Substance Abuse and Mental Health in Older Adults

Overview and Scope

When one thinks of substance abuse or drug addiction, the picture that is likely to come to mind is that of a young or middle-aged man who has wasted away as a consequence of drug and substance abuse. Yet cases of substance abuse in the older population have reportedly been on an upward trend. As will be demonstrated throughout this discussion, alcohol has emerged as one of the most abused substances among this particular population, alongside prescription and illicit drugs.

This discussion highlights the prevalence of substance abuse among older adults. In doing so, it examines various mental health disorders and how they affect this population, identifies the most commonly abused substances, and outlines the neurological and physical symptoms linked to each. The discussion also explores the dual diagnosis of anxiety and depression with substance abuse.

The relevance of a discourse of this nature cannot be overstated. It is only by familiarizing ourselves with the nature of substance abuse in the older population that we can develop the most effective approaches to address the issue.

DSM-5 and Mental Health Disorders in Older Adults

From the outset, it is important to note that "mental illness can contribute to drug use and addiction" (National Institute on Drug Abuse, 2020). The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is a detailed classification of numerous mental health disorders; it aims not only to advance diagnostic efforts but also to promote treatment and aid research. As a clinical handbook, the DSM-5 has become highly relevant in the diagnosis of mental disorders and has been revised multiple times to keep pace with new knowledge and research.

According to the DSM-5 classification, "mental disorders are characterized by problems that people experience with their mind (thoughts) and their mood (feelings)" (Grohol, 2020). As Grohol (2020) further notes, while the causes of some listed mental health disorders may not yet be well understood, their symptoms have been scientifically investigated and deemed valid. Mental health disorders affecting adults under the DSM-5 classification include, but are not limited to, alcohol and substance abuse disorders, anxiety disorders, bipolar disorder, depression, and schizophrenia. Three of these are discussed in greater detail below.

Health has been defined as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity" (Vendendyck, 2018). It therefore follows that mental health is an integral component of overall health. The impact of mental health disorders on older adults is not necessarily different from their impact on younger populations; in some cases, however, it can be more severe, particularly because mental health conditions can complicate the treatment of co-occurring chronic illnesses.

The number of older adults affected by mental health disorders appears to be increasing. Data from the World Health Organization (WHO, 2017) indicate that "approximately 15% of adults aged 60 and over suffer from a mental disorder." As the global population continues to age, WHO projects that this figure will increase significantly. Three disorders warrant particular attention in this context: major depressive disorder, anxiety disorders, and bipolar disorder.

According to DSM-5 criteria, major depressive disorder is associated with symptoms lasting two or more weeks (Halverson, 2019). Clinical depression therefore differs from ordinary sadness or "the blues," which typically resolves within a few days. For a diagnosis of major depressive disorder, a minimum of five specified symptoms must be present. These include, but are not limited to: loss of interest in previously enjoyed activities, indecisiveness and inability to focus or concentrate, loss of energy and persistent fatigue, psychomotor retardation or agitation, and unexplained weight loss or weight gain (Halverson, 2019).

Major depressive disorder is relatively common among older adults and can be particularly disabling in this population. Graham, Saunders, Flower, Timney, White-Campbell, and Zeidman (2014) note that the disorder "is linked to several negative health outcomes, including a higher risk of cognitive impairment, functional impairment, and development of Alzheimer's disease and vascular dementia" (p. 127). The authors also associate major depressive disorder in older adults with an elevated risk of death.

As per DSM-5, anxiety disorders encompass all conditions presenting with excessive anxiety and fear, as well as related behavioral concerns (Bhatt, 2020). These include generalized anxiety disorder (GAD), specific phobia, selective mutism, separation anxiety disorder, and medication- or substance-induced anxiety disorder. Presenting symptoms vary depending on the specific anxiety disorder involved.

According to the Anxiety and Depression Association of America (ADAA, 2020), "anxiety is as common among the old as among the young." The anxiety disorder most prevalent among older adults is generalized anxiety disorder. Those suffering from GAD are likely to experience persistent feelings of irritability and nervousness, sleep problems, gastrointestinal disturbances, difficulty concentrating, and an increased heart rate. These symptoms can severely affect the health and wellbeing of individuals with co-occurring conditions and significantly reduce quality of life. As Graham, Saunders, and Flower (2014) note, "generalized anxiety disorder in the elderly increases the risk of physical disability, memory problems, and reduced quality of life — as well as increasing the risk of death" (p. 79).

Bipolar disorder is a mental health condition associated with extreme mood swings. As per DSM-5 criteria, it presents with significant fluctuations in mood, as well as in a person's ability to accomplish routine tasks and function normally. Three distinct conditions fall under the bipolar disorder umbrella: bipolar I, bipolar II, and cyclothymic disorder (Graham et al., 2014). Importantly, "to be diagnosed with bipolar disorder, a person must have experienced at least one episode of mania or hypomania" (Graham et al., 2014, p. 110).

People of all ages can be affected by this condition, though it is more prevalent in younger populations. Sheehan (2008) observes that seniors diagnosed with bipolar disorder have often lived with the condition for decades without a formal diagnosis. The symptom profile in older adults can differ from that seen in younger individuals; classic signs of mania such as elation may be absent, while irritability and agitation are more common features. Older adults with the condition may also exhibit psychosis, confusion, and distractibility. As Sheehan (2008) notes, "seniors with bipolar disorder show significant changes in cognitive functioning, including difficulties with memory, perception, judgment, and problem-solving" — all of which negatively affect quality of life.

Substances Commonly Abused by Older Adults

Substance abuse among older adults is a growing problem, yet it has received comparatively little attention. Research indicates that drug and substance abuse is indeed prevalent among this population. According to Kuerbis, Sacco, Blaer, and Moore (2014), the misconception that substance abuse does not affect older adults has been reinforced by the fact that few in this group have historically presented themselves for substance abuse treatment. Nevertheless, "substantial evidence suggests that substance use among older adults has been under-identified for decades" (Kuerbis et al., 2014, p. 629). The substances most commonly abused by older adults include prescription medications, alcohol, and marijuana.

Addiction to prescription medications among older persons represents one of the most significant public health concerns in this area, particularly regarding benzodiazepines and opioids (Reimers, 2019). A key contributing factor is polypharmacy — the concurrent use of numerous medications on a daily basis, most often defined as five or more medications. Polypharmacy can produce a wide range of adverse reactions, including disorientation, falls, confusion, and in some cases death.

Reimers (2019) also documents a marked increase in opioid use among the older population. In this group, opioid use has been associated with "breathing complications, confusion, drug interaction problems, and falls." Additional symptoms of opioid abuse include poor coordination, drowsiness, euphoria, and nausea. Where prescription anti-anxiety medications are being abused, symptoms may include memory problems, loss of focus, slurred speech, and confusion.

Alcohol is one of the most widely abused substances across all populations. However, Reimers (2019) notes that alcohol abuse is frequently concealed under the guise of social enjoyment, which does not lessen the harm it causes. In older adults, the adverse effects of excessive alcohol consumption can be particularly severe. As Reimers (2019) explains, "older adults may experience marked intoxication symptoms following ingestion of amounts of alcohol that would be judged safe among younger adults, due to increased effects of alcohol on the central nervous system in the elderly."

Indicators of alcohol abuse in older adults include drinking in secret, extreme irritability and mood swings when sober, short-term memory loss and blackouts, diminished interest in previously enjoyed activities, and slurred speech. Alcohol abuse also significantly increases the risk of falls. For these reasons, Reimers (2019) recommends that older adults avoid alcohol consumption altogether. More information on alcohol's effects on aging adults is available through the National Institute on Aging.

Marijuana use is a growing concern among baby boomers. Recent trends indicate that marijuana use is more prevalent in this cohort than in previous generations, often among individuals who used cannabis or other substances in their youth (Reimers, 2019). These same individuals may turn to marijuana in older age to manage symptoms associated with conditions such as chronic pain.

Common symptoms associated with marijuana abuse among older adults include distorted perception, impaired judgment, anxiety, impaired memory, dizziness, and poor coordination. As with alcohol, abstinence from marijuana use is advisable for older persons. Studies have indicated that marijuana can adversely affect cardiac health and poses a significant risk of adverse medication interactions (Grinspoon, 2020). This concern is especially important given that "older people tend to have comorbid health conditions and may be taking multiple medications" (Grinspoon, 2020).

Conclusion and Recommendations

Substance abuse is a serious issue among the older population, despite the persistent misconception that older adults do not engage in substance abuse — a misbelief that has led to the under-identification of this concern. On the basis of the information presented in this discussion, this is an issue that deserves significant and sustained attention.

Various interventions could be implemented to address drug abuse among older adults. There is an especially urgent need to identify and address the risk factors for substance abuse in this population. This may require tracking substance abuse concerns that took root earlier in life but went unaddressed. Additionally, deliberate measures should be taken to ensure that symptoms of depression are identified and treated promptly following diagnosis — since, as discussed throughout this paper, depressive symptoms can drive individuals toward substance use as a coping mechanism. Early and integrated treatment of both mental health disorders and substance use disorders is essential to improving outcomes for this vulnerable population.

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World Health Organization – WHO (2017, December 12). Mental health of older adults. https://www.who.int/en/news-room/fact-sheets/detail/mental-health-of-older-adults