The issue of substance abuse is not a young privilege. From alcohol and cigarettes to "hard drugs", such as opioids and psychedelic substances, the issue seems to persist in all level of society.

The problem, however, is the lack of recognition that our parents may be an addict.

The hidden epidemic

The problem of substance abuse is a public health issue. Although the related literature is abundant in this field, most of them focus on niche populations such as drug addicts or patients with chronic pain. Relatively, little attention was given to the elderly population; probably, due to the common conception that the capacity for logical and rational thinking grows in conjunction with age.

However, emerging evidence suggests that the elderly have a growing propensity to abuse substances such as alcohol.

In developed nations such as the UK and Australia, risky drinking becomes a growing concern primarily in people over 50-year-old. Against the overall decline in risky drinking behaviour in the general population, the trend held strong in this particular older cohort. It was observed that episodic binge drinking was on the rise for older people as well.

One may argue that Asian countries have a vastly different drinking culture to that of our Western counterparts, in fact, some may not even have a problem at all when alcohol is prohibited for the majority of the population. Well, we may need to think again.

According to local reports, elderly (defined as one who's above 50-year-old) made up of just under 30% of the total drinking population, and more than one-in-three of them have the tendency to binge. The figure may be dwarfed by that of younger drinkers, but the impact should not be underestimated.

Professor Dr Philip George, a consultant psychiatrist and addiction medicine specialist, says Malaysian elderly have been found to abuse a myriad of substances. Alcohol is the most popular, but the older population is also abusing other substances such as nicotine and prescription drugs like benzodiazepines.

He says those who are above 55-years old in the country are the heaviest substance abusers.

When vulnerability creeps in...

Old people face considerably different challenges in life that propel them towards alcohol and drugs. Loneliness is among the most commonly cited issue, as children leave home and life-long friends or partners fall ill and die. These issues may be difficult for younger people to fathom, but the very real challenge of becoming old and frail has given the elderly a good reason to succumb to alcohol and drugs.

Diagnosing substance abuse is difficult in this population, not only do symptoms frequently masked by other co-existing conditions, such as dementia and depression, there is a significant social stigma that prevents them from seeking help in the first place. The shame of being labelled as an addict may further prevent family members to address the issue appropriately, where silence seems like the most fitting solution.

“Ageism” is another unique problem to the elderly that warrants scrutiny. The term was, as explained by the Substance Abuse and Mental Health Services Administration (SAMHSA), used to describe the society’s inclination to assign negative labels to the older population as a way to explain away their problems. Rather than clarifying the underlying medical, social, or psychological reasons that contribute to the clinical conditions, these people are simply being branded as "being old" and "senile".

The problem of ageism is further compounded by a lower expectation of a good quality of life after successful treatment, if treatment is given at all. The longevity these people enjoy turns out to be a primary reason for what the medical community calls “therapeutic nihilism”:

“They are going to die anyway, so what is the point of treatment?”

Unique approach to a niche population

Given the circumstances surrounding elderly who abuse alcohol and other substances, any treatment must be initiated with great care.

An editorial published by Rahul Rao and Ann Roche in the BMJ captured the issue succinctly. The authors argued that the appropriate identification of the different characteristics of these elderly substance abusers is critical to address the problem, as each distinct group requires different methods of assessment, interventions and treatment.

Health providers who are treating these older patients must pay additional attention to their specific age-related clinical needs. Most notably, these elderly patients may present with complex mental disorders such as cognitive impairment and depression, which contributes to their addiction.

In addition, the elderly is most likely to suffer chronic pain and other co-morbidities that warrant individualised approach to treatment. Systematic reviews have shown that age-adapted programmes are better at producing favourable outcomes for older people, resulting in “less severe addiction, higher rates of abstinence, improved health status and better aftercare”, as written by Rao and Roche.

All in all, there is an urgent need for a wider recognition that substance abuse among the elderly is as real as any other public health threats. To sufficiently address the issue also warrants a shift in medical thinking, that being old in life-year is not necessarily old, just think about young obese patients with multiple co-morbidities who may die much earlier than healthy old individuals. Thus, the society as a whole has little reason to abandon the elderly in our quest to pursue a better quality of life for all. MIMS

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