Best Practices - Treatment and Rehabilitation for Seniors with Substance Use Problems

2. Review of the Literature

2.1 Introduction

2.1.1 Terminology

A variety of terms pertaining to seniors with substance use problems was found in the literature. There was variation in what the researchers or authors designated as senior or older adult. Most researchers used lower cut off ages of 65 or 60, however, some used 55 or 50.

There was diversity in the terms for problem substance use, including, for example, problem alcohol use, alcohol abuse, drug use, substance use and medication misuse. Medication problems tend to use terms such as non-compliance, abuse and misuse. These differences have implications for interventions. "Non-compliance" refers to neglecting to fill a prescription, filling it but not taking the medication, or taking the medication in a manner other than that prescribed (Tamblyn & Perrault, 1998). Patterns are labelled "abuse" if they are a result of deliberate, excessive ingestion of medication. "Misuse" includes use due to misinformation or misunderstanding, and may occur when patients do not inform their doctor about all the medications they are taking (Barnea & Teichman, 1994; Ruben, 1992).

2.1.2 Young-Old versus Old-Old

Neugarten (1996) developed the typology of "young-old" and "old-old" for those over 55 years of age. The generally accepted transition age from young-old to old-old is 75 years. There are clearly problems with using chronological age as a marker. Some researchers in the field of aging see this model as too simplistic, while others find it helps conceptualize older adults and seniors, which includes an age span of about 40 years. There will be significant diversity among that age span, and functionally those at 65 may have more in common with someone 45 than someone 85. However, the opposite can also be true. A useful generalization is that those who are old-old will likely suffer a greater impact from health or substance use problems than those who are young-old. While the gerontology literature often makes this distinction, the substance use literature on seniors often does not.

2.1.3 Demographics on Aging

People aged 65 and over comprise 12.5% of the Canadian population (65-74: 7%, 75-84: 4%, 85+: 1.4%) (Statistics Canada, 2002), but with the large number of aging baby boomers, this proportion is expected to rise. Statistics Canada has projected that by 2021 seniors will represent 18.9% of the total population, and that by 2041 will represent 24.9% of the population (Statistics Canada, 2002). In 2000, women constituted the larger proportion of seniors, accounting for 53% of those over 65 to 74, 60% of those 75 to 84 years of age, and 70% of those 85 and over (Statistics Canada, 2002).

Substance use problems are an important factor in later life health issues. One study found that substance use was the third leading cause of health problems in Americans 55 years of age and older (King, Van Hasselt, Segal & Hersen, 1994). In Canada, it is estimated that more than $300 million a year is spent on substance abuse treatment (Rush & Ogborne, 1992). The characteristics and prevalence of substance use problems in seniors needs to be determined to ensure effective treatment and rehabilitation services.

2.1.4 Different Cohorts, Different Views

Rush & Ogborne (1992) report that for many who lived during the era of Prohibition, alcoholism was viewed as a moral weakness. Prohibition was common in many areas of Canada and was not repealed until the early 1920s (Rush & Ogborne, 1992). In the 1940s, Alcoholics Anonymous emerged and shifted perceptions to alcoholism as a disease. The corresponding shift in public perception made it more acceptable to seek treatment, but the personal views of some seniors may still reflect a moral bias. This may contribute to a reluctance to seek treatment for substance use problems (Widner & Zeichner, 1991). Another cohort, the baby boomers, begins to turn 60 in 2006. This generation matured during a time of social upheaval and tend to have different attitudes toward substance use (Patterson & Jeste, 1999).

Perceptions of substance use, misuse, abuse, and dependence change with the times (e.g. change in views of alcoholism as moral corruption in the times of prohibition, to alcoholism as a disease, to alcoholism as a multidimensional biopsychosocial problem). Similarly, opinions about marijuana use have changed from the 1950s to the 1960s and 1970s, to the new millennium where we now have regulations for medical marijuana. Currently, definitions of problem use usually refer to impaired control over consumption, or to continued use despite negative consequences. (Fingerhood, 2000; Kostyk, Lindblom, Fuchs, Tabisz & Jacyk, 1994). The term "binge drinker" is relatively new and refers to someone who does not necessarily drink regularly but drinks excessively (the equivalent of four drinks or more) (Blow et al., 2000).

Fingerhood (2000) reports that the problem with such a variety of terms to describe drinking behaviour is that it allows for subjective interpretation by researchers and creates a lack of consistency across studies. "At the core of the problem is accurately defining what is being measured: Is it alcohol abuse, alcohol dependence, alcoholism, heavy drinking or a drinking problem?" (Fingerhood, 2000, p. 985).

In many areas the disease model of addiction is prominent. Another emerging perspective is the biopsychosocial model, which incorporates biological and physiological mechanisms, psychological processes (learning, conditioning, modelling, and coping with stress), and social and environmental processes (interpersonal relationships and broader culture). This perspective highlights the multidimensional nature of causes and treatments (Rush & Ogborne, 1992).

2.1.5 Outline of Review

The review of the literature is organized as follows: Section 2 describes issues relevant to the aging population, Section 3 profiles the patterns of substance use in seniors, Section 4 describes physical and health issues related to substance use, Section 5 describes risk factors that may precipitate substance use problems in seniors, Section 6 describes screening tools and diagnostic criteria, Sections 7 and 8 discuss treatment issues and approaches, Section 9 focusses on barriers to treatment, and Section 10 discusses the issue of substance use problems within Canada's Aboriginal population.