Introduction
Scope of the problem
Risk factors
Drugs
Misuse of prescribed medications
Alcohol
Assessment
Management
Prognosis
Conclusion
References

Introduction

Alcohol and substance misuse can be easily overlooked in the older population. Studies show that the misuse of drugs and alcohol is an increasing phenomenon among older people impacting on both morbidity and mortality. The “baby boomer” population born between 1946-1964 appears to be at maximum threat of rising substance misuse in the older population.

Clinical knowledge and a developing literature base show that older people may use a mixture of legal and illegal substances, as well as prescribed and over-the-counter medications taken in accordance with medical practitioners’ directions.1 

The number of older substance misusers requiring treatment is likely to double in the next couple of decades. Patients can present to different social and medical care settings with these issues, so screening and assessment for substance misuse and alcohol abuse are important. Current services are not properly equipped to assess and treat older people. There may be difficulties in travelling to access services and physical and mental comorbidity may obscure the substance misuse problem.2 

Awareness of alcohol services among older people is improving but there is a general lack of health awareness about lower risk drinking limits among the public. This lack of awareness may also be found in practitioners assessing older people with alcohol misuse.3 

Scope of the problem

In Europe and the UK, the number of people over 65 years needing treatment for substance misuse is expected to more than double between 2001 and 2020. Between 2016 and 2017, people aged 65 and over formed 30% of hospital admissions in England associated primarily to alcohol. This proportion has doubled compared with admissions between 2010 and 2011, when this age group formed 14% of these admissions. UK statistics show a 20% rise in the number of people aged 65 and over drinking above recommended drinking limits in the last decade with older drinkers the only group to see a continued rise in heavy consupmtion.4 5 6 

Risk factors

Given that the proportion of the population aged 65 or above in Europe is estimated to rise to 25% by 2050, the predictable rise in older people with substance misuse has considerable repercussions for public health.4 

The prevalence of substance misuse in England is one of the highest in Europe with the burden of disease attributable to substance misuse influenced markedly by socioeconomic deprivation. Although this prevalence covers all substances, alcohol misuse accounts for the largest burden among older people in the UK.

Older people from black and minority ethnic backgrounds have higher levels of alcohol misuse than the general older population, with Irish and south Asian male migrants to the UK being at particular risk.

In certain areas of the UK, the combination of Irish ethnicity and social marginalisation is known to be associated with high rates of alcohol misuse. A combination of ‘Irish’ (greater number of drinks per drinking session) and ‘English’ (greater number of days engaged in drinking) drinking patterns may be responsible for the greater risk of harmful drinking. This is further compounded by negative stereotyping and low rates of primary care consultation in the Irish population. These factors may influence access to alcohol services.7 

Increased life expectancy has led to changes in the demographic structure of the UK population. Older people are at particular risk of the complications of substance use, misuse and dependence. This is due to decreased metabolism and resulting accumulation of substances including alcohol and many medications. Brain sensitivity to the effect of alcohol and other drugs may also be increased. Thus, older people do not need to use substantial quantities of substances for adverse effects to occur. The original ‘geriatric giants’ – ie iatrogenesis, immobility, intellectual deterioration, incontinence and instability – can all be associated with substance misuse.

The increased consumption of psychotropic drugs may be related to a less-restrictive prescription policy used by GPs today, but could also be related to changes in modern society, with an increased prevalence of psychological difficulties among vulnerable groups of people.8 9 10 

Drugs

In the UK, there are more than 2,000 people aged 60 and over receiving treatment for drug misuse in the UK. In England, more than 400 injecting drug users aged 60 or over undergo treatment for drug problems. However, many more people in this age group are probably experiencing problems relating to drug misuse because only a small number will be receiving  treatment. Illicit drugs most commonly used by those aged 60 and over in treatment with drug abuse services are opiates (65%), opiates and crack cocaine (18%) or crack only (2%).

Other substances used in this age group are cannabis, amyl nitrate (poppers) and magic mushrooms. The proportion of older people who inject drugs also appears to be increasing, at least in the developed world. Many people who inject drugs commenced their injecting careers in the drug epidemics of the 1980s and 1990s and continue to use substances (including injecting) through to today. Risk factors are poorly understood because research into illicit drug use has primarily focused on young people.12 13 14 

Misuse of prescribed medications

The most commonly prescribed drugs with the potential for misuse are benzodiazepines (for insomnia and anxiety), “Z” drugs zaleplon, zolpidem and zopiclone (for insomnia) − so called because they share the same first letter, opioids (for pain) and gabapentinoids (for pain and anxiety).

Older people may also use opioids for cough and diarrhea. Long-term prescribing (more than 30 days) is more common for each type of Z drug in older patients than younger patients. Studies have shown the most common use of psychotropic drugs among the elderly was the use of tranquillisers and sleeping medication prescribed by their GPs.15 

Alcohol

Heavy alcohol consumption in older adults is associated with poorer global cognitive function, learning, memory, and motor function. Furthermore, lifetime history of alcohol dependence is associated with poorer function in the same neurocognitive domains, in addition to the attention/executive domain, irrespective of age; while heavy current alcohol consumption is associated with significant impairment in a number of neurocognitive domains, history of alcohol dependence, even in the absence of heavy current alcohol use, is associated with lasting negative consequences for neurocognitive function.16 

In the older population, hazardous alcohol consumption is associated with a wide range of physical, psychological and social problems. There is evidence of an association between excessive alcohol consumption and increased risk of coronary heart disease, hypertension and haemorrhagic and ischaemic stroke, increased rates of alcohol-related liver disease and increased risk of a range of cancers. Alcohol is identified as one of the three main risk factors for falls. Excessive alcohol consumption in older age can also contribute to the onset of dementia and other age-related cognitive deficits and is implicated in one-third of all suicides in the older population.17 18 

Assessment

Assessments should start with questions about drinking, medication use, and illicit substances in a nonjudgmental way; a collateral history (from a suitable informant), mental-state examination, physical examination, social assessment, legal problems (if any) and investigations. Questions include changes in mood, eating patterns, ability to undertake activities of daily living, memory, concentration and medication compliance. It is also important to discern patients’ views of their drug and/or alcohol consumption, the current pattern of substance misuse, the type of drug used, quantities, level of dependence, risk behaviours, associated problems, source of help, source of access to psychoactive substance(s) and periods of abstinence and relapse.

To ascertain the level of dependency, it is important to ask about experiences of withdrawal symptoms or any medical complications. Barriers to identification of substance misuse in older people include assumptions that this is a rare phenomenon in old age, symptoms being masked by physical illness, reluctance of patients to discuss due to shame or denial and cognitive impairment.8 19 

Screening instruments for substance misuse in older people are confined to those that identify alcohol misuse. The CAGE (Felt that you should Cut down; Annoyed by others criticising your drinking; Felt Guilty about drinking; Had an Eye-opener/felt the need to drink first thing in the morning to steady nerves or get rid of a hangover) questionnaire helps one to rapidly screen for alcohol dependence. However, it does not particularly help in distinguishing between current and prior alcohol problems.

The Alcohol Use Disorders Identification Test assists in ascertaining alcohol use over the past year. The AUDIT can also be used as an outcome measure; adaptations that have been validated in older people include the AUDIT-5 and the AUDIT-C. The Short Michigan Alcoholism Screening Test – Geriatric version has been validated for use in older hospital in-patients.8 20 

Mental health services can make use of screening tests adopted by primary care such as DAPA-PC (Drug Abuse Problem Assessment for Primary Care). The Fagerstrom Test for assessment of nicotine dependence is also a rapid tool.11 

Management

Two diagnostic systems are used to make a diagnosis of Substance Use Disorder, with either Harmful or Dependent Substance Use. They include the DSM5 (Diagnostic and Statistical Manual of the American Psychiatric Association) and the ICD 10 (International Classification of Diseases).

The patient should be assessed for delirium, psychotic symptoms, mood/anxiety disorders, Wernicke’s encephalopathy and cognitive impairment. The physical examination should include an assessment of deep venous thrombosis, subacute bacterial endocarditis, stigmata of chronic liver disease, gait, balance and neurological manifestations of Wernicke’s encephalopathy.19 

Useful investigations may include urine or breath tests, blood alcohol levels, full blood count, mean corpuscular volume, urea and electrolytes, liver function tests, vitamin B12 and folate levels. More specialised investigations such as neuroimaging studies or screening for blood borne viruses may have to be undertaken.8 11 

It is important to tailor appropriate individualised management plans incorporating specific psychosocial and health needs relevant to older people. Geriatricians, old age psychiatrists and addiction specialists can help in this regard.8 11 

Prognosis

Evidence suggests that the treatment outcomes in older people for alcohol and substance misuse are better than younger adults. Older people tend to stay longer in treatment and have better abstinence rates when compared with younger adults. They also report significant improvements in their social functioning.8 14 

The outcome of alcohol-related dementia depends upon the nature and extent of brain damage. There is scope for recovery in mild or moderate  cognitive impairment. Abstaining from alcohol can be associated with some reversibility of cognitive function.11 18 

Conclusion

Older people misuse alcohol, nicotine, prescription medication and illicit drugs. All indications are that this is increasing. This may be as a cause and/or the result of physical or mental illness, and the consequent morbidity and mortality are costly to the patient, their families and society. Patients present to a wide variety of social and medical care settings, thus it is important to screen and assess for substance use.  This provides the opportunity to determine to what extent the substance problem is related to the presentation, which may be subtle in older people. Evidence suggests that there is a benefit in treating substance problems in the older population; this group should not be neglected by practitioners, researchers, educators and policymakers.

 

Ayesha Bangash, Consultant Old Age Psychiatrist, The Dales, Halifax

Saadiya Khan, ST5 General Adult Psychiatry, Folly Hall Mills, St Thomas Road, Huddersfield

John Wattis, Visiting Professor of Psychiatry for Older Adults at Huddersfield University, Queensgate, Huddersfield

Stephen Curran, Consultant Old Age Psychiatrist, Modular Accomodation, Fieldhead Hospital, Wakefield

 

Conflict of interest: none

 

References

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2. Carew AM, Comiskey C. Treatment for opioid use and outcomes in older adults: a systematic literature review. Drug Alcohol Depend 2018; 182: 48–57

3. Giles A. Older people and alcohol misuse: Helping people stay in their homes. London: Housing Learning & Improvement Network; 2016 [cited 2018 May 2]. Available from: https://www.housinglin.org.uk/_assets/Resources/Housing/Support_materials/Practice_briefings/HLIN_PracticeBriefing_PHE_OlderPeopleAlcohol.pdf.

4. Gossop M. Drugs in focus: briefing of the European Monitoring Centre for Drugs and Drug Addiction; 2008 [cited 2018 May 4]. Available from: http://www.emcdda.europa.eu/attachements.cfm/att_50566_EN_TDAD08001ENC_web.pdf.

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6. Baby Boomers told to drink much less than official limits. The Telegraph. 2018 Mar 7.

7. Rao R, Schofield P, Ashworth M. Alcohol use, socioeconomic deprivation and ethnicity in older people. BMJ Open 2015; 5

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9. Crome I. Substance misuse in the older person: setting higher standards. Clin Medicine 2013; 13(6): s46–s49

10. Isaacs B. The Challenge of Geriatric Medicine. Oxford: Oxford University Press: 1992

11. Our Invisible Addicts [internet]. London: Royal College of Psychiatrists; 2018 [cited 2018 May 1]. Available from: https://www.rcpsych.ac.uk/files/pdfversion/CR211.pdf.

12. Wadd S, Galvani S. The Forgotten People: Drug Problems in Later Life; 2014 [cited 2018 May 6]. Available from: http://www.biglotteryfund.org.uk/-/media/Files/Research%20Documents/Older%20People/the_forgotten_people.pdf.

13. Higgs P. Substance misuse in older people. BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3885

14. Carew AM, Comiskey C. Treatment for opioid use and outcomes in older adults: a systematic literature review. Drug and Alcohol Dependence 2018; 182: 48-57

15. Cartagena FJ, Porter L, McManus S, et al. Prescribing patterns in dependence forming medicines; 2017 [cited May 15]. Available from: http://phrc.lshtm.ac.uk/papers/PHRC_014_Final_Report.pdf.

16. Woods AJ, Porges EC, Bryant VE, et al. Current Heavy Alcohol Consumption is Associated with Greater Cognitive Impairment in Older Adults. Alcohol Clin Exp Res 2016; 40(11): 2435-44

17. Bell S. Association between clinically recorded alcohol consumption and initial presentation of 12 cardiovascular diseases: population based cohort study using linked health records. BMJ 2017; 356: j909.

18. Yasar S. Relation between alcohol consumption in midlife and dementia in late life. BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3164

19. Kuerbis A, Sacco P, Blazer DG, et al. Substance Abuse Among Older Adults. Clin Geriatr Med 2014; 30(3): 629–54