Dementia + Addiction Complicates Diagnosis and Treatment
Experts explain what can help people untangle the problems
Substance use disorders are a growing problem among the older population. Add a diagnosis of dementia and the situation can become nearly impossible to manage without professional intervention. Experts say as boomers age, this scenario will only become worse without adequate resources and training for caregivers, physicians and mental health professionals.
Family caregivers need to be aware of the warning signs of a substance disorder in an older loved one and take action to keep them safe and healthy. However, that’s easier said than done.
Even experienced professionals can have trouble telling the difference between brain changes caused by addiction/substance abuse and those caused by dementia, because the two are so closely intertwined. Misdiagnoses or missed diagnoses are common, since symptoms such as forgetfulness, behavioral changes, balance and cognition problems are common to both.
“If you do have cognitive impairment and you're actively drinking, the only way you can tell the degree of impairment is to get sober, and then see how well your cognition clears up on its own,” says Dr. George Dawson, a psychiatrist with the Hazelden/Betty Ford Foundation in Minnesota. Dawson is board-certified in geriatrics and addiction. Incidentally, despite all of the attention given to prescription opioids, most of the older adults Dawson treats actually struggle with alcohol abuse.
Problems Specific to Older Adults
More than 1 million individuals 65 or older had a substance use disorder (misuse of a substance and/or addiction -- meaning physical dependence) in 2014, including 978,000 older adults with an alcohol use disorder and 161,000 with an illicit drug use disorder, according to the Substance Abuse and Mental Health Services Administration (SAMHSA).
Loss of a spouse, grief, retirement, moving, all of the role changes and transitions people go through when they get older, are risk factors for developing a problem with alcohol or drugs, Dawson says.
"Since dementia affects our ability to manage our own behaviors, it's hard to expect someone with (a substance use disorder) will change on their own."
Treatment for substance disorder is challenging at any age, but older adults tend to have much more pervasive problems – meaning longer durations of illness, potentially greater levels of substance tolerance, more severe withdrawal and overall longer durations of maladaptive behaviors, experts at SAMHSA said.
Adding to the complexity of the problem are often co-existing medical conditions, like hypertension, diabetes, cardiovascular disease, which must be managed along with their substance and cognition problems.
Alcohol can interact dangerously with medications taken by older adults, including over-the-counter drugs, herbal remedies and prescriptions. Alcohol can also worsen common medical conditions, including high blood pressure, diabetes, osteoporosis, memory loss and mood disorders. The effects of combining several medications or pairing medications with alcohol is stronger in older adults than younger adults; it often results in a trip to the emergency department, according to SAMHSA data.
“Alcohol is legal almost everywhere. It has immediate effects, and it's less scary than other things because it is socially acceptable. You don't hear about people overdosing on alcohol, even though it happens,” Dawson says.
Both prescription and illegal drugs pose greater risk to older adults, especially if they are also cognitively impaired. Physicians tend to overprescribe medications and many are not well trained in geriatric care according to Dr. Yu-Ping Chang, a School of Nursing professor at the University at Buffalo in New York.
“Since dementia affects our ability to manage our own behaviors, it’s hard to expect someone with (a substance use disorder) will change on their own,” says Chang, whose research focuses on substance abuse and depression in older adults, as well as dementia care. “As the disease progresses, there are decreased levels of self-awareness, and they need lots of help.”
When impairment in memory or cognition occurs, it affects a person’s ability to remain compliant with medications, attend treatment and conduct the activities of daily living. Chang says caregivers need to be more involved earlier in treatment, and ensure compliance with the treatment plan.
Opioid Crisis ‘Hitting Older Adults Hard’
A third of Medicare enrollees were prescribed opioids as of 2016, according to Jason Molony, a program manager in the section of Geriatrics & Palliative Medicine at The University of Chicago Medicine. Molony, a social worker with geriatric training, runs a federally-funded patient education program around opioids, targeted to underserved communities on the margins of the health care system.
“More people died of opioid overdoses in Chicago than died of gun violence,” he says. “The rate was much higher among older and middle-aged adults than among younger people. It’s hitting older adults hard.”
Researchers from Johns Hopkins University found that between 2004 to 2015, first-time treatment admissions of U.S. adults age 55 and older increased from roughly 10% to more than 20%. Even more alarming, the number of first-time admissions of those 55 and older using heroin doubled between 2012 and 2015.
The Johns Hopkins study also found that older adults entering treatment for heroin use were more likely to be male, Black, retired and living in urban areas -- the same group Molony and his team are working to educate about substance use disorders.
Since many older adults are more socially isolated than younger people, adverse consequences of drug and alcohol use can pile up unseen. “It may be hard for people with dementia or cognitive impairment to recall what medications they had or hadn't used. You could also have an accidental overdose situation where somebody thought this was their first glass of wine and really, it's their fourth, or the same thing with a pill,” Molony says.
Involvement of Caregivers
Substance use disorder — which ranges from mild to severe — commonly triggers differences in routine behavior or abilities. Obvious signs may include financial difficulty or mismanagement, like past-due bills, or an empty refrigerator. Mood changes, such as increased irritability, and social isolation are common signs.
Caregivers should consider whether their loved ones have had any new difficulties with basic activities like bathing or dressing, or difficulty sleeping. Check the prescription bottles and see whether they are seeking refills sooner than they should, based on the pill supply and dosage. Also, be aware of any nausea, vomiting or unexplained injuries, experts advise.
"There's also the issue of stigma, which can fall especially hard on a caregiver trying to come to terms with a potential substance use disorder."
Family caregivers may try to rationalize the behavior, such as, “‘Just let Mom have her wine, she's fine.’ Or, ‘she says she really needs these pills for her back and we shouldn't question it,’” Molony says, adding that caregivers should question it.
There’s also the issue of stigma, which can fall especially hard on a caregiver trying to come to terms with a potential substance use disorder. While it’s hard to think your parent might have a drug or alcohol problem, “respectful nosiness” may be warranted if the signs point there, Molony says. “Maybe take a look in the medicine cabinet and see what's there, and liquor cabinet as well. Mention your concerns to their provider,” he says.
Any change in medication use “must be carefully managed by a physician,” Chang adds, to avoid severe withdrawal symptoms or side effects.
Treatment Options are Lacking
Screening for substance use and alcohol disorders should be part of the routine medical visit for all people over 60, according to research in the New England Journal of Medicine. However, the authors point out, “There are no guidelines for the management of alcohol withdrawal that are specific for older patients. Studies suggest that alcohol treatment in older patients is more likely to be successful when the patients receive age-specific treatment.”
Detox is the first step to overcoming substance abuse disorder, but most rehab centers are not appropriate for older adults, because there are no geriatricians on staff, Chang says. Even fewer options exist for older adults with substance use disorder and dementia, despite increasing prevalence.
Meanwhile, much of the burden continues to fall on family caregivers. “Detox is generally inadequate in the United States, for people at any age, but mostly inadequate for the elderly. It counts on a caregiver that is going to be able to monitor that person 24/7,” Dawson says.
Some outpatient programs for older adults may be available, but they are difficult to find and access. And older adults who require residential treatment may face a mountain of insurance obstacles, along with lack of appropriate facilities. Medicare pays for some inpatient programs, but not the cost of a private clinic like Hazelden. It’s important to check with any program about insurance coverage to avoid surprise bills.
Those with co-occurring medical conditions or dementia fare better in a hospital environment, where geriatricians and other specialists are on staff to help manage a range of health issues. If acute withdrawal requires hospitalization, make sure the facility has experience treating older adults with substance use disorder, then transfer the person to an appropriate skilled nursing facility, SAMHSA advises.
“If I make a diagnosis of dementia, I don't think it's a good idea to expect them to go through the standard treatment that a younger person will go through without dementia, because they're not going to learn anything,” Dawson says, adding that these adults need a supportive environment that will help them stay sober. “Get them into an AA (Alcoholics Anonymous) or NA (Narcotics Anonymous) program somewhere; there are groups composed primarily of elderly people with varying levels of sobriety.”
“The journey of a thousand miles begins with one step,” said philosopher Lao Tzu. It’s no less true for substance abuse problems. Experts say that first step is the most important, so if you have concerns about yourself or a loved one, take that first step in getting help.
