CONTENTS

Table of Contents
Introduction

1. Overview
2. Recognizing Alcohol Misuse and Abuse in Older Adults
3. Alcohol and Aging
4. Diagnosing Alcohol Problems in Older Adults
5. Recognizing Other Forms of Substance Abuse
6. Prevention and Early Intervention Strategies
7. Treatment
8. Outcomes and Cost Issues in Alcohol Treatment for Older Adults
9. Legal and Ethical Issues

Supplements
Resources

At Any Age, It Does Matter:
Substance Abuse and Older Adults (for Professionals)

Risk Factors for Alcohol Abuse

Risk factors make people more vulnerable to substance abuse. There are personal risk factors and environmental risk factors. For example, alcohol abuse is more prevalent among older adults who have been separated or divorced and among men who have been widowed.³

As individuals age, they not only lose their spouses but also other family members and friends to death and separation. Retirement may mean loss of income as well as job-related social support systems and the structure and self-esteem that work provides. Other losses include:

• Diminished mobility (e.g., greater difficulty using public transportation where available, inability to drive or driving limited to the daylight hours, problems walking);
• Impaired sensory capabilities, which may be isolating even when the elder is in physical proximity to others; and
• Declining health due to chronic illnesses.

Gender Differences

Studies indicate that older men are much more likely than older women to have alcohol-related problems.^3-5 Reports of epidemiological and clinical research consistently note later onset of problem drinking among women. Studies include the Epidemiologic Catchment Area Study of the National Institute of Mental Health⁶ and various clinical studies.^7-9

Women are more likely than men to start drinking heavily later in life. Male drinking behavior is typically defined earlier in life, with little change in behavior after age 30.¹⁰

A number of other differences between older male and female alcohol abusers have been reported. Women are more likely to be widowed or divorced, to have had a problem drinking spouse, and to have experienced depression.¹¹ Women also report more negative effects of alcohol than men,¹² greater use of prescribed psychoactive medication,^12-14 and more drinking with their spouses.

A recent study indicated that having a drinking spouse (versus an abstinent spouse) was associated with higher levels of drinking. These findings suggest that spousal influence on drinking is an important aspect of drinking among older persons. They may have implications for understanding the effects of gender and widowhood on the development of late-onset problem drinking.¹⁵

Although research has not identified any definite risk factors for drinking among older women, Wilsnack and colleagues suggest that increased amounts of free time and lessening of role responsibilities may serve as causal factors.¹⁶ It should also be noted that women generally are more vulnerable than men to social pressure, so their move into retirement communities where drinking is common probably has an impact.

Differences between men and women have implications for treatment. Women of all ages are less likely than men to seek care at treatment facilities. Among older women who may be socially isolated or homebound, outreach is particularly important.

Families, physicians, senior centers and senior housing staff, and the police play important roles in helping to identify older men and women who abuse alcohol. To be effective, however, all of these potential outreach agents must be sensitive to women's feelings of stigma, shame, and social censure.

Personal History

A strong relationship exists between developing a substance use disorder earlier in life and experiencing a recurrence in later life. Some recovering alcoholics with long periods of sobriety undergo a recurrence of alcoholic drinking as a result of major losses or an excess of free time.¹⁷ Among the 10 percent of older men who reported a history of heavy drinking at some point in their lives, widespread physical and social problems occurred in later life.¹⁸

Drinking problems early in life confer a greater than fivefold risk of late-life psychiatric illness despite cessation of heavy drinking. Indeed, some research suggests that a previous drinking problem is the strongest indicator of a problem in later life.¹⁹ "Studying older alcoholics today may help to anticipate the demands that these younger alcoholics will eventually place on our resources and society."³

Estimates of primary mood disorder occurring in older alcohol abusers vary from 12 to 30 percent or more.^20,21 Depression, for example, appears to precipitate drinking. A recent study showed that the risk for heavy drinking in women with a history of depressive disorder was 2.6 times greater than the risk in women with no history of depression.²²

Patients with severe cognitive impairment generally drink less than nonimpaired alcohol users. Individuals who are only mildly impaired, however, may drink more as a reaction to lower self-esteem and perceived loss of memory. Someone already depressed who drinks will be at risk for deepening depression.

Genetic Factors

There is substantial cumulative evidence that genetic factors are important in alcohol-related behaviors.²³ Some studies have suggested that there may be a greater genetic etiology of problem drinking in early-onset than in late-onset male alcohol abusers.²⁴ Researchers studying the genetic tendency of a group of male alcohol abusers assert that these men often have an early history of drinking that worsens over time.^25,26

Although most human genetic studies of alcohol use have been conducted on relatively young subjects, several studies using a twin registry of U.S. veterans have focused on significantly older individuals.^27,28 The results of these studies provide strong evidence that drinking behaviors are greatly influenced by genetics throughout the lifespan.^29,30

Environmental Factors

Environmental risk factors include those found in the community. Examples include lack of resources and activities for older adults and loss of social support. A new problem for many older adults is dealing with the drug problems of their children.

Many older people are now raising grandchildren and may use alcohol to cope with stresses such as finding daycare and health care providers. This problem is more common in some ethnic groups than in others.