Abstract
An increase in the population of older people, associated with the increasing demand for holistic care to meet their complex needs, has focused attention on substance misuse in older adults. There is growing awareness among health and social care professionals of the challenges that older adults face in accessing and receiving appropriate treatment for substance misuse and the need for policy revisions to define an inclusive substance misuse service that will be able to address addiction and the impact on physical, mental and social well-being of vulnerable and frail older people.
Introduction
An increase in the population of older people, associated with the increasing demand for holistic care to meet their complex needs, has focused attention on substance misuse in older adults. There is growing awareness among health and social care professionals of the challenges that older adults face in accessing and receiving appropriate treatment for substance misuse and the need for policy revisions to define an inclusive substance misuse service that will be able to address addiction and the impact on physical, mental and social well-being of vulnerable and frail older people.
Historically, substance misuse among older adults has received little attention because of misguided suppositions such as ‘substance misuse is seldom seen after middle-age’, ‘long-term drug addicts die prematurely or recover spontaneously’, ‘late-onset addiction is rare’ or ‘late-onset addiction is restricted to a small group of aging criminals’.1 But evidence from 1990 onwards has confirmed that this population will not necessarily die, go away or ‘mature out of it’! Meanwhile, the UK Office for National Statistics Study of Psychiatric Morbidity showed, as early as 2002, lifetime experience of any illicit drug use as 24 per 1,000 in 65–69 age group and 34 per 1,000 in the 70–74 age group with drug use in the previous year being 10 and 6 per 1,000 respectively.2
Many in this population will themselves not recognize substance misuse as a condition that needs treatment; and it may only be assessed when a crisis impacts on the physical or mental health, or the social well-being of the individual. An understanding of substance misuse in older adults has to focus on psychological aspects of addiction as those who have had long-term substance misuse from an earlier age have different characteristics to those who start their misuse in later life. For example, those who start in later life most likely misuse alcohol and rarely return to illicit drugs. The lack of diagnostic certainties in this population with complex physical and mental health comorbidities, along with the lack of rigorous training and exposure of healthcare professionals to these situations, suggests that services may ultimately fail to resolve substance misuse in this vulnerable population. As an example, McInnes and Powell report that junior doctors identify only 3 out of 88 medical inpatients as having harmful use of benzodiazepines.3
Healthcare professionals, psychiatrists in particular, have to be aware of atypical presentations caused by physical health comorbidities, the limited reliability of questionnaires and diagnostic tools, domestic and social precipitants, all of which need in-depth assessment. This is difficult where time has become an expensive commodity within primary and secondary care services. This chapter provides insights to the extent of the problems in older adults, their impact and consequences, and evidence-based treatments available for clinicians and their patients.
For the purposes of this chapter, older adults are defined as the population over 60 years of age; and misuse will be used in the wider context of occasional use, including (a) intoxication without complications not amounting to harmful use, abuse or dependence, (b) harmful use, (c) abuse and (d) dependence (as defined in ICD-10), as well as ‘abuse’ as defined by authors in their studies. This chapter does not deal with alcohol misuse and its related disorders except in passing, since these have already been dealt with in Chapter 6.
Extent of Substance Misuse and Risk Factors
In an English sample of over 4,000 people over the age of 50 years, lifetime cannabis abuse of 11.4%, past-year cannabis abuse of 1.8%, lifetime tranquilisers abuse of 2.3%, and past-year tranquilisers abuse of 0.4% was reported in the 50–64 years age group; and it was 1.7%, 0.4%, 1.5% and 0.4% respectively, for the 65 years and above population.4 In an American population, a higher proportion of abuse was reported in 2006 compared to 1985, with cannabis being the most commonly abused substance (1.6% vs 0.3%), followed by cocaine (0.3% vs 0.1%) and inhalants (0.1% vs 0%).5 In a sample of over 8,000 people 65 years and above, lifetime prevalence of the abuse of sedatives was reported as 1.1%; for tranquilisers it was 0.7%, opioids 1.1%, amphetamines 0.4%, cannabis 1.4%, crack cocaine 0.2%, hallucinogens 0.1%, inhalants 0.06% and heroin 0.01%.6
In terms of risk factors associated with substance misuse in this population, Lin et al. report divorce or separation.7 Blazer and Wu report major depression for cannabis and cocaine users, with male Afro-Caribbeans abusing cannabis and Caucasians abusing cocaine.8 Johnson et al. report older users have later onset of cannabis, cocaine and crack use, have earlier onset of heroin use and are more likely to have histories of sexually transmitted disease than young users.9 Finally, Lofwall et al. report admissions to hospitals increasing for comorbid substance and alcohol abuse compared to decreases in admissions for alcohol abuse only.10 Table 7.1 provides a summary of risk factors for substance misuse in older adults.
| Predisposing factors |
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| Factors that may increase substance exposure and consumption level |
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| Factors that may increase the effects and abuse potential of substances |
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Misused Substances
Benzodiazepines and Hypnotics
Improvement in recognition of anxiety disorders and reduction in use of antipsychotics have led to increase in use of benzodiazepines. As early as 1988, Morgan reported a prevalence of 16% for hypnotic drug use from a British sample of over-65-year-olds with a higher proportion over 75 years, 25% abusing benzodiazepines for more than 10 years and 71% reporting daily use.11 The National Survey on Drug Use and Health, an annual survey of over 70,000 respondents in the United States, reports that in the age group of 50 years and over, females use tranquilisers (benzodiazepines, meprobamate and muscle relaxers used non-medically) and sedatives (temazepam, flurazepam, triazolam and barbiturates used non-medically) more than males: 74.5% female vs 25.5% male, with a higher prevalence of tranquilisers amongst Caucasians and sedatives amongst Hispanics.12 For those who might think the Z-drugs are safer than benzodiazepines from the perspective of addiction, Cimolai has cautioned that there is emergence of addiction amongst those prescribed Zopiclone for insomnia.13
In older adults, physical dependence on benzodiazepines can arise without dose escalation owing to pharmacokinetic properties, duration of treatment, shorter half-lives and higher milligram potency of particular agents.14 Non-benzodiazepine factors for misuse include prior or concurrent alcohol or sedative drug dependence, chronic insomnia and/or pain, personality disorder, depression, anxiety and regular use of at least three non-psychotropic drugs.15 Fernandez and Cassagne-Pinel have suggested that drug addiction in older people cannot be reduced simply to a physiological addiction to a particular drug, but must be understood in terms of a complex process (which would require a detailed analysis to understand) of a psychological addiction to a particular drug too. With regard to benzodiazepine addiction in older people, multiple pathologies, as well as changes induced by the ageing process itself, are involved. Old age can engender a depression that results in addictive behaviour.16
Opioids and Cocaine
Pain relief, an essential part of the treatment of chronic illnesses, has led to varying degrees of opiate or opioid misuse ranging from inappropriate use to dependency. There has to be a distinction between dependence on prescribed and non-prescribed opiates, with prescribed opiate dependence starting with increasing doses made necessary for pain relief. In terms of heroin abuse though, it is more the case that the people dependent have commenced abuse of heroin at a younger age and present with polysubstance misuse (see below). Woo and Chen reported opiate use prevalence in psychiatric emergency patients at 3.3%.17 Moore et al. reported past-year prevalence for opioids as 0.5%,6 whilst Rajaratnam et al. gave past-month opioid use among people aged more than 55 years as 27% in a sample of 156 patients.18 Beynon et al., in a study of more than 1,000 substance misusers, showed that the proportion of 50–74 year olds in contact with syringe exchange programmes rose from 0.2% in 1998 to 3.8% in 2004.19 The majority of those receiving treatment in this group were aged 50–54, and there was an increasing number of both male and female drug users aged 55–59 years and of males between 60 and 64 years.19
Rivers and colleagues in a study amongst adults over 60 years reported 2% testing positive for cocaine in emergency departments and found rates of older adults entering treatment for cocaine use at 0.1%.20 There is anecdotal evidence to suggest increasing prevalence of cocaine use among the baby boomer generation as they get older.
Atkinson has stated that opioid misusers are often men who have survived their addiction for years, have led socially isolated lives and have been secretive about their drug use having avoided law enforcement agencies and supported their drug habits through legal employment.1 There have been observations of younger family members influencing older adults to misuse drugs. Alcohol dependence and childhood abuse are associated with opioid misuse and male gender, relatively young age (66 years) and alcohol/drug misuse with cocaine misuse.
Other Drugs
Fahmy et al. reported a 10-fold increase in lifetime use for cannabis, amphetamine and LSD from 1993 to 2007.4 White et al. found a significant increase in misuse of cannabis and inhalants,5 whilst Lin et al. reported lifetime prevalence of amphetamines at 0.11%.7 Blazer and Wu8 and Moore et al.6 reported past-year use of hallucinogens as 0.1% and methamphetamine as 0.1%.
Chronic and painful diseases increase the drive to misuse euphoric drugs such as cannabis, with men at the highest risk of abusing stimulants, sedatives and tranquilisers.21 Simoni-Wastila and Stricker associated misuse of illicit substances with misuse of prescription drugs.22
Inappropriate and Over-The-Counter Medications
Older adults are significant self-medicators. They purchase 40% of all over-the-counter medications. Commonly misused medications include analgesics, laxatives, and cough and cold products. On average older people are prescribed twice as many medications as working-age adults. One in ten older people is prescribed potentially inappropriate drugs.23 Prescribing is often less rational, with less stringent monitoring, particularly in institutional settings, and there is increased complexity around hoarding and drug sharing. Psychotropic drug misuse is four times higher in women compared to men and is associated with lower levels of education, income, health, social support as well as widowhood. Other risk factors for abuse in older adults include personality disorders, somatoform conditions, anxiety, adjustment and sleep disorders.24
Polysubstance Misuse
Polysubstance misuse usually takes the form of coexisting dependence on alcohol and either prescribed sedatives or opioid analgesics. Amongst prescription drug users, 77% were on drugs that interacted with alcohol and 19% reported concomitant alcohol misuse. Of all emergency department visits by older people involving opioid analgesics, 72% have been associated with multiple drug misuse.25
Diagnostic Challenges
Clinical services, including geriatric inpatient units and older adults’ community mental health settings, are still ill-equipped to provide the knowledge, skills and attitudes required for assessment and treatment of substance misuse in older adults.
There are several age-related factors that tend to reduce the likelihood of diagnosing substance misuse in older adults. Some of these factors are:
lack of recognition of urges as cravings
misattributions
lack of awareness that a previously safe situation has now become physically hazardous because negative effects might occur at relatively low doses
failure to connect symptoms to substance misuse
cognitive impairment interfering with monitoring
failure by family members to acknowledge that substance misuse is a problem
reduced social contact leading to lack of opportunity for peer recognition of drug abuse.
An audit in Norfolk conducted in 2005 found that 60% of older patients admitted to an acute psychiatric ward had no documented notes on drug or alcohol history. The same audit reported that junior doctors felt it was inappropriate to ask older adults about their drug or alcohol histories, believing that it would only be a negative finding or it may cause offence. They also reported a lack of focused training in assessing and treating substance misuse in older adults.
Symptoms and signs of substance misuse can be mistaken for depression or dementia. Delirium from substance withdrawal during admissions to acute medical hospitals can be misattributed to other physical illnesses. Substance misuse in older adults amongst ethnic minorities remains a much understudied area.
There are several ways to improve screening for substance misuse in older adults (see Table 7.2). It is necessary to be vigilant when assessing high-risk populations including the homeless, those with a history of substance misuse, depression or bereavement, retirement, social isolation and immobility. The eight-question NM-ASSIST (www.drugabuse.gov/nmassist/step/0) is a simple tool for exploring substance misuse. Apart from scored questions, it also includes questions about intravenous drug use. However, this tool is only one indicator of an older adult’s potential substance misuse problem.
Table 7.2 Improving diagnosis
Related posts:
Chapter 3 – Young-Onset Dementias
Chapter 9 – The Home Assessment in Old Age Psychiatry
Chapter 13 – To Scan or Not to Scan
Chapter 15 – What Can Person-Centred Care in Dementia Learn from the Recovery Movement?
Chapter 22 – Deprivation of Liberty
Chapter 19 – Reducing the Healthcare Burden of Delirium
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