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26 Substance Use in Older Adults
from co-occurring psychiatric disorders and physical conditions common in older adults.
SCREENING AND ASSESSMENT OF
SUBSTANCE USE DISORDERS
Background
As discussed in Chapter 1, SUDs are common among older adults who
seek care in a variety of health care and community settings. Older
adults with SUDs may be encountered in medical and psychiatric clinics, hospitals, home health care agencies, nursing homes, social service
agencies, senior centers, assisted living facilities, and faith-based organizations. Screening, diagnosing, and treating for SUDs in older adults
thus happens in many different settings and by a variety of health care
professionals.
In this section, we discuss the importance of screening for SUDs in
older adults, the process of assessing substance use in older adults, and
the barriers to screening and assessment. Screening is a process for de-
tecting the presence of a particular SUD or comorbid psychiatric syndrome (Substance Abuse and Mental Health Services Administration
[SAMHSA] 2020). The outc
or no (disorder is present or not) or a rating of severity, expressed within
a numerical range. Screening may be especially helpful to identify older
adults who are afraid or ashamed of spontaneously disclosing their use
of substances or face other barriers as described below. Assessment is the
process for defining the nature of the SUD, determining a diagnosis,
and developing specific treatment recommendations (SAMHSA 2020).
The U.S. Preventive Services Task Force recommends “screening for
unhealthy alcohol use in primary care settings in adults 18 years or
older” and “screening by asking questions about unhealthy drug use in
adults age 18 years or older” (U.S. Preventive Services Task Force et al.
2018, 2020). Unhealthy drug use is defined as “using illegal drugs, such
as heroin,
mended by a doctor, such as to ‘get high’ or affect someone’s mood or
wa
y of thinking” (U.S. Preventive Services Task Force et al. 2020).
use (type o
scription medications), consequences, medication–medication interactions, and medication–disease interactions. Screening should take place
at any initial evaluation and at follow-ups, as indicated. For example,
or using a prescription drug in ways that are not recom-
We recommend that clinicians screen all older patients for substance
f substance, frequency, quantity), misuse (including of pre-
ome of a screening test can be a simple yes
Comprehensive Assessment of Older Adults With Substance Use 27
lack of improvement of a psychiatric condition despite evidence-based
treatment should raise the possibility of an undiagnosed SUD. In addition, clinicians should be able to recognize the signs and symptoms of
SUDs in old
screening, assessment, and treatment or referral of older adults with
SUDs.
er adults. Each clinical setting should develop protocols for
Addressing Barriers to Identifying Substance
Use Disorders in Older Adults
Clinicians may have difficulty identifying the misuse of substances in
older patients. 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. There are many barriers to screening for SUDs in
adults, such as the limited time clinicians can devote to screening
older
and stigma related to addiction. In addition, substance use can present
in ways similar to other illnesses common in later life, such as depression and dementia, which means that screening, assessment, and diagnosis can be particularly difficult (Reimers 2019).
Older adults may face barriers to assessing their substance use
(Table 2–1). These may include ageism and other negative attitudes
about aging; clinicians who do not believe that older patients can have
alcohol or drug problems later in life; clinicians who feel uncomfortable
talking about substance use and misuse with older adults out of fear of
being disrespectful; lack of knowledge about drug and alcohol
screening and assessment tools; and misunderstanding the difference
between symptoms of substance abuse and similar symptoms of
physical and cognitive decline or mental illness common in older
populations, including dementia, pain, anxiety, and depression
(SAMHSA 2020).
In addition, racial/ethnic, cultural, gender, and identity factors can
affect how
help for addiction or mental illness, and receive treatment (National
Academies of Sciences, Engineering, and Medicine 2016). For instance,
older adults not fluent in English may feel uncomfortable asking for
help from clinicians who do not speak their language. Older gay, lesbian, or transgender adults may be slow to seek treatment out of fear
that clinicians will be unsupportive or even refuse to care for them.
Older women are especially vulnerable to certain barriers including
stigma, low income, or clinicians not recognizing their substance abuse
(Green 2006).
people think and speak about their behavioral health, seek
28 Substance Use in Older Adults
Table 2–1. Barriers to identifying SUDs in older adults
Population Barrier Explanation
Patients Lack of
knowledge
Lack of
awareness
Loss and grief Older adults may cope with loss and grief by
Social
isolation
Family,
caregivers,
and friends
Health care
professionals
and health
care system
Society Ageism Negative beliefs about aging or older adults
Source. SAMHSA 2020.
Permissive
attitude
Lack of
awareness
Denial Others may ignore or accept older adults’
Co-occurring
conditions
Access to
services
Financial and
rance
insu
Stigma Societal views of SUDs as moral failings or
Older adults may not know that they have
underg
one physiological changes that
make the effects of alcohol or drugs more
dangerous.
Cognitive impairment may interfere with an
older adult’s ability t
alcohol or other substances.
starting
Older adults with smaller or weaker social
networks ar
Others may view substance use as okay for
older adults (e.g., “one last pleasure”).
Others may not know how much an older
adul
appreciate the harmful effects of alcohol
and other substances.
substance misuse, especially if the problem
is long-standing.
Clinicians may mistake the symptoms of
substance misuse for medical or psychiatric
conditions.
Older adults may not have access to
evidence-based, culturally sensitive,
coordinated care necessary to identify
SUDs.
SUD treatment programs may not accept
patients’ health care insurance, especially
Medicare.
may lead to stereotyping or discrimination
(e.g., “older adults don’t benefit from
treatment”).
signs of weakness or untreatable (e.g.,
“once an alcoholic, always an alcoholic”)
may lead to older adults feeling ashamed
and not seeking help.
or increasing use of substances.
e less likely to seek care.
t is drinking/using other substances or
o monitor the use of
Comprehensive Assessment of Older Adults With Substance Use 29
Table 2–2. Defense mechanisms that people with SUDs may use
Defense mechanism Example
Rationalizing “I only drink because my wife died.”
Intellectualizing “Health experts recommend drinking two ounces
of al
cohol per day.”
Blaming “I wouldn’t smoke so much weed if my children
didn’t nag m
Switching “I have problems to deal with. The whole world is a
big mes
Minimizing “I take extra oxycodone only once a week.”
Joking “I can stop drinking anytime I want. In fact, I stop
once a week.”
greeing “You’re right. I really should stop.”
A
Projecting “John really has a drinking problem. I’m not as bad
as he
Threatening “Just try and stop me from going to happy hour.”
Generalizing “Yeah, I smoke. We all have a bad habit or two.”
Source. Adapted from Centre for Addiction and Mental Health 2021.
e all the time.”
s. The problem is all the politicians.”
is.”
People with SUDs may use various defense mechanisms to deflect
criticism or minimize the perceived consequences of their substance
use, for example, denial (Centre for Addiction and Mental Health 2021).
They may admit that there are problems in their lives but do not make
the connection between the problem and substance use. Common defense mechanisms are listed in Table 2–2.
Accurately identifying and diagnosing SUDs in older adults may depend, in part, on when substance use began (National Institute on Drug
Abuse 2020). Early-onset substance use is present in those with a history
of at-risk or harmful substance use that began when they were younger,
normally before age 50. For those patients, who represent the majority of
older adults with SUDs, long-term denial and the presence of medical comorbidities can complicate diagnosis and treatment. Late-onset substance
use is present in those who began to abuse substances only later in life,
possibly due to age-related stressors such as retirement, loss of income, or
loss of a partner. These individuals may seem relatively healthy, leading
clinicians to dismiss or minimize their symptoms of SUD.
Finally, recognizing, understanding, and working to remove barriers will help all older patients receive the best possible care. We as clinicians need education and skills training aimed at helping us better
30 Substance Use in Older Adults
recognize possible substance abuse in older patients—for example, by
reading this chapter. It is also critical for us to be aware of our own beliefs and attitudes toward older adults that could interfere with our
ability
to recognize SUDs in our patients.
DISCUSSING SUBSTANCE USE WITH
OLDER ADULTS
Asking all older adults about their use of alcohol and other substances
is an accepted and expected clinical practice. Ensuring that the patient
interview is conducted in a suitably private and secure location is essential to establish rapport and maintain appropriate confidentiality. Patients with SUDs may be defensive, may minimize use, or may feel a
tremend
effects on their lives. Older patients, in particular, may present with
certain preconceived negative impressions of what addiction is, compounded by societal conceptions of addiction as a primarily moral or
spirit
that is honest, open, curious, empathic, and nonjudgmental can lead to
more effective interactions. Avoid using stigmatizing terms such as “alcoholic” or “drug-seeker” and instead use person-first language (e.g.,
“a person with
techniqu
vision impairment and speaking slowly and clearly (Reimers 2019). You
can preface questions about alcohol or drug use with a link to a medical
condition. “Signposting” is a technique that may help you segue into
asking about substance use. When asking patients sensitive, intimate,
or potentially intrusive questions, it is best to “signpost” your intentions—tell the patient what you are going to do before you do it (Centre
for Addiction and Mental Health 2021). For example, you could say:
“Now that I understand the problem you have been having, I would
like to ask a few routine questions about your lifestyle that I ask all my
patients.” The signal that you are now going to inquire about issues that
may not be directly related to the presenting complaint allows you to
ask a well-rehearsed list of potentially uncomfortable questions, making them seem more routine and less threatening (Centre for Addiction
and M
volvement in determining goals of treatment that are meaningful to
ous amount of shame and guilt related to their use and its
ual failing. Asking questions during the interview in a manner
alcohol use disorder”).
To ensure effective communication with older adults, interviewing
es may require adaptation, such as accounting for hearing or
ental Health 2021).
Use a person-centered approach with emphasis on the patient’s in-
Comprehensive Assessment of Older Adults With Substance Use 31
them and the nature of their care (American Geriatrics Society Expert
Panel on Person-Centered Care 2016). Meaningful goals for patients
generally go beyond symptoms to include quality of life, functioning,
and a sense of hope and self-efficacy.
SCREENING TOOLS FOR SUBSTANCE USE
DISORDERS
We recommend that all psychiatric diagnostic evaluations of older
adults include a screening tool for SUDs. In Table 2–3, we describe evidence-based instruments for such evaluations.
CAGE and CAGE-AID (Table 2–4) remain in widespread use, although they are somewhat confrontational and may elicit defensiveness from patients (Canadian Coalition for Seniors’ Mental Health
2019). T
likely AUDIT-C, which is also brief (3 items instead of 10 in the full AUDIT screen), making it more suitable, easier to use, and generally more
appropriate for routine checkups (van Gils et al. 2021). Generally, the
higher the AUDIT-C score, the more likely it is that the patient’s drinking is affecting their health and safety. See Chapter 5, “Alcohol Use and
Use Disorder Among Older Adults,” for further discussion of screening
for alcohol us
wher
electronically. Note that some older adults may not be comfortable using computers or tablets and may require another format; some may
have difficulty reading or writing. To address the problem of limited
health literacy, clinicians can aim to provide patient-centered communication, clear communication techniques, teach-back methods, and reinforcement (Sudore and Schillinger 2009).
and how to s
to take when screening tests are positive, including communicating
screening results to the patient. Whether negative or positive, you
should inform all patients of their screening results. Substance use patterns can change with life events, cognitive functioning, and mental
health
casionally rescreen patients. SAMHSA recommends that health care
providers
licit drug use in all older clients at least annually (SAMHSA 2020).
he most suitable alcohol screening tool for most practitioners is
e disorder.
Clinic or hospital staff can administer some screening instruments,
eas patients themselves can complete others in paper format or
Knowing what to do after screening is as important as knowing why
creen in the first place. You will also want to identify steps
status, so even if a screening test is negative, it is advisable to oc-
should screen for alcohol, tobacco, prescription drug, and il-
Table 2–3. Screening for SUDs in older adults
Substances
Instrument
covered
Description Use in older adults Our recommendation
32 Substance Use in Older Adults
ASSIST and
ASSIST-Lite,
NIDA Quick
Screen V1.0
AUDIT-C Alcohol 3 questions are scored on a 12-point
CAGE-AID Alcohol, drugs Adaptation of CAGE to include ques-
Alcohol, tobacco,
cannabis, cocaine, amphetamines,
inhalants, sedatives, hallucinogens, opioids
ASSIST: 8-item screen developed for
the World Health Organization, measures lifetime use (never, past
3 months, >3 months ago) and frequency of use in past 3 months (never,
once or twice, monthly, weekly, daily
or nearly daily); ASSIST-Lite and
NIDA Quick
Screen are briefer versions
scale: How often the patient drinks,
how many drinks on a typical day,
and how often they have had 6+
drinks on one occasion in the last year
tions about drug use; see
Table 2–4
ASSIST has been shown to
be useful in screening elderly individuals
(Draper et al. 2015)
Score ≥3 is considered pos-
itive; ≥ 7 is highly sensitive for AUD in older
adults (Dawson et al.
2005; Towers et al. 2011)
Any “yes” should result in
further asse
(Hinkin et al. 2001)
ssment
ASSIST-Lite and the NIDA
Quick Screen V1.0 are somewhat easier to use
than the full ASSIST tool;
computer versions are available.
Excellent choice to screen for
AUD in older adults
May be used with, but not in
place of, more detailed alcohol and drug screeners
Table 2–3. Screening for SUDs in older adults (continued)
Substances
Instrument
covered
Description Use in older adults Our recommendation
Comprehensive Assessment of Older Adults With Substance Use 33
CUDIT-R Cannabis 8-item questionnaire that screens for
cannabis use disorder
Score ≥ 12 indicates possi-
ble cannabis use disor-
Consider using when cannabis
use is reported or suspected
der; sensitivity 0.91 and
specificity 0.90, although
not validated among
older adults (Adamson et
al. 2010)
MAST-G and
SMAST-G
Alcohol 10 yes-or-no questions, +1 for “yes”
responses and 0 for “no” responses
Score 2+ warrants further
investigation; MAST-G
has sensitivity 0.94 and
specificity 0.78 at cutoff
Excellent choice: well vali-
dated in older adult popula-
tions and easy to administer
and understand
5+ (Blow et al. 1992)
SAMI Alcohol 5-item questionnaire for older adults
who may engage in risky alcohol
use, administered by a health care
professional
ASSIST =Alcohol, Smoking and Substance Involvement Screening Test; AUD=alcohol use disorder; AUDIT-C= Alcohol Use Disorders Identification Test–
Concise; CAGE=cut down, annoyed, guilty, eye-opener; CUDIT-R=Cannabis Use Disorder Identification Test–Revised; MAST-G=Michigan Alcoholism
Screening Test–Geriatric Version; NIDA=National Institute on Drug Abuse; SAMI=Senior Alcohol Misuse Indicator; SMAST-G=Short Michigan Alcoholism Screening Test–Geriatric Version.
Source. Adapted from Radue 2022. Additional references: Blow et al. 1992; Humeniuk et al. 2010; SAMHSA 2020; CUDIT-R available at https://
bpac.org.nz/BPJ/2010/June/docs/addiction_CUDIT-R.pdf.
Validated in a community
sample; psychometric
properties not reported
(Purcell et al. 2003)
Designed to start a gentle, non-
threatening conversation
about alco
hol use
34 Substance Use in Older Adults
Table 2–4. CAGE-AID screening tool
C—Have you ever felt the need to cut down on your drinking or drug use?
Ye s/ No
A—Have people annoyed you by criticizing your drinking or drug use?
/ No
Ye s
G—Have you ever felt guilty about your drinking or drug use?
Ye s/ No
E—Have you ever felt you needed a drink or used drugs first thing in the
morning to stea
/ No
Ye s
Source. Hinkin et al. 2001.
dy your nerves or to get rid of a hangover (eye-opener)?
Clinical drug testing, particularly urine drug monitoring, is an important tool for substance abuse and adherence to a prescribed regimen.
Older adu
lts are not tested with urine drug screens as frequently as
younger adults, so important substance abuse indicators could be overlooked by clinicians (SAMHSA 2020). Urine drug test results can yield
false-positive (see Table 2–5) and false-negative results. In a false-
tive drug test, a drug of interest is present in the sample but is not
nega
detected, for example, because the concentration of drug is below the
cutoff threshold or because of cross-reactivity or contaminants in the
sample. Clinicians should base diagnosis on the overall clinical impression, not simply the drug screen result.
COMPREHENSIVE CLINICAL ASSESSMENT
Comprehensive assessment of SUDs is a multistep process to determine
whether substance abuse is present and to differentiate SUDs from possible co-occurring disorders, physical conditions common in older populations, and signs of normal aging. The most important parts of your
full assessment are gathering information about the patient’s substance
use, mental health, physical health, and SUD treatment histories and
listing prescribed and over-the-counter (OTC) medications. Completing the assessment may take multiple visits. As their trust in you builds,
patients
vocational, social, sexual, financial, le
ment histories; a full health history and physical exam for common cooccurring physical c
will feel safe sharing detailed information.
A complete assessment includes full mental health, medical, family,
gal, substance use, and SUD treat-
onditions that affect mental health and physical
Comprehensive Assessment of Older Adults With Substance Use 35
Table 2–5. False positives on urine toxicology screening
Drug thought to
be detected
Alcohol Short-chain alcohols (e.g., isopropyl alcohol)
Amphetamines Amantadine, bupropion, chlorpromazine,
Benzodiazepines Sertraline
Cannabinoids Dronabinol, efavirenz, hemp-containing foods,
Opioids, opiates, and
heroin
Phencyclidine Dextromethorphan, diphenhydramine, doxylamine,
Source. Adapted from Moeller et al. 2008.
Substance that could result in false positive
for drug
des
ipramine, dextroamphetamine, ephedrine,
labetalol, MDMA, methamphetamine,
L-methamphetamine (Vick’s inhaler),
methylphenidate, phentermine, phenylephrine,
promethazine, pseudoephedrine, ranitidine,
selegiline, thioridazine, trazodone
nonsteroidal anti-inflammatory drugs, protonpump inhibitors
Dextromethorphan, diphenhydramine, poppy
seeds, quinine, quinolones, rifampin, verapamil,
and metabolites
ibup
rofen, imipramine, ketamine, meperidine,
thioridazine, tramadol, venlafaxine,
desvenlafaxine
conditions that suggest the patient has substance abuse (e.g., sleep
problems, chronic pain); biological screening measures such as urine
drug screens and breath alcohol testing; and other laboratory tests.
A comprehensive analysis of patient’s clinical history, cognition and
function, physical examination including neurological examination,
mental status examination, and laboratory evaluation are all essential
and can lead to a high degree of confidence in clinical diagnosis. Older
adults require an expanded assessment, taking into account functional
capacity, social support, cognition, and safety.
Reviewing social history and learning about a patient’s social environment and relationships can guide treatment planning. Social factors
can affect whether a pa
tient stays in treatment or leaves treatment early,
as well as treatment outcomes. Valuable information about the social
environment includes the patient’s transportation, caregiver needs or
responsibilities, legal history, employment history, relationships, sexual
identity and history, and level of safety at home—particularly in terms
of potential for violence. Substance use greatly increases the risk of in-
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