Substance Abuse Among Older Adults
Treatment Improvement Protocol (TIP) Series 26

The DSM-IV defines the diagnostic criteria for substance abuse as a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one or more of the following, occurring within a 12-month period:

1. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household).
2. Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use).
3. Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct).
4. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights).

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Copyright 1994, American Psychiatric Association.

The DSM-IV defines the diagnostic criteria for substance dependence as a maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three or more of the following, occurring at any time in the same 12-month period:

1. Tolerance, as defined by either of the following:

   The need for markedly increased amounts of the substance to achieve intoxication or desired effect.
   
   Markedly diminished effect with continued use of the same amount of the substance.

2. Withdrawal, as manifested by either of the following:

   The characteristic withdrawal syndrome for the substance.
   
   The same (or closely related) substance is taken to relieve or avoid withdrawal symptoms.

3. Taking the substance often in larger amounts or over a longer period than was intended.
4. A persistent desire or unsuccessful efforts to cut down or control substance use.
5. Spending a great deal of time in activities necessary to obtain or use the substance or to recover from its effects.
6. Giving up social, occupational, or recreational activities because of substance use.
7. Continuing the substance use with the knowledge that it is causing or exacerbating a persistent or recurrent physical or psychological problem.

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Copyright 1994, American Psychiatric Association.

Diagnostic criteria for alcohol dependence are subsumed within the DSM-IV's general criteria for substance dependence. Dependence is defined as a "maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period" (American Psychiatric Association, 1994, p. 181). There are special considerations when applying DSM-IV criteria to older adults with alcohol problems.

1. Tolerance

May have problems with even low intake due to increased sensitivity to alcohol and higher blood alcohol levels

2. Withdrawal

Many late onset alcoholics do not develop physiological dependence

3. Taking larger amounts or over a longer period than was intended

Increased cognitive impairment can interfere with self-monitoring; drinking can exacerbate cognitive impairment and monitoring

4. Unsuccessful efforts to cut down or control use

Same issues across life span

5. Spending much time to obtain and use alcohol and to recover from effects

Negative effects can occur with relatively low use

6. Giving up activities due to use

May have fewer activities, making detection of problems more difficult

7. Continuing use despite physical or psychological problem caused by use

May not know or understand that problems are related to use, even after medical advice

Age at onset

Various, e.g., < 25, 40, 45

Various, e.g., > 55, 60, 65

Gender

Higher proportion of men than women

Higher proportion of women than men

Socioeconomic status

Tends to be lower

Tends to be higher

Drinking in response to stressors

Common

Common

Family history of alcoholism

More prevalent

Less prevalent

Extent and severity of alcohol problems

More psychosocial, legal problems, greater severity

Fewer psychosocial, legal problems, lesser severity

Alcohol-related chronic illness (e.g., cirrhosis, pancreatitis, cancers)

More common

Less common

Psychiatric comorbidities

Cognitive loss more severe, less reversible

Cognitive loss less severe, more reversible

Age-associated medical problems aggravated by alcohol (e.g., hypertension, diabetes mellitus, drug-alcohol interactions)

Common

Common

Treatment compliance and outcome

Possibly less compliant; Relapse rates do not vary by age of onset (Atkinson et al., 1990; Blow et al., 1997; Schonfeld and Dupree, 1991)

Possibly more compliant; Relapse rates do not vary by age of onset (Atkinson et al., 1990; Blow et al., 1997; Schonfeld and Dupree, 1991)

Drug

Action

Effects of Aging

Analgesics

Aspirin

Acute gastroduodenal mucosal damage

No change

Morphine

Acute analgesic effect

Increased

Pentazocine

Analgesic effect

Increased

Anticoagulants

Activated partial thromboplastin time

No change

Warfarin

Prothrombin time

Increased

Bronchodilators

Albuterol

Bronchodilation

No change

Ipratropium

Bronchodilation

No change

Cardiovascular Drugs

Adenosine

Minute ventilation and heart rate

No change

Diltiazem

Acute antihypertensive effect

Increased

Enalepril

Acute antihypertensive effect

Increased

Isoproterenol

Chronotropic effect

Decreased

Phenylephrine

Acute vasoconstriction

No change

Acute antihypertensive effect

No change

Prazocin

Chronotropic effect

Decreased

Timolol

Chronotropic effect

No change

Verapamil

Acute antihypertensive effect

Increased

Diuretics

Furosemide

Latency and size of peak diuretic response

Decreased

Psychotropics

Diazepam

Acute sedation

Increased

Diphenhydramine

Psychomotor function

No change

Haloperidol

Acute sedation

Decreased

Midazolam

Electroencephalographic activity

Increased

Temazepam

Postural sway, psychomotor effect, and sedation

Increased

Triazolam

Psychomotor activity

Increased

Others

Levodopa

Dose elimination due to side effects

Increased

Tolbutamide

Acute hypoglycemic effect

Decreased

Source: Adapted from Cusack and Vestal, 1986.

Class

Drug

Brand Name

Elimination Half-Life for Older Adults

Benzodiazepines

Alprazolam

Xanax

9-20 hours

Chlordiazepoxide

Librium

5-30 hours, with short- and long-acting active metabolites

Diazepam

Valium

20-50 hours, with short- and long-acting active metabolites effective up to 200 hours

Lorazepam

Ativan

18-24 hours; clearance may be reduced in older adults

Oxazepam

Serax

3-25 hours

Serotonin agonist

Buspirone

BuSpar

1-11 hours

^aRefer to product information insert for each drug as to its suitability for use in older adults.

Class

Drug

Brand Name

Elimination Half-Life for Older Adults

Benzodiazepines

Flurazepam

Dalmane

72 hours, with short- and long-acting active metabolites

Prazepam

Centrax

Less than 3 hours, with long-acting active metabolites

Quazepam

Doral

25-41 hours, with long-acting active metabolites

Temazepam

Restoril

10-20 hours

Triazolam

Halcion

2-6 hours, with reports of clinical effects up to 16 hours following a single dose

Imidazopyridine

Zolpidem

Ambien

1.5-4.5 hours (longer in older adults)

Chloral derivatives

Chloral hydrate

Noctec

4-8 hours (loses effect in 2 weeks)

Antihistamines

Hydroxyzine

Atarax

1-3 hours

Diphen-hydramine

Benadryl (over-the-counter)

8-10 hours

Doxylamine

Unisom (over-the-counter)

8-10 hours

^aRefer to product information insert for each drug as to its suitability for use in older adults.

Class

Drug

Brand Name

Comments

Opiates

Methylmorphine Morphine

Common ingredient of analgesics.

Codeine

e.g., Tylenol III, Robitussin A-C

Common ingredient of analgesics and antitussives. Can cause sedation and mild, dose-related impairment of psychomotor coordination.

Opioids (synthetic)

Hydrocodone

Lortab

Can produce dose-related respiratory depression and irregular breathing if taken in large amounts.

Meperidine

Demerol

Contraindicated if patient is taking MAO inhibitors. Can produce psychomimetic effects and impair vision, attention, and motor coordination.

Oxycodone

Percodan/ Percocet

Can produce substantial impairment of vision, attention, and motor coordination.

Propoxyphene

Darvon

Can produce sedation and mild, dose-related impairment of psychomotor coordination.

Pentazocine

Talwin

Age does not appear to increase sedative effects.

^aRefer to product information insert for each drug as to its suitability for use in older adults.

Drug

Adverse Effect With Alcohol

Acetaminophen

Severe hepatoxicity with therapeutic doses of acetaminophen in chronic alcoholics

Anticoagulants, oral

Decreased anticoagulant effect with chronic alcohol abuse

Antidepressants, tricyclic

Combined central nervous system depression decreases psychomotor performance, especially in the first week of treatment

Aspirin and other nonsteroidal anti-inflammatory drugs

Increased the possibility of gastritis and gastrointestinal hemorrhage

Barbiturates

Increased central nervous system depression (additive effects)

Benzodiazepines

Increased central nervous system depression (additive effects)

Beta-adrenergic blockers

Masked signs of delirium tremens

Bromocriptine

Combined use increases gastrointestinal side effects

Caffeine

Possible further decreased reaction time

Cephalosporins and Chloramphenicol

Disulfiram-like reaction with some cephalosporins and chloramphenicol

Chloral hydrate

Prolonged hypnotic effect and adverse cardiovascular effects

Cimetidine

Increased central nervous system depressant effect of alcohol

Cycloserine

Increased alcohol effect or convulsions

Digoxin

Decreased digitalis effect

Disulfiram

Abdominal cramps, flushing, vomiting, hypotension, confusion, blurred vision, and psychosis

Guanadrel

Increased sedative effect and orthostatic hypotension

Glutethimide

Additive central nervous system depressant effect

Heparin

Increased bleeding

Hypoglycemics, sulfonylurea

Acutely ingested, alcohol can increase the hypoglycemic effect of sulfonylurea drugs; chronically ingested, it can decrease hypoglycemic effect of these drugs

Tolbutamide, chlorpropamide

Disulfiram-like reaction

Isoniazid

Increased liver toxicity

Ketoconazole, griseofulvin

Disulfiram-like reaction

Lithium

Increased lithium toxicity

Meprobamate

Synergistic central nervous system depression

Methotrexate

Increased hepatic damage in chronic alcoholics

Metronidazole

Disulfiram-like reaction

Nitroglycerin

Possible hypotension

Lactic acidosis (synergism)

Phenothiazines

Additive central nervous system depressant activity

Acutely ingested, alcohol can increase the toxicity of phenytoin; chronically ingested, it can decrease the anticonvulsant effect of phenytoin

Quinacrine

Disulfiram-like reaction

Tetracyclines

Decreased effect of doxycycline

Source: Korrapati and Vestal, 1995.

The Elderly Services at the Community Mental Health Center in Spokane, Washington, created the Gatekeeper Program to recruit, organize, and train nontraditional referral sources who may be in contact with at-risk older adults during their daily activities. The Gatekeepers - apartment managers, meter readers, bank personnel, postal carriers, utility repair personnel, and others - are the Elderly Services' eyes within the community. They are trained to identify at-risk older adults and provide referrals back to the program, which in turn will send a case manager and a nurse team leader to the individual's home for an evaluation. The program integrates case management for older adults with mental health and substance abuse treatment services, with the Gatekeepers serving as the case-finding component. Overall, the Gatekeepers now account for 4 out of every 10 admissions to this multidisciplinary in-home evaluation, treatment, and case management program. Nearly half of the older adults treated specifically for substance abuse were referred by the Gatekeepers (Raschko, 1990).

• Sleep complaints; observable changes in sleeping patterns; unusual fatigue, malaise, or daytime drowsiness; apparent sedation (e.g., a formerly punctual older adult begins oversleeping and is not ready when the senior center van arrives for pickup)
• Cognitive impairment, memory or concentration disturbances, disorientation or confusion (e.g., family members have difficulty following an older adult's conversation, the older adult is no longer able to participate in the weekly bridge game or track the plot on daily soap operas)
• Seizures, malnutrition, muscle wasting
• Liver function abnormalities
• Persistent irritability (without obvious cause) and altered mood, depression, or anxiety
• Unexplained complaints about chronic pain or other somatic complaints<
• Incontinence, urinary retention, difficulty urinating
• Poor hygiene and self-neglect
• Unusual restlessness and agitation
• Complaints of blurred vision or dry mouth
• Unexplained nausea and vomiting or gastrointestinal distress
• Changes in eating habits
• Slurred speech
• Tremor, motor uncoordination, shuffling gait
• Frequent falls and unexplained bruising

1. Have you ever felt you should cut down on your drinking?
2. Have people annoyed you by criticizing your drinking?
3. Have you ever felt bad or guilty about your drinking?
4. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye opener)?

Scoring: Item responses on the CAGE are scored 0 for "no" and 1 for "yes" answers, with a higher score an indication of alcohol problems. A total score of 2 or greater is considered clinically significant.

Source: Ewing, 1984.

1. After drinking have you ever noticed an increase in your heart rate or beating in your chest?

YES

NO

2. When talking with others, do you ever underestimate how much you actually drink?

YES

NO

3. Does alcohol make you sleepy so that you often fall asleep in your chair?

YES

NO

4. After a few drinks, have you sometimes not eaten or been able to skip a meal because you didn't feel hungry?

YES

NO

5. Does having a few drinks help decrease your shakiness or tremors?

6. Does alcohol sometimes make it hard for you to remember parts of the day or night?

7. Do you have rules for yourself that you won't drink before a certain time of the day?

8. Have you lost interest in hobbies or activities you used to enjoy?

9. When you wake up in the morning, do you ever have trouble remembering part of the night before?

10. Does having a drink help you sleep?

11. Do you hide your alcohol bottles from family members?

12. After a social gathering, have you ever felt embarrassed because you drank too much?

13. Have you ever been concerned that drinking might be harmful to your health?

14. Do you like to end an evening with a nightcap?

15. Did you find your drinking increased after someone close to you died?

16. In general, would you prefer to have a few drinks at home rather than go out to social events?

17. Are you drinking more now than in the past?

18. Do you usually take a drink to relax or calm your nerves?

19. Do you drink to take your mind off your problems?

20. Have you ever increased your drinking after experiencing a loss in your life?

21. Do you sometimes drive when you have had too much to drink?

22. Has a doctor or nurse ever said they were worried or concerned about your drinking?

23. Have you ever made rules to manage your drinking?

24. When you feel lonely, does having a drink help?

Scoring: Five or more "yes" responses are indicative of an alcohol problem. For further information, contact Frederic C. Blow, Ph.D., at University of Michigan Alcohol Research Center, 400 E. Eisenhower Parkway, Suite A, Ann Arbor, MI 48108; (734) 998-7952. Source: Blow, F.C.; Brower, K.J.; Schulenberg, J.E.; Demo-Dananberg, L.M.; Young, J.P.; and Beresford, T.P. The Michigan Alcoholism Screening Test - Geriatric Version (MAST-G): A new elderly-specific screening instrument. Alcoholism: Clinical and Experimental Research 16:372, 1992.
© The Regents of the University of Michigan, 1991.

Characteristics

• Impairments in short- and long-term memory, abstract thinking, and judgment
• Aphasia (language disorder)
• Apraxia (inability to carry out motor activities despite intact comprehension and motor function)
• Agnosia (inability to recognize or identify items despite intact sensory function)
• Constructional difficulty (inability to copy three-dimensional figures, assemble blocks, or arrange sticks in specific designs)
• Personality change or alteration and accentuation of premorbid traits
• Mood disturbances
• Loss of self-care abilities

• Inability to appreciate and respond normally to the environment, often with altered awareness, disorientation, inability to process visual and auditory stimuli, and other signs of cognitive dysfunction
• Potentially life-threatening
• Acute onset
• Clouding of consciousness
• Reduced wakefulness
• Disorientation to time and space
• Increased motor activity (e.g., restlessness, plucking, picking)
• Impaired attention and concentration
• Impaired memory
• Anxiety, suspicion, and agitation
• Variability of symptoms over time
• Misinterpretation, illusions, or hallucinations
• Disrupted thinking, delusions, speech abnormalities

Causes

• Alzheimer's disease
• Vascular dementia
• Alcohol-related dementia

• Chronic drug-alcohol-nutritional abuse (e.g., Wernicke-Korsakoff syndrome)
• Organ system failure
• Anoxia
• Folic acid deficiency
• Hypothyroidism
• Bromide intoxication
• Hypoglycemia

• Neurosyphilis paresis (a syphilitic infection manifested as dementia, seizures, and problems walking and standing)
• AIDS/HIV-related disorders
• Meningitis
• Encephalitis

• Huntington's Chorea
• Parkinson's disease
• Jakob-Creutzfeldt disease
• Lewy body's dementia

• Infections (e.g., meningitis, encephalitis)
• Seizures
• Stroke
• Subdural hematomas
• Tumors

• Anesthesia
• Drug-drug or alcohol-drug interactions
• Intoxication and/or withdrawal from alcohol or drugs (particularly psychoactive drugs)
• Toxic effects of prescribed or over-the-counter drugs
• Giant cell arteritis (a chronic inflammatory process involving the extracranial arteries)
• Hip fracture
• Hydrocephalus (increased fluid in the brain)
• Hypercapnia (reduced ventilation often associated with chronic obstructive pulmonary disease)
• Infections
• Dehydration
• Malnutrition
• Metabolic disturbances (e.g., liver or kidney failure, electrolyte disturbances, hyper- or hypoglycemia, diabetes, thyroid disorders)
• Myocardial infarction (heart attack)
• Sudden environmental changes
• Depression

What risk is associated with the patient's current level of acute intoxication? Is there significant risk of severe withdrawal symptoms or seizures, based on the patient's previous withdrawal history, amount, frequency, and recency of discontinuation or significant reduction of alcohol or other drug use? Are there current signs of withdrawal? Does the patient have supports to assist in ambulatory detoxification, if medically safe?

Are there current physical illnesses, other than withdrawal, that need to be addressed or that may complicate treatment? Are there chronic conditions that affect treatment?

Are there current psychiatric illnesses or psychological, behavioral, or emotional problems that need to be addressed or which complicate treatment? Are there chronic conditions that affect treatment? Do any emotional/behavioral problems appear to be an expected part of addiction illness, or do they appear to be autonomous? Even if connected to the addiction, are they severe enough to warrant specific mental health treatment?

Is the patient actively objecting to treatment? Does the patient feel coerced into treatment? How ready is the patient to change? If willing to accept treatment, how strongly does the patient disagree with others' perceptions that he or she has an addiction problem? Does the patient appear to be compliant only to avoid a negative consequence, or does he or she appear to be internally distressed in a self-motivated way about his or her alcohol/other drug use problems?

Is the patient in immediate danger of continued severe distress and drinking/drug-taking behavior? Does the patient have any recognition of, understanding of, or skills with which to cope with his or her addiction problems in order to prevent relapse or continued use? What severity of problems and further distress will potentially continue or reappear if the patient is not successfully engaged in treatment at this time? How aware is the patient of relapse triggers, ways to cope with cravings to use, and skills to control impulses to use?

Are there any dangerous family members, significant others, living situations, or school/working situations that pose a threat to treatment engagement and success? Does the patient have supportive friendships, financial resources, or education/vocational resources that can increase the likelihood of successful treatment? Are there legal, vocational, social service agency, or criminal justice mandates that may enhance the patient's motivation for engagement in treatment?

Source: American Society of Addiction Medicine, 1996.

• Bereavement and sadness
• Loss of

  Friends

  Famiy members

  Social status

  Occupation and sense of professional identity

  Hopes for the future

  Ability to function

• Consequent sense of being a "nonperson"
• Social isolation and loneliness
• Reduced self-regard or self-esteem
• Family conflict and estrangement
• Problems in managing leisure time/boredom
• Loss of physical attractiveness (especially important for women)

• Physical distress
• Chronic pain
• Physical disabilities and handicapping conditions
• Insomnia

• Sensory deficits

  Hearing

  Sight

• Reduced mobility
• Cognitive impairment and change

• Impaired self-care
• Reduced coping skills
• Decreased economic security or new poverty status due to

  Loss of income

  Increased health care costs

• Dislocation

  Move to new housing, or family moves away

  Homelessness

  Inadequate housing

General Objectives/ Examples

General Approaches/Examples

Eliminate or reduce substance abuse

Cognitive-behavioral (group or individual)

• Alcohol (drug) effects
• Relapse prevention
• Stress management

Group approaches

• Alcohol (drug) effects education

Medical

• Naltrexone, acamprosate (alcohol)

Safely manage intoxication episodes during treatment

Medical

• Remove patient from activities and observe
• Link and refer to detoxification program

Enhance relationships

Cognitive-behavioral (group or individual)

• Social skills and network building

Group approaches

• Social support
• Socialization skill education
• Gender-specific issues

Marital and family approaches

• Spouse counseling
• Marital therapy
• Family therapy

Case management

• Linkage to community social programs
• Home visitation

Individual counseling

• Focus on psychodynamic issues in relationships

Promote health

• Improve sleep habits
• Improve nutrition
• Increase exercise
• Reduce tobacco use
• Reduce stress

Medical

• Provide primary medical care

Cognitive-behavioral (group or individual)

• Self-management skills training

Group approaches

• Health education
• Education on nutrition, diet, cooking, shopping
• Sleep hygiene

Stabilize and resolve comorbidities

• Medical
• Psychiatric (e.g., depression, anxiety)
• Sensory deficits

Medical

• Consultation and special assessments, including medication assessment
• Primary and specialized medical care
• Psychiatric care for chronic mental disorders (by geriatric psychiatrist, if possible)
• Pain management for chronic pain disorders
• Antidepressants, antianxiety medication

Cognitive-behavioral (group or individual)

• Relaxation training
• Depression