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46 Substance Use in Older Adults
Suicide risk assessment tools can be useful for clinicians. There is no
single tool that exists as a gold standard. The most commonly used is
the Columbia Suicide Severity Rating Scale (C-SSRS), which is easily
administered and has strong evidence in its validity across various cultures, languages, and ages (Posner et al. 2011). There are several versions of the scale for use in different settings, and there is a version
available for use in patients with cognitive impairment. It has six yes/
no questions and stratifies patients accordingly into three levels of risk.
Alternatively, the SAD PERSONS scale is another commonly used tool
for suicide risk assessment in older adults (Patterson et al. 1983). It considers interpersonal and environmental factors relevant for the suicide
risk of the patient, and also quantifies the severity of suicide risk into
three levels. We recommend that such screening scales be used as aids
to suicide assessment but not as substitutes for a thorough clinical evaluation of suicide risk in any individual patient.
A proper comprehensive assessment of suicide risk in an older adult
should not be based solely on a
taken using a holistic approach, involving history-taking, mental status
examinat
to address suicidality in “Addressing Suicidality and Other Threats to
Safety” in Chapter 3.
ion, and a healthy dose of clinical judgment. We discuss how
cutoff score of a tool but is best under-
MAKING THE DIAGNOSIS
Obtaining a Detailed Substance Use History
Asking about the patient’s history of substance use will help you learn
about the severity of use and effects of that use on their life. A systematic approach for collecting information on the various substances used,
both curr
are not missed (Greenfield and Hennessy 2014). Consider organizing
this part of your interview around the various classes of substances of
abuse:
• Central nervous system depressants, such as alcohol, benzodiaze-
•Psychostimulants, such as methylphenidate, caffeine, cocaine, meth-
• Cannabis (including edibles, hashish, hash oil)
• Opioids (prescription and nonprescription)
• Hallucinogens
ently and historically, can help you ensure that important data
pines, and barbiturates
amphetamine, and phencyclidine (PCP)
Comprehensive Assessment of Older Adults With Substance Use 47
•Nicotine
• Inhalants
• Designer drugs like ketamine and 3,4-methylenedioxymethamphetamine (MDMA)
Regularly asking the same series of questions, per substance used,
can help you as a clinician to formulate a more consistent approach to
assessing severity of illness and triage risk (SAMHSA 2020). For a detailed and thorough history of the use of each substance, ask about the
llowing:
fo
•Age at first use
•Frequency of use
• Amount of substance taken during an episode of use
• Route of administration (e.g., intravenous, oral, inhaled, smoked,
transdermal)
• Consequences of use
• Treatment history (including formal addiction treatment through
various levels of care: outpatient, psychopharmacological, intensive
outpatient, partial hospital, inpatient psychiatric, 12-step program
engagement, residential)
• Periods of abstinence
•Relapse history
Applying DSM-5-TR Criteria to Older Adults
SUD diagnoses are based on DSM-5-TR criteria (American Psychiatric
Association 2022). However, diagnostic issues can arise when applying
DSM-5-TR criteria to the older adult population. Some DSM-5-TR SUD
criteria may not apply to older adults with substance use problems
(Kuerbis et al. 2013). Relying solely on DSM-5-TR diagnostic criteria can
be misleading. Several key DSM-5-TR diagnostic criteria are not typically present in older adults, and many older adults who abuse substances may not meet full DSM-5-TR criteria for a specific SUD despite
enga
ging in risky use of substances (SAMHSA 2020). For example, in
retired older individuals with fewer familial and work obligations, substance use may not cause failure to fulfill major obligations at work,
school, or home. Nevertheless, it may negatively affect health or ADLs.
In older adults, withdrawal syndromes may present with nonspecific
symptoms such as confusion (Lehmann and Fingerhood 2018).
We present the DSM-5-TR criteria for alcohol use disorder in Box 5–1
(page 136) as an example; the criteria for tobacco use disorder (Box 6–1,
48 Substance Use in Older Adults
page 164), opioid use disorder (Box 7–1, page 190), sedative, hypnotic,
anxiolytic use disorder (Box 8–1, page 225), stimulant use disorder (Box
9–1, page 254), and cannabis use disorder (Box 10–1, page 290) are similar. Note that DSM-5-TR also specifies criteria for intoxication and
withdrawal from various classes of substances as well as psychotic disorders, bipolar disorders, depressive disorders, anxiety disorders, obsessive-compulsive and related disorders, sleep disorders, sexual
unction, delirium, and neurocognitive disorders due to substances
dysf
(American Psychiatric Association 2022).
Differential Diagnosis
Generating differential diagnoses is based on the patient’s clinical presentation and the details of their history. The differential will vary depending on the type of substance abused, the severity of addiction,
her the patient is presenting in a state of acute intoxication or with-
whet
drawal, comorbidities, and other factors. In addition to substanceinduced disorders, the following diagnoses may be considered, among
others:
• Delirium
• Cerebrovascular accident
•Infection
• Thyroid disorders
• Vitamin B
• Traumatic brain injury
• Neurocognitive disorder
• Psychotic disorders
• Depressive disorders
• Personality disorders
•Brain tumor
and other vitamin deficiencies
12
SUMMARY
Screening and assessment of SUDs in older adults can help clini-
cians identify and treat older adults with or at risk for substance abuse
elated conditions. Several screening tools approved for use with
and r
older adults can help you detect substance abuse. A comprehensive assessment will allow clinicians to better understand the full range of factors in an older adult’s substance abuse. We present a step-by-step
summary
of assessing substance use in older adults in Table 2–9.
Comprehensive Assessment of Older Adults With Substance Use 49
Table 2–9. Assessing substance use in older adults: a step-by-step
approach
Screen for SUDs during the initial evaluation of all older adults.
Use validated screening tools. See Table 2–3.
Let patients know the results of the screening, whether positive or negative.
Repeat screening periodically (e.g., when evidence-based care for psychiatric
conditions
Sensitively approach the topic of substance use.
Keep in mind the possibility that the patient could be experiencing stigma,
shame, guilt,
Use signposting to segue into the topic (e.g., “I’d like to ask a few routine
questions ab
Interviewing an older adult may need to be modified to account for hearing
or visual im
rapport.
It may take more than one session to get a comprehensive history.
The interview should include assessment of functioning (ADLs), pain, risk of
falling, elder abuse, caregiver concerns, medical history, and physical
examination.
Inquire about all substance use, including prescription medications, OTC
medications, complementary and alterna
cannabis, and illicit substances.
Consider ordering laboratory studies, including urine toxicology. See Table
2–5 regarding false-positive toxicology results.
Screen for psychiatric comorbidities, especially neurocognitive disorders and
suicidality. See
Use DSM criteria to diagnose SUDs and comorbid psychiatric disorders.
Keep in mind that not all criteria may pertain to older adults and that older
adults may have risky substance
disorder.
is ineffective).
or denial.
out your lifestyle that I ask all my patients”).
pairment, cognitive impairment, or the need to build trust and
tive treatments, alcohol, tobacco,
Tables 2–7 and 2–8.
use that does not meet criteria for a
KEY POINTS
• Substance use disorders (SUDs) are common among older adults
seen in health care and psychiatric service settings. However,
many clinicians do not screen for, diagnose, or treat SUDs among
this population.
• We recommend that clinicians screen all older patients for substance use (type of substance, frequency, quantity), misuse (includ-
50 Substance Use in Older Adults
ing of prescription medications), consequences, drug–drug
interactions, and drug–disease interactions.
• Clinicians can have difficulty noticing substance misuse in older
patients. The signs
necessarily the same as those in younger adults, and do not always
mirror diagnostic criteria.
• There are many barriers to screening and subsequent identification of substance abuse in older adults. A sensitive, patient-
centered approach may help cl
• Comprehensive assessment for SUDs is a multistep process that
will help you de
and differentiate SUDs from possible co-occurring disorders, physical conditions common in older populations, and signs of normal
aging.
and symptoms of SUDs in older adults are not
inicians overcome these barriers.
termine whether substance abuse is truly present
RESOURCES FOR PATIENTS, FAMILIES,
AND CAREGIVERS
Haroutonian H: Not as Prescribed: Recognizing and Facing Alcohol
and Drug Abuse in Older Adults. Danvers, MA, Hazelden, 2016:
This book provides
namics of addiction in older adults. You’ll learn to clearly distinguish between the signs of aging and the signs of addiction;
identify the indications of
diction; understand the unique treatment needs of older adults;
and ge
Substance Abuse and Mental Health Services Administration’s Na-
tional Helpline (1-800-662-HELP [4357]; www.samhsa.gov/findhelp/national-helpline): SAMHSA’s National Helpline is a free,
confidential, 24/7,
tion service (in English and Spanish) for individuals and families
facing me
help locator.
t the help needed to cope with a loved one’s addiction.
ntal and/or substance use disorders. Also with online
information needed to understand the dy-
drug abuse and its progression to ad-
365-day-a-year treatment referral and informa-
RESOURCES FOR CLINICIANS
Substance Abuse and Mental Health Services Administration: Iden-
tifying, screening for, and assessing substance abuse in older
ts, in TIP 26: Treating Substance Use Disorder in Older Adults
adul
Comprehensive Assessment of Older Adults With Substance Use 51
(Treatment Improvement Protocol [TIP] Series No. 26). Rockville,
MD, Substance Abuse and Mental Health Services Administration, 2020, pp. 37–86.
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CHAPTER 3
Management of
Substance Use Disorders
in Late Life
Jen McDonald, M.D.
Art Walaszek, M.D.
Older adults who have been found to have at-risk alcohol/substance
use or a substance use disorder (SUD) need evidence-based treatment.
The literature regarding the efficacy of various interventions for SUDs
for older adults is sparser than that for younger adults. On the whole,
older adults have better outcomes, are more likely to engage in treatment, and are less likely to relapse. Screening, brief intervention, and referral to treatment (SBIRT) may be helpful; older adults are especially
vulnerable to complications of intoxication and withdrawal (especially
with alcohol, sedatives, hypnotics, anxiolytics, and opioids) and may
need inpatient management. A number of psychosocial and medication
55
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