Ten top tips - substance misuse in the elderly
Psychiatrists Professor Ilana Crome and Dr Tony Rao offer their top tips on substance misuse in older people
1. Alcohol and prescription drugs are the most commonly misused substances in the elderly.
Some 10% of women and 20% of men aged 65 and over drink above recommended limits. The highest rates of alcohol-related deaths in the UK are in people aged 55–74.1 Rates of prescription drug misuse – both intentional and inadvertent – are particularly high in older women.
Illicit drug use is uncommon in older people, but significant increases are being seen in the over-40 age group. As this cohort ages, an increase in the number of older people using illicit drugs is anticipated.
2. Don’t dismiss the possibility of substance misuse because of a patient’s age.
It is estimated that the number of older people needing treatment for substance misuse is likely to double in the next two decades.
In older people there may not be any informant. This, plus unwillingness by health professionals to ask about substance misuse, lack of training and misattributing substance misuse to physical disorders or cognitive impairment, means that substance misuse in older people is often overlooked.
3. Symptoms include sleep and appetite changes, self-neglect and agitation.
Symptoms of substance misuse in an older person that should trigger further screening include changes in appetite and sleep, liver function abnormalities, poor hygiene and self-neglect, unusual restlessness and agitation, unexplained nausea and vomiting, changes in energy levels and frequent, unexplained falls.2
4. Recommended alcohol limits may need to be lower in older people.
Lower recommended alcohol limits may be more appropriate for older patients with co-morbid physical and mental disorders and those taking anxiolytics, sedatives or hypnotics, or opiates.3 Encourage patients who drink alcohol to drink slowly – sip not gulp – and to make sure they have eaten first.
Older people should be advised to consider carefully whether they should drink at all if they drive, swim or use machinery.
5. Be aware of different risk factors in older people.
Bereavement, retirement, boredom, loneliness and depression are strongly associated with alcohol misuse in older people, compared with younger people. Chronic pain and restriction in daily activities may also precipitate substance misuse.
Older people who misuse prescription and over-the-counter medication such as analgesics and anxiolytics or hypnotics are at high risk of subsequently misusing alcohol.
6. Opportunistic screening is invaluable.
All older patients presenting to primary care could be asked about substance use, so that you can do further screening if appropriate. In particular you should be vigilant in looking for significant changes in life circumstances, as this may help you to detect substance misuse at an early stage.
Initiating this conversation with the patient provides the chance for you to give credible, accessible and sensible messages to older people, their families and carers, who may feel stigmatised or be unaware of the consequences of substance use.
7. Alcohol misuse is commonly accompanied by other mental disorders.
In people with depression or anxiety, alcohol or other substances may be used as a way of self-medicating to reduce distress. Be alert for any evidence of self-harm, to prevent risk of suicide.
Alcohol misuse is known to be a contributory factor for dementia (alcohol-related dementia). This dementia differs from Korsakoff’s syndrome in that it affects global cognitive function and there may also be some degree of reversibility after two months of abstinence.4
Patients with concomitant mental health problems should be considered for referral to old age psychiatry services, for specialist support.
8. Older people may experience more physical complications.
Older patients are at risk of adverse physical effects of substance misuse – even with relatively modest levels of consumption – because of the physiological changes of ageing. Presentation may be non-specific, and many systems may be affected, including cardiovascular, gastrointestinal, neurological and respiratory.
Treatment of co-existing conditions is very important. Older substance misusers with physical complications will need support from secondary care substance misuse and old age psychiatry services, with GP input into care planning.
9. Don’t feel nihilistic – older patients can improve with treatment.
A common misconception is that older substance misusers are difficult to treat. But treatment produces similar – or in some instances, better – results compared with younger people. Many older people are receptive to support if it is offered and is accessible.
Older people should be offered psychological and pharmacological treatment. There is scope to offer brief interventions in primary care, as well as an appraisal of the patient’s motivation. Referral pathways to addiction services need to be well defined.
10. Adjust treatment regimes in older people.
Pharmacological treatment for substance misuse should be initiated cautiously and monitored regularly in older people. Doses should be lower and more slowly titrated, and shorter-acting medications should be used. Remember to take account of other medications and any physical and mental co-morbidities.5
You should also have a lower threshold for inpatient admission for withdrawal in older people compared with younger patients.
Professor Ilana Crome is an honorary consultant addiction psychiatrist at South Staffordshire and Shropshire NHS Foundation Trust, and Emeritus Professor of addiction psychiatry at Keele University.
Dr Tony Rao is a consultant old age psychiatrist and clinical academic group lead for dual diagnosis at South London and Maudsley NHS Foundation Trust, and visiting researcher at the Institute of Psychiatry, London
This article was produced in collaboration with the British Geriatrics Society. This topic will be covered at the British Geriatrics Society’s Autumn Meeting, 28-30 November 2012, Harrogate. For more details and to register, go to bgsevents.org.
1 Crome IB, Rao T, Tarbuck A et al. Our Invisible Addicts: Council Report 165. June 2011. Royal College of Psychiatrists.
2 Blow FC. Substance Abuse Among Older Adults (Treatment Improvement Protocol (TIP) Series 26). 1998. DHSS Publication No. (SMA) 98-3179. US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment.
3 Crome IB, Li T-K, Rao R and Wu L-T. Alcohol limits in older people. Addiction 2012;9:1541-3
4 Oslin D, Atkinson RM, Smith DM et al. Alcohol-related dementia: proposed clinical criteria. International Journal of Geriatric Psychiatry, 1998:13:203–12
5 Lingford-Hughes A, Welch S, Peters L and Nutt D. BAP updated guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP Journal of Psychopharmacology 2012;26:899-952