In 2009, the elderly constituted 12.9% of the US population. This translates to 39.6 million—a number that is growing.1 Perhaps as a result of generational stereotyping or ageism, the topic of substance abuse and dependence is rarely associated with the elderly. Although there is a dearth of literature regarding patterns of illicit drug use and abuse in older adults, recent surveys indicate that abuse of illicit drugs by older adults is on the rise.2 A 2009 study by the Substance Abuse and Mental Health Services Administration (SAMHSA) yielded some sobering conclusions regarding substance use in individuals aged 50 years or older.2
Consequences of substance abuse in the aging and elderly
Clinical research is beginning to elucidate the consequences of unrecognized substance abuse or dependence on an aging population. Complications that occur with increasing frequency with age, such as medical comorbidity, cognitive impairment, and frailty, contribute to the potential adverse interactions between substance misuse and an aging brain.
The 2009 SAMHSA's National Survey on Drug Use and Health revealed dramatic increases in illicit drug use in older adults, including nonmedical use of prescription drugs among women aged 60 to 64. Overall, alcohol(Drug information on alcohol) was the most frequently reported primary substance of abuse for persons aged 50 or older. Opiates were the second most commonly reported primary substance of abuse, reported most frequently by individuals aged 50 to 59. These individuals also had the highest proportions of inpatient admissions for cocaine, marijuana, and stimulant abuse.2
One-quarter of the prescription drugs sold in the United States are used by the elderly, and the prevalence of abuse of these agents may be as high as 11%.3 Commonly prescribed drugs with abuse potential include those for anxiety, pain, and insomnia, such as benzodiazepines, opiate analgesics, and skeletal muscle relaxants. A review of medical records of 100 elderly patients who were dependent on prescription drugs and were admitted to the Mayo Inpatient Addiction Program between 1974 and 1993 assessed the frequency of abuse by type of prescription drug. The most commonly abused were sedative/hypnotics (mostly benzodiazepines) and opioid analgesics.4
Aging induces physiological changes that increase susceptibility to the deleterious effects of alcohol and other illicit substances. Given these changes, the National Institute of Alcohol Abuse and Alcoholism recommends the following for men aged 65 or older: no more than 1 drink daily (ie, 12 oz of beer at 5% alcohol, or 5 oz of wine at 12% alcohol, or a 1.5-oz shot of hard liquor at 40% alcohol), a maximum of 2 drinks on any occasion, and even lower limits for women. These recommendations highlight how alcohol use in the elderly can potentially be problematic, even if it does not cause abuse or dependence.
What is already known about substance abuse in the elderly?
■ Recent surveys and studies indicate that alcohol and illicit drug use is on the rise in the elderly population. Complications that occur with increasing frequency in the elderly contribute to adverse reactions of substance misuse.
What new information does this article provide?
■ This article discusses the prevalence of substance use disorders in the elderly and the evidence-based approaches to treatment in this population.
What are the implications for psychiatric practice?
■ Substance dependence is under-recognized in the elderly. Careful medical and psychiatric assessments are essential for the diagnosis. This population shows good results once in treatment.
Early vs late onset
Older adult substance abusers can be categorized as early-onset or late-onset abusers. In early-onset abusers, substance abuse develops before age 65. In these individuals, the incidence of psychiatric and physical problems tends to be higher than that in their late-onset counterparts. It is estimated that early-onset substance abusers make up two-thirds of the geriatric alcoholic population.
In late-onset substance abusers, these behaviors are often thought to develop subsequent to stressful life situations that include losses that commonly occur with aging (eg, death of a partner, changes in living situation, retirement, social isolation). These individuals typically experience fewer physical and mental health problems than early-onset abusers.5