Geriatrics and Psychiatry

Addressing Substance Use Disorders in Geriatric Population

    It is estimated that, in the United States, nearly 1 million adults aged 65 or older live with a substance use disorder (SUD). As SUD becomes increasingly prevalent, it is now among the fastest growing public health concerns in the country.

    At NewYork-Presbyterian/Weill Cornell Medicine, geriatric psychiatrists, clinical psychologists, social workers, nurses, and others provide dedicated care to older people challenged by mental health issues, including SUD. Other comorbidities can make treating SUD in an elderly patient even more challenging. To gain insight into the complex issues surrounding substance use in geriatric patients and how these can inform screening techniques and treatment going forward, Nabil Kotbi, MD, and Dimitry Francois, MD, both geriatric psychiatrists and addiction medicine specialists at NewYork-Presbyterian/Weill Cornell Medicine, conducted a review of existing literature on SUD in older people; the review was published in the June 5 issue of Current Treatment Options in Psychiatry.

    In the paper, Dr. Kotbi, who is the Chief of the Addiction and Recovery Program at NewYork-Presbyterian Westchester Behavioral Health, and Dr. Francois provide a comprehensive overview of the growing concern of SUDs in the geriatric population, covering various substances and addressing the challenges specific to older adults.

    “A number of factors can lead to substance use disorders in the elderly,” says Dr. Francois. “Older adults may face unique social challenges, such as isolation, loneliness, or loss of support systems. These factors can contribute to self-medication with substances as a coping mechanism, leading to the development of SUDs.”

    Increased Use of Illicit and Prescription Drugs Found Among Geriatric Patients

    The study authors searched three major databases—Ovid MEDLINE, PubMed, and PsychINFO— from their inception through June 2022, using a variety of applicable keywords, including “substance use disorder,” “substance abuse,” “illicit substances,” “addiction,” “geriatric,” “older adult,” “alcohol,” “marijuana,” “opioid,” “benzodiazepine,” and others. They found alcohol to be the most commonly used substance in this population, with one survey from 2019 estimating that 10.7 percent of adults aged 65 years and older engaged in past-month binge alcohol use (defined as over 5 drinks on an occasion), while 2.8 percent engaged in past-month heavy alcohol use (defined as binging in at least 5 of the past 30 days).

    Older adults may face unique social challenges, such as isolation, loneliness, or loss of support systems. These factors can contribute to self-medication with substances as a coping mechanism, leading to the development of SUDs.

    — Dr. Dimitry Francois

    Cannabis was the second most used substance. Between 2016 and 2020, the prevalence of use of cannabis among adults 65 years and older increased significantly, from 3.3% to 6%. The fact that today’s cannabis products are stronger than in the past has made them of particular concern in older adults.

    “The baby boomers are typically familiar with drugs, but they’re familiar with the drugs they knew from when they were younger,” says Dr. Kotbi. “The cannabis that we see nowadays is very, very strong. It cannot be compared to the Woodstock cannabis.”

    Misuse of opioids and benzodiazepines, used for pain and anxiety, respectively, is also increasing. “An elderly person may go to their primary care physician asking for something for pain. And then before you know it, they’re addicted to opioids,” says Dr. Kotbi. “The opioid epidemic is not just affecting our youth.” Use of street drugs, such as cocaine and heroin, is increasing as well among older adults.

    An elderly person may go to their primary care physician asking for something for pain. And then before you know it, they’re addicted to opioids. The opioid epidemic is not just affecting our youth.

    — Dr. Nabil Kotbi

    Dr. Francois points out that the physiological and mental health changes that often accompany aging can affect how the body processes drugs and alcohol and may therefore have significant health impacts. Older people may live with chronic health conditions, such as high blood pressure, in addition to anxiety, depression, or cognitive impairments like dementia.

    “These conditions can mask or exacerbate symptoms of SUD, making it difficult for healthcare providers to differentiate between the underlying mental health issue and substance misuse,” he says. The review revealed that the majority of older patients admitted to substance abuse treatment programs were self-referred vs being referred by healthcare providers, suggesting room for improvement in the screening and discussion of substance use disorders.

    Shame and embarrassment about substance use is also common among older people, leading to underreporting their behaviors. Additionally, due to age-related stereotypes and biases, healthcare professionals may be less likely to consider SUD in older patients.

    Another significant barrier to treatment is related to racial and socioeconomic disparities that exist in SUD treatment for older adults. Only 18% of substance abuse treatment programs were specifically designed for the geriatric population, according to the review, and the general availability of SUD treatment facilities is more limited for those of lower socioeconomic status and certain minorities, making it even more difficult for these patients to seek proper care for their SUDs. “More research is needed to understand the interplay between age, race, and socioeconomic status in SUD treatment to address disparities effectively,” says Dr. Francois.

    Future Improvements in Screening and Awareness of SUD

    Based on the findings, the authors considered how to improve screening and awareness, including:

    • Developing and implementing SUD screening tools that are specifically tailored to older adults and consider age-related changes and challenges in communication and cognition.
    • Integrating behavioral health assessments into routine medical visits to identify underlying mental health issues and potential substance misuse.
    • Providing training and education to healthcare providers about the unique aspects of SUD in older adults to improve recognition and early intervention.
    • Using telehealth services to improve access to screening and treatment for older adults, especially those facing mobility or transportation challenges.

    “By shedding light on the challenges of recognizing and treating SUDs in the geriatric population, this review emphasizes the need for increased attention and tailored interventions for this vulnerable group,” Dr. Francois says. “The findings underscore the importance of further research, addressing racial and socioeconomic disparities and the impact of the COVID-19 pandemic, and developing specialized approaches to tackle SUDs in older adults effectively.”

      Learn More

      Lin J, Arnovitz M, Kotbi N, et al. Substance Use Disorders in the Geriatric Population: a Review and Synthesis of the Literature of a Growing Problem in a Growing Population. Current Treatment Options in Psychiatry (2023). doi:10.1007/s40501-023-00291-9

      For more information

      Dr. Nabil Kotbi
      Dr. Nabil Kotbi
      [email protected]
      Dr. Dimitry Francois
      Dr. Dimitry Francois
      [email protected]