Clinical Pearls & Morning Reports
Unrecognized substance-use disorders can cause substantial harm to older adults in the form of an increased risk of falls, confusion, cognitive impairment, and medical morbidity, which can contribute to hospitalizations and health care costs, as well as loss of independence. The Center for Substance Abuse Treatment recommends that screening for substance use and alcohol disorders be part of the routine medical visit for all persons over the age of 60 years. Read the Latest NEJM Review Article here.
Q: What are some of the challenges associated with identifying substance-use disorders in older adults?
A: Relying on an older patient’s report of the frequency and quantity of substance use as indicators of problematic use can lead to an underestimate of negative consequences. Older adults may lack awareness that their use of substances is problematic and might not bring it to the attention of the clinician. Even close family members may miss problematic consumption by an elderly relative whose drinking is occurring at home. To complicate matters, detecting substance-use disorders can be especially challenging in the presence of multiple coexisting medical conditions.
Q: Is alcohol-use disorder increasing among older adults in the United States?
A: Alcohol-use disorder remains the most prevalent substance-use disorder in later life. Although alcohol consumption generally decreases with advancing age, demographic trends show an increase in alcohol-use disorder among older adults in the United States, and 14.5% of older drinkers consume alcohol at a level above the limit recommended by the National Institute on Alcohol Abuse and Alcoholism for adults 65 years of age or older, which is no more than three drinks on a given day and no more than seven drinks in a week.
A: The Alcohol Use Disorders Identification Test (AUDIT) is a validated 10-item screening instrument developed by the World Health Organization that is specific for use of alcohol in the past year. On the AUDIT, the recommended cutoff score for the indication of potentially hazardous alcohol use is typically 8 (on a scale of 0 to 40, with higher scores indicating greater alcohol use), but for older adults, a score of 5 should be the cutoff that would prompt further investigation. An alcohol screening tool specifically designed for older adults is the geriatric version of the Michigan Alcoholism Screening Test (MAST-G). More than five “yes” answers indicates an alcohol problem, with a sensitivity of 91 to 93% and a specificity of 65 to 84%. The widely used four-question screening tool for alcohol use disorder, the CAGE questionnaire, may not be a useful screening tool in older adults, since it is not designed to detect binge drinking.
A: Studies suggest that alcohol treatment in older patients is more likely to be successful when the patients receive age-specific treatment. Clinicians should consider referring patients to Alcoholics Anonymous, though it may be difficult to find a group of peers in which an older adult feels comfortable. A primary care–based brief intervention, including a clinician-led discussion about the negative effects of alcohol on health, with direct advice about the need to change, has been shown to reduce the level of consumption in older adults who drink too much and may improve health-related quality of life. Older adults may reduce alcohol consumption if they perceive a benefit from doing so. Treatment plans for older patients should focus on overcoming isolation and on establishing social supports. Attendance at a senior center may be a helpful intervention for isolated older adults, promoting new interests and social contacts.