The baby boomers are aging. In 2011, members of the baby boomer generation (those born between 1946 and 1965) began to turn 65 years old. In 2012, the 50- to 64-year age group was made up entirely of baby boomers. By 2015, the entire baby boomer cohort will be in the 50+ age group. This cohort is having an effect on the U.S. population. The over-65-year age group is growing from a little over 13% of the U.S. population in 2010 to a projection of almost one in five Americans (19.3%) being 65 years or older by 2050 (see Figure 1; Administration on Aging, 2013). The baby boomer cohort differs from prior cohorts on a number of issues including both lifetime and current use of alcohol and other drugs. Are we prepared to care for older adults with a history of substance use that puts them at risk for adverse consequences? Do current models of prevention and treatment match the needs of older adults who use alcohol and/or other drugs?
In 2012, current illicit drug use (use in the past 30 days) increased in the 50- to 64-year age group. The biggest increase from 2002 to 2012 was among those aged 50 to 54 years (from 3.4% to 7.2%; Substance Abuse and Mental Health Services Administration [SAMHSA], 2013). The most frequently used illicit substance was marijuana (4.6%) followed by prescription psychoactive therapeutics (2.9%; Han, Gfroerer, Colliver & Penne, 2009; SAMHSA, 2013). There is a similar upward trend in at-risk alcohol use in the 50- to 64-year age group. Reporting of any alcohol use in the past 30 days remained similar from 2007 to 2012 with over 50% reporting use in the past 30 days. In contrast, only 41% of those over 65 years old reported current alcohol use in 2012. More concerning is the upward trend in binge alcohol use. In 2012, more than one in five persons aged 60-64 years (22.7%) reported binge alcohol use (five or more drinks on one occasion in the past 30 days) up from 16.7% in 2007. For those between the ages of 50 and 64 years, there was only a small increase in reported heavy use (five or more drinks on one occasion at least five times in the past 30 days; SAMSHA, 2013). Thus, at-risk alcohol use is more of a concern than heavy use and a possible substance use disorder (SUD). Yet, much of the focus continues to be on treatment for those who meet the criteria for an SUD.
In a recent article, Han, Gfroerer, Colliver, and Penne (2009) projected that the number of persons aged 50 years and over with an SUD would double from 2.8 million in 2002 to 5.7 million in 2020. This only reflects the tip of the ice berg because the use of psychoactive substances can result in adverse effects even without an SUD. When considering the increasing trend of substance use among older adults, the full continuum of use must be considered. On the basis of their findings, Han et al. (2009) concluded that there would be an increased demand for treatment of SUDs for this population. However, not all older adults at risk of adverse consequences associated with substance use will meet diagnostic criteria for an SUD and yet will need interventions aimed at prevention of these adverse consequences. Understanding substance use in older adults is complex, and current interventions developed for the healthy adult may not translate well to the older adult. Older adults who use alcohol and other drugs are more likely to have a noncommunicable disease such as cardiovascular disease and diabetes as well as being at risk for communicable diseases such as hepatitis C. Thus, there are two main issues related to the baby boomers and substance use: first, providing SUD treatment specifically tailored for the older adult, and second, addressing the adverse health consequences associated with substance use with and without an SUD.
When Han et al. (2009) concluded that there would be increased demand for SUD treatment, they did not raise the question of whether current treatment models are applicable to the older adult. There is a Treatment Improvement Protocol from SAMSHA specifically for older adults (SAMSHA, 1998). Although published over 15 years ago, it is a good starting point and highlights the importance of tailoring treatment to the specific needs of the older adult.
The challenge facing healthcare providers is the lack of current evidence-based interventions related to reducing the harm of substance use in older adults that address the wide spectrum of risk associated with substance use across the continuum of use. For example, the physiological changes that occur with aging affect the ability to metabolize alcohol and other drugs. What may have been low-risk use for a healthy adult under the age of 65 years could become high risk because of the reduced ability to metabolize these substances. The National Institute on Alcohol Abuse and Alcoholism's (NIAAA) recommended limit for those 65 years old or older is no more than three drinks on one occasion and no more than seven per week (NIAAA, 2007). Yet, the SAMSHA survey data related to binge drinking define binge drinking as five or more drinks on at least one occasion in the past 30 days (SAMSHA, 2013). Thus, percent of those at risk may be underestimated, and the need for effective prevention strategies for those engaged in binge drinking may be greater.
To address the increased trend in at-risk use of alcohol and other drugs in older adults, primary care providers must be knowledgeable about the pathophysiology of substance use in the older adults especially the adverse effects associated with long-term use. Many of the screening tools in use today such as the AUDIT or the CAGE-C provide a mechanism for determining the quantity, frequency, and pattern of use, but they do not capture the duration of use. It is important to distinguish between older adults who are hardy survivors, that is, those who have used it for a long time, and those who are late-onset users, that is, who have only recently begun to use substances at a level that puts them at risk. The hardy survivor is at greater risk for long-term consequences such as cancer, thiamine deficiency, or cardiovascular disease. The hardy survivor may have a 40-year history of use although they are currently not using it. Asking for current use may not be sufficient because the risk for medical complications may remain even after the alcohol use has stopped. Those with late-onset use may not be at risk for some of the long-term medical consequences yet may be in need of treatment to help prevent adverse events such as medication interactions and falls.
For adults who are currently engaged in at-risk substance use, the recommended approach is to conduct screening, brief intervention, and referral to treatment (NIAAA, 2007; SAMHSA, 2013). Current prevention research related to screening and brief intervention for the most part was conducted with adult or adolescent populations. There are reliable and valid tools available that have been recommended for use in screening for alcohol problems in older adults such as the Short Michigan Alcoholism Screening Instrument-Geriatric Version (Naegle, 2012). They do not provide a mechanism for determining duration or other consumption variables. No tools were found to screen for drug use in older populations. The increase in at-risk (binge) drinking in baby boomers and the increase in other drug use highlight the need for evidence-based interventions than can help identify those who may be at increased risk for adverse consequences but may not have a positive screen for an SUD. Adding duration, quantity, frequency, and pattern of use is an essential step in identifying all levels of risk associated with the full continuum of substance use in older adults (Savage, 2008).
In conclusion, healthcare providers caring for older adults must have the knowledge and clinical competence to identify not only older adults who may have an SUD but also those who are at risk for adverse consequences related to substance use across the continuum of use and across their lifetime. There is promising evidence that screening and brief intervention programs conducted with older adults can result in reduction of at-risk use (Schonfeld et al., 2010). Further research is needed to establish the efficacy and effectiveness of interventions related to older adults aimed at reducing adverse effects of substance use across the continuum of use. In addition, healthcare providers who provide care to older adults must begin to routinely screen for both past and present use and provide interventions that are specifically tailored to the older adults.
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