Elsevier

European Geriatric Medicine

Volume 6, Issue 6, December 2015, Pages 580-586
European Geriatric Medicine

Hot topic in geriatric medicine
Recent advances in treatment for older people with substance use problems: An updated systematic and narrative review

https://doi.org/10.1016/j.eurger.2015.07.001Get rights and content

Abstract

Background

Substance use disorders among the elderly are a growing public health concern but there is a limited evidence base on interventions designed specifically for this population group. This review aims to update the review by Moy et al., 2011, by examining recent advances in the treatment of substance use disorders in the elderly.

Methods

Medline, Embase, PsycInfo, and Cochrane Library databases were searched. Appropriate inclusion and exclusion criteria were applied and eligible papers were selected through a sequential screening process. Data were extracted using a standard data extraction form, and synthesised.

Results

Thirteen papers were eligible for inclusion in the review. All the studies were conducted in developed countries. The interventions included pharmacological and psychological treatments for alcohol consumption, cigarette smoking, and prescription medication use, all delivered in a range of healthcare settings. The evidence for treatments of alcohol use related problems supports psychological interventions for reducing alcohol consumption. Studies on the treatments for tobacco use point towards the strength of cognitive behavioural therapy and combined treatments for smoking cessation. For prescription medications, counselling interventions were found to be effective.

Conclusion

Older people were reported to have responded to interventions such as brief interventions, multicomponent interventions, educational interventions, counselling, amongst others. There remain limitations in this field of research, as the studies were undertaken only in developed countries, using psychological interventions with varying characteristics, and short follow-up periods.

Introduction

Substance use in the elderly is increasing parallel to the increase in the proportion of this particular demographic group [1]. In defining substance use amongst the elderly, it is useful to rely on the classification of early onset use and late onset use; with the former including users with a persistent history of substance use, and the latter including users who initiate substance use during old age. Substance use is associated with alteration of function and structure of the brain, and consequently affects mood, perception, and consciousness, may lead to dependence (physical and psychological), and may impair physical/psychological health and well-being, in addition to social and economic consequences for the individual as well as society [2]. The elderly form a vulnerable group for substance use related problems for many reasons, including early exposure of the baby-boom cohort (born between 1946–1964) to alcohol and drugs – which subsequently resulted in favourable attitudes towards substance use, and easy access to and reliance on prescription medications. The two substances reported as major sources of concern amongst the elderly population are alcohol and prescription medicine use [2], [3]. A gradual increase in illicit drug use, and decrease in tobacco consumption amongst the elderly population has been reported previously [1], [2].

Substance use in the elderly is associated with morbidity directly related to substance abuse, e.g. depression and anxiety disorders, cardiovascular and respiratory problems associated with smoking and alcohol, rapidly advancing liver disease associated with alcohol abuse, hepatitis C in intravenous drug users, chronic obstructive pulmonary disease (COPD) due to long-term smoking of tobacco, crack cocaine and heroin. Besides this, there are the indirect effects of substance abuse in this specific group, such as dietary neglect due to impoverishment, and isolation, amongst others [1], [2], [4]. The problems associated with substance misuse are more pronounced with higher dosage – for instance, the consumption of alcohol among older adults is considered problematic because of the tendency to drink more frequently (than younger counterparts), and a particularly high burden of disease in the particular age [2], [5]. However, even moderate levels of consumption can lead to a harmful impact, particularly because of the biological and psychological changes that appear during old age [1].

The number of persons aged 60 years or older in the world is estimated to rise dramatically from 605 million in 2000 to nearly 2 billion by 2050 [6]. In this age group, substance abuse, especially abuse of alcohol and psychoactive prescription medications, is an emerging public health concern [3], [7]. In the USA alone, it is estimated that by 2020 there will be a threefold increase in substance abuse among the elderly and approximately 5 million elderly people will need treatment for substance abuse [8]. The estimates for Europe reflect similar trends; with an estimated two-fold increase in substance use related problems amongst the elderly [2]. Another alarming trend is of poly-substance use, especially polypharmacy, amongst the elderly, which has a pronounced effect, given the biological makeup of older people [1]. Risk of developing particular substance use problems in old age has been reported to be associated with gender, with older women being at a lower risk of alcohol and illicit drug use related problems in comparison with older men or anyone below 65 years; and at a higher risk of prescription and over the counter medications related problems than older men [1].

Despite the magnitude of this public health problem, there are multiple barriers in the detection and management of substance abuse in the elderly. The lack of awareness and knowledge regarding alcohol and substance abuse in the elderly – especially the mistakenly held belief that substance abuse is rare in that age group – and the lack of universally recognized diagnostic criteria for the elderly pose a major barrier to detection and diagnosis [1], [2]. Other challenges to early detection and timely treatment of substance abuse in the elderly are absence of routine screening for substance use, denial of the problem, low rates of help-seeking [1], [3], [4] and masking by comorbid conditions [3], [9], [10]. Finally, a major barrier is the lack of empirical studies evaluating the treatment of substance abuse in the elderly [11]. Given these challenges, the treatment of substance use in the elderly calls for systems that are tailored to address the specific needs of the elderly, which do not necessarily apply to the general adult population [1], [4].

The need for establishing better diagnostic strategies and treatment alternatives for the elderly has been highlighted extensively by various groups [1], [2], [3]. In 2007, Moy et al. [11] conducted the first review of treatments for substance abuse in the elderly. The review synthesized findings from eight randomised controlled trials and eight descriptive studies assessing a range of psychological treatments for alcohol with or without drug misuse, prescription medications, and smoking. The main conclusions derived in this review were that:

  • there is some evidence for treatment responsiveness for substance use disorders amongst the older population;

  • however, there still exists an evidence gap for the treatment of substance use amongst older people, more specifically for the treatment of drug and/or medication use amongst older people;

  • there are limits to the generalizability of research predominantly conducted in one country (i.e. United States).

The goal of this current review is to update the review by Moy et al. [11] to uncover recent advances in the treatment of substance abuse amongst older adults.

Section snippets

Search strategy

Medline, EMBASE, PsycINFO, and Cochrane Library databases were searched using search terms under the following concepts: substance of abuse (e.g. alcohol, drinking, illicit drug use, etc.), subjects (e.g. elderly, older, geriatric), and intervention (e.g. treatment, management, etc.). The search was restricted by the date of publication from January 2007 (as the search for the Moy et al., 2011 was conducted in 2007) to October 2014 (when search for this review was conducted).

Inclusion and exclusion criteria

The inclusion

Results

The search resulted in the identification of 21,386 titles and after sequential screening, 13 papers were selected for inclusion in this review [7], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24]. More specifically, after excluding duplicates, 19,109 records from the 21,386 were eligible for title/abstract screening. During this stage, 19,088 records were excluded as they did not fulfil the eligibility criteria for inclusion in the review. The full texts of the remaining

Discussion

The discussion will highlight the findings of the current review, while comparing them with the synthesized findings from the 16 studies in the previous review by Moy et al. [11]. Both, the current, as well as the previous review found limited evidence for treating older adults with substance use, which indicates that there is a dearth of evidence available.

Thirteen studies fulfilling our criteria have been published in the last 6 years compared with 16 studies until 2007. Consistent with the

Conclusions

The review indicates that older people are able to utilize offered treatments, with positive effects on clinical outcomes. However, there is still a need to refine and develop the evidence base for treatments specific for the older cohort of substance users given the increasing number of older people – who are taking a range of substances – and their special needs. Since all of the evidence emerged only from the Western setting, there is an imperative need to develop and evaluate treatments in

Disclosure of interest

The authors declare that they have no conflict of interest concerning this article.

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