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To examine the prevalence and sociodemographic and health-related correlates of substance use, including alcohol, tobacco and non-medical drug use, among adults aged 65 years and older.
Cross-sectional, retrospective survey of a population-based sample, the 2001-02 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)
Eight thousand two hundred and five US adults aged 65 years of age and older. Measurements Prevalence of lifetime and past 12-month alcohol use, tobacco use, and non-medical drug use and associations among substance use and sociodemographic and health-related factors.
Almost 80% of older adults had used any of the three substances over their lifetimes and more than 50% reported such use over the past 12-months. Alcohol was the most commonly used substance both over the lifetime (74%) and in the past 12-months (45%), followed by tobacco (52% lifetime and 14% past 12-month use); far fewer reported non-medical use of drugs (5% lifetime and 1% past 12-month use). In general, being younger, male, and divorced or separated were factors consistently associated with use of any of the three substances compared to being older, female, and married.
Most older adults use substances both over their lifetimes and in the past 12-months. Alcohol is the substance of choice for this age group, followed by tobacco; few report non-medical drug use.
Compared with younger adults, fewer older adults report using substances including alcohol, tobacco and drugs for non-medical reasons.1-5 However, their use of such substances has a substantial impact on public health both because older adults are a large proportion of the population and they have increased health risks from substance use compared to younger adults.5 Estimates from the 2000 US Census indicate that adults aged 65 years and older were 12.4% of the US population; this percentage is estimated to increase to 19.6% by 2030 and to number more than 71 million persons.6 Increased health risks associated with substance use among older adults are due to age-related physiological changes that increase sensitivity to alcohol and drugs, an increased number of comorbid conditions, and concomitant use of medications that increase the potential harm from alcohol, tobacco and drugs used for non-medical reasons.7,8 Further, compared to earlier birth cohorts, the Baby Boomer generation (ages 45 to 63 years in 2009) uses more substances for non-medical purposes and this is expected to continue as they age.9
Although moderate alcohol use (e.g. 1 drink per day) among older adults has been associated with reduced risk for death, cognitive impairment, heart disease and related outcomes including disability,4,10,11 heavy alcohol use has been associated with an increased risk for harm.12 Even moderate alcohol use has been associated with increased mortality among older adults with comorbid conditions that may be worsened by alcohol or who take medications that can have negative reactions with alcohol.8 In contrast to alcohol, tobacco use is consistently associated with increased mortality and other health-related risks in adults.13,14 Finally, there are little data on non-medical use of drugs in older adults2,4,15,16 and no data on the health-related effects of such use in older adults.5 However, it is probable that non-medical use of drugs would have adverse effects on older adults’ health similar to, or more serious than, those observed among younger populations who use illicit drugs17 and also similar to the health-related risks among older adults who use prescribed psychoactive drugs including sedatives and opioids.4,18,19
Understanding sociodemographic correlates of substance use can target efforts to identify those who may be more likely to be using substances that may cause them harm, or in the case of alcohol, that may be beneficial. While such correlates are well documented among younger adults,2,20,21 they are poorly documented for older adults.4,19 To better understand the prevalence, sociodemographic and health-related correlates of lifetime and past 12-month substance use among older adults, we examined nationally representative data on alcohol, tobacco and non-medical drug use from the 2001-2002 National Institute on Alcohol Abuse and Alcoholism (NIAAA) National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) among a sample of 8,205 adults aged 65 years and older.22
The 2001-2002 NESARC is a population-based survey of the United States sponsored by the NIAAA.22 The target population was the civilian population 18 years and older residing in households and group quarters. Face-to-face interviews were conducted with 43,093 respondents, with a response rate of 81%. Of the total population surveyed, 8,205 (19%) were aged 65 years and older. Blacks, Hispanics, and young adults aged 18-24 were oversampled. Weighted data were adjusted to be representative of the U.S. civilian population based on the 2000 Census. The research protocol received ethical review and approval from the US Census Bureau and US Office of Management and Budget.
Information was collected on lifetime and past 12-month use of alcohol, tobacco, and non-medical use of particular drugs including sedatives, tranquilizers, opioids, amphetamines, cannabis, crack cocaine, hallucinogens, inhalants and heroin. Non-medical use was defined as use “without a prescription, in greater amounts, more often, or longer than prescribed, or for a reason other than a doctor said you should use them.” Data on quantity and frequency of alcohol use were collected and categorized into three drinking levels as has been done in prior reports using NESARC.1 The three drinking levels were: light drinker (3 or fewer drinks per week), moderate drinker (4-14 drinks per week for men and 4-7 drinks per week for women) and heavy drinkers (more than 14 drinks per week for men and more than 7 drinks per week for women). We also used drinking levels suggested by the American Geriatrics Society23 that define heavy drinking as more than 7 drinks per week for both men and women aged 65 years and older.
The sociodemographic and health-related variables examined included age (65-74 years, 75-84 years, 85 years and older), gender, race/ethnicity (Whites, Hispanics/Latinos, Asians/Native Hawaiians/Pacific Islanders, American Indian/Alaskan Natives, Blacks/African Americans), marital status (married or living with someone, widowed, divorced/separated, or never married), education (less than 12th grade, high school graduate/GED, some college or higher), employment status (currently employed, not currently employed), annual family income ($1-19,999, $20,000-34,999, $35,000-69,999, $70,000 or more), and self-perceived current health (excellent/very good, good, fair, poor).
Sociodemographic, health-related and substance use characteristics of the sample were described using numbers of respondents and weighted percentages. Cross-tabulations were used to derive prevalence estimates of lifetime and past 12-month use of: 1) any substance, 2) alcohol, 3) tobacco, 4) selected drugs, and 5) combinations of the three types of substances. Odds ratios (ORs) and 95% confidence intervals (95% CI), derived from multiple logistic regression analyses, were used to describe the association of sociodemographic and health-related factors with lifetime and past 12-month alcohol use, tobacco use and non-medical use of drugs. Among those who engaged in non-medical use of drugs, there were too few persons who were Asians/Native Hawaiian/Pacific Islanders (n=5 persons using drugs of 128 persons total), or American Indian/Alaskan Natives (n=5 persons using drugs of 113 persons total) to include in our logistic regression analyses. Removing these groups reduced the sample size to 7,964 persons. Also because of small sample sizes for the analyses of non-medical use of drugs, we collapsed the two age categories, 74-84 years, and 85 years and older, into one category and collapsed the two income categories, $35,000-69,999, $70,000 or more, into one category. All analyses were done with SUDAAN 24 which adjusts for design characteristics of complex sample surveys.
The sample of persons aged 65 years and older was predominantly younger than 75 years of age, female, White, married or living with someone and not employed. (Table 1) The sample was quite evenly distributed among the three education categories and most had annual family incomes less than $70,000 and had good or better self-perceived health.
Almost 80% of older adults had used at least one of the three classes of substances during their lifetimes and more than half of older adults had used at least one of the three classes of substances in the past 12-months. (Table 1) Almost three-quarters of older adults had ever used alcohol and almost half reported using alcohol in the past 12-months. Among current drinkers, 67.2% were light (54.7% of men, 76.3% of women), 22.2% were moderate (29.7% of men, 14.0% of women) and 10.7% (11.6% of men and 9.7% of women) were heavy drinkers. The percentage of heavy drinkers increased to 17.8% when using the more strict definition for older adults. More than half of older adults had ever used tobacco and one in seven older adults still used tobacco. Fewer than 4% of older adults reported ever engaging in non-medical use of drugs and about 1% reported using drugs in the past 12-months. Lifetime and past 12-month prevalence of non-medical use of specific drugs was: sedatives 1.1% lifetime (0.6% past 12-months), tranquilizers 0.7% (0.2%), opioids 1.1% (0.5%), amphetamines 0.4% (0%), cannabis 1.4% (<0.1%), crack cocaine 0.2% (0.0%), hallucinogens 0.1% (0%), inhalants 0.06% (0%), and heroin 0.01% (0%).
Addressing combinations of the three classes of substances, in their lifetimes, 43.5% of older adults used both alcohol and tobacco, 26.9% used alcohol alone and 5.9% used tobacco alone. Less than 3% used a combination of alcohol, tobacco and drugs and less than 1% ever used any other combination of substances. In the past 12-months, 37.3% of older adults reported using alcohol without other substances while 7.3% used both alcohol and tobacco and 6.1% used only tobacco. Less than 1% used any other combination of substances in the past 12-months.
Sociodemographic and health-related correlates of lifetime and past 12-month alcohol and tobacco use were similar in many respects. Adults aged 75 years and older and women were less likely to use each substance than adults aged 65 years and younger and men. Whites had higher lifetime use than non-Whites (except for American Indian/Alaskan Natives), and those who were married had lower lifetime use than those who were divorced or separated. (Table 2)
Differences in sociodemographic and health-related characteristics were also noted. Past 12-month alcohol use was higher among Whites than among Asians/Hawaiians/Pacific Islanders or Blacks/African Americans while past 12-month tobacco use was higher among Whites than Hispanics/Latinos. Those who were married had higher past 12-month use of alcohol but lower past 12-month tobacco use than those who were widowed. Higher education and income was associated with higher odds of past 12-month alcohol use but lower odds of past 12-month tobacco use compared to those with lower education and the lowest income group. Finally, compared to those in poor health, those with better self-perceived health had higher odds of using alcohol both over the lifetime and in the past 12-months and lower odds of using tobacco over the past 12-months.
The odds ratios for lifetime non-medical drug use indicate that persons aged 75 years and older and those with 12th grade or less education had lower odds of lifetime non-medical use of drugs compared to persons aged 65 to 74 years and those who had completed some college or more education. Men and divorced or separated persons had higher odds of lifetime non-medical use of drugs compared to women and those who were married or living with someone. The odds ratios for past 12-month non-medical drug use indicate that Latinos/Hispanics as well as divorced or separated persons had higher odds of past 12-month non-medical use of drugs compared to Whites and persons who are married or living with someone. Other comparisons were not statistically significant.
Almost 80% of adults aged 65 and older in the US, surveyed between 2001-2002, had used some substance during their lifetimes and more than half reported using some substance in the past year. Combined alcohol and tobacco were by far the most commonly used substances by over the lifetime but alcohol was the most commonly used substance over the past 12-months. Using gender specific definitions of moderate and heavy drinking, most older adults who drank alcohol were light or moderate drinkers, but more than 10% were heavy drinkers. Fewer than 5% of older adults reported ever having engaged in non-medical use of drugs or used any other combination of substances other than alcohol and tobacco.
These data are consistent with others’ findings of the prevalence of substance use in older populations;1-5,14-16, 25-27 and highlight that, for this generation, alcohol is the substance of choice for older adults, followed by tobacco. The National Survey on Drug Use and Health (NSDUH), 200215 is comparable to 2001-2002 NESARC. Both of these surveys collected data from a nationally representative sample on overall substance use patterns and correlates. Data from NSDUH, 2002 reveal that, among the sample of 2,019 adults aged 65 years and older, lifetime and past year alcohol use was reported to be 78% and 50% respectively, tobacco use was 70% and 16%, and illicit drug was use 9.2 and 1.3%. These rates are similar but higher than those observed in NESARC. The discrepancies between the two data sets have been attributed to factors related to privacy and anonymity since NSDUH data were collected by a private firm using computerized self-administration methods and names were not recorded or linked with respondents’ answers while NESARC data were collected by the US Census Bureau using face-to-face interviews and was not anonymous.26
Use of alcohol may have benefits or risks depending on the amount consumed, the presence of comorbidities, and the use of medications.7 While most older adults who consume alcohol do so in amounts that are unlikely to cause harm and likely to be beneficial, a significant minority drink more than is recommended7,25 and/or have comorbid conditions or take medications that may increase risk for harm.8 Up to one or two standard drinks per day is generally considered a safe limit of drinking for adults including those aged 65 years and older.1,23 But for those who have comorbidities (e.g., dementia) and symptoms (e.g., insomnia) that could be worsened by alcohol or those who take medications that may interact negatively with alcohol (e.g., sedatives) or be less efficacious with alcohol (e.g., antidepressants), even 1-2 drinks per day may be hazardous.7,8 Tobacco use declines over the lifetime among those who survive to older age but continued use increases risk for harm3 and the combined use of tobacco and alcohol increases risks more than use of either alone.13 Non-medical use of drugs is rare among older adults, possibly because of rare exposure to these drugs in their youths,27 high mortality rates associated with illicit drug use,17 and easy access to many psychoactive drugs (e.g. sedatives and opioids) with a physician’s prescription.19 Indeed, older adults are the age group most commonly prescribed psychoactive drugs. Aside from the less than 0.1% of older adults who reported cannabis use, the only drugs this population reported having used in the past 12-months were sedatives, tranquilizers and opioids. Though older adults may use these drugs in ways not prescribed by the physician, because they obtain them with a physician’s prescription, they may not view their use of such drugs as “non-medical”.
Among this group of adults aged 65 years and older, the use of alcohol and tobacco was more likely among those who were younger and male, and divorced or separated, compared to older age groups, females, and married persons. In contrast, those who were married, more highly educated, had higher income, and those with better-perceived current health were more likely to use alcohol but less likely to use tobacco in the past 12-months compared to those who were widowed, less educated, had lower income, and had worse health. Use of alcohol and tobacco have been observed among those with these demographic and health-related characteristics in a variety of studies,1,3,28,29 and illustrate that current alcohol use is associated with better socioeconomic and health status while current tobacco use is associated with lower socioeconomic status and worse health status. These data are also consistent with others’ findings that men and younger persons consistently use substances more than women and older persons in both younger and older populations.1-3,21,25,28,29 For example, using 2000 NHIS data, past year drinking was reported among those aged 65-69, by 55.7% of men and 45.1% of women and among those aged 80-84 years, by 44.5% of men and 29.2% of women.25
We observed few sociodemographic correlates of non-medical drug use. Using NESARC data, others have observed that younger persons, men and Whites engage in non-medical use of drugs more than older persons, women, and non-Whites.2,4 While we also found that younger persons and men had higher odds of lifetime non-medical drug use, compared to older persons and women, we did not observe such associations for past 12-month non-medical drug use. The numbers of those who engaged in non-medical drug use were quite small, particularly among those who reported such use in the past 12-months. The power to evaluate associations of non-medical drug use and sociodemographic and health-related correlates among older adults will increase as the Baby Boomer generation ages and the numbers of persons reporting engaging in non-medical use of drugs, including prescription and illicit drugs, increases.9
Aside from the relatively small sample of those engaging in non-medical drug use, limitations of this study include the possibility that rates of all three substances used among this older cohort may be lower than expected because of premature mortality among those who were heavy substance users. Recall bias and social undesirability of substance use, particularly for women, may have also contributed to underreporting. The cross-sectional design is another limitation but data from the 3-year follow-up of NESARC participants will enable us to look at longitudinal patterns and sociodemographic correlates of substance use in older adults in future investigations.
In summary, these data from NESARC, one of the largest population-based studies of older adults’ substance use available, add to our knowledge of alcohol, tobacco and non-medical drug use in the growing population of older adults in the United States and suggest that health care providers should ask about alcohol and tobacco and non-medical drug use regularly to identify those who may be using these substances. While any amount of tobacco use is harmful, alcohol use may have risks or benefits depending on the amount and pattern of use, comorbid conditions and medications used. The extent of non-medical drug use in this age group is not yet clear but is likely to be more common than the rare use identified in NESARC especially given the expected rise in such drug use in the Baby Boomer generation and the extensive use of psychoactive drugs in older adults. Because of the risks associated with psychoactive drugs, particularly those with abuse potential, it is prudent for health care providers to ask their patients who are using these medications about the amount and patterns of use as well as symptoms and signs (e.g., confusion, unsteady gait) that may indicate increased risk for harm. Future exploration of NESARC data will improve our understanding of the mental health correlates of substance use and longitudinal patterns and predictors of substance use among older adults. Such information will help to target screening and intervention efforts to reduce hazardous substance use in older adults as well as to better understand the benefits of moderate alcohol use.
Source of Funding: National Institute on Drug Abuse (R01DA020944), the National Institute on Alcoholism and Alcohol Abuse (K24AA15957), the National Institute on Aging (P30AG028748) and a VA Special Fellowship in Advanced Geriatrics.