Projections of Substance Use Disorder in Older Adults (OA)
A 2009 study designed to project the number of people aged 50 years or older with substance use disorder predicted that by 2020 – this year – the total would be 5.7 million (Han, et al, 2009). According to Teresa Sacks, MPH, “Two primary factors were a growing older adult population (a projected 39% increase) and higher rates of substance use resulting in a projected 44% increase in past-year Substance Use Disorder (SUD). In addition, older adults in general consume more prescription drugs and over-the-counter medications compared with other age groups. More often, older adults are treating one or more chronic health conditions. Acute and chronic pain impacts individuals in every age group, especially older adults.”
Regarding the opioid crisis among OA, the Agency for Healthcare Research and Quality (AHRQ) Prevention, Diagnosis, and Management of Opioids, Opioid Misuse and Opioid Use Disorder in Older Adults webpage states that “For adults aged 65 and older, opioid-related hospitalizations increased by 34% and emergency department visits increased by 74% between 2010 and 2015. Some of this increase is driven by opioid misuse, to which older adults as well younger adults are vulnerable, but some is also driven by the unique challenges of pain management in an aging population.” More recent reviews of the literature describe the rate of increase in older people with SUDs as among the fastest growing health problems in the U.S., and project the number of those over 50 with SUDs to increase to over 72.1 million by 2030 (Kuerbis, 2019).
The Baby Boomer Population in Contrast to Other Generations – and Why it is Relevant
The increase in substance use disorder among older Americans remains largely driven by “Baby Boomers,” born between 1946 and 1964. While older adults have not historically had high rates of SUDs compared with younger adults or inundated treatment programs in high numbers, they are a distinct population (Yarnell, et al., 2019; Kuerbis, 2014; Kuerbis, 2019). According to Ms. Sacks, “The baby boomers constitute a particular population of interest in this regard. However, an important consideration is the boomers represent a large group of individuals born between 1946 and 1964. The oldest boomers started turning age 74 at the beginning of the year, while the youngest boomers began turning age 56. By 2030, all the boomers will be age 65. Therefore, our current older adult population, age 65+ is comprised of individuals from the Greatest Generation (1910-1924), the Silent Generation (1925-1945), and about one-third of the Baby Boomers. If we include those age 50+, this includes some members from Generation X (1965-1980).”
Baby Boomers comprised about 30% of the US population in 2011 (Kuerbis, et al., 2014). According to population estimates for July 1, 2019 from the U.S. Census Bureau reported by the Pew Research Center, Millenials, defined as ages 23-38, are the current largest living adult generation, with 72.1 million. Boomers, ages 55-73, number 71.6 million, and Generation X, ages 39-54, number 65.2 million and are on course to surpass the Boomers in numbers by 2028. Baby Boomers came of age in the 60s and 70s when attitudes and usage of drugs and alcohol were in a state of flux. There is also research to support that the full amount of alcohol, drug, and tobacco (ATOD) use in aging “Boomers” is not being identified, making it difficult to treat SUDs in this population (Kuerbis, 2014, Yarnell, et al., 2020).
Facts About SUDs in Older Adults (OA)
In 1900 adults 65 years and older comprised just 1% of the population globally, and are expected to surpass 20% by 2050 (Kuerbis, 2019). As the population of OA has risen, so has the rate of SUD and the diseases and injuries with which it is associated. Some things that are known about SUD among OA which indicate a rapidly developing public health issue include:
- The most commonly used substances are alcohol, cannabis, and opioids, with alcohol use disorder (AUD) increasing by 44%, cannabis use disorder by 26%, and opioid use disorder by 47% (Kuerbis, 2019).
- There is a misconception that OA do not use ATOD that is perpetuated by the historical view of OA as a population not prone to SUD (Kuerbis, 2019).
- When SUD is developed during early or middle years this is called early onset. Early onset SUD may continue into later years despite treatment and other interventions, enabling people to survive into older ages while still using ATOD in ways that cause problems (Kuerbis, 2019).
- When OA develop SUD initially later in life, it is called late onset. This may be due to moderate use developing into a SUD due to multiple pathways, such as stress, events that occur later in life, or first time exposure to drugs such as opioids (Kuerbis, 2019).
- Distinctive concerns for OA (defined as persons aged 50 years and older) who have SUD include:
- high rates of risky and binge drinking,
- the fact that the “young” old, aged 45-64, have the highest rates of smoking (16.4%),
- the fact that OA in the U.S. have the highest past month use of past-month illicit substances in the world with the rates rapidly rising,
- increased risk of harmful drug interactions and misuse due to health conditions and the high rates of prescribed and over-the-counter medications taken by OA,
- and the fact that with widening acceptability , decriminalization, and legalization of cannabis use data for rates of cannabis use among OA is not available (Kuerbis, 2019; Rosen, et al., 2019).
- Formal diagnosis of SUD is dependent upon the criteria in the Diagnostic and Statistical Manual for Mental Disorder, 5th edition (DSM-5), and the diagnostic profiles are based on physical and social factors that do not necessarily apply to OA as a population group and may not prove accurate for assessing SUD in OA. Assessment tools for substance use that are validated for OA across cultures and nations are not currently available. In many cases, different screening and diagnostic tools are used and different editions of the DSM are used. Further complicating issues of diagnosis and treatment are the terminologies, such as abuse, dependence, misuse, use disorder) are not consistent and vary widely across studies (Kuerbis, 2019; Yarnell, et al., 2020; Rosen, et al, 2019).
- SUD among OA does not have the broad base of research needed to provide insights into both the prevalence of SUDs among OA or the psychiatric comorbidities and other issues that may require consideration during assessment and treatment (Kuerbis, 2019; Yarnell, et al, 2020). The issue of SUD in OA is often “underestimated, under identified, underdiagnosed, and undertreated… A paucity of research in this area, hurried office visits, ageism, a low index of suspicion, and denial by elderly patients and their caretakers adds to misperceptions by providers and underdiagnosis of SUDs in the elderly” (SAMHSA, 1998 as cited in Yarnell, et al., 2020; Rosen, et al., 2019).
What Can Behavioral Health Providers Do?
There is much that can be done to provide access to quality health care and address the health disparities which exist for OA. Some of the strategies should include standardized screening and brief interventions during the variety of opportunities presented by visits to primary care physicians and specialists throughout each year. Ms. Sacks states that “Unfortunately, misconceptions about substance abuse among older adults persist. Too often, signs and symptoms of abuse are misinterpreted as signs of aging or other conditions (e.g., dementia, depression, etc.). Addictions that develop in late life can be difficult to identify and thus may go unnoticed in otherwise healthy older adults. It takes a coordinated effort on all our parts, family members, physicians, neighbors, friends, aging service providers, and others to be aware and address changes in the elder.”
As clients age, behavioral health providers can follow her additional advice: “Understand that age-related changes will occur across all domains – physical, psychological, and social. While there are changes we all will experience, some changes are unique to the individual. Treatment needs may shift as one ages.” Treatment providers should consider the following from Substance Abuse Among Older Adults:
- Holistic, age-specific group treatment
- A focus on coping with depression, loneliness, and loss (e.g., death of a spouse, retirement, etc.).
- A focus on rebuilding the client’s social support network which often shrinks as we age
- A pace and content of treatment appropriate for the older adult (e.g., slower pace, more breaks, building in opportunities for socialization, a culture of respect)
- Staff members who are interested and experienced in working with older adults (i.e., have received education and training in gerontology or geriatrics)
- Linkages with medical services, aging services, and case management. (SAMHSA, 1998).
Impact of COVID-19 (Novel Coronavirus) on Older Adults in the U.S. and Nevada
According to Ms. Sacks, “The CDC has reported that 8 out of 10 COVID-19 deaths in the U.S. have been among older adults age 65 and over. Stay-at-home and shelter-in-place orders have impacted all Americans in extraordinary ways. Seniors that depend on senior center programs and services including congregate meals have seen these centers close; adult day services have had to suspend services to keep clients and employees safe, and our state’s over 454,000 home bound seniors have seen home visits and service provision changes. Fortunately, the response to ameliorate these issues has been remarkable. For example, the Nevada Department of Health and Human Services (DHHS) and its Nevada 2-1-1 program has partnered with agencies to ensure older adults receive the help they need. The Nevada CAN program will connect older adults to the services and supports they need. For more information, please visit NEVADA CAN: NEVADA COVID-19 AGING NETWORK.”
How Can Families and Providers Protect Their Senior Loved Ones and Clients?
Ms. Sacks stated that “Some older adults, especially those with chronic health conditions, weakened immune systems, lung and respiratory conditions, and behavioral health issues certainly can be impacted to a much greater degree. We are learning about this new disease as we go and the unknown justifiably raises concern and causes stress. We also must rely on authoritative sources to get our information and links to available resources and services. One of the best ways to protect our senior loves ones and clients is to ensure they are following the safety guidelines outlined by the CDC, their state and local governments, and health departments. The CDC and others have offered the following suggestions for helping our elder loved ones and clients:
- Check in with older relatives/friends and ask how they are feeling.
- Talk to them about how they are managing changes to their routine.
- Offer practical and/or emotional support if needed (e.g., offer to set up videoconferencing on their computer/tablet, offer to deliver groceries).
- Encourage them to do things they enjoy daily.
- If you think they are not coping, or are overly isolated, suggest they seek help from their primary care physicians, or encourage them to speak with a mental health professional.
- Keep up contact with elderly relatives by writing emails, calling them on the telephone, talking via videoconference, send them videos to watch via email, send photos or drawings from children via email, or to the facility where they are.
- Monitor for suicidality, increased substance use, interpersonal violence, complex grief and depression/anxiety”.
One final way that providers, families and friends of older adults can help is to become active and involved by participating in and observing National Older Adult Mental Health Awareness Day 2020 on May 20, 2020. This event, Sponsored by Administration for Community Living, U.S. Department of Health and Human Services (HHS), aims to:
- Raise awareness of older adults’ mental health needs
- Promote evidence-based prevention, treatment, and recovery supports
- Encourage collaboration between mental health and aging networks
- Highlight where to seek services when needed
On Thursday, May 7, from 1:00 – 2:30 P.M. please join Substance Abuse and Mental Health Services Administration, Administration for Community Living, Veterans Health Administration, and National Coalition on Mental Health, and Aging for the NATIONAL OLDER ADULT MENTAL HEALTH AWARENESS DAY 2020: Combating Social Isolation for Seniors during the COVID-19 Pandemic, “for a thoughtful discussion, including practical ideas to promote connection and recovery for older adults with serious mental illness and substance use disorders, during this unprecedented time in our history.
Suicide, depression, anxiety, and problems with alcohol and medications are issues that older adults face. The U.S. Census Bureau indicates that by 2030, there will be nearly 75 million Americans over age 65. A 2012 study from the Institute of Medicine found that nearly one in five older Americans has one or more mental health/substance use conditions. According to 2018 data from the Center for Disease Control and Prevention and reported by the American Foundation for Suicide Prevention, adults in the 75-84 and 85 and older age groups are among those with the highest rates of suicide.
Older Adult Mental Health Awareness Day 2020 will include important remarks from Assistant Secretary for Mental Health and Substance Use – Dr. Elinore McCance-Katz, Assistant Secretary for Aging – Mr. Lance Robertson, and the latest information on coping with social isolation and loneliness from University of California San Diego Distinguished Professor of Psychiatry, Dr. Dilip Jeste.” Please use the Registration Link for this event.
Special thanks to Teresa M. Sacks, M.P.H., for her huge contribution to this blog post. Her expertise is invaluable and very appreciated: “Teresa M. Sacks is a certified gerontologist. She completed her master’s degree in Public Health (MPH) with a Certificate in Gerontology from the University of Nevada, Reno. She also completed an Advanced Graduate Certificate in Addiction Treatment and Prevention Services (CASAT). Ms. Sacks has worked in the field of aging for twenty years and has extensive experience working with and advocating for older adults. In addition, she has ten years of experience teaching online and face-to-face classes in aging and addiction and health policy. She works to advance knowledge and advocate for the behavioral health of older adults.”