With most older adults now vaccinated against COVID-19, families are gathering for the first time in more than a year. In reuniting with an older family member or friend, some may notice red flags: New signs of memory issues or that previously identified cognitive impairments in their loved ones have worsened. Although social isolation and loneliness are known risk factors for dementia, older adults were forced into this scenario by the pandemic to save lives. Many older adults have reported an increase in alcohol and substance use to manage the stress and loneliness of the past year. These cognitive changes that families may observe in their loved ones could be a sign of a substance or alcohol use disorder.
Dementia is a broad term that describes difficulties with memory, thinking, and communication that can be the result of various diseases and brain disorders. Alcohol or substance-induced dementia is much more common than you might think. At Caron, we screen every person entering our Older Adult Program for cognitive impairment. A surprising number of individuals score below the threshold for what is considered normal. In other words, many of our new patients are unable to complete simple cognitive tasks; this impairment resembles dementia and interferes with a person’s daily functioning. The good news is that when alcohol and substance use disorders are contributing to the impairment, once we remove the substances, the brain can begin to recover.
What Substance Use in Older Adults Looks Like
It is important for family members to understand that substance use in older adults doesn't necessarily look like problematic drinking or drug use. They may simply be taking their medications as prescribed or drinking the same amount of alcohol they always have, but as people age, the body metabolizes these substances differently. Now two glasses of wine might have a very different impact than it did decades ago, especially when combined with prescription medications.
Many are unaware that mixing alcohol and medications may be toxic and can cause a range of problems. For example, if someone drinks regularly and is prescribed a sleep medication, an opioid, or an anti-anxiety medication, the mixture can be dangerous and even lethal. Older adults often visit multiple doctors and specialists, under-report their use of alcohol, or are simply not asked about their drinking.
Consider a person who has never abused a prescription medication in their life, but they are prescribed opioids for a chronic pain condition. Overtime, their body adjusts to the opioids, and they begin to experience withdrawal symptoms as the medication wears off. This may increase anxiety and make it difficult to sleep, so drugs like Xanax, Ativan, or Ambien are prescribed. Opioids and benzodiazepines (anti-anxiety medications) are another dangerous combination. This person may begin to experience serious side effects and may unknowingly meet the criteria for a substance use disorder.
The Impact of the COVID-19 Pandemic
Since the COVID-19 pandemic began, we have seen a significant uptick in cognitive impairment among older adults at Caron. This is part of a broader trend of sicker patients who are more advanced in the disease of addiction.
As I said, part of our initial evaluation process involves screening every new older adult patient for cognitive impairment. We ask patients to complete a standardized set of tasks that every adult, regardless of their age, is expected to be able to perform with ease. This measure is called the Montreal Cognitive Assessment (MoCA) and the maximum score is 30. A score of 26 or higher is considered normal.
The average MoCA score pre-COVID-19 (for those admitted to Caron November 2019 to February 2020) was 25.1, which constitutes mild impairment. The average score for those admitted during COVID-19 (November 2020 to February 2021) was 22.5, indicating mild to moderate impairment. In other words, patients are coming to us with higher levels of cognitive impairment.
The pandemic has made things worse for our patients. This is likely due to several reasons:
- Chronic fear and anxiety over contracting COVID-19
- Enforced social isolation from family members and friends
- Loss of activities that provide structure to daily living
- Loss of lifelines, such as 12-step meetings, that reinforce recovery
- Decreased exercise, increased feelings of loneliness, and even depression – all risk factors for cognitive decline
One of the biggest factors may be isolation from the family members who would notice something is wrong. The pandemic has kept family apart, and a problem that might once have been caught earlier just continued to worsen in quarantine.
Is it Dementia or a Substance Use Disorder?
Every older adult in treatment at Caron has a primary substance use disorder, most commonly for alcohol, followed closely by opioids and benzodiazepines.
Many patients come to us with previously diagnosed cognitive impairment. Additionally, many older adults fear they have Alzheimer’s Disease, recognizing that they are foggy, forgetful, or have trouble finding their words. They may even be on medications, like Aricept, to treat cognitive decline. Following a few weeks in treatment, cognition often improves once the patient is not actively using alcohol or other drugs.
But alcohol and substance use are not the only factors that might cause symptoms that mimic a more serious and permanent cognitive decline. Chronic pain, poor sleep, and co-occurring mental health conditions can also affect cognition. A severe depressive episode, particularly in older adults, can result in cognitive impairment. In fact, there is a condition called pseudodementia in which a person appears to have the behavioral and cognitive changes seen in dementia, but severe depression is the root cause. With the appropriate depression treatment, the signs of dementia disappear.
There are some very specific patterns we look for in the cognitive testing data. For example, someone with depression-driven pseudodementia typically has insight into their impairment. They will tell you they feel something is wrong with them, that they cannot think straight, or that they are becoming forgetful. Someone with other types of dementia or an alcohol-induced dementia more often lack that insight. The impairment clouds their ability to recognize their decline.
There are a lot of factors to consider before we can make the most accurate diagnosis and recommendations for treatment. As a residential treatment facility, we have the benefit of extended time with our patients. We have a sophisticated medical, psychological, and clinical team to support and observe our patients and to treat all aspects of the mind and body that may be contributing to cognitive impairment.
There is Hope
I wish there were a formula that allowed me to say that if you take these steps, your cognition will improve by a certain percentage during this period of time. Unfortunately, it’s not that simple. Still, we see dramatic improvements all the time. For example, a recent patient in her late 50s went from a MoCA score consistent with severe dementia upon admission to a score in the normal range just three weeks into treatment. The absence of alcohol combined with her individualized treatment resulted in an amazing difference in her cognition and overall well-being.
So, for families concerned about cognitive decline in an older loved one, it’s important to remember that there are many contributing factors. Every individual deserves a thorough evaluation to determine what is causing the issue – including a hidden substance use disorder – because it can make all the difference in a positive outcome.
By Carol Waldman
By Ming Wang, MD, FASAM