Substance misuse may be seen as a young person’s problem, but is increasingly affecting older people. Identifying and managing dependency in this population comes with its own set of difficulties.
Older people with issues relating to substance misuse will present in primary care on a regular basis. Primary care nurses are in a pivotal position to detect health issues and can play a crucial part in detecting substance misuse and advising older people about the risks.
Whyis it important?
There is a high prevalence of alcohol and drug misuse and a growing number of people considered to be older. Older people are usually considered those people who are aged 65 and over. Substance misuse is among the top ten risk factors for mortality and morbidity, and the numbers of older people misusing substances is increasing, creating a potential public health problem in the UK.1The number of older people in the UK is projected to increase by 50% between 2001 and 2031.2
The recommended weekly limits for alcohol consumption are 14 units for females and 21 units for males. The RCP (2008) identified that 1 in 6 older men and 1 in 15 older women are drinking enough to be harmful. The percentage of men and women drinking more than the weekly limits of alcohol has risen by 60% and 100% respectively between 1990 and 2006.3There appears to be a pressing need to address substance misuse due to the potential impact in primary care settings, as more people get older and more people misuse substances.
People who are older are misusing more substances, and the death rates linked to substance misuse are higher in older people than younger people.1Older people use a variety of non-prescribed medication, drink alcohol or use other substances. They are more likely to be prescribed medication in primary care settings and when combined with alcohol or other substances, there is a further risk for adverse effects. Illicit drug use in older people is uncommon.
Modest use of alcohol can have a significant harmful impact on health and wellbeing in older people and is a largely hidden problem. Older people do not drink alcohol at levels associated with drink problems. Tolerance to alcohol reduces with age and can amplify risk factors associated with alcohol, so patience is required during any assessment to identify modest alcohol use. Healthcare professionals can approach the subject of alcohol use among older people with hesitancy, not wanting to damage the reputation of the person or take away one of the few remaining pleasures.4Workers in hospital or community settings will, at some point, have cared for an older adult, who misuses alcohol, after a fall or physical injuries. Families may collude with their relatives by not wanting to remove a perceived pleasure and this can increase the risk of unrecognised alcohol misuse.
Who is at risk?
Alcohol is the most common substance used and people who are older are particularly susceptible to the effects of alcohol because they lose muscle, gain fat and break down alcohol more slowly. This means that people become more sensitive to the effects of alcohol (Figure 1).
Alcohol misuse frequently goes undiagnosed, is rarely assessed, is referred on, and older people are not routinely advised about alcohol consumption. There are three classifications of older drinkers; survivors, reactors and intermittent binge drinkers. Early onset drinkers (survivors) are those people who have had an existing chronic problem throughout their lives. Late onset drinkers (reactors) are those people who have developed an alcohol problem late in life often in response to traumatic events. There are intermittent/binge drinkers who use alcohol occasionally and its use can cause problems. It is believed that late onset and intermittent drinkers have a higher chance of managing their alcohol problem if they have access to the appropriate support.
As older people tend to not have regular employment and often have reduced social contact, their behaviour may go unnoticed. Alcohol misuse may go undetected as it presents in non-specific ways and may be linked to the ageing process, for example, accidents and self-neglect. Men are more than twice as likely as women to exceed sensible drinking limits, although women in younger age groups show the greatest increase in drinking over sensible limits. Mehta et al.5suggest that many older people admitted to hospital because of confusion, intoxication, repeated falls, recurrent chest infections and circulatory problems may have unrecognised alcohol problems.
Whenolder people use substances, men are significantly more at risk of developing alcohol and illicit substance use problems than women. Older women have a higher risk of developing problems related to the misuse of prescribed and over the counter medications. Physical health problems and the long-term prescription of anxiolytics, sedatives and pain killers are important factors in the development of substance misuse in older people. Co-existent mental health problems and substance misuse are common in older people, contributing to intoxication, delirium, withdrawal symptoms, anxiety, depression, cognitive changes and dementia. There are a number of factors in older people that increase the risk of increased alcohol misuse including bereavement, loneliness, homelessness, retirement, boredom and depression. Older people are at risk of adverse physical effects of substances even at low levels of consumption. Alcohol and tobacco have the greatest impact on physical health, and the presentation of substance misuse can be subtle and the causal role of substances in physical health problem is often overlooked.
How to help
Older people with substance use problems have high levels of unmet need. Primary care workers should screen every person over 65 for substance misuse as part of a routine health check (Short Michigan Alcohol Screening Test – Geriatric. See Figure 2) and careful assessment of current consumption of substances is advised. Re-screening should be carried out if certain physical or mental health symptoms are present or if the person is experiencing major life events. Older people benefit from substance misuse treatment and in some cases have better outcomes than younger people.
Signs of substance misusemay be difficult to recognise, as the presentation of substance misuse may mimic other chronic illnesses in older people. Signs that could alert a nurse to substance misuse include patients with unexplained mood changes, inconsistent progress in hospital, deterioration at home, or contradictions and inconsistencies in the clinical presentation. Alcohol is associated with liver disease, hypertension, diabetes, falls, thought process problems, depressed mood, self-harm, and incontinence. Older people may be reluctant to acknowledge that substance use is a problem.
Current recommended safe limits of alcohol consumption may not be appropriate as they are based on work completed with younger people. Due to the physical and metabolic changes associated with ageing, these safe limits may be too high. Recent evidence suggests that the upper safe limit should be 1.5 units per day for older people or 11 units per week. In older people, binge drinking should be defined as more than 4.5 units in a single session for men and more than 3 units of alcohol for women. Local polices for older people with substance misuse problems should be developed on the basis of need, not age. In October 2011, Professor Mansfield of the British Medical Association (BMA) gave evidence to the Commons Science and Technology Select Committee’sinquiry into the evidence base behind alcohol consumption guidelines. The BMA wants to encourage consecutive days of alcohol abstinence during a week rather than having daily alcohol limits.
Risksinclude thelargenumber of hospital admissions due to falls, possibly due to a primary substance misuse problem. This places a massive burden on already stretched and expensive hospital admissions. The most recent figures from the Office of National Statistics suggest that the problem is increasing for older people. In 2009/10, there were 1,057,000 alcohol-related admissions to hospital and of these 43% were aged 65 and over.3
What role for primary care?
Using screening tools and improving training about the impact of substance misuse should not be an optional extra. Clinical skills in screening and assessing motivation to change substance use6and delivering brief interventions and social interventions to older people to prevent relapse and harm minimisation should be viewed as a priority.7
Raising awareness and addressing how we are going to get the message about units of alcohol to this group could be a challenge, but ultimately unique and rewarding in terms of health problem prevention. Those aged 65 and over are less likely to have heard of alcohol units.3Health professionals are at the forefront to advise patients on their understanding of a unit of alcohol, as some patients may say they consume a ‘tot of whisky’ or have a ‘nightcap’. Patients may also seek advice on whether their consumption of alcohol or other substances has an effect on conditions such as diabetes or whether it interacts with prescribed medication. Patients may be reluctant to inform primary care services that they have a substance use problem if they fear medication may be stopped. Older people may not realise that they are damaging their health or not view substance use as a problem.
Primary care services are in a prime position to access people who are older and to support using older people as peers or role models to deliver the messages about safer alcohol use for older people. Improving attitudes to older people with substance misuse means addressing stigma, encouraging therapeutic optimism and reducing social exclusion.
In 2009, only 10% of male drinkers and 7% of female drinkers had discussions about their drinking in primary care settings; mostly with general practitioners.3The cost of hospital admissions and the increasing ageing population, alongside the increasing misuse of substances in older people is particularly worrying. The role of primary care could revolutionise the way in which we detect and disseminate information about substance misuse to older people by engaging older people to deliver health messages. Agreeing public health information about safe drinking levels for older people and relate this to drinks commonly consumed by older people can enable primary care nurses to set the agenda and inform training nationally. Using networks of older people to educate each other may make a major difference to the numbers presenting to primary and secondary care services for the future.
1. Royal College of Psychiatrists. Our invisible addicts: First Report of the Older Persons’ Substance Misuse Working Group of the Royal College of Psychiatrists London: Royal College of Psychiatrists; 2011.
3. National Health Service Information Centre for Health and Social Care. Statistics on Alcohol: England. London: NHSIC; 2011.
4. Clough R, Hartg R, Nugent M, et al. Older people and alcohol: A summary and recommendations arising from research in Ayrshire & Arran. 2004; Third Sector First: South Ayrshire Council.
5. Mehta MM, Moriarty KJ, Proctor D, et al. Alcohol misuse in older people: heavy consumption and protean presentations. Journal of Epidemiol Community Health 2006;60:1048-1052.
6. DiClemente CC, et al. A Trans-theoretical Model perspective on change: process-focused intervention in mental health-substance use. In D Cooper Intervention in Mental Health and Substance Use. London: Radcliffe; 2011.
7. National Institute of Health and Clinical Excellence. Alcohol Use Disorders: Diagnosis, assessment, and management of harmful drinking and alcohol dependence. London: NICE; 2011.
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