ALCOHOL AND DRUG ABUSE INSTITUTE University of Washington  Home  |   News  |  About Us  |  Research  |  Library  |  Staff  |  Publications  |  Funding  | Training |  Links  |  Search

SUBSTANCE ABUSE AND MISUSE

The Washington State Division of Alcohol and Substance Abuse has identified the prevention of substance abuse and misuse among the elderly as a priority area for attention and action. Abuse is differentiated from misuse in that substance abuse is deliberate and intentional; misuse is inadvertent and may be perpetuated by another, often by a health care provider. Among the elderly alcohol is the substance typically associated with abusive use whereas misuse involves prescription and proprietary drugs. Both abuse and misuse are related to undesirable physical, social, and psychological consequences, result in increased risks of development of other problems, and contribute significantly to health care costs. They also are factors in reduced quality of life. Older adults aged 65 and over make up 12% of the population of the state, with projections for further proportionate increases in the future. In light of these facts, efforts to prevent abuse and misuse in this segment of the population take on increased importance.

ALCOHOL

Risk Factors:
While the relative level of alcohol abuse problems among older adults is lower than for other age groups, the potential for development of these problems is comparatively high because of physiological changes that alter and increase alcohol effects. Drinking can be especially problematic for persons with medical problems and those taking prescription medications, conditions for a majority of older adults. Further, although most alcoholism develops in young adulthood, an estimated one-third of elderly alcoholics first experienced drinking problems as older adults. Such late onset alcoholism is often related to stresses associated with aging, retirement, and bereavement. Other older adults who have already developed drinking problems may increase their drinking in response to these stresses as well, behaviors that may lead to a recurrence of active alcoholism or contribute to additional health risks.

Prevalence:
The national prevalence rates for persons aged 60 and over who meet standard criteria for alcohol dependence or abuse range from 1.4% to 3.7%, depending on the study site. These rates are higher among elderly males than females, reaching 4.6% compared to less than 1%. Other national studies have found that about 6% of older adults can be classed as heavy drinkers, and thus subject to alcohol-related problems. Extrapolated to the Washington state population, these rates suggest that from about 11,000 to around 28,000 of the state's older adult residents have current alcohol abuse or dependence problems. With one third of these problems likely to be of recent onset, attention to prevention for this age group could intervene in the development of problem drinking for as many as 9,400 seniors. The elderly are typically under represented in alcoholism treatment, accounting for just 1% of the patients in inpatient and outpatient programs nationally.

Social and Psychological Factors:
Research shows that most people do not change their alcohol consumption with aging, and if they change, are more likely to decrease than to increase drinking. This stability of consumption generally holds even in the face of social and personal losses and stresses. The individuals most at risk of developing drinking-related problems as older adults are male, the younger old (under 75), those with lower education and incomes, and those who have been divorced or separated. Widowhood also is related to drinking problems for men but not for women. Most older adults are able to cope well with life stresses and are aided in this by social supports from family and friends. The elderly who have more chronic, ongoing sources of stress, coupled with a lack of social network supports and resources, are more likely to be excessive drinkers.

The significance of social messages about and social support for drinking is seen in the comparatively higher rates of consumption in retirement communities. In these settings, it is the most socially outgoing who are the heaviest drinkers, drinking increases for some people, and women also are likely to have higher rates of consumption. This responsiveness to social conditions suggests that the prevalence of problem drinking among the elderly may well increase with the aging of younger and more tolerant cohorts.

PRESCRIPTION AND PROPRIETARY MEDICINES

In contrast to alcohol abuse patterns, today's elderly are more likely to encounter problems with prescription misuse than those in other age groups. About 80% of older adults have some chronic medical condition, and the likelihood of multiple medical problems increases with advancing age. The elderly receive from 25% to 30% of all prescriptions and use these drugs at a rate as much as two and a half times that of younger persons. Seniors also are heavier users of proprietary or over the counter medications. Multiple medical conditions, complex medication regimens, and the use of multiple care providers sets up a situation for high risk of adverse drug reactions. It is estimated that the elderly suffer two to five times the frequency of adverse drug reactions as occur among younger people, and some 10% of hospital admissions for seniors are due to such reactions.

Risk Factors:
Prescribing practices are part of this problem. A recent report on a national study found that nearly one-quarter of the elderly are receiving prescription drugs whose use is contraindicated among that age group because of risks of adverse reactions. The elderly are particularly vulnerable to adverse reactions to psychotropic medications, a type of drug whose use is often not recommended for seniors or for prolonged periods because of risks of confusion, sleep disorders, falls, and misinterpretations of these symptoms as signs of senility. Older adults are nonetheless estimated to receive as many as 50% of the prescriptions for psychotropic medications. Older women, more likely to present symptoms of emotional distress to a doctor, are prescribed psychotropic medications at rates almost 160% higher than older men.

Miscommunication among providers and patients contributes to prospects of misuse, as does lack of coordination and follow-up of care. The older adult often has sensory and cognitive deficits that make understanding medication instructions difficult, but physicians typically spend less time with their older patients than with younger ones and are likely to provide them with less information about their medications. The elderly themselves also play a role in medication misuse, failing to fully report symptoms and often underusing medications to avoid side effects or to save money, or using them in combination with alcohol, a situation that heightens the risk of adverse effects.

PREVENTION STRATEGIES

Prevention strategies for older adult substance abuse and misuse need to take into account that the usual distinctions between primary, secondary, and tertiary prevention are a poor fit with the patterns of substance use and health problems already present among seniors. Among the elderly, a condition may be simultaneously a preventable disease and a problem in its own right, as well as being a precursor or risk factor for another condition. It is thus appropriate to direct prevention efforts toward management of conditions that have already developed as well as to the primary prevention of new ones. Intervention in alcohol problems, for example, becomes primary prevention against the development of other health problems, and perhaps the most appropriate strategy for misuse of licit drugs is appropriate medication management of a continuing health problem.

Model Approaches:
The targets for prevention of elderly substance abuse and misuse should be multiple ones, including older persons themselves, the physician and other health care providers, other senior service providers, family members, voluntary organizations, and the general public. The most common strategies used elsewhere are information and awareness campaigns and education and training of older adults and service providers. There are many published materials and pamphlets available to use in an informational package, as well as structured training programs designed for different audiences. Information about the risks of medication misuse is readily available at most pharmacies and, along with information on alcohol problems, through senior services providers.

For the most part, there is little indication of whether or not these strategies have been effective. There is some evidence that teaching the elderly to ask more questions and both provide and obtain more information during a doctor's visit reduces the risks of medication misuse. The training of physicians in better patient communication and compliance management also reduces medication misuse, and improved physician responses to indicators of alcohol problems would increase the prospects of early identification and appropriate referral. The most successful educational efforts for those at risk of developing problems follow up the provision of information and training with individual counseling and personal contacts. Such personalized strategies are thought to be particularly important for ethnic minority elderly. Connections with community and voluntary organizations and churches are also important for reaching older adults. Finally, since many of the factors affecting risks for elderly substance abuse and misuse are based in social norms, patterns, and institutions, attention to these and to public policies may be needed as well.

RECOMMENDATIONS

Recommendations for development of a substance abuse and misuse prevention program for this population include the involvement in program design of senior services and other interested agencies and organizations as well as representatives of older adults themselves. Strategies for consideration might involve the use of existing materials to compile a resource information package for widespread distribution, and education and training for the elderly, their families, and providers of other services and health care. A focus on general health behaviors and support for secondary intervention and treatment as well as primary prevention is suggested, as are considerations of pilot projects to link information and education with more personalized follow-up. Finally, there needs to be support for policy initiatives to underscore these and other efforts to improve the health and well-being of older adults.