent or having wealth
- Experiencing grief and loss
- Sudden retirement
- Living in isolation from others
Social isolation is something that is common for many people in active addiction to drugs or alcohol. What begins in a social setting often ends alone at home in despair. For seniors, this isolation is what can drive the use of alcohol or a substance. Many seniors, particularly those in what’s called the ‘young-late life’ stage, are experiencing a number of significant life changes. From getting divorced and moving to becoming empty nesters and not working any longer, life for this age group is changing rapidly.
One of the most troublesome events individuals in this stage of life face is dealing with grief and loss. During this part of life, many will lose their spouses or significant others. This can be tremendously painful and difficult to deal with for many—even those with the healthiest coping skills.
In addition, when seniors retire, their lives often drastically change. One part of this change is the sense of loss of purpose. For many their careers and families have been what drives them and gives their lives meaning. When this is gone, the pain and adjustment can be tremendous. This can lead to using alcohol or drugs to cope.
It’s vital to realize that many seniors are not only losing their significant others, but also a number of other loved ones. Loss of siblings, long time friends, past coworkers, parents, and more can weigh heavy. Along with the pain and grief also comes isolation for many older adults.
These changes, not all welcomed, can lead to the use of alcohol or another substance to help cope or ease the pain. These lifestyle changes make older adults more vulnerable to fall victim to addiction. However, it’s important to note that an individual can have none of these risk factors and still have an AUD or SUD. For that reason, it’s essential to understand what addiction in the elderly looks like.
Most Common Types of Addiction in the Elderly
According to the National Institute on Drug Abuse (NIDA), 65% of adults over the age of 65 reported high-risk drinking. Of even greater concern, is that more than one-tenth of adults 65 years of age and older reported binge drinking. High-risk drinking is defined as exceeding daily guidelines at least weekly for a year. Binge drinking is consuming five or more drinks on one occasion for men, and four or more on one occasion for women.
Alcohol is the most commonly used drug by older adults despite an increase in both prescription and illicit drug use by this same group. In fact, widows over the age of 75 have the highest rate of alcoholism in the country. Alcohol use disorders can often go overlooked in older adults. From an uncle who always enjoyed a few beers with the Sunday football game to the grandma who didn’t drink much before grandpa died who now needs a drink or two to get through the day and fall asleep at night, family members often miss alcohol use in their older relatives.
Not only does AUD carry with it the normal health concerns as it does for all age groups, in the elderly, there are even more risks. Long-term drinking can lead to:
- Immune system disorders, certain types of cancer, liver damage, and brain damage
- Contribute to the worsening of already present health issues like high blood pressure, stroke, diabetes, osteoporosis, ulcers, and mood disorders
- Cause symptoms that can be mistaken for, or mask other health issues, like Alzheimer’s, heart attack, etc.
As mentioned, the body metabolizes at a much slower rate as it ages, this too, increases the dangers of drinking for the older adult. Often, less alcohol is needed to be consumed for the same effect. Seniors don’t recognize this and continue to drink the same amounts as before. Coupled with the slower metabolism enabling the alcohol to stay longer in the body, this contributes to accidents, injuries, and falls in older adults—even hours after drinking.
In addition to physical complications, consuming too much alcohol can also exacerbate or lead to mental health disorders. When a person has a mental health disorder, in addition to an alcohol or substance use disorder, they have what’s called “co-occurring disorders.” Alcohol can also increase depression, anxiety, and other mental health issues already present.
While alcohol remains the most commonly used drug amongst older adults, illicit drug use is on the rise in this age group. With marijuana and cocaine leading the way, dependence on both is growing in the older adult population.
Marijuana or “cannabis,” is a psychoactive drug created from the cannabis plant. Marijuana, weed, pot, grass, ganja, herb, etc. are all names used interchangeably for this plant used mainly for medicinal and recreational purposes.
Today, medical marijuana is being used more and more regularly to treat a variety of medical and mental health issues. This is true for older adults as well as the rest of the population. Treating conditions like chronic pain, sleep issues, depression, malnutrition, and side effects from cancer treatment, the cannabis plant has been found to be helpful for all ages including older adults.
With more than 33 states and the District of Columbia now legalizing medical marijuana, the use of the substance continues to grow amongst all age groups. The National Institute of Health (NIH) reports that in 2012, 4.6 million American adults over the age of 50 reported marijuana use in the past year. The continued legalization and availability of medical marijuana has led experts to predict continued growth in the use of marijuana by older adults.
However, while many are touting the benefits of this healing plant, the research on the use of medical marijuana for these health conditions (and others) remains limited. For that reason, it is difficult for medical professionals to determine the validity of cannabis treatments. Regular use of marijuana—for medical and other reasons—has been shown to contribute to chronic respiratory conditions, depression, impaired memory, problems with cardiovascular health, altered judgment, and impaired motor skills.
The Baby Boomer generation was one of the first to embrace the use of marijuana. Trends amongst this group in the use of illicit drugs suggest the continued use of marijuana, particularly since it’s legal for medical purposes and easier to obtain. It’s important to realize that even though ‘weed’ is now legal in many states—in some states for recreational use—an individual can still become dependent on it. It’s important to look for the same addiction warning signs when it comes to marijuana use too.
Cocaine, Inhalants, Hallucinogens, Methamphetamine, and/or Heroin
Fewer than one million older adults (aged 50 years of age and older), report using the illicit drugs listed above in the last year, according to the same NIH report. However, there remains addiction for this aging group for each of these illicit substances.
Like alcohol, marijuana, and prescription drugs, these illicit drugs pose some unique issues for older adults. As mentioned, the body of the aging adult takes longer to metabolize substances, may already have other health issues present, and this age group is likely to be taking prescription medications. Each of these cases makes the older adult who uses one of these (or any other) illicit drugs more vulnerable to harmful consequences.
Prescription medications and their abuse are at the forefront of many discussions today. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), prescription drug misuse is the second most common type of illicit drug use in the U.S. Older adults are not exempt from this. SAMHSA also reports that in 2014, 1 million older adults in the U.S. had a SUD. In fact, not only are older adults not immune to this, data suggests that SUD amongst older adults is emerging as a significant public health concern.
Many first think of opioid abuse when it comes to problems with prescription medications. The opioid epidemic has brought into light the dangers of both overprescribing pharmaceuticals and misusing them. And, while the opioid epidemic certainly leads the way in prescription drug abuse news, there are also other prescription medications that many older adults take that are being misused. This discussion will focus on both opioids and benzodiazepines.
Older adults use prescription medications three times more than the rest of the population, according to a report from the Special Commission on Aging. And while much of the focus on opioid addiction is on younger age groups, older adults are misusing opioids at astonishing rates. According to research, hospitalization rates amongst older adults for opioid misuse grew by 34% between 2010 and 2015. During that same period, emergency room visits for opioid-related issues in this age group increased by 74%.
Opioids are a class of drugs that include prescription pain relievers such as oxycodone (OxyContin), hydrocodone (Vicodin), codeine, morphine, and more, as well as heroin and fentanyl. Regular use, even when prescribed by a doctor, can lead to dependence.
The Centers for Disease Control and Prevention (CDC), reports that in 2018 amongst adults 65 years of age and older, 25% had at least one prescription for an opioid. This includes 23.5% of men and 26.1% of women. It’s imperative that both medical professionals and anyone with older adults in their family understand the dangers associated with opioid use in older adults as well as warning signs of a problem.
Many mistakenly believe that if a physician has prescribed medication it must be safe. Even if a medication is taken as prescribed a person can still become addicted. This is also true with opioids. Misuse of opioids or other prescription medications can include the following use of the medication:
- Using in any way not directed by the prescribing physician
- Taking more than is prescribed
- Taking more often than is prescribed
- Continuing use longer than prescribed
- Consuming medication that isn’t from one’s own prescription
Older adults are at risk for the same problems the rest of the population faces when it comes to opioid use disorder (OUD). However, because of issues already mentioned with aging, this growing group faces other serious complications from the misuse of opioids. These include increases in:
- Falls and fractures
- Cognitive impairment
- Drug interactions (from polypharmacy)
- Compromised respiration
- Falls that result in hip and spine fractures
One of the issues with older adults is safe and effective pain management. Chronic pain is common as one ages. This is one of the reasons this age group is prescribed opioids, to which they are becoming dependent.
The management of chronic pain in the aging population is not going to end. And as more and more Baby Boomers enter retirement and their senior years, the need for safe and effective pain management is only going to increase. It’s vital to find evidence-based methods to treat pain not only in older adults but the entire population as well.
Not only do opioids for the treatment of pain present a problem in this age group, so too does the use of benzodiazepines for the treatment of anxiety and insomnia—two very common complaints in the older adult population.
Benzodiazepines or benzos as they’re more commonly called, are a class of psychoactive drugs that many primary care physicians prescribe for both anxiety and insomnia amongst other issues. The risk of becoming dependent on benzos is high, particularly with prolonged use.
More than 17 million prescriptions for benzos are given to older adults in the United States each year. Primary care physicians prescribe the most benzodiazepines. Despite the American Geriatric Society advising against prescribing older adults benzos, the number of prescriptions for benzos only grows—particularly among this age group.
Data shows that in the U.S., more than 10% of women and 6% of men aged 65 to 80 years old, filled a prescription for benzos in a one year period. Of even greater concern is that one-third of these older adults were receiving these habit-forming medications for more than 120 days.
Additionally, research reveals that as U.S. adults get older, the rate of prescribing benzos increases. This trend is particularly apparent in older women. A study by the NIH found that among women 65 to 80, one in ten were prescribed a benzodiazepine.
Benzos present the problem of addiction not only when misused, but dependence can also develop when used as prescribed. But, in addition to developing a SUD, older adults face other complications when it comes to this prescription medication.
Benzos are central nervous system (CNS) depressant drugs that slow brain function. For older adults, this can pose some additional risks. As discussed, older adults tend to be on multiple medications, increasing the risk of a dangerous interaction with another prescription. Alcohol can also cause serious risks when an individual is taking benzos. Common side effects of benzos can be exacerbated by other medications such as those used to treat pain, insomnia, acid reflux, heart disease, and more.
However, benzo use and misuse alone can increase the risk of certain issues for the older population. These include:
- Memory issues, dementia, and cognitive decline
- Falls and fractures
- Motor vehicle accidents
Alarmingly, research has shown that when it comes to all-cause mortality, individuals taking benzodiazepines died at a 1.2 to 3.7 times higher rate. Whether the link is causal or from other contributing causes will need to be determined with further study. Despite the unknown, this is still an important risk factor to consider.
As with opioids, it’s critical for those in the medical community to find safe, yet effective, alternatives for the treatment of anxiety and insomnia, particularly for the elderly. Educating primary care providers on safe ways to taper patients off of benzos, the dangers of prescribing benzos to this group, and evidence-based alternatives are vital for change.
It’s also crucial for primary care physicians to have the resources needed when a patient becomes dependent. It is extremely dangerous to stop taking benzos abruptly or “cold turkey.” For this reason, sending patients to an addiction treatment center that understands the unique treatment needs of this age group is important. Doctors should have a working knowledge of these treatment centers so they can advise their patients in need.
When it comes to addiction treatment in the older adult population, the results are very encouraging.
Treatment for AUDs and SUDs in Older Adults
Treatment for addiction to drugs or alcohol has never been as in demand as it is today. With thousands upon thousands of addiction treatment centers across the nation, there continues to remain a lack of specialized programs for the older adult population battling addiction.
According to the NIH, only about 18% of all the addiction treatment centers in the country have programs designed for older adults. However, they also report that after completion of treatment this age group has a “good” or “better” outcome than other age groups.
While more older adults are seeking help for an AUD or SUD, there continues to remain several age-specific barriers. These include:
- Lowest mental health utilization rates than any other age group
- Associated stigma and shame
- Lack of financial resources to pay
- Geographic isolation and lack of transportation
It’s imperative that older adults are able to get the treatment and help they need. The CDC reports that in 2017, older adults aged 55 years of age and up, saw the greatest jump in overdose deaths than any other group.
Treatment programs found to be particularly effective in this older adult age group include behavioral therapies and medications. Supportive therapy models (STM) and cognitive-behavioral therapy (CBT) have been shown to help older adults recover from drug and alcohol abuse. CBT may be so successful with the older population because of the highly structured, didactic approach, which lends itself to helping those with memory loss issues common in this age group.
STM is particularly important for this age group as they may not respond well to being in groups with younger individuals. Older adults may not relate or feel comfortable discussing their problems with younger people. This can enhance feelings of shame and isolation. In addition, it has been shown that this age group doesn’t respond well to confrontational or similar approaches.
It’s important for this age group that any co-occurring disorders are identified. In this population, various conditions can more easily mask others. However, taking the time to thoroughly assess the older adult seeking treatment is vital to long-term recovery. If a co-occurring mental health disorder such as depression or anxiety exists, treating both at the same time helps to build a solid foundation in recovery.
No matter what type of addiction an older adult may have, there are evidence-based programs to help them recover. As the numbers of senior citizens continue to grow, along with a longer life expectancy, the need for education about both alcohol and substance use disorders amongst the elderly also increases.
When it comes to the older adult population, identifying an issue can be the most difficult part. However, when you know what to look for, this makes the process easier. After identifying an issue, seeking treatment at an addiction treatment center that understands the unique needs and nuances of this group is essential.
Caron Treatment Centers has specialized care for older adults, including a separate unit of Older Adults. With an understanding of the different needs of seniors in recovery, Caron has programs for Grief and Loss, Chronic Pain, and utilizes proven cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT) therapies. Our non-confrontational approach and age-specific groups, enable peer interaction and socialization—both vital components of recovery.
The medical team at Caron completes a thorough and comprehensive assessment including a Fall Risk Assessment. The ongoing care provided by our medical team, allows seniors and their families to have peace of mind knowing that all medical issues will be taken care of while in treatment.
If you are an older adult or a loved one and think you may have a dependency on alcohol or another drug, Caron Treatment Centers is here for you, with the help you need.
By Ming Wang, MD, FASAM
By Ming Wang, MD, FASAM
By Devon Dautrich, Ph.D.