Psychiatric disorders in the elderly population have been an area overlooked for decades, and within that, addiction is no exception. Use of alcohol, tobacco, illicit substances, and prescription medications is an arena that demands exploration regarding the impact it has on older people, considering the biological and social changes that accompany advancing age. As per the Longitudinal Ageing study in India, Tobacco use in either smoke or smokeless form is prevalent in 30% of people above the age of 45 years in India. [1] With respect to alcohol use, 8% of the above-mentioned cohort are social drinkers; 3% consume alcohol frequently but in lower quantities, while another 3% are heavy episodic drinkers. [1] The prevalence of both alcohol and tobacco is higher in males, while prescription drug abuse is more common in females. [1–3]
There are several risk factors associated with old age that increase the vulnerability to substance abuse. In this article, such risk factors have been discussed in the Indian context along with possible solutions that can be worked upon.
Presence of co-morbid medical illness – People tend to suffer from several medical ailments as old age approaches. Some are due to senile changes, while others are complications of chronic diseases. The suffering can itself result in substance abuse. Increased use of opioids or painkillers over the counter to decrease pain associated with physical co-morbidities may pose serious health challenges. Sleep disturbances may lead to prescription drug misuse. Besides, alcohol use may increase the overall risk of all types of dementia. [4] Older adults often get involved in medication sharing among themselves, take more than the intended quantity of medication or confuse pills due to forgetfulness that may be part of normal ageing or dementia. Therefore, better psychoeducation of family members is necessary regarding the monitoring of medications and their dependence potential. An increase in awareness is required among other specialities to cross-check check total medications being received by the elderly before prescribing.
Presence of co-morbid psychiatric illness – One of the prominent risk factors that may have a bidirectional relationship with substance use disorder, with both contributing to one another. Evidence suggests a high correlation between substance use disorder, specifically alcohol, affective disorders and personality disorders. [5] India has limited mental health professionals, with only 4000 psychiatrists for 21 million elderly people. Besides, there is a dearth of geriatric mental health services in both the public and private sectors. In most of the hospitals, geriatric substance abuse is treated in general psychiatry or medicine wards. [6] Even the rehabilitation programs are mostly directed towards the younger demographic, while for the elderly population, control of substance accessibility is the major goal. Thus, policymakers should focus on setting up geriatric psychiatry units in hospitals. Furthermore, incorporation of geriatric psychiatry training in the post-graduation curriculum to improve the detection and better management of geriatric psychiatric disorders, including substance abuse, should be considered.
Past history of substance use – It increases the likelihood of problematic use in old age. [7] Regular follow-up is warranted for patients with addiction disorders who are entering the geriatric age group. A system of referral of such patients to geriatric psychiatry services, as mentioned above, can prove beneficial.
Stigma of mental illness – One of the reasons why older adults are less likely to disclose their substance abuse to mental health professionals. Despite the increase in awareness of mental health disorders, the older generation is less likely to acknowledge the need for professional help, especially when it comes to substance abuse, which in some cultures may even be socially acceptable. Primary care physicians are most often the first point of contact for elderly people for their common medical ailments. Therefore, training physicians in recognising and treating substance abuse disorders may increase the overall reach of deaddiction services. Digitally driven short and intermediate courses are being started for primary care physicians. [8] Special emphasis on old age addiction disorders via such training can prove to be invaluable. Besides, referral to psychiatrists in case of poly-substance use or associated psychiatric co-morbidities should also be encouraged.
Retirement – Considered an important life event in old age and has economic, social and psychological implications. Preretirement conditions like workplace stress, involuntary retirement, and lower socio-economic status can all increase the use of substances post-retirement. [9] Therefore, a gradual transition should be encouraged with policies towards financial stability and continuous engagement post-retirement.
Lack of social support – Various factors like migration of children, death of a spouse, family conflicts, etc., can cause loneliness and, in turn, increase substance use in the elderly. With urbanisation and gradual dilution of the joint family structure among Indian households, the older generation is at the receiving end of neglect and social isolation, further increasing the likelihood of mental health disorders, including substance abuse. Therefore, such elderly people should receive adequate social and financial support. There are some non-governmental organisations like HelpAge India, GeriCare that are working towards their cause, educating the younger generation about their needs and the problems faced by them, providing education initiatives for areas relevant to the elderly and arranging Healthy Ageing conferences. [6] Day care centres and respite homes for the elderly can provide a common place for social interaction and care. But the scarcity of such facilities still indicates a work in progress.
Conclusion – Several factors influence substance abuse in elderly people. While some require intervention at policy levels, even a mere understanding of the unique needs of the population and creating awareness can make a change. Therefore, a holistic approach incorporating all the aspects discussed is needed to deal with the increasing trend of substance abuse in elderly people.
References –
1. Longitudinal Ageing Study in India (LASI) India report national programme for health care of elderly & international institute for population sciences ministry of health & family welfare government of India.
2. Culberson JW, Ziska M. Prescription drug misuse/abuse in the elderly. Geriatrics 2008;63(9):22–31.
3. Simoni-Wastila L, Yang HK. Psychoactive drug abuse in older adults. Am J Geriatr Pharmacother 2006;4(4):380–94.
4. Thomas VS, Rockwood KJ. Alcohol abuse, cognitive impairment, and mortality among older people. J Am Geriatr Soc 2001;49(4):415–20.
5. Speer DC, Bates K. Comorbid mental and substance disorders among older psychiatric patients. J Am Geriatr Soc 1992;40(9):886–90.
6. Parkash R, Girdhar R, Sethi S, Parkash Vaid R, Khurana H. Geriatric mental health problems and services in India: A burning issue. J Geriatr Care Res [Internet] 2019;6(1). Available from: https://www.researchgate.net/publication/333662093
7. Platt A, Sloan FA, Costanzo P. Alcohol-consumption trajectories and associated characteristics among adults older than age 50. J Stud Alcohol Drugs 2010;71(2):169–79.
8. Nanjudaswamy MH, Joseph R, Sethi MS, Manjunatha N, Kumar CN, Chand PK, et al. Digitally Driven Short- and Intermediate-term Courses of Primary Care Psychiatry for Doctors: A Theme-based Analysis and Performance Audit. Indian J Psychol Med 2023;
9. Vigezzi G Pietro, Barbati C, Maggioni E, Stenholm S, Odone A, Amerio A, et al. Impact of retirement transition on health, well-being and health behaviours: critical insights from an overview of reviews. Soc Sci Med2025;375.
Dr Anirban Dutta
MBBS, MD Psychiatry (NIMHANS)
Senior Resident
All India Institute of Medical Sciences, Kalyani
