Psych · Addiction psychiatry
Addiction in older adults
Also known as Substance use disorder in older adults · Geriatric addiction · Late-life alcohol use disorder · Elderly substance misuse · Late-onset substance use disorder · Prescription drug misuse older adults
Exam-exhaustive fellowship topic on addiction and substance misuse in older adults — early- vs late-onset phenotypes, age-related PK/PD, alcohol binge trends, benzodiazepine and opioid iatrogenic dependence, atypical presentation (falls, confusion, self-neglect), SMAST-G and AUDIT-C screening, withdrawal and Wernicke traps, SBIRT/BRITE, naltrexone and acamprosate, EMPOWER/Beers deprescribing, dual diagnosis with late-life depression and suicide. FRANZCP-primary, globally tagged.
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Red flags
- Abrupt cessation of long-term benzodiazepines or high-dose alcohol on admission — seizure, delirium, and falls risk; reinstate cover then planned taper/detox
- Confusion, ataxia, or ophthalmoplegia in a malnourished older drinker — treat as Wernicke risk immediately; do not wait for the classic triad
- Recurrent falls, new cognitive decline, or hip fracture pathway with unreviewed night sedatives or alcohol — mandatory medication and substance review
- Late-life depression with alcohol use — elevated suicide risk; assess means, hopelessness, and dual treatment
- Opioid plus benzodiazepine co-prescription in frail older adults — synergistic overdose and fall risk
- Assuming the patient is 'too old to change' or that low absolute drink counts are safe — age-related sensitivity and comorbidity redefine harm
Meet the patient
An 81-year-old retired schoolteacher is admitted at 2am after her third fall this year, this time with a fractured wrist. She was widowed fourteen months ago and lives alone. Her daughter says she is "just not herself".[1][15]
Her medication list carries temazepam at night, started for insomnia after the funeral and never reviewed. Nobody has asked what she drinks. When somebody finally does, the answer is most of a bottle of sherry most evenings.[11][13][4]
On day two she becomes confused and tremulous, and the night registrar is asked to review "delirium on a background of dementia". Every diagnosis in this topic is already on that page. Not one of them has been written down.[1][2]
References16ShowHide
- [1]Lehmann SW, Fingerhood M. Substance-Use Disorders in Later Life N Engl J Med, 2018.PMID 30575463
- [2]Kuerbis A, Sacco P, Blazer DG, et al. Substance abuse among older adults Clin Geriatr Med, 2014.PMID 25037298
- [3]Kuerbis A, Sacco P. A review of existing treatments for substance abuse among the elderly and recommendations for future directions Subst Abuse, 2013.PMID 23471422
- [4]Barry KL, Blow FC. Drinking Over the Lifespan: Focus on Older Adults Alcohol Res, 2016.PMID 27159818
- [5]Han BH, Moore AA, Sherman S, et al. Demographic trends of binge alcohol use and alcohol use disorders among older adults in the United States, 2005-2014 Drug Alcohol Depend, 2017.PMID 27979428
- [6]Han BH, Moore AA, Ferris R, et al. Binge Drinking Among Older Adults in the United States, 2015 to 2017 J Am Geriatr Soc, 2019.PMID 31364159
- [7]Grant BF, Goldstein RB, Saha TD, et al. Epidemiology of DSM-5 Alcohol Use Disorder: Results From the National Epidemiologic Survey on Alcohol and Related Conditions III JAMA Psychiatry, 2015.PMID 26039070
- [8]Oslin D, Liberto JG, O'Brien J, et al. Naltrexone as an adjunctive treatment for older patients with alcohol dependence Am J Geriatr Psychiatry, 1997.PMID 9363289
- [9]Anton RF, O'Malley SS, Ciraulo DA, et al. Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial JAMA, 2006.PMID 16670409
- [10]Schonfeld L, King-Kallimanis BL, Duchene DM, et al. Screening and brief intervention for substance misuse among older adults: the Florida BRITE project Am J Public Health, 2010.PMID 19443821
- [11]Tannenbaum C, Martin P, Tamblyn R, et al. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial JAMA Intern Med, 2014.PMID 24733354
- [12]Glass J, Lanctôt KL, Herrmann N, et al. Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits BMJ, 2005.PMID 16284208
- [13]Markota M, Rummans TA, Bostwick JM, et al. Benzodiazepine Use in Older Adults: Dangers, Management, and Alternative Therapies Mayo Clin Proc, 2016.PMID 27814838
- [14]By the 2023 American Geriatrics Society Beers Criteria Update Expert Panel American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults J Am Geriatr Soc, 2023.PMID 37139824
- [15]Blow FC, Serras AM, Barry KL. Late-life depression and alcoholism Curr Psychiatry Rep, 2007.PMID 17257508
- [16]Blow FC, Brockmann LM, Barry KL. Role of alcohol in late-life suicide Alcohol Clin Exp Res, 2004.PMID 15166636