Best Practices: Treatment and Rehabilitation for Seniors with Substance Use Problems

2. Review of the Literature (continued)

2.3 Patterns of Substance Use Problems in Seniors

2.3.1 Alcohol

a) Prevalence

Alcohol is the substance most commonly used by seniors (Health Canada, 1999a). According to a Health and Welfare Canada report (1992), 22% of those over the age of 65 drink four or more times a week (Baron & Carver, 1997). Some of the warning signs of excessive drinking in this age group include confusion, forgetfulness, anxiety, depression, sleep problems, injury from falls, decrease in the effectiveness of medications, conflict or withdrawal from family and friends, and improper eating habits accompanied by weight loss (Addiction Research Foundation, 1993a). As previously mentioned, these signs of intoxication or of prolonged use can be misattributed to aging.

Adams, Magruder-Habib, Trued and Broome (1992) studied the prevalence of alcohol abuse among elderly patients (65 and over) admitted to the emergency department of a North Carolina hospital over a two-month period. Based on reviews of medical records, interviews, and self-report data, they concluded that 14% of the patients treated currently had an alcohol use problem.

As well, Canadian researchers attempted to identify the number of older individuals (65 and over) treated in the emergency department of a hospital. They found that 14% of the study participants screened positive for alcohol abuse (Tabisz et al., 1991). This number (14%) seems high in comparison to the low rates found in the Epidemiological Catchment Area study (Regier et al., 1988). One of the reasons for the discrepancy in rates from one study to another relates to the sample group which is being studied. When researchers draw their sample from hospitals, clinics, and elder- specific programs, a selection bias exists that would not be found in the general population who is not seeking health services.

A study at the University Hospital Leiden in the Netherlands used the Munich Alcoholism test to screen patients 65 and over for possible alcohol problems. Of the 132 patients in the study, the researchers classified 9% as having an alcohol dependency problem (Speckens, Heeren & Rooijmans, 1991). Ganry, Dubreuil, Joly and Queval (2000) assessed 370 patients 65 years or older for alcohol problems. Based on a structured personal interview that questioned drinking patterns, past and present, the researchers concluded that 9% of the patients could be considered as having a problem with alcohol.

Ticehurst (1990) discusses differences in prevalence rates of alcohol abuse and dependence observed between countries. He cites studies that found from 0% to 20% prevalence rates, and notes that cultural norms, religious considerations and socioeconomic factors determine the definition of problem drinking in different nations. Further, even within one country there can be large regional variations.

Another study noted Israeli cultural barriers to explorations of alcohol use by seniors. A search was conducted on 180 Israeli publications that focussed on alcohol research. Only five of these sources made any reference to aging. Weiss (1993) suggests that alcohol researchers are resistant to exploring alcoholism in the elderly, that those with an interest in the elderly are not interested in alcohol problems, and that alcohol abuse is not considered a problem of aging.

Alcohol consumption patterns tend to change as people age. McKim & Quinlan (1991) conducted a telephone survey in St. John's, Newfoundland and asked 3304 participants to answer questions regarding drinking behaviour patterns. They found a steady age-related decline in the quantity of alcohol consumed per drinking occasion but only a slight decline in the frequency of such occasions (McKim & Quinlan, 1991). Other researchers have also found that alcohol use declines with age for both men and women (Adams, Barry & Fleming, 1996; Barnea & Teichman, 1994).

Recently, revisions have been made in the recommendations about alcohol intake. Guidelines issued by the National Institute on Alcohol Abuse and Alcoholism recommend no more than one drink a day for both men and women over the age of 65 (Blow, Walton, Barry, Coyne, Mudd & Copeland, 2000). According to Adams et al. (1996), approximately 11% of men and 9% of women over age 75 exceed these recommendations. The effects of intoxication, such as confusion, unsteadiness and slurred speech, may be misinterpreted. Such behaviour may be attributed to dementia or cognitive impairment without consideration for the role of substance use problems (Allen & Landis, 1997).

b) Patterns

There is a consensus that there is not one specific type of drinker representative of this cohort (Allen & Landis, 1997; Fingerhood, 2000). Rather, there appear to be at least two broad categories of senior problem drinkers. "Early-onset" drinkers comprise roughly two-thirds of the group and "late-onset" drinkers make up the other third (Dufour & Fuller, 1995; Mellor et al., 1996).

The early-onset drinker usually has a lengthy history of alcohol-related problems that started before the age of 40 (Widner & Zeichner, 1991). Early-onset drinkers are more likely than late-onset drinkers to drink to intoxication, and to have a history of treatment for alcohol use (Fingerhood, 2000). They generally have less family and social support and more difficulties with employment (previous or current). They are considered to be alcoholics who have aged (Widner & Zeichner, 1991).

The late-onset drinker is generally considered to have developed an alcohol problem after the age of 40, often as a reaction to the losses and life changes associated with aging (Graham, Zeidman, Flower, Saunders & White-Campbell, 1992; Schonfeld & Dupree, 1991). Compared to early-onset drinkers, late-onset drinkers tend to have fewer behaviour problems, a more supportive social network, better relationships with family members, less alcohol-related health problems, and can be more responsive to treatment (Widner & Zeichner, 1991).

In a study designed to investigate the antecedents of recent drinking in early- and late-onset drinkers, it was found that several similarities exist between the two groups. Participants in both groups were likely to have a drink to ease feelings of loss, loneliness and depression. This similarity emphasizes the likelihood that age and the inevitable transitions that accompany the aging process contribute to the drinking behaviour of some seniors (Schonfeld & Dupree, 1991).

Graham et al. (1992) remarked on problems inherent in the late-onset/early-onset dichotomy in that the cutoff age of 40 is rather young to begin experiencing reactions to the stresses of old age. They used 36 case studies and an intuitive approach to develop a profile of four different types of drinkers: chronic alcohol abusers, reactive drinkers, problem drinkers with psychiatric or cognitive problems and problem drinkers whose drinking was interrelated to an abusive, heavy drinking partner. Although the possibility exists for different types of older drinkers, this typology was not supported when the case studies and profiles were given to independent raters. Only the chronic and reactive drinkers were consistently identified, and their profiles are very similar to those of the early-onset and late-onset drinker, respectively.

A recent classification distinguishes between four types of older drinkers based on drinking history patterns and length. In addition to the early- and late-onset categories, there is a smaller group of "intermittent" drinkers who binge periodically but otherwise drink moderately or not at all. The fourth type is proposed to be a subset of late-onset drinkers who were heavy drinkers all their life but only became problem drinkers later, in response to two factors. First, the need for sobriety was reduced by the removal of family and work responsibilities, and second, the grief and loss associated with aging were experienced (Mellor et al., 1996). Most of the current literature accepts the early- and late-onset profiles of the older drinker with increasing awareness of the intermittent or binge drinker (Baron & Carver, 1997; Fingerhood, 2000).

2.3.2 Prescription Drugs and Over-the-Counter Medication

a) Prevalence

Prescription drug use is more prevalent among those 65 and over than among younger people (Bergob 1994). The 1989 National Alcohol and Other Drugs Survey found that 18% of senior women and 14% of senior men used three or more prescription drugs in the month before the survey, whereas approximately 2% to 8% of younger adults used three or more prescription drugs in the month before the survey (Bergob, 1994).

Concern over the use and misuse of licit drugs has risen in recent years. Canadian seniors (65 and over) purchase 45% of all prescription drugs sold even though they comprise only about 12% of the population (Gander and District Continuing Care Program and the Seniors Resource Centre, 1994). According to recent surveys, 84% of seniors living in a private household, and 96% of seniors living in an institution had taken some form of prescribed medication during the two days prior to the surveys (Statistics Canada, 1997, 1999).

Bergob (1994) reported that the prescription medications that were most commonly used by seniors were heart or blood pressure medications (45% of women over 65, and 35% of men over 65), followed by pain relievers (33% of women over 65, and 30% of men over 65). Similar findings were reported in the 1994/95 National Population Health Survey, with pain relievers, blood pressure medications, diuretics, stomach remedies and laxatives being the most commonly taken medications by people aged 65 and over (Millar, 1998).

In one US study of patients receiving treatment for dependence on prescription drugs, drug dependence had developed at age 60 years or older in 35% of participants and the substances most commonly abused were benzodiazepines (Finlayson & Davis, 1994). The benzodiazepines are sedative-hypnotic drugs used to treat anxiety and sleep disorders. Seniors receive a relatively large amount of these prescriptions, despite clinical evidence that suggests caution due to side effects such as cognitive and psychomotor impairment (Closser, 1991). A Canadian study to promote safe medication use found that benzodiazepines were regularly used by 20% of older adults (aged 55 and over) in 22 Quebec communities (Paradis, 1990). Canadian researchers found that of seniors (65 and over) treated in the emergency department of a large hospital, 17% screened positive for potential benzodiazepine or opiate abuse problems (Tabisz et al., 1991).

Benzodiazepine use was examined in a study by Closser (1991) who noted that even though use of these drugs in senior clients presented certain age-related health risks, many physicians still prescribed them. In addition to anxiety, this class of medications is commonly used to combat sleep disorders. However, one investigator found that benzodiazepine-dependent participants actually suffered from poorer sleep quality due to the repression of certain sleep stages (Schneider-Helmert, 1988).

Researchers at the University of Manitoba conducted a study on prescription drug use. Results showed that 19% of acute care admissions to the hospital were due to improper use of medication by persons aged 50 and over (Canadian Coalition on Medication Use and the Elderly, 1992). In the US, one research group maintains that 20% to 25% of all hospital admissions of seniors (55 and over) are due to adverse drug reactions (Washington State Substance Abuse Coalition, 1995).

Bergob (1994) found that over-the-counter drugs are also subject to misuse and pose potential health hazards through interaction with other drugs. Many people do not think to tell their doctor about the medications they buy at the drugstore (Atkinson, Ganzini, & Bernstein, 1992). Also, problems may arise if they are buying over-the-counter medication to treat an ailment that is already being addressed by a prescription drug. One study noted that 20% of women and 19% of men aged 65 and over used non-prescription pain relievers in addition to their prescribed medication (Bergob, 1994), increasing the possibility of substance use problems and adverse side effects from various drug interactions.

b) Patterns

Barnea and Teichman (1994) reported that three main patterns of medication misuse could be identified in seniors:

• use of medications contrary to instructions;
• use of multiple medications resulting in adverse drug interactions; and
• misuse due to misinformation or misunderstanding.

The first pattern of misuse mentioned is generally the one associated with substance abuse or dependence as a result of deliberate, excessive ingestion of medication. Seniors with a dependence on prescription drugs may use denial, rationalization, defocussing and minimization when questioned about their medication usage (Solomon et al., 1993).

Denial: denying the existence of a problem or denying that the substance is addictive.

Rationalization: finding reasons to support the use of a substance (i.e., to calm nerves).

Defocussing: not focusing on the substance as the root of the problem.

Minimization: minimizing the impact or minimizing the amount consumed.

The second pattern of medication misuse is due to harmful drug interactions. Doctors need to be informed about all the medications a patient is taking. One report found that almost half of the persons over 55 years of age who received prescriptions from more than one doctor believed that the physicians communicated with each other about what drugs they prescribed for each individual (Canadian Coalition on Medication Use and the Elderly, 1992). This expectation can lead to problems. The possibility that medications may interact with each other rises in proportion to the number of medications used (Barnea & Teichman, 1994).

Many over-the-counter (OTC) drugs exert depressive effects on the central nervous system, and can have additive effects with other OTC drugs, prescription medication, or alcohol. Seniors or caregivers can reduce potential side effects from drug interactions by:

• informing the doctors about all medications currently being used, including over-the counter (OTC) drugs;
• always using the same pharmacy to fill the prescriptions; and
• being aware of the signs and symptoms of adverse drug effects, such as unsteadiness, drowsiness, confusion, dizziness, headaches, irritability and changes in heart rate (Addiction Research Foundation, 1993b).

The third pattern of medication misuse is due to misinformation or misunderstanding. Seniors may:

• forget to take their medicine;
• take a double dose to make up for missing it;
• take it at the wrong time;
• take an improper amount;
• misunderstand the instructions on the bottle;
• be unable to read the instructions on the bottle; and
• not get the prescription refilled either because they cannot afford it or because they do not think they need it as they feel fine (Ruben, 1992).

Schonfeld, Rohrer, Zima and Spiegel (1993) initiated a study of substance use problems in seniors because of concerns that they are a hidden population. The researchers interviewed service providers in Florida and North Carolina and asked them to estimate the percentage of their clients that they felt had alcohol or medication problems. There were two venues for service: either in-home care was provided, or the client was seen at an agency. Less than 2% of the admissions to alcohol treatment programs are seniors, even though estimates of alcohol abuse in this age group range from 2% to 15% or more (Schonfeld et al., 1993). The results of this study provided estimates for alcohol abuse that ranged from 1% (North Carolina, in-home) to 26% (Florida, agency), and estimates for medication abuse from 18% (North Carolina, agency) to 41% (Florida, agency). Both states registered a high level of concern over prescription drug use but reported that most of the medication problems were seen as misuse and mismanagement. Schonfeld et al. (1993) suggested that educating seniors about proper medication use and devising a medication management system tailored to their needs would help overcome this.

According to Ruben (1992), specific issues related to prescribing medications may be overlooked by medical professionals. Close attention needs to be given to the patient's prior medication history. Care needs to be taken to not prescribe too high or too low a dose, or too many drugs without adequate monitoring. Patients should be informed about possible side effects, especially if the effects are related to drug interactions. Seniors should also avoid the "gray market", which is when pills are borrowed or lent (Ruben, 1992).

2.3.3 Illicit Drugs

Less than 1% of Canadian seniors report using illegal drugs such as marijuana, cocaine and heroin (Statistics Canada, 2000). The Epidemiological Catchment Area data suggest a lifetime prevalence rate of 1.6% for illegal drug users over the age of 65 (Patterson & Jeste, 1999). Data from the Drug Abuse Warning Network in 1991 indicated that 1.8% of emergency room treatments for heroin or morphine abuse were for persons over the age of 55 (Patterson & Jeste, 1999).

In 1962, Winick proposed a "maturing out" theory that suggests that drug dependence is infrequently observed among seniors because they either grow out of their narcotic addictions due to adverse consequences or they die. To the extent that this theory has been accepted, research has declined. Some evidence for this theory has been found but it has also been acknowledged that enough senior addicts survive to warrant further investigation (Allen & Landis, 1997; Barnea & Teichman, 1994). Further, although mortality claims some older persons, medical advances are extending lifespans, and may counter the expected decreases in prevalence rates. As baby boomers grow to predominate the population of seniors, changes in prevalence of illicit drug use may occur (Barnea & Teichman, 1994).