Title : QGCoverTIP26 9-4-01gvp.qxd (Page 2)
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Quick Guide
For Clinicians

Based on TIP 26
Substance Abuse Among
Older Adults

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Contents
Why a Quick Guide?  . . . . . . . . . . . . . . . . . . . 2
What is a TIP?  . . . . . . . . . . . . . . . . . . . . . . . 3
Introduction  . . . . . . . . . . . . . . . . . . . . . . . . . 4
Alcohol and the Older Adult  . . . . . . . . . . . . . 6
Prescription Drugs and the Older Adult  . . . . 8
Risk Factors  . . . . . . . . . . . . . . . . . . . . . . . . 10
Screening for Substance Abuse . . . . . . . . . 13
Brief Interventions  . . . . . . . . . . . . . . . . . . . 16
Legal Issues  . . . . . . . . . . . . . . . . . . . . . . . 19
Resources  . . . . . . . . . . . . . . . . . . . . . . . . . 20
Glossary  . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

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Quick Guide
For Clinicians



This Quick Guide is based almost entirely on information con
tained in TIP 26, published in 1998 and based on information
updated through October 1996. No additional research has
been conducted to update this topic since publication of the
original TIP.
Based on TIP 26
Substance Abuse Among
Older Adults

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2
Substance Abuse Among Older Adults

WHY A QUICK GUIDE?

This Quick Guide was developed to accompany
Substance Abuse Among Older Adults, Number 26
in the Treatment Improvement Protocol (TIP)
Series published by the Center for Substance
Abuse Treatment (CSAT), Substance Abuse and
Mental Health Services Administration. This Quick
Guide is based entirely on TIP 26 and is designed
to meet the needs of the busy clinician for con
cise, easily accessed "how-to" information.

The Guide is divided into nine sections (see
Contents). These sections will help readers quickly
locate relevant material.

Terms related to substance abuse among older
adults are listed on page 22 in the Glossary.
These terms are included to enable clinicians to
talk knowledgeably with their clients and clients'
medical providers. The Resources section on page
20 provides information on developments in the
field of substance abuse treatment for older
adults.

For more information on the topics in this Quick
Guide, readers are referred to TIP 26.

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What Is a TIP? 3

WHAT IS A TIP?

The TIP series has been in production since 1991.
This series provides the substance abuse treat
ment and related fields with consensus-based,
field-reviewed guidelines on substance abuse
treatment topics of vital current interest.

TIP 26, Substance Abuse Among Older Adults

• Addresses concerns of a broad range of readers
including clinicians, social workers, medical per
sonnel, mental health workers, program admin
istrators, and policymakers
• Includes extensive research
• Lists numerous resources for further informa
tion
• Is a comprehensive reference for clinicians on
substance abuse treatment for older adults
See the inside back cover for information on how
to order TIPs and other related products.

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4
Substance Abuse Among Older Adults

INTRODUCTION

Facts
• Abuse of alcohol and prescription drugs among
adults 60 and older is one of the fastest growing
health problems facing this country.
• In the United States, it is estimated that 2.5 mil
lion older adults have problems related to alcohol.
• Adults age 65 and older consume more pre
scribed and over-the-counter medications than
any other age group.
Myths
• Treating older adults for substance use disorders
is not worthwhile.
• Alcohol or substance abuse problems cannot be
successfully treated in older adults. 
• Treatment for this population is a waste of
health care resources. 
These attitudes are not only misguided, but dan
gerous, and this Quick Guide is designed to pro
vide clinicians with methods for identifying and
handling substance abuse in older Americans.

The Problem Now
Problems stemming from alcohol consumption,
including interactions of alcohol with prescribed
and over-the-counter drugs, far outnumber any

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Introduction 5

other substance abuse problem among older
adults. Many over-the-counter drugs negatively
interact with other medications and alcohol.

The Problem Projected
It will be increasingly difficult for substance abuse
among older adults to remain a hidden problem
as “Baby Boomers” approach old age in the com
ing years. Not only are adults in general living
longer, substance abusers are also living longer
than ever before.

The overall increase in alcohol problems through
out the population, coupled with the aging of the
“Baby Boomers,” suggests that the number of
older adults with alcohol-related problems will rise
alarmingly.

Older Adults’ Unique Vulnerabilities
Drinking can be medically dangerous for older
adults even if they don't drink enough to be for
mally diagnosed with alcohol abuse or depend
ence. Undiagnosed psychiatric and medical condi
tions can further complicate treatment of older
people with substance abuse disorders. A thor
ough evaluation of all problems is essential when
caring for older adults.

For more detailed information, see TIP 26, 
pp. 1–5.

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6
Substance Abuse Among Older Adults

ALCOHOL AND THE OLDER ADULT

Clinicians need to tell older clients that three age-
related changes significantly affect the way an
older person responds to alcohol:

• The normal decrease in body water that comes
with age means the same amount of alcohol
that previously had little effect can now cause
intoxication.
• These changes in body water increase sensitivi
ty and decrease tolerance to alcohol.
• The decrease in the rate of metabolism of alco
hol in the gastrointestinal tract means blood
alcohol level remains raised for a longer time
and an increased strain is placed on the liver.
Clinicians should also tell clients that these age-
related changes, combined with alcohol consump
tion, can trigger or worsen serious problems
including

• Heart problems
• Risk of stroke
• Cirrhosis and other liver diseases
• Gastrointestinal bleeding
• Depression, anxiety, and other mental health
problems

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Alcohol and the Older Adult 7


Age-Appropriate Consumption Levels

The following are recommendations for low-risk
drinking for people over the age of 65

• No more than one drink per day
• Maximum of two drinks on special occasions
(New Year's Eve, weddings)
• Somewhat lower limits for women
A standard drink is 12 oz. of beer or ale; 1.5 oz. of
hard liquor; 5 oz. of wine; or 4 oz. of sherry,
liqueur, or aperitif.



For more detailed information, see TIP 26, 
pp. 13–19.

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8
Substance Abuse Among Older Adults

PRESCRIPTION DRUGS AND THE
OLDER ADULT

Many older adults take a variety of prescription
medications, many of which can interact negative
ly with alcohol. Older adults can also become
dependent on psychoactive medications (such as
benzodiazepines or opioids) without realizing it.
Older patients are more likely to misunderstand
directions for appropriate use of medicines, a
problem compounded by the multiple prescrip
tions they receive (often from multiple physicians).

Unintentional misuse can, however, progress into
abuse if an older adult continues to use a medica
tion for the desirable effects it provides, much as
a person who abuses any drug does.

Recognize the Signs
Psychoactive substance use, even at therapeutic
doses, has been associated with a variety of nega
tive central nervous system effects. Clinicians
should be on the lookout for any of the following
indications of problematic psychoactive substance
use:

• Diminished psychomotor performance
• Impaired reaction time
• Loss of coordination

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Prescription Drugs and the Older Adult 9

• Falls
• Excessive daytime drowsiness
• Confusion
• Aggravation of emotional state
• Amnesia 
• Dependence 
These reactions may be more serious in frail older
adults and in those with multiple chronic dis
eases.

For more detailed information, see TIP 26, 
pp. 31–35 and p. 44, for information on drug and
alcohol interactions.

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10
Substance Abuse Among Older Adults

RISK FACTORS

Clinicians should be aware that any of the follow
ing can trigger or worsen a substance use prob
lem.

Emotional and Social Problems
• Bereavement and sadness 
• Losses: of spouse, friends, family members,
social status, occupation and sense of profes
sional identity, hopes for the future, and ability
to function
• Social isolation and loneliness
• Reduced self-regard or self-esteem
• Family conflict and estrangement
• Problems in managing leisure time/boredom
• Loss of physical attractiveness
Medical Problems
• Loss of hearing or sight
• Chronic pain
• Physical disabilities and handicapping condi
tions
• Reduced mobility
• Insomnia
• Cognitive impairment and change

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Risk Factors 11

Practical Problems
• Impaired self-care
• Dislocation from housing
• Reduced coping skills
• Loss of income or increased health care costs
Watch For:
• Older men when their wives die: Depression,
development of alcohol problems, and suicide. 
• Medical settings: High rates of alcoholism
reported in medical settings indicate the need
for screening and assessment of patients for
problems other than substance abuse.
• Substance use disorder earlier in life: Research
suggests that a previous drinking problem is the
strongest indicator of a problem in later life,
especially among men.
• Mood disorders: Depression can lead to drink
ing, particularly among women. Patients with
severe cognitive impairment generally drink less
than nonimpaired people who use alcohol.
Those who are only mildly impaired may
increase use.
• Family history: Genetics may be a greater factor
in problem drinking in early onset than in late
onset males with substance abuse disorders.

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12
Substance Abuse Among Older Adults

• Psychoactive prescription drug use: The aging
process makes prescription drug use both more
likely and more risky, especially for females in
poor health.
• Psychiatric diagnoses: Older patients with sub
stance dependence disorders are more likely
than younger people with substance abuse dis
orders to have a dual diagnosis. Older adults
with a preexisting psychiatric disorder may be
more at risk to also develop a prescription drug
dependence.

For more detailed information, see TIP 26, 
pp. 23–35, p. 76.

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Screening for Substance Abuse 13
Ideally, all adults age 60 and over should be
screened for alcohol and prescription drug abuse
as part of a regular physical examination. 
SCREENING FOR SUBSTANCE ABUSE

Who and When To Screen



Rescreening should take place if the physical
symptoms listed below develop or if the older per
son is undergoing major life changes or transi
tions.

• Sleep-related problems
• Cognitive difficulties
• Seizures, malnutrition, muscle wasting
• Liver function abnormalities
• Persistent irritability (without obvious cause)
and altered mood, depression, or anxiety
• Unexplained complaints about chronic pain
• Incontinence, urinary retention, difficulty urinating
• Poor hygiene and self-neglect
• Unusual restlessness and agitation
• Complaints of blurred vision or dry mouth
• Unexplained nausea and vomiting

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14
Substance Abuse Among Older Adults

• Changes in eating habits
• Slurred speech
• Tremors, poor motor coordination, shuffling gait
• Frequent falls or unexplained bruising
Screening Instruments
For information on screening instruments, see TIP
26, pp. 53–57. For examples of several screening
instruments, see TIP 26, Appendix B.

Communicating Results
• Describe the impact that alcohol or prescription
drug abuse is having on the client's health or
functional status.
• Spell out how reducing or stopping use will
improve the person's life.
• Present options for addressing the problem.
Delirium and Dementia
Screening for substance abuse can be hampered
by the presence of a severe cognitive impairment.
If a client seems disoriented or "out of it," it is pos
sible that he or she has delirium or dementia. It is
particularly important to distinguish between
dementia and delirium, which can be mistaken for
each other by clinicians diagnosing older patients.

Withdrawal from psychoactive drugs can induce
delirium. Although delirium is relatively rare and

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Screening for Substance Abuse 15

generally reversible, it is very dangerous and
should be considered a medical emergency. Signs
of delirium include

• Disorientation
• Impaired attention, concentration, and memory
• Anxiety, suspicion, and agitation
• Misinterpretation, illusions, or hallucinations
• Delusions, speech abnormalities
Dementia is generally a chronic, progressive, and
irreversible cognitive impairment. Dementia
makes it more difficult to monitor outcomes of
drinking (clients may forget they drank), to get
clients into treatment, and to benefit from treat
ment. Signs of dementia include

• Impairments in short- and long-term memory,
abstract thinking, and judgment
• Language disorder
• Personality change or alteration
• Mood disturbances

It may be helpful to enlist family or close friends to
assist with a client who exhibits signs of delirium
or dementia.

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16
Substance Abuse Among Older Adults

BRIEF INTERVENTIONS

Because many older at-risk and problem drinkers
are ashamed about their drinking, intervention
strategies need to be especially nonconfrontation
al and supportive. A brief intervention should
include the following

• Feedback on screening responses
• Reasons for drinking
• Consequences of heavier drinking
• Reasons to cut down or quit drinking
• Sensible drinking limits and strategies for cut
ting down or quitting
• "Prescription" form drinking agreement
• Ideas on coping with risky situations
One approach to facilitate brief interventions is
known by the acronym FRAMES. This approach
emphasizes

• Feedback of personal risk or impairment as
derived from the screening
• Personal responsibility for change
• Clear advice to change
•A menu of options to increase the likelihood
that the patient will find a responsive treatment

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Brief Interventions 17
Motivational counseling can help offset the denial,
resentment, and shame experienced during an
intervention and can serve as a prelude to referral.
• An empathic counseling style
• Enhanced client self-efficacy and ongoing 
followup
Motivational Counseling
Motivational counseling acknowledges differences
in readiness for change and offers an approach
for "meeting people where they are" that has
proven effective with older adults. In this
approach, an understanding and supportive clini
cian listens respectfully and accepts the older
adult's perspective on the situation as a starting
point and then

• Helps to identify the negative consequences of
drinking or prescription drug misuse
• Helps to shift perceptions about the impact of
drinking or drug-taking habits
• Empowers the client to generate insights and
solutions 
• Expresses belief in the person's capacity for
change

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18
Substance Abuse Among Older Adults

About Treatment
The following six features should be incorporated
into treatment of the older person with a sub
stance abuse disorder:

• Age-specific, supportive, and nonconfrontational
group treatment that aims to build or rebuild
the client's self-esteem
• A focus on coping with depression, loneliness,
and loss
• A focus on rebuilding the client's social support
network
• An appropriate pace and content of treatment
• Staff members who are interested and experi
enced in working with older adults
• Linkages with medical services, services for the
aging, institutional settings for referral into and
out of treatment, and case management


For more detailed information, see TIP 26, 
pp. 66–73.

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Legal Issues 19
Neither this Quick Guide nor TIP 26 should be con
sidered a substitute for competent legal advice
from a qualified attorney.
LEGAL ISSUES



Disclosure and Consent
• Each State has its own set of rules, which
means that the scope of protection offered by
State law varies widely.
• These laws differ from Federal laws that govern
consent to disclose substance abuse-related
information.
• In most situations, providers can follow these
simple rules: (1) consult the client, (2) let the
client decide, and (3) be sensitive to how infor
mation is recorded or disclosed.
Legal Resources
• State Department of Health
• Single State Agency for Substance Abuse 
• State Attorney General
• Local bar associations
• Agency board members who are attorneys
• Local law schools
For more detailed information, see TIP 26, 
pp. 107–119.

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20
Substance Abuse Among Older Adults

RESOURCES

AARP
601 E Street, NW
Washington, DC 20049
(202) 424-2277
(202) 434-2562 (fax)
www.aarp.org
National Center on Addiction and
Substance Abuse at Columbia University
152 West 57th Street
New York, NY 10019
(212) 841-5200
(212) 956-8020 (fax)
www.casacolumbia.org
Join Together
441 Stuart Street
Boston, MA 02116
(617) 437-1500
(617) 437-9394 (fax)
www.jointogether.org
National Aging Information Center
U.S. Administration on Aging
330 Independence Avenue, SW, Room 4656
Washington, DC 20201
(202) 619-7501
(202) 401-7620 (fax)
http://www.aoa.gov/naic 

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Resources 21

SAMHSA’s National Clearinghouse for Alcohol and
Drug Information (NCADI)
P.O. Box 2345
Rockville, MD 20847-2345
(800) 729-6686
(301) 468-6433 (fax)
(800) 487-4889 (TTY)
www.samhsa.gov
National Council on the Aging
409 3rd Street, SW, Suite 200
Washington, DC 20024
(202) 479-1200
(202) 470-0735 (fax)
www.ncoa.org
National Institute on Aging
Public Information Office
Bldg. 31, Rm. 5C2, 31 Center Dr., MSC 2292
Bethesda, MD 20892-2292
(800) 222-2225
(800) 222-4225 (TTY)
http://www.nih.gov/nia/
For more detailed information, see the front
inside cover of TIP 26.

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22
Substance Abuse Among Older Adults

GLOSSARY
Case management: The coordination and moni
toring of the varied social, health, and welfare
services needed to support an older adult's treat
ment and recovery.

Delirium: A potentially life-threatening illness that
requires acute intervention, usually hospitaliza
tion.  Can often be reversed with proper medical
treatment. 

Dementia: A chronic, progressive, and generally
irreversible cognitive impairment sufficient to
interfere with an individual's daily living.

Older adult: For the purposes of this Quick Guide,
a person age 60 or older.

Problem drinker: One whose patterns of alcohol
use are more hazardous than at-risk drinkers. The
threshold for problem alcohol use decreases with
advancing age.

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Ordering Information
TIP 26 Substance Abuse Among
Older Adults

TIP 26-Related Products

TIP 26 Reference and Resource Guide for 
working with Hispano/Latino patients (English)
TIP 26 Reference and Resource Guide for 
working with Hispano/Latino patients (Spanish)
TIP 26 Consumer Brochure on Substance Abuse
TIP 26 Consumer Brochure on Mental Health
KAP Keys for Clinicians based on TIP 26

Do not reproduce or distribute this publication for a fee without specific,
written authorization from the Office of Communications, Substance
Abuse and Mental Health Services Administration, U.S. Department of
Health and Human Services.



Easy Ways to Obtain Free Copies 
of All TIP Products
1. Call SAMHSA’s National Clearinghouse for Alcohol
and Drug Information (NCADI) at 800-729-6686, 
TDD (hearing impaired) 800-487-4889
2. Visit CSAT’s Web site at www.csat.samhsa.gov

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Other Treatment Improvement
Protocols (TIPs) that are relevant to
this Quick Guide:



See the inside back cover for ordering information for all
TIPs and related products.


DHHS Publication No. (SMA) 01-3585
Printed 2001
TIP 19, Detoxification From Alcohol and Other
Drugs (1995) BKD172
TIP 24, A Guide to Substance Abuse Services for
Primary Care Clinicians (1997) BKD234
TIP 27, Comprehensive Case Management for
Substance Abuse Treatment (1998) BKD251
TIP 34, Brief Interventions and Brief Therapies
for Substance Abuse (1999) BKD341
TIP 35, Enhancing Motivation for Change in
Substance Abuse Treatment (1999) BKD342