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

2. Review of the Literature (continued)

2.6 Risk Factors

2.6.1 Practical Factors

According to Barnea & Teichman (1994), practical factors for substance dependence take into account things such as:

• how ill a person is;
• how many medications they are taking;
• how much they know about the medicines and their side effects;
• how many doctors are treating them; and
• how many pharmacists are filling their prescriptions.

The more health problems people have, the greater the number of medications they use. The more medications they use, the greater the odds that substance misuse or dependence could develop, especially if different doctors are prescribing the same medication (Barnea & Teichman, 1994). Tamblyn and Perrault (1998) examined the prescribing practices of medical professionals to seniors. Some evidence of inappropriate prescribing practices was associated with medical professionals who lacked areas of specialty, and the authors encouraged consultation with peers, especially if the professionals were operating in geographically isolated areas.

Another practical factor is the distance travelling to and from the clinic. This can impact on regular check-ups and make it harder for the doctor to detect problems. Distance from the pharmacy and the number of pharmacies in the area is another risk factor, if it allows easier access to medication (Barnea & Teichman, 1994).

2.6.2 Biological Factors

Seniors have less body water to dilute the alcohol they consume, so smaller amounts of alcohol are needed to induce intoxication (Allen & Landis, 1997). Age-related changes in body metabolism increase the sensitivity of the central nervous system to both alcohol and drugs, causing prolonged effects. The enhanced effect of psychoactive drugs (such as the benzodiazepines) and the ease with which seniors can generally access them through their physician, may create a vulnerability to medication problems (Allen & Landis, 1997).

With increasing age comes the increasing potential of pain or insomnia as a result of health problems. Chronic pain is responsible for the purchase of a great deal of OTC medication, especially painkillers (Adams, Zhong, Barboriak & Rimm, 1993; Atkinson & Ganzini, 1994). With the variety of psychoactive substances available (alcohol, prescription, OTC, and other drugs) and with the increased potency of drugs in the senior, risks increase for substance use problems (Gomberg & Zucker, 1998).

Graham, Clarke et al. (1996) interviewed 826 adults aged 65 and over to evaluate the relationship between alcohol use and other medications that depress the central nervous system (e.g., codeine). They included a checklist of four social reasons for drinking and 11 personal effect reasons (i.e., to pass the time, forget worries, etc.) They discovered that people who were already using depressant medication were also significantly more likely to endorse the use of alcohol for the following reasons: to relax, to relieve tension/anxiety, to forget worries and to relieve pain. Similar results were obtained when they examined the use of tranquillizers and sleeping pills as they related to alcohol use. The researchers concluded that seniors were using both alcohol and medication to treat psychological symptoms and such behaviour places them at risk for substance misuse, abuse and dependence.

2.6.3 Psychosocial factors

a) Retirement

Norton (1998) reported that a person's occupation can exert a strong influence on their self-definition. Some people, often women, focussed their energy on running a house and raising a family. For many people, their employment outside the home provided them with a certain status and self-esteem as well as a way to structure their time.

Once retirement occurs, individuals may be challenged to find new interests and activities. Difficulty during this adjustment period may place seniors at risk of substance use problems.

b) Bereavement and Other Losses

Bereavement, especially of one's spouse, is a critical process for people (King et al., 1994). Divorce and separations may be precipitants of alcohol use problems for some (Dufour & Fuller, 1995). Other losses may include "... standard of living and social status if retirement income is less than pre-retirement income, empty nest syndrome, loss of health, loss of cognitive functions, loss of motor abilities and functions, loss of vigour, loss of sexual drive and/or performance, loss of meaning of life, loss of interest in things previously valued..." (Norton, 1998, p. 377). A string of losses is considered a precipitant of depression in seniors and may initiate use of psychoactive substances to counteract the depression. As well, losses in later life may raise the individual's awareness of their own mortality and can sometimes prompt reminiscence as the individual begins to review their life so far (Boggs & Leptak, 1991) and alcohol or other substances may be used or increased to lessen troublesome negative cognitions.

c) Losses in the Social Network

According to Hanson (1994), changes in a person's social network are inevitable as one ages. The senior may lose friends and neighbours by moving to a new location or family and friends may move away. Contacts with co-workers may be lost after retirement and physical health problems may prevent participation in previously enjoyed activities or social groups. Hanson (1994) examined the relationship between social networks and heavy drinking in a random sample of 500 men who were all 68 years old at the time of the study. Results showed that heavy drinkers were more likely to live alone, had fewer contacts with friends and family, less participation in social events and a less integrated social network.

d) Enabling Attitudes and Behaviours

Enabling refers to attitudes and behaviours in people that allow substance use problems to develop unimpeded and may interfere with recommended treatment. Sometimes family members want to protect themselves from embarrassment and other times they want to protect the substance abusing senior. They might believe that seniors should be allowed to do as they please because they have less time left in which to enjoy their life (Baron & Carver, 1997; Segal et al., 1996).

e) Chronic Stress

Welte and Mirand (1995) conducted a telephone survey with 2325 randomly selected inhabitants aged 60 or more in Erie County, New York, and questioned them about drinking behaviour, stressful life events, chronic stresses, social support, medical and physical problems and coping styles. Contrary to expectations, no relationship was found between stress, heavy drinking and an individual's style of coping with life stressors. What they did find, however, was that a history of chronic stress was a strong predictor of alcohol problems. From this perspective, the use of alcohol may be regarded as a means of coping.

According to Anetzberger and Korbin (1994), the dynamics of the relationship between the perpetrator and the abused in elder abuse are extremely complicated and may involve a history of family violence, alcohol abuse or conflict. Some seniors may be required to look after aging parents or other family members. As a result, some seniors may use alcohol or medications as a means of dealing with the stress related to their present situation. In addition, substance use problems may also be evident among seniors who live in or have experienced abusive situations. (Anetzberger & Korbin, 1994).

f) Family and Personal History

Late-onset drinkers differ from early-onset drinkers with respect to family and personal histories of drinking. Those with early-onset or chronic alcohol use problems are more likely than those with late-onset alcohol use problems to have had family members who abused alcohol, with the emotional and social trauma that accompanies such behaviour (Goldstein, Pataki & Webb, 1996). They also have a personal history of heavy drinking that will influence the use of alcohol in older adulthood. Gurnack and Hoffman (1992) examined the influences of emotional distress on drinking behaviour in males and concluded that even though heavy drinking in seniors may be perceived as a consequence of these stressors, it is more likely a continuation of lifelong patterns.

g) Education and Income

Ganry et al. (2000) found that higher educational levels and family incomes consistently increased the frequency of alcohol use. Higher income allows seniors the option of moving to a retirement community where more social drinking may occur. Having the financial resources and unlimited time in which to drink are potential risk factors (Norton, 1998).

2.6.4 Protective Factors

In addition to the noted risk factors, both researchers and treatment experts have acknowledged the importance of protective factors. For those seniors who seem resilient to risks, there are certain protective factors that give them the needed strength to overcome potential risks. Protective factors may be viewed as the reciprocal of risk factors. Sometimes the same factor can operate as a risk factor and a protective factor, for example, caring for an elderly spouse is stressful and therefore a risk factor, but if it gives the carer a role at a time of potential role loss, it can also be a protective factor.