Summer 2026 Issue

What Does Addiction Look Like Over 60?
By Diana Santiago, LCSW, CAADC
Social Work Today
Vol. 26 No. 3 P. 10

Rethinking a Social Worker’s Assessment Tools for Older Adults

Substance use in older adults is one of the most underrecognized and undertreated challenges facing social workers today. While the opioid crisis and substance use by younger populations are prevalent in the news, misuse of alcohol and prescription medication in adults age 60 and older is quietly increasing. That comes with serious consequences for health, safety, and quality of life.

Not only can it be challenging for social workers to identify substance use in older adult populations, but recognition is made more difficult when masked by the normal processes of aging, complicated by co-occurring conditions and shielded by generational attitudes around privacy, independence, and stigma.

In fact, many of the side effects of substance use disorder can mimic aging. And this overlap creates a diagnostic gray area requiring social workers to use both clinical skill and compassionate persistence to navigate.

Social workers need to be attuned to the unique vulnerabilities of older adults, barriers to treatment, and actionable, person-centered strategies to support recovery and improve quality of life.

How Substance Use in Older Adults Can Remain Hidden
It’s a common stereotype that substance misuse is a problem only for younger people. Because of that, substance use in older adults often goes unnoticed. Older adults may present as stable, private, and socially appropriate, but they can still be significantly struggling.

Alcohol use disorder is frequently overlooked, but its impact is profound. Overuse of alcohol in older adults contributes to accidents, medical complications, and diminished functioning. While society may be skeptical that substance use is an issue for people aged 60+, social workers need to actively challenge that misconception. Most people don’t think of a grandmother whose reputation is as a proper Southern woman drinking two bottles of wine every night, but it’s a reality.

Ageism plays a subtle but powerful role. When an older adult presents with cognitive decline, fatigue, or mood changes, providers may first attribute these symptoms to dementia, depression, or “just getting older,” rather than considering substance use as a contributing factor.

Warning Signs Social Workers Should Watch For
Recognizing substance use in older adults requires a nuanced understanding of behavioral, physical, and environmental indicators. These signs are often subtle and easily misidentified.

1. Social Withdrawal and Isolation
One of the earliest and most telling warning signs is a change in social engagement. Older adults may do the following:

• frequently cancel plans;
• stop answering texts or phone calls; and
• withdraw from family or community activities.

Isolation can be linked to mobility issues or grief, but it can also signal increasing substance use. As isolation deepens, so does risk. This creates a cycle that exacerbates both substance use and mental health concerns.

2. Changes in Mood and Personality
Symptoms like irritability, anxiety, and signs of emotional distress closely resemble clinical depression or anxiety disorders. But they are also common indicators of substance use. Changes may appear suddenly or intensify over time, and social workers should consider whether those changes correlate with patterns of alcohol or medication use.

3. Cognitive Changes
Memory issues, confusion, or decreased executive functioning are often attributed to dementia or early Alzheimer’s disease. However, substance use can produce similar effects, especially when combined with prescription medications.

In some cases, individuals initially suspected of having cognitive disorders experience significant improvement once substances are reduced or eliminated. This underscores a critical clinical principle: It is often necessary to address substance use first to accurately assess cognitive functioning.

4. Neglect of Personal Hygiene and Living Conditions
Subtle declines in self-care, such as the following, can be revealing:
• wearing the same clothes for extended periods;
• poor grooming;
• accumulation of trash or clutter in the home; and
• unpaid bills or disorganization.

These signs may indicate diminished functioning linked to substance use, in addition to aging.

5. Medication Misuse and Polypharmacy Concerns
Adults over age 60 take four or more daily prescription medications, on average. Nearly one in three adults in this age group takes five or more medications, according to the CDC. This increases the risk of misuse and dangerous interactions.

Warning signs include the following:

• confusion about medication schedules;
• taking more medication than prescribed;
• combining medications with alcohol; and
• minimizing or denying use.

Many older adults do not see misuse of prescribed medication as problematic. Instead, it is framed as adhering to medical treatment.

6. Evidence of Alcohol Use in the Home
The presence of alcohol, especially in large quantities, can be a key indicator of a larger issue. However, older adults may minimize or underreport their consumption.

While lab work can sometimes reveal patterns of heavy alcohol or prescription drug use, primary care providers can miss these patterns unless they’re specifically looking for evidence of substance use.

A Uniquely Vulnerable Population
Understanding why substance use develops or escalates in later life is essential for effective intervention.

Life Transitions and Loss
Older adulthood often involves significant transitions, including the following:

• retirement;
• loss of a spouse or peers;
• changes in physical health; and
• reduced mobility.

These shifts can disrupt identity, routine, and social connections. This can create a prime environment for substance use as a coping mechanism.

Loss of Purpose
It is human nature for us to gain a sense of identity from our roles as workers, parents, community members, and caregivers. When these roles diminish, it can leave a void.

Twenty-four hours every day, seven days a week is a lot of time to fill. And without meaningful structure, days can feel unanchored.

A valuable exercise is to map out a weekly schedule to visualize how much unstructured time exists. The goal is not simply to “stay busy,” but to be planful and engage in activities that provide purpose and fulfillment.

Generational Attitudes
Older adults, particularly those from earlier generations, may value privacy and self-reliance and be less comfortable discussing personal struggles. It’s common for older adults to resist group-based interventions and even experience greater stigma around substance use.

These attitudes can make engagement in treatment more challenging.

Living Situations
Risk can also vary depending on a person’s living situation. Individuals living alone after the loss of a spouse may face profound changes and isolation. Others may still be working or supporting adult children, which leads to different stressors.

Recognizing variations unique to everyone’s situation helps social workers tailor their approach.

Barriers to Treatment
Even when substance use is identified, multiple barriers can obstruct treatment.

Denial and Minimization
Many older adults view their behavior as manageable and believe they can quit on their own. Substance use is often underreported. Denial can also be reinforced by cognitive impairment, making it difficult to recognize the extent of the problem.

Shame, Stigma, and Pride
Feelings of shame often prevent individuals from seeking help. It’s very common to hear older adults express that they don’t want to “burden” their family members. Additionally, maintaining independence often carries extra importance as we age, and interventions can be perceived as a threat to autonomy.

Fear of Losing Independence
There is often a concern that disclosing substance use could lead to loss of control over living arrangements or finances. This fear can limit honesty during assessments.

Physical, Medical, and Financial Barriers
Accessing treatment can also be complicated by mobility limitations, lack of transportation and medical complexity. Co-occurring medical conditions are common and can limit treatment options, as not all treatment programs are equipped to handle serious medical needs, such as liver disease or mobility issues.

Coverage for substance use treatment also varies widely. Medicare may not fully cover certain levels of care, and intensive inpatient treatment can be difficult to access. Outpatient and step-down programs may be more feasible, but navigating these complicated systems is often overwhelming and discouraging for individuals and families.

Clinical Challenges for Social Workers
Working with older adults requires adapting traditional approaches.

Older models of substance use treatment often rely on confrontation. This approach is generally ineffective, and even potentially harmful, with older adults.

Instead, social workers should emphasize collaboration instead of authority. Use respectful, nonjudgmental language and present clear, evidence-based information.

How information is presented matters. Older adults often respond well to concrete explanations of how substances affect the brain and body as well as clear connections between use and functional decline. Above all, it’s vital to respect their life experience and autonomy.

Importantly, older adults don’t always identify as “older” or “old.” Instead, it’s helpful to communicate about what they’re experiencing and what they have in common with others, including retiring, adult kids moving away, physical issues, and loss.

A Compassionate Framework for Support
At the heart of effective intervention is a commitment to dignity, connection, and quality of life. It can be helpful for social workers to follow a general roadmap and customize it to the unique needs and situation of each patient.

1. Lead With Empathy and Respect
Approach conversations with curiosity rather than judgment. Acknowledge the individual’s life experience and strengths.

2. Emphasize Quality of Life
A powerful motivator is the question: “How do you want to live your remaining years?” Framing recovery in terms of improved relationships, physical health, and independence can resonate more than focusing on risks alone.

3. Build Structure and Purpose
Help clients develop a weekly routine that includes social activities, physical movement, engagement that is meaningful to them (such as volunteering), and connection with family and peers. Structure provides stability and reduces the likelihood of substance use.

4. Foster Connection
Isolation is one of the greatest risk factors. Social workers can act as care navigators, linking clients to community resources, facilitating peer connections, and encouraging participation in age-relevant groups. Connection is vital; the more adult substance users are alone, the more dangerous their situation tends to be. Programs that bring together individuals with similar life experiences can be especially effective.

5. Involve Family When Possible
With appropriate consent, family members can play a critical role in encouraging engagement with treatment, supporting care planning, and providing accountability.

In fact, in many cases, older adults are more willing to enter treatment when family members are involved.

Actionable Steps for Social Workers

Routine Screens
Incorporate substance use screening into regular assessments, even when it is not the presenting issue. Use validated tools for both substance use and depression.

Connect With Specialized Providers
In my work at Caron, I’ve seen first-hand how important it is for social workers to develop relationships with local substance use treatment programs. These providers can conduct comprehensive assessments, recommend appropriate levels of care and assist with treatment planning.

Navigate Systems and Resources
Many older adults are unaware of resources available to them. Social workers are uniquely positioned to bridge gaps by coordinating care across providers, assisting with insurance navigation, and connecting clients to community services (eg, meal delivery, transportation).

It’s also critical for social workers to ensure follow-through.

Address Legal and Planning Needs
Encourage early planning around health care directives, financial management, and power of attorney. Without these documents, families may face significant challenges if a loved one becomes impaired.

Advocate for Accessibility
When referring patients to treatment programs, consider physical accessibility, availability of transportation, and ability to manage medical complexity.

Not all programs are equipped to meet the needs of older adults.

Follow Up Consistently
Initial referrals are helpful, but not enough. Ongoing follow-up helps address barriers, reinforce engagement, and build trust.

What Recovery Makes Possible
For many older adults, the idea of change can feel daunting. Yet the benefits of recovery are substantial and often transformative.

Clients frequently experience the following:

• improved physical strength and mobility;
• enhanced cognitive clarity;
• better emotional regulation;
• stronger relationships with family; and
• renewed sense of purpose.

People are often shocked about how limited they have been and how much they’re able to do without using substances. Recovery is not simply about abstinence; it’s about reclaiming the ability to engage fully in life.

Broadening Perspective
Substance use in older adults demands greater attention within social work practice. By expanding the lens through which we view aging and challenging assumptions about who is at risk, social workers can play a pivotal role in early identification and intervention.

The work requires patience, clinical insight, and a deep respect for the complexity of later life. It also requires a shift from problem-focused thinking to a broader vision of wellbeing, one that centers on connection, purpose, and quality of life.

When social workers recognize the signs, address barriers, and guide older adults toward meaningful support, the impact extends far beyond the individual. Families are strengthened, communities are enriched, and people are given the opportunity to live their remaining years with dignity, clarity, and fulfillment.

Ultimately, that’s the goal. Not just more years, but better years.

— Diana Santiago, LCSW, CAADC, is the clinical supervisor in the Older Adult Program at Caron Treatment Centers, based in Wernersville, Pennsylvania. For more information, visit www.caron.org.

SORTING THROUGH CO-OCCURRING CONDITIONS
Substance use, mental health disorders, and cognitive decline frequently intersect. Determining the primary driver of symptoms can be complex. Accurate assessment often requires a period of abstinence. Only then can providers differentiate between substance-induced symptoms and underlying conditions.