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General Principles in Older Adults

A growing number of older adults misuse alcohol, psychoactive prescription drugs, and/or other substances, including tobacco. The emerging literature on the baby boom cohort of aging adults (born between 1946 and 1964) indicates that they are continuing to use alcohol and psychoactive prescription medications, in particular, at a higher rate than previous generations, and they are beginning to present larger issues for the health care system and the intervention and treatment communities. The development and refinement of evidence-based practices to address these problems and provide early intervention services is crucial to meeting the needs of this growing population.

Tobacco remains an important concern. A number of programs and medications are available to help individuals stop using tobacco products. Clinicians can guide patients to appropriate programs and/or medications. The important thing to address with older adults is that it is not too late to quit. There are benefits from quitting at any stage in life. (For more on smoking cessation, see Chapter 34, “Chronic Obstructive Pulmonary Disease.”)

However, when working with older adults, 2 major categories of substances generate the most concerns for clinicians: (a) alcohol and (b) psychoactive prescription medications (eg, medications for anxiety, medications for sleep, and pain medications). These substances are the focus of this chapter.

The misuse and abuse of alcohol and psychoactive medications in older adults pose challenges for identification of the problem, which interventions will be the most effective, and determinations of the best treatment options, when needed. Problems related to substance use are often unrecognized and, if recognized, generally undertreated in this age group.

There have been a number of community surveys over many years estimating the prevalence of problem drinking among older adults. The prevalence has varied from 1% to 16%, depending on the definitions of “at-risk” and “problem” drinking, and alcohol abuse/dependence.

In 2002, more than 616,000 adults age 55 years and older reported alcohol dependence in the past year: 1.8% of those age 55–59, 1.5% of those age 60–64, and 0.5% of those age 65 or older. Although alcohol and drug/medication dependence are less common in older adults when compared to younger adults, the mental and physical health problems related to higher levels of use can be serious.

Health Risks Associated with Hazardous and Harmful Use in Older Adults

There are a number of physical health problems that have been related to harmful use of alcohol. Drinking at hazardous levels increases the risk of hypertension and may increase the risk of breast cancer and diabetes, among other medical conditions in both younger and older adults.

However, symptoms of harmful drinking are often not as noticeable in older adults because these symptoms can be masked by social challenges (eg, isolation), medical conditions (eg, gastrointestinal distress), or psychological problems (eg, depressed feelings, confusion). ...

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