Substance misuse in the elderly
The ‘baby boomer’ generation, the generation born in the two decades after the Second World War and who came of age in the 1960s, a time of great social change and unprecedented affluence….is getting old. Addiction in the elderly is a huge and growing challenge.
There are particular social and therapeutic demands for treating this population and there is a rationale for establishing support and recovery in the familiarity and security of home.
Research undertaken in the United States suggests the prevalence of older adults with alcohol misuse disorders in the general population is about 4 percent but may be as high as 22 percent among medical inpatients, those in outpatient geriatric psychiatric care and those who present to accident and emergency. At risk drinking and binge drinking prevalence rates for older adults are estimated at around 10%.
Whilst these rates are lower than for younger adults, they are likely impacted by underreporting of heavy drinking, difficulties with differential diagnoses in older adults and unidentified comorbidity.
Illicit drug use is more common among older adults now than at any time in history. Research in 2007 suggested approximately 9 percent of adults age 50-59 used an illicit or non-illicit drug in the past year, marking an increase driven by the baby boomer generation. Older adults were also using more cocaine, inhalants, hallucinogens, amphetamines and heroin. In essence the baby boomer cohort (those born between 1946 and 1960) is aging but not necessarily gracefully and drug free. There is increasing evidence that the misconception that individuals “mature” out of their drug use is no longer true.
Treating addiction in older people throws up a number of challenges. These include ageism, denial, stereotyping and stigma. There is however an opportunity, since older people are more often in contact with the healthcare system, where their substance misuse can be identified.
There are a number of risk factors for substance misuse in the older population which include family history, a history of substance misuse and increasing social acceptance. Men and those with chronic illness are more at risk along with those with chronic insomnia and anxiety. Bereavement is another risk factor. The effects of substance misuse are also greater due to pharmacokinetic and pharmacodynamic factors in the elderly and the comorbidity of chronic medical illnesses. There is more risk of drug-drug interaction.
The health risks to the elderly are significant and often greater than in the younger population. They include gastrointestinal disease (including disease of the liver, pancreas, stomach and oesophagus). There is increased risk of lung disease and cancer as well as cardiovascular disease and diabetes.
We can, however, approach this challenge with some optimism. Research demonstrates that older people who want to change have the capacity to change and can be effectively treated with approaches similar to those of other patients. They often have outcomes at least as favourable. Approaches should incorporate the least intensive and non-confrontational strategies, with supportive options to build self-esteem.
The myth that older people are “too old to change” is at odds with reality. Research evidence shows that if older people enter treatment they will do as well if not better than younger patients. Older people have a rich vein of experience to draw on and might be more motivated to change because they have experienced more harm. A team approach is essential to address other difficulties which may include poor housing, loneliness, and physical or psychological problems. The introduction of a befriender or sober companion is an important initial strategy in managing substance misuse.
An accessible drug and alcohol service for older people would be accessed from multiple referral routes and would be networked with community resources. There would be strong links with older people’s mental health services.
We should aim to improve detection and engagement in treatment and to provide methods of harm reduction. These include detox and maintenance treatments and psychological assessments and therapy.
It is certain that home intervention and treatment will increase access to the healthcare system of people who might otherwise avoid treatment due to stigma or isolation. This is increasingly feasible as the older generation becomes more technologically savvy.
Home treatment services offer a number of advantages over hospital treatment for substance misuse. There is increased accessibility and links with community services and the opportunity of 24 hour one to one general and mental health nursing at home. Links to GPs and addiction therapists as well as treatment being overseen by older adult psychiatrists offers the highest standard of care. Ultimately establishing recovery in the home establishes recovery in the place it needs to continue and is most likely to offer the best outcomes for patients and families.
Dr Ian Martin