Substance misuse in older adults is common but remains under-recognised.
This first in a two-part series on substance misuse among older people discusses the pattern of misuse in this group and outlines the different types of misusers. It also explores the risk factors for alcohol misuse and its effects, as well as other types of substance misuse.
Citation: Rassool GH (2012) Substance misuse in older people 1: types of substance misuse and risk factors. Nursing Times [online]; 108: 30/31, 12-14.
Author: G Hussein Rassool is independent consultant and visiting professor of addiction and mental health, Universidade de São Paulo and Universidade de Minas Gerais, Brazil, and director, Inter Cultural Therapy Centre, Mauritius.
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- Read part 2 of this series here
Alcohol and drug misuse in older adults is a common but under-recognised problem, which has significant negative effects on physical and psychological health and quality of life.
Evidence suggests that many middle-aged and older people have problems with alcohol, illegal drugs and prescription medication, as well as complex mental health needs that may make these problems worse (Royal College of Psychiatrists, 2011). More older people than ever are reporting that they have experiences with drugs at some point in their lives, and drug problems have no age limits (European Monitoring Centre for Drugs and Drug Addiction, 2010).
However, the traditional view that substance misuse is uncommon in older people means that clinicians fail to ask about misuse and it can lead them to overlook or discount evidence of such problems (Royal College of Psychiatrists, 2011).
Given the impact that substance misuse problems in older people are likely to have on health and social care services, there is now a pressing need to respond to these challenges.
In the context of this article, “substance misuse” refers to a psychoactive substance being consumed in a way in which it was not intended to be used, and which causes physical, social and/or psychological harm. Substance misuse may take the form of physical or psychological dependence or be part of a wider spectrum of harm. Older substance users can be categorised as early-onset users (“survivors”) or late-onset users (“reactors”) (EMCDDA, 2008). In addition, there are intermittent or binge drinkers.
Older people are more likely to drink regularly but tend to drink less alcohol than younger people; even so, one in six older men and one in 15 older women are drinking enough to harm themselves (Royal College of Psychiatrists, 2008). The over-55s in Britain are more likely than their European counterparts to be regular drinkers and a substantial percentage of older adults consume alcohol above recommended limits (Moos et al, 2009).
Early-onset misusers are the largest group of older adult drinkers and often have a family history of alcoholism. In addition, they have had a lifelong pattern of problem drinking, have probably been alcoholics for most of their lives and have psychiatric illness, cirrhosis and organic brain syndromes (McGrath et al, 2005; Menninger, 2002). The chances of reaching old age are reduced among this group.
Late-onset drinkers or reactors begin problematic drinking later in life, often in response to traumatic life events such as the death of a loved one, loneliness, pain, insomnia and retirement (Institute of Alcohol Studies, 2007). Intermittent or binge drinkers use alcohol occasionally and sometimes drink to excess, which may cause them problems. Both late-onset drinkers and intermittent/binge drinkers have a high chance of managing their alcohol problem if they have access to treatment such as counselling and general support (Institute of Alcohol Studies, 2007).
Risk factors and effects of alcohol misuse
A family history of alcohol is a risk factor for early-onset drinkers and may be related to genetic factors.
With the process of ageing, older people may become more sensitive to alcohol’s effects; the same amount of alcohol can have a greater effect on them and produces a higher blood-alcohol concentration than it does in younger people. Evidence suggests that older adults may be impaired even under a moderate dose of alcohol, although they may not be aware of this (Gilbertson et al, 2009).
Alcohol has a significant influence on older people’s reaction time and increases the risk of accidents. It may also increase the risk of injury through road trauma, violence and accidental death.
There is also concern that older adults are taking prescribed or over-the-counter medication in conjunction with alcohol, which may cause adverse side-effects. Alcohol is contraindicated for use with many drugs taken by this group and the risk is considerably greater when multiple medications are involved.
Problems among older people may develop as a result of social exclusion, social isolation, bereavement, lack of social support, diminishing responsibilities, cognitive impairment and general ill-health, and these are associated with higher rates of alcohol use (Royal College of Psychiatrists, 2011).
Alcohol-use disorders in older people can cause a wide range of physical and psychosocial problems, such as liver or brain damage, heart disease, high blood pressure and cancers. Alcohol misuse can intensify problems associated with insomnia, and increase the likelihood of continence and gastrointestinal problems (Tabloski and Maranjian Church, 1999).
Psychiatric problems such as depression, phobias, anxiety and the risk of suicide are associated with alcohol misuse in older age. The association between alcohol use and dementia is complex and not well understood. Studies indicate that heavy use of alcohol increases the risk of developing vascular dementia and alcohol-related dementia (Farcnik and Persyko, 2005).
Alcohol can also act as a trigger for Parkinson’s disease in older people, and delirium tremens is associated with higher mortality rates in this age group (Feuerlein and Reiser, 1986).
Psychiatric disorders such as schizophrenia may coexist with alcohol problems in older people, resulting in complex needs and treatment interventions (Dar, 2006). Table 1 shows risk factors for alcohol problems in older people.
Illicit psychoactive substances
There is limited data on the prevalence of illicit substance misuse in older people. Where data is available, it is estimated that the prevalence of illicit drug use among older Europeans is increasing (EMCDDA, 2010).
The prevalence of drug misuse in England in older people is lower than in younger people and is less than 1% for those aged over 60 (Beckett et al, 2005). In the EU, the majority (65%) of older drug users (aged 40 or over) reported heroin as the primary drug of choice, followed by cocaine, cannabis and synthetic stimulants (EMCDDA, 2010). Because cannabis, cocaine and synthetic drug use is rising in the younger generation, it is likely that the number of older people using these psychoactive substances will increase significantly in the future.
As regular recreational and dependent users of illicit drugs grow older, they may experience more physical and psycho-social complications with the ageing process. Both physical and psychosocial problems are associated with drug use among older people. Drug use may increase the risk of, or exacerbate, conditions associated with the ageing of the body and the brain (Benyon et al, 2009).
Drug-related ailments found among older people include: cardiopulmonary conditions (due to injecting drug use); changes in blood pressure; risk of deep vein thrombosis; and infection with bloodborne viruses such as HIV and hepatitis C. Drug use has also been shown to be a risk factor for earlier onset of diabetes, neurological disorders and cancer (EMCDDA, 2010).
In relation to psychological conditions, prolonged use of illicit psychoactive substances has been shown to be associated with depression and cognitive impairments (Dowling et al, 2008). In addition, common symptoms including anxiety, loneliness, memory problems, confusion, disorientation and dementia are present in older drug-using adults.
Psychoactive drugs, such as anxiolytics, hypnosedatives, tranquillisers and antidepressants are often prescribed for older people and many people in this group are frequent consumers of over-the-counter medications. Addictive behaviours to psychoactive substances among older people are due to iatrogenic dependence, that is, following inappropriate prescribing of psychoactive substances.
In Europe, people over 65 use about one-third of all prescribed drugs, including benzodiazepines and opioid analgesics (EMCDDA, 2008). Older women are more likely to be prescribed and to misuse psychoactive medications than men and are also at higher risk of pre-scription drug misuse than other age groups (EMCDDA, 2008). The risk of dependence is increased in women who are: widowed; less educated; of lower income; in poor health; and who have reduced social support (King et al, 1994). Benzodiazepine dependence in general can be more problematic among older people, because tolerance to alcohol and benzodiazepines decreases with age (Bogunovic and Greenfield, 2004).
Several medicinal preparations, available without prescription in pharmacies, are bought for their non-medical therapeutic effects. Antihistamines can be used for their sedative effect and/or mixed with methadone or heroin. The amphetamine derivatives in decongestants can be used as a stimulant, while cough linctus and diarrhoea drugs can be used for their opiate content.
Tobacco is the most commonly used psychoactive substance among older people. The over-60s are also more likely than younger people to have smoked at some time in their lives; however, they are more likely than younger people to have given up. In addition, only 12% of the over-60s smoked in England in 2007 - the smallest proportion for any age group (NHS Information Centre for Health and Social Care, 2009).
In England in 2009, an estimated 81,400 deaths among adults aged 35 and over were attributable to smoking, accounting for 18% of all deaths in this age group (NHS Information Centre for Health and Social Care, 2010). In 2009, around 35% of deaths in England from respiratory diseases and 29% of deaths from cancer were attributable to smoking. Smoking also accounted for 14% of deaths from circulatory diseases and 6% of deaths from diseases of the digestive system (Department of Health, 2011).
The consequences of tobacco smoking occur later in life and many older people have long-term conditions related to this, including cardiovascular diseases, lung cancer, bladder cancer and chronic obstructive pulmonary disease. Many studies have shown that broken bones tend to take longer to heal if those who are injured have smoked (Hoogendoorn et al, 2002).
The nature and pattern of alcohol and drug misuse in older people and the associated psychological and physical comorbidity are different from those in younger people.
The development of substance misuse is more likely to be associated with alcohol, and prescribed and over-the-counter medicines. Older people also use illicit psychoactive substances.
Practitioners should routinely ask older people questions on the use of alcohol and drugs. In view of the complexity of the health and social issues involved, care, management and treatment should be tailored to meet the specific needs of this vulnerable group.
- Many older people have problems with alcohol, illegal drugs and prescription medication
- Practitioners fail to ask about substance misuse because of the traditional view that it is uncommon in older people
- Older people are more likely to drink regularly but tend to drink less alcohol than younger people
- Psychiatric problems are associated with alcohol misuse in older age
- Both physical and psychosocial problems are associated with drug use among older people
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Benyon C et al (2009) Self reported health status, and health service contact, of illicit drug users aged 50 and over: a qualitative interview study in Merseyside, United Kingdom. BMC Geriatrics; 9: 45.
Bogunovic OJ, Greenfield SF (2004) Practical geriatrics: use of benzodiazepines among elderly patients. Psychiatric Services; 55: 233-235.
Dar K (2006) Alcohol use disorders in elderly people: fact or fiction? Advances in Psychiatric Treatment; 12: 3, 173-181.
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Types of substance misuse and risk factors