Multiple indicators focusing on different alcohol-related domains should be used to describe alcohol use profiles among older patients

Multidimensional identification of relevant typologies could improve diagnosis and treatment by establishing the nature of alcohol problems and the various clinical and demographic differences among older adult treatment seekers.

Ageing populations, liberal use of alcohol and other drugs, improved treatment options for substance use disorder (SUD), and harm-reduction programmes have all contributed to longevity of individuals with SUD.

This has resulted in higher SUD prevalence and SUD-related problems among older adults. For example, the share of drug-related mortality among 50-year-olds and older in Sweden increased from 26% in 2000 to 36% in 2015.

While misuse of prescription drugs and rising use of illicit drugs are also concerns among older adults, alcohol use disorder remains the primary implicated substance in this age group. Swedish data, for example, show that the proportion of at-risk alcohol drinkers among those aged 65–84 years more than doubled between 2004 and 2016. Moreover, over 25% of Swedish patients hospitalised for alcohol-related diagnosis in 2004 were 60 years and older, and this proportion had grown to 40% in 2015.

Older adults invisible in SUD research and practice

While certain studies have predicted an ‘invisible epidemic’ of SUD among older adults, younger age groups have long been the priority for researchers, policy makers, and funders. Findings from systems and theories on the nature of the alcohol problem which were developed to describe and categorise individuals with alcohol use disorder are therefore questionable among older adults.

Detection of SUD in older adults has also been shown to be challenging due to its atypical presentation and similarities with physical and cognitive deteriorations, leading to misdiagnosis and reluctance to assess and refer appropriately. Furthermore, ageist assumptions among practitioners and arbitrary age cutoffs for treatment admission make SUD identification difficult.

Current evidence is not enough

Currently, as the strain on healthcare and services continues to increase, there is a sign of a shift among decision-makers towards addressing ‘the elephant in the room’. However, we need more evidence to make informed decisions about designing effective intervention and shifting the paradigm of addiction care for older adults. Much of the evidence on SUD, including alcohol typologies, is derived from younger study populations.

Despite the biopsychosocial attributes of alcohol use disorder and the heterogeneity of older adults, previous studies on this age group have used a dichotomous unidimensional classification based on the age of onset of problem drinking.

Predictably, by clamping older patients into early versus late onset groups, these studies have failed to discover the divergence in these addiction treatment seekers’ and service users’ sociodemographic characteristics, health profiles, and intervention needs.

Using the ASI for generating multidimensional alcohol subtypes

Jemberie and colleagues (2020) used data from the national Addiction Severity Index (ASI) database (between 2003 and 2017), which includes assessment data from the addiction treatment system in Swedish municipalities and regions, to identify heterogeneous subtypes among older treatment seekers.

The study included 1747 individuals (28% women) aged 50 years and older, all of whom reported, during their assessment, that there had been at least one day in the past 30 days where they had experienced alcohol problems. The researchers then constructed 11 lifetime and current indicators from six ASI risk/problem areas (somatic health, alcohol use, drug use, legal problems, family and social problems, and psychiatric health).

They performed statistical analysis on this risk/problem data and identified five heterogeneous groups of older adults with harmful alcohol use, varying in onset age, comorbidities, criminality, and illicit drug use.

Some older adults had better functionality

The first group, identified as a functional group with fewer alcohol-related consequences, accounted for one third of the study population. This group was mainly composed of men (about 75%), and they had a late onset of problem drinking. Compared to the other groups, they were older, had stronger social support, and were more likely to be employed.

Another group, predominantly male (87%), with early onset of problem drinking, had also reported a fair life-domain profile, second only to the functional group. However, given the chronicity of their problem drinking, this group had more treatment episodes, more incidences of delirium tremens and criminal charges for disorderly conduct.

Gender inequality in mental health

The third group, with late onset of problem drinking similar to the first group, was characterised by high levels of anxiety and depression. Almost half of this cluster were women (only 28% of the total treatment seekers were women). Group members reported very high levels of loneliness, current depression and anxiety, and histories of emotional, sexual, and physical abuse.

The fourth group of older adults with harmful alcohol use had started problem drinking at a very early age and reported several mental health problems (anxiety, depression, suicidal ideations and attempts, impulsive behaviour) and isolation.  Women accounted for only 27% of the cases in this group.

These findings are particularly noteworthy: the study showed women were more likely to start problem drinking at a later age and also had other mental health comorbidity. Meanwhile, older male drinkers who had reported comorbid mental health problems had early onset age of problem drinking.  Previous studies that used onset age as the only criterion of classification reported a better profile for the late onset age group, and failed to discover this inequality.

Polysubstance use problem and multiple needs

The study by Jemberie and colleagues also found that the treatment seekers included a group of primarily older men (83%) with early onset of problem drinking (first ever intoxication at age 12) that had concurrent illicit drug use and very high paternal alcohol use.

About 60% of them were infected with either hepatitis B or C. While members of this group were under 65, they had high unemployment and early retirement rates as well as low education status, high criminality history, and mental health comorbidity.

The findings from the study show that dichotomising older treatment seekers by onset age does not capture the heterogeneity and multidimensionality of their problems and intervention needs.

Practitioners should be aware that despite similarities in the current alcohol use profile of their patients, there are significant differences by sub-group in mental health, polysubstance use, chronicity of alcohol use, and other attributes. These differences need to be acknowledged in order to design needs-matched interventions. Given their age, older adults may also benefit from accessible integrated addiction and mental healthcare.