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Psicologia: teoria e prática

versão impressa ISSN 1516-3687

Psicol. teor. prat. vol.19 no.2 São Paulo ago. 2017 



Elderly substance abuse: an integrative review



Ana DinizI; Sandra Cristina PillonII; Sara MonteiroIII; Anabela PereiraIV; Joana GonçalvesV; Manoel Antônio dos SantosV

IUniversidade de Aveiro, Portugal
IIUniversidade de São Paulo, SP, Brazil
IIIUniversidade de Aveiro, Portugal
IVUniversidade de Aveiro, Portugal
VUniversidade de Aveiro, Portugal
VIUniversidade de São Paulo, SP, Brazil

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This is an integrative review of the literature with the objective of analyzing the scientific production on psychoactive substance use in the elderly, with a specific focus on socio-demographic and clinical characteristics. The systematic research was performed on the Scopus, Web of Knowledge, Academic Search Premier, PubMed and ScienceDirect databases. After considering the criteria for inclusion and exclusion, 13 studies were selected, with no restriction on the period of time. Elderly users of psychoactive substances are predominantly men with low levels of education and income, who are unemployed, unmarried and living alone, besides presenting organic and psychological comorbidities. Alcohol is the most common drug used in this age group, followed by abuse of medication, although the use of illicit substances has increased progressively. Despite evidence being limited, studies indicate lower rates of high-risk behavior to health in the elderly. The literature is consensual about the need for more studies in order to fill gaps in the knowledge and to facilitate early identification of these users.

Keywords: elderly; drug users; substance-related disorders; prescription drug misuse; evidence-based practice.




The planet is going through a demographic and epidemiological transition which results in an increasing number of elderly people in the world population. Future predictions indicate that this increase will continue and that, by 2050, a quarter of the population will be 65 or more. Europe is the continent with the oldest population (EMCDDA, 2010). Between 2001 and 2011 Portugal increased its aging index, from 103 to 128 elderly persons for every 100 young persons, due to its low birth rate and improved life expectancy. In the same period, Portuguese population with 65 years or more grew from 16.6% to 19% (INE, 2013). This change in the demographic profile brings new challenges to public health; not only through increasing demand but also through the way each generation's behavior patterns have changed (Fahmy, Hatch, Hotopf, & Stewart, 2012).

The use of illegal drugs by the elderly, associated with the acceleration of chronic conditions in this age group, characterizes as a serious problem for public health. This fact is generating a high social cost for healthcare, as well as a substancial financial burden on contributors and government agencies (EMCDDA, 2010; Schlaerth, Splawn, Ong, & Smith, 2004).

There is still an idea that drug use is restricted to the young, especially those who frequent nightclubs (EMCDDA, 2010). However, there is increasing evidence that age is no guarantee against drug abuse (Fahmy et al., 2012; Schlaerth et al., 2004; Lofwall, Schuster, & Strain, 2008; Sacco, Kuerbis, Goge, & Bucholz, 2013; Beynon, Roe, Duffy, & Pickering, 2009). The consumption of alcohol, nicotine and prescription drugs among the elderly is regarded as preferential in this population, although little is known about the epidemiology of psychoactive drug use in this age group (Simoni-Wastila & Yang, 2006). According to EMCDDA (2010, p. 7), the definition of the problematic use of drugs is "the use of injection drugs or long-term regular use of opiates, cocaine and/or amphetamines".

Defining "older drug users" among consumers of psychoactive substances is a challenging task (Lofwall et al., 2008) as there is no exact definition and there are variations in understanding of the terms "older" or "elderly" even in the general population (EMCDDA, 2010). The retirement age in Europe generally begins at 60, but for administrative and legislative purposes it is more common to consider the age of 65 (EMCDDA, 2010), this being the cut off age used in Portugal to define elderly (INE, 2013). Nevertheless, when dealing with substance dependence, the cutoff point for older individuals is normally much lower. In some cases it is as low as 35; some studies have used 40 (EMCDDA, 2010), and others have adopted 50 or more (Beynon et al., 2009; Lofwall, Brooner, Bigelow, Kindbom, & Strain, 2005). Using 40 as a cutoff point may be due to the fact that individuals at this age generally have a long history of problematic drug use, which may exacerbate or accelerate conditions associated with age, prematurely leading to metabolic aging and complications such as atherosclerosis or cardiopulmonary ailments. Furthermore, in this population, it is estimated that the aging process is accelerated by at least 15 years (EMCDDA, 2010). Studies that adopt 50 as the cutoff recognize that this is not a chronically old age, but consider it as such, due to elderly patients dependent on substances having higher levels of medical morbidities, when compared to younger people (Lofwall et al., 2005).

Alcohol, nicotine, and drugs consumed under medical prescription have been the most referred substances in use by older adults. However, it has long been predicted that the consumption of illegal drugs by this population, would increase (Simoni-Wastila & Yang, 2006). In the United States (USA), the elderly have been increasingly seeking help due to problems related to drug use (Sacco et al., 2013). In England, the use of some illicit drugs has increased rapidly among the middle-aged and the elderly (Fahmy et al., 2012). Also in relation to Europe, the available evidence indicates that the levels of illicit drugs being used among elderly Europeans are growing significantly and that Portugal had, in 2008, the highest percentage of people between 40 and 49 years old in treatment among European countries (EMCDDA, 2010). With aging, the population that uses injection drugs has also reached more advanced ages, according to studies carried out in Australia (Horyniak et al., 2013) and the USA (Armstrong, 2007).

There are various reasons for this phenomenon, including the baby boom. Baby boomers are considered to be all those born between 1946 and 1964. This generation, besides being numerically significant, had greater exposure to psychoactive substances. A study in the USA on the consumption of people aged 50 or over, estimates that, by the year 2020, the use of cannabis in the "last year" will have increased from 1% (719 thousand) to 2.9% (around 3.3 million). It also estimates that consumption of any illicit drug will grow from 2.2% (1.6 million) to 3.1% (3.5 million), between 1999-2001 and 2020 (Colliver, Compton, Gfroerer, & Condon, 2006). In regard to the diagnosis of disorders resulting from the use of psychoactive substances, an increase from 2.8 million to 5.7 million is predicted from 2002-2006 to 2020 (Han, Gfroerer, Colliver, & Penne, 2009). It is also estimated that the necessity for treatment among the elderly population will increase from 1.7 million in 2000-2001 to 4.4 million in 2020 (Gfroerer, Penne, Pemberton, & Folsom, 2003). Moreover, the data shows a significant increase in the lifespan of consumers in contact with drug treatment services (Beynon, McVeigh, Hurst, & Marr, 2010). Thus, these consumers remain under treatment for many years, or even decades, continually or with interruptions, reaching old age during treatment (EMCDDA, 2010). Finally, it is expected a greater involvement of the judicial system in the increase of treatments for drug abuse at these ages (Lofwall et al., 2008), as there would be many more referrals to health services and treatment services issued by courts.

Gossop & Moos (2008) reported that older consumers of substances can be classified into two categories: "survivors", these being people that began in their youth and have a long history of consumption, and "reactives", who are those that began using drugs late on, probably due to problems experienced in the course of life. Regardless of classification, the aging process can trigger psychological, social or health problems that enhance the probability of, and susceptibility to, substance abuse, which, in turn, aggravates pre-existing problems (Gossop & Moos, 2008). Risk factors, such as lack of personal resources (low labor skills, low emotional intelligence, lack of belief in personal prospects, poor self-concept and a sensation of incapacity in conducting one's own life), as well as a progressive rupture of social ties (family, work and friendship), also contribute to increasing chronic psychic deterioration, reinforcing the necessity to promote a high level of specific healthcare (Roibás, Melendro, & Montes, 2010).

On the other hand, the acceleration of medical morbidities and the progression in organic deterioration of these individuals means that this population has unique treatment necessities (Lofwall et al., 2008; Roibás et al., 2010). It is known that advancing age alters the functioning and composition of the human body, which makes it crucial to adjust the type of medicine and its dosage. The excretory function of the kidneys diminishes, particularly in mal-nourished or debilitated individuals, and there is a gradual reduction of homeostasis mechanisms, which lead to stronger reactions in the course of drug use, increasing the rate, intensity and adverse effects (Turnheim, 2003). These factors, together with the decrease in body water content, mean that the elderly can maintain levels of substances in the blood for longer after consumption. This physical susceptibility affects motor and cognitive functions, increasing the risk of accidents, falls and injury or increasing the difficulty of conducting activities of daily living (ADL). ADL can be understood as personal tasks concerning self-care, as well as other abilities pertinent to the individual's day to day life.

The elderly have increased sensitivity, which makes them feel the effects induced by the use of psychoactive substances whilst consuming lower quantities, with tolerance also being diminished, which means they don't need to use as much as they used to in order to obtain the same effect. Furthermore, many of the prescription drugs used by this population interact adversely with the consumption of psychoactive substances (Han, Gfroerer, & Colliver, 2009), be it negating or enhancing their effects. Drug users continue dying younger than the general population and the types of death not related to the use of more common substances are hepatic and neoplastic diseases, chronic inferior respiratory infections and hepatitis. Despite these morbid conditions not being classified as such, they may be associated with harmful substance use (Beynon et al., 2010).

However, drug users are not always identified as people that have a problem related to substance use. There is a lack of knowledge of healthcare professionals about this phenomenon, due to the lack of technical training or the erroneous belief that consumption only affects young people. This lack of knowledge, along with the scarcity of elderly people reporting consumption during consultations with healthcare professionals - due to embarrassment, fear, dementia or social isolation - may be among the causes of difficulty in detection (Pillon, Cardoso, Pereira, & Mello, 2010). In a study performed at an emergency room, only two out of 18 drug users over 60, in whose urine cocaine metabolites were found, were identified by the doctors as drug users presenting a problem related to chronic cocaine use (Rivers et al., 2004).

The interaction between the effects of consumption and the aging process are still not well understood (Beynon et al., 2009), which contributes to the underreporting of these users (Pillon et al., 2010), who may present characteristics specific to the level of consumption effects and consequent treatment (Lofwall et al., 2005). It is, therefore, necessary to understand the needs of this age group (Pillon et al., 2010). Thus, this study had the objective of analyzing the scientific production on the use of psychoactive substances among the elderly, with a specific focus on socio-demographic and clinical characteristics (consumption history, current consumption and physical and mental health).



This study is an integrative review of scientific production retrieved from the following databases: Web of Knowledge, PubMed, Scopus, Academic Search Premier, and ScienceDirect. The bibliographic research was carried out combining the following terms: elderly, older, old age, older adult or aging with drug addict, illicit drug dependence, addicts, illicit drug use, heroin, opiate, cocaine, junkie, methadone or injection drug.

This review was based on the following guiding question: "What are the socio-demographic and clinical characteristics of elderly users of psychoactive substances?" Data collection was carried out between January and February 2014.

The criteria for inclusion were: articles published in Portuguese, English or Spanish; with no restriction on a period of time. Articles involving themes such as tobacco consumption, use of medicine, experiments with animals, opioids prescribed to relieve pain were excluded, as well as studies focusing exclusively on alcohol use or young age groups, besides review studies. Theses, dissertations, monographs, books, and chapters were also excluded.

Firstly, all the titles and abstracts were read, enabling the exclusion of studies that were outside the scope of the review, in accordance with the adopted inclusion/exclusion criteria. Through the preliminary reading of the documents, 53 articles were selected. The remaining studies from this preliminary stage subsequently had their full texts located and recovered. Then, the complete texts were read in full, once more applying the established inclusion/exclusion criteria. After detailed reading of all the material, the final sample consisted of 13 articles. These stages were carried out independently by two researchers who later discussed any doubts which emerged during the process. Occasional disagreements as to the inclusion/exclusion of an article were resolved by the two researchers reaching a consensus.

The same procedure was used to classify the Level of Evidence (LE) of each article. In evidence based practice, LE is an indicator enabling classification of the methodological quality of the published research, from the perspective of the contribution they offer to the incorporation of modifications to professional practice which result in improved care (Valdanha, Scorsolini-Comin, Peres, & Santos, 2013). This indicator has been used as a universal evaluation criterion in various areas of knowledge, based on an appreciation of the chosen methodological design (Solomons & Spross, 2011).

LE is categorized at six levels, in accordance with the classification proposed by the Agency for Healthcare Research and Quality (AHRQ). LE 1 corresponds to meta-analyses conducted based on various controlled studies. LE 2 involves studies with experimental design. LE 3 covers research with quasi-experimental design, such as studies conducted without randomization with one group pre and post-test, longitudinal studies or case-control studies. LE 4 refers to non-experimental studies, such as descriptive correctional or qualitative research, or case studies. LE 5 corresponds to case reports or program evaluations. LE 6 applies to opinions of specialists or respected authorities in the area, including information not based on research (Hughes, 2008).



As a result, the following occurrences of studies were found in each consulted databases: Web of Knowledge (1170), PubMed (395), Scopus (208), Academic Search Premier (853) and ScienceDirect (976). Through the preliminary reading of the documents, which involved careful analysis of the titles and abstracts, 53 articles were selected. A detailed reading of all the material, which involved the complete reading of all the texts, based on the established inclusion/exclusion criteria, provided a selection of 13 articles.

The Table 1 presents a synthesis of the information contained in the articles compiled in this review, whereby eight come from studies carried out in the United States (USA), two from the United Kingdom and one each from Brazil, Spain, and Australia. Of these, seven refer to data extracted from epidemiological studies, carried out to monitor the population (Armstrong, 2007; Blazer & Wu, 2009; Fahmy et al., 2012; Han et al., 2009; Horyniak et al., 2013; Lofwall et al., 2008; Sacco et al., 2013), based on large samples - between 3417 and 452,567 individuals. Four studies reported on data obtained through the application of questionnaires, evaluations or analysis of clinical histories of users of treatment services for problems related to drug use (Beynon et al., 2009; Lofwall et al., 2005; Pillon et al., 2010; Roibás et al., 2010). Two articles reported on data related to urine analyses at emergency services (Rivers et al., 2004; Schlaerth et al., 2004).

To evaluate the LE of the studies, the scientific methodology that was the basis of each selected article was analyzed. Table 1 shows that the recovered studies fit into levels of evidence 3 and 4. They are well designed, developed in temporal series (level 3), besides presenting the non-experimental methodological design, performed at more than one research center or group (level 4).

The studies showed that the use of some illicit drugs, such as cocaine, crack, cannabis, opiates, mushrooms and amphetamines, has increased rapidly among the middle aged and the elderly (Beynon et al., 2009; Fahmy et al., 2012; Sacco et al., 2013; Schlaerth et al., 2004). Users over 60 represent 3.2% of a service attending drug users (Pillon et al., 2010) with 11.7% of the consultations carried out being directed at people aged 50 or over (Roibás et al., 2010). At emergency services, 3.1% of the users over 50 presented metabolites in a urine test for drugs (Schlaerth et al., 2004) and 2% tested positive for cocaine (60 or over) (Rivers et al., 2004).

In all the studies making reference to gender, there was a much higher number of male consumers compared to female consumers, representing 90.6% (Pillon et al., 2010) and 87.6% (Roibás et al., 2010) of the populations at specialized services with more than 60 and 50 years, respectively, and 69.2% (Schlaerth et al., 2004) and 88.9% (Rivers et al., 2004) of positive tests at hospital emergency rooms for illicit drugs and cocaine, respectively. In epidemiological studies, the male sex also remained prevalent (Blazer & Wu, 2009; Han et al., 2009). In a study that compared samples collected with a 10-year interval, the men remained at a higher number in both samples (Sacco et al., 2013). Another study confirmed that admissions for drug or alcohol abuse, or a combination of the two; were predominantly men, although it should be noted that this percentage decreased between 1992 and 2005 for all drugs (Lofwall et al., 2008).

In relation to schooling, low levels of education are found among the population that consumes psychoactive substances (Han et al., 2009); 78.5% had only completed the 9th grade and 12.6% were illiterate (Pillon et al., 2010); with less than 15% having reached higher education (Roibás et al., 2010). However, another investigation did not find an association between illicit drug use and education, but significantly associated the consumption of alcohol with more educated elderly people (Blazer & Wu, 2009). Nevertheless, educational levels increased between 1991-1992 and 2001-2002 (Sacco et al., 2013), as did the percentage of elderly people with, at least, 12th-grade study, in the period from 1992 to 2005 for all drugs (Lofwall et al., 2008). Regarding the professional situation, unemployment has been associated with the consumption of illicit drugs (Han et al., 2009); and it has also been found that 45% of the elderly in treatment were retired and 34% unemployed (Pillon et al., 2010). Another study showed that 61.7% were out of work (61.7%) (Roibás et al., 2010), and between 1992 and 2005 the percentage of unemployment increased (Lofwall et al., 2008). In turn, low incomes and economic problems are very common (Han et al., 2009; Roibás et al., 2010), such that in 2001-2002 the elderly that sought help were more likely to have lower incomes in comparison to 1991-1992 (Sacco et al., 2013).

In contrast to what happens with alcohol consumption (Blazer & Wu, 2009), the use of illicit drugs is more common among unmarried individuals (Blazer & Wu, 2009; Han et al., 2009), with disorganization and lack of family support often found. In one specialized treatment center, only 34.5% of the users were married and living with their partners, while 65.4% lived alone (Roibás et al., 2010). In regard to users that had frequented services related to the abusive use of drugs "in the last year", in 1991-1992, 56.9% were married, while in 2001-2002 this number decreased to 49.4%. It is worth highlighting that this date is even earlier than the studies that refer to these users as predominantly unmarried, which were from 2009 and 2010. These users have also been associated with high rates of prevalence of organic pathologies and psychological disturbances, whereby 64.2% have been diagnosed with somatic diseases and 58% with associated psychiatric pathologies (Roibás et al., 2010).

Major depression disorder is common, in both the young and the elderly (Lofwall et al., 2005) and in this population, it was associated with higher prevalence of cannabis consumption and lower use of alcohol (Blazer & Wu, 2009). It was also found that the elderly had had more major depressive episodes "in the last year" (Han et al., 2009). High levels of general physical morbidity are also found in the studied population (Beynon et al., 2009; Lofwall et al., 2005), especially high erythrocyte sedimentation rate (ESR) (Beynon et al., 2009) and cardiovascular illnesses (Schlaerth et al., 2004); when compared to young people. The users also present a higher amount of prescription medicine use and significantly lower average quality of life-related to health. However, both the young and the elderly present high levels of psychiatric problems "during life" and generally poor health, compared to norms of the general population (Lofwall et al., 2005).

At treatment centers for users with problems related to the use of psychoactive substances, the most commonly consumed substance by the elderly was alcohol, with prevalences of 83.8% (Pillon et al., 2010), 72.9% (Roibás et al., 2010) and 75.6% (Lofwall et al., 2005). In the first study (Pillon et al., 2010) this was followed by abuse of medication (2.6%) and alcohol together with cocaine or crack (2.6%), and then cannabis (2.1%). In the second study (Roibás et al., 2010), it was heroin (43.2%) and cocaine (34.6%) and, in the third study (Lofwall et al., 2005), it was cocaine (73.2%), followed by cannabis (41.5%) and sedatives/hypnotics (36.6%).

Regarding admissions to treatment services specialized in drug abuse, alcohol was also the most commonly used drug in this age group. However, it was the only drug for which the rate of admission decreased between 1992 and 2005. Nevertheless, the admissions related to the abusive use of heroin, cocaine, prescription opioids, cannabis, and methamphetamines increased during this period. It should be highlighted that the admissions for heroin use decreased significantly, but only in the period between 2002 and 2005, in people in the 50-54 age group. The most commonly used illicit drugs in this age group were heroin and cocaine (Lofwall et al., 2008). The consumption of alcohol maintained the highest rates, with almost 60% "in the last year", followed by the use of cannabis (2.6%) and cocaine (0.41%). For 15% of the individuals that had used two or more drugs "in the last year", the percentage of diagnosed disorders in these age groups related to substance use, is lower for alcohol (3%), cocaine (0.18%) and cannabis (0.12%) (Blazer & Wu, 2009).

Another study also reports a decrease (between 1991-1992 e 2001-2002) in disorders from alcohol use "in the last year", in the "lifelong" consumption of alcohol and in teetotalers, who also figured in smaller numbers. However, the consumption of alcohol without a diagnosed disorder "in the last year" increased; as did disturbances from the "lifelong" use of alcohol and those who "currently consume" at least 12 units of liquor in a year. The consumption of illicit drugs increased, be it "lifelong" (but not "in the last year"), or "current use", as did disorders through the use of drugs "in the last year" and "lifelong"; while the number of people that never consumed drugs diminished (Sacco et al., 2013). The use of substances "in the last year" increased between 2002 and 2007 for illicit drugs, including cannabis, and abuse of medication; with these users also being considered alcohol consumers. The majority of users (90%) began consuming before the age of 30 (Han et al., 2009) and presented lower than the average age for their first use of drugs, compared to most young people (Lofwall et al., 2005). Among the population that resorted to emergency services, the drug that was mostly found was cocaine (62.6%), such that in 85% of the cases cocaine was the only positive result; followed by opiates (15.9%), with 64.7% of these users only consuming opiates and, lastly, cannabis (14%), of which 40% had only consumed this substance. In the same population, of the positive users, 42% had also consumed alcohol (Schlaerth et al., 2004).

Cannabis use has also increased among this population, as has the prevalence of illicit drugs, especially among the urban population. More specifically, the "lifelong" use of cannabis, amphetamines, cocaine, and LSD, in people between 50 and 54 years old, increased 10 times more from 1993 (Fahmy et al., 2012). Despite the sick not considering nicotine a drug of abuse and, as such, they not always reporting it to professionals, or not always being asked by the professionals (Pillon et al., 2010), the "lifelong" use of drugs is related to the consumption of tobacco (Han et al., 2009), whereby 49.5% of drug users that presented a positive drugs test were smokers (Schlaerth et al., 2004). However, this consumption "in the last year" and "lifelong" consumption decreased between 1991-1992 and 2001-2002 (Sacco et al., 2013). Voluntary admissions in this age group have diminished, whether for illicit drugs or for illicit drugs and alcohol, although admissions by criminal justice services increased between 1992 and 2005 (Lofwall et al., 2008).

In a study related to clinical maintenance programs, the elderly presented significantly less positive urine tests than young people for opiates, which were also at lower levels, albeit without reaching statistical significance, for cocaine, cannabis, and benzodiazepines (Lofwall et al., 2005).

A study related to injection drug use history reported that, between 1979 and 2002, the average age of injection use "in the last year" increased from 21 to 36 and "lifelong" use from 36 to 42. Between 2000 and 2002, 59.4% of the people that reported injection usage were aged between 35 and 49. It is estimated that due to the baby boomers, in 2015 people with 55 had a higher probability of already having injected drugs than those of 25 (Armstrong, 2007). However, older consumers had lower levels of high-risk behavior than younger users, such that, for every five years, significant reductions can be found in injection drug use in public, sharing needles and problems related to this behavior, whereby the older group refers to individuals of 35 and over (Horyniak et al., 2013).

These studies endorse the necessity to conduct further investigations on this phenomenon (Beynon et al., 2009; Schlaerth et al., 2004), especially for the evaluation of the necessities of this age group (Pillon et al., 2010), so as to facilitate the establishment of specific treatment (Lofwall et al., 2008; Roibás et al., 2010), as well as policies and treatment infrastructure that are sensitive to their needs (Fahmy et al., 2012). Despite the bureaucratic and economic difficulties found in different countries and socio-cultural contexts, the planned responses should be more suited to the vulnerabilities and resources of the users (for example, it is important that accommodation does not be given a time limit) (Roibás et al., 2010). Triage of those presenting increased risk factors should be refined (Han et al., 2009); healthcare professionals should question the patients on their illegal drug use and pay attention to the possibility of receiving less sincere responses (Schlaerth et al., 2004).



This study had the objective of analyzing the scientific production on the use of psychoactive substances by the elderly, as well as the socio-demographic and clinical conditions of elderly users. The majority of the reviewed studies were developed in the USA, which corroborates the findings of the literature review by Rosen, Hunsaker, Albert, Cornelius, & Reynolds (2011). In relation to sociodemographic characteristics, the studies show a predominance of males with a low level of education, among elderly users, especially in regard to the consumption of illicit drugs, although educational levels have been increasing. Lack of employment resulting in low income was also shown, confirming the results of another study (EMCDDA, 2010), an association that has been more and more evident in the literature. The consumption of illicit drugs has also been associated with groups of unmarried individuals living in isolation, while another study reported that these individuals live alone more than younger consumers, which may be related to aging itself (EMCDDA, 2010). The results indicate a high prevalence of organic and psychiatric pathological conditions, as referred to in another study (EMCDDA, 2010), highlighting infectious diseases and major depression.

Alcohol continues to be the most commonly used drug, although its consumption has been decreasing, in contrast to what has been observed in relation to illicit substances. There does not appear to be any unanimity as to the most used illicit substance, as it varies, possibly due to the different types of data collection and locations from which samples are obtained. The existence of poly-consumption can be highlighted; that is, the simultaneous consumption of various illicit substances. It also stands out the combination of these substances with alcohol and tobacco. However, the use of nicotine is not usually documented by the studies.

The literature describes the possibility of the elderly responding better to treatment (EMCDDA, 2010; Rosen et al., 2011). In fact, in the present review, some references to this situation were found, whereby elderly people on treatment maintenance programs present lower consumption. I addition, despite the age of injection drug usage is on the rise, older users are still less associated with such high-risk behavior. Nevertheless, the elderly people on methadone maintenance programs have more body pain compared to the population norms for the same age and sex (Lofwall et al., 2005).

Finally, the reference to the necessity of making more studies available in the area was a recurrent theme among the articles reviewed, as was the formalizing of treatment options and the provision of specific infrastructure. The lack of detection of the difficulties of these users delays the possibility of early intervention (Pillon et al., 2010), which reinforces the necessity to understand the situation of these individuals in the most diverse areas of life (Roibás et al., 2010), document their specific necessities (EMCDDA, 2010), define specific protection factors and also investigate their caregivers, as well as the socio-economic, environmental and clinical factors associated with the problem (Simoni-Wastila & Yang, 2006). Therefore, more studies related to the characteristics of these users may contribute to the knowledge and comprehension of the factors involved in the phenomenon, facilitating identification of the problem by healthcare professionals, with early detection of their necessities and suitable responses and resources to optimize the beneficial effects of treatment, thus favoring rehabilitation and improved quality of life.

The studies recovered in the present review have some limitations that should be pointed out. Lack of definition of the term "elderly" in the studies on the consumption of alcohol and/or other drugs, and the indiscriminate use of this terminology, makes a comparison between the diverse studies difficult. At times, the articles make reference to consumption statistics without explanation of the diagnostic classification utilized (use, abuse or dependence). Besides this conceptual problem, some studies are centered only on the consumption of the principal drug, while others are fixed on the multiple drugs being consumed. Types of consumption are also diversified in the different studies, from recreational use to substance use disorder. Rosen et al. (2011) report that the ways in which the diagnoses of mental illnesses are evaluated vary considerably, which was also shown to be present in these studies. However, Hulse (2002) reports that the DSM-IV identifies this type of consumer less precisely, in comparison to ICD-10. This is because the diagnosis of abuse or dependence in DSM-IV centers on social, legal, interpersonal and professional consequences, which may not be so applicable given the lifestyle changes that occur in this age group. As already stated, this reinforces the necessity of defining specific forms of evaluation and diagnosis for this population (Gfroerer et al., 2003; Rosen et al., 2011; Hulse, 2002).

Another limitation found in the reviewed studies refers to the methodological design, whereby some investigations use small convenient samples(Rosen et al., 2011). Moreover, with the exception of the studies carried out at hospital emergency services, data collection was based on self-reporting, which may influence the data, be it through the distortion of the patient's memory or through the desire for social acceptance (Han et al., 2009). Finally, it should be considered that it is necessary to perfect the LE of publications so as to provide more solid basis for professional orientation and practice. The limitations mentioned also ultimately influence the conclusions of the present review.

Future studies should consider larger samples, either with users in treatment or with those that are without treatment (Rosen et al., 2011). The clinical consequences of "lifelong" use should be observed (Fahmy et al., 2012) and understanding should be sought as to whether consumption among this age represents a pattern of continuous use since youth, with relapse after abstinence, new use, or even a combination of these possibilities (Lofwall et al., 2008). The researchers should also seek to prioritize robust methodological designs, which provide more consistent LE.

The use of illegal drugs by the elderly is characterized as a health problem that has been neglected by public policies, despite implicating in high social cost, with repercussions in terms of the financial burden (Schlaerth et al., 2004). Consequently, interventions involving this population should be efficient and cost effective (EMCDDA, 2010), without neglecting the prevention and promotion of health through inter-sectoral cooperation. The practice of physical activity and engagement in leisure activities should be stimulated in order to promote a healthy lifestyle.

There should also be development of a framework to direct clinical care, service development, staff training and orientation on appropriate medication for this population (EMCDDA, 2010; Gfroerer et al., 2003; Rosen et al., 2011), including for substitution treatments, besides integrating professionals experienced in drug treatment at geriatric services (EMCDDA, 2010). Greater investment is desirable for research aimed at the use of trans-culturally adapted diagnostic instruments that are valid for the detection of substance use and abuse among this population.

This review reinforces the necessity for more sophisticated production of knowledge in this area, especially in Portugal, given that no Portuguese studies were found. Considering the high rate of aging in the population, the increase in chronic conditions resulting from the epidemiological transition, as well as the associated social and health costs, it can be concluded that it is necessary to know the reality of licit and illicit substance use in the elderly population so as to understand the dimension of its impact on public health.

Due to the already expected increase in the number of elderly people dependent on psychoactive substances, their specific vulnerabilities (physical, psychological and social) and the scarcity of existing literature, especially in Europe, it is necessary to invest in research on the social and health characteristics and necessities of this population. This would enable the development of treatment capable of offering responses, which should be implemented in the coming years. It would also enable increased awareness and capacitation of the professionals with knowledge on this population, establishing subtle differences between the diverse age groups, so as to facilitate the development of evaluation instruments, as well as methods and places for the tracking of these users and the design of future strategies of prevention, intervention and promotion of health.



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Mailling address:

Ana Diniz
Rua Conselheiro Luís Magalhães, 32
3810-137, Aveiro, Portugal 910048528
E-mail: anadiniz@ua.ptil
Submission: 18.8.2015
Acceptance: 20.6.2017

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