More elderly patients with substance abuse issues are using the emergency department for their only means of intervention. Last week, two elderly patients in their seventh and eighth decades of life, presented to the ED, one confabulating and inebriated with a blood alcohol level many times the legal limit and the other with a daily alcohol consumption of two-three drinks along with being addicted to opiates.  They have had multiple ED encounters, specialty care visits and yet virtually no continuity regarding their underlying mental health care and substance abuse counseling.  The only outpatient offering was to have follow up crisis intervention based on the next available opening, which was several months later and never occurred.  A family member of one of the patients shared their insight, that the increased daily alcohol use and reliance on pain medication was just a part of getting old and a way to get through the day.  Alcohol abuse amongst the elderly can be a very insidious and quickly overlooked, and has been coined the invisible epidemic. “It is believed that about 10% of this country’s population abuses alcohol, but surveys revealed that as many as 17% of the over-65 adults have an alcohol-abuse problem.”  Addiction Medicine FYI: Elderly Alcohol and Substance Abuse, NY State Office of Alcoholism and Substance Abuse Services

Amongst the more than 130,000,000 emergency department visits throughout the US in 2014, there have been a higher percentage of patients with mental health disorders requiring assessments and follow up services.  It is very challenging to get exact percentages of those with mental health disorder diagnostic codes (MHD-DC) and it can vary widely, from less than 5% to 20% or more of patient encounters depending on the setting and demographics.  Unfortunately, EDs are finding themselves far less prepared to offer the necessary baseline care for psychiatric conditions, and particularly so for the elderly, a mounting problem without viable solutions that has been recognized for several years“One-quarter of the prescription drugs sold in the United States are used by the elderly, and the prevalence of abuse of these agents may be as high as 11%.  Commonly prescribed drugs with abuse potential include those for anxiety, pain, and insomnia, such as benzodiazepines, opiate analgesics, and skeletal muscle relaxants. A review of medical records of 100 elderly patients who were dependent on prescription drugs and were admitted to the Mayo Inpatient Addiction Program between 1974 and 1993 assessed the frequency of abuse by type of prescription drug. The most commonly abused were sedative/hypnotics (mostly benzodiazepines) and opioid analgesics.”  Substance Abuse in Aging and Elderly Adults, Psychiatric Times, July 27, 2012.

As our country’s population continues to grey with the baby boomers, those born between 1946 and 1964, the risks and challenges in recognizing and treating mental health disorders and substance abuse in the elderly is going to push the already strained resources, particularly in acute care settings, at a far greater pace.  Fortunately, there is evidence-based support in treating substance abuse in this population that sets it apart from treating addiction in the population at large.  “In a 2004 paper published in the American Journal of Psychiatry, the researchers found that study participants were more open to receiving mental health and substance abuse treatment within primary care (the integrated model) than in specialty clinics (the referral model). ‘People vote with their feet,’ said lead author Stephen J. Bartels, M.D., M.S., a professor of psychiatry and community and family medicine at Dartmouth Medical School in Hanover, NH. ‘The engagement step is substantially facilitated by integrated, collaborative care, even when we did everything we could to make the referral model the Cadillac of referrals.’”  Treatment for Older Adults: What Works Best? SAMHSA News, Jan/Feb, 2007, Vol. 15, No. 1

As providers facing more geropsychiatric patients with substance abuse issues, there needs to be accurate use of data along with analytic assessments to effectively integrate resources for this patient population. “The high numbers of ED visits and hospital admissions for patients with any type of MHD-DCs, for those aged ≥65 years (especially with dementia), and for those with low-acuity MHDs [mental health disorder diagnostic codes], indicate a need for system adjustment. Strategies are needed to counteract the effects of inpatient bed shortages and the increased volume of MHD-DC-related visits to EDs. Surveillance is the first step, because identifying trends in ED use by patients with MHDs can guide policies and procedures designed to reduce hospitalization, improve access to ambulatory care services, and develop new ways to care for the elderly with MHDs in the ED.”  Emergency Department Visits by Patients with Mental Health Disorders- North Carolina, 2008-2010., CDC MMWR, June 14, 2013. This is a patient population who really would benefit by the next available appointment and/or walk-in availability offered by integrated primary care models.

The gap in not addressing MHDs and substance abuse in the elderly is getting bigger and is a huge concern.  Yet, it is a population that is more responsive in several ways to primary care interventions, than several others. Therefore, opportunity exists to make a difference through integrating and increasing the availability of primary care and mental health resources.  We currently have very limited options and leave many of our elderly patients and their families with nowhere else turn, other than the ED and awaiting specialty services, which are next to impossible to access or never become integrated in patients’ continuum of care.


Lukas Kolm, MD, MPH

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