Older patients at increased risk for substance use, comorbid psychiatric disorders

Substance use is increasing among elderly patients, a population also presenting with increasing needs related to comorbid psychiatric disorders, according to a presenter at the Psych Congress 2020 Virtual Experience conference.

“Over the course of the past decade, the National Surveys on Drug Use and Health have indicated an increase in prevalence of alcohol use disorders, as well as cannabis use disorders and cocaine use,” Olivera Bogunovic, MD, medical director of ambulatory services at Harvard Medical School’s McLean Hospital, said during the presentation. “According to the 2012 Treatment Episode Data Set study, there were 14,230 admissions [to substance abuse treatment programs] for patients aged 65 years and older, and it is very important to note that a lot of these hospitalizations led to significant morbidity and mortality. We also have the survey from the Drug Abuse Warning Network that indicated a number of ER visits related to substance use disorders [among older adults].”

Data of this patient population collected from the latter survey revealed 2,056 drug-related ED visits, of which 290 were related to illegal drug use, nonmedical use of pharmaceuticals or use of alcohol in combination with other drugs. According to Bogunovic, alcohol use disorder is predicted to increase in the aging geriatric population. Study data have shown that along the spectrum of older adult drinking, 60% abstain, 20% engage in at-risk drinking, 18% are considered moderate drinkers and 2% are alcohol dependent. Geriatric alcohol problems occur among patients in accident and emergency departments (14%), medical inpatients (6% to 11%), psychiatric inpatients (20%) and nurssing home patients (up to 49%).

Risk factors for alcohol use disorder among older patient populations include physiological factors, gender, family history of alcohol use disorder, prior history of alcohol use, psychiatric disorders, social factors and chronic medical illnesses, such as osteoarthritis.

Bogunovic said older patients with alcohol use disorder rarely seek help in a psychiatric setting, with 87% diagnosed in a primary care setting.

“The most important piece in the assessment is skillful interviewing, particularly using motivational interviewing techniques,” Bogunovic said. “It’s very important to do detailed psychiatric, neurological and social evaluations, and what is going to be most helpful is evaluation of the motivational stage of change.”

Specifically, clinicians can ask older patients questions related to quantity and frequency of drinking and use instruments including the Cut down, Annoyed, Guilty, Eye-Opener questionnaire, the Alcohol Use Disorders Identification Test and the Michigan Alcoholism Screening Test – Geriatric Version.

Although there remains an overall low prevalence of illicit drug use among older individuals, longitudinal data suggest increasing trends. Specifically, cannabis and prescription opiate use have increased more than expected. Further, the proportion of older adult admissions including heroin as the primary substance of abuse rose from 7.2% in 1992 to 16% in 2017, and for cocaine, this increased from 2.8% to 11.4% in the same years.

Regarding prescription drugs, 8.7% of older adults are prescribed benzodiazepines and 4% to 9% are prescribed opioids. Researchers have observed a linear increase in rates of opioid misuse and suicide intent, according to Bogunovic.

“There are definitely barriers to diagnosing substance use disorders in this population,” Bogunovic said. “Often when they present to the emergency room, there's a misinterpretation of physical symptoms and symptoms of dependence vs. withdrawal or normal consequence of aging... Other barriers to diagnosing substance use disorders, particularly opioid and benzodiazepine disorders, are that the commonly used questionnaires are less sensitive in the elderly and some of the social markers are not applicable to the diagnosis.”

Psychiatric comorbidities are common among this patient population, with 25% having comorbid depression and 10% to 15% having cognitive and anxiety disorders. Further, 13% of those with a lifetime diagnosis of depression also met criteria for lifetime alcohol abuse, and older patients with alcohol dependence appeared three times more likely to have depression than those without this dependence.

“The most important thing in doing an assessment is to assess if there is a need for detoxification,” Bogunovic said. “Particularly in this population, if it's not assessed and not treated, we see very often a significant increase of medical morbidity and mortality as well... Prevention is very important in this population, and it happens at the primary care offices. Brief interventions are very important, especially if there is a medical complication associated with a substance abuse.”