Seventy-year-old Mark presents with a chief complaint of anxiety. As part of his intake, you screen him for additional diagnoses, including substance use disorders.

Although you may routinely think about substance use disorders (SUDs) in younger adults, SUDs in older adults often go undetected. This is partly due to patients and clinicians misattributing symptoms like fatigue, cognitive decline, or balance problems to dementia or other medical issues. Clinicians may not ask older adults about substance use due to their own biases. Detection rates are also hindered by a lack of screening guidelines and treatment recommendations in this patient population.

Older adults may experience greater harms from substance use due to a variety of factors, including changing metabolism, polypharmacy, and medical and neurological comorbidities. Substance use is often associated with cognitive impairment and deficits in memory, attention, and decision-making (Ramey T and Regier PS, CNS Spectr 2019;24(1):102–113). In addition to falls and fractures, older adults with substance use or medication misuse are more prone to car accidents and non-medical emergencies.

Screening

A helpful rule is to screen for medication misuse and for alcohol, tobacco, and substance use at intake and annually, depending on risk factors and clinical concerns (Alford DP et al, J Addict Med 2022;16(4):e219–e224).

Brief screening measures are more useful than strict adherence to DSM-5-TR cutoffs. Certain criteria may not apply to some older adults (see the Q&A with Dr. Trevisan in this issue for more on using DSM-5-TR criteria for SUDs in older adults). In addition, most screening tools are not specifically validated in older adults (see “Screening Tools for Substance Use Disorders” table on page 8).

The most efficient practice is to pick one or two screening tools and use them consistently. For example, I screen my older patients for alcohol use disorder using both the Cut down, Annoyed, Guilty, Eye-opener (CAGE) questionnaire (www.tinyurl.com/msvcv95s) and the three-question AUDIT-C (www.tinyurl.com/dybu22z3), a shortened version of the Alcohol Use Disorders Identification Test (AUDIT). The AUDIT-C questions are:

• How often do you have a drink containing alcohol?
• How many standard drinks containing alcohol do you have on a typical day?
• How often do you have six or more drinks on one occasion?

It’s scored on a scale of 0–12 with four possible points for each question. A total AUDIT-C score of 3 or more for women and 4 or more for men is enough to warrant further assessment (Joshi P et al, Curr Geriatr Rep 2021;10(3):82–90; Han BH and Moore AA, Clin Geriatr Med 2017;34(1):117–129). Some clinicians may prefer using the geriatric version of the Short Michigan Alcohol Screening Test (SMAST-G), which contains 10 yes/no questions (www.­tinyurl.com/y6hu4apv).

For cannabis use disorder, I use the Cannabis Use Disorder Identification Test-Revised (CUDIT-R). Alternatively, many clinicians prefer screening all patients with a single instrument, such as the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), although the ASSIST tool has not yet been validated in older adults (Gryczynski K et al, Addiction 2015;100(2):240–247).

You decide to use the ASSIST tool as part of the intake. Mark scores in the moderate risk level for alcohol use. You follow up by asking questions about the frequency and quantity of his alcohol use, as well as how his drinking affects his relationships and activities. Mark tells you that he drinks a six-pack nightly. He admits that his wife recently shared her disappointment in him after he gave up their evening stroll to stay home and drink.

Brief assessments and ­interventions

What do you do if a patient has a positive screen? A good first step is to complete a brief assessment focused on severity of use, problems associated with use, frequency of problems related to use, and comorbidities.

Based on the results of the brief assessment, the next step is deciding whether the patient would benefit from a brief intervention or treatment, or whether they need a referral to specialty treatment. I recommend using the Screening, Brief Intervention, and Referral to Treatment (SBIRT) model, which is available as an app at www.sbirtapp.org/intro (Babor TF et al, Subst Abus 2007;28(3):7–30).

Low-risk patients

Provide feedback based on motivational interviewing (for more on motivational interviewing, see our Q&A with Dr. Trevisan).

Moderate-risk patients

Consider brief interventions such as the following:

• Further motivational interviewing
• Meeting the patient where they are
• Focusing on the consequences of substance misuse and strategies for cessation

Moderate- to high-risk patients

These patients may benefit the most from brief treatments, such as the following (Babor et al, 2007):

• A short series of cognitive behavioral therapy (four to six sessions) focused on substance use
• Motivational enhancement therapy
• Adjustment of existing pharmaceutical therapy if applicable

Patients at highest risk usually require referral for specialized treatment, which may include detox or clinical stabilization services.

Based on his screening score and moderate risk level, you decide to use motivational interviewing with Mark as a first step. Mark reflects on the amount he drinks and expresses motivation to decrease his drinking. You provide general education on potential consequences of heavy alcohol use and discuss techniques to cut down. You also share that brief treatments are available if needed. At his follow-up appointment one month later, Mark reports a 50% decline in his alcohol intake.