Managing medication and alcohol misuse by your older patients
Age-appropriate screening and in-office interventions are sufficient in many cases
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.
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 programs 4 ( 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.
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.
Comparing screening tools for alcohol use disorders in the elderly
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
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
22-item yes/no self-report; questions specific to elderly
First-line; designed to identify a population that drinks less than heavy drinkers
10 items; shorter version of MAST-G with similar characteristics
Less sensitive and specific than MAST-G; may be useful when time is limited
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
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
Spectrum of alcohol use disorders: Heavy drinking to dependence
Recommended intervention for patients age ≥65
Brief alcohol intervention
>3 drinks in 1 sitting or >7 drinks/week; places patient at risk for adverse consequences
Brief alcohol intervention
Greater than hazardous use, with evidence of negative physical or psychological consequences
Brief alcohol intervention
Signs of increasing use or decreasing functioning, including engaging in fewer activities, preoccupation with substance, continued use despite adverse consequences
Brief interventions (advise to cut down, educate regarding deleterious effects, and consider referral to substance abuse specialist for evaluation)
Clear interference with daily function (such as increased falls, otherwise unexplained cognitive impairment); unsuccessful quit attempts; continued use despite adverse consequences
Refer to substance abuse specialist for treatment, including detoxification and age-specific rehabilitation program
Drug abuse or medication misuse. Illegal drug use is relatively rare in the geriatric population, 8 although the rates in patients age 50 to 59 increased from 2.7% in 2002 to 5.0% in 2007. 9 In part this may reflect a higher lifetime use of illicit drugs by the baby boomers compared with previous generations.
Evidence also suggests an increasing risk for misuse and abuse of prescription drugs. One factor associated with this risk is medical exposure to prescription drugs with abuse potential. Among older adults in the United States:
- 10% are taking sedative-hypnotic medications
- 15% have been prescribed an opioid-analgesic medication. 10
Other factors associated with prescription medication misuse and abuse by older adults include female sex, social isolation, history of substance use or psychiatric disorder, polypharmacy, and chronic medical problems. 11
Very few screening instruments detect illicit drug use or prescription medication abuse. To screen older patients, ask about the drugs they are using (prescription and nonprescription), ask about side effects, and look for behavioral signs of medication misuse ( Table 3 ). 12,13
Laboratory tests for alcohol’s metabolic effects can identify biologic markers of alcohol use disorders. An elevated mean corpuscular volume (MCV) or gamma-glutamyl transpeptidase (GGT) above the upper normal value can indicate possible problem drinking, even without considering total alcohol intake. Normal lab values are the same for older and younger adults.
Evidence suggests a poor association between findings of the CAGE questionnaire and MCV and GGT tests. Di Bari et al 14 reported that biologic markers help identify older drinkers with compromised health status independent of a positive CAGE. This suggests that using a combination of tools to screen for psychosocial and biologic consequences could be more accurate than a single instrument in identifying older individuals with alcohol use disorders. 14 We often use a GGT and MCV, along with the CAGE and the AUDIT-5 or SMAST-G.
Tobacco use. Smoking rates decrease with age, but this trend may reflect early mortality among tobacco users. Nicotine dependence remains a significant public health issue among the 7% to 9% of adults age ≥65 who smoke. 15 An estimated 70% of all smokers want to quit, and 46% make an attempt each year. 11
The single most important step in addressing tobacco use and dependence is screening. After asking about tobacco use and assessing the patient’s willingness to quit, you can provide appropriate interventions. 16
Behavioral signs of medication misuse by elderly patients
Excessive worry about whether the medications are working
Strong attachment to a particular psychoactive medication
Resisting cessation or decreased doses of a prescribed psychoactive drug
Excessive anxiety about the supply and timing of medications
Decline in hygiene or grooming
Medical symptoms such as fatigue, weight loss, or insomnia
Psychiatric symptoms such as irritability, memory problems, or depression
General treatment options to consider for older patients with SUDs include a brief outpatient intervention, referral to a substance abuse specialist or inpatient treatment, and appropriate pharmacotherapy ( Table 4 ).
Brief interventions vary from relatively unstructured interactions in a physician’s office to more formal therapy. Components of these interventions include expression of concern, assessment and feedback, and direct advice. For older patients with SUDs, psychosocial approaches can improve treatment outcomes. One useful example—designed for alcohol use disorders—is the BRENDA model ( Table 5 ). Any trained health care staff member can administer this model, which is standardized with a comprehensive manual. 17
Several brief intervention trials—including Project Guiding Older Adult Lifestyles (GOAL), the Health Profile Project, and the Staying Healthy Project—found that brief intervention results in significantly decreased alcohol consumption, sometimes even at 12-month follow-up. 18 These trials were conducted in primary care settings, but brief interventions likely would be effective in psychiatric practice as well. Project GOAL included two 10- to 15-minute sessions with a physician scheduled 1 month apart and a follow-up phone call 2 weeks after each visit. The Health Profile Project consisted of a single motivational enhancement session. 19
When to refer. Severe cases may require evaluation by a substance abuse specialist of the need for detoxification from alcohol, benzodiazepines, or opioids. Referral is appropriate if the patient has:
- a history of complicated withdrawal, including withdrawal seizures or delirium tremens
- complicated underlying medical conditions, such as severe coronary artery disease, uncontrolled hypertension, or uncontrolled diabetes.
Because of age-related physiologic changes, the older population is at risk for a more protracted withdrawal with more severe symptoms, compared with younger patients. 20 Specialized care may include detoxification (outpatient or inpatient, depending on withdrawal symptom severity), day hospital program, or—in the case of a patient with a long history of substance use and multiple relapses—a longer-term residential program.
Recommended treatments for substance use disorders in the elderly
Assess for withdrawal symptoms; brief intervention
Assess for withdrawal symptoms; Alcoholics Anonymous; use of BRENDA model ( Table 5 ); pharmacotherapy (naltrexone, acamprosate); structured rehabilitation program with age-appropriate programming
Prescription medication misuse*
Assess for withdrawal symptoms; taper off medication (slowly and gradually); buprenorphine detoxification; brief intervention
Appropriate detoxification; drug-free trial; harm reduction approach with methadone or buprenorphine; age-appropriate psychosocial groups; Narcotics Anonymous
*Sedative-hypnotic and opioid pain medications (such as oxycodone HCl)
The BRENDA model:
A brief psychosocial intervention for alcohol use disorders*
Reporting the assessment to the patient
Assessment of patient reaction to the advice
*Any trained health care staff member can administer this model, which is standardized with a comprehensive manual
Source: Reference 17
Pharmacotherapy is an important component in the treatment of older adults with SUDs. Other elements include psychosocial interventions, brief interventions, cognitive-behavioral therapies, and supportive programs such as Alcoholics Anonymous or Narcotics Anonymous. Randomized controlled trials on the use of medications for SUDs in older patients are limited. As with any other medication trial in the elderly, start with the lowest possible dose and titrate slowly to treatment effect.