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. 2019 Sep 18;6(4):1299–1306. doi: 10.1002/nop2.339

The social context of substance use among older adults: Implications for nursing practice

Manpreet Kaur Gill Thandi 1,✉, Annette J Browne 1
PMCID: PMC6805716  PMID: 31660156

Abstract

Aim

The purposes of this paper are (a) to critically analyse the social context of substance use among older adults and (b) to offer strategies for nurses and other health care providers to support the health of older adults experiencing problematic substance use.

Design

Discussion paper.

Methods

This analysis is informed by two theoretical lenses: an intersectional lens in examining the various factors influencing health and health care access; and a social justice lens, focusing on promoting health equity for older populations.

Results

As a result of various social and sociopolitical factors, key issues are likely to arise for older adults experiencing problematic substance use including health and social inequities, stigma, and discrimination, all of which can result in serious negative health outcomes. Health care providers can help mitigate these effects by (a) promoting harm reduction principles; (b) participating in social justice actions; and (c) engaging in contextual assessments of substance use.

Keywords: ageing, gerontology, harm reduction, health care, health inequities, intersectionality, nursing, older adults, problematic substance use, social justice, substance use

1. INTRODUCTION

Substance use can affect people of all ages; however, the prevalence of substance use in older adults is very difficult to estimate (Benyon, 2009; Canadian Centre on Substance Use & Addiction, 2018; Han, Gfroerer, Colliver, & Penne, 2009; Varcoe, Browne, & Michaelson, 2018). One of the reasons for this is that the current diagnostic criteria for substance use issues may not be appropriate for this population. Current predictions state that more than 1 million individuals over the age of 65 were reported to have a problematic substance use disorder in 2014 in the United States and it appears this number is expected to increase considerably in upcoming years, perhaps double by 2020 (Mattson, Lipari, Hays, & Van Horn, 2017). Due to the difficulties in assessing substance use disorders in older adults, there are no current projected estimates in Canada (Canadian Centre on Substance Use & Addiction, 2018), implying that more attention needs to be paid to this problem of substance use in the ageing population.

Globally, older adults over the age of 65 are predicted to increase to 1.53 billion in 2050 (Wu & Blazer, 2013); in Canada, approximately 25% of the population will be over 65 by 2036 (Canadian Centre on Substance Use & Addiction, 2018). Similarly, in the United States, individuals over 65 will constitute approximately 20% of the population in the 2030s (US Census Bureau, 2018). As this population continues to grow larger, there will be a significant impact on the health care system; the needs of older adults will be much larger and more complex if the issue of substance use in this population is not taken into consideration. Because substance use often begins at earlier ages and may continue into later life and due to the age‐related changes in medical conditions, older adults who use substances are at a significant risk for substance‐related consequences (Wu & Blazer, 2013).

The substances most commonly used by older adults are alcohol, tobacco, marijuana, and prescription drugs with the potential for overuse or misuse such as pain relievers and sedatives. Older adults are also at a higher risk of adverse events due to age‐related physical changes and adverse reactions and interactions from the, often, high number of prescription drugs they are taking compared with younger populations (Kuerbis, Sacco, Blazer, & Moore, 2014). The projected increase in the older adult population is concerning because problematic substance use in older adults is associated with sometimes more serious negative physical, cognitive, and emotional health outcomes (Canadian Institute for Health Information, 2016; Kuerbis et al., 2014).

2. BACKGROUND

Problematic substance use can be defined as alcohol or other drug use that negatively affects an individual's life, where they may experience social, financial, psychological, physical, or legal consequences related to substance use (Health Canada, 2018). Although rates of illicit and prescription drug misuse are increasing among older adults, alcohol is still the most commonly used substance; tobacco use is also very prevalent, with about 14% of individuals over the age of 65 reporting tobacco use within the past year (Kuerbis et al., 2014). Conditions common to older adults such as boredom, loneliness, social isolation, loss of loved ones, and depression are also linked to greater alcohol consumption (National Initiative for the Care of the Elderly, n.d.). Further, the common use of prescribed and over‐the‐counter medications among older adults puts them at a significant risk of harmful drug interactions, misuse, and abuse (Kuerbis et al., 2014).

Individuals experiencing problematic substance use may also simultaneously experience social conditions such as poverty, poor housing, and living in unsafe neighbourhoods, all of which create increased risks of violence, accidents, stigma, and discrimination, among various other issues that may have a negative impact on health, quality of life, and life expectancy (Bennett et al., 2018; Pauly, MacKinnon, & Varcoe, 2009), leading to significant health disparities (Public Health Agency of Canada, & Pan‐Canadian Public Health Network, 2018). Older adults are more likely than individuals in younger age groups to experience long‐term health conditions and to take multiple prescription medications, which may further complicate the negative effects of substance use (Mattson, Lipari, Hays, & Horn, 2017). Often, substance use is very difficult to identify, assess, and treat in this population, as too often, the signs and symptoms of substance use are dismissed by clinicians, who see these symptoms as those of old age (Canadian Centre on Substance Use & Addiction, 2018; De Jong et al., 2016; Steinhagen & Friedman, 2008).

Issues about stigma are particularly relevant for health care providers to consider when working with older adults who may be at risk for substance use. The terms substance use, substance abuse, addiction, and dependence are sometimes wrongfully used interchangeably. Because certain terms are stigmatizing and because labelling people can reflect negative judgements, the American Psychiatric Association has replaced “addiction”, “substance abuse”, and “substance dependence” with the category “substance use disorder”. In the Diagnostic and Statistical Manual of Mental Disorders (DSM‐5), people with substance use issues receive a diagnosis of mild, moderate, or severe substance use disorder (American Psychiatric Association, 2013; Varcoe et al., 2018).

To help mitigate and prevent the negative effects of substance use and to develop health‐promoting nursing practice, health care providers need to understand the intersecting factors that contribute to substance use, the social and health effects related to substance use, the root causes of substance use, as well as harm reduction principles and their implications for practice (Varcoe et al., 2018). The purposes of this paper are (a) to critically analyse the social context of substance use among older adults and (b) to offer strategies for nurses and other health care providers to optimally support the health of older adults experiencing problematic substance use issues. The points in this paper are not limited to nurses and will be applicable to other health care providers who are typically involved in the care of older adults; thus, when the term “health care providers” is used, it encompasses nurses as well.

3. DESIGN AND METHODS

This is a discussion paper focusing on the issue of problematic substance use in the older adult population. We provide nurses and other health care providers context around this issue and strategies to provide ethical and optimal care to older adults experiencing substance use.

This discussion is informed by two theoretical lenses: an intersectional lens in examining the various factors influencing health and access to health care; and a social justice lens, which focuses on promoting health equity in this population. In doing so, strategies will be discussed that can be used by nurses and other health care providers to support older adults [or people] living with substance use issues.

The intention of applying an intersectional lens to ground this critical analysis is to examine multilevel interactions, forces, factors, and power structures that influence individuals’ lives and health (Hankivsky et al., 2017). Peoples’ health and experiences with substance use are shaped by various intersecting factors such as age, gender, social class, social environment, geography, life experiences, and other social determinants of health (SDOH) (Public Health Agency of Canada, & Pan‐Canadian Public Health Network, 2018; Smye, Browne, Varcoe, & Josewski, 2011). For example, some of the common reasons why older adults may use substances include adjusting to challenging socio‐economic or housing conditions, retirement, changes in physical or mental health, long‐term health conditions, pain, social isolation, withdrawal, and loss of loved ones, among others (Canadian Centre on Substance Use & Addiction, 2018; Kuerbis et al., 2014). For older adults, substance use may also be linked with issues of mental health, trauma, driving accidents, falls, violence, aggression, and changes in mental state (Varcoe et al., 2018); thus, these interacting issues cannot be considered separately. An intersectional lens explicates the need for nursing and health care approaches that reflect an understanding of the socio‐cultural and political forces that influence responses to substance use, mental illness, and overall health and quality of life (Smye et al., 2011).

A social justice lens is also relevant, specifically in addressing nursing implications for individuals experiencing problematic substance use. Social justice focuses on the relative position of social groups in relation to others in society and on the root causes of disparities (CNA, 2018). Social justice aims to achieve fairer distribution of society's benefits and responsibilities; thus, a social justice lens draws attention to the various underlying factors influencing the health of older adults with problematic substance use. The promotion of social justice and equity are vital in applying an intersectionality based lens (Hankivsky et al., 2017). The Canadian Nurses’ Association's policy document on social justice gauges how social justice is addressed in health programs, policies, and throughout nursing practice with the application of three questions: (a) does it acknowledge that individuals and groups occupy different positions relative to others in society, (b) does it acknowledge the differences, or inequities, that exist in different individuals and groups and (c) does it acknowledge root causes of inequities (CNA, 2018). As nurses, it is key to consider these social justice questions in practice to provide optimal and ethical patient care.

4. DISCUSSION

Key issues are likely to arise for the patient population experiencing problematic substance use, specifically older adults. Health and social inequities, stigma, and discrimination can be detrimental, and nurses and other health care providers can play a key role in supporting older adults.

4.1. The impact of health and social inequities on substance use in older adults

In a survey completed by the National Health Service in the United Kingdom, 75% of doctors expressed concern about the treatment of older adults, stating that older people were less likely to be considered for essential treatments or specialist care (Davies, 2011); this issue is one of international proportions. As a result of social and sociopolitical factors, many individuals with problematic substance use, including older adults, are excluded from full participation in social life and often experience isolation (Canadian Centre on Substance Use & Addiction, 2018; Public Health Agency of Canada, & Pan‐Canadian Public Health Network, 2018). Dominant sociopolitical values create structural conditions, or broad structures and beliefs in society, that shape life opportunities, access to resources, and societal positioning. For example, the relationship between comorbid health conditions and substance use among older adults has been relatively understudied (Millar, Starks, Gurung, & Parsons, 2017). Older adults make up a large percentage of hospitalized inpatients; they have a high burden of comorbid health conditions and mental health issues, for which problematic substance use is usually ruled out as a cause. However, older adults may be wrongfully diagnosed with cognitive impairment or aggressive violent behaviour without assessing the root causes of these behaviours. Because substance use may more likely affect younger age groups, the older adult population is not usually the focus of conversations around problematic substance use and thus may not get the care they require, often leading to age discrimination. Age discrimination is defined as a type of prejudice that might include denying or limiting opportunities to people due to their age; in health care, this might mean that older people do not receive basic standards of care solely because they are older (Davies, 2011). Understanding structural inequities will help health care providers move away from using individualistic approaches to care and towards understanding how social contexts of older peoples’ lives can shape their health and their health care; effects may stem from gender, age, class, ethnicity, and/or other dimensions (Varcoe, Browne, & Cender, 2014).

Health equity is a social justice issue, defined by the WHO (2018) as the absence of systematic and potentially remediable differences in one or more characteristics of health across population groups defined socially, economically, demographically, and geographically. Individuals experiencing problematic substance use are highly vulnerable to inequities in health and access to health care as a result of unjust social and living conditions shaped by various factors and values discussed previously (Pauly et al., 2018; Public Health Agency of Canada, & Pan‐Canadian Public Health Network, 2018). People with problematic substance use experience significant health disparities; they have higher rates of morbidity and mortality than the general population and are at increased risk of HIV, overdoses, suicides, and infections (Pauly, McCall, Browne, Parker, & Mollison, 2015). Older adults are at an even greater risk of morbidities and health complications that may intensify the effects of drugs and alcohol. Many individuals with problematic substance use also have histories of abuse, crime, economic and social disadvantage, mental illness, and a lack of family and social support; thus, stigma is also a highly significant issue intersecting with and contributing to the harms associated with problematic substance use (Smye et al., 2011). Further, people affected by problematic substance use often delay or do not access appropriate health care for many complex, interconnected reasons. These reasons may be exacerbated in the older adult population, who may already face significant barriers to health care such as a lack of health insurance, lost or stolen health care cards, transportation issues, pharmaceutical costs, social isolation, and limited family resources. Additionally, marginalizing discourses of blame and personal responsibility are also significant barriers in accessing health care services (Canadian Centre on Substance Use & Addiction, 2018; Pauly et al., 2015), as some older adults cannot access and/or do not feel comfortable in accessing mainstream addictions services (National Initiative for the Care of the Elderly, n.d.).

4.2. Stigma and discrimination

Embedded in Western society is a common ideology that perceives individuals as being responsible for their own health and capable of accessing their own resources; for example, substance use is often viewed as a personal failure (Pauly et al., 2015). The ideology of individualism, thus, reinforces assumptions about people being entirely responsible, creating a context of blame for substance use issues, regardless of people's circumstances, history of trauma, family history, etc. (Smye et al., 2011). Substance use is severely stigmatized around the world; research demonstrates that social disapproval of addiction is greater than social disapproval of various highly stigmatized conditions such as HIV, homelessness, neglect of children, and even having a criminal record (Pickard, 2017). The strongly held societal view of substance use as primarily a “choice” often diverts attention from the underlying causes and factors that influence substance use; rather, it increases blaming and stigmatizing of people who use substances (Varcoe et al., 2018). In the context of this paper, stigma stems from interrelated social processes and negative societal attitudes towards the behaviour of people experiencing problematic substance use. Stigma is the disqualification from social acceptance and marginalization encountered by individuals who use substances, resulting in social exclusion, discrimination, ill health, and social suffering (Browne et al., 2012; Room, 2005).

Stigma surrounding people who use substances is created through five interrelated social processes: labelling individuals as different; negative stereotyping about individuals’ characteristics such as fear of being dangerous; labelling the person as “others” and “them”; the loss of status, blame and discrimination; and finally, the creation of power dynamics where power imbalance is experienced by the labelled person's ability to access key resources such as health care (Smye et al., 2011). For example, Smye et al.’s study (2011) reports that hospital staff are committed to providing care to people with substance use issues; however, they admittedly treat these patients differently than others, especially in the context of pain control where these patients are often labelled as having “drug‐seeking” behaviours or as “addicts”.

People living with substance use issues commonly face challenges to receiving optimal health care, housing, benefits, and employment—stemming from societal stigma and misconceptions about whether it is beneficial or “cost‐effective” to provide medical and health benefits to people who are “to blame for their own drug use” (Pickard, 2017). Older adults may potentially face additional stigma around shame surrounding substance use because they might often be viewed as less productive than their younger counterparts; they often also face barriers to accessing services related to geographic isolation, inability to pay for services, or difficulties with transportation (Kuerbis et al., 2014). Stigmatization of people who have problematic substance use issues has been shown to result in increased depression, feelings of worthlessness, isolation, anger, anxiety, and fear of being “socially unacceptable” (Pauly et al., 2015). These consequences might be even greater in the older adult population, given the increased rates of depression, social isolation, and loneliness among older adults. These factors can further result in detrimental effects on health such as cognitive decline, dementia, delayed medical stays, decreased immune response, and hypertension, among others, all of which are increasingly prevalent among older adults (Landeiro, Barrows, Musson, Gray, & Leal, 2017). To make matters worse, there is also a certain stigma associated with ageing, possibly causing health care providers to miss signs of substance use; for example, the symptoms of alcohol and other drug use can be similar to illnesses that are common in later life such as dementia, delirium, confusion, gait imbalances, and violent aggressive behaviour (Kuerbis et al., 2014). This may lead to a common misconception among older adults that their symptoms are seen as a “normal” part of ageing, rather than that of substance use. Thus, not only is there stigma associated with substance use, but also with ageing, which contributes to the complex nature of substance use among older adults.

Perceived negative attitudes, judgements, and discrimination towards people who use substances creates power imbalances, significantly affecting peoples’ health care experiences and often access to services. For example, several misconceptions with regard to substance use among older adults exist among health care professionals; some fail to recognize substance use as a potentially harmful issue among older adults, while others believe that it is too late to improve the life quality of someone who uses substances in older age because the damage is “already done” (Canadian Centre on Substance Use & Addiction, 2018). These varying perceptions have important implications for practice that need to be considered by nurses and other health care professionals in order to provide optimal health care services for older adults.

4.3. Implications for practice

It is beyond the scope of this paper to discuss the full range of nursing implications for individuals with problematic substance use; however, we focus on a few key implications informed by a social justice and harm reduction lens.

4.3.1. Promoting harm reduction principles

People with problematic substance use often do not seek health care because they face significant stigma from health care providers. This is because a common societal value surrounding substance use is that the best outcome for people and society is abstinence from drugs (Varcoe et al., 2018). This stems from the assumption that people are responsible for and equipped with adequate resources to assume responsibility for their own health; these assumptions downplay the various intersecting factors influencing individuals’ health, behaviours, and ability to abstain (Varcoe et al., 2018). Abstinence may not be necessary or realistic for many older adults; rather, providing support with goals related to improving quality of life and safety are often more important. Thus, the first strategy for promoting ethical nursing practice when working with older adults with problematic substance use issues is educating nurses and other health care providers about using harm reduction principles; it is noted that these principles can be applied to any age group.

Harm Reduction International (2019) describes harm reduction as evidence‐based policies and programs which attempt primarily to reduce the adverse health, social, and economic consequences of mood‐altering substances to individuals, their families, and communities, without requiring a decrease in substance use; it is both a philosophy and policy that views substance use as a health issue (Browne et al., 2018). As a philosophy, harm reduction centres on respecting the rights of individuals and appreciating the intersecting variables in the context of their lives. As a policy, harm reduction is a set of pragmatic approaches designed to minimize harmful consequences of substance use. Generally, practicing harm reduction means accepting people as they are, avoiding judgement, emphasizing the dignity of people, being compassionate, and challenging existing policies and practices that may cause unnecessary harm to individuals (EQUIP Health Care, 2017).

Many older adults may begin to have problems with substances during transitional times in their lives such as retirement, loss of loved ones, new health concerns, and loss of independence (National Initiative for the Care of the Elderly, n.d.). Because older populations are more likely to experience stigmatization and thus be less likely to seek treatment or services, a non‐judgemental, harm reduction approach is necessary. Harm reduction is a helpful stance in practice because it can encourage rather than dissuade people, including older adults, to seek adequate care, facilitate access to medical and social services, and encourage care providers to be non‐judgmental in their care (Pauly et al., 2018). As a philosophy, harm reduction shifts the focus from stigma and discrimination to a focus on moral worth—and by promoting a view of older people as deserving of care versus a potential drain on resources. Using a harm reduction lens emphasizes that problematic substance use is better understood as a complex, relapsing, long‐term condition (Pauly et al., 2015) and shifts the culture of health care from one where resources may be rationed on the basis of deservedness to one where everyone is seen as deserving of care. A growing body of research demonstrates that in practice, harm reduction approaches build trust, avoid stigmatization and judgements, (Smye et al., 2011) and improve health overall (Pauly et al., 2018).

4.3.2. Participating in social justice actions

As a second strategy for ethical nursing practice, nurses and other health care providers are encouraged to engage in self‐reflection and critical analysis. When providing care, health care providers should avoid judging people negatively based on their substance use history or current patterns of use; they should refrain from judging, labelling, and demeaning behaviours towards patients; and they should engage in questioning of their own practices and biases. Individuals who use substances are often identified by health care providers as “difficult”, “unpopular”, and may be pejoratively labeled as “frequent fliers”. Health care providers need to be reflective of their own biases when working with this population to prevent further stigmatization caused by such activities as delaying or providing limited care, avoiding patients, doing inaccurate assessments, and/or having negative responses (Pauly et al., 2015). These strategies promote social justice by drawing attention to the humanistic values of people; they acknowledge the active role of the individual in their care and ensure that everyone remains integrated in society. Health care providers are encouraged to recognize that all older adults are deserving of access to health care, regardless of the physical or mental state they are in, and should not be refused health services; this process can begin only if health care providers first self‐reflect on their own personal biases and assumptions. Strategies to support these practices may include debriefing with other colleagues around their feelings about specific patients, taking the time to read the literature about substance use in their patient population, and recognizing, for example, that an older adult who is presenting with signs of substance use may not just be “confused”, “aggressive”, have “cognitive impairment”, or another symptom commonly perceived as being related to age. Rather, health care providers should presume that there may be an underlying cause, such as substance use, that may need to be addressed. In these ways, health care providers can challenge and question societal assumptions about ageing, substance use, and the connections between them. They should also question the language they are using when addressing older adults who are living with problematic substance use issues. Questioning of one's own practice is a significant and important step in helping move health care practice towards being equity based and holistic.

4.3.3. Contextual assessment of substance use

Given the intersectoral nature of social disadvantages, and to promote social justice and equity, substance use needs to be viewed as a consequence of other factors. Nurses and other health care providers need to remind themselves that substance use can vary depending on social, historical, and economic contexts, and that the consequences of substance use are often shaped by social inequities based on gender, age, and/or income (Varcoe et al., 2018). Health care providers are encouraged to assess substance use comprehensively within the context of these various intersecting factors influencing health and access to health care services for their specific patient population (Anderson et al., 2009; Varcoe et al., 2018).

Older adults may experience multiple health conditions which may exacerbate the effects of substance use; for example, mental health and psychiatric disorders often occur with substance use such as those that relate to mood, psychosis, anxiety, and depression (Canadian Centre on Substance Use & Addiction, 2018; Degenhardt et al., 2018) often leading to the mislabelling of older people as “confused”, “aggressive”, “noncompliant”, or other descriptions commonly associated with ageing. It is important to be aware of common health issues in each age group; many older adults take multiple medications; thus, overmedication with prescription drugs may be a concern to address. Additionally, if an older person presents with repeated falls, head injuries, and/or a failure to thrive diagnosis, the assessment of substance use should be initiated in a non‐threatening way as part of a comprehensive patient history (National Initiative for the Care of the Elderly, n.d.). However, it is important not to generalize or make assumptions about health conditions or qualities as being a normal part of ageing, but rather to be aware of common diagnoses that may exist in older populations and their potential intersections with substance use, so that health care assessments can be tailored effectively (Varcoe et al., 2018).

Additionally, an equity lens can help health care providers understand that substance use and the harms of use are increased by social conditions such as abuse, trauma, grief, loss, and social determinants of health such as income and social environments (Browne et al., 2018; EQUIP Health Care, 2017). These harms may be exacerbated for older adults who are facing multiple transitions as they age; older adults are often neglected, might face elder abuse, experience additional grief and loss as loved ones pass away, and might be subject to changes in financial and social contexts (Kuerbis et al., 2014). Understanding how multiple contextual challenges can influence substance use will also help health care providers use potentially successful interventions to address substance use (Varcoe et al., 2018). To promote ethical and optimal health care for older populations, factors such as social determinants, risk behaviours and environments, and health and social care aspects need to be addressed in a comprehensive and contextual assessment of substance use.

Furthermore, it is not enough to simply be cognisant of the contextual challenges faced by older adults living with problematic substance use; the way health care providers interact and engage with their patients is also important. Being respectful, accepting, and as non‐harming as possible when trying to gather information on substance use from patients is key to ethical nursing practice (Browne et al., 2018; Pauly et al., 2015; Varcoe et al., 2018). This can be achieved by learning about the context of the population one is serving; being clear about why particular information is being gathered; avoiding gathering information that is not needed or will not be used; assessing individuals in context; starting with the least intrusive questions; using assessment as an opportunity to suggest health promotion and harm reduction strategies; and, avoiding assumptions or being influenced by stereotypes. It is also important to ensure that the spaces where people may come for help are safe and welcoming. These strategies are essential to consider when working with older adults and are particularly important in the context of the multiple forms of age discrimination that older adults often experience. Additionally, the Canadian Centre for Substance Use and Addiction (2018) discusses specific detection, screening, and assessment strategies that are unique to older adults. Some of these include: using (and further developing) screening tools that are tailored specifically to older adults; refraining from applying standard diagnostic criteria for substance use to this population, as it may have limited applicability; engaging in a full comprehensive assessment with older adults including medication use, mental health, medical and psychiatric issues, social and family history, and functional and cognitive screening; and finally, to recognize that there is a need for better training of health care professionals in preventing, detecting, supporting, and caring for older adults with substance use disorders.

5. CONCLUSION

There is a definite need for enhanced awareness by health care providers around the growing problem of substance use in the older adult population. Population predictions indicate that by 2036, approximately 25% of the Canadian population will be over the age of 65 (Statistics Canada, 2018). As the world's population continues to get older, there is a growing need for assessments, treatments, and services that target older adults with substance use issues. Addressing the social context of substance use can help nurses and other health care providers better understand the complex context of older people experiencing substance use issues. Using an intersectionality and social justice approach in combination with a harm reduction lens permits an opportunity to address the root causes of substance use, allowing for comprehensive, context‐specific, and tailored patient care.

The myriad of health consequences related to substance use are well known; however, the various contextual and intersecting factors associated with substance use among older adults are relatively poorly understood. Factors such as age, gender, social environment, geography, health status, life experiences, life transitions, and other social determinants of health can significantly shape older adults’ experiences with substance use and should be incorporated into a comprehensive, holistic, and tailored approach to patient care. As discussed in this paper, the complexity of comorbidities and health and life challenges faced by older adults requires further attention. Substance use can be very difficult to assess and identify in the older adult population, as symptoms of substance use are often confused with symptoms that may reflect the aging process. Further research and clinical practice guidelines are needed to address the range of complex factors associated with substance use in the older adult population and to provide relevant, meaningful, and supportive care.

CONFLICT OF INTEREST

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

ETHICAL APPROVAL

Research Ethics Committee approval was not required.

Thandi MKG, Browne AJ. The social context of substance use among older adults: Implications for nursing practice. Nursing Open. 2019;6:1299–1306. 10.1002/nop2.339

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