Year : 2022 | Volume
: 6 | Issue : 2 | Page : 113--116
Geriatric substance use: Challenges for practice
Avinash De Sousa
Consultant Psychiatrist and Founder Trustee, Desousa Foundation, Mumbai, Maharashtra, India
Dr. Avinash De Sousa
Carmel, 18, St., Francis Road, Off SV Road, Santacruz West, Mumbai - 400 054, Maharashtra
|How to cite this article:|
De Sousa A. Geriatric substance use: Challenges for practice.Ann Indian Psychiatry 2022;6:113-116
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De Sousa A. Geriatric substance use: Challenges for practice. Ann Indian Psychiatry [serial online] 2022 [cited 2022 Oct 7 ];6:113-116
Available from: https://www.anip.co.in/text.asp?2022/6/2/113/354115
Substance abuse in the elderly is a complex problem that causes a number of challenges to the clinician in question. Over the years, the number of elderly patients with substance abuse has been increasing exponentially. Clinicians need to be aware of the various nuances of managing the elderly with substance abuse. The management of these patients entails a route entirely different compared to adults and adolescents. Elderly patients with substance use are more likely to have comorbid medical illnesses, physical complications, and longer duration of substance use that complicates the recovery process and prognosis. The patterns and types of substances used and abused by the elderly may differ from adolescents and younger adults and even the quantity consumed may vary. The major substance used by the elderly is tobacco (nicotine), alcohol, benzodiazepines, and abuse of prescription drugs or pain killers. The unique features of the elderly with substance use/abuse and the growth of the problem have posed a number of challenges clinically. These challenges are faced at the levels of epidemiology, clinical assessment, diagnosis, screening, and medical management along with psychological management of the problem.
Challenge 1: Lacunae in the epidemiology of substance use/abuse in the elderly
Although substance use disorders have been described in the elderly, there is a dearth of good epidemiological studies that give us sound facts and figures about substance abuse patterns and the nature and extent of the problemMany large-scale epidemiological studies have shown alcohol use to be a major problem in the elderly. Of the elderly that use alcohol regularly, 6%–10% are heavy drinkers, and 2%–4% were considered binge drinkersMany of these patients do not seek help or treatment. Many of them stay alone and are not even detected. The presence of other psychopathology, family history of alcohol dependence or substance use, smoking, male gender, and loneliness were key factors in elderly substance abuseThe use of other substances in the elderly has also received poor attention. We need detailed epidemiological data on the patterns of substance use in the elderly with regard to opioids and other forms of drug use. Prescription abuse patterns and benzodiazepine abuse have also been understudied.
Challenge 2: Problems related to alcohol use in the elderly
Alcohol use and abuse in the elderly brings a myriad of problems. First, the recommendations for drinking limits are also different in the elderly as compared to the younger population. The National Institute of Alcohol Abuse and Alcoholism recommends the limit of 1 drink/day, as more than that constitutes at-risk drinking for men and women above 65 years as compared to more than 14 standard drinks per week for men and more than 7 standard drinks per week for woman under 65 years of age, which is in accordance with risk-free drinking among the elderlyMany elderly women start the consumption of alcohol after the death of their spouse who was alcohol dependent. Elderly women who drink or abuse alcohol are at a greater risk of social isolation and economic deprivation. They also are far more reluctant to seek treatment and abstain. There is a need for specific programs in the rehabilitation and treatment of female elderly patients that start alcohol use for the first time after the age of 65 yearsAs with alcohol-dependent patients of any age, there is a strong tendency for geriatric alcoholics to try and hide their illness. Most elderly alcoholics drink alone while at home which may further contribute to the precipitating factors of loneliness and lack of social support and create an unavoidable downward spiral.
Challenge 3: The physical complications of alcohol dependence in the elderly
Elderly persons are particularly prone to problems from acute alcohol intoxication. Clinically, the same amount of alcohol consumed in earlier years with impunity may now cause clinical symptoms such as slurred speech, instability, falls, and confusion. Some regions of the brain are more vulnerable to ethanol than others. The neocortex, basal ganglia, hippocampus, and reticular activating system undergo neuronal aging at a faster rate than do other regions of the brain. These changes result in impaired cognition and motor skillsAlcohol also has an acute effect on cardiac muscle, leading to increased cardiac rate and output. Systolic blood pressure may be increased and blood shunted from splanchnic circulation to the periphery. The latter phenomena cause cutaneous vasodilatation and loss of body heat. When coupled with the elderly problem of maintaining thermoneutrality, the elderly person is at a greater risk of developing hypothermiaAlcohol increases acid production by the gastric parietal cells. Because aging results in a reduction in gastric parietal call mass, a significant problem may not result unless an abnormal mucosal lining coexists. As the amount of alcohol consumed increases, there is a greater risk of hyperemia, increased mucus production, and decreased acid secretion, leading to acute gastritis. Resulting nausea and vomiting may lead to electrolyte and fluid imbalance earlier in the elderly as a consequence of decreased physiological reserveAcute alcohol ingestion may result in alcoholic ketoacidosis. Supportive care and rarely bicarbonate administration are needed until metabolic balance returns. The elderly are particularly prone to alcohol-induced hypoglycemia. Hypoglycemia has a greater impact on the elderly because they have less efficient counter-regulatory mechanisms and fewer brain, cardiac, and renal cells. This decreased reserve may result in more significant tissue damage and altered functional statusThe most common complication is liver toxicity. A spectrum of illnesses has been described, ranging from fatty liver to cirrhosis. Consequences may include systemic complaints of fatigue, anorexia, and weight loss. Until jaundice is noticed, these vague complaints may not be ascribed to alcoholic liver disease in elderly persons with other age-prevalent disordersA multidisciplinary medical team may thus be needed in the management of such complications in patients who abuse alcohol above the age of 60 years. The team must manage both the psychological and physical aspects of the illness in tandem and this shall help in better recovery for the patient.
Challenge 4: Prescription drug misuse in the elderly
It has been suggested that elderly individuals have high rates of prescription medication misuse. There is a shortage of studies assessing the prevalence of prescription drug use/misuse. Among the drugs abused, we have benzodiazepines (such as alprazolam, clonazepam, diazepam, and lorazepam), pain killers, opiate analgesics, antacids, laxatives, codeine-based cough syrups, and anti-histaminicsStudies also suggest that being female, being socially isolated, and having a history of substance abuse/other psychiatric illness are factors more likely to be associated with prescription drug abuse or misuse among the elderly. Many elderly patients visit multiple doctors and may pick up prescriptions for the same drugs from multiple doctors and may abuse the drugs at their will. They often do not follow the prescribed dose and may escalate or reduce the dose at will. There is a need for stringent monitoring of prescriptions given to the elderly. This form of abuse can also cause medical complications that may be attributed to other causes and prescription abuse may be missed.
Challenge 5: Heterogeneity of substance use in the elderly
There are some important features that need to be kept in mind while dealing with an elderly person using substances. As an elderly person is more likely to suffer from age-related stressful life situations, he or she is more likely to use drugs to cope with these problems. In fact, substance use in the elderly has been drubbed as an invisible epidemicMost people consider the elderly as someone who cannot have a drug/alcohol problem, leading to nondisclosure of the problem. There are two types of elderly that abuse substances. One has been a regular substance user in his younger days and the trend continues into old age and the other where substance use has started for the first time after the age of 65 years. The general trend among the elderly appears to be a reduction in substance use after the age of 50 years successively. This has been described as a growing out of or aging out of substance useSubstance use in the elderly may be a defense, a coping mechanism, a cause of depression, a reaction to depression, an escape mechanism from stress, a recreational pattern, or just a trend carried over from adulthood. There is gross denial and treatment is never sought. Many elderly substance users often believe that substance use is all that they have in their lives and they do not want to give it up as the fun component of their lives shall then go away. They do not mind the medical complications and even death if it may ensue with substances as many may use substances as a method of self-annihilation.
Challenge 6: Lack of proper treatment guidelines for elderly with substance use
Although many approaches for treatment have been proposed, evidence for each of them and the studies on comparative efficacy are almost nonexistent. One of the reasons is the small number of patients coming to a treatment setting, issues related to geriatric research, and the lack of randomized controlled studies in the areaThere is a dearth of studies on various medical treatments used in the management of substance use and alcohol use in the elderly. There is also a dearth of sound treatment guidelines of treatments that work. The poor adherence, lack of compliance, and refusal of treatment are other causes of the sameThere is a lack of data on sound psychosocial and psychotherapeutic treatments for substance use in the elderly. There is a need for effective family-based and individualized psychological interventions. Psychosocial needs and additional psychiatric illnesses may also need to be looked into and dealt with. There is also a need for training in the same as psychotherapy with elderly patients is very different from that in adults.
Challenge 7: Nonpharmacological interventions for substance use in the elderly
For the management of prescription drug misuse, nonpharmacological approaches are also employed to improve treatment outcomes. These may include brief intervention, patient psychoeducation, motivational counseling, and rehabilitation. Brief intervention is effective even in “real world” clinical situations in the elderlyBrief intervention and motivational counseling are usually done in a similar manner as in adults. However, in all the steps, it is important to also add patient education about the prescription drug and the associated problems. These may include the reasons for altered compliance, medication management information, dosing details, and the consequences of misuseMost routine nonpharmacological methods such as individual psychotherapy, family therapy, and psychoeducation as well as self-help support groups are studied lees in the elderly and have rarely been used. There is a need for developing empirically sound psychotherapy for substance use in the elderly that not only looks at individual factors but also helps in the management of various psychosocial problems that may be seen with respect to the elderly.
Challenge 9: Incorporating spirituality and religion into treatment
Religion and spirituality remain important social and psychological factors in the lives of older adults and there is continued interest in examining the effects of religion and spirituality on health status. Elders with greater religiosity were more likely to report good health status in various studies and a positive association between organized religiosity (i.e., religious service attendance) and health status has been found. The use of religion and spirituality in the management and promotion of abstinence in elderly patients with substance abuse shall be a vital tool in the psychosocial managementMany patients with substance use in psychiatric care may want to discuss different aspects of religion and spirituality with the treating psychiatrist and may also want to discuss the same in psychotherapy. Questions such as death, life after death, and heaven or hell along with religious dialogues interest the elderly. Psychiatrists treating the elderly need to be abreast with religion and spirituality as well as religious philosophies so that they may discuss the same with their patients. There is a need for psychiatrists being open to discuss the same as well as to respect the religious beliefs of clients that they treat.
Challenge 10: Geriatric substance use research
Before delivering any form of treatment in geriatric substance abuse, it needs to be tested. There are many barriers to research in the elderly which range from monetary to ethical and permission-delivery dilemmas. Primarily, the lack of research can be attributed to the lack of funding from the government to support ongoing researchSecond, it is hard to conduct research on the elderly, especially in relation to their inclusion in clinical drug trials with pharmaceutical interventions due to their age-related physiological changes. The relationship between age and the dynamics of drugs is not well established, but it is generally believed that geriatrics are more prone to adverse effects of a drug than younger participants due to the prevalence of comorbidities and concomitant drugs among themMany elderly patients with substance abuse may be incapable to understand the procedures of a study and give informed consent. It has been reported that nearly one-third of those with cognitive impairment were found to lack decisional-making capacity. While in these cases, proxy consent can be taken from one's caregiver; it was found that proxies often underestimated the risks associated with participation in a study due to their belief that all institutionally conducted studies were safe. The inability to give informed consent breaches one of the basic ethical guidelines set up for all research and thus this prevents researchers from taking up geriatric studies.
Challenge 12: Need for specific geriatric substance abuse rehabilitation centers
The world has a limited number of mental health professionals catering to the geriatric populations in need of mental health services. At present, most of the geriatric outpatient department services and rehabilitation services are available at tertiary care hospitals in big cities. Public sector hospitals suffer from problems of inaccessibility, inequitable distribution, lack of staff, drugs, and equipment, whereas the private sector is largely unregulated with serious complaints regarding the poor quality of care and unethical behaviorThe geriatric substance abuse clinic may need to design and implement several processes it needs. It may have to prepare or procure the material required for its functioning, keeping in mind the societal environment and the target audience. The center shall need to have a treatment pathway, communication conventions, and counseling approach that take into account the needs of patients with substance abusePublic outreach efforts may be needed. As families may not think of coming to the clinic, you may need to actively reach out to families that may need help. Active publicity and myth-busting in the localities may be needed to make people aware that the clinic can be useful to them. Use of the existing patient base and inpatient wards of hospitals to identify persons who may benefit from substance abuse rehabilitation may be needed.
It is well known that the elderly population is particularly vulnerable to substance use. However, studies on factors associated with such abuse and the screening/management of it are scarce. Failure to obtain an adequate sample to study this population is among the most common reasons for these problems. Alcohol and prescription drugs are the most commonly found substances of abuse among the elderly. Age-related changes in the elderly associated with medical comorbidities make the use of substances a more problematic issue in this age group.
Further research is needed to characterize elderly substance users. Often, such populations are hidden due to their limited mobility, hence community-based studies can best assess their prevalence, the impact of substance use on their health, the sources of procuring the substance, the individuals' motivation of continuation, and other associated contextual factors may be assessed for better understanding of the facets of substance use in the elderly.
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