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16 Substance Use in Older Adults
The consequences, complications, and comorbidities of substance
use are especially apparent in older adults. This is largely due to the potential for longer-term substance use in this population, increased numbers of prescription medications, generally more medical conditions at
baseline, and changes in metabolism of substances with age. Older
adults continue to be vulnerable to common consequences of substance
use such as infection and tolerance and may be more vulnerable to the
harmful effects of withdrawal. Older adults with SUDs have higher
rates of medical comorbidities than older adults without SUDs as well
as younger patients with SUDs. Substance use can also worsen preexisting comorbidities or cause disease processes to progress more
quickly. The relationship between psychiatric disorders and SUDs in
older adults is not well characterized. Substances do contribute to reversible and irreversible cognitive impairment in older adults, and abstinence can mitigate some of these risks.
KEY POINTS
• The number of older adults with substance use disorders is increasing rapidly, although these disorders continue to remain under-
recognized, undertreated, and understudied in this population.
• Substance use disorder screening is recommended yearly and
en major life changes occur in all adults age 60 and older.
wh
• The diagnostic term substance use disorder has replaced sub-
stance abuse and substance dependence, with addiction roughly
equivalent to a se
• Clinicians should avoid using language (e.g., “addict,” “user”)
that either
• Addiction can be thought of as a recurring cycle of three stages:
binge/intoxication, withdrawal/negative affect, and preoccupa-
tion/antic
neural circuitry of reward and of executive function.
— The dorsal prefrontal cortex and cingulate cortex drive craving
— Various neurochemical systems are implicated in addiction, in
promotes ageism or stigmatizes people with SUDs.
ipation. Each stage is associated with adaptations of the
and engage habits related to substance us
whereas the ventromedial prefrontal cortex inhibits impulsivity
and responses to negative emotional states (“stop” system).
ticular the dopaminergic system and the HPA axis.
par
vere substance use disorder.
e (“go” system),
Introduction to Substance Use Among Older Adults 17
— Multiple genes have been linked to alcohol and tobacco use.
Tobacco use is also associated with epigenetic modifications
that are reversible upon cessation.
— Older adults may be especially prone to the neurocognitive ef-
fects of chronic substance use, in particular alcohol and cocaine.
• Older adults with SUDs are at higher risk for experiencing medication–medication intera
and substance–health condition interactions than younger adults.
• Alcohol, sedatives, hypnotics, anxiolytics, and tobacco contribute
to both rever
adults.
sible and irreversible cognitive impairment in older
ctions, medication–substance interactions,
RESOURCES FOR PATIENTS, FAMILIES,
AND CAREGIVERS
National Institute on Drug Abuse
For Your Patients: The NIDA webpage includes information about
stigma, plain language summaries of different drugs, and explanations of the science of addiction. NIDA also has a Spanish-language website (https://nida.nih.gov/es). Note that NIDA may
soon be r
Addiction (nida.nih.gov/nidamed-medical-health-professionals/for-your-patients).
Words Matter: Preferred Language for Talking About Addiction:
Another NIDA
ple with SUDs and it recommends changes in the language that
people use to
(nida.nih.gov/research-topics/addiction-science/words-matterpreferred-language-talking-about-addiction).
enamed the National Institute on Drugs and Diseases of
web page, this one covers how stigma affects peo-
make sure that words aren’t stigmatizing
National Institute on Alcohol Abuse and
Alcoholism
Alcohol’s Effects on Health: Older Adults: The NIAAA website cov-
ers many topics related to alcohol use, with this short page focused on older adults. Note that NIAAA may soon be renamed
the National Institut
e on Alcohol Effects and Alcohol-Associated
18 Substance Use in Older Adults
Disorders (www.niaaa.nih.gov/alcohols-effects-health/alcoholtopics/older-adults).
RESOURCES FOR CLINICIANS
National Institute on Drug Abuse
Words Matter: Terms to Use and Avoid When Talking About
Addiction: This NIDA page provides background information
and tips for clinicians to keep in mind while using person-first
language, as well as terms to avoid to reduce stigma and negative
bias when discussing addiction (nida.nih.gov/nidamed-medicalhealth-professionals/health-professions-education/words-matterterms-to-use-avoid-when-talking-about-addiction).
Substance Abuse and Mental Health Services
Administration
Treating Substance Use Disorder in Older Adults: SAMHSA has pub-
lished a series of Treatment Improvement Protocols (TIPs), including TIP 26, which covers older adults (www.ncbi.nlm.nih.gov/
books/NBK571029).
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CHAPTER 2
Comprehensive
Assessment of Older
Adults With
Substance Use
Karen Reimers, M.D.
Substance use disorders (SUDs) are common among older adults
in primary care and specialty care settings, but many clinicians do not
screen for, diagnose, or treat SUDs in this population. The signs and
symptoms of SUDs in older adults are not necessarily the same as those
in younger adults and do not always mirror diagnostic criteria, so clinicians may have difficulty detecting the misuse of substances in older
patients. In
tifying SUDs in older adults. Comprehensive assessment of SUDs helps
dete
rmine whether an SUD is present and helps differentiate SUDs
addition, there are many barriers to screening for and iden-
25
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