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College Report CR165College Report CR165
© 2011 Royal College of Psychiatrists
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Our invisible addicts
First Report of the Older Persons’ Substance Misuse
Working Group of the Royal College of Psychiatrists
College Report CR165
June 2011
Royal College of Psychiatrists
London
Approved by Central Policy Coordination Committee: January 2011
Due for review: 2016
Disclaimer
This guidance (as updated from time to time) is for use by members of the Royal College of
Psychiatrists. It sets out guidance, principles and specic recommendations that, in the view of the
College, should be followed by members. None the less, members remain responsible for regulating
their own conduct in relation to the subject matter of the guidance. Accordingly, to the extent
permitted by applicable law, the College excludes all liability of any kind arising as a consequence,
directly or indirectly, of the member either following or failing to follow the guidance.
3
Royal College of Psychiatrists
Contents
Working Group 4
Executive summary and recommendations 6
Introduction 11
Risk factors 17
Effects and complications 23
Assessment of substance misuse in older people 25
Treatment of addiction 31
Service models: implications for service development 37
Appendix 1: Assessment of substance misuse in older people 42
Appendix 2: Guidance for pharmacological treatment of
substance problems in older people 44
Appendix 3: Model alcohol misuse services for older people 48
Appendix 4: Online resources 51
References 53
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Working group
eDitorial Group
Professor Ilana Crome
Dr Karim Dar
Dr Stefan Janikiewicz
Dr Tony Rao
Dr Andrew Tarbuck
members of the WorkinG Group
Professor Ilana Crome
(Chair)
Professor of Addiction Psychiatry and Academic
Director of Psychiatry, Keele University Medical
School; Consultant Addiction Psychiatrist,
South Staffordshire and Shropshire Healthcare
NHS Foundation Trust
Andrew Brown Director of Programmes, Mentor UK
Dr Karim Dar Consultant Addiction Psychiatrist, Central and
North West London NHS Foundation Trust
Dr Linda Harris Clinical Director, Substance Misuse and
Associated Health Unit, Royal College of
General Practitioners
Dr Stefan Janikiewicz General Practitioner Principal; Royal College of
General Practitioners’ North West Substance
Misuse Co-Lead; Clinical Director, Substance
Misuse Service, Cheshire and Wirral
Partnership NHS Trust
Dr Tony (Rahul) Rao Consultant in Old Age Psychiatry, North
Southwark Community Mental Health Team,
South London and Maudsley NHS Foundation
Trust, and Associate Dean, Royal College of
Psychiatrists and London Deanery
Dr Don Shenker Chief Executive, Alcohol Concern
Dr Andrew Tarbuck Consultant in Old Age Psychiatry, Norfolk
and Waveney Mental Health NHS Foundation
Trust; Honorary Senior Lecturer, University of
East Anglia; Director, DeNDRoN East Anglia
(Dementias & Neurodegenerative Diseases
Local Research Network)
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Royal College of Psychiatrists
Working group
We are indebted to Dr Michael S. Dennis (School of Medicine, Swansea
University), Dr Michael Farrell and Dr Owen Bowden Jones (on behalf of
the Faculty of Addictions), and Dr David Anderson and Dr Peter Connelly
(on behalf of the Faculty of Old Age Psychiatry) for their contribution to the
development of the report
We would like to acknowledge the excellent secretarial support of Marion
Riley and Corrina Knight
6http://www.rcpsych.ac.uk
Executive summary
and recommendations
Both alcohol and illicit drugs are among the top ten risk factors for
mortality and morbidity in Europe and substance misuse by older people
is now a growing public health problem. Between 2001 and 2031, there is
projected to be a 50% increase in the number of older people in the UK. The
percentage of men and women drinking more than the weekly recommended
limits has also risen, by 60% in men and 100% in women between 1990 and
2006 (NHS Information Centre, 2009a). Given the likely impact of these two
factors on health and social care services, there is now a pressing need to
address substance misuse in older people.
This report has brought together a group of health professionals with
expertise in substance misuse in older people, whose remit it has been to
develop the existing knowledge base according to the following terms of
reference:
examining the nature and extent of substance misuse in older people
identifying precipitants and complications
highlighting best-practice guidance
exploring training opportunities
developing future strategy, encompassing clinical service provision and
developments, training and education, research, and policy.
nature anD extent of the problem
The proportion of older people in the population is increasing rapidly,
as is the number of older people with substance use problems
Mortality rates linked to drug and alcohol use are higher in older people
compared with younger people
High rates of mental health problems in older people (including a
high prevalence of cognitive disorders) result in frequent, complex
psychiatric comorbidity accompanying substance use disorders
Older people may show complex patterns and combinations of
substance use (e.g. alcohol plus inappropriate use of prescribed
medications)
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Royal College of Psychiatrists
Executive summary and recommendations
Older people use large amounts of prescription and over-the-counter
medication and rates of misuse (both intentional and inadvertent) are
high, particularly in older women
Although alcohol use does decline with age, a signicant number of
older people consume alcohol at dangerous levels
Although illicit drug use is uncommon in the over-65 age group at
present, there have already been signicant increases in the over-
40 age group. As this cohort ages we should anticipate a signicant
increase in the number of older people using illicit drugs
precipitants anD complications
Late-onset substance misuse has different aetiological and
demographic associations, and probably a better prognosis, than early-
onset misuse
In older people, the relationship between cognitive function and
substance (particularly alcohol) use is complex, as is that between
functional mental health problems (e.g. anxiety and depression) and
substance use. The direction of causality is often unclear
Older men are at greater risk of developing alcohol and illicit substance
use problems than older women. However, older women have a higher
risk of developing problems related to the misuse of prescribed and
over-the-counter medications
Physical health problems and the long-term prescription of medication
(especially hypnotics, anxiolytics and analgesics) are important factors
in the development of substance misuse in older people
Psychiatric comorbidities of substance misuse are common in older
people (including intoxication and delirium, withdrawal syndromes,
anxiety, depression and cognitive changes/dementia)
Among older people, psychosocial factors (including bereavement,
retirement, boredom, loneliness, homelessness and depression) are
all associated with higher rates of alcohol use
Because of physiological changes associated with ageing, older people
are at increased risk of adverse physical effects of substance misuse,
even at relatively modest levels of intake
Alcohol and tobacco use have the greatest impact in population terms
on physical health, affecting many systems (including the cardio-
vascular, gastrointestinal, neurological and respiratory systems)
Presentation can be subtle or non-specic and the aetiological role of
substance use in physical conditions is frequently overlooked
best practice
Older people with substance use problems have high levels of unmet
need
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College Report CR165
General practitioners should screen every person over 65 years of age
for substance misuse as part of a routine health check, using specic
tools such as the Short Michigan Alcoholism Screening Test – Geriatric
version (SMAST-G); screening should also incorporate cognitive testing
using tools such as the Mini-Mental State Examination (MMSE)
Re-screening should be carried out if certain physical and/or
psychological symptoms are present or if the person is experiencing
major life events
Older people can and do benet from treatment and in some cases
have better outcomes than younger people
Treatment of coexisting physical conditions (including chronic condi-
tions such as hepatitis C and chronic obstructive pulmonary disease)
and psychological conditions is a very important part of management
Although applying the standard diagnostic criteria for substance use
disorders is useful, it should be noted that sometimes they may not be
appropriate for older people
Patients who repeatedly do well in hospital and badly at home, those
with unexplained ‘ups & downs’ in health presentation, those with
inconsistencies and contradictions in the history and presentation are
of particular concern
Association of substance misuse (particularly alcohol) and conditions
such as liver disease, hypertension, diabetes, falls, cognitive problems,
depression, self-harm, incontinence (often not a readily apparent
association) indicates specic physical investigations
Close liaison between all professionals, disciplines and agencies
involved in the care of the patient is very important
Current recommended ‘safe limits’ for alcohol consumption are based
on work in younger adults. Because of physiological and metabolic
changes associated with ageing, these ‘safe limits’ are too high for
older people; recent evidence suggests that the upper ‘safe limit’ for
older people is 1.5 units per day or 11 units per week
In older people, binge drinking should be dened as >4.5 units in a
single session for men and >3 units for women
Local policies regarding older people with substance use problems
should be developed: access on the basis of need, elimination of age
barriers, easy transfer between services, joint working and decisions
regarding who will be the lead service in these circumstances, as well
as protocols regarding admission for detoxication
traininG
Training about the impact of substance misuse on the older person is
not an optional extra
Training for all medical professionals should commence at under-
graduate level, through specialist postgraduate education and continue
as part of continuing professional development (CPD)
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Royal College of Psychiatrists
Executive summary and recommendations
Old age psychiatrists, addiction specialists and psychiatrists,
geriatricians, as well as nursing, psychology, social care and other
allied professionals should be suitably trained
It is essential that health professionals have adequate knowledge of
substance use disorders in older people; this includes being aware
of associations with mental disorders and physical health problems,
as well as vigilance over interactions between substances and both
prescribed and over-the-counter medications
Clinical skills in the areas of screening, assessing motivation to change
substance using behaviours, as well as delivering brief interventions
and social interventions to reduce relapse within a harm reduction
model should be core competencies for health and allied health
professionals
Improved attitudes to older people with substance misuse in areas
such as addressing stigma, therapeutic nihilism and social exclusion
are required at individual, community and public health levels
research
Examination of trends in the extent, nature and predictors of substance
use problems in older people is required
Standardised age-appropriate assessment and outcome measures that
encourage comparability should be developed
Effective interventions for adults should be evaluated and innovative
treatments for older people developed
Service models with a particular focus on long-term outcome should
be developed and evaluated
recommenDations anD future strateGic Direction
1 At a policy level, advocating for the inclusion of this issue in more
substantive terms in all relevant policy documents. An initial step
might be inuencing policy makers to develop clinical guidelines
through care pathways addressing the varied needs of older substance
misusers.
2 At a public health level, developing a consensus on information for the
public and healthcare professionals on drinking limits specically for
older adults and highlighting risks to health.
3 At the service delivery level, access to prevention and treatment should
be enhanced by removing barriers, training of healthcare staff, use of
valid screening instruments and developing closer working models –
including innovative paradigms – between services at all levels.
4 At the treatment intervention level, exploring how to augment the
cautious implementation of drug treatment interventions currently used
for younger adults.
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College Report CR165
5 At the educational level, developing comprehensive training and
education packages in conjunction with other medical Royal Colleges
for professionals of different backgrounds.
6 At the research and development level, improving knowledge of the
epidemiology of substance problems in various settings and developing
an evidence base on effective treatments and service provision barriers
from systematic research, audit and evaluation.
7 At the ethical level, developing, implementing and promoting service
delivery based on need, but targeted in an age-appropriate way
through multi-agency partnership is the way forward.
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Royal College of Psychiatrists
Introduction
Both alcohol and illicit drugs are among the top ten risk factors for mortality
and morbidity in Europe (European Commission, 2006) and substance
misuse by older people is now a growing public health problem. Between
2001 and 2031, there is projected to be a 50% increase in the number of
older people in the UK (Ofce for National Statistics, 2004). The percentage
of men and women drinking more than the weekly recommended limits has
also risen, by 60% in men and 100% in women between 1990 and 2006
(NHS Information Centre, 2009a). Given the likely impact of these two
factors on health and social care services, there is now a pressing need to
address substance misuse in older people.
This report has brought together a group of health professionals with
expertise in substance misuse in older people, whose remit it has been to
develop the existing knowledge base according to the following terms of
reference:
examining the nature and extent of substance misuse in older people
identifying precipitants and complications
highlighting best-practice guidance
exploring training opportunities
developing future strategy, encompassing clinical service provision and
developments, training and education, research, and policy.
Terminology
The terms ‘drug’ or ‘substance’ will be used to cover licit substances, tobacco
and alcohol, illicit substances, central nervous system depressants such as
opiates and opioids (e.g. heroin and methadone), stimulants (e.g. cocaine,
crack cocaine, amphetamines and 3,4-methylenedioxymethamphetamine,
known as MDMA or ecstasy), lysergic acid diethylamide (LSD), khat and
magic mushrooms. They will also be used in describing ‘street’ use, use
of prescription drugs (e.g. benzodiazepines) in a manner not indicated or
intended by a medical practitioner, and similar use of over-the-counter
preparations such as codeine-based products (e.g. cough medicines,
decongestants) or drugs bought over the internet.
Clinical experience and a growing literature base indicate that older
people may use a combination of licit and illicit substances, as well as
prescribed and over-the-counter medications taken in accordance with
medical practitioners’ instructions. This so-called ‘polypharmacy’, ‘polydrug
misuse’ or ‘polydrug dependence’ is a particular issue in older people who
have comorbid physical and psychological problems. Patients may be offered,
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College Report CR165
borrow or share out-of-date medications, take foods, and/or drugs and/
or medications that interact, and store medications inappropriately. With
increasing anxiety and poor memory, they may forget to report what they
have taken, or simply forget that they have taken it at all. With the growing
complexity of the range of substances available by a number of routes or
means, this becomes a major risk faced by all medical teams (Crome &
Ghodse, 2007; Crome & Bloor, 2008).
For the purpose of reaching a ‘diagnosis’, the two systems that
have emerged are the International Classication of Diseases (ICD-10)
(World Health Organization, 1992) and the Diagnostic and Statistical
Manual (DSM-IV) (American Psychiatric Association, 1994). These should
be administered thoughtfully and with clinical judgement, since there is
some debate as to whether they can be applied to older people. These
classication systems have similarities, but are not identical. In particular,
DSM-IV diagnostic criteria for substance ‘abuse’ and ‘dependence’ may not
be adequate to diagnose older adults with substance use problems, as they
are based on knowledge of young to middle-aged adults. Frequency, quantity
and pattern of consumption, which may be more appropriate considerations
for assessing older adults, are not included in the criteria in either ICD-10 or
DSM-IV (Oslin & Holden, 2001). Table 1 lists considerations that should be
taken into account in using DSM-IV with older adults.
The prevalence of substance misuse among ‘older’ or ‘elderly’ people
varies according to denitions of ‘old’ (usually over 65 years of age in the
UK, but often as low as 40 in countries such as the USA) and of ‘substance
misuse’ (Crome & Day, 1999). Nevertheless, there are considerable grounds
for concern that there are unmet needs within communities and that
problems are likely to increase.
In the case of opiate misuse, people aged 40 and over are regarded
as ‘older’ (National Treatment Agency for Substance Misuse, 2010a). This
Table 1 Applying DSM-IV diagnostic criteria for substance dependence to older adults
Criteria Special considerations for older adults
1 Tolerance Even low intake may cause problems owing to
physiological changes
2 Withdrawal May not develop physiological dependence
3 Taking larger amounts or over a longer
period than was intended
Cognitive impairment can interfere with self-monitoring
4 Unsuccessful efforts to cut down or
control use
Reduced social pressures to decrease harmful use
5 Increased time spent obtaining
substances or recovering from effects
Negative effects can occur with relatively low use
6 Giving up activities because of use Decreased activities because of comorbid psychiatric
and physical disorder
Social isolation and disability making detection more
difcult
7 Continued use despite physical or
psychological consequences
May not know or understand that problems are related
to use, even after medical advice
Failure of clinician to attribute problems to alcohol or
drug misuse
Adapted from Blow (1998).
13
Royal College of Psychiatrists
Introduction
is because opiate misuse has traditionally been seen as a problem mainly
in people under the age of 40; now that many more opiate misusers are
surviving for longer, 40 is used as a cut-off point to dene the ‘older’
population (Crome et al, 2009).
epiDemioloGy
The proportion of the UK population aged 65 years and over will increase
in the next 20 years. Projection studies have estimated that the number of
patients over the age of 50 who will require treatment for ‘substance abuse’
in the USA will increase from 1.4 million in 2000–2001 to 4.4 million in 2020
(Gfroerer et al, 2003; Colliver et al, 2006; Han et al, 2009). In 1995, 49%
of the US ‘baby-boom’ cohort, then aged 31–49, had used illicit drugs during
their lifetime, compared with 11% of those who were over 50 (Gfroerer et
al, 2003). In the USA, the lifetime prevalence rates for dependence on illegal
substances have been estimated to be 17% for 18- to 29-year-olds, 4% for
30- to 59-year-olds and 1% for the over-60s (Crome, 2005). This picture is
mirrored in Europe and the UK, where estimates suggest that the number
of people over 65 with a substance use problem or needing treatment will
more than double between 2001 and 2020 (European Monitoring Centre
for Drugs and Drug Addiction, 2008; NHS Information Centre, 2009b;
National Treatment Agency for Substance Misuse, 2010a). It is likely that
the consequences of improved healthcare of substance misusers have only
recently become apparent in the increased prevalence of chronic substance
use problems among older people.
morTaliTy
Smoking tobacco is the largest cause of premature death in the UK, causing
106 000 deaths every year (Department of Health, 2006).
Strikingly, the number of deaths in the UK linked to alcohol more
than doubled between 1992 and 2008, from 4023 to 9031, with the highest
death rates found in men aged 55–74. Among women, those aged 55–74
had the highest alcohol-related death rates (Ofce for National Statistics,
2009a).
Deaths related to drug poisoning among people over the age of 40
have also increased since 2004 (Ofce for National Statistics, 2009b). Cohort
studies have demonstrated a mortality rate in drug users between 12 and
22 times greater than that in the general population; older (over age 34)
injecting drug users are between two and six times more likely than younger
(under age 25) users to die from drug-related causes (Oppenheimer et al,
1994; Frischer et al, 1997; Bird et al, 2003).
Post-mortem ndings from drug users often show a combination of
methadone, opiates or benzodiazepines and sometimes alcohol. Although
this association is maintained in older drug users, those aged 45 and over
are more likely to die from self-harm or suicide, rather than accidental
overdose (Ghodse et al, 2009). Underreporting may be associated with
underestimation of drug-related deaths and with alcohol misuse as a
contributing factor rarely being recorded on death certicates as a direct or
indirect cause of death. Coroners in different areas also vary in the manner
in which alcohol misuse is recorded on death certicates.
14 http://www.rcpsych.ac.uk
College Report CR165
alcohol consumpTion
Alcohol is now by far the most commonly misused drug by people of all
ages. The price of alcohol relative to average UK income has halved since
the 1960s, while per capita consumption of total alcohol has nearly doubled,
from less than 6 litres a year in the early 1960s to over 11.5 litres a year in
2000. If this trend continues, the UK will become Europe’s biggest per capita
consumer of alcohol within a decade (Gupta & Warner, 2008).
A substantial percentage of older adults who drink consume above the
recommended limits (Moos et al, 2009).
In 2008, 21% of older men reported drinking more than 4 units of
alcohol on at least one day a week, and 7% more than 8 units; 10% of older
women said they drank more than 3 units of alcohol on at least one day in
the week, and 2% of this age group drank at least 6 units (NHS Information
Centre, 2010). In comparison, in 2001, 18% of older men said they drank
more than 4 units of alcohol on at least one day a week, and 5% drank at
least 8 units; 5% of older women reported drinking more than 3 units of
alcohol on at least one day in the week, and 1% of this group drank at least
6 units (National Statistics, 2003).
Drug misuse
During 2008/2009, 4.8% of over-45-year-olds in the UK reported use of any
illicit drug in the previous year, and 0.7% reported use of a Class A drug
within the previous year (Hoare, 2009). Although the number of people
coming into treatment has fallen across all other age groups, it has been
rising for people aged 40 and over since 2005–2006 (National Treatment
Agency for Substance Misuse 2010a: p. 6). The main problem for this age
group is heroin, either alone or in combination with crack cocaine. Only a
quarter started using in the past 5 years, and 27% appear to have been
using drugs for 25 years or more.
Consequently, there is likely to be an increased demand for specialist
drug treatment services to cater for the needs of these patients as they age.
This has been demonstrated in north-west England, where the proportion of
over-45-year-olds attending services has increased from 6.4% in 2003/2004
to 10.1% in 2006/2007 (Benyon et al, 2007). Older patients receiving
methadone maintenance treatment are more stable and more likely to have
improved treatment outcomes than younger people (Firoz & Carlson, 2004).
It should be noted that older methadone clients exposed to illegal drug use
in their social networks and neighbourhoods in the past month were more
likely to have used illicit drugs (Rosen, 2004).
smoking
Although people over the age of 60 have the lowest prevalence of smoking,
13% of men and 12% of women in that age group smoke. This has reduced
from 16% in 1998 (Seymour & Booth, 2010). Twenty-two per cent of people
aged 50–59 still smoke, a reduction of 5% since 1998. It has been shown
that people who are well into middle age when they quit smoking can avoid
more than 90% of smoking-related lung cancer risk (Peto et al, 2000).
Forty-four per cent of smokers aged 50 or over want to quit (Rimer et al,
1990), but some older smokers think that they cannot stop or that they have
already caused so much damage that quitting would not be benecial to their
health (Appel & Aldrich, 2003).
15
Royal College of Psychiatrists
Introduction
prescripTion Drug misuse
Older people receive the highest proportion of the prescription medication
dispensed in the UK, often as multiple prescriptions, and there is a 10%
chance that it is potentially inappropriate (Gottlieb, 2004; McGrath et al,
2005; De Wilde et al, 2007). About a third of men and women over the age
of 65 in private households take four or more prescribed medicines daily
(Falaschetti et al, 2002). Over-the-counter availability (and different methods
of obtaining medicines other than through legitimate channels) makes
multiple analgesic drug use a particular problem. This may lead to poor
pain control because of reduced tolerance, increasing dosage, abstinence
syndrome and dependence (Chrischilles et al, 1990). This is compounded
further by the use of prescription drugs such as codeine-based medications
for pain or coughs and benzodiazepine tranquillisers or hypnotics for affective
and anxiety disorders (Culberson & Ziska, 2008). Failure to adhere to
prescribing instructions can cause a wide range of adverse effects (Balestrieri
et al, 2005), including tolerance, withdrawal symptoms and compulsive use
in the long term (Lingford-Hughes et al, 2004).
The prevalence of psychotropic drug misuse is four times higher in
older women than older men and the risk of dependence is enhanced if the
woman happens to be widowed, less educated, of lower income, in poor
health and/or with reduced social support (Simoni-Wastila & Yang, 2006).
Older women also show comparatively less drinking, smoking and illicit drug
use than older men and people under 65, regardless of gender (Graham
et al, 1995).
psychiaTric comorbiDiTy
One in six people presenting in primary care with substance misuse is over
the age of 50. In the over-50 age group, presentation is often complicated
by the increased prevalence of comorbid physical and mental illnesses. In an
epidemiological study of psychiatric illness and comorbid substance misuse in
primary care, a 27% increase in comorbidity occurred in those aged 75–84
compared with an average 62% across all age groups. This increase was due
to dependence on licit substances, i.e. benzodiazepines, and was associated
with delirium (Frisher et al, 2005). This study demonstrates that there may
be differences in rates of different types of comorbid condition in older
people compared with younger people and further highlight the potentially
deleterious cumulative effects of benzodiazepines – especially in combination
with other substances such as alcohol. Psychiatric disorders predisposing
to substance misuse may have been precipitated in early life by emotional,
physical and sexual abuse.
The UK Ofce for National Statistics’ study of psychiatric morbidity in
the 16–74 age group (Coulthard et al, 2002) showed decreases in lifetime
and past-year use of any illicit drugs from age 55 to 69, but an increase in the
70–74 age group, in keeping with Frisher et als (2005) data. Nine per cent of
those in the 55–59 age group who had ever taken drugs had experienced an
overdose, as had 5% of those over 60 who had ever taken drugs.
An American study reported that the prevalence of comorbidity
declined signicantly with age in a population in long-term contact with
treatment services. In the survey of patients attending the Veterans
Administration Hospital, 26.7% of patients under 65 years of age and 6.9%
of those aged 65 and over still had comorbid psychiatric and substance
abuse disorders (Prigerson et al, 2001).
16 http://www.rcpsych.ac.uk
College Report CR165
key messaGes
The proportion of older people in the population is increasing rapidly, as is the number
of older people with substance use problems
Older people may show complex patterns and combinations of substance use (e.g.
alcohol plus inappropriate use of prescribed medications)
The standard diagnostic criteria for substance use disorders may not be applicable to
older age groups
Older people with substance use problems have high levels of unmet need
Mortality rates linked to drug and alcohol use are higher in older people compared with
younger people
Although alcohol use does decline with age, a signicant number of older people
consume alcohol at dangerous levels
Although illicit drug use is uncommon in the over-65 age group at present, there
have already been signicant increases in the over-40 age group. As this cohort ages
we should anticipate a signicant increase in the number of older people using illicit
drugs
Older people use large amounts of prescription and over-the-counter medication
and rates of misuse (both intentional and inadvertent) are high, particularly in older
women
High rates of mental health problems in older people (including a high prevalence of
cognitive disorders) result in frequent, complex psychiatric comorbidity accompanying
substance use disorders
17
Royal College of Psychiatrists
Risk factors
case viGnet te 1
Mr A, a 67-year-old White widower, was referred by his general practitioner (GP)
to the community alcohol team for alcohol dependence after repeated falls.
Following a period of controlled drinking during his 20s and early 30s, his alcohol
use had escalated when his wife was diagnosed with post-natal depression and
their children were taken into care. Over the years, further perpetuating factors
included his wife’s suicide and brother’s death. He had no signicant periods
of abstinence from alcohol for over three decades. Mr A was aware of the
association between drinking and falls, but considered alcohol helpful in dealing
with chronic insomnia. He was under the care of psychiatric services and had
been diagnosed with depression at the age of 36, when he had had psychological
therapy and antidepressant medication. He had last seen a psychiatrist 10 years
ago and had been prescribed an antidepressant by his GP before referral to the
community alcohol team.
Mr A had regular motivational interviewing sessions with the community alcohol
team and successfully completed in-patient detoxication. His mood improved
considerably during his in-patient stay and he was discharged with a plan
for follow-up by the community alcohol team, for relapse management and
monitoring of his mood disorder. However, he disengaged from the services
soon afterwards and was discharged from the team’s care. However, the GP re-
referred him after a few months, as family had become increasingly concerned
about deterioration in his mood and physical health. Although he attended
appointments at the clinic and his family was eager to admit him again for
detoxication, he was certain that he would like to continue to drink and refused
detoxication. He had been assessed as having capacity to make decisions
regarding his treatment. While fur ther motivational interviewing sessions were
provided by the team, which he attended erratically, his mental and physical
health deteriorated, with suicidal ideation and falls. As he refused admission or
any intervention to address his alcohol problem and family repeatedly requested
treatment against his will, input from the older adults psychiatric services was
sought and a referral made. This was declined until the case was discussed
individually with the consultant psychiatrist in the older adults team; Mr A was
then jointly assessed at home by psychiatrists from the community alcohol team
and older adults team. Joint work bet ween the two teams was facilitated and he
was later discharged to the care of older adults teams.
18 http://www.rcpsych.ac.uk
College Report CR165
case viGnette key points
There is a recognisable association between major life events, psychiatric disorder
and alcohol problems
Periods of relapse may occur against a background of long-standing comorbid mental
health problems
Quick and effective response to depressive symptoms can be associated with improved
treatment outcome
It is important to determine mental capacity of older people who are disengaging from
services/treatment
Joint working between specialist addiction and elderly services can have a considerable
impact on prognosis
case viGnette key points
Sociocultural issues have a bearing on risk, particularly the risk to Mr B’s grandchild
Mr B’s chronic physical ailments may have masked long-standing alcohol problems
and delayed presentation to specialist alcohol services
Non-adherence in taking a large number of prescribed medications posed risks for
physical health
Joint work between specialist services led to a diagnosis of dementia, extended
interventions and a favourable treatment outcome
case viGnette 2
Mr B is an 82-year-old Asian man living in his own home with wife, children and
grandchild. He has chronic physical problems, which have necessitated numerous
hospital admissions. There is a history of at least four decades of alcohol misuse.
He lost his job in his late 50s because of his drinking. This is his rst presentation
to a specialist alcohol team, and it has come about because family can no longer
cope with him. Risks include poor self-care, threatening his family members with a
knife when they deny him access to alcohol, falling onto the bed of his grandchild
when drunk, losing his way when out of the house and showing poor adherence
to taking his 13 prescribed medications for physical illness. Following engagement
with the community alcohol team, his care was discussed with the older adults
team because of evidence suggestive of dementia. He was admitted to an in-
patient detoxication unit, where a diagnosis of dementia was made, and he was
subsequently referred to a day hospital for further assessment of the dementia.
Social Services assessment was sought both to support the carers as well as to
assess risk to the grandchild. Mr B remained abstinent from alcohol and engaged
with the day hospital until he was discharged 3 months later. He was supported
in the community by a clinical nurse specialist from the community alcohol team,
jointly working with the older adults team. Mr B’s family reported improved self-
care and no further episodes of violence or aggression; he himself identied an
improved nancial situation and improved relationship with his family, who felt
better able to support him in adhering to treatment for his physical illness.
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Risk factors
alcohol misuse
The alcohol misuse literature shows that it is important to identify histories
and effects of drinking among older people.
long-Term misuse (Drinking from an early age)
Early-onset drinkers have had alcohol-related problems over several
decades and have survived into old age. It is estimated that two-
thirds of older drinkers fall into this category. Various studies have
demonstrated that, typically, this group have often been arrested
for intoxication, have family histories of alcoholism, greater levels of
depression and anxiety, and have changed residence more frequently.
It has been suggested that they feel loneliness and depression after
years of alienating signicant others and age-related loss (Schonfeld
& Dupree, 1994).
laTe-onseT misuse
Late-onset misuse may be milder, more circumscribed, have a lower
genetic component, a stronger association with stress/adverse life
events (such as bereavement) and higher socioeconomic status,
female preponderance and better prognosis. Late-onset drinkers
usually begin drinking in their 50s or 60s. A conglomeration of different
studies indicate that this group are more motivated to change their
drinking habits, more likely to complete treatment and have greater
life satisfaction. Stressful life events and losses are common in this
group: Glatt (1978) demonstrated that 70% of late-onset drinkers had
had stressful life events, compared with 25% of early-onset drinkers.
However, the former had greater psychological stability and better
attendance at treatment.
alcohol anD cogniTive impairmenT
The relationship between alcohol use and cognitive impairment
in older people is complex. Heavy, prolonged alcohol use may
increase the risk of developing vascular dementia and Alzheimer’s
disease, and may have indirect effects on neuronal function through
decreased absorption of thiamine (vitamin B1), resulting in the
development of organic amnestic states (e.g. Wernicke–Korsakoff
syndrome).
Alcohol may also have a direct neurotoxic effect, producing
‘alcoholic dementia’, although the validity of this concept remains
controversial (for a discussion see Atkinson (2002) and Gupta &
Warner (2008)).
Irrespective of the underlying pathophysiology, there is no doubt
that the management of alcohol misuse in patients with cognitive
impairment/dementia presents a signicant clinical challenge.
20 http://www.rcpsych.ac.uk
College Report CR165
risk factors for substance misuse in General
Risk factors relating to substance misuse in older people can be classied
in a number of ways, including biological/physical, psychological and social
factors (O’Connell & Lawlor, 2008), or predisposing, precipitating and
maintaining factors. Atkinson (2002) grouped them into predisposing factors
(family history, previous substance misuse, personality), factors that may
increase exposure to/consumption of substances (e.g. chronic painful illness,
insomnia, long-term prescribing, stress, loneliness, depression, substance
availability, nances) and factors that may increase the effects and misuse
potential of substances (pharmacokinetic and pharmacodynamic factors,
chronic medical conditions and use of other medication).
A family history of alcohol or substance misuse is a risk factor
for early-onset substance use disorders and may be related to genetic
factors, which may in turn overlap with genetic factors predisposing to
other psychiatric conditions. The relationship between substance use
disorders and mental health problems such as depression and anxiety is
complex and the direction of causality is often in doubt (e.g. does increased
alcohol intake result from ‘self-medication’ in depression, or is the depression
secondary to high levels of consumption?). It has been suggested that late-
onset alcohol misuse is associated with ‘neurotic’ and ‘depressive’ personality
traits (Mulder, 2002).
In general, men are at greater risk of developing substance use
disorders. Although this is true for both alcohol and illicit drugs in older
people, it is older women who are at highest risk of developing problematic
use of sedative/hypnotic and anxiolytic medication.
Another factor relevant to the development of substance use disorders
in older people is chronic illness that leads to the long-term prescription
of strong analgesics and medication to manage symptoms such as pain,
insomnia and anxiety. The presence of underlying medical conditions,
age-related changes in liver and renal function, and interactions between
multiple medications may also place older people at higher risk of developing
substance-related problems, even at relatively low levels of consumption.
Over-use of ‘as required’ medicines, either by the patient or by paid carers
or family members, may be an additional factor. Although many older
people live in relative poverty, a substantial number of retired people have
signicant disposable income and leisure time, which can contribute to the
development of alcohol problems.
Loss of support over the long term owing to loss of occupation, income,
skills or function, earlier marital breakdown, inadequate social networks,
loneliness and isolation due to bereavement or retirement may affect
use. There are indications that social factors inuence outcome in late-life
drinkers. Schutte et al (2003) followed the progress of 447 older former
problem drinkers over 10 years and compared them with a group of lifetime
non-problem drinkers. They found that 1.6 times more former problem
drinkers died over the 10-year period than non-problem drinkers. Although
most of the former problem drinkers continued to drink alcohol, they did
so at levels below those of the lifetime non-problem drinkers. Risk factors
for relapse among the former problem drinkers were a less severe drinking
history, heavier baseline alcohol consumption and lower baseline income.
The authors noted that, despite improvements in functioning, the former
problem drinkers continued to have greater nancial, health-related and
life-context decits compared with the lifetime non-problem drinkers. They
21
Royal College of Psychiatrists
Risk factors
concluded that drinking history is as valuable as current drinking behaviour
when considering alcohol consumption by older people, and that the long-
term effects of problem drinking on nances, health and lifestyle persist,
even when remission is maintained.
psychosocial risk facTors for alcohol misuse
Most alcohol misuse problems among older people are dealt with in primary
care. Particular risk factors for alcohol misuse have been identied, including
homelessness, bereavement, retirement and depression. In the UK, 40%
of older homeless men are known to be heavy drinkers or to have alcohol-
related problems. The problems are most pronounced among men in
their 50s. The majority of these men are White British or Irish, with only
a small proportion from minority ethnic groups (Crane, 1998; Crane &
Warnes, 2001).
The relationship between bereavement and alcohol misuse is complex.
In a cohort study of male community residents aged 65 years and over,
recently widowed men were assessed at 6 weeks, 6 months and 13 months
after bereavement and age matched with married men who were followed
up at the same time intervals. Although similar proportions of older
widowers and married men reported drinking alcohol, recently widowed
older men reported signicantly greater frequency and quantity of alcohol
consumption than married men: 19% of widowers and 8% of married men
reported drinking ve or more standard drinks per drinking day (Byrne et al,
1999). However, this nding is at odds with a study in Liverpool reporting
no signicant difference between the rates of regular drinking among
married men and men who had been widowed 3 years earlier (Saunders
et al, 1989). It is possible that the excess alcohol consumption of recently
widowed older men diminishes after the rst year following bereavement.
Using a longitudinal approach, a study examining the impact of negative life
events on alcohol consumption among 2040 men and women aged 65 and
over found that, in men who were married at baseline, death of a spouse
did not independently predict change in alcohol consumption. However, there
was a signicant interaction effect between death of a spouse and baseline
alcohol consumption, with men who consumed greater amounts of alcohol
at baseline being more likely to increase their alcohol consumption following
bereavement (Glas et al, 1995). It would appear that conjugal bereavement
in men increases the risk of alcohol misuse in established drinkers.
Retirement is an important landmark during a lifetime. In a long-
term follow-up of men who had successfully completed a behavioural
treatment programme for alcohol problems when they were over 60 years
of age, participants were contacted between 2 and 4 years after the end
of treatment. It was found that 71% of those who had not yet retired
when successfully treated for late-onset abuse began drinking heavily
again when they did retire (Carstensen et al, 1985). This nding has been
replicated elsewhere (La Greca et al, 1988). However, the effect of reverse
causality on the relationship between alcohol misuse and retirement cannot
be overlooked, with evidence that men showing existing problems with
alcohol misuse are more likely to retire than men without such problems
(Bacharach et al, 2004). An understanding of different trajectories among
older substance misusers may help in directing treatment towards those
affected more severely (Jacob et al, 2009).
22 http://www.rcpsych.ac.uk
College Report CR165
key messaGes
Late-onset substance misuse has different aetiological and demographic associations,
and probably a better prognosis, than early-onset misuse
In older people, the relationship between cognitive function and substance (particularly
alcohol) use is complex, as is that between functional mental health problems (e.g.
anxiety and depression) and substance use. The direction of causality is often unclear
Older men are at greater risk of developing alcohol and illicit substance use problems
than older women. However, older women have a higher risk of developing problems
related to the misuse of prescribed and over-the-counter medications
Physical health problems and the long-term prescription of medication (especially
hypnotics, anxiolytics and analgesics) are important factors in the development of
substance misuse in older people
Psychiatric comorbidities of substance misuse are common in older people (including
intoxication and delirium, withdrawal syndromes, anxiety, depression and cognitive
changes/dementia)
Among older people, psychosocial factors (including bereavement, retirement,
boredom, loneliness, homelessness and depression) are all associated with higher
rates of alcohol use
23
Royal College of Psychiatrists
Effects and complications
A detailed review of the physical and psychiatric complications of substance
misuse by older people is beyond the scope of this report. A comprehensive
account of such complications can be found elsewhere (e.g. Crome & Day,
2002; Crome & Bloor, 2005b).
physical complications
The most common problems related to substance misuse by older people
are the cardiovascular and respiratory problems associated with smoking
and alcohol, both exacerbated by lack of exercise. The biggest problem by
far is alcohol misuse, as older drug users also move from illicit drugs to
use of alcohol or of both substances. Since about 50% of intravenous drug
users have hepatitis C, liver disease advances rapidly. There is a high level
of lung disease, particularly chronic obstructive pulmonary disease (COPD)
secondary to long-term smoking of tobacco, crack cocaine and heroin. There
is early morbidity with co-infection of hepatitis B and C.
Older people are particularly at risk from the harmful effects of
substances because of polypharmacy (Crome, 2005) and altered metabolism
(Dunne & Schipperheijn, 1989). As people age, there is a fall in the ratio
of body water to fat, decreased hepatic blood ow and inefciency of liver
enzymes. The responsiveness of the brain alters, so that alcohol produces
a more rapid depressant effect, resulting in, for example, impaired
coordination and memory.
Apart from the direct effects of drugs on general health, there are
indirect effects such as dietary neglect due to impoverishment, depression
and isolation. Malnutrition, for instance, may result from drug-induced
anorexia, malabsorption and/or economic deprivation. Liver dysfunction
associated with, for example, HIV, hepatitis B and C, produces psychological
as well as physical problems.
The presentation of such problems can be subtle or non-specic and
underdiagnosis and/or underreporting may therefore have contributed to
unreliable estimates of the level of problems associated with substance
misuse (O’Connell et al, 2003). One Australian study found low levels of
detection and appropriate onward referral to specialist services of older
substance misusers by medical staff, some of whom believed that ‘to give up
established habits is inappropriate’ (McInnes & Powell, 1994).
24 http://www.rcpsych.ac.uk
College Report CR165
psychiatric complications
The co-occurrence of psychiatric disorder and substance misuse (dual
diagnosis) can have a range of differing psychological effects, including
those caused by intoxication and withdrawal (Banerjee et al, 2001; Crome
& Day, 2002; Day & Crome, 2002; Waller & Rumball, 2004). Chronic use,
intoxication with depressant drugs and withdrawal from stimulants produce
symptoms similar to those of depressant drugs, including suicidal intent.
Acute intoxication with stimulants or cannabis may mimic a schizophrenic
illness. Withdrawal from depressant drugs may result in symptoms of
anxiety, panic and even confusional states. These complex interactions have
implications: not only does drug use interfere with emotional, cognitive and
social behaviour, but the combination of disorders results in poorer treatment
adherence and poorer short- and longer-term outcome.
The interrelationships between physical health, mental health and
drug misuse are well documented. Psychiatric conditions such as anxiety,
depression, post-traumatic stress disorder, drug-induced psychosis,
schizophrenia, delirium and dementia may lead to, be a consequence of,
or coincide with drug misuse. Delirium is associated with withdrawal from
barbiturates and benzodiazepines, but delirium and dementia are also
associated with factors such as head injury and serious infection. The
differing mechanisms and types of relationship demand careful history-taking
and judicious interpretation. Among older people, depression, dementia,
delirium and a heightened risk of suicide are probably the problems most
commonly faced by clinicians. Of course, some of these conditions are
associated with chronic pain and sleep disorders, which may make patients
vulnerable and cause them to seek relief in inappropriate use of prescription
and non-prescription medications.
key messaGes
Because of physiological changes associated with ageing, older people are at increased
risk of adverse physical effects of substance misuse, even at relatively modest levels
of intake
Alcohol and tobacco use have the greatest impact in population terms on physical
health, affecting many systems (including the cardiovascular, gastrointestinal,
neurological and respiratory systems)
Presentation can be subtle or non-specic and the aetiological role of substance use in
physical conditions is frequently overlooked
Psychiatric comorbidities of substance misuse are common in older people (including
intoxication and delirium, withdrawal syndromes, anxiety, depression and cognitive
changes/dementia)
25
Royal College of Psychiatrists
Assessment of substance misuse
in older people
case viGnette key points
This case illustrates several points regarding the assessment and management of alcohol
problems in people with cognitive impairment:
the value of taking a history from an informant
case viGnette 3
Mr D, a 72-year-old retired teacher, had been living alone in his own house since
the death of his wife 3 years ago. He was referred to old age psychiatry services
because of progressive memory changes over approximately 2 years. Other
concerns included deteriorating self-care, poor appetite, weight loss and several
falls. His daughter commented that he had episodes when he appeared much
more muddled and that he was still driving, which caused her great concern.
Mr D was assessed at home with his daughter present, and was found to have a
mild to moderate degree of cognitive impairment (Mini-Mental State Examination
(MMSE) score of 20 out of 30) and the clinical picture was felt to be consistent
with a diagnosis of Alzheimer’s disease. Mr D was unwilling, or unable, to give a
clear account of his current level of alcohol intake. His daughter said that Mr D’s
drinking had gradually increased since the death of his wife and she thought that
he was probably consuming at least one bottle of wine a day. She had repeatedly
asked her father to cut down his drinking, but to no effect (he was still buying his
own alcohol from the local supermarket). The kitchen contained several empt y
wine bottles, as did the dustbin. There was no evidence of physical dependence,
but his psychiatrist felt that his drinking was undoubtedly contributing to his
episodes of more marked impairment and falls.
Mr D surrendered his driving licence and his daughter began to do the shopping
and refused to buy alcohol for him. Initially, his cognitive state improved slightly
and he put on some weight. After a few months, he deteriorated and started
falling again; it was noted that signicant amounts of money were missing from
his bank account, as a neighbour had started buying alcohol for Mr D and had
been taking nancial advantage of him. Vulnerable-adult protection procedures
were instigated and the police became involved. As Mr D now lacked the capacity
to manage his affairs, and had not previously made a lasting power of at torney,
an application to appoint a receiver was made to the Court of Protection.
Unfortunately, Mr D continued gradually to deteriorate and was eventually placed
in residential care.
26 http://www.rcpsych.ac.uk
College Report CR165
the value of home assessment (allows inspection of the environment for evidence of
alcohol use)
the enhanced effects of alcohol in people with underlying cognitive impairment
(including worsening cognitive function and falls)
signicant improvement can occur if people stop drinking
a particular vulnerability to exploitation
if patients are found to lack capacity in particular areas (e.g. management of nances)
then one should follow the principles of the Mental Capacity Act 2007 and take
decisions that are in their best interests
case viGnette key points
Substance misuse can occur at unexpected stages in older users, even in in-patient
care
Families can be complicit in substance misuse
Individuals can hide and deny illicit drug use when least expected
barriers anD obstacles – ‘if you Dont think about it,
then you Wont see it
Full assessment of a patient entering a substance misuse unit is often
carried out over a number of interviews and examinations and may amount
to several hours. Engagement of older patients often requires a degree of
common sense and change in policy. For moderate- to long-term retention
in treatment, making the patient welcome, listening and being empathetic
may be more important than simply gleaning information.
The lack of awareness and knowledge regarding alcohol and substance
use disorders in older people is a major barrier to detection and diagnosis
(Table 2). The traditional view that alcohol misuse is uncommon in older
people and that the misuse of other substances is very rare means that
clinicians fail to ask about misuse and also leads them to overlook or
discount evidence of such problems. Stereotyped views regarding ‘typical’
case viGnette 4
Mr C was admitted to a care home and was on a low dose of methadone. He
accepted the decision to withdraw his methadone over the course of a few weeks.
Before closing the case, the care coordinator was asked to visit Mr C at the nursing
home and, if possible, obtain a urine test. On visiting, the patient was assertive that
he did not need any further visits or follow-up as he was now doing well. This was
conrmed by a urine test that was negative for all substances – apart from cocaine!
27
Royal College of Psychiatrists
Assessment of substance misuse in older people
proles of alcohol and substance misusers hinder accurate identication.
For example, binge drinking, rather than chronic heavy drinking, occurs in
14% of men and 3% of women aged over 65 (Blazer & Wu, 2009).
Signs and symptoms of substance misuse may be mistakenly attrib-
uted to other physical or mental health conditions, or may be masked by the
presence of other illnesses. Thus, an underlying substance use disorder may
be missed unless a high degree of clinical suspicion is maintained.
Physical symptoms that should trigger screening include the following
(Blow et al, 1998):
sleep complaints
cognitive impairment, memory or concentration disturbance
seizures, malnutrition, muscle wasting
liver-function abnormalities
persistent irritability without obvious cause
unexplained chronic pain or other somatic symptoms
incontinence, urinary retention
poor hygiene and self-neglect
unusual restlessness and agitation
complaints of blurred vision or dry mouth
unexplained nausea and vomiting
changes in eating habits
slurred speech
tremor, poor motor coordination, shufing gait
frequent falls and unexplained bruising.
Clinicians may be embarrassed to ask about substance use, and
patients, relatives and carers may be reluctant to reveal information for a
variety of reasons, including shame, denial or a desire to continue using the
Table 2 Barriers to identication of substance misuse in older people
Practitioner barriers Individual barriers
Ageist assumptions
Failure to recognise symptoms
Lack of knowledge about screening
Discomfort with topic
Lack of awareness of substance misuse in older
people (‘If you don’t think about it, you won’t
see it’)
Misuse traditionally considered to be rare in old
age
Symptoms may mimic or be hidden by
symptoms of physical illness
Unwillingness to ask
Absence of informants
Attempts at self-diagnosis
Symptoms attributed to ageing process or other
illness
Many do not self-refer or seek treatment
Perceived stigma of the word ‘addiction’
Reluctance of patients to report – shame,
denial, desire to continue using, pessimism
about recovery
Cognitive problems – substance-induced
amnesia, underlying dementia
Unwillingness to disclose
Collusion of informant(s)
28 http://www.rcpsych.ac.uk
College Report CR165
substance in question (Table 2). Assessing levels of consumption in patients
with cognitive impairment, especially in the absence of a reliable informant,
is particularly problematic. Screening instruments may not be appropriate
for an older population, and criteria such as ‘safe limits’ (see pp. 35–36)
for alcohol consumption may be set too high to be of valid use with elderly
people. The belief that ‘nothing can be done’ because of the person’s age,
or that it would be ‘cruel’ to take away an activity that appears to provide
some degree of comfort, may be other factors that result in the under-
diagnosis and under-treatment of such problems in older people. Even when
misuse is detected and diagnosed, elderly people are less likely to be given
adequate treatment or to be referred to specialist services (O’Connell et al,
2003). Possible explanations for this are that, in some localities, they are
excluded from specialist treatment on the basis of age or that facilities are
not available in their area.
screeninG tools
Screening should never be considered as a substitute for a thorough
clinical assessment. However, appropriate screening tools can be useful
in identifying patients at high risk, who should then be comprehensively
assessed (Table 3). To the best of our knowledge, all of the literature
regarding screening for substance use disorders in older people relates
to alcohol, mainly using self-report instruments developed for use in
younger populations (although some have been adapted for older people).
It is important that screening for substance misuse in older patients is
undertaken using age-appropriate instruments, if available, or that if the
instruments standardised on working-age adults are used then this is taken
into account (Beresford, 2000).
The utility of alcohol screening tests with older people has been
systematically reviewed, both for in-patient populations (O’Connell et
al, 2004) and in primary care (Berks & McCormick, 2008). The general
conclusions of these reviews are that, although the CAGE questionnaire
(Ewing, 1984) is well-known and quick to perform, its primary purpose is
in detecting alcohol dependence and it is relatively insensitive to harmful/
hazardous drinking. The CAGE has been validated in samples of older people,
but in one study up to 60% of older people at risk of alcohol dependence in
a community sample were CAGE-negative (Adams et al, 1996). Therefore, if
the CAGE is used, it should be combined with careful assessment of current
consumption.
Table 3 Goals and rationale for screening older people for alcohol problems
Identication goals Rationale
Low-risk drinking (less than 21 units per week
for men and less than 14 units per week for
women)
Incidence is high enough to justify routine
screening
Hazardous drinking (22–50 units per week for
men, 15–35 units per week for women)
Adverse effects on health and quality of life may
be signicant
Dependent drinkers (more than 50 units per
week for men, more than 35 units per week for
women)
Effective treatments exist
Need for further assessment and treatment Available treatments are cost-effective
29
Royal College of Psychiatrists
Assessment of substance misuse in older people
The Short Michigan Alcoholism Screening Test – Geriatric version
(SMAST-G; Blow et al, 1998) has been validated for use in older hospital
in-patients (Joseph et al, 1995). It is longer than the CAGE and not as well-
known but it may be useful in specialist settings.
The Alcohol Use Disorders Identication Test (AUDIT) is a 10-item
self-report questionnaire developed to identify both alcohol dependence and
hazardous use in adults (Saunders et al, 1993). Various adaptations have
been made and tested in older populations. These include the AUDIT-5, a
ve-item version of the full AUDIT (Piccinelli et al, 1997) and the AUDIT-C,
which asks only the three alcohol consumption questions of the full AUDIT
(Bush et al, 1998).
A study comparing the MAST-G and AUDIT with the Alcohol-Related
Problems Survey (ARPS) and the Short Alcohol-Related Problems Survey
(shARPS) reported that the ARPS has some advantages over the MAST-G in
older patients in a primary care setting (Moore et al, 2002).
Given the paucity of specic instruments for screening for alcohol
problems in older people, the use of a combination of methods is advised
(Reid et al, 2003). Existing screening tools can increase the detection of
alcohol problems in this population, but a more comprehensive framework
for assessing and managing alcohol- and drug-related problems is
recommended and is a useful way of formulating the assessment process,
as it translates into specic management plans (Raw et al, 1998).
assessment
The key to appropriate management is the taking of a thorough history
(Crome & Bloor, 2005a,b, 2006; Crome & Ghodse, 2007), although clinicians
may be reluctant to observe this degree of rigour in assessing older people.
They may lack condence in what to ask and experience or support in what
to do; they may rationalise older people’s substance use (e.g. ‘Drinking is all
they’ve got’) or deny that the problem exists in this age group. Of course,
older people and their relatives may be reluctant to disclose and/or may not
realise the extent of the problem.
Assessment should include a full history (including a collateral history
from a suitable informant), mental state examination, physical examination
and further appropriate investigations. The assessment will need to cover
current and past levels of substance use, frequency of use and quantity of
substances taken, route of ingestion, evidence of withdrawal symptoms and
other features of physical and psychological dependence, context of use,
and the physical, psychological and social consequences of prolonged use.
Questions will need to be phrased in a sensitive, non-judgemental fashion.
It is often helpful to ask questions that address the presence or absence
of ICD-10 or DSM-IV diagnostic criteria for harmful use, dependence and
withdrawal (O’Connell & Lawlor, 2008).
It is particularly important to consider alcohol and other substance
misuse in patients who repeatedly present with unexplained falls and
uctuations in their physical or psychological state, or in patients who do well
in hospital only to relapse again on their return home.
A simple model, which has a similar approach to that of the ve-phase
framework (Ask, Assess, Advise, Assist, Arrange: see Appendix 1), has been
used with older patients with substance use problems (Kaempf et al, 1999).
During all phases, close attention should be paid to the appropriateness of
30 http://www.rcpsych.ac.uk
College Report CR165
key messaGes
Screening
Screening should be user-friendly and take account of sensory, cognitive,
environmental and other specic needs (e.g. cultural background and ethnicity)
General practitioners should screen every person over 65 years of age for substance
misuse as part of a routine health check, using specic tools such as the SMAST-G;
screening should also incorporate cognitive testing using tools such as the MMSE
Re-screening should be carried out if certain physical and/or psychological symptoms
are present or if the person is experiencing major life events
Questions should be linked to medical conditions or health concerns
Assessment leading to a diagnosis of dependence
Although applying the standard diagnostic criteria for substance use disorders is useful,
it should be noted that sometimes they may not be appropriate for older people
Patients who repeatedly do well in hospital and badly at home, those with unexplained
‘ups & downs’ in health presentation, those with inconsistencies and contradictions in
the history and presentation are of particular concern
Physical assessment
Association of substance misuse (particularly alcohol) and conditions such as liver dis-
ease, hypertension, diabetes, falls, cognitive problems, depression, self-harm, inconti-
nence (often not a readily apparent association) indicates specic physical investigations
Useful standard investigations: FBC, MCV, B12 and folate, LFTs, urine/blood/breath
alcohol levels and/or drug screens
Special investigations: neuroimaging, blood-borne virus screening if indicated
various options for the particular individual, i.e. they should be ‘tailor-made’
where possible (U.S. Department of Health and Human Services, 2005).
There are clear associations between substance misuse (particularly
alcohol) and a variety of physical conditions, including: liver disease,
hypertension, diabetes, falls, cognitive changes, depression, self-harm
and incontinence. However, these associations can be very non-specic
and difcult to pick up. Alcohol (or other substance) misuse should always
be considered as a possibility in patients presenting with these problems.
Conversely, a full physical and mental state assessment focusing on these
areas should be performed in any patient suspected of misusing alcohol or
other drugs. Often, further investigations (such as urine or breath tests,
blood alcohol levels, full blood count (FBC), mean corpuscular volume
(MCV), urea and electrolytes (U&Es), liver function tests (LFTs), vitamin B12
and folate levels) will be required. If clinically indicated, more specialised
investigations such as neuroimaging studies or screening for blood-borne
viruses may have to be considered (O’Connell & Lawlor, 2008).
In the case of illicit drug use, urine testing is a useful objective
measure, although the window for detection in the urine is often brief.
The use of a breath alcohol meter in the clinical setting provides valuable
evidence of inappropriate alcohol levels and can aid diagnosis of a
dependence syndrome (Han et al, 2009).
31
Royal College of Psychiatrists
Treatment of addiction
It is important to note that many of the drugs used in the treatment of
addiction are not used in everyday clinical practice by either old age or
addiction psychiatrists for patients over the age of 60. However, it is vital to
point out that older people can and do benet from treatment.
The Mesa Grande project from the USA (Miller & Wilbourne, 2002)
is the largest systematic review of controlled trials comparing treatment
for alcohol use disorders, but it does not provide evidence for treatment
outcomes specifically for the over-65s. Similarly, other UK-based
observational and analytical studies of drug and alcohol treatment outcomes
have not included older adults.
There is a vast literature on pharmacological and psychological
treatments for adult substance misusers, from which evidence-based
guidance and numerous consensus statements have resulted (Lingford-
Hughes et al, 2004; National Collaborating Centre for Mental Health,
2007a,b; National Institute for Health and Clinical Excellence, 2007a,b). A
detailed discussion of these is beyond the scope of this report, but the list of
online resources in Appendix 4 and the reference list should direct readers
to related documents and organisations. Appendix 2 offers a summary of the
guidance from some of these sources.
The National Institute for Health and Clinical Excellence (NICE) has
issued no guidance on the treatment of substance misuse in general or
opiate dependence in particular in older people (National Collaborating
Centre for Mental Health, 2007a,b; National Institute for Health and Clinical
Excellence, 2007a,b). The studies on which its recommendations are based
usually exclude those over 65 (sometimes even those over 50), as well as
those with physical and psychiatric comorbidity. The Department of Health’s
guidelines on drug misuse and dependence include a brief section on older
addicts (where the older patient is dened as 40+ years), but little specic
detailed information on management is provided (Department of Health,
2007). The National Service Framework for the care of older people does
not discuss addictions and substance misuse (Department of Health, 2001).
In a literature review carried out to determine whether there is
evidence to support the treatment of substance misuse in older people
and to identify which treatments, if any, are appropriate for this population
(Moy et al, 2011), older people were dened as those aged 50 and above.
Sixteen studies were found to t the inclusion criteria and were categorised
according to the British Association for Psychopharmacology consensus
statement (Lingford-Hughes et al, 2004). Eleven studies related to alcohol
misuse (Dupree et al, 1984; Fleming et al, 1999; Blow et al, 2000; Gordon
et al, 2003; Lemke & Moos, 2003a,b; Oslin et al, 2002, 2005; Satre et al,
2003, 2004a,b), three to nicotine dependence (Vetter & Ford, 1990; Morgan
et al, 1996; Schroeder et al, 2006), one to opiate dependence (Firoz &
32 http://www.rcpsych.ac.uk
College Report CR165
Carlson, 2004) and one to dependence on prescription medications (Brymer
& Rusnell, 2000).
Moy et al (2011) report that, despite the current and potential future
impact of substance misuse on an ageing population, little research is being
conducted into the treatment of substance misuse in older patients. They
conclude that the evidence to date indicates that, if treated, older people
do not have worse outcomes than their younger counterparts and in some
cases even do slightly better. It does appear that older people can respond
to treatments that have been developed and tested in younger populations.
Standardisation of age range, diagnostic tools and assessment instruments,
treatment options and style of delivery would enhance comparability.
A study by Brennan et al (2003) indicated that access of older
substance misusers to specialised out-patient mental health services was
similar to that of younger patients and that they showed better outcomes.
Older patients were less likely to be experiencing drug problems and
psychiatric problems, but were more likely to report alcohol and medical
problems. This equality of access was despite the fact that older people
perceived the relative importance of treatment for psychological problems to
be less than did younger people. The authors raise the interesting question
of whether older people are more robust than younger people or whether
there is a cohort effect in accepting that psychological factors play a role in
both aetiology and recovery.
In this context, a meta-analysis of brief interventions for problem
drinking (Cuijpers et al, 2004) demonstrated that they appear to reduce
mortality. This has far-reaching implications for public health measures and
the role of primary care and, potentially, has application to the drug-misusing
population. It should be noted that key components of brief interventions
include therapist characteristics (e.g. development of a therapeutic alliance,
competence, adherence to treatment plan); user characteristics (e.g. culture,
ethnicity and gender); and setting (e.g. whether conditions are optimal for
the purpose) (National Treatment Agency for Substance Misuse, 2006).
Satre et al (2004a) conducted a comparative study of the 5-year
outcomes of a group of older adults (aged 55–77) v. younger and middle-
aged people after alcohol and drug treatment. They found that the older
adults were less likely to be drug dependent at baseline than younger (aged
18–39) and middle-aged (aged 40–54) adults, and had longer retention
in treatment than younger adults. At 5 years, older adults were less likely
than younger adults to have close family or friends who encouraged alcohol
or drug use. Fifty-two per cent of older adults had been totally abstinent
from alcohol and drugs in the past 30 days v. 40% of younger adults. Older
women had higher 30-day abstinence rates than older men or younger
women. Thus, although older adults had a favourable long-term outcome,
these differences may be accounted for by variables associated with age,
such as type of substance, retention in treatment, social network or gender.
These results provide valuable information on which to base service provision
for older people: for example, persistence in treatment has long-lasting
benets, adequate social support is important, and family and friends are
less likely to encourage substance use.
The treatment of substance misuse in older people also needs to take
account of comorbid physical problems such as neuropsychiatric disorders
and hepatic complications (e.g. alcoholic liver disease and hepatitis C), as
well as respiratory complications such as chronic obstructive pulmonary
disease (COPD). Clinicians should discuss with patients options and plans for
terminal and palliative care and end-of-life treatment.
33
Royal College of Psychiatrists
Treatment of addiction
Most pharmacological agents should be used with caution, as
pharmacokinetic and pharmacodynamic considerations mean an inevitable
dosage reduction and careful monitoring in older people.
We are unaware of any specic guidance on the use of acamprosate,
naltrexone, disulram, methadone or buprenorphine with older people.
Addiction psychiatrists initiating treatment in older people should therefore
work jointly with old age psychiatrists and/or geriatricians and frequently
monitor treatment.
cost-effectiveness
Treating people with alcohol use disorders is cost-effective. For every £1
spent on treatment, the public sector saves £5. Providing alcohol treatment
to the 10% of the population with dependent drinking in the UK could reduce
costs by between £109 million and £156 million each year (South West Public
Health Observatory, 2008). There are no comparable data conned to older
people so the cost-effectiveness of treatment for substance misuse in this
population remains to be evaluated.
family anD carers
There is little literature concerning carers of older people with substance
misuse. However, there are two relevant points to highlight. First, carers
are central to the detection of alcohol misuse and the majority are aware
of referral pathways (Wesson, 1992). However, their apparent lack of
awareness of alcohol as a causative or contributing factor may result from
their reluctance to judge the role of alcohol in the life of the person for
whom they care. Second, the risk to older people from other older and
younger people with alcohol misuse has potentially serious consequences for
safeguarding older drinkers, who are already vulnerable to abuse (Homer &
Gilleard, 1990; Reay & Browne, 2001).
key messaGes
There is a paucity of UK-based research and evidence for treatment interventions and
services relating to the management of substance use disorders in older people
Older people can and do benet from treatment and in some cases have better
outcomes than younger people
Treatment of alcohol misuse in older people appears to reduce mortality
Treatment of coexisting physical conditions (including chronic conditions such as
hepatitis C and chronic obstructive pulmonary disease) and psychological conditions is
a very important part of management
Close liaison between all professionals, disciplines and agencies involved in the care of
the patient is very important
34 http://www.rcpsych.ac.uk
College Report CR165
case viGnette key points
Changes in social circumstances such as bereavement may be powerful precipitants
of alcohol misuse
There may be problems in joint working between specialist teams, particularly where
patients ‘fall through’ gaps in service provision
The inclusion of social (including family) support in the treatment package is an
essential factor in reducing harm and improving health and social function
case viGnette 5
Mrs E is an 81-year-old widow living in sheltered accommodation. She was referred
to the specialist community alcohol team by the older adults team, to whom she
had originally been referred by her GP. She suffered from recurrent depressive dis-
order and her GP had prescribed an anti depressant as well as sedatives. Mrs E’s
relationship with her daughter was strained and there were concerns about her
safety after she was found walking the streets in her nightdress in the early hours
of the morning. She had previously sustained injuries following falls and, 6 years
earlier, had consulted a neurologist for ‘resting tremor and cogwheel rigidity’.
Mrs E reported a 5-year history of alcohol dependence following her husband’s
death. After admission for in-patient alcohol detoxication, she was referred to the
older adults psychiatric team, but the referral was not accepted. She was therefore
supported in the community by the community alcohol team before discharge to her
GP. The GP re-referred Mrs E after a matter of weeks, following concerns regarding
her safety secondary to falls and cognitive impairment. There was deterioration in
the relationship with her daughter, who had distanced herself from her mother’s
care. A re-referral to the older adults team was declined. Social Services input was
sought and put in place. This included attendance at a day centre and input from a
home care service, following which Mrs E was again discharged to her GP.
case viGnette 6
Mrs F is a 66-year-old living with her partner (aged 52). Both have been on stable
methadone maintenance for over 10 years (Mrs F was prescribed a daily dose of
80 mg) and were being managed through a shared-care arrangement between their
GP and the local drug and alcohol service. Mrs F was referred to old age psychiatry
services because of concerns regarding her cognitive state. On assessment she was
found to have signicant impairment (MMSE score of 16 out of 30). Her partner
indicated that he felt ‘unable’ to look after her any longer and said he intended
to leave the relationship. She was admitted to a dementia assessment ward,
where her 80 mg dose of methadone was continued, but she very rapidly became
oversedated and the dose was reduced. It was suspected that her partner had
either been using or selling part of her daily prescription. Following discussions
with the local drug and alcohol service, the consultant old age psychiatrist decided
that the methadone should gradually be withdrawn in order to assess its effect
on Mrs F’s cognitive function. Following this withdrawal, she showed a marked
improvement in cognition and self-care (MMSE increased to 24 out of 30). She
underwent full investigations (including for blood-borne virus infections) and was
diagnosed as having a late-onset dementia secondary to Alzheimer’s disease. Her
partner had ‘disappeared’ at this stage, and Mrs F was discharged into sheltered
accommodation with Social Services support.
35
Royal College of Psychiatrists
Treatment of addiction
case viGnette key points
This case illustrates several points regarding the assessment and management of opiate
use in people with cognitive impairment:
such patients are very vulnerable and readily exploited
opiates at high doses can have a signicant deleterious effect on cognitive function,
particularly in patients with underlying cognitive impairment
close, joint working between the different teams involved in the care of these patients
is essential
alcohol misuse anD olDer people: shoulD GuiDelines
forsensible limitsbe moDifieD?
Sensible limits for alcohol consumption by older people need to be re-
examined. Effects of the ageing process and metabolic changes probably
mean that they are lower than the limits recommended by the World Health
Organization for men and women of working age.
The concept of ‘sensible limits’ in assessing harm from alcohol is
now more than 15 years old. Over the past 5 years, new evidence has
emerged that suggests that guidelines for people aged 65 and over should
be changed. The original concept of drinking over ‘sensible limits’ arose
from a consensus statement from a working group of the Royal Colleges
of Physicians, Psychiatrists and General Practitioners in 1995, dening
recommended weekly limits of 21 units of alcohol for men and 14 units
for women (Royal College of Physicians, 1995). To improve the accuracy
of these recommendations in relation to drinkers who concentrate their
alcohol consumption over a shorter time and remain under the threshold for
recommended weekly limits, the Department of Health (1995) dened these
limits in terms of units of alcohol per day: a maximum of 4 units per day for
men and 3 units for women.
Older people tend to show higher blood alcohol levels than younger
people on drinking the same amount of alcohol. This difference is attributable
to a lower body mass : water ratio and less efcient alcohol metabolism in
older people. In older drinkers, there is also ample evidence for alcohol-
related harm at lower levels of alcohol intake compared with younger
people. For example, increased body sway in older people is associated with
normal blood alcohol levels (Beresford & Lucey, 1995). Drinking more than
13 units of alcohol per week for either men or women over 65 is associated
with impairment in activities of daily living (Moore et al, 2003). More recent
evidence from the USA, based on alcohol-related harm/alcohol misuse, has
dened ‘at-risk’ drinking in older people as being more than 1.5 units of
alcohol on any one day or more than 11 units per week for both men and
women (National Institutes of Health, 2005). The most recent evidence
suggests that more than 3 units per day and 11 units per week for older
men and women are associated with alcohol-related problems. Whereas
in younger people, acute heavy (‘binge’) drinking is dened as 8 or more
units in a single session for men and 6 units for women, the corresponding
limits for older men and women are 4.5 and 3 units respectively (Moos
36 http://www.rcpsych.ac.uk
College Report CR165
et al, 2009). Recommended limits for safe drinking by older people in the
UK require further consideration to address the problem of a growing older
population, in whom the cohort effects of changing drinking habits are likely
to be associated with an increasing public health burden from alcohol-related
morbidity and mortality.
key messaGes
Current recommended ‘safe limits’ for alcohol consumption are based on work in
younger adults. Because of physiological and metabolic changes associated with
ageing, these ‘safe limits’ are too high for older people
Recent evidence suggests that the upper ‘safe limit’ for older people is 1.5 units per
day or 11 units per week
In older people, binge drinking should be dened as >4.5 units in a single session for
men and >3 units for women
37
Royal College of Psychiatrists
Service models: implications
for service development
policy anD pracTice where are we now?
Few models have been developed to address the needs of older people with
substance misuse within the UK’s National Health Service (two of these are
outlined in Appendix 3). However, there has been considerable development
in the voluntary sector, with alcohol and drug treatment charities such as
Foundation 66 promoting the case for better recognition and treatment of
substance misuse – particularly alcohol misuse – in older people.
The current situation in terms of a policy framework for the prevention
of substance misuse by older people and the planning and provision of
services for its treatment is generally characterised by a disturbing silence.
The National Service Framework for Older People (Department of Health,
2001) did not acknowledge that addiction, in its broadest or narrowest
sense, is of relevance to planning service provision for older people. There
is no specic mention of substance misuse in policy documents from elderly
care medicine, other than that relating to delirium or falls (British Geriatrics
Society, 2006, 2007).
Similar public health guidance, in Alcohol Use Disorders: Preventing
the Development of Hazardous and Harmful Drinking (National Institute
for Health and Clinical Excellence, 2010), makes even briefer reference to
older people, highlighting that mortality in this group is inuenced by alcohol
pricing, suggesting the use of the AUDIT-5 as a suitable screening tool and
emphasising the disparity between screening and brief intervention in older
compared with younger people.
The most signicant advance in highlighting the need for assessment
and treatment of alcohol misuse in older people has been the publication of
the second report of the UK Inquiry into Mental Health and Well-being in Later
Life (Age Concern, 2007). The report highlights several areas, notably:
the high rates of alcohol-related deaths in the 55–74 age group
the need to pay closer attention to ‘invisible’ groups such older people
with alcohol and drug misuse problems
epidemiology and psychosocial risk factors (including dual diagnosis,
ethnicity and social isolation)
physical and mental health consequences (such as falls and suicide)
the detection, treatment and referral of older people with substance
misuse, irrespective of age.
38 http://www.rcpsych.ac.uk
College Report CR165
As we were writing this report, the nal draft NICE guideline Alcohol
Use Disorders: Diagnosis, Assessment and Management of Harmful Drinking
and Alcohol Dependence was published (National Collaborating Centre for
Mental Health, 2011). Although it does not address alcohol misuse by older
people in any great detail, it does highlight trends in a rising proportion of
older men and women drinking above sensible limits (Department of Health,
1995) over the past decade. The guideline also notes the rise in alcohol-
related mortality in older people, the need for lower doses of medication
when managing alcohol withdrawal and need to redene sensible limits for
alcohol intake in this population. It emphasises that the threshold for alcohol
misuse should be lowered when using screening instruments and assessing
the severity of alcohol dependence, and highlights the need to consider in-
patient care more readily for detoxication. Furthermore, it draws attention
to the fact that, although many drug treatments are not licensed for use in
older people, there is no reason why they should not be considered clinically
effective in this age group.
Our report demonstrates that it would be imprudent for policy makers
not to take account of the multiple manifestations of substance use, misuse,
harmful use and dependence as part of the phenomenon of polypharmacy
and polysubstance misuse and dependence in older people, who often have
multiple psychological, physical and social needs. Indeed, we would go so
far as to say that it is an abuse of the trust older people still place in their
physicians if any problem with which they present is not set in the framework
and context of use of substances, be they prescribed, over the counter, licit
or illicit, so that patients are offered optimal and quality treatments for these
difculties.
A very different picture has emerged in the USA, with a specic
Treatment Improvement Protocol (TIP) guide for the implementation of
substance misuse services for older people (U.S. Department of Health and
Human Services, 1998) towards which we should aspire.
Substance misuse service provision for older people needs to tackle
the deep-rooted age discrimination that has dominated mainstream addiction
services in the UK. If needs are to be addressed, such discrimination is no
longer appropriate or acceptable (Department of Health, 2009). Policies
should be based on the agreement that patients should be able to access the
most appropriate clinical service on the basis of need and that age must not
be an exclusion criterion (Royal College of Psychiatrists, 2009). This principal,
however, is likely to have an impact only if this subject is highlighted and
given more than cursory mention in the policy documents that drive the
prioritising and funding of healthcare problems. Even within professional
bodies there has been no consensus on how to tackle this problem.
However, the recent government initiative of positioning addictions as
a public health priority and to create a new body, the Public Health Service,
for this purpose (National Treatment Agency for Substance Misuse, 2010b)
might provide an opportunity to advocate for this group and redress some
of the problems highlighted.
Given that up to a third of older people with alcohol use problems
develop them in later life (Council on Scientic Affairs, 1996), there are good
reasons for targeting older people (in addition to the more usual focus on
younger groups). Strategies could include: better education on the effects
of alcohol and ‘safe’ limits for consumption for older people; restrictions on
the advertising and pricing of alcohol; and increasing awareness regarding
the potential problems of alcohol use in older people. Similarly, attempts
39
Royal College of Psychiatrists
Service models: implications for service development
to reduce the misuse of prescribed and over-the-counter medications by
increasing awareness and education of prescribers, dispensers and the
general public, regular review of repeat prescriptions and possibly the use
of ‘structured dispensing systems’ such as dosette boxes, blister packs and
automated medication carousels may be effective in the primary prevention
of medication misuse (O’Connell & Lawlor, 2008).
Focusing on groups of older people who are at particular risk of alcohol
or substance misuse (e.g. those with a previous history or those experiencing
stresses such as bereavement, retirement, social isolation, physical or mental
health problems), perhaps administering screening instruments, could
identify individuals at an early stage, preventing morbidity and mortality
and reducing costs to the whole healthcare system. As this needs to be done
mainly at a primary care level it would be a public health initiative.
The Department of Health and the Royal College of Psychiatrists
consider that, owing to their skills and experience, consultant addiction
psychiatrists have a unique contribution to make (Royal College of Physicians
& Royal College of Psychiatrists, 2001; Royal College of Psychiatrists, 2005).
Addiction psychiatrists are best placed to develop the knowledge, skills and
attitudes required in the treatment of older people with substance misuse,
as they will have had experience in dealing with the most complex cases and
providing clinical leadership. Although a sizeable minority of their patients
will need the help of a specialist addiction psychiatrist, clinicians who come
into contact with older substance misusers in their everyday practice, be
they working as old age psychiatrists, geriatricians, liaison psychiatrists,
general practitioners or in forensic psychiatry, would benet from the skills
sharing that specialist addiction psychiatrists might offer. Older people
with alcohol and substance use problems are likely to present to a wide
variety of health services, including primary care, general hospitals (e.g.
accident and emergency, medicine for the elderly, gastroenterology), old
age psychiatry and specialist alcohol and drug services. The presentations
are often non-specic and may mimic other disorders in presenting with
physical illness, depression, anxiety, cognitive impairment, or delirium from
alcohol withdrawal (Royal College of Psychiatrists, 2004). They also present
to other agencies, such as Social Services and the police. In many cases,
the underlying cause of the presentation (alcohol or substance misuse) may
well be missed unless practitioners are aware of this possibility and maintain
a high index of suspicion.
The management of alcohol misuse in patients with cognitive impair-
ment or dementia often presents a signicant clinical challenge. Usually these
patients are felt to be unsuitable for specialist drug and alcohol services as
they lack insight and motivation to accept help, and are unable to engage
with or retain information from individual or group counselling. Care for this
group is usually best provided by old age psychiatry services (with specialist
input and advice from alcohol services and the general hospital where
necessary). Management strategies will usually need to involve the patient’s
family, Social Services and other formal and informal support networks.
Often the problem has to be approached by environmental manipulation,
for example working with the family to reduce the amount of alcohol they
purchase or supply to the individual concerned. Sometimes the only way
forward may be to ‘take control of the money supply’ (e.g. by activating a
nancial lasting power of attorney or referral to the Court of Protection), on
the basis that this is in the older person’s best interests, or by moving the
person into more supervised accommodation such as residential care.
40 http://www.rcpsych.ac.uk
College Report CR165
Within specialist services there is an obvious need for the development
of clear local policies regarding older people with substance use problems.
Policies should allow for easy transfer between services, joint working and
should delineate clear arrangements for which service will take the lead
where two (or more) are involved in the care of an individual patient. Policies
should also cover arrangements for detoxication, including guidelines
and administrative arrangements for organising in-patient detoxication
on an elective and emergency basis, in a mental health unit or general
hospital.
Training
In order to detect and manage alcohol and substance misuse in older
people, appropriate training is required for all professional staff (including
doctors, nurses, psychologists, allied health professionals and social workers)
who encounter patients from this age group. Such education needs to
begin at undergraduate level and progress through specialist training and
continuing professional development (CPD). Addiction specialists and old age
psychiatrists will have a particular role to play in providing such education,
but a multidisciplinary approach will be necessary. Training programmes will
need to increase levels of awareness and provide specic skills in screening,
assessment, basic management and knowledge of referral pathways.
key messaGes
Training about the impact of substance misuse on the older person is not an optional
extra
Training for all medical professionals should commence at under graduate level, through
specialist postgraduate education and continue as part of continuing professional
development (CPD)
Old age psychiatrists, addiction specialists and psychiatrists, geriatricians, as well as
nursing, psychology, social care and other allied professionals should be suitably trained
It is essential that health professionals have adequate knowledge of substance use
disorders in older people; this includes being aware of associations with mental
disorders and physical health problems, as well as vigilance over interactions between
substances and both prescribed and over-the-counter medications
Clinical skills in the areas of screening, assessing motivation to change substance using
behaviours, as well as delivering brief interventions and social interventions to reduce
relapse within a harm reduction model should be core competencies for health and
allied health professionals
Improved attitudes to older people with substance misuse in areas such as addressing
stigma, therapeutic nihilism and social exclusion are required at individual, community
and public health levels
Local policies regarding older people with substance use problems should be developed:
access on the basis of need, elimination of age barriers, easy transfer between
services, joint working and decisions regarding who will be the lead service in these
circumstances, as well as protocols regarding admission for detoxication
41
Royal College of Psychiatrists
Service models: implications for service development
research, evaluaTion anD auDiT
Research into substance misuse among older people in the UK has been
highlighted as a signicant gap (Crome, 1999, 2000). Most of the evidence
showing the effectiveness of treating alcohol use disorders in older people
originates in the USA. Much of this research is limited to White men in
US veterans hospitals. Few empirical studies have compared treatment
modalities and no studies have compared treatment with no treatment.
Very few studies have looked at the safety and efcacy of pharmacotherapy
to aid abstinence in this population (Dar, 2006). The positive results are
preliminary, but they do provide an optimistic picture of the outcome for
older substance misusers and form a basis for new research. Implementation
should be cautious, but with a degree of condence, so that patients are not
denied effective treatments (Moy et al, 2011).
A comprehensive research programme is required which includes
epidemiology, development of age-appropriate assessment instruments,
evaluation of psychological and pharmacological treatments, longer-term
outcomes, management within specic service models, and the roles of
professionals and carers (Table 4).
key messaGes
Examination of trends in the extent, nature and predictors of substance use problems
in older people is required
Standardised age-appropriate assessment and outcome measures that encourage
comparability should be developed
Effective interventions for adults should be evaluated and innovative treatments for
older people developed
Service models with a particular focus on long-term outcome should be developed and
evaluated
Table 4 Areas for future research
Research area Focus Specic requirements
Epidemiology Regional, gender and diversity
differences
Development of age-specic
questionnaires to establish the scale of
the problem in a variety of settings
Assessment Clinical needs of older adults Development of standardised age-
appropriate tools and protocols
Treatment Factors associated with treatment
success and the safety of
pharmacotherapy
Critical review and empirical
implementation of treatment strategies
used in adults
Specic efcacy and safety studies in
older people
Optimum delivery of services to meet
the special needs of older people
Outcome Long-term outcomes of older adults
with substance misuse
Development of appropriate
methodologies with standardised
outcome measures
42 http://www.rcpsych.ac.uk
Appendix 1: Assessment of
substance misuse in older people
X
X
X
X
Fig. A1.1 A ve-phase framework for assessing substance misuse in older patients (after Crome & Bloor
2006).
Recent onset
or early onset?
Abstinence
or harm
reduction?
Anxieties and
concerns dealt
with?
Set a quit
date?
Is specialist
input needed?
V
?
Phase 2 - Assess
Assess degree of dependence and educate patients about the effects of
substances
Assess the level of motivation or ‘stage of change’ at which the patient is
and suggest staged goals, e.g. abstinence or harm reduction
Discuss and negotiate treatment choices, e.g. pharmacological
interventions, admission to specialist services
Be aware that clinical manifestations of the condition and age-related
effects such as neurocognitive dysfunction may impair history-taking
Phase 3 – Advise
Use a brief 5–10 minute motivational interviewing framework
Give the patient the opportunity to ventilate anxieties and concerns
Offer feedback about clinical ndings, including physical examination and
biochemical and haematological tests
Outline and discuss the benets and risks of continued substance use;
outline safe levels of drinking
Provide self-help materials, e.g. manuals
Phase 4 – Assist
Be supportive and encouraging, and instil positive expectations of success
Acknowledge that previous failed attempts to cut down or give up may
have engendered loss of condence and self-esteem
If the goal is abstinence, suggest that a quit date is set, so that the patient
can plan accordingly (e.g. get rid of any alcohol in the house) and safely
(e.g. is it safe abruptly to stop drinking?)
Work through a range of alternative coping strategies, including the
identication of cues that might help distract the patient
Phase 5 – Arrange
Be prepared to refer or organise admission to a specialist or appropriate
unit if the patient:
is in severe withdrawal, including delirium tremens
is experiencing unstable social circumstances
is likely to develop serious withdrawal symptoms owing to a severe
dependence or previous severe withdrawal, including delirium tremens
is severely dependent
has a serious comorbid physical illness
has comorbid mental illness, including suicidal ideation
is using multiple substances
has a history of frequent relapse
Phase 1 – Ask
Ask all patients about alcohol, drug, nicotine and other substance misuse,
including prescribed and over-the-counter medications
Differentiate between use, harmful use and dependence
Consider using appropriate screening instruments
Be aware of, and sensitive to, the ambivalence that patients may feel
about their substance misuse
Be non-judgemental and non-confrontational
V
?
V
?
V
?
V
?
43
Royal College of Psychiatrists
Appendix 1: Assessment of substance misuse in older people
Each substance should be
discussed separately
Alcohol
Amphetamines
Benzodiazepines
Cannabis
Cocaine
Ecstasy
γ-hydroxybutyrate (GBH)
Heroin and other opiates
Methadone
Nicotine
Episodes of treatment for
substance problems
Medical history
Family history
Psychiatric history
Age at which substance rst tried
Age at onset of weekend, weekly and daily
use
Pattern of use during each day
Route of use (if applicable), e.g. oral,
smoking, snorting, intramuscular, intravenous
Age at onset of specic withdrawal symptoms
and features of dependence syndrome
Current use over previous day, week, month
and maximum use ever
Current cost of use
How is use being funded?
Periods of abstinence
Relapse triggers
Preferred substance(s) and reasons
Dates, service, practitioner details,
treatment/interventions, success or
otherwise, relapse triggers
Episodes of acute or chronic illness:
respiratory, infective, HIV, hepatitis, injury
(including accidents), surgery
Admission to hospital, dates, problems,
treatment and outcome
History of substance misuse and related
problems
History of psychiatric problems, e.g. suicide,
self-harm, depression, anxiety, psychotic
illness
Assessment by general practitioner for
‘minor’ complaints, e.g. anxiety, depression
Treatment by general practitioner with any
psychoactive drugs
Referral to specialist psychiatric services:
dates, diagnosis, treatment and outcome
Mental Health Act assessments
Is there any debt to nance substance
problems?
Biochemical, haematological, urinary,
salivary, sweat, hair, alcohol levels
Family, friends and colleagues
Social Services
Criminal justice agencies
Health services
Voluntary agencies
V
V
V
V
V
Financial situation V
Investigations V
Collateral information V
X
X
X
X
X
X
X
Fig. A1.2 Suggested outline for schedule of issues to be covered in assessment (after Crome & Bloor,
2006).
44 http://www.rcpsych.ac.uk
Appendix 2: Guidance for
pharmacological treatment of
substance problems in older people
The guidance that follows is drawn partly from the consensus statement
produced by the British Association for Psychopharmacology (Lingford-
Hughes et al, 2004) and from NICE and Department of Health guidelines that
reect the most up-to-date evidence available (Department of Health, 2007;
National Collaborating Centre for Mental Health, 2007a,b; National Institute
for Health and Clinical Excellence, 2007a,b) (see also Crome & Bloor, 2006).
Note that all of those documents focus on the younger adult population. It
is beyond the scope of this report to provide a comprehensive account and
readers should consult appropriate sources on substance use problems.
Pharmacological treatments are usually reserved for patients who
have substance dependence, and they are available to treat withdrawal
syndromes, to maintain abstinence, to prevent complications (including
vitamin replacement). Pharmacological interventions are also used to treat
psychological and physical disorders in substance misusers.
manaGement of alcohol WithDraWal anD Detoxification
Although the basic mechanisms of alcohol withdrawal are not age dependent,
there is evidence that alcohol withdrawal may be more severe and more
prolonged in older patients in general hospital settings, compared with a
younger age group (Liskow et al, 1989; Brower et al, 1994). This nding was
not replicated in a study of older patients admitted to a detoxication unit,
but the presence of a comorbid physical illness was an exclusion criterion
in the study (Wetterling et al, 2001). The effect of comorbid physical illness
in modifying the course of alcohol withdrawal syndrome in older patients
has been investigated in a study of 892 patients in Poland (Wojnar et al,
2001). This demonstrated that age itself did not affect the severity of the
syndrome, but associated physical illness and age-related inrmities were
a signicant modifying factor. Alcohol withdrawal can be a life-threatening
condition and prompt medical intervention is essential if there are major
signs of withdrawal syndrome.
From the evidence, it is clear that older people respond to interventions
with the same degree of success as younger patients, and a review of the
treatment of alcohol problems in older patients emphasised the importance
of providing adequate pharmacological and psychosocial interventions for
this population (Whelan, 2003).
45
Royal College of Psychiatrists
Appendix 2: Guidance for pharmacological treatment of substance problems in older people
benzoDiazepines
There is evidence that different benzodiazepines are equally efcacious
in managing alcohol withdrawal and detoxication (Whelan, 2003). For
uncomplicated withdrawal, 20 mg of chlordiazepoxide four times a day for
7 days, supplemented by additional treatment for symptom suppression, is
‘typical’ in a younger adult, although age, degree of severity of dependence,
and the need for seizure prevention should be taken into account. There
is some evidence that alcohol withdrawal in older patients may be more
severe and prolonged in general hospitals, but this may not always be the
case (Wetterling et al, 2001; Crome & Bloor, 2006). In older patients, a
lower starting dose of chlordiazepoxide is advised, with an increase in dose
if withdrawal symptoms are not controlled. This is a clinical judgement,
and the dose should be sufcient to be effective, but should take account
of the patient’s overall clinical condition. A longer-acting drug may prevent
seizures and delirium, but could lead to accumulation. Each patient should be
assessed, treated and monitored regularly. Other methods of administering
benzodiazepines are by ‘front-loading’ (i.e. until light sedation is achieved,
at which point no further medication is given) or when ‘symptom-triggered’
(as opposed to a xed regime). All these regimes require skilled staff.
Best practice guidance for the use of benzodiazepines in older
patients indicates that shorter-acting preparations are preferable (National
Collaborating Centre for Chronic Conditions, 2010). The evidence for the use
of lorazepam in the treatment of alcohol withdrawal syndrome in older people
was reviewed by Peppers (1996) and has been incorporated in Canadian
(Seeking Solutions Project, 2004) and American Medical Association (Mayo-
Smith, 1997) guidelines. Similar guidance is offered by the Dutch College of
General Practitioners in their guidelines for the management of delirium in
older people (van der Weele et al, 2003). The usual lorazepam regime for a
younger adult would be a slow tapering dose starting at 2 mg four times a
day; as with all detoxication regimes it is safest to titrate the dose against
symptoms, which results in better control and a lower total dose. In older
patients, particularly those with severe liver disorder, the risk of accumulation
is reduced with shorter-acting preparations such as oxazepam.
chlormeThiazole
Chlormethiazole is not recommended for older patients because of its effect
on respiration, cardiovascular complications and the unpredictability of the
serum levels achieved (Broadhurst et al, 2003).
carbamazepine
Carbamazepine has not been evaluated in older populations and is therefore
not recommended.
Thiamine anD wernickes encephalopaThy
Despite the commonness of vitamin deciency in alcohol dependence,
the quality of evidence for the prevention and treatment of Wernicke’s
encephalopathy is weak. A Cochrane review of the evidence for the efciency
of thiamine (vitamin B1) in treating Wernicke’s encephalopathy concluded
46 http://www.rcpsych.ac.uk
College Report CR165
that, although there is good empirical evidence to support current best
practice guidelines, there is insufcient evidence from randomised controlled
trials to guide the clinician on the correct dose, frequency of administration
or duration of treatment (Day et al, 2004).
The use of oral thiamine is not recommended in the treatment of
Wernicke’s encephalopathy, as the levels reached from oral administration
are not sufcient to address the deciency. All patients at risk of developing
Wernicke’s encephalopathy, particularly those with poor diet or malnutrition
(Sgouros et al, 2004), should be given 250 mg thiamine intramuscularly
or intravenously once daily for 3–5 days. For suspected or actual
Wernicke’s encephalopathy, the recommendation is a minimum of 500 mg
intramuscularly or intravenously three times a day for at least 2 days for as
long as there is some improvement, followed by 250 mg once daily for 3–5
days, depending on the response. Thiamine for parenteral administration
is also available in formulations combining vitamins B and C. One such
formulation (now withdrawn in the UK) was associated with a very small risk
of anaphylaxis, mostly on intravenous administration (Committee on Safety
of Medicines, 1989). Consequently, intravenous administration should ideally
be given in facilities where anaphylactic shock can be treated. If delivery in
the community is necessary, procedures should be followed to ensure safe
administration (Lingford-Hughes et al, 2004).
treatment of opiate misuse
There is considerable evidence for the use of methadone, buprenorphine
and α2-agonists (clonidine and lofexidine) in the management of withdrawal
states, but it has been obtained in populations of younger adults. The choice
of medication will depend on such factors as preferred duration of treatment,
adverse effects (brachycardia and hypotension due to α2-adrenergic
agonists) and the severity of withdrawal symptoms. Obviously, the patient’s
clinical condition, degree of dependence and preference, together with the
practitioner’s experience, will determine which drug to use.
Similarly, there is an established evidence base for methadone
maintenance treatment and, more recently, for buprenorphine. Once again,
this relates to younger people. There is inadequate evidence for treatment
with naltrexone and injectable opioids, and for using coercive methods.
special consiDerations
alcoholic DemenTia anD alcohol-relaTeD DemenTia
The role of alcohol as the primary aetiological factor (primary alcohol
dementia) remains uncertain. It is more likely that alcohol is a contributory
factor for dementia (alcohol-related dementia). This dementia differs from
other dementias both clinically and in radiological ndings. Criteria for the
clinical diagnosis of probable alcohol-related dementia include a clinical
diagnosis of dementia at least 60 days after the last exposure to alcohol. The
disorder is supported by the presence of any of the following: alcohol-related
end organ (including neurological) damage; improvement/stabilisation of
cognitive impairment and/or reversal of radiological changes after at least
47
Royal College of Psychiatrists
Appendix 2: Guidance for pharmacological treatment of substance problems in older people
60 days of abstinence; and neuroimaging evidence of cerebellar atrophy. The
presence of language impairment, focal neurological signs and neuroimaging
evidence of infarction/haemorrhage cast doubt on the diagnosis (Oslin et al,
1998).
hepaTiTis c anD chronic obsTrucTive pulmonary Disease
Hepatitis C in combination with alcohol misuse is becoming a disease
predominantly associated with older people (Cainelli, 2008). A similar
observation has been made for chronic obstructive pulmonary disease
associated with smoking (Huisman et al, 2005). In this context, clinicians
should discuss options, recommendations and plans for terminal and
palliative care and end-of-life treatment with older people who have
developed these comorbid illnesses.
48 http://www.rcpsych.ac.uk
Appendix 3: Model alcohol misuse
services for older people
service provision for olDer people With Dual
DiaGnosis in south lonDon anD mauDsley nhs
founDation trust, lonDon
North Southwark Community Team for Older People is a multidisciplinary
community mental health team responsible for the assessment and treatment
of older people with mental disorders, covering a large inner-city area of
south-east London. The catchment area of approximately 13 000 people
aged 65 and over has a sizeable population with a history of heavy drinking.
This is inuenced by the large number of older men who were previously
employed on the docks and in the construction industry, environments that
were associated with a culture of heavy drinking. However, this drinking
culture has also been incorporated into the lifestyle of a number of older
women, irrespective of their previous occupation. The team comprises a
consultant psychiatrist, specialty doctor, four community psychiatric nurses,
two occupational therapists, a consultant clinical psychologist, an assistant
clinical psychologist and a social worker. The North Southwark team is unique
in offering a service based on the what the Department of Health now calls
‘New Ways of Working’ (Care Services Improvement Partnership & National
Institute for Mental Health in England, 2007), although the service was set
up in 1981, long before the government initiative was launched.
The service (called the ‘Guy’s model’) was the rst open-access service
in the UK for older people’s mental health, accepting referrals from any
source (including self-referrals) and offering a system of multidisciplinary
assessment and case management across the range of specialties. It remains
one of the few services in the country that has doctors as care coordinators/
key workers, thereby allowing a ‘hands-on’ approach to care and an in-depth
experience of day-to-day management problems. This has been particularly
advantageous in the area of dual diagnosis involving alcohol misuse, where
the consultant psychiatrist is care coordinator for older people with complex
problems relating to alcohol misuse, sharing expertise and seeking help from
other specialties when required.
In response to the considerable number of referrals of older people with
alcohol misuse who were unable to access standard NHS substance misuse
services, the team’s consultant psychiatrist has acquired particular expertise
in the area of alcohol misuse, thereby enabling knowledge and skills to be
shared with the rest of the team. This has been helped by the creation of
a specialised support service (Older Adults Support in Southwark, OASIS),
49
Royal College of Psychiatrists
Appendix 3: Model alcohol misuse services for older people
which is jointly funded by the government’s Supporting People programme
and Southwark Social Services.
The provision of a specic service within the North Southwark team
to meet the needs of older people with mental health problems and alcohol
misuse took 10 years to accomplish. The main obstacle was that it had to be
delivered within existing resources. The rst seeds of change were sown in
1999, when it was noted that up to 1 in 5 referrals to the team each month
involved alcohol misuse, but the way in which the existing substance misuse
service was set up meant that it was not suitable for the team’s home-based
model of care. Furthermore, it lacked the age-specic knowledge, skills and
attitudes necessary for effective treatment of older people. By 2002, it was
noted that up to 50% of psychiatric admissions of older people involved a
dual diagnosis, with alcohol misuse being central to the clinical problems.
In 2003, an audit of the team’s case-load revealed that only 5%
of clients showed evidence of alcohol misuse, but all those who did were
drinking at harmful levels. As a result, the consultant psychiatrist on the
team embarked on an MSc in clinical and public health aspects of addictions,
providing much needed expertise to managing older people with substance
misuse. Five years on, following a series of awareness seminars to GPs in
the catchment area and the introduction of OASIS in 2005, the team was
nally able to manage dual diagnosis involving alcohol misuse in older people
more effectively, cutting down the percentage of mental health admissions
to fewer than 5%. The impact of the North Southwark Community Team
for Older People, in partnership with OASIS, earned the team a Clinical
Governance Award in the category of ‘choice and empowerment’ from South
London and Maudsley NHS Trust in 2006. Engagement of other stakeholders,
such as the Southwark Irish Pensioners Project, has also resulted in
increased awareness of alcohol misuse and dual diagnosis in the borough.
However, the problem of alcohol misuse in the area is still increasing,
and there has been an 80% increase in the number of older people with dual
diagnosis on the team case-load between 2003 and 2009.
As awareness also improved within the addictions directorate of the
Trust, the provision of level 1 (generic) dual diagnosis training to 15 clinicians
across a number of disciplines in the Older Adults Directorate took place in
2009, followed by a training-needs analysis. The existence of generic training
has provided non-medical clinical staff within the North Southwark team with
the skills to screen for the presence of coexisting mental health difculties
and substance misuse; develop and sustain collaborative therapeutic
relationships with patients who have a dual diagnosis; systematically assess
the needs of these patients and construct basic care plans designed to
address these needs; implement simple, low-intensity, evidence-based dual
diagnosis interventions safely and effectively in partnership with patients;
and recognise patients whose needs are sufciently complex to require high-
intensity dual diagnosis interventions and refer them to specialist services.
Over the past decade, considerable progress has been made in meeting
the needs of older people with alcohol misuse and accompanying mental
disorders such as depression and cognitive impairment. The Trust now has
its own older adults’ dual diagnosis steering group. It is hoped that continued
delivery of level 1 training and a further training-needs analysis will equip a
range of clinicians with the knowledge and skills to be able to manage dual
diagnosis in older people more effectively and with positive health and social
outcomes.
50 http://www.rcpsych.ac.uk
College Report CR165
Joint service provision by the aDDictions Directorate
central & north West lonDon nhs trust anD the olD
aGe Directorate West lonDon mental health trust
This model underpins the key message of the Department of Health’s Dual
Diagnosis – Good Practice Guidance (2002) that comorbidity should be
‘mainstreamed’. The agreed policy thus explicitly states that services for
older people with comorbid mental health and alcohol-related problems will
be delivered by the older peoples’ psychiatric services, supported by the
local community alcohol service. The model has clearly dened reciprocal
and complementary referral processes for both services. The following are
the salient points of the model.
Screening tools are to be used by older peoples’ services for all
patients presenting by incorporating screening into their routine
assessment procedures. The SMAST-G (Blow et al, 1998) will be the
instrument used for this. Alcohol services would use the MMSE (Folstein
et al, 1975) in addition to the clinical psychiatric examination to assess
patients as a routine.
A simple tool has been introduced to help clinical staff in older peoples’
services to determine the extent and context of alcohol consumption
by patients.
Emphasis is placed on knowledge and recognition of the demarcation
between hazardous, harmful and dependent use of alcohol.
Hazardous and harmful alcohol use have linked to them a stepped
approach for interventions on the brief intervention/motivational
interviewing model, carried out by older peoples’ services for a
specied period (8 weeks). Patients who do not respond to this
are referred to the community alcohol service. Alcohol dependence
means an automatic referral to the community alcohol service. The
same principle applies to the alcohol service for patients in their care:
those who have less severe mental health problems are managed
by the alcohol team or in primary care. Those with severe mental
health problems are referred to and treated jointly with older peoples’
services.
At point of referral and subsequently, the model has agreed criteria
that trigger joint assessments and joint home visits by the two teams.
This involves assessments by both services in both community and
in-patient settings. The older peoples’ services will take the lead for
patients who are subject to the care programme approach (CPA).
There is a need for a clear and systematic plan to develop a training
package and the protocol does this by paving the way for staff on both teams
to be allowed to spend time on brief attachment to each other’s service,
attend multidisciplinary team meetings and receive more formal training
on core competencies such as screening and identication, motivational
interviewing and recognising the different levels of severity of alcohol misuse
and mental health problems.
Owing to the special needs of this population, the involvement of family
members and carers is emphasised and the provision of information and
support to them is included in the protocol.
51
Royal College of Psychiatrists
Appendix 4: Online resources
royal colleGe of psychiatrists
‘Alcohol and Older People’: leaet, podcasts and links to related
information (http://www.rcpsych.ac.uk/mentalhealthinfo/problems/
alcoholanddrugs/alcoholandolderpeople.aspx)
‘Alcohol-related dementia: a 21st-century silent epidemic?’: podcast
in which Dr Susham Gupta discusses this editorial in the British
Journal of Psychiatry with Dr Mark Salter (http://www.rcpsych.ac.uk/
pressparliament/podcasts/alcohol-relateddementia.aspx)
‘UK heading towards a “silent epidemic” of alcohol-related
dementia’: press release on Dr Susham Gupta’s editorial in the
British Journal of Psychiatry, with a link to the editorial (http://
www.rcpsych.ac.uk/pressparliament/pressreleases2008/bank2008/
pralcoholrelateddementia.aspx?theme=print)
John Wattis (1998) Personality disorders and alcohol dependence. In
Seminars in Old Age Psychiatry (eds R. Butler & B. Pitt): pp. 163–179.
Gaskell. PDF of chapter (http://www.rcpsych.ac.uk/pdf/semOAP_ch11.
pdf)
‘Signicantly more alcohol misuse among mentally ill older men
in Glasgow than in Dundee’: summary of ndings presented by Dr
C. Rodriguez and colleagues at the Royal College of Psychiatrists’
Annual Meeting in 2000 (http://www.rcpsych.ac.uk/pressparliament/
pressreleasearchive/pr98.aspx)
Minutes of Meeting of the Executive Committee and Regional
Representatives of the Faculty for the Psychiatry of Old Age, 22
November 2007 (http://www.rcpsych.ac.uk/docs/2007%2011%20
22%20minutes.doc)
Roberts, A. (2002) The older drinker. Old Age Psychiatrist, 28, 10
(http://www.rcpsych.ac.uk/pdf/OAP28.pdf)
Hillam, J. (2005) Supporting quality of life. Old Age Psychiatrist, 37, 2
(http://www.rcpsych.ac.uk/pdf/OAP_371.pdf)
O’Connell, H. (2005) Alcohol use disorders in older people. Old Age
Psychiatrist, 37, 3 (http://www.rcpsych.ac.uk/pdf/OAP_371.pdf)
Royal College of Physicians & Royal College of Psychiatrists (2001)
Role of Consultants with Responsibility for Substance Misuse (Addiction
Psychiatrists): Position Statement by the Faculty of Substance Misuse
52 http://www.rcpsych.ac.uk
(Council Report CR97). Royal College of Psychiatrists (http://www.
rcpsych.ac.uk/les/pdfversion/cr97.pdf)
Royal College of Psychiatrists (2005) Roles and Responsibilities of
Doctors in the Provision of Treatment for Drug and Alcohol Misusers
(College Report CR131). Royal College of Psychiatrists (http://www.
rcpsych.ac.uk/les/pdfversion/cr131.pdf)
other sources
Institute of Alcohol Studies (2010) Alcohol & The Elderly: IAS Factsheet
(http://www.ias.org.uk/resources/factsheets/elderly.pdf)
Shaw C. & Palattiyil, G. (2008) Issues of alcohol misuse among older
people: attitudes and experiences of social work practitioners. Practice,
20, 181–193 (http://www.informaworld.com/smpp/content~db=all~c
ontent=a902096844~frm=titlelink)
University of Brighton (2008) Cheers!? A project about older people
and alcohol (http://www.brighton.ac.uk/sass/research/publications/
Cheers_Findings.pdf)
Social Care Institute for Excellence (2006) SCIE Guide 3: Assessing the
mental health needs of older people. Extended resume of: Herring R &
Thom B (1997) Alcohol misuse in older people: the role of home carers.
Health and Social Care in the Community, 5, 237–245. (http://www.
scie.org.uk/publications/guides/guide03/resumes/resume04.asp)
Social Care Institute for Excellence (2006) SCIE Guide 3: Assessing the
mental health needs of older people. Extended resume of: Derry A D
(2000) Substance use in older adults: a review of current assessment,
treatment and service provision. Journal of Substance Use, 5, 252–
262 (http://www.scie.org.uk/publications/guides/guide03/resumes/
resume02.asp)
53
Royal College of Psychiatrists
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Our invisible addicts
First report of the Older Persons’ Substance Misuse
Working Group of the Royal College of Psychiatrists
College Report CR165
June 2011
... "Baby boomers" (people aged between 55 and 64) are "atrisk" for problems with alcohol intake as they have shown a steady increase in weekly consumption, compared to a decrease in intake by people aged 16-24 [1]. Crome and Rao [2] have called for a policy response to the over 50 s drinking habits based on increasing incidents of harm such as hospital admissions. ...
... Socialarbetarna i äldreteamet hade inte någon specifik kunskap om äldres missbruksproblematik. Forskarnas slutsatser var att det behövdes mer riktade insatser, bland annat varaktigt stöd i äldres hem och utbildning om alkoholbruk bland äldre. I rapporten ''Our invisible addicts'' har Royal College of Psychiatrists tagit fram underlag för hur man kan arbeta med äldre personer med missbruksproblem (Crome & Rao, 2011). På samma sätt som Socialstyrelsen påpekat, menar forskarna i rapporten att äldre personer med missbruksproblem är en fö rbisedd grupp och att mer kunskap och utbildning behövs för bland annat geriatriker, sjuksköterskor och socialarbetare. ...
Article
Full-text available
Aim:: The aim of this study was to investigate how care managers went about in their work with older people living at home and having alcohol abuse problems. Method:: Six focus group interviews and one interview with two participants were carried out. In total, 23 care managers from five different municipalities participated. Results:: The care managers all stressed the fact that within home care, no addiction treatment was conducted. The role of home care was to provide good care helping older people in their everyday lives irrespective of their problems. The care managers had to push the limits for the available services to be able to help older people with alcohol abuse problems. The services offered are however strictly regulated in guidelines. Many older people with alcohol abuse problems were not interested in receiving home care, and they were seldom interested in having contact with the addiction unit. The self-determination of older people in need of home care is strongly stressed in legislation. If the older person did not want any help, there was not much the care managers could do. Conclusions:: Since older people today drink more alcohol than earlier generations, there is a need for services and addiction treatment specifically directed at older people with alcohol abuse problems suitable for their needs.
... Problematic AOD use in older adults has been noted to increase risk of falling, complicate existing medical conditions, and have a relationship with mental health problems, predominantly mood disorders, in older adults (Coulson et al., 2014;200 Kurzthaler et al., 2005). The Royal College of Psychiatrists, London (Crome, Dar, Janikiewicz, Rao, & Tarbuck, 2011) has labelled older adults "invisible addicts," primarily due to poor assessment and detection of AOD use in this cohort. AOD use in the older adult population occurs along a spectrum, from drink-205 ing in excess of Australian Government guidelines, which may be considered innocuous, to heavy consumption that meets the DSM V criteria for substance use disorder (American Psychiatric Association, 2013;National Health and Medical Research Council, 2009). ...
Alcohol use disorder in older adults is associated with a number of substantial medical complications, including cognitive decline. Due to limited success and application of screening approaches in this cohort, older adults are more likely to present to general hospital settings with undiagnosed problematic alcohol use. Consultation-liaison psychiatry services operating in general hospital settings are likely to be referred older adults with alcohol use disorders for assessment and management. A 77-year-old female presented to a metropolitan hospital with symptoms including frequent falls, slurred speech, difficulty judging distance, hypersomnia, poor reasoning, and odd behaviours. She also presented with severe anxiety and bruxism. Several diagnostic tests were inconclusive, and a consultation-liaison psychiatry assessment revealed a prominent heavy drinking pattern and concurrent abuse of oxycodone and benzodiazepines. This report adds further support to the case for uniform screening of all older adults for alcohol and other drug (AOD) use. A number of weeks had passed before the patient's drinking pattern was established, with no withdrawal management in place. A multifaceted treatment approach, including antidepressant therapy, anticraving medication, benzodiazepine as well as opiate rationalisation, and AOD counselling support was commenced prior to discharge from the general hospital.
... Despite these findings, little research explores dual diagnosis in the older adult (65 years and over) population. Older adults pose substantial challenges in respect of screening and assessment of alcohol and other drug (AOD) use, and have been labelled the "invisible addicts" as their presentations may differ markedly from their younger counterparts (Crome et al. 2011;Searby et al. 2015b). ...
Article
Co-occurring mental illness and substance use disorder, known as dual diagnosis, is a significant challenge to mental health services. Few older adult specific alcohol and other drug treatment services exist, meaning older adult mental health services may become the default treatment option for many. Evidence suggests that dual diagnosis leads to substandard treatment outcomes, including higher rates of psychiatric relapse, higher costs of care and poorer treatment engagement. This paper explores the prevalence of co-occurring alcohol and other drug (AOD) use in an older adult community mental health service in inner Melbourne, Australia. This aim was accomplished by using a retrospective file audit of clinical intake assessments (n = 593) performed on consumers presenting to the service over a two-year period, June 2012-2014. Of consumers presenting to the service, 15.5% (n = 92) were assessed by clinicians as having co-occurring AOD use. Depression predominated in the dual diagnosis group as the primary mental health disorder. Dual diagnosis consumers in this sample were statistically more likely to be male and younger than their non-dual diagnosis counterparts. A limitation of this audit was the lack of implementation of screening tools, leaving assessment to clinical judgement or the interest of the clinician. This may also explain the discrepancy between the results of this study and previous work. Although appearing to be a relatively small percentage of assessments, the results accounted for 92 individuals with complex mental health, AOD and medical issues. Poor screening procedures in a population that is traditionally difficult to assess need to be rectified to meet the future challenges inherent in the ageing baby boomer generation, changing drug use trends and extended lifespans through harm reduction initiatives and medical advancements.
... As indicated by the Royal College of Psychiatrists in the UK, older adults who use AOD are effectively 'invisible addicts' (Crome et al. 2011a). This title was given to the Royal College of Psychiatrists' report due to a number of concerns regarding substance use disorders in older adults; a lack of screening and assessment, complexity of co-occurring mental and physical health problems, the stigma of substance use, and a lack of education among health-care providers. ...
Article
In 1962, Charles Winick proposed that addiction was a self-limiting process, whereby individuals stopped using substances once the stresses of life transitions ceased. The notion of maturing out, as labelled by Winick, often forms the basis of the natural recovery movement in alcohol and other drug (AOD) research, aiding the notion that older individuals either cease their substance use or fall victim to the higher mortality rates prevalent in substance-using populations. As more consumers present to adult mental health treatment settings with co-occurring substance use disorders, the idea that individuals will simply cease using AOD is outdated. Given the future challenges of an ageing population, it is prudent to explore those who fail to mature out of substance use, as well as challenge the notion that older adult mental health services rarely encounter substance-using individuals. The present study explores Winick's research in the context of an ageing population and older adult mental health services. It also ponders the proposition put forth in subsequent research that older individuals with lifelong substance use switch to substances that are easier to obtain and better tolerated by their ageing bodies. © 2015 Australian College of Mental Health Nurses Inc.
... Older adults have previously been described as "invisible addicts" [1]. Social isolation, changing life roles, grief and loss, clinician reluctance to explore alcohol and other drug use and a lack of comprehensive screening instruments make identification of substance use disorders in older adults difficult [2,3]. ...
Conference Paper
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Older adults are often described as “invisible addicts” due to difficulties in assessment and identification of substance us disorders. These difficulties are often as a result of different characteristics and presentations when compared to younger adults, including alcohol being the predominant substance used in this cohort. This paper reviews the literature concerning problematic alcohol consumption in older adults, arguing that all nurses are responsible for identifying substance use disorders in older adults. A search of the Scopus electronic journal database was performed to identify articles relevant to this discussion. Although specific treatment services are essential for addressing alcohol problems in older adults, assessment needs to be broader, with screening and identification of alcohol use disorders extending to medical nursing settings. Further research is required given the potential for an increase in problematic alcohol use as the older adult cohort expands; particularly as the ageing baby boomer demographic requires greater healthcare resources.
... 530 The notion of under-diagnosis, as mentioned throughout the literature, is of concern. Older adults with substance use disorders are often described as a 'hidden population' (Crome, Dar, Janikiewicz, Rao, & Tarbuck, 2011), many with a high prevalence of comorbid psychological distress (DiNitto & Choi, 535 2010). Accurate, timely assessment and identification of substance use disorders in older adults is paramount to effective engagement and treatment. ...
Article
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Dual diagnosis is associated with frequent relapse, poor treatment engagement and overall unsatisfactory treatment outcomes. A comprehensive review of the contemporary literature examining this issue was conducted, finding a paucity of literature concerning dual diagnosis in older adults. Of the literature appraised for this review, a number of studies examined US Veteran's Affairs populations, which were largely male. Studies concerning older mental health populations were scarce. During the literature search, a number of background studies that influenced contemporary research regarding dual diagnosis in older adults were found; these studies were examined regarding their contribution to contemporary paradigms concerning older adults with co-occurring mental illness and substance use disorders. This review presents the results of the contemporary literature concerning dual diagnosis in older adults. Several recurring themes emerge from the literature, including the notion of a statistically small population that, in absolute terms, represents a sizeable number of individuals coming to the attention of aged mental health services in the future. Additionally, the potential for under-diagnosis in this cohort is highlighted, potentially creating a hidden population of older adults with dual diagnosis.
Article
Older adults with dual diagnosis remain an under-diagnosed population in mental health services, with complex needs and high rates of medical comorbidity. Dual diagnosis is a significant challenge to contemporary mental health services, with recognition of the increased rate of relapse and costs of care of poorly managed dual diagnosis identified through comprehensive research. Unfortunately, the research attention paid to those with dual diagnosis in younger age groups has not been replicated in the older adult cohort, with few studies specifically exploring the treatment needs of these individuals. Of the studies that do exist, many identify poor screening and assessment, clinician frustration and a lack of cohesive treatment for co-occurring alcohol and other drug use disorders for older adults. We draw from a mixed methods exploratory study conducted in an inner Melbourne community older adult mental health service providing care to consumers with dual diagnosis to formulate recommendations to improve the care provision to this cohort. We discuss changes to the way older adult mental health services operate that are essential to improve the care and response to consumers presenting with dual diagnosis. Ultimately, we aim to discuss how older adult mental health services can improve to provide timely, responsive care to those with dual diagnosis.
Article
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Background: People over 50 are increasing their alcohol intake, potentially increasing their risk of dementia. Objective: This study investigates whether people would be willing to adhere to current United Kingdom (UK, “low-risk”) alcohol guidelines to reduce dementia risk. Methods: A national cross-sectional online survey recruited a non-probabilistic sample of 3,948 individuals aged 50 and over without dementia in the UK. Self-reported willingness to comply with low-risk guidelines was predicted using multivariate logistic regression. Other relevant self-reported variables included physical health, lifestyle, and current alcohol intake. Results: Majority of the sample (90%, n=3,527) reported drinking alcohol at least once a month with 23% (n=795) exceeding the low-risk guidelines (>14 units per week). A larger proportion of men, those who were overweight, and people without a partner reported drinking above the recommended level. Most people who consumed alcohol (n=2,934; 74.3%) appeared willing to adhere to low-risk guidelines if they were told that their risk of having dementia could be reduced. Increased willingness was found in women (OR 1.81; CI 1.47-2.23), in people who had at least one child (OR 1.36; CI 1.09-1.70) and those who slept well (OR 1.45; CI 1.06-2.00). People who were obese (OR 0.72; CI 0.54-0.95), those who drank alcohol above limits (OR 0.13; CI 0.11-0.16), and those who were smokers (OR 0.56; CI 0.36-0.88) were less willing to adhere to current guidelines. Conclusion: Men and people with more lifestyle risk factors for common chronic diseases (e.g., smoking, obesity and excess alcohol consumption) are less willing to adhere to current alcohol low-risk guidelines to reduce dementia risk.
Article
Studies have shown that up to 10% of the elderly drink daily and as much as 4% have alcoholism. Although many elders visit a primary care provider, the problem frequently is overlooked or misdiagnosed. We have found that primary care-based nursing is an effective treatment for older adults with alcoholism. In this article, we introduce the BRENDA model and show its effectiveness in retaining older adults in treatment. BRENDA involves biopsychosocial assessment, reporting the assessment to the patient, an empathetic approach. identified and stated patient needs, direct advice to stop or decrease alcohol consumption, and assessment of the compliance with or outcome of the direct advice. We also describe the utility of the BRENDA model for the pharmacotherapeutic treatment of addiction in tate life.
Chapter
Treating Drinkers and Drug Users in the Community is the second book in a new collection from Addiction Press. Addiction Press was set up with the express purpose of communicating current ideas and evidence in this expanding field, not only to researchers and practising health professionals, but also to policy makers, students and interested non-specialists. These publications are designed to address the significant challenges that addiction presents to modern society. The drugs field has undergone a phase of rapid change in recent years and all the non-medical treatment interventions for those with alcohol problems and dependence can be equally helpful for drug users. This has opened the way for unification of alcohol and drug treatment services at a clinical level, with potential for more efficient service provision and for effective interventions which can be readily adopted in a wide range of settings. Modern drug and alcohol services and all professionals working with substance users will benefit from the initiatives and procedures discussed in this book. Key features * Describes a wide range of treatments for young people and adults with drug and alcohol dependence * Integrates alcohol and drug prevention and treatment * Provides an invaluable and accessible guide for many different professionals * Sets out assessment criteria, questionnaires, and a joint treatment framework. © Daphne Rumball and the estate of Tom Waller, 2004. All rights reserved.
Article
This chapter outlines the historical background of alcohol problems, current classificatory systems for diagnosis, psychological and physical related disorders, and the epidemiology of alcohol disorders. A variety of research methodologies have been adopted to examine the relative contribution of genetic and environmental factors to alcohol dependence. Explanatory models for age and sex differences in adolescent drug use can be derived from a variety of theories, including social learning theory and social control theory. The general protocol is adapted from that developed for nicotine dependence and is a useful way to formulate the assessment process, because it translates into specific management plans. Psychological treatments are pivotal to treatment effectiveness, even when pharmacological treatments are administered. The relationships between alcoholism and other psychiatric disorders are some times complex, and it is not always easy to achieve abstinence from alcohol to make an adequate assessment of the nature of the relationship.
Article
Treating Drinkers and Drug Users in the Community . By Tom Waller and Daphne Rumball, Blackwell Science, Malden, MA, 2004, £38.50. Paperback: 480 pp. ISBN-10: 0632035757 This book is grounded in the principle of a unified approach to understanding and helping alcohol and drug takers with problems or dependence. So for instance, combined services for drug and alcohol users are espoused. Tobacco smoking is omitted ‘reluctantly’ except in relation to pregnancy, prevention in young people and physical health because of size constraints to the book, but the authors acknowledge that for a truly combined substance approach it would be more fully covered. With the statement in the foreword ‘The old battles of abstinence-orientated treatments versus maintenance and harm reduction are battles based on ignorance and grounded …
Article
Substance misuse in the elderly population has been referred to as a silent epidemic. One of the factors that contributes to the appropriateness of this description is the difficulty of diagnosis in this age group. There is abundant evidence that substance misuse is under-diagnosed in elderly people and that this applies to both alcohol and drug misuse, although the general principles of a diagnostic approach are not age-related. The increased incidence of anxiety, depression, dementing illness, and physical illness in this population, independent of substance misuse, means that diagnoses can often be missed. The impact of co-morbidity (Figure 1) in older age groups is such that it remains the most important confounding factor in diagnosis. In this second section of the review we explore the range of psychiatric and physical illnesses that can coexist with, or be caused by, substance misuse in the elderly population. The issue of assessment as part of a treatment framework is considered in the third section of the review. The risk of missed diagnosis in this age group was illustrated in a study of diagnosis of substance misuse problems in patients aged 65 and over who had been admitted to hospital. Only three out of a total of 88 patients using benzodiazepines, 29 out of 76 smokers, and 33 out of 99 problem drinkers were correctly identified. Of those who were identified only a small proportion were referred on for specialist treatment.
Article
This review is the first in a three-part series on substance problems in older people. This section reviews terminology, epidemiology, outcome studies and policy directions. Subsequent articles will provide an overview of assessment, physical and psychological co-morbidity, as well as treatment options.