Substance abuse in older adults: Underdiagnosed and undertreated

Substance abuse is a major mental health problem in older adults, and is often unrecognized and undertreated, leading to a reduced quality of life.

Alcohol and drug abuse among older adults has been called one of the fastest growing health problems in the United States. According to Hazelden’s Butler Center for Research, recent census data estimates that nearly 35 million people in the United States are 65 years of age or older. Substance abuse among those 60 years and older (including misuse of prescription drugs) currently affects about 17 percent of this population. By 2020, the number of older adults with substance abuse problems is expected to double. See Hazelden’s website at for more information.

As the baby boomer generation has begun to age, attitudes about the use of alcohol and drugs have also changed. According to Dr. Frederic Blow, professor in the Department of Psychiatry at the University of Michigan and a Huss Research Chair on Older Adults and Alcohol/Drug Problems at Hazelden’s Butler Center for Research, “These individuals have had more exposure to alcohol and illegal drugs, and there is more acceptance among them about using substances to “cure” things. We expect to see an increase in drug and alcohol use; and more use means more problems.”

According to the Geriatric Education Center of Michigan at Michigan State University, when people age, their sensitivity to alcohol increases as their tolerance decreases. Also, the percent of their body weight composed of water decreases, and alcohol affects them more quickly and more strongly. Alcohol takes longer to metabolize in older persons. It accumulates in their bodies and leads more quickly to intoxication if consumption is not controlled. Because of their physical make-up, older women are more vulnerable to the negative effects of alcohol.

Greater numbers of older men have substance abuse problems, but women are more likely than men to start drinking heavily later in life. According to the Hazelden Foundation, substance abuse is more prevalent among persons who suffer a number of losses, including death of loved ones, retirement and loss of health. The fact that women are more likely to have lost a spouse because of death or divorce, to have had experience with depression, and to have been prescribed medicines that increase the negative effects of alcohol help explain these gender differences.

Health care providers often underdiagnose substance abuse among older adults because they have not been trained to look for unique features of substance abuse in older adults. Symptoms of substance abuse in older adults can often look like symptoms of other medical and behavioral disorders common among this population, such as diabetes, dementia and depression.

There are several short assessment tools that health care professionals can use to point to possible substance abuse in older adults. The CAGE questionnaire is one common quick tool used by health professionals to determine if they need to look more closely at an older adult’s substance use.

The CAGE Questionnaire

1. Have you ever felt you should cut down on your drinking?

2. Have people annoyed you by criticizing your drinking?

3. Have you ever felt bad or guilty about your drinking?

4. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye opener)?

Scoring: Item responses on the CAGE are scored 0 for “no” and 1 for “yes” answers, with a higher score an indication of alcohol problems.

A total score of 2 or greater is considered clinically significant.

Source: Ewing, 1984.

As this large generation of people become older and more frail, it will be even more important to support them through an honest, informed assessment if substance abuse is suspected. Because substance use has been much more common in the boomer generation over time, it can be more likely that substance abuse may be a problem for some as they age. Not only can health care costs be reduced with reduced substance use, but the quality of life for older adults and their families can be improved. See the Substance Abuse and Mental Health Services Administration’s Center for Substance Abuse Treatment website at for more information on assessment tools.

Michigan State University Extension staff works with the Geriatric Education Center of Michigan at Michigan State University to bring the latest health information about older adults to health care providers throughout the state. See or read Helping older adults with substance abuse problems for more information.

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