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

2. Review of the Literature (continued)

2.4 Gender Differences

Certain gender differences are recognized in the substance use literature. Men consume larger quantities of alcohol and drink more often than women at all ages; by contrast, women may be at greater risk of becoming dependent on prescription drugs (Allen & Landis, 1997; Bristow & Clare, 1992; Liberto, Oslin & Ruskin, 1992; McKim & Quinlan, 1991). When researchers reviewed the medical records of 100 elderly patients admitted to an inpatient substance dependence program, they determined that female patients outnumbered male patients by a ratio of 7 to 3 for prescription drug dependence. Eighty percent of all patients were dependent on a sedative or hypnotic drug, and 83% of these drugs belonged to the category known as benzodiazepines (Finlayson & Davis, 1994).

Tamblyn et al. (1994) examined questionable high-risk prescribing practices in Quebec and found that senior women received more high risk prescriptions than men. More older women than older men were given questionable combinations of psychotropic drugs, given benzodiazepines for longer than 30 days, and were prescribed long-acting benzodiazepines that are contraindicated in the elderly.

Brennan, Kagay, Geppert and Moos (2000) examined the medical records of 22,768 elderly inpatients over a four-year period and found that 37% of the admissions who were diagnosed with a substance use disorder were women. Although there were more men than women with a substance use problem, more of the women received a concomitant psychiatric diagnosis (20% compared to 10% of the men). Compared to the men (8%), women (13%) were also more prone to accidents as a result of substance use problems. The elevated number of accidents among women may be caused by metabolic differences that increase the potency of alcohol on a woman's system along with the tendency to use more psychoactive drugs than men (Bradley, Badrinath, Bush, Boyd-Wickizier, & Anawalt, 1998; Gomberg, 1995).

Millar (1998) noted that the 1994/95 National Population Health Survey found that in most age groups, a higher proportion of women reported taking medications. This pattern may be because women visit physicians more often than men.

Graham, Carver and Brett (1996) analysed the results obtained from the National Alcohol and Other Drugs Survey conducted by Statistics Canada in March 1989. Women aged 65 and over were most likely to be lifelong abstainers or former drinkers and least likely to be current drinkers. Where illicit drugs were concerned, only 1% of both men and women 65 years or older reported ever using marijuana. However, 20% of senior women and 14% of senior men reported using at least one psychoactive prescription drug (tranquillizers, sleeping pills, antidepressants, or narcotic analgesic) in the 30 days prior to the survey. The researchers suggested that stereotypes may play a role in dependence behaviour, particularly with the choice of substance involved. Senior women may consider drinking to be wrong but see no problem with reliance on a doctor's prescription. Men, on the other hand, may suffer equally as much from stress, anxiety or sleeping disorders but they are less likely to go to the doctor for such complaints and more likely to use alcohol.

2.5. Physical and Mental Health Issues

2.5.1 Health Problems Associated with Substance Use Problems

Heavy alcohol use in seniors is associated with increased health risks. Some of these risks result from lifelong alcohol abuse but even heavy drinking that begins late in life can also be associated with negative health consequences. The most common problem ascribed to heavy drinking is liver disease, but alcohol also contributes to rheumatism, arthritis, osteoporosis and other musculoskeletal conditions (Manisses Communications Group, 1995). Alcohol use may also interact with prescription or over-the-counter medications to decrease their effectiveness or produce adverse reactions.

a) Injury from Falls

Substance use problems can contribute to injury from falls. It can affect balance and judgment, and age-related changes in bone density and muscular strength predispose seniors to bone fractures (Rigler, 2000). In those who are alcohol dependent, up to 50% of hospital admissions may be due to injury from falls (Mulinga, 1999). One study that examined the relationship between hip fracture and chronic alcohol use problems found that hip fracture rates increased steadily with age. As well, 12% of hip fracture patients with alcohol use problems were discharged to a nursing home compared to only 5% of patients without alcohol use problems. Mortality rates were also significantly higher for hip fracture patients with chronic alcohol use problems (Yuan et al., 2001).

b) Liver Disease

Gambert (1997) described liver disease as probably the most well known and widely studied medical problem associated with excessive alcohol use. Liver problems include hepatitis, fatty liver and cirrhosis, all of which interfere with the vital metabolic processes necessary for good health. In one study, 50% of the elderly patients with cirrhosis died within a year of diagnosis (Smith ,1995). The problem of alcohol-related liver disease increases with age (Fingerhood, 2000). Management with diuretics that increase urine production produce more side effects in senior patients (Fingerhood, 2000; Gambert, 1997).

c) Heart Problems

It is difficult to specify the extent to which heavy drinking affects the heart, since heart attacks and heart disease are generally associated with age-related changes, especially in men. Alcohol abuse frequently increases blood pressure (Marmot et al., 1994). Alcohol may also cause a rise in systolic pressure that results in blood being shunted from the viscera to the body's periphery. At the same time, a senior may already be suffering from age-related changes that affect the body's ability to maintain adequate body temperature. These two factors combined may put the senior drinker at risk of hypothermia and are particularly dangerous for those who live alone (Gambert, 1997). Cardiac arrhythmias, including atrial fibrillation, are seen in seniors with alcohol abuse (Fingerhood, 2000). Alcohol abuse also increases risks of cerebrovascular problems, including strokes and intracranial bleeding (Fingerhood, 2000). One study showed that men who were heavy drinkers had an increased risk of stroke (17%) as compared to moderate drinkers (8%) and abstainers (7%) (Colsher & Wallace, 1990). Alcohol consumption is also responsible for a temporary heart condition known as "holiday heart syndrome". This syndrome is characterized by an irregular heart rhythm that occurs following an alcohol binge. Such binges tend to happen during times of celebration and holiday and increase the chance of stroke and cardiac related deaths (Rigler, 2000).

d) Gastrointestinal Disorders

Gastrointestinal problems may result from prolonged alcohol intake and account for many of the visits senior chronic drinkers make to hospital emergency departments (Rigler, 2000). These problems may be instrumental in inducing vitamin deficiencies (Gambert, 1997). Gastrointestinal problems that result in nausea or vomiting may increase risks for electrolyte disturbances and dehydration (Gambert, 1997). One study found that 24% of heavy male drinkers had stomach or intestinal ulcers compared to 19% of moderate drinkers and 17% of abstainers (Colsher & Wallace, 1990).

e) Sexual Dysfunction

Gambert (1997) notes that the aging process itself is not a cause of impotence in senior males. Many men retain normal capabilities for sexual function well into their late adulthood. Senior male chronic drinkers, however, are prone to impotence because alcohol affects normal testosterone production. No research was found on senior women and sexual dysfunction.

f) Nutritional Deficiencies

According to Fingerhood (2000) and Gambert (1997), malnutrition and vitamin deficiencies are common in heavy drinkers. Sometimes the calories they consume through alcohol appease their hunger, other times they neglect to prepare a meal or are unaware that they should do so. Korsakoff's syndrome is often found in chronic alcoholics. It is caused by prolonged thiamine deficiency and is characterized by memory loss (Gambert, 1997). With poor nutrition, those with alcohol use problems may experience a suppression of the immune system and be at increased risk of infection. Especially in older drinkers, doctors should also be aware of a possible reactivation of tuberculosis acquired during childhood exposure to the disease (Rigler, 2000). Also, vitamin deficiencies can lead to peripheral neuropathy, perceived as tingling then numbness in the extremities (Fingerhood, 2000).

g) Cancer

The risk for cancer increases with abuse of alcohol, including risks for breast cancer in women, prostate cancer in men, as well as cancer of the larynx, esophagus, and colon (Fingerhood, 2000).

h) Withdrawal Complications

Kraemer, Mayo-Smith & Calkins (1997) predicted that the older a person was, the more complications they might experience during a withdrawal episode. They compared a group of patients younger than 35 to a group of patients older than 49 who had been admitted to the same detoxification unit. Contrary to expectations, the groups did not differ in withdrawal severity or medical complications. Their lengths of stay were, however, affected by age, with older patients requiring longer stays. The researchers also noted greater cognitive and functional impairments in the older population, and suggested that regardless of whether these impairments were due to age or to alcohol withdrawal, senior people require more attention and care during the withdrawal phase. Another research group wanted to investigate the phenomenon of "kindling" which suggests that the more often an individual goes through a withdrawal episode, the more severe each successive episode will be (Brower, Mudd, Blow, Young & Hill, 1994). They conducted a retrospective chart review of younger (ages 21 to 35) and older (60 and over) patients who had received detoxification treatment at the same hospital and used a predetermined coding system to identify various withdrawal symptoms. Although no support for the kindling theory was found, results showed that the detoxification period was significantly longer for older adults.

Contrary to Kraemar et al. (1997), this study did find that older adults suffered more withdrawal symptoms, however, different age groupings may account for some of the differences seen.

i) Increased Risk of Mortality

Banks, Pandiani, Schact and Gauvin (2000) examined mortality rates for 1853 white adult males from 18 to 79 years of age who had accessed alcohol treatment services in Vermont in 1991. In comparison with a large non-drinking group, it was established that mortality rates increased substantially with increasing age. Of those over 50 years of age, those in the treatment group were 1.5 times more likely to die than those in the general population.

2.5.2 Psychiatric Problems Associated with Substance Use Problems

a) Cognitive Deficits

There is a dilemma for health professionals in determining whether the etiology of a decline in cognitive abilities is due to substance use problems, related factors such as vitamin deficiencies, or due to the onset of chronic diseases or dementia (Allen & Landis, 1997). Overall, the general level of cognitive functioning remains intact in most who have alcohol use problems, although when specific abilities are tested, deficits are observed in memory, perceptual-motor skills, conceptual learning, and problem solving. Sometimes deficits ameliorate after detoxification, but deficits in abstraction and visuo-spatial abilities often persist (see Allen & Landis,1997 for a review; Liberto et al., 1992).

b) Dementia

Woods (1996) reports that 5% of people over the age of 65 and 20% of people over the age of 80 will show some form of dementia. It is difficult to determine how much of a person's cognitive decline is due to aging, medical problems, or substance use problems. Carlen et al. (1994) studied 130 cognitively impaired individuals (age 50 and over) living in long-term care facilities. Case histories, medical records and standardized testing were used to determine the type of dementia involved. There were four main categories of dementia established: 1) dementia of the Alzheimer's type (35%), 2) vascular dementia (19%), 3) alcohol-related dementia (24%), and 4) dementias due to miscellaneous causes (22%). Patients with alcohol-related dementia were, on average, 10 years younger than those diagnosed with other dementias. One of the criteria used to establish alcohol-related dementia was stable cognitive performance (i.e., no decline) for the year following admittance to the facility. For some with alcohol use problems, cognitive performance may improve after admission to a residential facility if alcohol intake is controlled. It was also found that for the 75% of patients who received a diagnosis of alcohol-related dementia, this diagnosis was absent in their medical records, suggesting that symptoms are often mis-diagnosed. Some researchers question whether alcohol-related dementia exists apart from the cognitive changes that result from nutritional deficiencies (Liberto et al., 1992).

Korsakoff's dementia (sometimes called Wernicke-Korsakoff's syndrome) is the dementia most commonly associated with alcoholism (Allen & Landis, 1997). It is due to a prolonged thiamin deficiency and has a characteristic pattern of both anterograde amnesia (an inability to form new memories) and retrograde amnesia (an inability to retrieve long-term memories). Wernicke-Korsakoff's dementia has a faster onset compared to alcohol-related dementia. Those with alcohol-related dementia may experience a broad range of cognitive dysfunction, often encompassing visuo-spatial and problem-solving as well as memory problems (Allen & Landis, 1997).

The connection between Alzheimer's and alcohol use problems has only recently been studied. Alzheimer's disease and alcohol abuse or alcohol-related dementia can be co-morbid. One study examined the drinking behaviour of 64 patients who had received a diagnosis of probable Alzheimer's disease, 31% of whom had a current or a past history of alcohol abuse. Those with a long history of alcohol abuse presented a clear example of Alzheimer's disease with co-morbid substance abuse. For those who had a short history of alcohol abuse (late-onset), however, researchers suggested that the alcohol abuse may have been a manifestation of disinhibition brought on by the Alzheimer's (Larkin & Seltzer, 1994).

c) Psychiatric Conditions

Research has shown that seniors with alcohol use problems suffer from more psychiatric disorders than does the general population (Liberto et al., 1992). According to the Epidemiological Catchment Area study, people diagnosed with an alcohol abuse or dependence disorder were 2.9 times more likely to be diagnosed with another mental disorder at some time during their life span (Regier et al., 1988). A review of the records of 3986 US Veterans Affairs patients (aged 60 to 69) with alcohol dependence revealed the following rates of concomitant disorders: affective (includes depression) (21%), anxiety (10%), schizophrenia (9%) and personality disorders (6%) (Blow et al., 1992). The preceding statistics may not be comparable to the Canadian context in light of the age grouping and the health conditions in Canada.

Depression is by far the most common disorder co-morbid with substance abuse, but it is difficult to determine the nature of the relationship between the two (Krause, 1995; Segal, VanHesselt, Hersen & King, 1996). Are people depressed because they drink or do they drink because they are depressed? One useful categorization emphasizes the timing of the depression. If the depression begins before a drinking episode or during a period of abstinence, then it is considered "primary" depression. Secondary depression refers to depression that develops as a consequence of drinking (Oslin, 2000a).

One study used the 30-item Geriatric Depression Scale (GDS) to screen a sample of seniors (age 62 and over) presenting to a geriatric outpatient clinic for general care. On this scale, a score of greater than 10 indicates depression. Results showed that 70% of the participants who scored in the depressed range on the GDS had not previously been diagnosed as depressed. Furthermore, 19% of the patients classified as depressed were on anti-anxiety medication, indicating that either depression co-exists with anxiety, or that the depression was misdiagnosed in the elderly (Fulop et al., 1993).

Anxiety disorders are common to seniors, but they are not always recognized or treated. Anxiety is often an early symptom in cardiovascular, endocrinological, and neurological disorders (Bortz & O'Brien, 1997). Anxiety symptoms themselves can lead to medical complications, for example, cardiac arrhythmia or insomnia (Sheikh, 1994). The current emphasis on pharmacological treatment is not always appropriate for seniors who may confuse the dosage or instructions or discontinue use because they do not feel any improvement. On the other hand, they may take too much of the medication to achieve an effect and this creates a substance dependency (Bortz & O'Brien, 1997).

Older people in general have high suicide rates compared to other age groups (Health Canada, 1999b; Woods, 1996). Seniors who suffer from alcoholism and depression are at increased risk of suicide (Fulop et al., 1993). Since problem alcohol use and depression are implicated in suicide, and given the high rate of suicide in older adults, substance use treatment providers as well as other health care professionals need to be sensitive to the presence of suicidal ideation in older clients (Holroyd & Duryee, 1997).