A dramatic increase in the number of adults who will meet the retirement milestone is projected for the time frame between 2010 and 2030 (Federal Interagency Forum on Aging-Related Statistics, 2012). By 2030, the number of older adults turning 65 is projected to be twice as large as the number who turned 65 in 2000, reflecting a growth in population from 35 to 72 million. Older adults will represent approximately 20% of the total U.S. population by 2030 (Federal Interagency Forum on Aging-Related Statistics, 2012). As individuals mature through young adulthood into adulthood, substance use generally declines. However, current research reflects relatively higher rates of substance use, including nonmedical use of prescription drugs, among those of the Baby Boomer generation (born between 1946 and 1964) when compared to prior generations (Blank, 2009). If this older population continues to use substances at the current rate, health care providers will face many challenges.
Until recently, little attention in health policy or practice was given to substance and tobacco use in older adults. The focus of this article is to examine contributing factors that support substance use and abuse among older adults and evaluate evidence-based assessment and intervention approaches for psychiatric nurses. Evidence indicates that positive behavior change, even late in life, can result in improved quality of life (American Lung Association, 2010).
Current data collected on substance use in older adults are limited to treatment admissions for hospital and emergency department (ED) visits and survey data. Survey data response rate from this cohort is low, and survey instruments utilized may not capture the true picture of substance use. However, data that are available reflect that treatment admissions for individuals 50 and older increased from 6.6% of all hospital admissions in 1992 to 12.7% in 2009. Alcohol-related admissions of older adults with co-occurring psychiatric problems tripled during this same time period. Also within this time frame, older adults who reported an increase in alcohol use in combination with drug use grew from 12% to 42% (Blank, 2009).
The Substance Abuse and Mental Health Services Administration 2007 to 2009 National Surveys on Drug Use and Health estimated 4.8 million (5.2%) adults 50 and older had used an illicit drug in the past year (U.S. Department of Health and Human Services [USDHHS], 2011). Of the 2.2 million adults 50 and older who used illicit drugs in the past month, 54% used only marijuana; 28% used only prescription drugs in a nonmedical fashion; and 17% used a different illicit drug (e.g., cocaine) (USDHHS, 2010a). Statistics for ED visits by older adults (50 and older) associated with illicit drug use were estimated at 118,495. Cocaine was the most commonly reported (63%), followed by heroin (26.5%), marijuana (18.5%), and stimulants (5.3%). Nearly one third (33.1%) of these ED visits also involved alcohol (USDHHS, 2010a). Among individuals 50 and older, alcohol is the most commonly used substance (USDHHS, 2010a).
For those diagnosed as alcohol dependent, it is estimated that approximately 80% are tobacco users. Tobacco use is strongly associated with alcohol and illicit drug use. Tobacco dependence is a chronic condition that leads to significant morbidity and mortality. Each year in the United States, more than 400,000 people die from tobacco-caused disease, and another 50,000 die from exposure to second-hand smoke, making it the leading cause of preventable death (American Lung Association, 2010). In 2010, an estimated 45.3 million Americans older than 19 smoked, with 21.1% of adults ages 45 to 64 and 10% of adults 65 and older among these smokers (Centers for Disease Control and Prevention [CDC], 2010). Older adults who continue to smoke have smoked longer (up to 40 years or more) and tend to be heavier smokers (compared to younger smokers) and are less likely to believe that their smoking presents a health risk. Older smokers have lower quit rates than their younger peers, contributing to their eventual death from tobacco-related chronic disease. Long-term smokers, who have a strong urge to smoke according to the Fagerström Test of Nicotine Dependence, are also likely to have a strong dependence on alcohol (John et al., 2003). Smokers who are alcohol dependent die from smoking-related diseases more often than alcohol-related diseases (Andrews, Heath, & Graham-Garcia, 2004; Williams & Ziedonis, 2004).
Several factors contribute to and support substance use and abuse among older adults. There is increased vulnerability to substance use with aging related to chronic health problems, depression, and changes in brain reward mechanisms.
Chronic Health Problems
As adults reach age 50, they may begin to experience chronic pain associated with advancing age. Statistics from the National Institute on Aging-sponsored Health and Retirement Survey of more than 20,000 Americans indicate that those ages 54 to 59 report the highest level of pain and more chronic health, drinking, and psychiatric problems than those surveyed from earlier cohorts (National Institute on Aging, 2007). As a person ages, his or her body cannot process alcohol in the same way it had when they were younger. To complicate matters, alcohol is often taken in combination with another substance. A complex history of prescription and non-prescription drug use to deal with medical issues combined with new life stresses (e.g., loss of a loved one, retirement) can trigger late-onset abuse of alcohol and other drugs.
It is estimated that 15.7% of adults 50 and older report a lifetime diagnosis of depression and 10.6% report a lifetime diagnosis of anxiety. In particular, the high comorbidity of alcohol use disorders and depression is well established (Satre, Sterling, Mackin, & Weisner, 2011). Older adults, especially those ages 50 to 60, report higher rates of depression when compared with younger and older cohorts. Because of their disposition for depression, they are more likely to use alcohol and drugs and misuse prescription medication (Satre et al., 2011).
Major depressive disorder is a leading cause of death in the United States and around the world. Suicide rates for men are highest among those 75 and older (rate 35.7 per 100,000), with non-Hispanic white men 85 and older most likely to die by suicide (CDC, 2012). Women, in particular, seem to be more affected by negative mood states and may smoke to alleviate affective discomfort. Increased depression seems to increase women’s vulnerability for alcohol use disorders across all age groups (Tait, French, Burns, & Anstey, 2012).
Although there are genetic differences in vulnerability to drug addiction, stress, and depression, alteration in mid-brain reward mechanisms has been shown to increase vulnerability. Drug addiction in vulnerable individuals generally progresses from occasional recreational use to impulsive use to habitual compulsive use.
In a review, Hyman (2005) reported that addiction represents a hijacking of the neural mechanisms of reward-related learning and memory that are necessary for survival. Behaviors involved in obtaining basic rewards (food, shelter, sex) become overlearned and therefore automatic. Addictive drugs also elicit reward-seeking behaviors, but with such power as to supplant almost all other survival goals.
Addictive drugs seem to have a competitive advantage over natural stimuli, in that they produce more dopamine release and prolong stimulation of neurons. Homeostatic mechanisms that occur produce dependence and withdrawal symptoms with cessation of the drug. Withdrawal then becomes analogous to hunger, thirst, and sexual desire. However, re-exposure to drugs and cues associated with drugs also motivates drug-seeking behavior. Thus, the drug-dependent person seeks the drug, whether deprived of it or not. Reward occurs consistently as expected, and as a result, the positive reinforcement is greater than that which would be normally expected from intermittent reinforcement from natural rewards (Hyman, 2005; Hyman, Malenka, & Nestler, 2006).
Investigation into the reward mechanisms associated with the aging brain is evolving. Age-related changes in the dopamine system (e.g., decrease in dopamine receptors and transporter) have been identified (Dreher, Meyer-Lindenberg, Kohn, & Berman, 2010). In animals and humans, mid-brain dopamine activity is strongly associated with reward. Within the mid-brain, the nucleus accumbens is the central point for reward. Use of substances enhances dopamaneric synaptic function within the nucleus accumbens and provides drug-induced pleasure. Strong evidence suggests that serotonergic, opioid, cannabis, GABAergic, and glutamatergic mechanisms are also involved in the addiction process. Aging alters this regulatory relationship such that there is a mostly negative correlation between mid-brain dopamine and reward (Dreher et al., 2010). Although obtaining reward within the aging process is possible through activities that enhance self-confidence or esteem, these may not always be available, and rather than enduring negative emotions related to depression or loss, substance use may be a natural response for older adults at risk for mood disorders.
Mary, age 66, was referred to a psychiatric clinic for evaluation of depression by the advanced practice nurse who managed her medical problems. Mary met the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (American Psychiatric Association, 2000) criteria for major depressive disorder. Initially, she was vague about her history, preferring to focus on her church activities and caring for her grandchildren. With coaxing, she revealed a history that belied her current presentation. Mary admitted to lifelong, heavy use of both drugs and alcohol, starting at age 15 when she first ran away from home. To support her heroin habit, she engaged in prostitution and sold drugs until she was arrested and sent to jail in her late 20s. By this time she had one child, whom her mother cared for while she was in jail. Upon release from jail she was determined to “get control of her life.” She attended a job training program and worked at minimum wage jobs until her recent retirement. Currently, she smokes a pack of cigarettes and drinks alcohol on a daily basis. When questioned about specific drugs, she admitted to snorting cocaine and heroin, but “only when I see my bad girlfriend who can make me feel sad and do bad things.” She believes her substance use is in control and is not willing to stop using. Mary endorsed symptoms associated with depression and agreed to a trial of antidepressant medication. She continued to take antidepressant medication and was able to cut back on her substance use and engaged in volunteer work at her church.
Older adults similar to Mary can achieve recovery from substance use with medication intervention. The dorsolateral prefrontal cortex and nucleus accumbens are activated by antidepressant medications, resulting in mood disorder improvement (Samson et al., 2011). There is also activation of the ventral striatum (a target site of dopamine) after a trial of antidepressant medication. This area of the brain is involved in motivated behavior and reward anticipation (Ossewaarde et al., 2011). However, due to ambivalence surrounding medication, older adults may abort treatment and relapse back to unhealthy behaviors. Understanding changes in brain physiology can offer insight to treatment options that can be as effective or adjunctive to medication.
Implications for Practice
The current health system will require a shift in focus to adequately respond to the demands of the older adult substance user (Lin, Zhang, Leung, & Clark, 2011). Stigma surrounding mental health issues and substance use and misuse can make it difficult for an older adult to seek help. Health care providers have a great impact on whether clients seek treatment. Many older people have a “don’t ask, don’t tell” relationship with health care providers about some problems, especially those related to sensitive subjects (e.g., driving, substance use, sexuality). Hidden health issues (e.g., memory loss, depression) pose further challenges within the relationship (Doolan & Froelicher, 2008). Health providers may overlook problems due to a misperception that illicit drug use is an adolescent/young adult health problem. Others may believe that symptoms of mental disorders (e.g., sadness, depression, anxiety) are simply a part of the aging process or related to recent loss or illness. Therefore, it is critical that personal stereotypes and bias not interfere with adequate screening or intervention.
Some available assessment tools are tailored to an older population. The CAGE screen is one widely used assessment tool. The name is an acronym for the four questions used to assess alcoholism: (a) Have you ever felt you needed to cut down on your drinking? (b) Have people annoyed you by criticizing your drinking? (c) Have you ever felt guilty about drinking? (d) Have you ever felt you needed a drink first thing in the morning (eye-opener) to steady your nerves or to get rid of a hangover? The tool provides a simple way to initiate discussion and has been shown to be an effective and useful screening tool for older adults (Conigliaro, Kraemer, & McNeil, 2000).
When using any screening tool, questions should be asked in a confidential setting and in a nonthreatening, nonjudgmental manner. The connection between tobacco and other substances is synergistic; therefore, both issues must be addressed in an assessment of use. Although alcohol is the drug most often used in this population, all substances (alcohol, recreational drugs, nicotine, prescription and over-the-counter medications, herbal and food supplements) must be included in an assessment.
Increasing Motivation for Behavioral Change
Many people who face lifestyle changes experience ambivalence. Motivational interviewing (MI) recognizes ambivalence as the major obstacle to behavioral change. MI was first developed by William A. Miller in 1983 in his work with alcohol-dependent individuals (Rollnick & Allison, 2004). Miller’s approach was designed to decrease resistance and exploit ambivalence about cessation of drinking. Within this theory, motivation for change comes from within, rather than being imposed or forced onto the substance user by the treatment team. By examining and resolving ambivalence, change becomes a more likely outcome (Rollnick & Allison, 2004). Behavior change is a process of overlapping stages that include pre-contemplation, contemplation, action, and finally maintenance. Movement through these stages occurs through a decisional balance where the individual continuously weighs the pros and cons for change (Prochaska, DiClemente, & Norcross, 1992). Because this is a process, it is important to remember that substance use is a chronic condition that often requires repeated intervention.
Empathic listening is a core skill and the primary way to remain in step with the patient (Rollnick & Allison, 2004). When a nurse uses empathic listening, he or she tries to understand feelings, goals, and problems from the patient’s perspective. The nurse suspends judgment and tries to imagine what it feels like to be that person. By suspending judgment, the other side of the patient’s ambivalence is able to emerge. Any discussion of substance use must be approached incrementally at the older adult’s cognitive pace, providing information regarding positive screening results along with a description of the impact the alcohol or prescription drug use is having on the older adult’s health or functional status. This approach will increase collaboration and strengthen the therapeutic partnership.
Similar to antidepressant therapy, cognitive-behavioral approaches have been shown to increase gray matter volume in the prefrontal cortex and seem to modulate specific sites in the limbic and cortical regions particular to prefrontal-hippocampal pathways (Goldapple et al., 2004). Cognitive-behavioral strategies are based on the theory that learning processes are critical to the development of maladaptive behavioral patterns (e.g., substance abuse). A central process in cognitive-behavioral therapy (CBT) is learning to identify and correct problematic behaviors by applying new approaches to old problems and anticipating future problems. Techniques specific to substance use include (a) exploring the positive and negative consequences of continued drug use, (b) self-monitoring to recognize cravings early and identify triggers or situational cues that might put one at risk for use, and (c) development of new coping skills to avoid high-risk situations (National Institute on Drug Abuse, 2012). The use of brief therapy techniques has increasingly become an important part of the continuum of care in treatment of substance use problems.
Brief Intervention—Solution-Focused Therapy
Application of CBT principles within brief interventions can provide a clinical opportunity to increase positive outcomes by using these modalities independently as stand-alone interventions or in addition to other forms of substance abuse and mental health treatment (USDHHS, 2000). Brief intervention is a short-term intervention consisting of one to five sessions, usually directed toward substance abusers who are not yet substance dependent. Brief interventions provide evaluation for a potential substance abuse problem and motivate individuals to begin to take action about their substance use (USDHHS, 2010b). Solution-focused therapy, a brief intervention, places emphasis on a person’s inherent strengths. Practical or problem-solving training provides an efficient approach to target specific issues. By focusing on strengths, individuals can recognize how they managed to cope in difficult circumstances in the past and how they might apply those same strategies to current situations. Through empowerment, small changes can be made within the context of everyday life. Basic assumptions of solution-focused approaches identify the client as (a) in control, (b) the expert, and (c) having the capacity to change (Walter & Peller, 1992). By using a solution-focused approach, efforts are directed toward successful and positive behaviors, rather than problems and failures.
Solution-focused approaches are collaborative and engage the client in problem solving that is empowering and, as a result, provides for a cooperative therapeutic relationship that acknowledges the individual’s ability and resources as he or she begins to recognize and challenge his or her behavior (Wand, 2010). Allowing the older adult to identify concerns about making a behavior change, or difficulties encountered in prior attempts, can provide a way to identify what worked and what did not work in the past. Within a solution-based framework, for example, a smoker is encouraged to envision a future without tobacco and is supported in any movement toward the stated goal, no matter how small the increment toward change. Empowerment is accomplished by building on positive thoughts, feelings, and behaviors already used by the older adult. Within this approach, the smoker is helped to identify times in his or her current life that are closer to the envisioned future and examine what is different on these occasions. By bringing these small successes to awareness and repeating successful actions, the older adult can begin to move toward the preferred identified future. For example, noticing success at not smoking at particular times, such as while sleeping or at church, can provide an incentive to keep moving toward the identified goal and increase confidence in problem solving.
Focusing on even small triumphs will help older adults embark on a life without tobacco or alcohol. They can learn new ways of dealing with stress, such as anticipating and avoiding temptations to smoke and drink, developing strategies to deal with negative moods, avoiding relationships that exploit substance triggers, and finding new ways to attain pleasure and reward. Skill training in self-monitoring of situations and feelings is one way to increase early identification of cravings, triggers, or situational cues that can place one at risk for use. Self-monitoring increases feelings of competency and control by placing the older adult in charge of the behavior change process. Affirmation and support are critical to staying focused toward positive behavior change. Feedback from peers can reinforce the positives associated with behavior change and emphasize consequences of continued abuse of alcohol or prescription medication. Recommendations for self-help or support groups can assist in abstinence and provide social support and affirmation.
Use of client-centered counseling approaches that recognize the older adult’s developmental need for autonomy and choice in decision making have been shown to be effective in increasing motivation. Independence can be supported through meeting competence needs and self-stated goals. Through the therapeutic relationship, nurses can advise the older adult to engage in healthy behaviors. Through effective use of empathy, nurses can help preserve the older adult’s integrity and support decision making and self-efficacy. Supporting older adults at all points in their process of change can motivate movement toward small positive changes. Although further research is needed to identify specific motivational incentives and the exact nature of the reward systems, addressing tobacco, alcohol, and other substance use in older adults can enhance not only life span of this population but overall quality of life.
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