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)

The Need for Diagnostic Criteria

Diagnostic criteria reflect the consensus of clinicians and researchers on which patterns of behavior or physiological characteristics constitute symptoms of alcohol abuse or dependence. They also allow clinicians to:

• Plan treatment and monitor progress
• Communicate with other clinicians and researchers
• Work with public health planners to ensure available treatment facilities
• Allow clients access to medical insurance coverage
• Help health care insurers decide whether treatment will be reimbursed

Diagnostic and Statistical Manual of Mental Disorders

Health care providers, epidemiologists, and researchers use very specific criteria for diagnosing substance abuse problems. Most clinicians rely on the conventional medical model defined in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) IV¹ for classifying the signs and symptoms of alcohol-related problems.

The DSM-IV criteria include alcohol abuse indicators within the general categories of substance abuse and dependence. Specific criteria distinguish between those drinkers who abuse alcohol and those who are dependent on alcohol.

Although widely used, the DSM-IV criteria may not apply to many older adults, because they experience none of the legal, social, or psychological consequences specified. For example:

• "A failure to fulfill major role obligations at work, school, or home" is less applicable to a retired person with minimal family responsibilities. However, the emphasis for a retired person can be placed on maintaining a dwelling, managing finances, and participating in social or recreational activities.
• "Recurrent substance use in situations in which it is physically hazardous," a substance abuse criterion in the DSM-IV,¹ need not mean driving drunk. Climbing a ladder, crossing a street, or taking a bath while impaired by alcohol is dangerous for a frail older person.
• "Continued use of the substance(s) despite persistent or recurrent problems" may not always apply. Many older alcoholics do not realize that their persistent or recurrent problems are related to their drinking. In addition, health care clinicians may attribute these problems, in whole or in part, to the aging process or age-related comorbidities.

Limitations of Diagnostic Criteria

The DSM-IV has other limitations for older persons. Tolerance is one of the criteria for a diagnosis of substance dependence and is weighted heavily by clinicians performing assessments. However, the thresholds of consumption that indicate tolerance may be set too high for older adults because of their altered sensitivity to and body distribution of alcohol.³¹ In addition, the aging process, as well as diseases commonly found in older patients, lowers the threshold for onset of physiological dependence on prescription drugs. The presence of tolerance among older adults is not necessarily characteristic of substance-related psychological dependence.

Conversely, the lack of tolerance to alcohol does not necessarily mean that an older adult does not have a drinking problem or is not experiencing serious negative effects as a result of his or her drinking. In addition, many late-onset alcoholics have not developed physiological dependence and do not exhibit signs of withdrawal. Because of these issues, the DSM-IV criteria for alcohol abuse and dependence need to be viewed as they apply to older adults.

Although the drinking practices of many older adults do not meet the diagnostic criteria for abuse or dependence, they may still be at risk of complicating an existing medical or psychiatric disorder. For vulnerable older adults, consuming one or two drinks per day, for example, may cause the following:

• Increased cognitive impairment in patients who already have Alzheimer’s disease
• Worsening of sleep problems in patients with sleep apnea
• Interactions with medications, rendering them less effective or causing adverse side effects

A barrier to good clinical management in these cases may be the lack of understanding of the risks of so-called "moderate drinking." Limiting access to treatment because symptoms do not meet the rigorous diagnostic criteria of the DSM-IV may preclude an older patient from making significant improvements in his or her life. Newer approaches such as brief interventions are appropriate for older adults who do not meet DSM criteria for abuse/dependence (see Module 6).

Another source of criteria is the International Classification of Diseases, 10^th Revision (ICD-10).² While the current ICD and DSM definitions of substance dependence are nearly identical, the two manuals differ sharply on the concepts of abuse, which the ICD classifies as harmful use.

The ICD manual is intended to be used on an international basis. The socially defined "American" criteria in the DSM-IV cannot be adequately transferred to a wide range of cultures. Therefore, ICD-10 criteria may be helpful for health care providers working with individuals from other countries.