There are a range of issues facing us in relation to substance misuse in the older person: some are ongoing controversies and uncertainties; some are myths; and others certainties. Much of these issues are covered in depth in a new report published by the Royal College of Psychiatrists this year – Our Invisible Addicts.
There is a general sense that substance problems mainly afflict young people, especially young men. Older people are not perceived as using substances, because it is felt, they will have ‘matured’ out of this ‘habit’ with age, and certainly by the time they are in their 60s or 70s. However, the proportion of older people with substance misuse is rising disproportionately to the rate of population aging. The baby boomer population (aged 54-72 years) has the fastest increase in substance misuse in the population as a whole – both classical and novel substances. Deaths from poisonings in older people have more than doubled in the last decade, while admissions for alcohol has more than doubled from 14% to 30%.
It is certain that older people with substance problems display some distinctive features. Although substance use decreases with age, the impact can be more dangerous in the older person due to changes in physiology. Substances accumulate due to decreased metabolism and brain sensitivity to drugs may be increased. Thus, older people are at risk of the adverse medical effects at comparatively low levels of use. They may not be dependent, but can often be badly affected, including through interference or synergy with prescribed medications, and should be taken into account in substance use assessments Their medical presentations are often atypical and subtle: without a high index of suspicion, physical and psychiatric problems may not be detected.
There are a host of misconceptions about relationship between treatment and older substance (mis)users: that treatment doesn’t work anyway, that older people don’t want treatment, that they’ve been using for so long there’s no hope, or actually that drug use may be one of the few enjoyable things left in their lives.
Some of the key questions are whether pharmacological treatments are safe and effective, whether older people should be treated in mixed age or age specific units, and whether brief treatment or intensive treatment is preferable.
What is the evidence? Much evidence derives from NICE, BAP and Dept. of Health guidelines. However, these are usually dictated by clinical trials in which complex patients, like older substance misusers, who often have comorbid conditions, are excluded. These guidelines generally do not include people over the age of 60 years old. Furthermore, combinations of psychological and pharmacological treatments are rarely studied.
However, studies show that utilising interventions that are effective in younger people in the older age group are effective and that older substance misusers should not be excluded from treatment centres, nor indeed from treatment trials! Treatment modified for older people may potentiate positive outcomes, facilitating abstinence for many older people who are currently poorly catered for.
Generally it is the case that the more treatment is delivered, the better the outcomes. It is also the case that pharmacological treatments can be safe if delivered by a specialist multidisciplinary team and always with psychosocial support. The most effective services offer supportive and non-confrontational care, paced according to the needs of individuals. There needs to be a focus on client functioning, coping and social skills as well cultural needs. Families and carers are integral to the treatment offered. They need to be inherently flexible with regard to treatment goals, approach, location, mode of delivery and duration.
Collaboration of a variety of services to monitor psychological, physical, social, vocational and legal aspects is fundamental. These may include old age psychiatry, primary care, geriatric medicine as well as those related to social care. It seems that ‘mainstreaming’ detection and treatment in old age services is the only practical solution in the short to medium term given the paucity of specialist addiction services and the overwhelming need for help.
Standardisation of assessment and outcome measures that are clinically meaningful would optimize the relative dearth of research findings to date. Given the vast age range, age bands need to be stratified. Follow-up periods need to be of a reasonable length and modalities require clear description and examination of different intensities and duration of treatment and aftercare is necessary.
It is certain that age should be no bar to treatment as treatment does work. Although there are few specific treatments for older substance misusers, adaptation of those known to work in younger people, is certainly beneficial. For the moment multiprofessionalism is the way forward, but with old age services taking the lead and collaborating with social care.
In conclusion, this growing and diverse area must be prioritised. Unfortunately, it certainly remains the case that there is considerable stigma around addiction and ageing. Prejudice is unjustified and must be reversed in the policy, treatment and research arenas. The wishes and needs of patients, families and carers are paramount. The impact of substance misuse in older people on families, communities and society is considerable.
However, governmental funding is clearly critical: the cost of inaction is incalculable and must be mobilised in order to fill the huge existing research gap.