As the eldest post-World War II “baby boomers” turn 64 this year, relaxed social attitudes about substance use during their lifetimes may predict an increasing risk for substance use disorders (SUDs) in older Americans.1 This presents challenges for psychiatric clinicians:
- Common screening tools used for younger patients might not adequately diagnose SUDs in patients clinically defined as elderly (age ≥65).
- DSM-IV-TR’s definition of substance use as causing clinically significant impairment or distress—such as occupational difficulties, legal problems, or decreased participation in social activities—might not apply to older patients, or these problems could be caused by other factors in older individuals.2
This article describes screening and treatment approaches shown to be most effective for identifying and managing primary SUDs in older patients. Our goal is to help you ask the right questions and provide appropriate care.
Phase-of-life issues
Most older adults have a primary care physician, but their SUDs often go unrecognized.3 Clinicians and family members might hesitate to ask about substance use or prescription medication misuse, and complications—such as falls or cognitive impairment—may be misattributed to normal aging. Thus, SUD screening of older individuals referred for psychiatric care is important.
Older adults respond with higher adherence rates when SUD treatment addresses age-specific issues—such as recent losses, medical problems, and challenges of keeping scheduled appointments or multiple providers/referrals. A combination of psychosocial and biologic treatments may be most beneficial. Although outcomes vary, some evidence indicates that age-specific programs for older alcoholics significantly improve abstinence rates at 6 and 12 months, compared with mixed-age programs4 ( see Related Resources ).
We recommend that you incorporate phase-of-life considerations at all stages of treatment. These include:
- education regarding lowered alcohol intake recommendations
- assessment tools that use criteria relevant to older adults
- treatment interventions that involve age-specific groups and programming.
Screening tools
In a routine office visit, a sensible approach is to screen for alcohol, tobacco, and prescription medication misuse. First-line screening tools for alcohol abuse include the AUDIT-5, CAGE, or MAST-G ( Table 1 ), accompanied by questions about medication side effects and observation of behavioral signs of medication misuse.
Alcohol use disorders. The spectrum of alcohol use disorders includes heavy drinking, hazardous use, harmful use, abuse, and dependence ( Table 2 ). Taking into account older adults’ physiology—these individuals have slower metabolism and smaller volume of distribution—National Institute on Alcohol Abuse and Alcoholism (NIAAA) alcohol consumption guidelines for the elderly differ from those for younger adults.
NIAAA guidelines for the elderly define hazardous use as >3 drinks in 1 sitting or >7 drinks in 1 week for both men and women. This is in comparison with guidelines for younger adults that define hazardous use as >5 drinks in 1 sitting (or >2 drinks/day) for men and >3 drinks in 1 sitting (or >1 drink/day) for women. The NIAAA recommendation considers a standard drink to be 12 oz of beer, 5 oz of wine, or 1.5 oz of distilled spirits, each drink containing approximately 0.5 oz of alcohol.5
Not all screening tools developed to assess alcohol use have been studied extensively in older cohorts,6 and some might not be useful in certain populations.7 The CAGE screening tool, for example—although easy to administer and widely studied—has low sensitivity in psychiatric populations, does not address past vs current drinking problems, and does not distinguish age-specific criteria for problem drinking.
Consider using instruments specific to an older individual’s comorbidities:
- the AUDIT-5 is appropriate for an older patient with psychiatric illness
- the ARPS (or the shorter shARPS) for an older individual with medical problems is likely to improve the rate of identifying problem drinkers.
Table 1
Comparing screening tools for alcohol use disorders in the elderly
| Screening tool | Characteristics | Clinical usefulness |
|---|---|---|
| CAGE | 4 items; self-report; most widely used/studied alcohol use screen; specificity > sensitivity | First-line; most useful if goal is to identify alcohol dependence; may miss misuse or hazardous use |
| AUDIT-5 | 5 items; self-report; specificity > sensitivity; a shortened version of the 10-item AUDIT | First-line; helpful for identifying hazardous use; sensitive for a broader spectrum of alcohol misuse than CAGE |
| MAST-G | 22-item yes/no self-report; questions specific to elderly | First-line; designed to identify a population that drinks less than heavy drinkers |
| SMAST-G | 10 items; shorter version of MAST-G with similar characteristics | Less sensitive and specific than MAST-G; may be useful when time is limited |
| Cyr-Wartman | 2-question screen (“Have you ever had a drinking problem?” “When was your last drink?”); specificity > sensitivity | Use for brief screening; follow up with more thorough screening in case of positive response |
| ARPS/shARPS | 18 items in ARPS (shARPS is shorter); self-report; classifies patients as nonhazardous, hazardous, or harmful drinkers; good sensitivity | Focuses on relationship of alcohol and medical problems, medication use, and functional status |
| ARPS/shARPS: Alcohol-Related Problems Survey/short version of ARPS; AUDIT-5: Alcohol Use Disorders Identification Test, 5-item version; CAGE: Cut down, Annoyed, Guilty, Eye opener; MAST-G: Michigan Alcoholism Screening Test—Geriatric version; SMAST-G: shorter version of MAST-G | ||