Difficulty in Identification of Abuse

The physiologic, psychologic, and sociologic changes associated with aging make the identification and treatment of substance abuse in older adult clients difficult. Most studies report that the average older person is not taking the prescribed medication at all or is taking unnecessary drugs with dosages that are too high, even though a safer alternative to the drug is available. Age-related psychologic and sociologic changes and symptoms can be subtle or atypical and can mimic symptoms of substance abuse (Mohundro & Ramsey, 2003; Videbeck, 2004). Often clinicians and family members are hesitant to ask whether the older adult is having problems with substance use or misuse of prescription medications. Traditionally accepted ways of detecting problems with substances (e.g., time lost from work, legal problems, or decreased participation in important social activities) are not helpful in older adults because they generally have fewer activities and obligations (Trevisan, 2008).

Physiologic Changes

Patients with early-onset alcohol dependence appear to have a more severe course of illness. They make up about two thirds of the dependent drinkers in the elderly, are predominantly male, and have more alcohol-related medical problems and psychiatric comorbidities. Patients with later onset alcohol dependence tend to have a milder clinical picture and fewer medical problems because of the shorter exposure to alcohol. They are more affluent, include more women, and are likely to begin their alcohol use after a stressful event, such as loss of a spouse, job, or home (Trevisan, 2008).

The pharmacokinetics, or the activity or fate of a drug within the body, includes absorption, distribution, plasma protein-binding, hepatic metabolism, and elimination or clearance of a drug. These processes can be affected by age, nutritional status, altered physiology, and pathologic conditions. Absorption in the elderly can be influenced by a decreased ability to swallow, increased gastric pH, delayed gastric emptying, and decreased intestinal motility. The absorption issues may reduce the bioavailability of a drug or reduce its clinical efficacy or onset.

Distribution of a drug in the elderly is affected by decreased muscle mass, decreased total body water, and increased total body fat. Because many drugs are lipophilic, an increase in body fat can lead to an increase in a drug’s half-life without changing the plasma steady state.

Plasma protein-binding can be affected by changes in albumin and alpha-1–acid glycoprotein levels, and both levels can be somewhat altered by age, malnutrition, and an increased medical burden. The clinical significance of protein binding on drugs is highly variable and is affected by age, gender, health, and the specific medication. However, one important aspect is that only an unbound drug can cross the blood–brain barrier and reach its intended receptor site. An unbound drug may also interact with peripheral sites of action and cause unintended and unwanted side effects.

Nurses should be aware of these age-related physiologic changes of absorption, distribution, plasma protein-binding, hepatic metabolism, and elimination or clearance of a drug. The assessment of these changes in relation to substance use is essential in planning interventions to prevent or halt substance abuse and misuse in the older adult population.

Psychologic Changes

Psychologic changes in older adults result primarily from the numerous losses this age group may experience in a relatively short period. Separation from family and friends, retirement, a decline in physical health, and a decreased ability to participate in previous social activities can contribute to feelings of loss. Two thirds of this age group has long-standing problems with alcohol and multiple medical complications. One third develop a drinking problem late in life, often in response to bereavement, retirement, loneliness, relationship stress, and physical illness (Eliopoulos, 2001) (Fig. 18–1).

In addition, nurses should be aware of the misconception that select prescribed or over-the-counter substances can help the client deal with unmet psychologic needs. For example, an older adult may become anxious if sleep has decreased to less than 8 hours and may seek sedatives. In addition, some older adults tend to use certain substances to mask negative feelings about themselves; they may eventually attribute some of their positive personality characteristics to substances. Examples of such substances include alcohol and benzodiazepines (e.g., diazepam [Valium]). Clients who are given a benzodiazepine by a physician for a limited period may become dependent on the medication. An older adult client who is dependent may find another physician to prescribe the medication when the original physician discontinues it.

The nurse must also assess older adult clients for suicidal ideation. Clients should be asked whether they have had thoughts of harming themselves and whether they have a plan to carry out these thoughts. Advancing age and substance abuse are among the greatest risk factors for suicide. Suicide rates tend to increase with age in white men, and it should be noted that suicide is a leading cause of death in older adults.

Sociologic Changes

Sociologic changes, such as decreases in finances, transportation, and social support, tend to place older adults at risk for substance abuse and misuse. As a result of decreased finances and transportation, many older adults fill prescriptions through mail-order pharmacies. Mail-order pharmacies tend to increase the potential for drug abuse and misuse as a result of prescription errors, late arrivals, and large quantities of drugs. Social conditions such as low income, difficulty shopping, and lack of socialization tend to affect the nutrition of older adult clients. The nurse should educate older adults about the dual effects of poor nutritional status and drug metabolism.

Sociologic changes are based on the cultural values and attitudes about substance abuse behaviors that are passed from one generation to another. There is a lower incidence of substance abuse in cultures whose religious and moral values prohibit or limit their use. Older adults are targeted by advertisements for prescription and nonprescription drugs because they experience minor aches, pains, and major health problems. Substance abuse is symptomatic of the larger social problems among minority groups (e.g., poverty, substandard housing, inadequate health care, and lack of power). The lack of culturally competent care is an additional barrier to substance abuse care for the older adult.

Substance Abuse History

The DSM-IV-TR criteria for substance abuse are developed for the general population, not specifically for the older adult population (see Box 18–1). Therefore it is essential for the nurse to assess clients’ medical and psychologic histories. After a history is complete, the nurse should identify whether the key medical and psychologic manifestations of substance abuse are present (Boxes 18–2 and 18–3).

Screening Tools

A number of screening tools are available to assess alcohol use (Figs. 18–2 to 18–4). The two most commonly used tools are the CAGE (Mayfield, McLeod, & Hall, 1974) and the Michigan Alcoholism Screening Test (MAST) (Selzer, 1971). The Brief Michigan Alcoholism Screening Test (BMAST) is a modified form of the MAST (Pokorny, Miller, & Kaplan, 1972). Frederick Blow developed the MAST—Geriatric Version (MAST-G) (Morton, Jones, & Manganaro, 1996). Results indicate that the MAST-G is an instrument that is more reliable and valid in the older adult population than the MAST (Knight & Mjelde-Mossey, 1995). Even though further research is required to validate the use of these tools for the assessment of abused substances besides alcohol, positive clinical results have been demonstrated with the use of these tools, substituting the words substance or prescription medication for drink.

Clients undergoing detoxification from alcohol abuse should be assessed on an ongoing basis using the Clinical Institute Withdrawal Assessment tool. The tool measures the severity of alcohol withdrawal based on 10 common signs and symptoms: nausea and vomiting; tremor; paroxysmal sweats; anxiety; agitation; tactile, auditory, and visual disturbances; headache; and orientation. The maximum score is 67, and clients who score higher than 20 should be admitted to a hospital (Fontaine, 2003).

Nursing Caveats

In assessing older adults for substance abuse, the nurse must be aware of his or her own perceptions and attitudes regarding substance abuse in the older adult population. Many health care providers overlook the possibility that the presenting symptoms in an older adult may be related to substance abuse. It is important to have a healthy collaborative relationship with patients, showing respect for their values and choices.

Inherent changes in tissue and organ function are highly variable and individual. Hence the response to medication is just as variable and as unpredictable in this population. Guiding principles are to start low and go slowly when prescribing medications; change or add only one medication at a time; review each medication to see whether the patient is still taking it; and determine the dose, frequency, and time (see Evidence-Based Practice Box).

Interventions

Multidisciplinary interventions are appropriate for all individuals overcoming substance abuse because no single intervention is appropriate. Effective interventions attend to the multiple needs of individuals, not just their drug or substance use. Interventions must address medical, nursing, psychologic, social, vocational, and legal problems.

Interventions and treatment options include brief therapy, intensive outpatient or inpatient treatment, and residential treatment. Brief therapy is usually provided by a trained professional in a community drug treatment center. Goal setting, self-monitoring, and identifying high-risk situations are specific behaviors that clients learn in order to stop or reduce their substance abuse. Intensive outpatient programs allow clients to remain at home and continue working while they participate in treatment in an unrestricted setting for 4 to 5 hours every day. Intensive inpatient treatment occurs in the emergency department or acute care inpatient units for clients at risk of severe withdrawal symptoms, for those who are psychiatrically disabled, and for those who have not responded to less intensive treatment efforts. Residential treatment programs are downsizing and closing because third-party reimbursement is rapidly decreasing. Traditionally treatment lasted 7 to 21 days and offered a safe and structured environment for those who lacked social and vocational skills and drug-free social supports to be abstinent in a less restricted setting (Fontaine, 2003).

Older adults resist referrals to substance abuse programs and are more comfortable in senior-oriented programs. Some are unable or unwilling to leave their homes; thus programs should