Substance misuse in older adults
Substance misuse is on the rise in older adults due to an ageing population and ‘the baby boomers’9 approaching older adulthood. It is estimated that substance misuse will double between 2001 and 2020 in adults over 65 and is related to increased mortality and morbidity. 1, 3
Substances misuse ranges from the harmful use of alcohol, tobacco, and illicit drugs to prescribed and over the counter medication. Older people are more vulnerable to harmful effects of substance misuse due to the physiological changes associated with ageing, polypharmacy and co-morbid illnesses as well as the direct impact on physical health due to poor diet, isolation and poverty.1 Healthcare professionals may be uncomfortable asking about substance misuse in older people and the information may not be disclosed by patients or carers but certain symptoms should trigger screening for substance misuse especially as they can be easily attributed to ageing or an early dementia1 (see box 1). Risk factors for substance misuse can include loneliness, retirement, isolation, bereavement or an underlying depression, anxiety or cognitive disorder.
Box 1: Symptoms suggestive of substance misuse1
Altered sleep patterns Unexplained weight loss
Impaired coordination Unexplained chronic pain
Confusion Unexplained falls
Poor hygiene/self-neglect Short term memory difficulties
Box 2: Acute presentations of alcohol misuse
Acute presentations of alcohol misuse
Physical problems associated with alcohol
Joe, 77, presents with blackouts, falls and some short term memory difficulties. During the interview he admits to drinking one bottle of wine a day and two shots of brandy a night (approx. 84 units/week). He was a social drinker until his wife died 18 months ago.
The recommended number of units of alcohol is 14 units a week but drinking more than 13 units a week in the over 65s can lead to impaired ADLs1,3. There were 1.1 million hospital admissions related to alcohol consumption in 2014 to 2015, with older people tending to have increased stays in hospital.2,4 Alcohol misuse can be missed in acute hospital admission due to non-specific and subtle signs and symptoms but is a common cause for delirium in older people admitted to inpatients.5,6 An accurate assessment of alcohol consumption can be difficult in patients with cognitive impairment but an informant’s history could be useful. Screening tools such as the CAGE, AUDIT (Alcohol Use Disorders Identification Test) can be used but the Short Michigan Alcoholism Screening Test- Geriatric Version (S-MAST-G) has been validated for use in older inpatients.1,7 There are no specific blood tests to detect alcohol misuse - a raised Gamma GT or macrocytic anaemia performed routinely when patients are admitted could suggest an underlying problem.
Early onset or long term misusers have had alcohol related issues for many years and have simply grown older while late onset drinkers tend to start misusing alcohol in their 50’s or 60’s. Late onset misuse can be associated with stress, life events and bereavements.
Joe gradually reduced his consumption of alcohol to approximately 20 units a week and started to attend bereavement counselling as a result of his sessions with local alcohol services. His memory improved and he had no further blackouts and falls.
Rose, 84, was admitted to the short stay ward following an overdose of codeine due to persistent headaches not responding to codeine, despite her GP increasing this to 30mg qds. Her daughter reported to the admitting doctor she had been buying codeine for her mother from a pharmacy and Rose may have been taking up to 90mg qds.
Illicit drug use is still uncommon in older people but is likely to increase as the ageing population changes.8 Long term prescription or poor adherence prescribing advice for benzodiazepines or hypnotics can lead to inadvertent or intentional misuse. This can cause tolerance, withdrawal or compulsive use and in the case of analgesics poor pain control.1,9 Older people who are more likely to develop problems tend to be female, socially isolated or have a previous history of substance misuse or mental health disorder.8
During her hospital admission Rose had her codeine gradually reduced to 15mg qds. A discussion was had with her and her daughter about the safe use of medication. During her admission it became evident she had a number of depressive symptoms and was referred to the mental health liaison team.
Management of Substance abuse in older adults
There has been little research into substance misuse in older people, particularly the management despite the impact this will have in the future. There is no current guidance from NICE for the management of substance misuse for older people. There are also far too few services providing dedicated services to older people with substance misuse.
Guidance on the management of illicit and prescribed drug misuse in younger adults is widely available and may need to be adapted to older people taking into account co-morbidity, polypharmacy and the physiological differences.
The management of alcohol misuse will depend on whether the person is in the community or on a inpatient unit. Alcohol withdrawal may be more severe and prolonged in older inpatients1 but respond to the same interventions as younger people. Patients with alcohol withdrawal may present with agitation as well sweating, tremors, tachycardia and insomnia, and in more severe cases, seizures. Long acting benzodiazepines are useful in alcohol withdrawal but at lower doses for older adults especially if there is hepatic dysfunction.
Intravenous thiamine should be considered in patients with Wernicke’s encephalopathy as left untreated it could lead to Korasakoff’ s psychosis which can result in permanent cognitive impairment. Low dose anti–psychotics may be needed in patients with marked agitation or hallucinations. Pharmacological interventions (e.g. Acamprosate, Disulfrum and Nalmefene for the long term management of alcohol misuse is used in conjunction with psychosocial interventions in younger people but the evidence of effectiveness in their use for older people is limited).
Substance misuse in older people is becoming increasingly common and detecting this problem during an inpatient admission could help reduce morbidity.
Consultant Psychiatrist, Bensham Hospital,Gateshead
Consultant Psychiatrist, Wrexham, Honorary Senior Lecturer, University of Chester