58: Managing Misuse of Alcohol & Psychoactive Prescription Medications 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.

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). The physiologic aging processes and the presence of health conditions common to old age can reduce a person’s tolerance to alcohol. Comparable amounts of alcohol produce higher blood alcohol levels in older adults than in younger persons, and may exacerbate other health problems. Drinking produces higher blood alcohol levels in older adults than in younger persons when comparable amounts of alcohol are drunk, and many problems common among older people, such as chronic illness, poor nutrition, and polypharmacy, may be exacerbated by even small amounts of alcohol.

Although light-to-moderate alcohol use for someone in their 30s may not cause health or social problems, that amount may actually have a number of negative health effects in an older person. Clinicians who treat older patients should assess the amount of alcohol use and should be aware of health implications of any individual’s pattern of use.

Although older adults, in general, have high rates of medication use compared to younger individuals, there are very few studies that have specifically examined the prevalence of psychoactive medication use, misuse and abuse among older adults. This literature indicates that psychoactive medication misuse affects a small but significant minority of the older adult population.

A relatively recent study found that 25% of older adults use prescription psychoactive medications that have abuse potential. The characteristics of older adults who may be more likely to have problems with psychoactive medications include (a) being female, (b) being socially isolated, and (c) having a history of substance abuse or a mental health disorder. In addition, longer-term use of psychotropic medications, especially benzodiazepines, is associated with cognitive losses and depressed feelings. Also, combining alcohol and psychoactive medications has even more potential for poor health and social outcomes.

The National Institute of Alcohol Abuse and Alcoholism (NIAAA) developed drinking limit recommendations for younger and older adults: The following are the drinking limits by age group.

• Younger than age 65 years: No more than 7 standard drinks/week for women (no more than 1 drink/day), and no more than 14 standard drinks/week for men (no more than 2 drinks/day).

• For men and women age 65+: At risk drinking is no more than 1 drink/day. The limits are the same for both men and women in this age group.

The World Health Organization defines alcohol use in 3 major categories: nonhazardous, hazardous, and harmful use. This categorization allows for variation based on individual differences in metabolism, response, history, and use patterns. It fits particularly well when working with older adults because it avoids stigmatizing terms such as “alcoholic” and “addict.”

Nonhazardous or Low-Risk Use

Alcohol use or short-term psychoactive medication use that does not lead to problems is called nonhazardous or low-risk use (see Case 58–1, adapted from Barry and Blow, 2010). People who use alcohol and/or medications at a low risk level can set reasonable limits on alcohol consumption and do not drink when driving a car or boat, operating machinery, or using contraindicated medications. They also do not engage in binge drinking. Among older adults, low-risk use of medications could include short-term use of an antianxiety medication for an acute anxiety state during which the physician’s prescription is followed and no alcohol is used, or drinking 1 drink 3 times/week without the use of any contraindicated medications.

Hazardous Use or At-Risk Use

Hazardous or at-risk use is use that increases the chances that a person will develop problems and complications related to the use of alcohol. These individuals have more than 7 drinks/week or drink in risky situations (see Case 58–2). They do not currently have health problems related to alcohol, but if this drinking pattern continues, problems may result. Misuse of psychoactive medications includes taking more or less medication than prescribed; hoarding or skipping doses of a medication; using medication for purposes other than those prescribed; and using medications in conjunction with alcohol or other contraindicated medications.

Harmful Use

“Harmful use” includes both “problem use” and “dependence.”

Problem Use

Problem use refers to a level of use that has already resulted in adverse medical, psychological, or social consequences (see Case 58–3). Although most problem drinkers consume more than the low-risk limits, some older adults who drink smaller amounts may experience alcohol-related problems. As mentioned above, medication misuse can also fit into the problem use category. Assessment is needed by the clinician to determine severity.

Dependence

Dependence is part of the World Health Organization (WHO) “harmful use” category and is a medical disorder characterized by loss of control, preoccupation with alcohol, continued use despite adverse consequences, and, sometimes, physiologic symptoms such as tolerance and withdrawal as in Case 58–4.

A wide range of legal and illegal substances can be abused. Medication abuse involves medication use that results in diminished physical or social functioning, medication use in risky situations, and continued medication use despite adverse social or personal consequences. Dependence includes medication use that results in tolerance or withdrawal symptoms, unsuccessful attempts to stop or control medication use, and preoccupation with attaining or using a medication.

Screening

Because of the relationship between the amount of alcohol consumed and health problems, questions about consumption (quantity and frequency of use) provide a method to categorize patients into levels of risk for alcohol use. The traditional assumption that all patients who drink have a tendency to underreport their alcohol use is not supported by research. People who are not alcohol dependent often give accurate answers. To assess for misuse of psychoactive medications, key questions include amounts used, other medications taken, and any concomitant use of alcohol.

Clinicians can attain more accurate histories by asking questions about the recent past; embedding the alcohol use and psychoactive medication questions in the context of other health (ie, health history, exercise, nutrition, smoking, medications used, alcohol use). Screening questions can be asked by verbal interview, by paper-and-pencil questionnaire, or by computerized questionnaire. All 3 methods have been shown to have equivalent reliability and validity. To successfully embed alcohol and medication misuse screening into clinical practices, the screening needs to be simple and consistent with other screening procedures already in place.

Potential Prescreening Questions

• Prescreening question: Do you drink beer, wine, or other alcoholic beverages?

• Follow-up: If yes, how many times in the [past year; past 3 months; past 6 months] have you had 4 or more drinks in a day (for older men)/3 or more drinks in a day (for older women)?

• On average, how many days/week do you drink alcoholic beverages? If weekly or more: On a day when you drink alcohol, how many drinks do you have?

• Prescreening questions: Do you use prescription medicines for pain? Anxiety? Sleep? Do you use any of these prescription drugs in a way that is different from how they were prescribed?

• Follow-up: If yes, follow up with additional questions regarding which substances, frequency and quantity of use.

Screening instruments exist that can be used with older adults: the Alcohol Use Disorders Identification Test (AUDIT) developed by the WHO (Table 58–1), the Short Michigan Alcoholism Screening Test–Geriatric Version (SMAST-G) (Table 58–2), and ASSIST, a drug use questionnaire developed by the National Institute on Drug Abuse (NIDA) and modified for older adults to assess misuse of psychoactive prescription medication.

The Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Treatment (CSAT) developed a series of treatment improvement protocols (TIPs), including TIP #26, “Substance Abuse in Older Adults.” The expert panel recommended that all adults age 60+ years should be screened on a yearly basis (generally, embedded with other health-screening questions) and rescreened if there are major life changes that could precipitate increased use and problems (eg, retirement, death of a partner/spouse, etc).

There is a large body of evidence that motivational brief interventions, delivered in a variety of health care and social service settings, can effectively reduce drinking, particularly for at-risk and problem users. Over the past 25+ years, there have been more than 100 preventive intervention trials in a variety of medical and social service care settings that have proven motivational brief interventions to be efficacious in reducing alcohol misuse among younger and older adults. The general form of the interventions in these studies included personalized feedback based on the individual’s responses to screening questions, and messages regarding cutting back or stopping use. Results indicate that, across studies, participants reduced their average number of drinks per week by approximately 30% compared to controls. Psychoactive prescription medication misuse has been incorporated into alcohol brief interventions for older adults so as to address these 2 issues in a systematic framework.

Use of a Brief Intervention Workbook

Brief intervention protocols often use a workbook. Using a workbook can make it easier for both the older adult and the clinician to discuss cues to use, reasons for the level of use, reasons to cut down or quit, negotiate an agreement for next steps, and introduce using daily diary cards for self-monitoring. Brief interventions take approximately 20–30 minutes to conduct (Barry, CSAT, 1999).

Identification of substance-use problems in older adults can take place in many health care-related settings, including primary care clinics, specialty care settings, home health care, elder housing, and senior center programs. Both from a public health standpoint and from a clinical perspective, the aging of the baby boom cohort means that there is a critical need in the health care field to implement effective screening and intervention strategies with older adults who are at-risk for more serious health, social, and emotional problems as a consequence of their use of alcohol, psychoactive prescription medications, and other drugs.

Innovative screening, intervention, and treatment methods have been developed for alcohol and drug misuse among older adults. Successful implementation of these strategies can improve the physical and emotional quality of older adults’ lives.