SAMHSA logo Report to Congress - Nov 2002








Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services

Chapter 3 - Prevention of Co-Occurring Disorders - Prevention for Older Adults


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Prevention for Older Adults

Americans are living longer. By the year 2020, adults age 65 years and older will account for 20 percent of the Nation's population, up from 13 percent in 2000. Already, the fastest growing segment of the population is among people 85 years and older (Administration on Aging, 2001). Among those Americans are millions who are living longer with mental disorders and substance abuse disorders and others who will develop these illnesses in later life for the first time.

Co-Occurring Disorders in Older Adults

Co-occurring disorders manifest differently in older adults than in younger adults. Little research has been undertaken regarding the epidemiology, clinical care, and prevention of co-occurring disorders in older adults. However, a few key facts may help point prevention efforts in responsible directions. For example, primary mood disorders (e.g., depressive disorders) are estimated to occur in from 12 to 30 percent of older adults who also abuse alcohol (CSAT, 1998). While research does not support the idea that mood disorders are precursors of alcohol disorders in older adults, some evidence suggests that depressive illness and other mental disorders - if undiagnosed and untreated - may precipitate or help maintain late onset drinking. Depression, for example, appears to precipitate drinking, especially among women (CSAT, 1998). The alcohol may become a form of self-medication. Moreover, research has disclosed that the most frequent configuration of co-morbid disorders among older adults in residential or hospital settings is depression joined with alcoholism and personality disorder (Bartels and Liberto, 1995). In fact, older adults who have a lifetime substance abuse problem are nearly three times as likely to also be diagnosed with a mental disorder (CSAT, 1998).

Further, the substance abuse and mental disorder issues experienced by older adults are often misdiagnosed, remain hidden, or are neglected (Derry, 2000). This results in limited or inappropriate treatment or opportunities to prevent the disorder, even though research has shown that the prevalence of prescription drug misuse, alcohol abuse and mental disorders for those aged 65 years or older is significant. Gerontologists have pointed out that the abuse of alcohol and other drugs by the present cohort of baby boomers as they age will vary significantly from the previous generation's substance abuse patterns. Baby boomers have a different attitude towards alcohol and other drugs than their parents, and they are more likely to have experimented with drugs during their lifetime (CSAT, 1998).

Risk and Protective Factors

Older adults face a number of significant transitions and new developmental tasks that, in some instances, may precipitate mental or substance abuse disorders. Risk factors for older individuals include relationship loss and bereavement, chronic illness and caregiver burden, social isolation, and loss of meaningful social roles (Mrazek and Haggerty, 1994). Indeed, bereavement is a well-established risk factor for depression (U.S. DHHS, 1999b). Older adults also may experience chronic pain, physical disabilities, and handicapping conditions; impaired self-care; and reduced coping skills, that alone, or in combination, may act as risk factors for substance abuse and mental disorders (CSAT, 1998).

Protective factors at this time of life include social support in the form of family, peers, and informal relationships; more formal support groups; health and social services such as respite care; and opportunities for new, productive social roles (Mrazek and Haggerty, 1994). For example, self-help support groups for people experiencing bereavement have been found to improve the mental health status of widows and widowers (Administration on Aging, 2001; U.S. DHHS, 1999b; Mrazek and Haggerty, 1994).

Prevention Opportunities for Older Adults

The Surgeon General's Report on Mental Health (1999) recommends ways in which prevention can improve the independence and health of older adults. Specifically it calls for efforts to prevent depression and suicide, excess disability, and premature institutionalization. It also recommends grief counseling for widows and widowers, and calls for the prevention of medication side-effects and adverse reactions.

The physicians of older adults are unlikely to identify a substance abuse problem in their patients, even though 87 percent of older adults see their physician regularly (Raschko, 1990 in CSAT, 1998). Further, approximately 40 percent of older adults do not self-identify or seek services for substance abuse problems. To overcome these problems in identification and screening it is important to improve identification efforts among the various disciplines of health care providers and apply "multitiered, nontraditional case-finding methods within the community." (Derry, 2000; CSAT 1998). Often people such as friends, family, senior center employees and volunteers are in a position to know the daily lives and routines of older adults. It is necessary to engage these people who are closely involved with older adults to be aware of behavioral changes that may indicate a problem (CSAT, 1998).

Realizing these goals can be complicated by the frequent isolation of older adults in their homes. A unique program, now 25 years old, uses nontraditional community referral sources, "gatekeepers," to identify at-risk older adults who typically do not come to the attention of service providers (Administration on Aging, 2001).


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