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)

Costs of Diseases Related to Substance Abuse

Of the 10 major causes of death in the United States, seven are directly related to external factors involving individual behavior:

• Tobacco
• Diet and activity patterns
• Alcohol
• Firearms
• Sexual behavior
• Motor vehicles
• Illicit use of drugs⁵⁵

The effect of mood, especially depression, on an individual’s use of tobacco, drugs, alcohol, and firearms is compelling. Of the 10 major causes of disability worldwide, five are mental health and substance abuse problems, with major depression ranking first.

Alcohol and Illicit Drugs

Nearly 15 million Americans use illicit drugs and more than 12 million are heavy drinkers. Less than 1 percent of persons age 65 and over use illicit drugs, but this still represents about 200,000 people. In addition, nearly 2 million older adults engage in binge drinking and about 500,000 of these are considered heavy drinkers.⁵⁶ The costs of alcohol abuse and dependence are estimated to be over $100 billion a year, due in part to increased mortality, significant social costs, and health consequences.^44,54,57,58

Individuals who use alcohol and other drugs are at elevated risk of acquiring certain diseases. Diseases attributable to alcohol and other drug use can be prevented and the costs of treating them avoided. Therefore, substance abuse prevention programs can help reduce health care costs.

Prescription Drugs

Although a low percentage of older adults use illicit drugs, major problems can occur with prescription and over-the-counter drugs (see Module 5, Recognizing Other Forms of Substance Abuse). One study found that in a single year, more than 2 million hospitalized patients had serious adverse drug reactions and over 100,000 died as a result of their medication. If adverse reactions to medications were classified as a distinct disease, it would rank as the fifth leading cause of death in the United States.⁵⁹

The economic costs attributable to medication-related problems total nearly $85 billion a year, including nursing homes, hospitals, and the community. Most of these costs (almost $77 billion) occur in people living in the community.^60-62 The economic cost of medication-related problems rivals that of cancer, Alzheimer's disease, diabetes, and other diseases commonly affecting older adults.^60,61

Measures exist to prevent adverse reactions. One study found that drug regimen review conducted by consultant pharmacists improved optimal therapeutic outcomes by 43 percent. The savings from avoided medication-related problems was $3.6 billion. For every dollar spent on medications, $1.33 is spent to treat medication-related problems.⁶¹

Cost Model

A special cost model was used to calculate the costs of various diseases related to substance abuse. This model attempts to bridge the gap between economic cost studies of substance abuse and epidemiologic research on the association between substance abuse and negative health consequences.

Because substance abuse is rarely reported on medical records, except when the person requires immediate medical assistance such as detoxification or substance abuse treatment, the population attributable risk (PAR) model is used. This model can be used to estimate the proportion of diseases that are attributable to substance abuse but are not clearly identified on medical records.⁶³

A literature review of research linking alcohol and other drug use to subsequent disease or trauma showed more than 50 conditions that are attributable in part to substance abuse. Some conditions were excluded from the final analysis, because the percentage of cases related to substance abuse was not deemed significant. Efforts to prevent such illnesses might cost more than treatment.⁶³

The PAR is based on prevalence of substance use and relative risk. Relative risk is an individual substance abuser’s increased risk of contracting a disease relative to that of a non-substance abuser. For example, a relative risk of 7.6 for cirrhosis means a drinker is 7.6 times more likely to contract cirrhosis than a nondrinker.

The formula for the number of substance abuse-related cases is PAR x Total Number of Cases. To determine the number of cases among people 65 and older, the number of cases was multiplied by 12.65 percent. This is the proportion of older people in the U.S. population.

The formula for costs is number of cases x cost per case. Because the cost figures are derived from formulas, some data limitations should be noted. The PAR formula⁶³ is:

[Prevalence x (Relative Risk – 1)/Prevalence x (Relative Risk – 1) + 1] x 100

The example below illustrates how the number of cases and total costs for alcohol-related cirrhosis are calculated.

Number of Cases of Alcohol-Related Cirrhosis and Total Costs General Population Total number of cases = 90,000 Relative risk = 7.6 Prevalence = 47.3% PAR = [.473 x (7.6 – 1)/.473 x (7.6 – 1) + 1] x 100 = 75.7% Number of alcohol-related cirrhosis cases = 90,000 x 75.7% = 68,130 Total cost = Number of substance-related cases x Cost per case Number of alcohol-related cirrhosis cases = 68,130 Cost per case = $13,619 Cost of alcohol-related cirrhosis cases = 68,130 x $13,619 = $928,339,135 Age 65+ Number of alcohol-related cirrhosis cases = 68,130 x 12.65% = 8,618 Cost of alcohol-related cirrhosis cases = 8,618 x $13,619 = $117,368,542

For most diseases, the cost per case is based on average length of stay (LOS) (in days) and cost per day.⁶⁴ Costs are broken out by diagnosis related group (DRG). Total charges for a DRG were divided by total hospital days to yield the cost per day. The cost per day was multiplied by the average LOS to yield a cost per case for each DRG. If a condition involved more than one DRG, the costs per case for all DRGs related to the condition were added together and divided by the number of DRGs.

For sexually transmitted diseases (STDs), the cost per case is based on average cost for a physician visit. The cost per case is the average cost per physician visit for a variety of procedures, such as removal of lesions. The cost per case for assaults and injuries came from the literature.