Substance abuse in older adults is a serious concern, and often misdiagnosed, misunderstood, and mistreated. According to the American Geriatrics Society (AGS) (2015), substance abuse is defined as "the use of chemical substances that lead to an increased risk of problems and an inability to control the use of the substance." The most common types of abused substances include alcohol, nicotine (cigarette, pipe, or cigar), and both prescription and over-the-counter medications (most commonly anxiety pills, sleeping medications, and pain medications) (AGS). Older adults can also abuse illegal drugs such as marijuana, cocaine, hallucinogens, and injected narcotics, although these are not as frequently abused substances. Substance abuse is especially worrisome in older adults because of an increase in harmful effects such as mental problems, kidney and liver disease, and falls (AGS). Additionally, substance abuse may mimic symptoms of dementia, diabetes, and depression, so it is imperative home healthcare clinicians understand and are aware of substance abuse to aid in accurate diagnosis and treatment.
According to the National Council on Alcoholism and Drug Dependence, Inc. (NCADD, 2015), there are 2.5 million older adults with an alcohol or drug problem, and 6% to 11% of emergency room admissions and 20% of psychiatric hospital admissions by older adults are due to alcohol or drug problems. Home healthcare clinicians should be aware that alcohol or drug abuse or a smoking habit can be the continuation of a pattern from earlier in life, or it may be a way to cope with the stress of aging or disease (AGS, 2015). Older adults may turn to alcohol or drugs later in life due to failing physical health, life changes (including loss of job and/or home), changing family obligations, stress, loneliness, and loss of mobility.
Risk factors that may increase a patient's risk of developing a problem with alcohol or other substances include: family history, male gender, living alone, being single, mental health issues, use of substances earlier in life, chronic pain, sleep issues, life stressors, hospitalization, living in a long-term-care facility, tobacco dependence, misunderstanding how to take medications, over use of drugs that affect mood, disability, and boredom (AGS, 2015). Mental health issues are especially problematic, as the risk of dementia, suicide, depression, anxiety, and sleep issues is higher in those dependent on alcohol. Quitting alcohol can slow down or reverse many of these conditions (AGS).
Signs of alcoholism and drug dependence are different for older adults than in young people, and they are often hidden, overlooked, and misdiagnosed. Some signs of a drinking or drug problem include: drinking alone or in secret; always drinking before, during, or after dinner; loss of interest in hobbies or pleasurable activities; drinking in spite of warning labels on prescription drugs; frequent use of tranquilizers; slurred speech; empty alcohol bottles; smell of alcohol on the breath; change in appearance; chronic and unsupported health claims; hostility or depression; and memory loss and confusion (NCADD, 2015). To aid in recognizing or diagnosing alcoholism, clinicians may utilize the CAGE questionnaire (AGS, 2015). The four questions include:
1. Have you ever felt you should Cut down on your drinking?
2. Have you ever felt Annoyed by criticism about your drinking?
3. Have you ever felt Guilty or bad about drinking?
4. Have you ever felt the need for a drink (an "Eye-opener") in the morning to steady your nerves?
An answer of "yes" to any of the questions may indicate the patient has an issue with alcohol.
Medication misuse is another common and serious issue in older adults. Signs for medication misuse include increased confusion or memory impairment, mood changes (such as agitation, depression, or irritability), sleep problems and daytime sleepiness, dizziness, changes in blood pressure, anemia, fatigue/weakness, altered liver function tests, and falls (AGS, 2015).
Substance abuse is a serious issue in older adults in part because of the aging process. As people age, the body is less able to handle the same amounts of medications and alcohol as when they were younger. Alcohol and some medications tend to break down slower as aging occurs, which means they stay active for a longer period of time. Additionally, older adults often have multiple chronic illnesses, thus increasing the number of prescription and over-the-counter drugs they take compared with their younger counterparts. The medications may not work well together, or they may alter the amount of each drug in the body, thus leading to overdoses even when the patient is taking exactly the dose prescribed. It is important for home healthcare clinicians to review their patients' medications and educate patients to avoid alcohol with medications such as benzodiazepines, sleeping pills, pain medications, antiseizure or antipsychotic medications, antihistamines, and antidepressants (AGS, 2015).
Once a substance abuse problem is identified, treatment may begin. One of the first steps a clinician may take is to communicate the issue with the patient and caregiver. The patient may be unaware of the issue or risk they are taking by using the substance. They may be continuing a substance they have used in the past without realizing that risks have increased, so education is imperative (NCADD, 2015). Education about taking medications and alcohol at the same time may also be helpful, as many patients are not aware of the dangers of combining these substances. Additional care and treatment of a patient with substance abuse may include talk therapy with a trained counselor, keeping a diary to record patterns of use of the substance, smoking cessation programs (including the use of nicotine replacement therapies or medications such as bupropion and varenicline), slow tapering of the problem substance with drug substitutes, nutritional counseling and multivitamin use, antidepressants (if necessary), and medications to reduce the cravings of addictive substances (naltrexone for alcohol or methadone for narcotics) (AGS, 2015).
Home healthcare clinicians must also be aware of withdrawal symptoms, as an abrupt stop of substances can cause signs and symptoms such as shaking, sweating, feeling hot or cold, delirium, seizures, sudden heart problems, elevated vitals, hallucinations, and irritability (AGS, 2015). Home healthcare clinicians have an obligation to monitor for, and educate patients and caregivers about, these symptoms and side effects to facilitate safe and complete withdrawal from undesirable substances.
Home healthcare clinicians should also be aware that patients may relapse in their recovery. This is especially true if there are new stressors in the patient's life (such as a new living situation, new disease, death of a loved one, etc.). Patients need to be monitored by the home healthcare clinician to adjust the treatment plan of care as needed, especially during times of stress (AGS, 2015).
Clearly, substance abuse can be a serious issue in older adults. Clinicians working with patients in the home need to be knowledgeable with regard to watch for to avoid misdiagnosis and mistreatment. Home healthcare clinicians also play a key role in managing the recovery from substance abuse in the home-bound community-based patient.
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