April 29, 2013, 2:31 pm
A Rising Tide of Substance Abuse
By RICHARD A. FRIEDMAN, M.D.
America’s 78 million aging baby boomers are heading into retirement with more than their considerable wealth, health and education. They are also bringing into their golden years an epidemic of drug and alcohol abuse and mental illness that has yet to be recognized, according to a recent Institute of Medicine report.
The notion that the elderly might be abusing or addicted to alcohol, illicit drugs or prescription medications may strike some as improbable. After all, the common notion is that alcohol and substance abuse are for young people.
Dead wrong. Baby boomers, who came of age in the ’60s and ’70s when experimenting with drugs was pervasive, are far more likely to use illicit drugs than previous generations. For example, a 2011 study by the Substance Abuse and Mental Health Services Administration found that among adults aged 50 to 59, the rate of current illicit drug use increased to 6.3 percent in 2011 from 2.7 percent in 2002. Aside from alcohol, the most commonly abused drugs were opiates, cocaine and marijuana.
To get a sense of the magnitude of this looming mental health crisis, consider that in 2010 the best estimates are that six to eight million older Americans — about 14 percent to 20 percent of the overall elderly population — had one or more substance abuse or mental disorders. The number of adults aged 65 and older is projected to increase to 73 million from 40 million between 2010 and 2030, and the numbers of those needing treatment stands to overwhelm the country’s mental health care system.
Detecting drug or alcohol problems in the elderly is difficult in part because family members and clinicians alike are reluctant to ask about it. Perhaps it’s just a form of ageism, but drug abuse is not the first thing that pops into the mind of physicians when they encounter an older patient.
My mother has Type 2 diabetes, but she won’t eat. My father gets up and snacks in the middle of the night. My mom’s A1c is almost 8 percent. Why won’t she use her glucometer?
Dr. Medha Munshi, director of the geriatrics program at the Joslin Diabetes Center in Boston, hears these and other gripes from her patients’ children all the time. And they’re right to worry about diabetes, which affects nearly 27 percent of older adults. Older diabetics face higher risks of such complications as heart attacks, kidney disease and blindness; they’re more likely than other seniors to wind up in nursing homes.
But Dr. Munshi’s response often startles anxious relatives. “You can relax a little,” she often tells them. “Sometimes quality of life is more important than achieving a certain number.”
Treatments and their risks and benefits play out differently in the elderly population, she noted in a recent interview. Diabetes is rarely the only ailment affecting people in their 70s and 80s; most must cope with several chronic conditions, along with their associated medications. That makes keeping blood sugar at reasonable levels a complicated business.
Moreover, treating diabetes too aggressively can make seniors more prone to hypoglycemia, or low blood sugar. For frail older people with multiple conditions, the condition can be more dangerous than high blood glucose readings.
“If it goes too low, it can aggravate existing medical conditions like heart disease and cognitive disability,” Dr. Munshi said. Depending on which medication is prescribed, “it can make people dizzy, so it increases the risk of falls and fractures.” A 40-year-old who falls will probably get up uninjured, she said, while “an 80 year-old can be harmed by the treatment of the disease itself.”
The Choosing Wisely campaign, which alerts doctors and patients to questionable and overused tests and treatments, made the same point in February. The American Geriatrics Society, participating in the campaign, cautioned against prescribing medications to reach “tight glycemic control,” which the group defined as below 7.5 on the commonly used A1c test.
Dr. Munshi assures family members that a 7.5 or 8 reading isn’t as risky as it might appear. The serious complications of diabetes commonly develop over decades. So while younger diabetes patients should work hard to prevent them, for seniors with fewer years ahead, “we are not looking at tight control to prevent complications in 40 years,” she said. “You don’t want to harm people today to avoid things that might not happen tomorrow.”
Another reason to treat diabetes differently in older people: They may find it increasingly difficult to manage the daily monitoring, medications and dietary requirements. “No other disease requires as much self-care,” Dr. Munshi said.
Cognitive impairment that affects decision-making and memory, depression that makes patients less able to handle self-care, worsening eyesight that makes it harder to use glucometers or syringes — all can make diabetes routines more challenging.
“If we give patients complex regimens, they won’t be successful” and will make errors, Dr. Munshi said.
In fact, The New England Journal of Medicine just published data from the Centers for Disease Control and Prevention, Emory University and the National Institutes of Health showing that among diabetics over 65 without complications, only about two-thirds maintained target glucose levels when the A1c goal was 7, but more than 80 percent met a less strict 7.5 target. Among those with complications, more than 84 percent met an 8 percent A1c target. (Older people generally did a better job at meeting their targets than younger groups, by the way.)
“The trick is in understanding the barriers,” Dr. Munshi said. If patients are alone at home and likely to forget midday medications, for instance, her team may devise a different schedule or prescribe a combined insulin dose in the morning, using a longer-acting formulation.
Exercise is crucial, but older patients have more trouble getting outside or to gyms and they may fear falls. “They think they have to walk fast for 30 minutes,” Dr. Munshi said. She urges them to start by walking inside their houses for five minutes before each meal.
Geriatric medicine involves compromises and balance. “It may not be the best way to treat diabetes, but it’s the best way to treat the patient,” she said.
As for those occasional ill-advised snacks, Dr. Munshi is fairly tolerant of those, too. “If they want to eat something, let them,” she said of her elderly patients. “It’s not just one disease they’re dealing with. It’s life.”
Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”