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At your age what does it matter? negativity
 It is just a phase - you grow out of it denial
 It’s your age – there is nothing you can
do about it – resignation
 Illicit drug use: no longer a young man’s
disease - fact
 Drug use and the older person – a
contradiction in terms? – No!
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Cannabis case
grandmother is
spared prison
17% of the UK population is over 65 years
old
 This proportion will increase
 Alcohol related deaths in UK doubled
form 1991-2005
 Highest death rate from alcohol among
those aged 55-74
 Smoking is the largest cause of
premature death in UK2.
 Older people use at least twice as many
prescription drugs as younger people
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Older people are particularly at risk from
effects of substances due to changes in
metabolism
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Assessment is key - Under-diagnosis of
substance use and misuse may have
contributed to lower known levels of misuse
Presentation may be subtle and easily
missed
 Current evidence based treatment
guidance does not include people over 50
years old. Age range > 40 years
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>50 years old
1999/2001
2020
Past year
marijuana users
Any illicit
1% (719,000)
2.9% (3.3 m)
2.2% (1.6 m)
3.1% (3.5 m)
Non-medical use 1.2% (911,000)
2.4% (2.7 m)
drug misuse
drug dependence
licit dependence
rate per 100,000 PYE
100
80
60
40
20
0
5-15
16-24
25-34
35-44
45-54
age group
55-64
65-74
75-84
85+
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Over the last ten years there has been an
overall increase (numbers and rate) in older
people
Using illicit substances and alcohol
Hospital admissions for poisoning, drug
related mental disorders, alcohol related
physical disorders
Drug related deaths and alcohol related
deaths
Usually men > women, older usually use less
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Vignette
A 60 year old man was found wandering around his local
area picking up cigarette stubs and begging for money to
buy alcohol. He was very disheveled.
Neighbours said that he had lost his job several months
previously, because he had been drinking heavily. He had
had chest pains and asthma and had been noted to have
hypertension. He had not taken the treatment for his
cardiovascular problems for several months.
He was not eating properly and was neglecting himself. He
had had a period of heavy drinking years ago, but had
managed to cut down.
His wife died suddenly and his social network seemed to have
contracted to such an extent that he was isolated and
bored, especially at the weekends.
He had therefore taken to drinking regularly.
On admission to a geriatric unit, he was diagnosed as having
alcohol-induced dementia.
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Vignette
A specialist registrar was called to see a 69 year old
man in the surgical ward, who was extremely
agitated and distressed.
He was attending for assessment for inpatient
admission.
Although he had drunk seven pints of cheap cider
that morning he was tremulous, sweaty and
confused.
He did not know the date and had difficulty walking.
He was depressed and said that he wanted to die.
He complained of failure and guilt in relation to his
children and felt hopeless about the future. He was
unemployed and living alone.
His blood pressure was 168/102 and his pulse rate
was 100. After several hours at the service it became
clearer that he was in severe alcohol withdrawal and
so he was admitted immediately for detoxification
and assessment of his mental state.
Missed, neglected, overlooked,
misinterpreted
 Altered or erratic: mood, memory, selfharm, anxiety
 Isolation: loss of spouse, friends, family,
income, job
 Insomnia, sleepiness, drowsiness, delirium,
confusion
 Pain, psychomotor and performance
diminished
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Level of risk = malaria, TB, measles
 Pharmacology
 Toxicity
 Withdrawal
 Deficiency syndromes
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Domestic violence
 Drink driving injury
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No absolute threshold below which there
are no effects
 BAC 25 mg% euphoria
 BAC 50-100 mg% lack of coordination
 BAC 100-200 mg% unsteadiness, ataxia,
poor judgment
 BAC 200-400 mg% periods of amnesia
 BAC 400-700 mg % Coma
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Increased risk of other pathologies eg
trauma from head injury
 Age, sex and degree of dependence alter
presentation
 High tolerance may be associated with
high alcohol levels with low levels of
impairment
 Low alcohol dose in the elderly is
associated with greater subjective
perception of intoxication and the effects
last longer; alcohol effect on psychomotor
ability more detrimental in older people
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Precipitated by lack of money, acute
illness, nausea and vomiting
 Mild moderate severe continuum
 Greater in older people, and can follow
infrequent or low volume drinking
 Seizures, hallucinations and delirium are
major symptoms
 Seizures occur after about 12-48 hours,
due to toxicity, withdrawal, trauma
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Thiamine deficiency
 Wernicke Korsakoff syndrome – reversible
condition, but can fatal if not treated
 WK – ocular, ataxia and confusional
state
 Korsakoff’s – lack of insight, apathy,
amnesia
 Dementia – neuronal loss –major
problem
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Liver and gastrointestinal disorder
 Cancer
 Cardiovascular disorder
 Muscle disorder
 Bone disease
 Skin disease
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Pharmacology
 Quantity
 Toxicity
 Route of use
 Contaminants
 Purity
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In the elderly, multiple stressors, way of
coping, underestimate the risks, hoard,
previous failed attempts at reduction
 Dizziness, tiredness, unsteadiness
 With alcohol and opiates overdose can
be fatal
 Dependence on low doses
 Convulsions on withdrawal
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Overdose and death due to depressed
respiration
 Injected, oral or suppositories – in
pharmaceutical formulations eg
cocodamol –codeine based
 Heroin - Inhaled, snorted, crushed,
smoked, injected IV, IM, Subcutaneously
 Dependence develops rapidly
 Craving, sweaty, shivers, aches
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Depression, anxiety and paranoia
 Panic attacks
 Psychosis – exacerbated, and possibly
‘causes’
 Cancers of head and neck, and lung
cancer
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Anxiety, exhaustion, depression and
weight loss
 Paranoid and/or confusional state occur
 Violent and aggressive behaviour
 Intravenous use of cocaine may result in
fits, stroke and cardiac pain
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Amnesia
 Psychomotor performance diminished
 Pain
 Bereavement, loss and loneliness
 Past history or family history of substance
misuse
 Investigations: LFTs, metabolic
(cholesterol, urate, glucose)
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Setting: WHEREVER - general psychiatric
and medical wards, nursing homes, care
homes, homes
 Change – unpredictability
 Unkempt
 Erratic mood and behaviour
 Sleep: insomnia, oversleeping, drowsiness
 Sharing medication with family, friends,
acquaintances
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History is important even if patients are in
remission because of financial, health and
life context deficits which have lasting
effects (Schutte et al 2003)
 Smoking, friends’ approval, avoidance
coping predict late-life drinking problems
 Heavy drinking, problems, response to life
events by drinking related to late life
drinking
 Help from family and friends related to
lower likelihood
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108 survivors 58.4 years (33 year cohort)
Used heroin for 29.4 years
Current use : 84% used cigarettes, 17.6%
drank alcohol daily, 23% heroin, 21%
marijuana, 11% cocaine. 6%
amphetamines
 51% hypertension, 22% hyperlipidemia
 13% elevated blood glucose, 50%
overweight
 33% abnormal pulmonary function
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50% abnormal liver function
 94% tested positive for Hep C, 86% for
Hep B, 3.8% for syphilis and 27% for TB
 Perceived themselves as having worse
physical functioning, worse emotional
well being, less energy and worse
general health when compared to the
general population
 Probably conservative estimates
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Age range 45-55 years
95% of cohort were white Caucasian males
85% were single at time of study; 50% had
separated/divorced by age 35yrs.
Limited education: 65% had no
qualifications; 30% had between 4-9 O
levels.
90% were currently unemployed; 10% have
never been in employment.
Lifelong polydrug users:
Licit drugs: Nicotine (100% of cohort)
Alcohol (47%)
Illicit drugs: Cannabis (75%),
Amphetamines (60%), Crack (50%),
Hallucinogens (20%)
 Current substance use: Cannabis (55%),
Crack (35%) and Benzodiazepines (35%)
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Opiate use was usually started in late
20’s
 Average age first exposed to heroin 29.8
years (range 16-46 years: SD=8.8years)
 Average length of heroin use 18.5 years
(range 6-38 years; SD-8.7years)
 In 20% of cases a major life event had
occurred prior to using heroin
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Special health needs highlighted
Present in study
in national guidelines
Infectious disease
 Hepatitis C
√ (67%)
 Hepatitis B
√ (50%)
 HIV
X ( 0% - only 10% tested)
Medical
 Respiratory disease
√ (25%)
 Diabetes
√ (10%)
 Not mentioned
Musculoskeletal pain
(35%)
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Special health needs highlighted
Present in study.
in national guidelines
Cardiovascular
 P.E./D.V.T
√ (25%)
 Venous/Arterial damage
X Information not
documented
 Hypertension
X ( 0%) (Inadequate
information)
 Cardiac valve destruction
X (0%) (No
documentation)
Psychiatric
 Self harm
√ (42%)
 Depression
√ (40%)
 Memory loss
√ (25%)
Despite the complaint of memory loss in
25% of cohort, in only 1 patient was mini
mental state examination documented.
 40% sample with a respiratory complaint
did not have a diagnosis or treatment
plan.
 55% of cohort had no documentation of
Hepatitis B and C status.
 15% sample were receiving opiate
analgesia for musculoskeletal pain.
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Positive outcomes
› 50% in treatment for over 3 years.
› All reported reduction in quantity of heroin
used
› Amount spent reduced from £300 to
£20/week.
› Reduction in intravenous administration from
70% to 5%.
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‘Negative’ outcome
› Only 22% showed consistently negative
opiate urine samples in the previous 6
months.
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This is the first study of this kind in the UK
Treatment is associated with positive outcomes
The older substance misuser has a diverse
range of health problems i.e. Social, physical
and psychiatric
All special health needs may not have been
identified as there was no routine screening
Where they were identified, they were
› Not appropriately further assessed & investigated &
monitored
› Not treated by a comprehensive multidisciplinary
team in liaison with other health practitioners
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Study has substantiated the special health
needs which older substance misusers
experience
Current national guidance does not provide
evidence based management specific to
older opiate users
UK guidance appropriate for this
group needs
4:
further development in terms of
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Screening & assessment
Specific treatment regimes & medication licences
Service delivery in multidisciplinary teams (e.g.
geriatricians, old age psychiatrists, psychologists,
physiotherapists, social workers, occupational
therapists, nurses, health care workers, counsellors)
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Need to diagnose dependence
ON EACH DRUG SEPARATELY
Management of withdrawal symptoms
eg benzodiazepines, carbemazepine;
methadone, clonidine, lofexidine
buprenorphine;nicotine replacement,
bupropion
 Maintenance of abstinence eg
methadone, buprenorphine;nicotine
replacement, bupropion
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Prevention of complications eg vitamin
supplementation: Wernicke Korsakoff’s
syndrome Thiamine
Relapse prevention
1. Block pleasant effects: naltrexone
2. Reduce craving: acamprosate
3. Unpleasant reaction with alcohol:
disulfiram
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Psychiatric conditions eg depression
Physical conditions eg diabetes
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Drugs not investigated/licensed for over 65s
Benzodiazepines – caution due to
accumulation but need to give enough to
cope with withdrawal
Acamprosate, disulfiram and naltrexone
with utmost caution WITH SPECIALIST
SUPPORT
Methadone and buprenorphine supervised
Nicotine replacement and bupropion if not
contraindicated
Current evidence based guidance does
not include over 50s
 Mainly alcohol (11); smoking (3); opiates
(1) and prescription drugs (1) in over 50s
 2 studies in the UK
 Some in services for older people; some
in mixed age services
 Almost all treatments were variety of
psychological interventions
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Messa Grande Project
 Systematic reviews for
HTB for Scotland
Swedish Council on Technology
Assessment in Healthcare
Australian National Drug Strategy
 Project MATCH
 UKATT United Kingdom Treatment Trial
 NTORS
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Objectives:
1.
2.
To determine if there is evidence of
effective treatment for older
substance misusers.
To outline which treatments are
appropriate for this population.
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2500 titles generated.
50 studies thought to be appropriate and full
articles obtained.
16 studies fulfilled inclusion criteria:
- 9 on alcohol misuse
- 2 on treatment of alcohol and drug
misuse (grouped with alcohol misuse for
analysis)
- 3 on smoking cessation
- 1 on methadone maintenance
- 1 on prescription medications
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Time period: 1984-2001; 14 of these after
1990.
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Country: 13 in US, 2 in UK, 1 in Canada.
Settings: 5 studies conducted in primary
care, 4 in outpatient setting, 1 inpatient
 Sample size: 24 to 3,622; some of the
larger studies had a relatively small
proportion of adults in ‘older’ age range.
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 Demographic information:
- Varied - Age cut-off for ‘older’ varied,
from 50+ years and
65 + years.
- Male -Majority of participants in 14 studies
were male; other 2 were 93% and 100%
female.
- Caucasian - 6 studies >70% Caucasian
participants.
Ethics approval: 6 studies described
ethical approval or exemption.
 Design: 5 studies contained a control
group.
 Programmes:
 Elder-specific programs or examined older
patients in 7 studies
Older patients treated in adult addiction
programs and compared with younger age
groups in 8 studies
 1 compared outcomes of older adults in
both elder-specific and adult addiction
programs.
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 Interventions:
Psychosocial interventions in all studies, 3 of
which provided medications when needed
Psychosocial interventions used varied eg
health promotion, counselling, goal setting,
‘brief interventions’, cognitive behavioural
therapy, 12 step, peer support/education.
Efficacy of pharmacological intervention in
1 study (some psychosocial input provided)
Number of patients who achieve their follow-up
goal is at least comparable to that of other
populations6.
Physicians can help older adults who drink
excessively7.
Those patients in elder-specific treatment appear
to improve across a wide variety of outcome
domains8.
Older adults who seek treatment have the
capacity to change and do well compared with
younger adults, and can be treated effectively
outside of an age specific program9.
Brief Advice and Motivational Enhancement are
equally successful for both older and adult
populations10.
Similar treatment considerations appeared
to apply for older people as applied
generally, so older age should not be a
barrier to addressing drinking problems11.
Potential for good outcomes in those older
people who seek treatment; possible they
may have achieved even better
outcomes in an elder-specific program12.
Overall recovery prospects of older patients
found to be encouraging13.
Both older men and women are capable of
achieving abstinence if given access to
alcohol abuse programs14.
Good outcomes for older adults, especially
women, so they should be encouraged to
seek treatment for substance
dependency15.
Value in treating older adults and that they
are able to respond positively to treatment,
but that there was a lack of knowledge on
long-term management16.
Smoking:
Intervention with the nurse practitioner led to
a decrease in smoking17.
Older smokers appeared to benefit as much
as younger smokers from brief office-based
counselling18.
Women found simple smoking cessation
interventions in primary care helpful; light
smokers were more likely to stop than
heavy smokers19.
Heroin:
Older patients might have fewer problems
and do very well in treatment for heroin
dependence20.
Prescription Drugs:
Participation was associated with a
significant reduction in benzodiazepine,
narcotic and overall prescription use; the
reduction in health care utilisation
observed may translate to savings in
health care costs21.
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Majority of studies (10) included not found
through search strategies – there may have
been other studies which would have met the
inclusion criteria.
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Most studies on alcohol misuse; few on
prescription drugs and heroin.
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Heterogeneity of baseline and outcome
measures make direct comparisons of findings
are difficult.
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Variety of interventions administered are not
described in sufficient detail to allow
replication.
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Small sample size
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Patient self-report
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Low cut-off age threshold for ‘older’
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Relatively short follow-up
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To our knowledge this is the first systematic
review on older substance misusers.
Certain myths are dispelled: Older people do
respond to treatment developed for adults.
In some cases they may do better than, and
certainly do not achieve worse outcomes, than
younger patients
Findings are preliminary, but they do provide an
optimistic picture for the future of older
substance misusers, though there is not enough
information to draw firm conclusions on all older
adults who are treated or who need treatment
for substance problems.
A UK based research programme on
older substance misusers is required
which focuses on:
 Prescription drug use, especially
polypharmacy, as well as other
substances.
 Whether any particular intervention can
be recommended over another.
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Whether outcome may be improved in
programmes tailored to the specific
needs of older people.
Control access to alcohol: sales, taxes
 Promote responsible industry practices
 Measures to reduce drink driving
 Education and health promotion
 Early intervention and treatment
 International cooperation on alcohol
control
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Simple brief
intervention –
structured advice
taking no more than
a few minutes
Extended brief
intervention –
structured therapies
taking perhaps 20-30
minutes, one or more
repeat sessions
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Are NOT effective for dependent drinkers
Effective in hazardous/harmful drinkers to
low risk levels in primary care, A&E,
psychiatric patients, needle exchange
schemes, somatic illness
Persist, need boosters, reduce mortality
Effective in reducing alcohol related
problems eg in A&E in young men
Inconclusive evidence for drinkers in
general hospital where MI may be better
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Chronic disease and multiple diseases
increase with age seeing multiple specialists
Combined treatments and effects of
treatments
Complicated interaction: aging,
medication, substances, environment
Evidence from unrepresentative samples
Problem focussed, judgement & acumen
Rapid and accurate diagnosis can lead to
dramatic recovery
Psychological state:
(a) Strong coping & problem solving abilities &
skills as well as role models
(b) Awareness of personal networks and
stable emotional relationship
(c) Internal locus of control
(d) Positive cognitions
(e) Life events (intrauterine, postnatal and
beyond)
(f) A sense of humour!
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Trained personnel who can prevent ridicule
Inaccessible: homebound, transportation,
rural
Create a safe environment, financial
problems
Explanations simple, content age specific,
pace
Literacy and language, and sensory, needs
Age specific
 Supportive, non-confrontational
 Cognitive behavioural approaches
 Improving social support
 Trained motivated practitioners
 Appropriate pace and content
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Implementation of ‘what works in adults’
Adaptation - addiction and old age services
Evidence base for the older age group:
length, dosage, type of intervention
Development of protocols and care plans
Innovation
Flexible, adaptive, optimistic and long term
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Health condition or impairment eg mental
illness, cognitive impairment, learning disability
Any devalued life circumstance eg
homelessness, poverty, in prison, family conflict
or breakdown, social isolation
Any devalued behaviour eg substance misuse,
criminal activity
Any devalued status eg older, asylum seeker,
refugee or immigrant, victim of abuse
Any devalued personal quality eg self esteem,
functional life skills