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• W2972997887 abstract "The numbers of older adults with substance use disorders are increasing as populations age. Research is urgently needed to help understand factors underlying substance use and use disorders in this age group so that interventions to combat them can be effectively targeted. Populations in western countries are aging. Increasing life expectancies lead to prolonged risk exposure of substance use (SU) and substance use disorders (SUDs) late in life and to chronic or recurring SUD courses well into old adulthood 1. Factors typical for old adulthood (e.g. spousal loss, illness, pain) also presumably pose a risk for problematic SU and SUDs. Among older adults in western countries, prevalence rates are high for problematic SU and considerable for SUDs, spanning a range of substances 1-3. For example, prevalence rates of cannabis use, binge drinking and alcohol use disorder (AUD) among older adults aged 50+ have recently increased 4, 5, daily smoking is widespread (e.g. 15% in Danes aged 65–74 years) 2, nicotine dependence is among the most frequent mental disorders in 50–64-year-olds 6, benzodiazepine dependence occurs in 10% of users aged 65+ 7 and there is evidence of a recent increase in numbers of older adults seeking treatment for opioid use disorders 8. As SU and SUDs are important contributors to societal cost, morbidity and mortality, western societies are facing major public health challenges regarding older adults’ SU and SUDs; namely, timely and targeted prevention, detection and treatment. However, older adults’ problematic SU and SUDs remain under-detected and under-treated, and age-adapted prevention and intervention concepts are scarce, especially regarding older adults with dementia 9. Tacking these problems requires a sound knowledge of the predictors of SUD development late in life within a framework of life-time psychopathology. Analytical, prospective–longitudinal epidemiological studies with classificatory SUDs and other mental disorder diagnoses are essential, because they enable the unbiased identification of core aspects of SUD development as predictors and periods of risk. In older adults, with few exceptions, such studies are rare 3. In consequence, significant research gaps exist for this increasingly important topic, creating at least three critical barriers to tailored prevention and intervention for SUDs in older adults. First, predictors (e.g. mental disorders, policy changes) remain under-researched for SUD diagnoses and for the use of illegal 10 and prescription drugs. Despite substantial mental disorder prevalence among older adults 6 and indications that SUDs occur within underlying vulnerabilities for psychopathology 11, there are few studies of mental disorder diagnoses as risk factors of older adults’ problematic SU and SUDs, and those studies are often limited by insufficient case numbers. Knowledge gained from younger samples may not be transferable because of different age-related risk factor thresholds 12, 13. Existing studies also do not address mental disorder proximity and chronicity and life-time psychopathology vulnerabilities as predictors 11, 12. Secondly, pain, illness and insomnia are prevalent among older adults, affecting functioning and quality of life 14. Existing studies suggest that the role of such age-related factors in older adults’ SU and SUDs needs to be studied in relation to other mediating and moderating factors 15, but such research, especially on SUDs, is relatively rare. Thirdly, old adulthood spans several decades, but knowledge is limited on risk-periods of incidence, prevalence and critical transitions (progression, remission) of SU and SUDs in different age brackets within old adulthood. Existing studies indicate moderate to high stability of AUD and nicotine and benzodiazepine dependence in older adults 16, but SUD symptom patterns and the course of SUDs and SUD symptoms remain under-studied 7. These research gaps limit theoretical models of SUD etiology in older adults. Self-medication for age-specific factors (pain, isolation) is widely assumed to explain SU(D) in older adults, but existing studies do not clearly support this 15. Future research therefore needs to broaden self-medication models by investigating the role of age-specific risk factors in the context of prior SU and SUDs, proximity and chronicity of preceding mental disorders, life-time psychopathology vulnerabilities, early adversity and different pathways to SU and SUDs in old age. For example, life-time internalizing psychopathology could predict benzodiazepine use disorder in older adults. This risk could increase with internalizing disorder chronicity and proximity, prior SU intensity and upon occurrence of age-specific stressors. However, there are also methodological barriers to conducting epidemiological studies that would close those research gaps. Classificatory diagnostic instruments are crucial for high-quality, internationally comparable epidemiological data, but little is known about the psychometric properties of such instruments in older adults. Existing classificatory instruments may overlook mental disorders, including SUDs, in older adults by failing to adapt to older adults’ cognitive performance 17. Shortening questions and adding explanations might provide a better assessment of mental disorders for older adults 3. Under-reporting of SUDs in classificatory interviews with older adults may also be caused by misinterpreting questions due to different life circumstances. For example, older adults rarely admit to ‘alcohol use in hazardous situations’ 18, but they might not realize what constitutes a hazardous situation for an older adult (for example, climbing stairs with an unsteady gait). Here, content adaptations of interviews need to be researched. Importantly, these diagnostic requirements of older adults may pose a challenge in epidemiological studies where older adults are part of a sample with a broad age range. Epidemiological studies of older adults are also at risk of sampling bias towards healthy, well-functioning participants. To address this, institutionalized individuals could be included 19. However, this leads to diagnostic and ethical challenges when institutionalized people suffer from dementia. Also, health and disability status, where available from national registries, could be included in sampling weights. Finally, the choice of outcomes to study must be adapted to older adults, who may have lived through long periods of exposure. Whereas onset rates for SUDs among older adults are low 13, outcomes in the form of current and continued use are important among older adults. Outcomes studied should represent the range of different SU(Ds) in older adults, including SU(Ds) regarding illegal drugs and medications. In summary, analytical epidemiological research with prospective study designs, classificatory diagnoses and a life-time psychopathology perspective has an important role to play in understanding core aspects of SU and SUD etiology in old adults in aging western societies. This knowledge is a prerequisite for age-adapted prevention and intervention. Silke Behrendt has received speaking honoraria from institutions within the addiction care system in Germany." @default.
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• W2972997887 date "2019-11-01" @default.
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• W2972997887 title "Research is needed to understand substance use disorders in old adulthood" @default.
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• W2972997887 doi "https://doi.org/10.1111/add.14811" @default.
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