Substance abuse in older adults: Underdiagnosed and undertreated

Substance use is a major mental health problem in older adults, and is often unrecognized and undertreated, leading to a reduced quality of life.

A shot of an elderly person's hands as they take medication, with a pill in one hand and a glass of water in the other.
MorgueFile/LadyHeart

Alcohol and substance misuse, particularly prescription opioids, among older adults has been called one of the fastest-growing health problems in the United States. According to the most recent US Census Bureau data, there were 52.4 million people age 65 and over in the United States as of 2018. Substance use among those 60 years and older (including misuse of prescription drugs) currently affects 17 percent of this population. 

Now that the baby boom generation, people born between 1946 and 1964, is between 56 and 74 years old, attitudes about the use of alcohol and drugs have also changed.  According to an article titled "Substance Abuse Among the Elderly" by Dr. Frederic Blow, professor in the Department of Psychiatry at the University of Michigan and a Huss Research Chair on Older Adults and Alcohol/Drug Problems at Hazelden’s Butler Center for Research, “[t]hese individuals have had more exposure to alcohol and illegal drugs, and there is more acceptance among them about using substances to 'cure' things. We expect to see an increase in drug and alcohol use, and more use means more problems.”

Dr. Blow and other experts in the field note that people’s sensitivity to alcohol changes as they age; specifically, their tolerance to alcohol decreases and their sensitivity increases.  Also, the percent of their body weight composed of water decreases, and alcohol affects them more quickly and more strongly.  Alcohol takes longer to metabolize in older persons, accumulating in their bodies and leading more quickly to intoxication if consumption is not controlled.  Because of their physical make-up, older women are more vulnerable to the negative effects of alcohol.

Greater numbers of older men have substance use problems, but women are more likely than men to start drinking heavily later in life. According to Dr. Blow's article, substance use is more prevalent among persons who suffer losses, such as the death of loved ones, retirement and loss of health. The fact that women are more likely to have lost a spouse because of death or divorce, to have had experience with depression, and to have been prescribed medicines that increase the negative effects of alcohol help explain these gender differences.

Health care providers often underdiagnose substance use among older adults because they have not been trained to look for unique features of substance use in older adults. Symptoms of substance use in older adults can often look like symptoms of other medical and behavioral disorders common among this population, such as diabetes, dementia and depression.

There are several short assessment tools that health care professionals can use to point to possible substance abuse in older adults.  According to the Alcohol and Drug Abuse Institute of Washington, the CAGE-AID questionnaire is the most common screening tool used to assess for potential alcohol dependence. The CAGE-AID was adapted to include drugs (AID) in addition to alcohol use. It is one common, quick tool used by health professionals to determine if they need to look more closely at an older adult’s substance use. 

The CAGE-AID Questionnaire

Have you ever felt you should Cut down on your drinking or drug use?

Have people Annoyed you by criticizing your drinking or drug use?

Have you ever felt bad or Guilty about your drinking or drug use?

Have you ever had a drink or used drugs 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 is an indication of alcohol and/or other drug problems.
A total score of 2 or greater is considered clinically significant.

The following websites also provide information and tools on how family, friends or caregivers can learn to recognize and help prevent substance use among older adults:

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